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Learning Objectives
Review basic definitions and classification of seizures Discuss the specific epilepsy syndrome of febrile seizures Review the neurologic exam in the context of the concept of anatomical localization of neurologic symptoms and deficits
The Basics
Definition of a Seizure sudden event caused by abrupt, uncontrolled, hypersynchronous discharges of neurons
More Definitions
Epilepsy condition characterized by the tendency for recurrent seizures that are unprovoked by an immediate cause Status epilepticus > 30 minutes long OR Back-to-back without return to baseline
SeizuresDifferential Dx
Loss of tone or consciousness
Abnormal heart rhythm Vasovagal syncope (classic fainting) Attention deficit disorder
Disorders of breathing
Breathholding spells Hyperventilation
SeizuresDifferential Dx (2)
Unusual movements
Benign sleep myoclonus Shuddering attacks Migraine (torticollis, ataxia, confusional) Tics Pseudoseizures
Night terrors Sleep walking Rocking Head banging Infantile masturbation
Behavioral or Self-stimulation
SeizuresEtiology
V(ascular): AVM, stroke, hemorrhage, HTN I(nfectious): meningitis, encephalitis T(raumatic) A(utoimmune): SLE, vasculitis, ADEM M(etabolic/toxic): electrolyte imbalance, tox I(diopathic): idiopathic epilepsy N(eoplastic) S(tructural): cortical malformation, prior stroke, other causes of CP S(yndrome): genetic disorder
Classification by Syndromes
Definition of a syndrome Cluster of symptoms, signs, and lab findings (EEG) Consistent Implies diagnosis, treatment, or prognosis There are syndromes specific to children
Febrile Seizures
Definition a seizure in association with a febrile illness in the absence of a CNS infection or acute electrolyte imbalance in children older than 1 month of age without prior afebrile seizures
Febrile Seizures
Epidemiology 2 to 5 % of children in the US Most common form of childhood seizures Peak at 18 months Simple = isolated, brief, generalized Complex = focal, multiple, or prolonged
st 1
Feb Sz
Febrile seizure in 1st/2nd degree relative Day care Neonatal nursery stay of >30 days Developmental delay Height of temperature
Evaluation in FS (2)
EEG Does NOT predict recurrence or epilepsy More likely to be abnormal in: Older children Neurodevelopmental abnormalities Family history of febrile seizures Complex febrile seizure
Febrile SeizuresTreatment
May reduce short-term recurrence But NO effect on occurrence of epilepsy AND the side effects ! The approach is based on epidemiological data that FS are benign, so Prevent status epilepticus
FSTreatment (2)
Antipyretics
No data that this reduces risk FS at onset of fever => highest recurrence
Benzodiazepines
Rectal diazepam (Valium) 2-5 y/o 0.5 mg/kg 6-11 y/o 0.3 mg/kg (round up to 2.5, 5, 10 mg) Oral diazepam 0.33 mg/kg q8 hrs x 48 hrs during illness
FSTreatment (3)
Daily medications NOT recommended
Phenobarbital Drowsiness, sleep problems, hyperactivity, IQ Valproic acid Hepatotoxicity Phenytoin and carbamazepine Not effective
SeizuresExam
Temp, BP, HC Skin (rash, neurocutaneous lesions), Neck Evidence of dysmorphisms, developmental delay Evidence of increased intracranial pressure Bulging anterior fontanelle Depressed level of consciousness Pupillary asymmetries Downgaze/sunsetting eyes Abducens palsy Papilledema
SeizuresExam (2)
Evidence of focal deficits
Weakness Intracranial lesion versus Todd paresis Tone or reflex asymmetry ? Chronic versus acute
SeizuresEvaluation
Lumbar puncture
Strongly consider in patient <12 mo with first febrile seizure Kernigs, Brudzinskis, nuchal rigidity low sensitivity (Thomas 2002) But usually more than isolated seizure History of irritability/lethargy Complex febrile seizure Slow postictal clearing of mentation
SeizuresEvaluation (2)
Neuroimaging
Emergent HCT Concern of acute focal lesion, mass effect I.e. persistent paresis or change in MS MRI (nonurgent) Focal sz Cognitive/motor impairment Focal EEG findings
EEG
Not if simple febrile seizure
General
Growth parameters (HC) Vital signs (temp, BP) Anterior fontanelle Flattening of the occiput Dysmorphic features Cardiac abnormalities Hepatosplenomegaly Cutaneous lesions
Mental Status
Change in mental status = brain is not working correctly Level of consciousness
Lethargy Stupor Coma
Cranial Nerves
= Brain stem or nerve CN2 = optic nerve
Funduscopic exam Visual fields/blink to threat Visual acuity/color vision
CN7 = facial
Wide palpebral fissure and flat nasolabial fold Both upper and lower face = LMN Only lower face weak = UMN
CN12 = hypoglossal
Tongue in cheek
Motor
Hypotonia = LMN or UMN, cerebellum Hypertonia = UMN lesion, basal ganglia Bulk/Fasciculations Tone
Resistance to passive ROM Traction response, horizontal/vertical suspension
Power
0 to 5 grading scale Techniques to bring out asymmetry
Pronator drift, finger tapping, gait
Gait
Motor cortex, corticospinal tracts, basal ganglia, cerebellum, vestibular system, nerves, muscles, vision, proprioception
Good screening test Natural gait Toe walk, heel walk, tandem walk Romberg (proprioception, vestibular) Sit to stand
Coordination
Limb ataxia = cerebellar hemispheres Gait ataxia = midline cerebellum
Finger-to-nose testing/reaching for toys Rapid rhythmic alternating movements Titubation (truncal ataxia)
Reflexes
Hyperreflexia = UMN lesion Hyporeflexia = LMN lesion
0 to 5+ grading scale Babinskis sign = UMN lesion Correspond to spinal roots Primitive reflexes
Sensation
Stocking-glove = nerve Vibration/proprioception = dorsal columns Pain/temp = spinothalamic tracts Extinction = cortex
http://medstat.med.utah.edu/pedineurologicexam/home_exam.html
Bibliography
Baumann RJ and Duffner PK. Treatment of children with simple febrile seizures: The AAP practice parameter. Pediatr Neurol 2000;23:11-17. Hirtz D et al. Practice parameter:evaluating a first nonfebrile seizure in children. Neurology 2000;55:616. Knudsen FU. Febrile seizures: Treatment and prognosis. Epilepsia 2000;41:2-9. Prensky AL. An approach to the child with paroxysmal phenomena with emphasis on nonepileptic disorders. In: Pellock JM, ed. Pediatric epilepsy diagnosis and therapy. New York: Demos Medical Publishing, 2001:97.
Bibliography
Provisional committee on quality improvement, subcommittee on febrile seizures. Practice parameter: the neurodiagnostic evaluation of the child with a first simple febrile seizure. Pediatrics 1996;97:769. Shinnar S and Glauser TA. Febrile seizures. J Child Neurol 2002;17:S44-52. Thomas KE et al. The diagnostic accuracy of Kernigs sign, Brudzinskis sign, and nuchal rigidity in adults with suspected meningitis. Clin Inf Dis 2002;35:46. Warden CR et al. Evaluation and management of febrile seizures in the out-of-hospital and emergency department settings. Ann Emerg Med 2003;41:215.