FEBRILE FITS AND EPILEPSY

SEIZURE
A sudden disruption of the brain's normal electrical activity accompanied by altered consciousness and/or other neurological and behavioral manifestations.

FEBRILE FITS
Febrile fits (F.C.) are defined as fits occurring in association with fever in children between 3 months and 6 years of age, in whom there is no evidence of intracranial pathology or metabolic derangement that could be the cause of the fit. Febrile fits, febrile seizure and febrile convulsions are synonymous terms.
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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

Simple Febrile Fits Complex Febrile Fits

Duration short, < 15 minutes Generalised fits that do not occur more than once in a febrile episode. Duration prolonged, > 15 minutes Unilateral or recur within a single febrile episode Residual neurological deficit postictally e.g: Todds paralysis
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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

Investigation
FBC, lumbar puncture, urinalysis, chest x-ray, blood culture and many others will be done depend on clinical assessment of the individual case. An LP is not recommended in children considered to be haemodynamically unstable.Strongly consider LP if the child is less than 12 months and consider LP if the child is less than 18 months Measurement of serum calcium and electrolytes are rarely necessary. EEG is not indicated even for those with multiple recurrences or with complex febrile convulsions.
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Management
Reasons for admission. 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 Place child in the left lateral position with head lower than the body Wipe off vomitus or secretion Do not insert any object to the mouth Do not give drugs or fluid orally. Diazepam (0.5mg/kg)

If not in a convulsive state:

Tepid sponging Anti-pyretic (PCM rectal or syrup- 15 mg/kg/6hourly) Look for cause if initial infection
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Prognosis
Are benign event with excellent prognosis 3-4% of population have febrile convulsions 30% recurrence after the 1st attack 48% recurrence after the 2nd attack 2-7% develop subsequent afebrile seizure or epilepsy No evidence of permanent neurological deficit. No deaths reported from simple febrile convulsions.
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Epilepsy
Epilepsy recurrent usually unprovoked epileptic seizures that result from excessive synchronous and abnormal firing patterns of the cerebral cortical neurons. Epileptic seizure paroxysmal stereotyped disturbances of consciousness, motor function, sensation, emotion, behavior or perception than results from cortical neuronal discharge.
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 Epileptic syndrome A complex of signs and symptoms that define a unique epilepsy condition. Syndromes are classified on the basis of seizure type, clinical context, EEG features and neuroimaging.

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Epidemiology
5 per 1000 school aged children
10% are severely affected.

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Causes of epilepsy

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Generalized vs Partial Epilepsy

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 or may not be associated change in consciousness or more generalized motor jerking
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Partial seizures

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Partial seizures with secondary generalised

Focal seizure manifest clinically or on an ictal EEG followed by generalised tonic-clonic seizures (with loss of consciousness)

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Generalised Epilepsy
Absence seizures Myoclonic seizures Tonic seizures Tonic-clonic seizures Atonic seizures

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Absence seizures
Transient loss of consciousness, with an abrupt onset and termination, unaccompanied by motor phenomena 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 precipitated by hyperventilation. Occurs for a few seconds (< 30s) Child does not recall seizure. EEG - 3Hz spike-wave activity with frontal accentuation.
A bsence Seizure.flv

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EEG

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Myoclonic seizures
Brief often repetitive, jerking movement of the limbs, neck and trunk. 10-20 years old, (Females: Males = 2:1) Myoclonic predominates but absences and tonic-clonic seizures also occur

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Tonic-clonic seizures
Rhythmical contraction of muscle groups following the tonic phase In the rigid tonic phase, children may fall to the ground, 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 saliva may accumulate in the mouth May be biting of the tongue and incontinence of urine. Lasts a few seconds to minutes, followed by unconscious or deep sleep for several hours.
Tonic C lonic Seizure.flv

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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 of the 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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Epileptic Syndrome

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Common epileptic syndrome

Infantile spasm (West syndrome) Lennox-Gastaut syndrome Juvenile Myoclonic Epilepsy Childhood absence epilepsy Benign rolandic epilepsy

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INFANTILE SPASM
2 month-2 years of age Sudden truncal flexor spasm with arm and head extension or adduction (Morolike) Occasional truncal entensor spasm, occur in cluster typically upon awakening or entering sleep. Poor prognosis for neurodevelopmental outcome. Associated with tuberous scerosis, Down syndrome, brain injury or malformation. EEG- hypsarrthymia disorganised high voltage pattern (spikes, slow waves,periods of attenuation)

