Rosalina Q. De Sagun,M.D.Maria Antonia Aurora Moral - Valencia, M.D.

Seizure: is an abnormal excessive neuronal discharge arising from the brain capable of causing alteration in function and/ or behavior.

Convulsion: is a type of seizure with a motor component.

Epilepsy: Recurrent unprovoked seizures (operational definition more than two).

Everyone is entitled to a diagnosis for prognosis and management to be specific and precise.

The diagnostic label epilepsy is unsatisfactory for both physician and patient because epilepsy is not a single disease entity .

First: Are these epileptic seizures?

Second: What is their cause and what is the epileptic syndrome?

Breath-Holding Spells Benign Paroxysmal vertigoNight terrorsSyncopeShuddering attacksParoxysmal torticollisRage attacksMasturbationHereditary chin tremblingNarcolepsy/CataplexyParoxysmal Kinesigenic choreoathetosisPseudoseizures

Paroxysmal disorder Altered neurological function (motor, sensory, psychic, autonomic) Abnormal cortical electrical discharge Beginning and an end (sudden and transitory)Involuntary

History with an exact description of the eventPhysical and Neurological Examination Age of onsetPrecipitating events: possible prenatal or postnatal insults to the CNS such as trauma and infections. Possible etiology of seizures.Occurrence of prior seizures ( non-convulsive)Classify the seizureFamily history of seizures

Look for physical and neurological signs that may suggest a possible etiology.

Any signs of trauma, dysmorphic features, signs of increased ICP or metabolic disorders.

Serum glucose determinationElectrolytes Drug screens BUN and creatinine Thyroid function tests

If the seizure is clearly related to a metabolic disturbance an EEG is unnecessary.

Treatment with antiepileptic drugs may be needed to control seizures until the underlying pathology responsible for the acute encephalopathy has been corrected.

Classification of the seizure

Provide additional clues in making an etiologic diagnosis

A normal EEG is of limited value and does not rule out the fact that a seizure episode has occurred

I. Partial seizureA. Simple partial seizure (consciousness nintact)B. Complex partial seizure (with impairment ofconsciousness)C.Partial secondarily generalized II. Generalized seizures (bilaterally symmetrical and without local onset)A. Absence seizures B. Myoclonic seizures C. Clonic seizuresD. Tonic seizuresE. Tonic-clonic seizuresF. Atonic seizures (astatic)III.Unclassified epileptic seizures (inadequate or incomplete data)

Consciousness is preservedMay have motor, sensory, somatosensory or special sensory, autonomic or psychic symptomatology.No post-ictal confusion

Characterized by impairment of consciousness and purposeless behaviors or automatisms.Warning signs or auras may occur

Simple evolving to GTC Complex evolving to GTC Simple evolving to complex evolving to GTC

Begin throughout both hemispheres, more or less simultaneouslyDo not have localized onsetReflect generalized disturbance of cortical function

AbsenceMyoclonic seizuresMyoclonic jerks, single or multipleTonic-clonic seizuresClonic seizuresTonic seizuresAtonic seizures (astatic)

Brief ( less than 30 seconds)With impairment of consciousnessNo auraNo post-ictal symptomsTypical EEG: generalized 3-4 Hz slow spike and wave dischargesFundamentally and pharmacologically unique from other seizures

Brief jerks of whole body or individual muscle groups, usually without impairment of consciousnessShock-like contractions are commonly precipitated by the patients falling asleep or awakening.May evolve into a tonic-clonic seizure

Most common and most dramaticGeneralized stiffening followed by clonic movements of the extremitiesAt the end of the seizure the patient frequently falls into deep sleep.

Sudden loss or diminution of muscle tone without apparent preceding myoclonic or tonic events, lasting for 1-2 seconds involving the head, trunk, jaw or limb musculature.

