Febrile Seizures

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  • Febrile Seizures

    1. 1. Febrile Seizures Amy Kao, MD 2005-2006 Division of Pediatric Neurology Oregon Health & Science University Stirred, Not Shaken Getting Comfortable with Neurology
    2. 2. Learning Objectives <ul><li>Review basic definitions and classification of seizures </li></ul><ul><li>Discuss the specific epilepsy syndrome of febrile seizures </li></ul><ul><li>Review the neurologic exam in the context of the concept of anatomical localization of neurologic symptoms and deficits </li></ul>
    3. 3. The Basics <ul><li>Definition of a Seizure </li></ul><ul><ul><li>sudden event caused by abrupt, uncontrolled, hypersynchronous discharges of neurons </li></ul></ul>
    4. 4. More Definitions <ul><li>Epilepsy </li></ul><ul><ul><li>condition characterized by the tendency for recurrent seizures that are unprovoked by an immediate cause </li></ul></ul><ul><li>Status epilepticus </li></ul><ul><ul><li>> 30 minutes long OR </li></ul></ul><ul><ul><li>Back-to-back without return to baseline </li></ul></ul>
    5. 5. Seizures—Differential Dx <ul><li>Loss of tone or consciousness </li></ul><ul><ul><li>Abnormal heart rhythm </li></ul></ul><ul><ul><li>Vasovagal syncope (classic fainting) </li></ul></ul><ul><ul><li>Attention deficit disorder </li></ul></ul><ul><li>Disorders of breathing </li></ul><ul><ul><li>Breathholding spells </li></ul></ul><ul><ul><li>Hyperventilation </li></ul></ul><ul><li>Other medical disorders </li></ul><ul><ul><li>Hypoglycemia </li></ul></ul><ul><ul><li>Gastroesophageal reflux </li></ul></ul>
    6. 6. Seizures—Differential Dx (2) <ul><li>Unusual” movements </li></ul><ul><ul><li>Benign sleep myoclonus </li></ul></ul><ul><ul><li>Shuddering attacks </li></ul></ul><ul><ul><li>Migraine (torticollis, ataxia, confusional) </li></ul></ul><ul><ul><li>Tics </li></ul></ul><ul><ul><li>“ Pseudoseizures” </li></ul></ul><ul><li>Behavioral or Self-stimulation </li></ul><ul><ul><li>Night terrors </li></ul></ul><ul><ul><li>Sleep walking </li></ul></ul><ul><ul><li>Rocking </li></ul></ul><ul><ul><li>Head banging </li></ul></ul><ul><ul><li>Infantile masturbation </li></ul></ul>
    7. 7. Seizures—Etiology <ul><li>V (ascular): AVM, stroke, hemorrhage, HTN </li></ul><ul><li>I (nfectious): meningitis, encephalitis </li></ul><ul><li>T (raumatic) </li></ul><ul><li>A (utoimmune): SLE, vasculitis, ADEM </li></ul><ul><li>M (etabolic/toxic): electrolyte imbalance, tox </li></ul><ul><li>I (diopathic): “idiopathic epilepsy” </li></ul><ul><li>N (eoplastic) </li></ul><ul><li>S (tructural): cortical malformation, prior stroke, “other causes of CP” </li></ul><ul><li>S (yndrome): genetic disorder </li></ul>
    8. 8. Classification of Seizures By Onset <ul><li>Generalized </li></ul><ul><ul><li>Begins simultaneously in both hemispheres </li></ul></ul><ul><ul><li>Generalized-tonic-clonic = “grand-mal” </li></ul></ul><ul><ul><li>Absence = “petit-mal” </li></ul></ul><ul><ul><li>Myoclonic </li></ul></ul><ul><ul><li>Tonic </li></ul></ul><ul><ul><li>Atonic </li></ul></ul>
