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what Qs need to be asked in hx of funny turn?
- consciousness: loss, awareness, altered
- abnormal movements: limbs, face
- altered tone
- altered colour
- eye movements
- sphincter control
- trigger factor - flashing light
- birth, development
- recent head injury
- FH: epilepsy, febrile convulsions
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what is a seizure?
transient episode of abnormal and excessive neuronal activity in the brain
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what is epilepsy?
tendency to recurrent seizures
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what is the differential diagnosis of a seizure in an infant?
- jitteriness
- benign myoclonus
- apnoeas
- GORD
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what is the differential diagnosis of a seizure in a toddler?
- breath holding attack
- reflex anoxic seizure
- rigors
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what is the differential diagnosis of a seizure in a child?
- vaso vagal syncope
- tics
- night terror
- day dreaming
- migraine
- panic attack, tantrum
- BPPV
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what is a breath holding attack precipitated by?
anger or frustration
-
what is a breath holding attack - what happens?
scream - hold breath in expiration - blue - pale - limp
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what is the recovery of a breath holding attack like?
- rapid
- spontaneous recovery
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what is a reflex anoxic seizure precipitated by?
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what happens in a reflex anoxic seizure?
- stimulus - stop breathing - pale - LOC syncope due 2ry to vagal induced BRADYCARDIA
- hypoxia can induce tonic clonic seizure
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what is recovery of reflex anoxic seizure like?
rapid recovery
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what are the features of BPPV?
- vertigo
- nystagmus
- ataxia - unsteady, falling
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what is BPPV due to?
viral labyrinthitis
-
what type of seizures are febrile seizures?
generalised tonic clonic seizure
-
what must be ruled out in all children with fever and seizure?
-
what are the features of generalised tonic clonic seizure?
- tonic phase of rigidity
- loss of posture
- then clonic movements of all 4 limbs
- LOC
-
how long does generalised tonic clonic seizure last?
2-20 minutes
-
what is the recovery of generalised TC seizure like?
post ictal drowsiness
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what age do absence seizures affect children?
4-12y
-
does absence affect girls or boys more?
girls
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how do absence seizures affect development?
- no effect
- may interfere with schooling
-
what are features of absence seizure?
- brief unawareness lasting few seconds
- no loss of posture
- may stare momentarily, stop moving, eyelid twitch
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how long do absence seizures last for?
30secs max
-
how long does it take to recover from absence seizure?
immediate
-
what is absence seizure associated with?
- AUTOMATISMS
- blinking
- lip smaking
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are absence seizures partial or generalised? what were old name for them?
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what is typical EEG of absence seizure?
- generalised bilaterally synchronous
- 3 per second spike and wave discharge
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what can absence seizures be induced by?
hyperventilation
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what is the drug of first choice for absence seizures?
- sodium valproate
- (2nd = ethosuximide)
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what is the prognosis of absence seizures?
- good
- 95% remission in adolescence
-
what age do absence seizures affect children?
4-12 years old
-
what age does juvenile myoclonic epilepsy affect children?
adolescent - adult
-
what is juvenile myoclonic epilepsy?
myoclonic seizures
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what is typical history of JME?
throwing drinks or cereal about in the morning as myoclonus occurs at this time
-
what is prognosis of JME?
- lifelong
- but good response to Rx
-
what are the 3 main focal epilepsy syndromes in children?
- BCECTS: benign childhood epilepsy with centrotemporal spikes
- benign occipital epilepsy
-
what age does BCECTS aka rolandic epilepsy affect?
4-10yo
-
what type of seizure do you get with BCECTS?
- tonic clonic
- or
- simple partial
-
what time of day does BCECTS occur?
sleep
-
what does the person experience during BCECTS?
- abnormal feeling in tongue - tingling
- distortion of face (supplied by rolandic area of brain)
- can have speech arrest
-
what is more common BCECTS or absence?
BCECTS - 15% of all childhood epilepsies
-
what does EEG of BCECTS look like?
focal sharp waves from rolandic or centrotemporal area
-
how does BCECTS affect someone?
- it is benign
- but can affect daily life
-
what is prognosis of BCECTS?
- good
- almost all remit in adolescence
-
what is a partial seizure?
involvement of only part of body
-
what are partial seizures associated with?
aura
-
what is it called when partial seizure then spreads to involve whole body?
secondary generalised epilepsy
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what is the difference between a simple and complex partial seizure?
-
what are the features of frontal seizures?
- motor cortex
- clonic movements
-
what is a Jacksonian march?
clonic movements travel proximally
-
which is the most common type of epilepsy?
temporal lobe epilepsy
-
what are the features of TLE?
- aura with smell and taste abnormalities
- distortion of sound or shape
- lip smacking, plucking at clothes, automatisms after spread to pre-motor cortex
-
what does occipital seizures cause?
distortion of vision
-
what are feature of parietal lobe seizure?
