Seizure disorders in children for Undergraduates- Dr. D. Gunasekaran - Pediatrics, Professor of Pediatrics.

2. Seizure disorders in
children
Dr. D. Gunasekaran
Consultant Paediatrician

3. To enable you :
To identify the seizure
To identify the probable type
To initiate managing a child with seizure
To identify and manage Febrile seizures
To understand the stepwise management of status
epilepticus and its significance

4. Define: Seizures / Convulsions / Fits:
Sudden, excessive discharge of neurons resulting in
involuntary motor, sensory or autonomic disturbances
with or without alteration in sensorium
USA statistics: 5% of children are at risk of getting at
least once in a life time

5. Focal: Neurons in one hemisphere.(conscious +): Focal insult (tumour)
Generalized: Neurons of both hemispheres (conscious is lost)
(Generalized insult to both hemispheres – hypoxia)
Febrile seizures: Seizures due to fever of extra-cranial origin
Acute symptomatic seizures: secondary to an acute problem
(Electrolyte, Glucose, Encephalitis & Meningitis), usually GTC
Unprovoked seizures: No obvious reason
Epilepsy: >2 unprovoked seizures, >24 hours apart

6. Epileptic syndrome: 1 or more specific seizure types, specific age of
onset & specific prognosis.
Idiopathic epilepsy: No underlying disorder; presumably genetic
Symptomatic epilepsy: Underlying brain disorder (epilepsy
secondary toTuberous sclerosis)
Cryptogenic epilepsy (presumed symptomatic epilepsy):
Presumed underlying brain disorder but the cause is not known
Epileptic encephalopathy: Severe EEG abnormality, Cognitive
impairment

7. Excitatory Amino acid
Injury to Neurons
Death of neurons
Excessive discharge  concerned activity
Motor cortex  jerking of limbs

8. Do you know the most common investigation
used to diagnose seizures?

11. Electrodes
Electrical activity of brain
Waveforms: theta, delta, alpha and beta
Abnormalities of wave form: spike & slow waves
Epileptiform activity may be enhanced by activation procedures:
hyperventilation, photic stimulation & sleep deprivation
Use: to diagnose seizures; to classify seizures

12. FOCAL
CONSCIOUSNESS IS MAINTAINED
a. Focal seizures with retained
consciousness (Simple partial)
b. Focal dyscongnitive (Complex partial)
c. Partial seizures with secondary
generalization
GENERALIZED
CONSCIOUSNESS IS IMPAIRED
a. Petit mal (Absence)
b. Grandmal
c. Myolconic
Rare & complex seizure types and syndromes are not
included in this classification

13. Aura: Sensory experiences (depend on the location)
Visual (flashing lights/seeing colours)
Somato-sensory (tingling)
Olfactory, auditory, vestibular
Experiential (dejavu)
Post-ictal period:
Sleep, vomit, automatism

15. 1. Simple Partial (Focal S with retained consciousness):
Motor: tonic/ clonic – particular limb
Sensory: abnormal sensation of a particular limb or part of limb
Autonomic: excessive sweating, palpitation
Versive: head turning & conjugate deviation of eyes
 May verbalize during the seizures - 10-20 sec only
 No post-ictal phenomenon
 EEG: spikes or sharp waves

16. 2. Focal dysconjugative seizures (Complex Partial) :
 1/3 has Aura: Epigastric discomfort, fear
 Act: brief blank stare or sudden cessation of activity; lasts for 1-2
m min.
 2/ 3 has Automatism: usually, alimentary; lip smacking, repeated
chewing , repeated swallowing; pulling at clothes, walking &
running aimlessly
 EEG: sharp waves or focal spikes and multi focal spikes
 MRI: may show abnormalities over temporal regions

17. 3. Focal  Generalized seizures

19. 1. Petit mal or Typical Absence seizures:- (5-8 years)
 Aura: Absent
 Breathing: Hyperventilation for 3 min, could ppte. a seizure.
 Seconds – each seizure lasts for seconds, but can have 100 such seizures
in a day.
 Eye lid flutter with brief blank stare or sudden cessation of activity, or
upward rolling of eyes
 No florid automatisms (if at all, simple automatisms like lip smacking)
 Three Hz spike – slow – wave discharges –Typical in EEG

20. 2. Grandmal seizures:-
Prodromal: hours to days- irritability; uneasiness
Aura: Minutes to seconds- Epigastric discomfort, fear
Tonic: 10-30 sec- Resp. muscle spasm: cry as the air is expelled –
cyanosis may be +; consciousness is lost
Clonic: 1-5 min- jerking of all 4 limbs & face; may bite teeth;
urine & fecal incontinence can occur
Post-ictal state: 30 min -2 hours: semicoma to deep sleep;
may have headache / vomiting.