    9. 9. Classification by Onset, continued <ul><li>Partial (=Focal) </li></ul><ul><ul><li>Onset in a focal region of the brain </li></ul></ul><ul><ul><li>Simple partial </li></ul></ul><ul><ul><li>Complex partial </li></ul></ul><ul><ul><li>Secondarily generalized </li></ul></ul>
    10. 11. Classification of Seizures By Cause <ul><li>Acute Symptomatic </li></ul><ul><ul><li>Shortly after an acute insult </li></ul></ul><ul><ul><ul><li>Infection </li></ul></ul></ul><ul><ul><ul><li>Hypoglycemia, low sodium, low calcium </li></ul></ul></ul><ul><ul><ul><li>Head trauma </li></ul></ul></ul><ul><ul><ul><li>Toxic ingestion </li></ul></ul></ul>
    11. 12. Classification by Etiology, continued <ul><li>Remote Symptomatic </li></ul><ul><ul><li>Pre-existing brain abnormality or insult </li></ul></ul><ul><ul><ul><li>Brain injury (head trauma, low oxygen) </li></ul></ul></ul><ul><ul><ul><li>Meningitis </li></ul></ul></ul><ul><ul><ul><li>Stroke </li></ul></ul></ul><ul><ul><ul><li>Tumor </li></ul></ul></ul><ul><ul><ul><li>Developmental brain abnormality </li></ul></ul></ul>
    12. 13. Classification by Etiology, continued <ul><li>Idiopathic </li></ul><ul><ul><li>No history of preceding insult </li></ul></ul><ul><ul><li>Likely “genetic” component </li></ul></ul>
    13. 14. Classification by Syndromes <ul><li>Definition of a syndrome </li></ul><ul><ul><li>Cluster of symptoms, signs, and lab findings (EEG) </li></ul></ul><ul><ul><li>Consistent </li></ul></ul><ul><ul><li>Implies diagnosis, treatment, or prognosis </li></ul></ul><ul><li>There are syndromes specific to children </li></ul>
    14. 15. Febrile Seizures <ul><li>Definition </li></ul><ul><ul><li>“ 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” </li></ul></ul>
    15. 16. Febrile Seizures <ul><li>Epidemiology </li></ul><ul><ul><li>2 to 5 % of children in the US </li></ul></ul><ul><ul><li>Most common form of childhood seizures </li></ul></ul><ul><ul><li>Peak at 18 months </li></ul></ul><ul><ul><li>Simple = isolated, brief, generalized </li></ul></ul><ul><ul><li>Complex = focal, multiple, or prolonged </li></ul></ul>
    16. 17. Simple Febrile Seizures <ul><li>< 15 minutes </li></ul><ul><li>Generalized-tonic-clonic </li></ul><ul><li>Fever > 100.4 rectal to 101 F (38 to 38.4 C) </li></ul><ul><li>No recurrence in 24 hours </li></ul><ul><li>No post-ictal neuro abnormalities (e.g. Todd’s paresis) </li></ul><ul><li>Most common 6 months to 5 years </li></ul><ul><li>Normal development </li></ul><ul><li>No CNS infection or prior afebrile seizures </li></ul>
    17. 18. Risk Factors for 1 st Feb Sz <ul><li>Febrile seizure in 1 st /2 nd degree relative </li></ul><ul><li>Day care </li></ul><ul><li>Neonatal nursery stay of >30 days </li></ul><ul><li>Developmental delay </li></ul><ul><li>Height of temperature </li></ul>
    18. 19. Risk Factors for Recurrent FS <ul><li>1/3 will have a recurrence </li></ul><ul><li>10% will have 3 or more </li></ul><ul><li>FH of febrile seizures </li></ul><ul><li>Age <18 months </li></ul><ul><li>Height of temperature </li></ul><ul><li>Duration of fever </li></ul>
    19. 20. Risk Factors for Epilepsy <ul><li>2 to 10% will go on to have epilepsy </li></ul><ul><li>Developmental delay </li></ul><ul><li>Complex FS (possibly > 1 complex feature) </li></ul><ul><ul><li>5% > 30 mins => ¼ of all childhood status </li></ul></ul><ul><li>FH of epilepsy </li></ul><ul><li>Duration of fever </li></ul>