- contralateral dysaesthesia - altered sensation
- or distorted body image
-
which type of seizures require brain scans?
children with partial seizures
-
which part of the body should always be examined in children with recurrent seizures? why?
- skin
- wood's light examination - ashleaf patch hypopig (tuberous sclerosis)
- neurocutaneous syndromes
-
what are indications for neuroimaging in epilepsy?
- partial seizures
- intractable, difficult to control seizures
- focal neurological deficit
- neurocutaneous or neurodegenerative syndrome
- child <2yo with non febrile convulsions
-
what age do children get west syndrome?
4-6 months (infantile)
-
what is West syndrome? characterised by?
- infantile spasms
- salaam attacks - violent flexor spasm of head, trunk and limbs followed by extension of arms
-
what are infantile spasms misdiagnosed as?
colic
-
what cause west syndrome?
2/3 may have underlying neurological cause - tuberous sclerosis or perinatal HIE
-
what does ECG of west syndrome look like?
hypsarrhythmia - chaotic pattern of large amplitude slow waves with spikes and sharp waves
-
are most causes of west syndrome idiopathic or symptomatic?
- symptomatic
- tuberous sclerosis
- perinatal HIE
-
what is Rx of west syndrome?
ACTH
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what is Rx of west syndrome if assoc with tuberous sclerosis?
viGABAtrin if associated with tuberous sclerosis (inhibits GABA)
-
what SE is vigabatrin associated with?
permanent visual field defects
-
what is prognosis of west syndrome?
- poor
- most have LD and epilepsy later
-
what age does lennox gastaut syndrome affect?
1-3yo
-
what type of seizure occurs in LG?
- multiple seizure types
- astatic - drop attacks, atypical absence, tonic seizure
-
what may a child with LG have in PMH?
infantile spasms
-
what are other features of LG?
neurodevelopment arrest or regression
-
what is prognosis of LG?
poor
-
what special precautions must be taken with children with epilepsy?
- certain activities
- swimming
- bathing
- climbing
- cycling - helmet at all times, avoid traffic
-
what is the recommended first line Rx for generalised epilepsy?
sodium valproate
-
what is the recommended first line Rx for partial epilepsy?
carbamazepine
-
what is the most common cause of seizures in childhood?
febrile seizures
-
what age do febrile seizures occur?
6months to 6 years
-
what is a febrile seizure?
- seizure associated with fever
- in absence of intracranial infection (meningitis encephalitis)
- or an identifiable neurological disorder
-
what % of children get febrile seizures?
3%
-
what kind of predisposition may there be to febrile seizures?
familial
-
when do febrile seizure occur?
when body temperature rises rapidly
-
how long does febrile seizure last and what type of seizure is it?
- brief 1-2 minutes
- generalised tonic clonic
-
what are the clinical features of a febrile seizure?
- child noted to suddenly go stiff
- eyes stare ahead or roll up
- then shaking movements of all 4 limbs
- 1-2 mins
-
what Qs do you need to ask the parents?
- fever
- duration
- focal elements
- happened before
- FH
-
what is the differential diagnosis?
- rigors: v brief tremulous movements of limbs occurring with high fever - UTI
- meningitis or encephalitis
-
what may examination of the child reveal?
- source of infection causing fever
- otitis media
- pneumonia
- UTI
- tonsillitis
-
what are features O/E towards meningitis?
identify features which may raise suspicion of meningitis - rash, level of consciousness, meningeal irritation eg neck stiffness, tense/bulging anterior fontanelle
-
which Ix is needed in children <18/12 with febrile seizure?
lumbar puncture to exclude meningitis
-
if convulsion is prolonged what is Rx?
terminate with rectal diazepam after ensuring blood glucose checked with BM stick to exclude hypoglycaemia
-
what is management of febrile seizure?
- identify infection: FBC, blood culture, urine microscopy, CXR, LP
- keep patient cool with antipyretic and tepid sponging
- terminate prolonged convulsion with rectal diazepam
- antibiotics if bacterial infection has been identified
- parental education
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what is the recurrence risk of febrile seizures?
30%
-
parents: will febrile seizure happen again?
about a third get recurrent
-
what makes recurrence more likely?
- if first seizure occurs under age of 18 months
- or if FH
-
how can further febrile seizure be prevented?
during febrile illnesses, child kept cool with antipyretics, removal of clothing, tepid sponging
-
what should i do if another convulsion occurs?
- child in recovery position
- rectal diazepam if seizure is >5mins
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is febrile seizures epilepsy?
febrile seizures are not classified as epilepsy
-
what % of children with febrile seizure go on to develop epilepsy (afebrile recurrent seizures) in later childhood?
3%
-
what are the 5 risk factors for epilepsy in someone with febrile seizures?
- focal seizures
- prolonged > 15 mins
- recurrent seizures in same illness
- first degree relative with epilepsy
- neurological abnormality
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