DIAGNOSIS :

HISTORY : Description about seizure activity.• Age of Onset.

• Duration.

• Focal / Generalized.

• Loss of conciousness, associated features .

• H/o previous attack.

• H/O Trauma, Drug ingestion.

• Meningitis , encephalitis.• Precipitating factor (fever, viral illness, diarrhoea).• Frequency.• Time of day –early morning ,in drowsy state childhood

epilepsy.

• Detail treatment hist, response to treatment.

• Prolonged personality change or intellectual deterioration, regression of milestone –neurogenerative disorder.

• Family history.• Developmental history.

PHYSICAL EXAMINATION :

• Head Cicumference & Fontanale.

• Facial abnormality.

• Sign of degenerative, Metabolic and Congenital disease.

• Hepatosplenomegaly –storage disease.

• Neurocutaneous marker. Skin rash –Meningitis, Sepsis.

• CVS— H.R , BP , Peripheral perfusion.

• RESPIRATORY : Cyanosis, Irregular breathing.

• CNS :• Pupil . Fundus --Papilledema.

• Cranial Nerves.

• Sign of meningeal irritation.↑ ICP.

• Sensory , Motor system examination.

INVESTIGATIONS :

EEG : Support diagnosis. Confirm diagnosis. Classification type. Locate the epileptic focus.

• A normal EEG does not R/o epilepsy.• Abnormal EEG always not indicates Epilepsy.

• If standard EEG normal --• sleep/ sleep deprived EEG.• 24 hrs Ambulatory EEG. • Vediotelemetry.

EEGIt is a record of the underlying neuronal activity of brain.

• What are normal brain waves?

• β wave (fast ) >13Hz/sec --alert state.• α wave (intermediate) 8—13Hz/sec –quite

awareness.• Theta wave (slow) 4—7 Hz/sec –drowsiness.• δ wave (slower) <4Hz/sec –deep sleep.

• α Activity seen is normally seen in children.

• Depression of normal activity.

• Slow waves.

• Spikes.

• Spikes & waves.

• Sharp waves.

BLOOD EXAMINATION :

• Serum electrolytes.

• Serum Ca+ , Mg +. Blood sugar.

• CBC, Septic work up Including LP.

• RFT , LFT.

• Toxicological screening.

OTHERS : CT / USG/ MRI.

DIFFERENTIAL DIAGNOSIS :

1.BREATH HOLDING SPELL :

• Age group — 6month — 2years. - rarely upto 5 years.

• Precipitated by Fear , Frustration , Anger & Anxeity.

• Cry vigorously holds breath apnea cyanosis LOC Convulsion.

• But in seizure , convulsion cyanosis.

2.REFLEX ANOXIC SEIZURE:

• Age group : Toddler.

• Precipitated by : Pain, Discomfort, Fright, cold food , Head trauma.

• Severe pain stop breathing Hypoxia Pale convulsion rapid recovery.

• This episode occurs due to cardiac asystole from vagal inhibition.

3.SYNCOPE :

• Preceeds by pallor , Nausia , Vomiting , Sweating , Blurring of vision ,Hypotension.

• POSITION : Prolonged standing.

• Precipitating Factor : Emotional upset , Pain , Anxiety.

• Duration : few min.

• Bradycardia , Hypotension, Clonic convulsion.

• H/o heart disease .

4.MIGRAINE :

• Paroxysmal headache.

• Unsteadiness or Light headedness.

• Visual or Gastro intestinal disturbance.

5.BENIGN PAROXYSMAL VERTIGO :

• Recurrent attack of vertigo lasting for several minutes.

• Nystagmus.

• Unsteadiness or even Falling.

• Occurs as a result of Viral Labyrinthitis.

6.CARDIAC ARRYTHMIA :

• Prolonged Q T Interval may some time cause

Collapse or Cardiac Syncope.

• Usually occurs after Exercise.