    20. 21. Evaluation in Febrile Seizures <ul><li>Exclude acute etiologies </li></ul><ul><ul><li>HCT, lytes/cbc if history/PE suggests </li></ul></ul><ul><ul><li>Strongly consider LP </li></ul></ul><ul><ul><ul><li>< 12 months old </li></ul></ul></ul><ul><ul><ul><li>Prior antibiotic therapy </li></ul></ul></ul><ul><ul><ul><li>Suspicious findings on history/PE </li></ul></ul></ul><ul><ul><ul><li>Not absolutely necessary in > 18 mos </li></ul></ul></ul>
    21. 22. Evaluation in FS (2) <ul><li>EEG </li></ul><ul><ul><li>Does NOT predict recurrence or epilepsy </li></ul></ul><ul><ul><li>More likely to be abnormal in: </li></ul></ul><ul><ul><ul><li>Older children </li></ul></ul></ul><ul><ul><ul><li>Neurodevelopmental abnormalities </li></ul></ul></ul><ul><ul><ul><li>Family history of febrile seizures </li></ul></ul></ul><ul><ul><ul><li>Complex febrile seizure </li></ul></ul></ul>
    22. 23. Febrile Seizures—Treatment <ul><li>May reduce short-term recurrence </li></ul><ul><li>But NO effect on occurrence of epilepsy </li></ul><ul><li>AND the side effects ! </li></ul><ul><li>The approach is based on epidemiological data that FS are benign, so </li></ul><ul><li>Prevent status epilepticus </li></ul>
    23. 24. FS—Treatment (2) <ul><li>Antipyretics </li></ul><ul><ul><li>No data that this reduces risk </li></ul></ul><ul><ul><li>FS at onset of fever => highest recurrence </li></ul></ul><ul><li>Benzodiazepines </li></ul><ul><ul><li>Rectal diazepam (Valium) </li></ul></ul><ul><ul><ul><li>2-5 y/o 0.5 mg/kg </li></ul></ul></ul><ul><ul><ul><li>6-11 y/o 0.3 mg/kg (round up to 2.5, 5, 10 mg) </li></ul></ul></ul><ul><ul><li>Oral diazepam </li></ul></ul><ul><ul><ul><li>0.33 mg/kg q8 hrs x 48 hrs during illness </li></ul></ul></ul>
    24. 25. FS—Treatment (3) <ul><li>Daily medications NOT recommended </li></ul><ul><ul><li>Phenobarbital </li></ul></ul><ul><ul><ul><li>Drowsiness, sleep problems, hyperactivity, IQ </li></ul></ul></ul><ul><ul><li>Valproic acid </li></ul></ul><ul><ul><ul><li>Hepatotoxicity </li></ul></ul></ul><ul><ul><li>Phenytoin and carbamazepine </li></ul></ul><ul><ul><ul><li>Not effective </li></ul></ul></ul>
    25. 26. Seizures—Exam <ul><li>Temp, BP, HC </li></ul><ul><li>Skin (rash, neurocutaneous lesions), Neck </li></ul><ul><li>Evidence of dysmorphisms, developmental delay </li></ul><ul><li>Evidence of increased intracranial pressure </li></ul><ul><ul><li>Bulging anterior fontanelle </li></ul></ul><ul><ul><li>Depressed level of consciousness </li></ul></ul><ul><ul><li>Pupillary asymmetries </li></ul></ul><ul><ul><li>Downgaze/sunsetting eyes </li></ul></ul><ul><ul><li>Abducens palsy </li></ul></ul><ul><ul><li>Papilledema </li></ul></ul>
    26. 27. Seizures—Exam (2) <ul><li>Evidence of focal deficits </li></ul><ul><ul><li>Weakness </li></ul></ul><ul><ul><ul><li>Intracranial lesion versus Todd paresis </li></ul></ul></ul><ul><ul><li>Tone or reflex asymmetry </li></ul></ul><ul><ul><ul><li>? Chronic versus acute </li></ul></ul></ul>