History of event (witnesses and personal recall)Medical history Risks for epileptogenesisGeneral physical examinationNeurologic examinationBlood tests (toxicology)Electroencephalography (EEG)Video TelemetryBrain scanning (MRI, CT-scan)Other investigations

No Routine Laboratory requests EEGNeuroimaging: MRI > CTOthers for specific indicationsCSF, head-up tilt table test and/or other cardiologic work-upendocrinological, metabolic, genetic work-upneuropsychological investigations

Diffrential Diagnosis for other Paroxysmal eventsDifferentiate Partial from Generalized SeizuresIdentification of certain Epilepsy Syndromes

Abnormal epileptiform activities- absent in 10-40 % of epileptic patients- present in 1-5 % of non epileptic people

Partial onset seizures especially in adultsFindings suggest of progressive neurologic disease Intractable seizuresSeizures increasing in frequency and intensity despite adequate treatment.

MRI- has higher sensitivity than CT Scan for structural epileptogenic foci.

Classification of epilepsies and epileptic syndromes based on clusters of signs and symptomsPredominant seizure type (EEG and clinical)Age of onsetFamily historyAnatomic correlationPrecipitating factorsSeverityChronicityPrognosis

Age specific epileptic disorderOccurs between 3-12 months, peaking at 4-7 monthsTriad: Infantile spasm, mental retardation and hypsarrythmia on EEGSpasms are brief but recurrentFlexor, extensor or mixedMost are associated with perinatal injury

Triad of seizure disorder, mental retardation and stypical petitmal on EEGSeizure types are variable and mixedTonic seizures are the most frequentForms a continuum with Infantile spasm.Seizures are usually resistant to treatment.

Common between 3- 13 years of age, peak at 9-10 yearsMale preponderanceOccur more frequently in sleepMay begin as focal siezures 2-3 hours after falling asleep and may generalizeAffected children are otherwise normalComplete remission bt 15-16 years of ageEEG : characteristic centro-temporal spikes

Onset between 6-7 years3 times more common in girlsSimple or complexSimple: blank staresComplex- associated with automatisms, clonic jerks or change in tone.Triggered by hyperventilation for no less than 3 minutes

Antiepileptic Drugs (AEDs)Avoidance of Predisposing FactorsVagus nerve stimulationEpilepsy Surgery

A seizure in association with a febrile illness with a temperature greater than 38.4 C ( although the fever may not be evident until after the seizure).Without evidence of any causative disease such as CNS infection, metabolic abnormality, intoxication, etc., in children older than 1 month of age without prior afebrile seizures.

Simple:ShortGeneralizedOccurs only once in a febrile illness.Complex:Prolonged (>15mins)FocalRecurrent within a 24 hour period.

About 2-3 % children worldwide will experience at least 1 febrile seizure.

1/3 of them will have a second attack.

of those who have had a second attack will have a third episode.

< 9 % altogether will experience more than 3 episodes.

More than 3 is already considered atypical and requires further investigation.

Complex febrile seizures

Child is neurologically impaired ( e.x. CP or has developmental delay.

Multiple risk factors: highest risk of recurrence. - > 2 risk factors : > 30 % risk of recurrence - 3 or more risk factors: > 60 % risk

Family history for febrile seizures.Age younger than 18 monthsThe lower the maximum temperature at occurrence the higher the risk.The shorter duration or recognized fever the higher the risk.

American Academy of Pediatrics recommendations for Lumbar Puncture:A must for children under 12 months.Strongly recommended for children between 12-18 months.Not necessary in a child > 18 months.First complex febrile seizures and or persistent lethargy.Strongly recommended for children who have received prior antibiotic therapy.

3 Medications have been found effective in preventing recurrences: Diazepam, Phenobarbital and Valproic acid

Most recommended: Intermittent diazepam treatment at 0.5 mg/k per rectum every 12 hours or 0.2 mg/k per orem every 8 hours during the febrile illness.

Most children however require no treatment considering the benign nature of the disease.More important is educating and counselling parents and caregivers of children with FS.Control fever which is the trigger for the seizure

The risk of death , mental retardation and cerebral palsy ( motor deficits) is no different from that of the general population who do not experience febrile seizures.

No difference were seen in the IQ scores and performance on the Wide range Achievement Tests between children with and without febrile seizures.

Risk of epilepsy ranges from 2- 10% in the presence of the following risk factors:1. The child is neurologically impaired prior to the seizure.2. Positive family history for epilepsy.3. Complex febrile seizures.

Risk of epilepsy after a first febrile seizure however is no different from that of the general population.