Paeds: Epilepsy (DrClarke) presentation

Question 1

Definition

Answer 1

Recurrent transient paroxysmal attacks of disturbed consciousness and sensorimotor function, resulting from abnormal electrophysiological discharges of cerebral neurons

Question 2

Epidemiology
Incidence
Age range
Sex distribution

Answer 2

I: 500/100,000 of UK population (~37,000 people)
A: extremes (congenital in kids/degeneration in elderly)
SD: M:F –> 1:1

Question 3

Pathophysiology

Answer 3

Electrical activity spread of between cortical neurones is normally restricted. In seizures there is a failure of inhibitory synaptic contact between neurones –> overall excitation of large groups of neurones.
Each individual has a threshold for seizure activity. Some individuals have a low threshold -> having seizures in response to flashing lights stimulus.

Question 4

International league Against Epilepsy: Classificaton

Answer 4

1. Generalised
2. Partial
3. Unclassified

Question 5

Generalised

Answer 5

• Tonic-clonic seizures (grandmal)
• Typical absence seizures (petit mal)
• Myoclonic seizures
• Tonic seizures
• Atonic seizures/akinetic seizures/Drop attacks

Question 6

Partial (focal)

Answer 6

• Simple partial seizures (Jacksonian seizures)
• Complex partial seizures
• Partial seizures with 2ndry generalised tonic-clonic seizures

Question 7

Tonic-clonic presentation

Answer 7

• Vague warning - unconsciousness and generalised tonic-clonic convulsions
• Tonic phase: body becomes rigid for up to a mintute, pt utters a cry then falls -> serious injury sometimes, tongue usually bitten may be incontinent of urine or faeces
• Clonic phase then begins: generalised convulsions, frothing at mouth and rhythmic jerking lasting secs -> mins.
  Self-limiting -> drowsiness, confusion or coma for several hrs.

Question 8

Typical absence seizures (petit mal)

Answer 8

• Begins in childhood - dev. abnormality of neuronal growth
• Brief episodes of unconsciousness with little or no motor component
• Accompanied by3 Hz spike + wave ECG activity
• Activity ceases, pt stares and is spaced out for a few secs. Interruption mid-sentence carries on as normal afterwards.
• Eyelids twitch, a few muscles may jerk
• After attack, normal activity is resumed
• Usually develop generalised tonic-conic seizures in adult life.

Question 9

Myoclonic seizures

Answer 9

• Single/multple sudden or uncontrollable isolated muscle jerking
• Juvenile myoclonic epilepsy: common, ocurs b/t 8&26 yrs of age, but usually stars between 12 and 16.
• Girls>boys affected

Question 10

Myoclonic seizures 3 types of epilepsy can occur

Answer 10

1. Tonic-clonic (usually occurs AM with 1/2hrs of waking, lack of sleep)
2. Myoclonic (soon after waking up & when getting dressed or at brekkie, can also occur in evening if tired)
3. Absence (any time of the day, more in the morning)

Question 11

Tonic seizures

Answer 11

Intense stiffening of body NOT followed by convulsive jerking

Question 12

Atonic seizures/Akinetic seizures/Drop attacks

Answer 12

Sudden loss of tone with falling and LOC.

May have severe injury from falls

Question 13

Partial (focal) seizures description

Answer 13

An ‘aura’ describes effects of initial focal electrical events e.g. unusual smell, tingling in a limb or strange inner feeling usually recognised by pt as a WARNING SIGN

Question 14

Simple partial seizures (Jacksonian seizures

Answer 14

• Originates in motor cortex
• Typically begins at angle of mouth or in thumb & index finger spreading to the limbs on the side opposite epileptic focus (jacksonian march pattern)
• WEakness of convulsive limbs for several hrs (Todd’s paralysis)
• No impairment of consciousness!

Question 15

Complex partial seizures

Answer 15

• Impairment of consciousness
• Prodrome symptoms experiences: changed hearing, Visual disturbances, smell sensations, mood changes, muscle pain, muscle tremor

Question 16

Complex partial seizures location

Answer 16

Temporal lobe seizures
Frontal cortex
Parietal cortex
occipital cortex

Question 17

Temporal lobe complex partial seizures

Answer 17

Simple or comples -> feelings of unreality (jamais vu) or familiarity (deja vu).
May have absence attacks, vertigo, visual hallucinations

Question 18

Complex partial seizures Frontal cortes

Answer 18

autonomic disturbances - piloerectin, flushing, overbreathing, strange smells

Question 19

complex partial seizures parietal cortex

Answer 19

sensory disturbance.

