neuro

1. Childhood
epilepsy
AREVIEW
DR OMAR ALI NAFI
MRCP

2. EPILEPSY DEFINITION
 Seizure Disturbance in the electrical activity of the brain
 Epilepsy Is recurrent (2 or more) unprovoked seizures
 Transient provoked seizures caused by
fever
electrolyte imbalance
toxic expos
head injury
Are not classified as epilepsy

3. Status epilepticus
 Continuous seizures >5 minutes , generalized or focal ,
during which the patient remains unconscious or has 2
or more sequential seizures without full recovery of
consciousness between seizures .

4. Etiology
 70% Unknown cause
 30% are due to the following:
 Head trauma
 Poisoning
 Infection
 Maternal injury
 Brain tumor and CVA

5. Classification of epilepsy
3 classifications
 1- accordind to semiology :
generalized
partial :simple ,complex
 2-according to cause :
idiopathic
sypmtomatic
cryptogenic
3-according to clinical + EEG + age : syndromic
classification

6. PARTIAL SEIZURES
 a. Simple partial (no impairment of consciousness) -
motor/sensory/autonomic/psychic
 b. Complex partial (impairment of consciousness)
- simple evolving to complex
- complex from outset
 c. Partial seizures evolving to secondary GTCS

7. GENERALIZED SEIZURES
The first clinical and EEG changes indicate involvement of both cerebral
hemispheres.
 a. Absence
 b. Myoclonic
 c. Clonic
 d. Tonic
 e. Tonic-clonic
 f. Atonic

8. Generalized convulsive (grand
mal) or generalized tonic-clonic
 sudden, immediate loss of consciousness
without warning
 initial generalized tonic contraction and
posture (causing fall and epileptic cry)
 then, generalized, bisynchronous rhythmic
forceful jerking movements
 slowing of the frequency of the convulsive
movements
 Typically last 1-3 minutes
 post-ictal exhaustion, sleep, disorientation

9. Childhood Absence Epilepsy
 Seizure type: simple
absence seizures. 1/3 or less
will also have at least one
generalized tonic-clonic
seizure. Often frequent
(many per day).
 Etiology: unknown
(idiopathic). often familial.
 Age: childhood (5-12years)
 EEG: generalized 3/sec spike
and wave discharges.
 Treatment: ethosuximide or
valproic acid.
 Prognosis: excellent. easy
seizure control. remission in
70% or more. few with long
term sequellae
No aura
Abrupt onset
Brief duration
Prompt recovery

10. Epileptic Syndromes
West syndrome
 Infantile spasm
 Described>170 yr ago
 Triad of:
- Infantile spasm flexor extensor
mixed
- Arrest psychomotor development
- Hypsarrythmia
 Onset peak 4-7 months
 Alwayas before 1yr age
 Treatment :
- ACTH
- VIGABATRIN
Fp1-F3
F3-C3
C3-P3
P3-O1
Fp2-F4
F4-C4
C4-P4
P4-O2
Fp1-F7
F7-T3
T3-T5
T5-O1
Fp2-F8
F8-T4
T4-T6
T6-O2
1 sec
50 µV
Hypsarrhythmia Electrodecremental
Seizure

11. Juvenile Myoclonic Epilepsy
 Seizure type: early morning
myoclonic seizures (single or
multiple myoclonic jerks). absence
seizures. generalized tonic-clonic
seizures.
 Etiology: unknown (idiopathic).
often familial. presumed ion
channel?
 Age: childhood (10-16years); female
predominance.
 EEG: generalized fast spike and
wave discharges (4 to 6 cycles/sec)
often with photosensitivity.
 Treatment: valproic acid.
 Prognosis: generally excellent
seizure control possible but
remission is rare

12. Rolandic Epilepsy
 The most common seizure disorder of
childhood.
 Seizure type: partial or secondarily
generalized sensory-motor seizures occurring
at the transitions between wakefulness and
sleep. usually affect oral-motor function
particularly. infrequent (weekly or less)
 Etiology: unknown (idiopathic). often
familial. presumed ion channel?.
 Age: childhood (5-12years)
 EEG: focal, centrotemporal (Rolandic) spikes.
 Treatment: no treatment or carbamazepine.
 Prognosis: excellent. easy seizure control.
remission in 95%. no long term sequellae.