    27. 28. Seizures—Evaluation <ul><li>Lumbar puncture </li></ul><ul><ul><li>“ Strongly consider” in patient <12 mo with first febrile seizure </li></ul></ul><ul><ul><ul><li>Kernig’s, Brudzinski’s, nuchal rigidity low sensitivity (Thomas 2002) </li></ul></ul></ul><ul><ul><li>But usually more than isolated seizure </li></ul></ul><ul><ul><ul><li>History of irritability/lethargy </li></ul></ul></ul><ul><ul><ul><li>Complex febrile seizure </li></ul></ul></ul><ul><ul><ul><li>Slow postictal clearing of mentation </li></ul></ul></ul>
    28. 29. Seizures—Evaluation (2) <ul><li>Neuroimaging </li></ul><ul><ul><li>“ Emergent” HCT </li></ul></ul><ul><ul><ul><li>Concern of acute focal lesion, mass effect </li></ul></ul></ul><ul><ul><ul><li>I.e. persistent paresis or change in MS </li></ul></ul></ul><ul><ul><li>MRI (nonurgent) </li></ul></ul><ul><ul><ul><li>Focal sz </li></ul></ul></ul><ul><ul><ul><li>Cognitive/motor impairment </li></ul></ul></ul><ul><ul><ul><li>Focal EEG findings </li></ul></ul></ul><ul><li>EEG </li></ul><ul><ul><li>Not if simple febrile seizure </li></ul></ul>
    29. 30. Location, Location, Location
    30. 31. Overview of the Neuro Exam <ul><li>Mental Status </li></ul><ul><li>Cranial Nerves </li></ul><ul><li>Motor </li></ul><ul><li>Gait </li></ul><ul><li>Coordination </li></ul><ul><li>Reflexes </li></ul><ul><li>Sensory </li></ul><ul><li>“General” </li></ul>
    31. 32. General <ul><li>Growth parameters (HC) </li></ul><ul><li>Vital signs (temp, BP) </li></ul><ul><li>Anterior fontanelle </li></ul><ul><li>Flattening of the occiput </li></ul><ul><li>Dysmorphic features </li></ul><ul><li>Cardiac abnormalities </li></ul><ul><li>Hepatosplenomegaly </li></ul><ul><li>Cutaneous lesions </li></ul>
    32. 33. Mental Status <ul><li>Change in mental status = brain is not working correctly </li></ul><ul><li>Level of consciousness </li></ul><ul><ul><li>Lethargy </li></ul></ul><ul><ul><li>Stupor </li></ul></ul><ul><ul><li>Coma </li></ul></ul><ul><li>Attentive/interactive </li></ul><ul><li>Language (receptive, expressive) </li></ul>
    33. 34. Cranial Nerves <ul><li>= Brain stem or nerve </li></ul><ul><li>CN2 = optic nerve </li></ul><ul><ul><li>Funduscopic exam </li></ul></ul><ul><ul><li>Visual fields/blink to threat </li></ul></ul><ul><ul><li>Visual acuity/color vision </li></ul></ul><ul><li>CN3, 4, 6 = oculomotor, trochlear, abducens </li></ul><ul><ul><li>Eyelids </li></ul></ul><ul><ul><li>Pupils </li></ul></ul><ul><ul><li>Extraocular movements </li></ul></ul>
    34. 35. Cranial Nerves (2) <ul><li>CN5 = trigeminal </li></ul><ul><ul><li>Sensation </li></ul></ul><ul><ul><li>Masseter function </li></ul></ul><ul><ul><li>Corneal reflex (comatose or focal brain stem) </li></ul></ul><ul><li>CN7 = facial </li></ul><ul><ul><li>Wide palpebral fissure and flat nasolabial fold </li></ul></ul><ul><ul><li>Both upper and lower face = LMN </li></ul></ul><ul><ul><li>Only lower face weak = UMN </li></ul></ul>