LENNOX-GASTAUT SYNDROME
Any age > 2 years of age Mixed seizures pattern with atonic, myoclonic, atypical absence and generalized tonic-clonic convulsions. Developmental arrest or regression & behavior disorder. Poor prognosis EEG-1-2.5 Hz generalized, anteriorly predominat spike and slow wave discharges

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BENIGN ROLANDIC EPILEPSY

Common 5-15 years old Boys > girls Partial or generalized convulsions in sleep, rarely occur during wakefulness Seizure stop by mid-teens & may not require treatment EEG - Interictal spikes discharges in centrotemporal (rolandic) regions bilaterally independently, augmented with sleep.

JUVENILE MYOCLONIC EPILEPSY

10-15 years of age Mixed-seizures pattern with combinations of myoclonic, absence and generalized tonic-clonic convulsions. Myoclonic seizures typical after awakening EEG interictal fast-spike wave 4-6 Hz poly spike discharge.

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Differential diagnosis of epilepsy

NEONATES AND INFANTS
Jitteriness Benign myoclonus Apnoea GERD Shuddering attacks Benign paroxysmal torticollis hyperekplexia YOUNG CHILDREN Breath holding spells Reflex anoxic seizures Parasomnia Benign paroxysmal vertigo Tics and ritualistic movements CHILDHOOD AND ADOLESCENT Vasovagal syncope Migraine Narcolepsy Panic attacks Pseudoseizures

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Diagnosis
History taking is the main diagnostic tools
Parents can be asked to record the seizures with camera.

Investigation procedures are performed to support the diagnosis and identify the etiologies if provoked seizures. EEG
All patients with epilepsy will require EEG. Video-EEG is the most useful tools. diagnosis does not depend on it

MRI of brain Other metabolic and genetic

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Treatment for epilepsy

Anticonvulsant therapy Surgical management Nonpharmacologic management
Ketogenic diet Vagal nerve stimulation

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Anticonvulsant therapy
Recommended 2 episodes Attempt to classify the seizure type(s) and epileptic syndrome. Monotheraphy is recommended. Increase dose gradually until the desired effect is achieved Add 2nd drug if 1st has failed, optimize second drug and try to withdraw 1st drug. ( alternative monotherapy) Rational combination (2 or maximum 3 drugs with different mechanisms)-consider drug interaction and side effects. Monitor drug levels to check compliance Withdrawal after 2 years of being seizure free
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Anticonvulsant by seizure type

SEIZURE TYPE PARTIAL SEIZURES Simple partial Complex partial Secondarily generalised GENERALISED SEIZURES Tonic clonic Clonic valproate Lamotrigine Topiramate, clonazepam, carbamazepine, phenytoin, phenobarbitone valproate valproate Lamotrigine, clonazepam Lamotrigine Topiramate, clonazepam Valproate, clonazepam Topiramate, clonazepam, phenobarbitone, piracetam, levetiracetam, lamotrigine Nitrazepam, clonazepam, 35 valproate 1ST LINE carbamazepine valproate 2ND LINE Lamotrigine Topiramate Levetiracetam, phenytoin, phenobarbitone, clonazepam

Absence Atypical absence Atonic,clonic Myoclonic

Infantile spasms

ACTH, prednisolone, vigabatrin

Surgical management
2 major kinds of brain surgery in epilepsy
Palliative
Anterior callosotomy- still performed but rare

Curative
Lobectomy Lesionectomy

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Nonpharmacologic management
KETOGENIC DIET Primarily used in childhood epilepsy. Mechanism- unknown. The high-fat, low-protein, no-carbohydrate diet mimics some effects of starvation that seem to inhibit seizures. Appears to reduce seizure frequency in 1/3 of patients and should be offered to child after 2-3 AED have been used unsuccesfully. 37

VAGAL NERVE STIMULATION The mechanism of antiepileptic effect is unknown. About 40% of patients may relieve atleast 50% of seizure reduction.

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Status Epilepticus
Prolonged episode of seizure activity (> 30 minutes) or an intermittent seizures without regaining full consciousness in between for > 30 minutes Refractory status epilepticus
Seizures lasting > 60 minutes or not responding to adequate doses of benzodiazepine and 2nd line medication.

Its a medical emergency !!

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