Fits/seizures

Question 1

What is a fit

Answer 1

Paroxysmal abnormality of motor, sensory, autonomic, and/or cognitive function, due to transient brain dysfunction

Question 2

What is a convulsion

Answer 2

a seizure (epileptic or non-epileptic) with motor components,

Question 3

What is a seizure

Answer 3

Unstimulated and usually appear as repetitive, rhythmic (clonic) movements of the limbs which PERSIST DESPITE RESTRAINT and are often accompanied by eye movements or changes in respiration

Question 4

What are the causes of seizures

Answer 4

Epileptic: hyper-synchronous electrical activity
- Infantile spasms (west syndrome)
- benign rolandic seizures
- Lennox-gastaut
- Childhood absence epilepsy
- Myoclonic epilepsy
Structural/metabolic: cerebral dysgenesis/malformation, vascular occlusion, damage (infection, HIE, haemorrhage), tuomur
Acute symptomatic: stroke, TBI, infection, electrolyte abnormalities, poison/toxin, meningitis or encephalitis
Febrile convulsion
Paroxysmal: blue breath holding spells, vasovagal syncope, hypovolaemic syndrome

Question 5

What are the causes of seizures in neonates

Answer 5

Hypoxic-ischaemic encephalopathy
Cerebral infarction
Septicaemia/ meningitis
Metabolic: Hypoglycaemia, Hypo/hypernatraemia, Hypocalcaemia, Hypomagnesaemia, Inborn errors of metabolism,Pyridoxine dependency
Intracranial haemorrhage
Cerebral malformations
Drug withdrawal e.g. maternal opiates
Congenital infection
Kernicterus

Question 6

What investigations/initial management should be done for first seizures

Answer 6

Immediate hospital assessment by a paediatrician
Refer to first fit clinic

Bedside: ECG, urine dip
Bloods: GLUCOSE, U&Es, FBC, genetic testing, toxicology, serum prolactin
Other: EEG, LP

Question 7

At what age do infantile spasms (west syndrome) occur

Answer 7

3-12 months

Question 8

What are the symptoms of infantile spasms

Answer 8

Spasms - sudden, rapid, tonic contraction of muscles + gradual relaxation - “Salam attacks”
- Violent flexor spasms of the head, trunk, and limbs followed by extension of thee arms (“jack-knife”)
- Lasts 1-2s, often multiple bursts of 20-30
- Often on waking or many times a day
Social interaction/development often deteriorates
Hyperpigmented skin lesions
Growth restriction

(May be misinterpreted as colic)

Question 9

What would EEG show for infantile spasms and what is the management

Answer 9

EEG: Hypsarrhythmia

Mx: Vigabatrin and/or corticosteroids

Question 10

What is the prognosis for infantile spasms

Answer 10

70% have a good initial response to medication but not a good long term prognosis
Most lose skills and develop a learning disability + epilepsy

Question 11

Describe Lennox-Gastaut - age range, symptoms

Answer 11

1-3yo
PMHx infantile spasms/neuro disorders
Multiple seizure types, but mostly atonic, atypical (subtle) absences, and tonic seizures in sleep
Neurodevelopmental arrest or regression and behaviour disorder

Question 12

What would EEG show for Lennox-Gastaut

Answer 12

Slow generalised spike and wave (1-2.5Hz)

Question 13

What is a blue breath holding spell

Answer 13

Occurs in toddlers when they are upset
Cries → holds breath → turns blue
May have LOC but should recover rapidly (NO post-ictal state)

Question 14

What will EEG show for blue breath holding spells and what is the management

Answer 14

EEG is normal
Drug therapy is unhelpful. Attacks resolve spontaneously, but treating iron deficiency anaemia, if present, may help

Question 15

Describe Anoxic reflex asystolic syncope (cause, age group, RF, symptoms)

Answer 15

Caused by cardiac asystole from excessive vagal inhibition
Infants and toddlers
RF: FHx of faints

Triggers: pain, discomfort, HEAD TRAUMA, cold food, fright, fever
Child gasps, becomes pale and falls to the floor
Hypoxia → generalised tonic-clonc seizure
Seizure is brief, child may not recover rapidly

Question 16

Describe vasovagal syncopes

Answer 16

Fainting
Brief clonic movements
Preceding blurred vision, light-headedness, sweating, nausea - resolves on lying down
triggers: hot/stuffy environments, standing for long periods, fear

Question 17

Describe benign paroxysmal vertigo of childhood

Answer 17

Primary headache disorder of childhood.
Recurrent episodes of vertigo (1-2 minutes)
+ Nystagmus, unsteadiness, falling
No postictal state

(NOT the same as benign positional vertigo)

Question 18

What are tics

Answer 18

Rapid, repetitive, brief, involuntary movements which can be voluntarily controlled

Question 19

What are night terrors

Answer 19

Wakes from sleep disorientated and frightened. May have autonomic signs

Question 20

What is the epidemiology of childhood absence epilepsy

Answer 20

4-12y
2/3 female
2% of childhood epilepsy

Question 21

What are the symptoms of childhood absence epilepsy

Answer 21

May be triggered by hyperventilation
Momentary unresponsive stare with motor arrest
May twitch eyelids of a hand or mouth minimally
Sudden onset
Lasts a few seconds (<30s)
Child has no recall, but may realise they have missed something and look puzzled/say pardon
Developmentally normal but may interfere with schooling

Question 22

What are the EEG changes for childhood absence epilepsy

Answer 22

Generalised spike and wave (4-3Hz) discharges, bilaterally synchronous during and sometimes between absences
Can ask to blow on a windmill for 2-3mins

Question 23

What is the prognosis for childhood absence epilepsy

Answer 23

Good, 80% in remission in adolescence
Few evolve into juvenile absence or juvenile myoclonic epilepsy

Question 24

Describe childhood/benign rolandic epilepsy - age range, prevalence, symptoms

Answer 24

Epilepsy with centro-temporal spikes
4-10y
15% of childhood epilepsies
Tonic-clonic seizures in sleep, or simple focal seizures with awareness of abnormal feelings in the tongue
Distortion of the face (supplied by the rolandic area of the brain)

Question 25

What is Panayiotopoulos syndrome (early-onset benign occipital epilepsy)

Answer 25

5% of childhood epilepsies, 1-5yo

S/S
Autonomic features
Vomiting
Unresponsive staring in sleep
Head and eye deviation
May progress to a convulsive seizure

Question 26

What are the features of Panayiotopoulos syndrome (early-onset benign occipital epilepsy) on EEG

Answer 26

Posterior focal sharp wave
Occipital discharges when the eyes are shut