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Prepared by: Nurul Syazwani Ramli
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SEIZURE
A sudden disruption of the brain's
normal electrical activity accompanied
by altered consciousness and/or other
neurological and behavioralmanifestations.
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FEBRILE SEIZURE
Febrile fits, febrile seizure and febrile
convulsions are synonymous terms.
Febrile fits (F.C.) are defined as fits
occurring in association with fever inchildren between 6 months and 6 years
of age, in whom there is no evidence of
intracranial pathology or metabolicderangement that could be the cause of
the fit.
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Epidemiology
There is no comprehensive local
epidemiological data.
3-4% of children < 5 years experiencing
febrile fits (Western Europe)
Higher figures of up to 8% in Japan.
The single most common problem in
paediatric neurology
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Types of Febrile Fits
Duration short (< 15 minutes)
Generalised fits
do not recur during febrileepisode
Simple
FebrileFits
Duration prolonged (> 15 minutes) Focal features
> 1 seizure during the febrile episode
Residual neurological deficit post-ictally, such as Todds paralysis
ComplexFebrile
Fits
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Diagnosis
Diagnosis of febrile seizures is based on
history.
Also ask about possible ingestions of drug or
toxins
Physical examination to rule out of
meningitis or encephalitis
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Investigation
Blood counts, blood glucose, lumbar puncture,urinalysis, chest x-ray, blood culture etc dependon clinical assessment of the individual case.
Lumbar punctare must be done (unlesscontraindicated)
Measurement of serum calcium and electrolytesare rarely necessary.
EEG is not indicated even if multiplerecurrences or complex febrile convulsions.
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Management
Need for admission.
Not all children with febrile fits need to be
admitted. The main reasons for admission are:-
To exclude intracranial pathology especially infection
Fear of recurrent fits
To investigate and treat the cause of fever besides
meningitis or encephalitis.
To allay parental anxiety, especially if they are staying
far from the hospital.
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Management
if in a convulsive state:
Loosen clothing around neck
Wipe off vomitus
Diazepham (0.5mg/kg)
If not in a convulsive state (control fever): Tepid sponging
Anti-pyretic (PCM rectal or syrup- 15mg/kg/6hourly)
Look for cause if initial infection
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Prognosis
Benign events with excellent prognosis
3-4% of population have FC
30% recurrence after 1st attack
48% recurrence after 2nd attack
2-7% develop afebrile seizure orepilepsy
No evidence of permanent neurologicaldeficit.
No deaths reported from simple FC
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Epilepsy
* A neurological condition characterised by
recurrent unprovoked epileptic seizures.
An epileptic seizure is the clinical
manifestation of an abnormal andexcessive discharge of a set of neurons
in the brain
An epileptic syndrome are complexsigns and symptoms that define a
unique epilepsy condition.
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Epidemiology
5 per 1000 school aged children
10% are severely affected.
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Causes
Perinatal Conditions:
Cerebral
malformation
Intrauterine infection
Hypoxic-ischemic
Trauma
Hemorrhage
Infections:
Encephalitis
Meningitis
Brain abscess
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Causes
Metabolic Conditions Hypoglycemia
Hypocalcaemia
Hypomagnesaemia
Hyponatremia
Hypernatremia Storage diseases
Reye syndrome
Degenerative disorders
Porphyria
Pyridoxine dependencyand deficiency
Poisoning Lead
Cocaine
Drug toxicity
Drug withdrawal
NeurocutaneousSyndromes Tuberous sclerosis
Neurofibromatosis
Sturge-Weber syndrome
Klippel-Trenaunay-Weber syndrome
Linear sebaceous nevus
Incontinentia pigmenti
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Causes
Systemic Disorders
Vasculitis (CNS or
systemic)
SLE
Hypertensive
encephalopathy
Renal failure
Hepatic
encephalopathy
Other
Trauma
Tumor
Febrile
Idiopathic
Familial
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Classification of Seizures
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Tonic Clonicgrand-mal or convulsion
Loss of consciousness,
stiffening of body then
jerking of limbs
Absencepetit mal or starting fit or
trance like state
Tonic or Atonicdrop attack
Abrupt fall, either with
stiffening (tonic) or with
loss of muscle tone (atonic
or astatic attacks)
MyoclonicSudden muscle jerks
Seizure Classification
Partialseizure activity starts in one area of the
brain
Generalizedseizure involves whole brain &
consciousness is affected
SimpleRetains awareness
ComplexAltered awareness and behavior
Secondary generalization(spreading from one area to the whole brain)
"jacksonian" seizure
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Generalized vs. Partial
Generalized Seizures- Always loss of consciousness
No warning
Symmetrical seizure
Bilateral synchronous seizure discharge on EEG
Partial Seizure- Begins in a relatively small group of
dysfunctional neurons in one of the cerebral
hemispheres. May have an aura which reflects site of origin
May/not- change in consciousness or more
generalized motor jerking
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Partial Seizures
Simple Partial Seizures The child will retain awareness with
consciousness unimpaired
Complex Partial Seizures Altered conscious state or confusion due to the
abnormal electrical discharge spreading from theoriginating site
Partial Seizures with SecondaryGeneralisation Focal seizure manifests clinically or on an ictal
EEG followed by a generalized Tonic-ClonicSeizure
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Generalised Epilepsies
Absence seizures Transient loss of consciousness, with an abrupt
onset and termination, unaccompanied by motorphenomena except for some flickering of the
eyelids and minor alteration in muscle tone. Onset 4-12 years old.