    35. 36. Cranial Nerves (3) <ul><li>CN8 = vestibulocochlear nerve </li></ul><ul><ul><li>Finger rub </li></ul></ul><ul><ul><li>Weber’s—louder ear = conduction deafness </li></ul></ul><ul><ul><li>Rinne—confirms above ear (air < bone) </li></ul></ul><ul><li>CN9, 10 = glossopharyngeal and vagus </li></ul><ul><ul><li>Palate elevation, gag </li></ul></ul><ul><li>CN11 = spinal accessory </li></ul><ul><ul><li>L SCM turns head to R, ear to ipsi clavicle </li></ul></ul><ul><li>CN12 = hypoglossal </li></ul><ul><ul><li>Tongue in cheek </li></ul></ul>
    36. 37. Motor <ul><li>Hypotonia = LMN or UMN, cerebellum </li></ul><ul><li>Hypertonia = UMN lesion, basal ganglia </li></ul><ul><li>Bulk/Fasciculations </li></ul><ul><li>Tone </li></ul><ul><ul><li>Resistance to passive ROM </li></ul></ul><ul><ul><li>Traction response, horizontal/vertical suspension </li></ul></ul><ul><li>Power </li></ul><ul><ul><li>0 to 5 grading scale </li></ul></ul><ul><ul><li>Techniques to bring out asymmetry </li></ul></ul><ul><ul><ul><li>Pronator drift, finger tapping, gait </li></ul></ul></ul>
    37. 38. Gait <ul><li>Motor cortex, corticospinal tracts, basal ganglia, cerebellum, vestibular system, nerves, muscles, vision, proprioception </li></ul><ul><li>Good screening test </li></ul><ul><li>Natural gait </li></ul><ul><li>Toe walk, heel walk, tandem walk </li></ul><ul><li>Romberg (proprioception, vestibular) </li></ul><ul><li>Sit to stand </li></ul>
    38. 39. Coordination <ul><li>Limb ataxia = cerebellar hemispheres </li></ul><ul><li>Gait ataxia = midline cerebellum </li></ul><ul><li>Finger-to-nose testing/reaching for toys </li></ul><ul><li>Rapid rhythmic alternating movements </li></ul><ul><li>Titubation (truncal ataxia) </li></ul>
    39. 40. Reflexes <ul><li>Hyperreflexia = UMN lesion </li></ul><ul><li>Hyporeflexia = LMN lesion </li></ul><ul><li>0 to 5+ grading scale </li></ul><ul><li>Babinski’s sign = UMN lesion </li></ul><ul><li>Correspond to spinal roots </li></ul><ul><li>Primitive reflexes </li></ul>
    40. 41. Sensation <ul><li>Stocking-glove = nerve </li></ul><ul><li>Vibration/proprioception = dorsal columns </li></ul><ul><li>Pain/temp = spinothalamic tracts </li></ul><ul><li>Extinction = cortex </li></ul><ul><li>Localization of stim </li></ul><ul><li>Purposeful withdrawal to painful stim </li></ul><ul><li>Spinal level </li></ul>
    41. 42. Questions re:Neuro Exam? http://medstat.med.utah.edu/pedineurologicexam/home_exam.html
    42. 43. Bibliography <ul><li>Baumann RJ and Duffner PK. Treatment of children with simple febrile seizures: The AAP practice parameter. Pediatr Neurol 2000;23:11-17. </li></ul><ul><li>Hirtz D et al. Practice parameter:evaluating a first nonfebrile seizure in children. Neurology 2000;55:616. </li></ul><ul><li>Knudsen FU. Febrile seizures: Treatment and prognosis. Epilepsia 2000;41:2-9. </li></ul><ul><li>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. </li></ul>
    43. 44. Bibliography <ul><li>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. </li></ul><ul><li>Shinnar S and Glauser TA. Febrile seizures. J Child Neurol 2002;17:S44-52. </li></ul><ul><li>Thomas KE et al. The diagnostic accuracy of Kernig’s sign, Brudzinski’s sign, and nuchal rigidity in adults with suspected meningitis. Clin Inf Dis 2002;35:46. </li></ul><ul><li>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. </li></ul>

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