Indian Write- Ups

Paediatrics

Childhood Seizures
- Dr. Anuj Rastogi

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Absence seizure

Features :

Typical Absence : Patient abruptly loses consciousness and eye stares vacantly straight ahead or may roll eye upwards, no change in posture and no movement.

(a) No post ictal confusion or drowsiness

(b) Dozen to hundred seizures may occur in single day and the presence of seizure free days casts doubts about diagnosis

(d) Onset 4 to 8 yrs of age. It may occur with :

Impairment of consciousness only
With mild clonic component like eye lid blinking, mouth twitching but posture is not disturbed
With tonic component
With automatism
With automatic component
With tonic clonic component

Diagnosis

1. EEG : is diagnostic, B/L sudden onset of generalized 3 Hz spike and slow wave activity which is frontally predominant. Following discharge record return to normal or its preictal appearance.

Drug of choice : Sodium valproate

Epileptic Syndromes

Generalized
Localized
Undetermined

i Idiopathic age related :

Childhood absence or true petit mal or pyknolepsy (CAE)
Juvenile absence (JAE)
Infantile Myoclonic Epilepsy (IME)
Grandmal on awakening.
Generalized idiopathic

ii Cryptogenic

West Syndrome (Infantile spasms)
Lennox-Gastaut Syndrome (Childhood epilepsy)
Myoclonic astatic seizures
Myoclonic absences.

Partial
Idiopathic age related

Rolandic Seizure.
Epilepsy with occipital Paroxysm

Symptomatic

Chronic progressive Epilepsy, Epilepsy partialis continual
Seizures with temporal, Frontal, Parietal or Occipital Lobe mode of presentation.
Undetermined syndrome

Neonatal seizure

Severe myoclonic epilepsy of Infancy
Acquired Epileptic aphasia

Differentiation between	Generalized Absence	Complex Partial Absence
Age	Childhood or early adulthood	Any
Prevalence	Uncommon	Common
Aeitology	Primary generalized epilepsy	Any focal pathology of idiopathic
Duration of Attack	Short (usually < 30 sec)	Longer (several minutes
Other Clinical	Slight tone changes or motor phenomena	May be marked tone or motor phenomena.
Posticidal	Quick recovery	May be gradual often with confusion
Frequency	Numerous	Less frequent
EEG	3HZ spike wave	Focal temporal disturbance
Drug of choice	Valporate or Ethosuximide	Carbamazepine or Phenytoin
Hyperventilation	Precipitates attack	Does not precipitate

Important epileptic syndromes :

Juvenile Absence Epilepsy (JAE), onset late 9 to 10 years of life, usually as with Generalized Tonic clonic seizure, EEG typical 3 Hz but complex of 4 or 5 Hz also seen.

Drug of Choice: Sodium valproate.

Juvenile Myoclonic Epilepsy (JME) : or Impulsive Petitmal Autosomal recessive (AR) onset 10-20 years of age

EEG : Generalized clusters of spikes followed by slowwave jerks are rapid & usually symmetrical, affecting mainly shoulders & arm (eg. Shaving cuts or blurred lipsticks may be evidence of morning jerks).

Drug of choice: Sodium valproate

Infantile Spasm / West Syndrome

Onset 4 to 8 months
Brief symmetric contraction of neck, trunk, or extremities
Flexor spasm
Extensor spasm
Mixed Spasm, most common.

EEG – Hypsarrhythmia

Drug of Choice : ACTH or Predinisolone

Lennox Gestaut Syndorme

Age of onset, 2-6 years.

Minor motor seizure, stare, jerks and fall, resistant to conventional anticonvulsant,

Mental handicap 80-90%

EEG – Slow spike and wave (1.5 2.5 Hz)

Drug of choice : ACTH, Ketogenic diet

Epilepsy with Myoclonic absences (EMA):

Age of onset 5 years

Frequent daily absences occur with severe bilateral rhythmic myoclonus.

Neonatal Seizures

They are most often focal or multifocal rather than generalized

Etiology

Hypoxic – ischaemic encephalopathy
Intracranial infections
Cerebral malformations
Metabolic causes
Benign or familial syndromes
Toxic or withdrawal convulsions
Specific epileptic encephalopathies

S/S grimacing,eye movement staring, assumption of toxic postures, or boxing & pedaling movement without clonic activity.

T/T Specific treatment of the cause AEDS include sodium valproate, phenytoin & phenobarbitone.

Benign Rolandic Epilepsy (BRE)

Onset age 2 – 12 years, peak 9 years of age.

Oropharyngeal onset with sensory involvement, usually of the tongue with tonic clonic involvement of facial muscles (Hemifacial seizures).

Foci accounts for 16% of childhood epilepsy Treatment may be delayed until 3rd night time, carbamazepine is sufficient

c. Febrile Convulsions

Convulsions have long been known to occur with pyrexia due to non-cerebral infections in certain otherwise norm children between the ages of 3 months and 6 years. The tendency to convulse with fever usually ceases by age of 5 or 6 years.

Second attack of febrile convulsions occurs approximately in 30 to 40% of children.

Prevalence nearly 4%

Children of parents who have themselves had febrile convulsions have an overall risk 4.4 times greater than general population being greatest (8 times) for the sons of females probands.

Age of onset is three months to three yrs. Maximally out of which highest incidence is in second year.

T/T – Sponging antipyretics I/V or P/R diazepam

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