Absences may be typical (petit mal) or atypical
can often be precepitated by hyperventilation.
Occurs for a few seconds (< 30s) Child does not recall seizure.
EEG would not a 3Hz Spike and wave activity withfrontal accentuation.
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Absence Seizure.flv
http://localhost/var/www/apps/conversion/tmp/scratch_2/Absence%20Seizure.flv7/29/2019 Febrile Seizure and Epilepsy
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EEG
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Generalised Epilepsies
Myoclonic epilepsy (Juvenile Myoclonic
Epilepsy)
Brief often repeatitive, jerking movement of
the limbs, neck and trunk. 10-20years old, (Females: Males = 2:1)
Myoclonic predominates but absences and
tonic-clonic seizures also occur
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Generalised Epilepsies
Tonic-Clonic Seizure Rhythmical contraction of muscle groups following
the tonic phase
In the rigid tonic phase, children may fall to theground, sometimes injuring themselves.
Do not breath and become cyanosed. Followed by the clonic phase, with jerking of the
limbs.
Breathing is irregular, cyanosis persists and salivamay accumulate in the mouth
May be biting of the tongue and incontinence ofurine.
Lasts a few seconds to minutes, followed byunconscious or deep sleep for several hours.
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Tonic Clonic Seizure.flv
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Generalised Epilepsies
Atonic Seizures
Often combined with a myoclonic jerk
followed by a transient loss of muscle tone
causing a sudden fall to the floor or drop ofthe head.
1-2 years old, last 1-4seconds
Most frequent during awakening of falling
asleep.
Often have Mental Retardation or underlying
brain abnormalities
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Generalised Epilepsies
Infantile Spasms (West Syndrome) 4-6months
Violent flexor spasms of head, trunk and limbs,followed by extension of the arms (Salaam Spasms)
Last 1-2s, bursts of 20-30spasms, usually on waking 2/3 children are neurologically abnormal before onset
of seizures- development process further arrested
EEG- hypsarrthymia, a chaotic background of highvoltage dysrhymic slow-wave activity with sharp
components. 30-40% respond well to treatment
Loss of skills and later learning disability or epilepsy.
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Infantile spasms.flv
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Other epilepsies
Lennox-Gaustaut
1-3 years old
Multiple seizure types:
Myoclonic single jerk,
atonic drop attacks oratypical absences.
Developmental arrest
or regression &
behaviour disorder.
Poor prognosis
Benign rolandic
epilepsy of childhood
Common (5-10 yo)
Sleep: generalized
tonic-clonic
Day: distortion of face
and arm on one side +
abnormal feeling of
tounge Seizure stop by mid-
teens & may not
require treatment
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Differential Diagnosis
Neonates and
infants
Jitteriness
Benign myoclonus
Apnoea
Gastro-Oespophageal
reflux
Shuddering attacks
Benign paroxymaltorticollis
Hyperekplexia
Young children
Breath holding spells
Reflex anoxic seizures
Parasomnia
Benign paroxysmal
vertigo
Paroxysmal
choreoathertosis
Tics and ritualisticmovements
Rage attacks
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Differential Diagnosis
Childhood andAdolescents
Vasovagal syncope
Migraine
Narcolepsy
Panic attacks
pseudoseizures
Any Age
Drug-Induced
dystonia
Cardiac Dysrhythmias
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Investigations
EEG
- if normal, try barbiturate induced sleep,
sleep deprivation recording or 24 hour
monitoring. CT or MRI of brain indicated (< 5 years)
Blood electrolyte analysis
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Treatment for epilepsy
Medications
Surgery
Ketogenic Diet
Vagus Nerve Stimulation
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Medication
>2 episode
Attempt to classify the seizure type(s),monotheraphy is recommended. Increase dosegradually until the desired effect is achieved
Add 2nd drug if 1st has failed, optimize seconddrug and try to withdraw 1st drug.
Rational combination (2/3 with differentmechanisms)
Monitor drug levels to check compliance
Withdrawal after 2 years of being seizure free
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Surgical
Lobectomy and Cortical Resection
Hemispherectomy
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Ketogenic Diet
Primarily used in childhood epilepsy.
Mechanism- unknown.
The high-fat, low-protein, no-
carbohydrate diet mimics some effectsof starvation that seem to inhibitseizures.
The diet is very rigid and carefullycontrolled and must be supervised by aphysician -- sometimes in a hospitalsetting.
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Vagus Nerve Stimulation
Approved to treat partial seizures inpatients 12 years of age or older
stimulator is surgically implanted under theskin in the chest. The device is attached to awire that is tunneled under the skin andattached to the vagus nerve, which islocated in the left side of the neck
adjusted to automatically stimulate thevagus nerve from every few seconds toevery few minutes.
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Status Epilepticus
Prolonged episode of seizure activity
(>30 minutes) or an extended period of
recurrent seizures between which the
patient does not return toconsciousness.
Its a medical emergency !!
Can lead to hypoxia, brain damage anddeath
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Management of Status
EpilepticusABCs
ECG monitoring
Oxygen and pulse oximetry
IV access Immediate laboratory tests (electrolytes,
glucose..)
a rapid infusion of 5 mL/kg of 10% dextrose
Antiepileptic drug levels
Toxicologies
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