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SEIZURES, BRAIN DEVELOPMENTAND THEIR CONSEQUECES
Agus SoedomoDepartment Of Neurology Faculty Of Medicine Sebelas
Maret University / Dr. Moewardi General HospitalSurakarta
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Outline
Introduction Definition Etiology Pathogenesis Consequence / Influences Tackling / Prevention Summary
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Introduction Seizures occur in 1-5% of infants Seizures are triggered by an acute illness Seizure in the new born signal brain pathology Neonates seizures sign of acute neonatal
encephalopathy major risk factor for death and subsequent neurologic disability
Neurologist & neonatologist face a number in resolved facts & some controversies : define, monitor, treat seizures,& consequences
INFANT : neonates seizures – febrile seizures & status epilepticus
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Seizures and Epilepsy
Secondary•Symptomatic•Partial •Age disease related
Primary•Idiopathic •Partial General•Age Related
Transient•Symptomatic•Metabolic•Toxic
Non recurrent Recurrent ( Epilepsy )
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Definition
Definition of seizures Time limited paroxysmal, that result from
sudden, temporary change in brain dysfunction caused by abnormal, rhythmic, involuntary neuronal discharge (Clancy&Geyer, 2010)
Seizures are usually unpredictable Seizures usually brief (<5 minutes) self
terminating or stop spontaneously Convulsion ictus, event, spell, attack, fit
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Definition of Epilepsy
A disease as paroxysmal of cerebral dysfunction, characterized by spontaneous recurrence of unprovoked seizures ( at least 2 time per year ), ILAE, 1993
Seizures are symptoms, while epilepsy is a disease
Epilepsy is seizures disorderEpilepsy is a syndrome disease
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Each Epilepsy Syndrome is Determine Based on :
Type of seizureAge at seizures onsetFamily historyPhysical examinationEEG findingsNeuroimaging findings
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Definition of Febrile Seizures
A simple febrile seizure is generalized seizure occurring in infant or child between age of six months and five years, lasting less than 15 minutes and occurring only once in 24 hours. The child should not have an intracranial infection or a severe metabolic disturbances ( American Academy of Pediatrics Practice Parameter, 1999)
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A seizure occurring in childhood after one month of age, associated with a febrile illness not caused by an infection of central nervous system, without previous neonatal seizures or previous unprovoked seizures and not meeting criteria for other acute symptomatic seizures ( ILAE, 1993 )
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Three Critical Element of Febrile Seizures
Age of first seizures onsetTemperature of feverType seizures
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Neonatal Seizures
Under recognized Especially in sick neonates Often difficult to treat Manifestation of underlying neurological
conditions Most common caused by HIE : 50 – 60%
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Epidemiology Seizures are common in human Incidence ± 80 / 100.000 population Overall risk of epilepsy of 1% - 3% 3% - 4% at least one FS before 7 years Incidence FS depend of regional variation
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Cumulative Incidence of FS
United State : 2 – 5%South America : 2 – 5%Western Europe : 2 – 5%India : 5 – 10%Japan : 8,8%Guam : 14%( Hauser WA at Liu at al, 2010 )
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Prevalence of Neonates Seizure (Jkt)
RS Ciptomangunkusuma : 0,9%RS Harapan Kita : 0,3%RS Padmawati : 0,3%
Daisy et al, 2006
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EtiologyToxic / metabolic cause of seizures
Drug intoxication Drug withdrawal Electrolyte Heavy metals : lead and mercury Hyperosmolarity Hypoxia
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Causes of Fever in Febrile Seizures
Upper Respiratory Tract Infection : 38%Otitis Media : 23%Pneumonia :15%Gastroenteritis : 7%Roseola Infantum : 5%Non Infectious Illness : 12%
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Genetic Causes of Epilepsy
Aminoacidurias Channelopathies Lisosomal Storage Disease Phakomatosis Phenylketonuria Sturge Weber Syndrome
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Pathogenesis
Seizure arise secondary to a number etiologiesIdiopathicCryptogeneticSymptomatic
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Idiopathic
No apparent causeNo brain lesionPresumably - genetic alterations in brain
excitabilityKnowledge about the cause of epilepsy
increase the number of idiopathic cases will diminished
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Cryptogenic
Cases of epilepsy where the cause is unknown, but lesion & dysfunction pathogenesis are presumed
The lesion of temporal lobe epilepsy is mesial temporal sclerosis but the cause of the lesion is unknown
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Symptomatic
Cases of epilepsy in known which the disorder is due to a cause some but not all, symptomatic cause are also lesional, meaning that an identified structural brain abnormality or lesion is present
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TraumaEarly Post Traumatic Seizures :Intracranial hemorrhageFocal neurological deficitsPost traumatic amnesia > 24 hoursLinier skull fracturesLate post traumatic seizuresSome as above, but :Depressed skull fracturesInjury after age 16 years
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Congenital Malformations
Structural anomaliesGenetic cause of epilepsy ( table )Not associated with structural
malformations
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Infection
Meningitis, encephalitis feverBacterial abscess formationsHSV, seizures & catastrophicCMV, various viral, fungal & toxoplasmosis
Developing seizures
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Cerebral ischemiaCommon cause of seizures in the neonates
but uncommon in older pediatric populationsTumor slow growing seizures
Supratentorial more frequently than cerebellar or brain stem tumor
Toxic metabolic Table The derengement can cause seizures can
worsen pre-existing epilepsy
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The Pathophysiology of Febrile Seizure Unknowns
Possible three pictures interact :Immature brainFeverGenetic predisposition
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Consequences / InfluencesDirect effect of seizures in human brain
are difficult to detectRecently :
Animal studiesNeuroimaging examinationAmplitude integrated EEG or video
EEG monitoring
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Influence of Neonatal Seizures
Recurrent neonatal seizures reduced cell number, but not causing cell death
Recurrent seizures during early life pronounced effect on brain development are different from those occurring in mature brain
Brain of neonatal seizures are smallerThe long term functional consequences can
be detrimental
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Influence of Febrile Seizures
Recurrent febrile seizuresRecurrent later epilepsy
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Risk Factors for Recurrent Febrile Seizures
Young age of onset, the earlier, the greater
Relative low fever, the lower, the greater
Family history : first degree relativeDuration between fever onset &
seizure onset, the shorter, the greater
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Risk Factors for Later Epilepsy
Abnormal neurological or development status prior to onset
Family history of a febrile seizuresComplex febrile seizuresOnset FS after the age of 5 years no risk15% of children with epilepsy have one or
more preceding FSLess 7% FS developed epilepsyThe risk were higher : family history of
epilepsy, cerebral palsy, or low APGAR score
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Tackling / PreventionNeonatal seizures and complex febrile seizures
may have a global effect on brain development, especially in immature brain
Neonatal seizure must early detect and be able effective therapy especially for underlying etiologies
Febrile seizure are usually brief and self limited but if the convulsion is prolonged, airway & oxygenation should be kept
After resolution of neonatal seizures still be needed less frequent and shorter phenobarbital treatment, although there remains considerable variation in practice
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SummarySeizure in infant : neonatal seizures, febrile seizures
and status epilepticusSeizures are symptom, while epilepsy is a diseaseIncidence FS depend on regional variationEtiologies seizures : toxic / metabolic, and genetic
causesPathogenesis is divided into : idiopathic,
symptomatic, and cryptogenicConsequence of seizures are detected by animal
study, neuroimaging examination and video EEG monitoring
Neonatal seizure and complex febrile seizure may have a global effect on brain development
Neonatal seizures must early detected and treated
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