7. NIGHT TERROR.

8.NON EPILEPTIC ATTACK DISORDER:( NEAD)

1. Pseudoseizure.

2. Fabricated illness.– fabricated by parents.

3. Induced illness.- Induced by hypoglycemia or Insulin over dose.

• PSEUDOSEIZURE :

• Incidence –5—10 %.

• Female.

• Age – 10—12yr.

• Unresponsive to AED.

• Precipitating factor –Emotional upset.

• Tendency to occur in company.

• Never occur when the patient is alone.

• Poor psychosocial history.

TREATMENT :

• Confirm diagnosis before starting treatment.• Explain to the parents about AED.

• Monotherapy at minimum dose should be attempted first.( the single most effective drug should be started)

• If not control by monotherapy switch to poly therapy.

• Drug level may be measured routinely.

• Anti epileptic therapy can usually be discontinued after 2 years

• Anti epileptic therapy can be discontinued after 2 years of Seizure free period over a period of 3—6 month.

• Indications of Polytherapy :

1. Worsening seizure.

2. Status epilepticus.

3. Non compliance.

4. Adverse effect.

SEIZURE TYPE 1st LINE 2ND LINE.

GENERALIZED:

- Sodium valproate. - Lamotrigine

1. Tonic clonic. - Carbamazepine.

2. Absence - Valproate. - Lamotrigine.

- Ethosuximide.

3. Myoclonic - Valproate. - Lamotrigine.

4. Infantile Spasm - ACTH. - Prednisolone

- Vigabatrine. - Valproate.

PARTIAL SEIZURE :

Simple partial - Carbamazepin Gabapentine.

& - Valproate.

Lamotrigine.

Complex partial

Topiramate.

DRUGS , DOSES & SIDE EFFECTS OF AED :

CARBAMAZEPINE : ( Tegretol)

DOSE : 10 mg / kg/ day.

- Increase upto 20—40 mg /kg /day B.D.

SIDE EFFECTS :

- Hepatotoxic .

- Bone Marrow depression ( Aplastic Anaemia ).

- Skin Rash.

PHENOBARBITONE (Luminal)

• DOSE :

- 15—20 mg/ kg loading dose .

- 5 mg/ kg/ day . B.d.

• SIDE EFFECTS :

- Drowsiness.

- Hyperkinesia.

- Drug dependency.

PHENYTOIN ( EPANOTIN)

• DOSE :

- 15—20 mg /kg loading dose . - 5mg/kg/day B.D.

• SIDE EFFECTS :

• Gingival hyperplasia.• Hirsutism.• Rickets. , Megaloblastic anaemia. Skin Rash ,

Nystagmus , Ataxia.

VALPROATE ( DEPAKINE )

• DOSE :

- 15—20mg/kg day stat.

- increase 5mg/week maximum

60mg/kg/day. BD ,TID , QID. • SIDE EFFECTS:

- Hepatic Necrosis.

- Pancreatitis.

- Weight gain.

- Hair loss.

ETHOSUXIMIDE (Zanotin)

• DOSE :

- 20—30 mg/kg/day B.D.

• SIDE EFFECTS :

- Nausia, Lethargy.

- Blood dyscrasias.

- SLE , Steven johnson Syndrome.

GABAPENTINE (Neurontin)

• DOSE :

- 30—60 mg/kg/day T. i. d.

• SIDE EFFECT: Nausia.

LAMOTRIGINE (lamictal)

• DOSE : 2mg/kg stat , 5—15mg/kg/day B.D.

• SIDE EFFECT: Skin rash.

TOPIRAMATE (Topamax )

• DOSE : - 1—9mg/kg/day BD.

• SIDE EFFECT : - Drowsiness. - Weight loss.

• VIGABATRINE (Sabril )

• DOSE : 50—150mg/kg/day. OD , BD.• SIDE EFFECT : Sedation , Restiction of visual field.

CLONAZEPAM (Klonopin)

DOSE :

- 0.01 –0.02mg/kg/day. B.D.

SIDE EFFECTS :

- Sedation.