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Contents

What is a seizure?

Seizure types

Etiology of seizures

Febrile convulsions

Epilepsies of childhood

Epilepsy syndromes

Status epilepticus

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What is a Seizure ?

Paroxysmal, involuntary & sudden

disturbance of neurological function caused

by an abnormal or excessive neuronal

discharge.

With or without LOC.

If manifests as motor act – “convulsions”

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Seizures

Epileptic Non

epileptic

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Etiology of seizures

Idiopathic (70-80%) – cause unknown but

presumed genetic

Secondary

Cerebral malformations

Cerebral vascular occlusion

Cerebral damage (ex; congenital infections,

hypoxic-ischaemic encephalopathy…)

Causes for Epileptic seizures

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Cerebral tumour

Neurodegenerative disorders

Neurocutaneous syndromes

Neurofibromatosis

Tuberous sclerosis

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Causes for Non-epileptic seizures

Febrile seizures

Metabolic

Hypoglycaemia

Hypocalcaemia

Hypomagnesaemia

Hypo/hyper natraemia

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Head trauma

Meningitis/Encephalitis

Poisons/Toxins

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Definition

A seizure accompanied by a fever in the

absence of intracranial infection due to

bacterial meningitis or viral encephalitis.

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Incidence

Affects 3% of children

Positive family Hx in 10%-20%

Autosomal dominant inheritance (thus family hx

important)

Recurrent febrile seizures in 30%-40%

1%-2% of subsequent epilepsy after a simple febrile

seizure

4%-12% in complex febrile seizure

Boys > Girls11

Diagnostic criteria

Age

6 months – 60 months (5yrs)

Peak 14 – 24 months

Temperature

Usually >= 38C with rapidly rising temp.,

within 24hrs of onset of fever

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Should not last >10min

Generalized, not focal

No residual weakness of limb or disability

except a brief period of drowsiness

No evidence of CNS infections. (meningitis,

encephalitis, abscess….)

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Extra cranial infection may be there. ( URTI,

tonsillitis, otitis media…)

No Hx of previous afebrile seizure

No acute systemic metabolic abnormality

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Classification

SIMPLE COMPLEX

Most common Uncommon

Lasts less than 15min Lasts more than 15min

One fit only in the same

illness

Recurring during same

illness within 24hrs

Generalized tonic-clonic Focal

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Risk factors for recurrent febrile

seizures

Younger than 18 months (younger the child, higher

the risk...)

Shorter duration of fever before the seizure

Height of fever (lower the peak, higher the risk…)

Positive family Hx

Complex febrile seizure at onset

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Pathogenesis

Not well known

Due to temporary impairment of the

balance between convulsant and

anticonvulsant system of brain

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Studies done in children suggest that the

cytokine network is activated and may

have a role in the pathogenesis of febrile

seizures

Threshold level of anticonvulsant system in

these genetically predisposed children is

lower

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Other suggestions

Endogenous pyrogens such as IL-1

increase neuronal excitability & cause

seizures

Hyperthermia induced alkalosis

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Investigations

Usually not needed in simple febrile

convulsion

Complex form may need,

Blood glucose, serum electrolytes

LP and CSF analysis

Neuro-imaging (CT, MRI)

EEG

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Lumbar puncture is strongly

recommended ,

Hx of irritability, reduced feeding or lethargy

Clinical signs of meningitis/encephalitis

Systemically ill

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Prolonged post-ictal altered consciousness

After a complex convulsion

After pretreatment with antibiotics

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In these situations,

LP must be undertaken to check for,

CSF

sugar

protein

organisms

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Neuroimaging is considered If,

Micro/ macrocephaly

Neurocutaneous syndrome

Pre-existing neurological defect

Recurrent complex febrile seizures

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EEG

Not a guide for treatment

Does not predict recurrence

So not usually indicated

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Management

Fever

Find the cause (usually viral illness)

Must exclude meningitis

○ Infection screen blood culture

urine culture

LP for CSF culture

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Treating fever promote comfort.

Not important in preventing seizures.

