I have nothing to disclose Pediatric Seizures Kimberly S. Jones, MD Assistant Professor of Child Neurology University of Kentucky April 22, 2016 Generalized vs Partial Seizures Generalized seizures affect the entire brain at the same time Absence seizures (Petit mal) Febrile seizures Generalized tonic clonic seizures (Grand mal) Partial seizures start in a focus and can spread to affect a larger area of the brain Simple partial seizures Complex partial seizures CPSz with secondary generalization Generalized Seizures Caused by channelopathies problem with sodium or potassium channels, etc. Usually have a genetic basis Febrile seizures Generalized tonic clonic seizures Absence seizures Myoclonic seizures Febrile Seizures Age 6 months 5 years Genetic basis Simple Febrile Seizures Less than 15 minutes Generalized tonic clonic seizure One in 24 hours Complex Febrile Seizures Still benign disorder Sometimes difficult to sort out from epilepsy Differential Diagnosis ENCEPHALITIS (or other CNS infection) Underlying seizure disorder Febrile seizure Key Features Normally developing child? Do they wake up after the seizure? Only 2% of kids with febrile seizures have a nonfebrile seizure by 7 yo 1
Treatment Reassurance febrile seizures are benign Antipyretics don t help much The side effects of anticonvulsant medication outweigh benefit Rectal Valium at home in case of future prolonged seizure Generalized Tonic Clonic Seizures Grand Mal Seizure Often part of an epilepsy syndrome Juvenile myoclonic epilepsy Lennox Gastaut Syndrome Longer than 15 minutes = status epilepticus Turn patient on their side and keep safe Most stop in less than 3 minutes Juvenile Myoclonic Epilepsy Accounts for about 10% of epilepsy cases Onset of GTC seizures 13-30 May have had absence seizures when they were younger Ask about Myoclonic Seizures!!! VIDEO Absence Seizures Most staring spells are NOT seizures Onset usually age 5-8, normal children Typically last 5-10 seconds No post ictal phase Can occur up to 100 times daily Behavior arrest, unconscious staring Often with rhythmic movements of eyelids or subtle head bobbing 50% will have at least 1 GTC seizure Distinguishing Features TV staring spells DON T COUNT Many seizures every day Occur anywhere (not just at school) Unconscious cannot be interrupted No memory of the events Stereotyped events (same every time) EEG pattern 3 Hz spike and wave interictal Myoclonic Seizures In general, myoclonic epilepsy is more severe and has a worse prognosis Infantile spasms Benign myoclonic epilepsy Severe myoclonic epilepsy Lennox-Gastaut Syndrome 2
Infantile Spasms Onset is usually around 6 months of age Underlying cause found in 75% Tuberous sclerosis in 20% HIE Brain malformations HSV or CMV, etc Typically occur in clusters shortly after awakening Can be flexor or extensor Often misdiagnosed!! Reflux Colic Startle Treatment ACTH therapy difficult, high risk, $$$ Vagabatrin retinal damage, better data for children with Tuberous Sclerosis Prognosis Very poor, especially if cause is known Occasionally there is spontaneous remission, but rare Most children progress to have Lennox-Gastaut Syndrome Partial Seizures Focal lesion in the brain Can spread quickly and may be impossible to visibly distinguish from GTC seizure Complex Partial Seizures Most often arise from temporal lobe, but can be from any part of the cortex Impaired consciousness and amnesia of the event are key features Aura reported in less than 30% of children Nondescript unpleasant feeling Fear Stereotyped auditory or visual hallucination Abdominal discomfort or emesis Autotomatisms same with each seizure Facial grimacing or mouth movements Fumbling of hands Walking Rolandic Epilepsy Onset age 3-13, typically 7-8 yo Seizures typically stop by age 14 10% only have 1, 70% have infrequent seizures, 20% have frequent seizures Wakes child from sleep, usu in first 2 hrs Unilateral facial twitching, speech arrest and drooling, often spread to arm and leg, sometimes to GTC seizure Typical EEG pattern, even when awake Ask parents if child s Mouth was twisted? What Else Could It Be? Infant Apnea Reflux Breath holding spells Benign myoclonus of infancy Child over 2 Migraine esp paroxysmyl vertigo Night terrors Syncope Staring spell 3
Apnea 15 seconds Rare seizure manifestation Reflux accounts for apnea much more than seizures Premies have more apnea even when they reach 40 weeks gestational age Unusual after 52 weeks GA Breath Holding Spells Occur in 5% of children Cause immaturity of central autonomic regulation Genetic Cyanotic or pallid spells 80% start before 18 months Usu end by 4 yo, no later than 8 yo PROVOKING STIMULUS usu pain or anger/fear Spells longer than a few seconds commonly with tonic posturing and trembling, eyes roll up Child is often tired afterwards Night Terrors Onset by 6 yo, usu around 4 yo 2 hours after falling asleep Child awakens in a terrified state, doesn t recognize people, inconsolable Usu last 5-15 min, can be longer Goes back to sleep, no memory of event ent Usu have about 1 per week Commonly associated with sleep walking Lasts til adolescence, ½ stop by 8 yo Associated with sleep-disordered breathing Treatment: make them sleep more deeply Melatonin or Clonidine Syncope Common in 10-20 year olds Transitory decrease in cerebral blood flow Vasovagal reflex Valsalva Emotional response Standing up quickly Being hot Brushing hair in the morning Feels light headed, becomes pale, limply falls Stiffening and trembling are very common!! Work Up Acutely Transfer to Neurologist Any evidence of underlying cause Infectious symptoms Concern for metabolic disorder (abnormal labs) Multiple or escalating seizures First time Focal Seizure Status epilepticus (even if it has stopped) Child does not wake up Postictal state is common, but should get mostly back to normal in a couple hours New Onset Seizure 1/3 of people who have a seizure will never have another one OK to just wait for a second seizure IF Child is normal with normal development IF seizure was less than 10 min No focal features Advice for parents Turn child on their side Do not put anything in their mouth Look at the clock Call 911 4
EEG Inexpensive, noninvasive Very subjective Pediatric EEG is different please get the study somewhere they see a lot of kids Sedated EEGs are not very helpful Not the end-all be-all of epilepsy diagnosis Negative EEG does not necessarily rule out epilepsy CT Scan Rarely indicated for seizures Acute head trauma only!! If child wakes up quickly, NO CT High radiation dose Increases likelihood of future brain cancer Not appropriate study for epilepsy diagnosis MRI head w/wo per Epilepsy protocol Not indicated for generalized epilepsy Absence seizures EEG with generalized spike and wave pattern Any child with focal seizure should get an MRI Child with seizures and developmental delay warrants an MRI Sedation up until about 8 or 9 yo When to Refer Any child who has a seizure I won t do much for typical simple febrile seizures or first GTC seizure in a normal child 5