21. 2. Grandmal seizures:
 Age: 9-25 years
 Usually within 2 hours after sleep.
 Photic stimulation, sleeplessness & hypoglycemia
can precipitate.
 EEG: 2.5 to 4 Hz spike and wave activity enhanced
by hyperventilation & photic stimulation

22. 3. Myoclonic seizures:-
Brief, symmetric muscular contractions ( 1-2 seconds)
Loss of body tone –fall forward -cause injuries to the
face and the mouth (if he is standing)
Several types
Prognosis may vary - very good to very bad.

23. Benign:
Benign childhood epilepsy with centrotemporal spikes
Benign epilepsy with occipital spikes
Serious:
Temporal lobe epilepsy
Landau-Kleffner epileptic aphasia syndrome
Rasmussen encephalitis (chronic encephalitis-intractable epilepsy
–progressive atrophy of cerebral hemisphere)

24. Type of myoclonic
epilepsies
Age Symptomatic/
Idiopathic
EEG Prognosis Drug
Early myoclonic
encephalopathy
Neona
te
Severe
Neurological
abnormalities
Suppression alternating
complex bursts of spike,
sharp & slow wave
Very poor;
early death
West syndrome
(Infantile
spasms) Flexor /
Extensor/ Mixed
3-8
mon
MR +;
70% HIE, NTD;
CNS infn.
30% crypto
Hypsarrythmia (high
voltage, slow, chaotic
background with
multifocal spikes)
Very poor;
5% may recover
Valproate,
ACTH,
Benzodiazepines
Vigabatrin
Benign
myoclonic
epilepsy of
infants
1-2yrs Normal .Normal Very good; stops
by 2 years of
age
No drug
Lennox-gestaut
syndrome triad:
developmental
delay, multiple
seizure types,
EEG)
3-5yrs MR,
Neurologically
abnormal:90%
Diffuse slow spike &
wave
Very poor; often
status epi for
days
Resistant to
many drugs.
ACTH tried.
Myoclonic
astatic
3-5yrs Normal in the
beginning
Irregular spike & wave
in sleep
50% better
Juvenile
myoclonic
epilepsy of Janz
8-
26yrs
Normal 4-6 Hz polyspike & slow
wave gen discharges
Better with drug Valproate
Life long

25. Landau Kleffner: Acquired aphasia with epilepsy syndrome
 Aphasia +
 Behavioural problems are common
 Seizures: partial or generalized
 EEG:
 Prognosis: long term recovery of language function is not
very good
 Treatment: Valproic acid is the drug of choice

26. Duration, type of movements, aura, automatism, frequency
Associated illness: fever, loose stools, …
Sometimes, parents may overlook: absence, CPS
Precipitating events: less sleep, stress, television, menstruation
H/O Prenatal or perinatal insult
H/O Regression of mile stones
H/O Personality changes / ICT: Brain tumour

27. If the child is convulsing in front of you..

28. Inititial steps:
 Shift child to a safer place (away from water, fire..)
 Put him in left lateral position (to prevent aspiration, ifV)
 Roll a kerchief and keep between teeth, if possible
 ABC
 Airway: clear the secretions
 Breathing: give O2 / bag and mask / intubation
 Circulation: Pulse/ BP/ CFT: IVF

29. Emergency therapy: Stop the convulsions with fast
acting Benzodiazepines..
Diazepam / Lorazepam/ Midazolam:
Lora: Longer duration of action; (0.05 mg/kg)
Midazolam: by any route: IM/Nasal/Buccal (0.1mg/kg)

30. Even 5 minutes after the 1st dose of
Benzodiazepines, if convulsions do not stop:
Give 2nd dose of Benzodiazepines
+ Start long acting drugs IV (Phenytoin/PB)
At 10 min: 3rd dose of Benzodiazepines
At 15 min: 4th dose of Benzodiazepines
Then plan Investigations

31.  Blood sugar
 Serum electrolytes
 Serum calcium
 Smear for malaria
 CSF analysis
 CT scan / MRI
 EEG
 If it is a symptomatic seizure, usually they may not
require long term anticonvulsants.
 Otherwise, give daily anticonvulsants until 2 years
of seizure free interval

32. Anti- convulsants: which one to choose?
 It depends on the type of the seizure
 Age of the child (Valproate is avoided in < 2 yrs)
 Sex of the child (Phenytoin avoided in
adolescent females)
 Pre-existing disease if any. (Jaundice)

