Dr. Amit VatkarMBBS, DCH, DNB Pediatrics

Fellow in Pediatric Neurology, MumbaiTrained in Neurophysiology & Epilepsy, USA

Contact No. : +91-8767844488Email: vatkaramit@yahoo.com

Diagnosis & Treatment

of Pediatric Epilepsy

Ayurveda and epilepsy

• APASMARA/ APASMRITI

• 4 Types –– Vata

– Pitta

– Kapha

– Sannipata

• Caraka Samhita- 1000- 800 BC– Nidana Sthana (Diagnosis)

– Chikitsha Sthana (Treatment)

DefinitionsSeizure

Acute clinical change due to an abnormal neuronal discharge

Epilepsy

Two or more unprovoked seizures more than 24 hrs apart – epileptic tendency

One Seizure with abnormal Neurological Examination Or EEG Or MRI

Situation related

Seizures provoked by illness / metabolic disturbance / toxic event, does not denote epileptic tendency

How do children differ?

• 70% of epilepsy starts in childhood

• Age related seizures eg. Infantile spasms, febrile seizures

• Status epilepticus is common

• Generalized seizures common

• Effects on brain development

• Drugs – dosage, side effects

• High rate of spontaneous remission

Clinical Presentation

Events That Mimic Seizures

Apnea

Breath Holding

Dizziness

Myoclonus

Pseudoseizures

Psychogenic Seizures

Rigors

Shuddering

Syncope

Tics

Transient Ischemic Attacks

Seizure precipitants

• Stress, emotion

• Sleep/sleep deprivation

• Hyperventilation

• Fever

• Medications, metabolic disturbance

• Reflex epilepsy

– Photic stimuli: TV, flashing lights, visual patterns

– Startle, music, reading, eating

First Unprovoked Seizure:

Diagnostic Testing

Laboratory tests are based on individual clinical circumstances and may include: CBC with differential

Blood glucose

Electrolytes

Calcium, magnesium, phosphorous

Urine drug/toxicology screen

Urine HCG (age dependent)

Lumbar puncture is only indicated if there are other symptoms that suggest a diagnosis of meningitis.

First Unprovoked Seizure:

Diagnostic Testing – MRI

Outpatient MRI should be considered for: Children under 1 year of age

All children with significant acute cognitive or motor impairment

Unexplained abnormalities on neurologic exam

Seizure of focal onset without generalization

Abnormal EEG

Abnormalities on MRI are seen in up to 1/3rd of children However, most abnormalities do not influence immediate

treatment or management (such as need for hospitalization)

First Unprovoked Seizure:

Diagnostic Testing – EEG

Obtain on ALL children in whom a nonfebrile seizure has been diagnosed

Can be arranged as an outpatient

Should be interpreted by a neurologist (preferably pediatric neurologist)

EEG results will: Help predict the risk of recurrence

Classify the seizure type or epilepsysyndrome

Influence the decision to perform additional neuroimaging studies

Overall Recurrence Risk

• 42% recurrence

• Mean time to recurrence 11.3 months

– 36% in first month

– 53% in 6 months

– 88% in 2 years

Why do we treat?

• Reduce recurrence risk

• Prevent prolonged seizures

• Minimize impact on development/academic achievement

• Does NOT affect natural history

– if you are going to outgrow it, you will regardless of treatment

Treatment?

• Every child/family is different

– Treatment may reduce recurrence risk by as much as 50%.

– AED’s are toxic medications!

• For the most part we do not treat after a first time seizure.

• The one exception- Remote symptomatic presenting in status.

Treatment options

• Daily anti-epileptic drugs (AED’s)

• Abortive medications

• Specialized diets

• Surgery

– Resective

– Devices, ie Vagal nerve stimulator

No seizures and No side effects!

First vs Second generation

• First generation

• Phenobarbital

• Phenytoin (Dilantin)

• Carbamazepine (Tegretol)

• Ethosuxamide (Zarontin)

• Valproate(Depakote,Depakene)

• Benzodiazepines

– Lorazepam (Ativan)

– Midazolam (Versed)

– Diazepam (Valium)

– Clonazepam (Klonipin)

– Chlorazepate (Tranxene)

• Second generation

• Ox-carbazepine (Trileptal)

• Lamotrigine (Lamictal)

• Gabapentin (Neurontin)

• Topiramate (Topamax)

• Levetiracetam (Keppra)

• Zonisamide (Zonegran)

• Pregabalin (Lyrica)

• Lacosamide (Vimpat)

Side Effects• Phenobarbital-sedation

• Valproate-weight gain, liver toxicity, decreased platelets, pancreatitis

• Sodium abnormalities-ox-carbazepine

• Lamotrigine-Steven’s Johnson syndrome

• Topiramate-weight loss, language dysfunction, kidney stones, glaucoma

• Levetiracetam-irritability,agitation

Long Term Follow-up

• 37 year f/u of 144 patients

• 31% enter remission in first year of Rx

• 19% are resistant from the beginning

• Overall 67% achieve terminal remission

– 14% on AED’s

– 86% off AED’s

Lesional epilepsy

• Complete resection of lesion AND electrographically abnormal region

• 92% have good outcome

• sz free or >90% reduction

• Electrographically abnormal region

• Electrocortiography

• Chronic subdural grid recordings

THANK YOU

Dr. Amit VatkarPediatric Neurologist, Navi Mumbai

MBBS, DNB

Email: vatkaramit@yahoo.comContact No.: +91-8767844488

Visit us at: http://pediatricneurology.in/

THANK YOU !