Question 20

Occipital cortex

Answer 20

Crude visual shapes

Question 21

Unclassified seizures

Answer 21

Seizures that don’t fit in any of the categories

Question 22

Aetiology

Answer 22

• Trauma/hypoxia/surgery
• Genetic/developmental abnormalities
• Pyrexia
• Brain tumours/absences
• Vascular
• Alcohol/drugs/drug withdrawal
• Encephalitis and inflammatory conditions
• Metabolic abnormalities
• Degenerative brain disorders
• Provoked seizures (e.g. photosensitivity)
• sleep deprivation

Question 23

Trauma/hypoxia/surgery

Answer 23

• Post traumatic epilepsy in 2%
• Perinatal trauma and fetal anoxi are common in childhood seizures
• Hypoxic damage to hippocampi ->childhood epilepsy
• May get early epilepsy within a week brain injury, or late epilepsy months/yrs later.
• 10% of neurosurgical ops on crebral hemispheres leads to seizures

Question 24

Genetic/ developmental abnormalities

Answer 24

• 30%
• 1st degree relative with seizures Hx
• Inheritance mode uncertain
• Generalised typical absence seizures: autosomal dominant with variable penetrance.
• Developmental abnormalities e.g. harmatomas, neuronal migration abnormalities

Question 25

Pyrexia

Answer 25

Can lead to febrile convulsions in pyrexic kids

Question 26

Brain tumours/abscessess

Answer 26

Cerebral tumours -->6% - Mass cortex lesions -> epilepsy, (partial/secondary generalized seizures) - Hydrocephalus also lowers the seizure threshold.

Question 27

Vasuclar

Answer 27

May follow cerebral infarctions (esp elderly) ~15% of seizures. - A brain arteriovenous malformation may present with a seizure

Question 28

Alcohol/drugs/drug withdrawal

Answer 28

Alcohol - 6% - drinking heavily, withdrawal or alcohol induced hypoglycaemia. - (overdose, theraputic levels): Phenothiazines, MAO inhibitors, tricylic antidepressants, amfetamines, lignocaine and nalidixic acid can lead to fits . - Anticonvulsant withdrawal.

Question 29

Encephalitis and inflammatory conditions

Answer 29

Often presenting feature of encephalitis, cerebral abscess, cortical venous thrombosis, neurosyphilis, chronic meningitis (e.g. TB) and rarely bacterial meningitis

Question 30

Metabolic abnormalities

Answer 30

- Hypoglycaemia - Hypocalcaemia - Hyponatraemia - Acute hypoxia - Porphyria - Uraemia - Hepatocellular failure - Mitochondrial disease

Question 31

Degenerative brain disorders

Answer 31

e.g. alzheimers, 3 times more common in MS

Question 32

Provoked seizures (e.g. photosensitivity)

Answer 32

e.g. flashing lights, flickering TV, music

Question 33

Sleep deprivation

Answer 33

Missing a nights slepp - seizure in susceptible people

Question 34

Diagnosis of epilepsy

Answer 34

- Confirm pt has epilepsy based on Hx and examination - Do FBC, glucose, U+E's, LFT, ESR, CRP? metabolic, infective or inflammatory cause - EEG to investigate suspected epilepsy: ambulatory EEG, video telemetry ->? nature of attacks\- CT?MRI indications: if epilepsy after 20, EEG shows focal seizure type, seizures have focal features, difficult to control seizures -> intracranial masses

Question 35

Differential diagnosis

Answer 35

1. Hyperventilation and panic attacks 2. Breath-holding attacks 3. Day dreaming 4. Migraine 5. TIA 6. Transient global amnesia 7. movement disorders 8. Hypoglycaemia 9. Vertigo 10. Syncope/vasovagal attacks 11. Non-epileptic attacks (pseudoseizures) 12. febrile convulsions

Question 36

Hyperventilation and panic attacks

Answer 36

- During stress periods - Altered awareness, dizziness and LOC - May get chest pain, dyspnoae, blurred visions, parasathesia - Hyperventilation and palpitations, sweating, abdo discomfort - -> occasionally similar pattern to TEMPORAL seizures

Question 37

Breath-holding attacks

Answer 37

- Occurs when child is angry - Period of crying - cessation of breathing - cyanosis and child becomes limp and unresponsive - Trembling and few clonic movements - Persists for 2 mins - rapid recovery

Question 38

Day dreaming

Answer 38

Can be mistaken for absence seizures | Child however can be easily altered here

Question 39

Migraine

Answer 39

- Syncope may occur when vomiting - Basilar migraine may -> LOC followed by headache. differentiated on FH and brainstem symptoms - Migraine preceded by visual or sensory disturbance may be mistaken for partial seizures

Question 40

TIA

Answer 40

- Weakness and sensory symptoms - TIAs usually last longer and theres raraely LOC - Sensory phenomenon may spread like Jacksonian march, not seen in TIA

Question 41

Transient global amnesia

Answer 41

- Usually an isolated episode lasting several hrs - Pt unable to remember - Pt alert & communicative during the episode but may repeatedly ask the same question - Recovery afterwards normally complete

Question 42

Movement disorders

Answer 42

- Tics and chorea sometimes confused with myoclonus | - paroxysmal choreoathetosis -> no LOC

Question 43

Hypoglycaemia

Answer 43

- Uncommon: pts with DM on insulin or oral hypoglycaemic, very rarely due to insulinoma - Usually pt gets warning signs of autonomic changes e.g pallor, sweating, tachycardia - Loss of hypoglycaemic awareness/no warning signs -> coma ensues -> genuine seizures

Question 44

Vertigo

Answer 44

- Often paroxysmal - >epilepsy | - Very occasionally is a symptoms of an epileptic seizure particularly PARIETAL LOBE EPILEPSY

Question 45

Syncope/vasovagal attacks

Answer 45

-LOC

Question 46

Non-epileptic attack (pseudoseizures)

Answer 46

- Often resembles grand mal seizures | - Prolactin levels however are normal here (increased in a true grandmal)

Question 47

Febrile convulsions

Answer 47

Occurs in children when there is a rapid increase in body temp