33. Seizure types Drug of choice
Focal Carbamazepine
GTC Valproate / Phenytoin / Phenobarbitone
Absence Valproate / Ethosuximide
Myoclonic Valproate / clonazepam / clobazam

34. Drugs Not serious but common Serious
Phenytoin Gingival hyperplasia,
hirsuitism, ataxia
Stevens –Johnson syndrome
Liver damage
Phenobarb
itone
Disturbances is memory,
mood & sleep
Same as above
Carbamaz
epine
Weight gain, Nausea Stevens Johnson syndrome
Liver damage
Aplastic anemia
Valproic
acid
Weight gain, Menstrual
irregularities, alopecia
Liver damage
Pancreas damage
Benzodiaz
epines
Sedation Respiratory depression

35.  In emergencies: loading dose: PB / PH: 20 mg
 In non emergencies: maintenance dose is started
 Small dose  gradually increased (carbamazepine)
 Steady blood level after 5 half-lifes (2-7 days) (PB: 2-4 wks)
 Monotherapy-max. dose-start another-taper the first one
 Monitored for side effects (Vit D: PB, Phenytoin;
PH: good oral hygiene; rinsing the mouth after phenytoin)
 Stopping: if child is seizure free > 2 years; gradually, even
over 3 months

37. Defn: “Seizures due to fever of extra-cranial origin”
Neurologically normal children

38.  Prevalence: 3-4% in the community
 Risk is more, if parents / siblings have FS (10-45%)
 Genetical predisposition: Chromosomes 19, 9 & 5

39. Patho-physiology:
Rise in temp  rise in excitatory postsynaptic
potential  convulsion
Rise in temp  failure of Na-K pump at cellular
level convulsion

40. Age: 6 months to 60 months
Within 24 hours of onset of fever
Usually occurs once only for one episode of fever
Lasts < 15 minutes; GTC in type
After 24 hours: No focal deficit
EEG: 2 wks after seizure (sleep & awake 20 min): normal
Those who do not satisfy any of the above criteria, ATYPICAL

41. Chance of relapse: 25-30% with every episode of
fever
Recurrence risk is more:
First episode of seizures < 1 year
Family H/o Febrile seizures / epilepsy
Atypical febrile seizures

42. Risk of epilepsy:
Complex FS / Neuro developmental abnormalities
Risk of developing Status epilepticus: 5%
If child already had status, the risk of getting another status is more

43. 1) Control of temp (Para & tepid sponging)
2) Intermittent Prophylaxis: Diazepam / Clobazam – 48 hours
3) Treat the cause for fever
4) If the child is throwing the seizures: ----

44. Definition:
Single or Multiple episodes of seizures, without regaining consciousness
lasting for > 30 min; mostly generalized / can be partial
To be more practical:
Any child convulsing for > 5 min, should be considered as status
(because, all self limited seizures usually stop in < 5 minutes)
Any child presenting to the casualty with active seizures should be
considered as status only.

45. Why it is important?
Risk of cerebral edema,
hypoxia, hyperthermia, hypoglycemia,
vasomotor in-stability,
vomiting & aspiration and
respiratory depression
Risk of death / residual neurological sequelae

46.  1/3: first seizure itself will present with status
 1/3: occur in already diagnosed epilepsy patients
 1/3: occur due to some acute insult
 In India, the most common cause is febrile seizures

47. 0 min: ABC; send blood for investigations (Blood glucose, serum
electrolytes, BUN, Toxicology screen & serum anticonvulsants
levels)Give one dose of Benzodiazepine
(Lora 0.1mg/kg; Mid 0.15mg/kg; Dia 0.3mg/kg)
+ Phenytoin : 20mg/kg @ 1mg/kg/min
+ if CBG less, give dextrose 4 ml/kg
At 5 min: if seizures + : repeat Benzo
At 10 min: if seizures +: repeat Beno
At 15 min: if seizures + : repeat Benzo
At 20 min: if seizures + : (Refractory Status)add PB 5-10mg/kg @
1mg/kg/minrepeat
At 40 min: if seizures+ : midazolam infusion: 2-10mcg/kg/min

48. Physical and neurological examination:
LP & Antibiotics if meningitis suspected
Trauma with intracranial bleed:
CT & Neuro surgeon’s opinion
Serum anti-convulsants levels

49.  Mortality rate is 5%
 Morbidity (Neurologic sequelae) common < 1 yrs

50. Thank
you