Physical methods

Fanning

Tepid sponging (now not recommended)

Light clothing

Drugs

PCM

ibuprofen

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Management at home

Move danger away

Left lateral position

Do not try to stop fitting

Do not put anything in mouth

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Loosen clothing

Wipe secretions from mouth

No fluids or drugs orally

Note the time

Do not panic

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If seizure lasting >5-10 min,

Seek medical advice

Diazepam

0.5mg/kg rectal

Midazolam

0.5mg/kg buccal

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Prognosis

Generally excellent

Risk of further febrile seizures – 30%

Risk of epilepsy after single febrile seizure – 3%

No increased risk of death

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Information for parents

FC are common

Recurrences likely

Brain damage

Later epilepsy

Very rare

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No evidence of deaths

What to do when fitting

If lasting >10 min & not stopping

Rectal diazepam

-OR-

Take to the hospital

Information & advice sheets

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Definition

Chronic neurological disorder

characterized by recurrent unprovoked

seizures, associated with abnormal,

excessive or synchronous neuronal activity

in brain

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Pathogenesis

Sudden, excessive, disorderly

discharging neurons

Increased GLUTAMATE levels &

decreased GABA levels

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Classification

Generalized

Discharges from both hemispheres

○ Absence

○ Myoclonic

○ Tonic

○ Tonic-clonic

○ Atonic

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Focal

Arise from one or part of one hemisphere

○ Frontal seizures

○ Temporal lobe seizures

○ Occipital seizures

○ Parietal lobe seizures

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Generalized seizures

There is,

Always LOC

No warning

Symmetrical

B/L synchronous discharge on EEG

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AbsenceTransient LOC

Abrupt onset & termination

Typical(petit mal) or atypical

Often due to hyperventilation

MyoclonicBrief, repetitive, jerky movements

Limbs, neck or trunk

Physiologically in hiccoughs

Tonic Generalized increased tone

Tonic – clonic

Rhythmic contractions of muscle

groups

Become cyanosed

Jerking of limbs

Tongue biting & incontinence

Atonic Combined with myoclonic jerk

Followed by transient loss of muscle

tone

Sudden fall or drop of head40

Focal seizures

Begin in one hemisphere

May herald by an aura

May or may not have change in

consciousness

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Frontal Motor phenomena

Temporal Auditory or sensory (smell

or taste) phenomena

Occipital Positive or negative visual

phenomena

Parietal Contra lateral altered

sensation

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Diagnosis

Primarily by detailed Hx

Child & eye witnesses

Video if available

Skin markers of Neurocutaneous syn.

Or neurological abnormalities

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Investigations

EEG Indicated whenever suspected

To detect structural abnormalities

Neuronal hyperexcitability

○ Sharp waves

○ Spike-wave complexes

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Many children with epilepsy

Many children never had epilepsy

Normal initial EEG

Abnormal initial EEG

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Additional techniques

Sleep deprived record

24h ambulatory EEG

Video – telemetry

Subdural electrodes (prior to surgery)

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Imaging studies

Structural scans

MRI

CT brain

Can identify

Tumours

Vascular lesions

Sclerotic areas

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Functional scans

Structural lesions not always possible to see

Can see areas of abnormal metabolism

Suggestive of focal seizures

Ex :- PET, SPECT

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West syndrome

Age of onset 4-6 months

Violent flexor spasms of head, trunk &

limbs

Extension of arms

“salaam spasms”

EEG shows hypsarrhythmia

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Childhood absence epilepsy

Age of onset 4-12 y

Suddenly stop moving & stare

Lasts only few seconds

Has no recall

May look puzzled

Induced by hyperventilation

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Benign epilepsy with

centrotemporal spikes (BECTS)

Age of onset 4-10 y

Tonic clonic seizures in sleep

Abnormal feelings in tongue & face

Focal sharp waves in EEG

Benign so important to recognize

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A seizure lasting >30min or repeated

seizures for 30min without recovery of

consciousness in between

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Management

Diazepam 0.5mg/kg PR

Lorazepam 0.1mg/kg IV Midazolam 0.5mg/kg buccal

Check blood glucose

If <3mmol/L give IV glucose & recheck

AirwayBreathing Circulation

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Rapid-sequence induction with Thiopental

Mechanical ventilation Transfer to PICU

Phenytoin 18mg/kg IV over 20min or

Phenobarbital 15mg/kg if on oral phenytoin

Paraldehyde 0.4ml/kg PR

(If no response in 10min)

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Summary

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Febrile convulsions

Affect 3% of children

Usually tonic-clonic with

rapid rise in fever

Must exclude CNS infection

Family advice about

management

Does not affect intellect

Reassure the parents

Epilepsy

Affects 1 in 200 children

Underlying etiology important

If suspected EEG is indicated

Need psychological help

Parents & teachers need to be

aware of the management

Avoid injurious situations

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