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Approach to a child with Epilepsy
-Dr K.N. Shah |
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Epilepsy is a very common disorder constituting 70% of all pediatric neurological disorders. Of all epilepsies 70% have their onset in the pediatric age group.
| Table I |
| Epilepsy in children : advances in recent years |
- Classification of seizure types (1981)
- Classification of syndromes (1989)
- Neuroimaging (CT, MRI, SPECT, PET)
- Ambulatory EEG
- Long term video EEG monitoring
- Knowledge of neurotransmitters
- Pharmacokinetics of AEDs
- Pathophysiology of Epilepsy
- Newer digital EEG machines
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- History taking
- Rule out non-epileptic paroxysmal events
- Type of epileptic seizures
- Type of epileptic syndromes
- Etiology of syndromes
- Rx of epilepsy
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FIRST STEP
History taking
- Patient or eye witness
- GTC easy to diagnose
- Myoclonic, Partial, Complex Partial -> Observation - not always correct. Aura in a child - difficult, frequency and duration of spell difficult to remember
- History of precipitating factors
- Time of occurance
- Post ictal state etc.
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SECOND STEP
Once certain about paroxysmal events -> rule out non-epileptic paroxysmal events
- Febrile seizures are very common and are divided into typical and atypical. Atypical ones are more likely to develop future epilepsy. They disappear after 6 years of age, EEG is normal in the majority of cases.
- Breath-holding spasms which is very often misdiagnosed as epilepsy. Proper history taking is very important and they disappear after 3-5 years.
- Migraine - which is not uncommon in children and can mimic various aura of epilepsy and can have focal seizures.
- Pseudo seizures can mimic frontal lobe seizures and simultaneous video EEG helps in its differentiation from true epilepsy.
- Syncope ( Reflex, cardiac). Syncope may have mild GTC.
- Situation related seizures are common in children due to electrolyte disturbance, meningoencephalites, tumors, infarcts etc. By definition, seizures occur during acute illness within 7 days and if they persist, then such cases are diagnosed to be suffering from secondary, symptomatic epilepsy.
- Recurrent abdominal pain and cyclical vomiting are also very common and come in the differential diagnosis of TLE.
- Narcolepsy, cataplexy, spasms nutans, paroxymal vertigo, apnoea in new born, behavioural outbursts like temper tantrums, crying episodes etc.
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A thorough history taking and EEG evaluation are very crucial in differentiating above conditions from epilepsy.
Hallmarks of epileptic seizures:
- Recurrent
- Spontaneous, unprovoked, sudden
- Brief
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Sensory, motor, behavioural and emotional functions can be recurrent, spontaneous and brief and epilepsy should be suspected in such circumstances.
Single, isolated but unprovoked, sudden, spontaneous, brief episode by definition is not considered to be epileptic and should not be treated although from the history it appears to be epilepsy.
In view of social and economic implications, as a rule epilepsy should not be diagnosed without unequivocal clinical evidence, supported by EEG and other investigations. Normal EEG does not rule out epilepsy and when in doubt, it is better to observe the child.
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