13. EVALUATION
 Detailed history
 Physical examination
 EEG
 Labs
 Imaging technique

14. HISTORY
 Carefull detailed history corner stone for accurate
diagnosis
 Video tape the event diagnostic
 Ask parents to mimic the event
 Physician may mimic different seizure type to find a
match with the child event

15. Phisical examination
 Anthroprometric parameteres measured and
plotted
 Vital signs
fever---hypothermia
BlP bradicardia alt concious ICP
 Meningeal signs
neck stiffiness meningencephalities
subarachnoide hemorrage
cerebellar herniation

16. Physical exam cont
 Examination of skull
shape
fontanelle size tension
sututre prem closure
wide separation

17. Physical examination cont
 Ophthalmic examination
lisch nodule
retinitis pigmentosa
cherry red spots

19. Physical examination cont
Skin examination
ash leaf spots
facial angioma
café au lait spot

21. Investigation
 Laboratory testing
electrolytes
ca po4 alp
mg
glucose
 Febrile child
CBC
blood and urine culture
 Lumbar puncture
strongly 12 mo or if
previous antibiotics
considered 12-18 mo
indication more 18

22. electroencephalogaphy
 EEG
56% abnormal in newly dx epileptics repeat additional
11%
20% of epileptics repeatedly normal EEG
5% of normal children epileptiformeactivity

23. Neuroimaging cont
Indications
partial onset seizure
focal or new focal deficit
neonatal
persistent altered mental status
HX of anticouagulation
HX of cancer

24. Differential diagnosis cont
 BREATH HOLDING SPELLS
cyanotic spells
Always provocated
Cry-apnea-cyanosis-loc-myoclonic
Onset 6 mo---peak 2yr abate 5 yr
EEG normal
pallid spells
Trauma to the back of head or startle
Apnea—loc—pallor---hypotonia—tonic
EEG normal

25. Differential diagnosis cnt
SYNCOPE
Decrease blood flow----hypotension
Loss of conciousness—deviation of eyes
Provoked by pain fear excitement
Rare before 10-12 years
More in females

26. Differential diagnosis cont
 Prolonged Q-T syndrome
sudden LOC during exercise or
emotional orstressfull experience
Onset late childhood or adolescence
during event recover or die

27. Treatment
 Medication
 Vagus Nerve stimulator
 Surgical
 Dietary

28. Medication

29. • Zonisamide - 2000
• Leveteracetam - 1999
• Tagabine - 1998
• Topiramate - 1996
• Lamotrigine - 1994
• Felbamate - 1993
• Gabapentin - 1993
• Vigabatrin - 1992
• Valproic Acid - 1973
• Carbamazepine - 1965
• Ethosuximide - 1955
• Primidone - 1950
• Phenytoin - 1938
• Phenobarbitone - 1912
DRUGS NAME YEAR

30. Phenobarbitone (Luminal)
• Used for all types and
all ages.
• Nowadays also used
for treatment of neonatal
seizures, and status
epilepticus
• Side effects:
•1)In children 
Hyperactivity, cognitive
impairment.
•2)In adults 
•Sedation

31. Phenytoin (Epanuten)
• Broad spectrum
•The drug of choice in
Status epilepticus
•Follows Zero-order
pharmacokinetics
•Side effects:
•1)May reach toxic levels
•2)Hirsutism
•3)Coarse features
•4)Hypertrophic gums

32. Ethusoximide (Zarontin)
• Narrow spectrum
•The drug of choice in
Absence epilepsy
•Side effects:
•1) Skin rash
•2)Agranulocytosis

33. Carbamazipine (Tegretol)
• The drug of choice in
Partial seizures, also
used in complex
seizures, and
secondary
generalization.
• Also used in treatment
of trigeminal neuralgia.
• Side effects:
•1) Skin rash
•2) Agranulocytosis
•3) Hyponatremia

34. Valproic acid (Depakine)
• Broad spectrum
• A component in all anti-
epileptic regimens.
• When given with
Lamotrigine, the dose should
be lowered to (1/10 th) of the
usual dose, since Valproic
acid increases the half life of
Lamotrigine.
•Mood stabilizer
• Side effects:
1)Hepatotoxic
2)Transient hair loss
3)Weight gain

35. Vigabatrin (Sabril)
• New generation anti-
eplipletic drugs
• The drug of choice in
West syndrome( which
results from tuberculous
sclerosis)
• Side effects:
1)Visual field defects

36. Gabapentin (Neurontin)
• Broad spectrum
• Has no interactions
with other drugs
• Safe to be used in
organ failure( Liver or
renal failure)
• Used in treatment of
neuropathic pain

37. Lamotrigine (Lamictal)
• Broad spectrum
• Side effects:
•1) Measeles like rash
•2) Stevens Johnson
syndrome

38. Topiramate (Topamax)
• Broad spectrum
• Used for intractable partial
complex seizures especially
in combination with tegretol
•Also used in prophylaxis of
migraine
•Side effects:
•1)Renal stones
•2)Decreases attention and
ability to concentrate

39. Levetiracetam (Keppra)
• Used for children and
neonate age group
•Used as a primary drug.

40. Treatment
 Primary generalized
valproic acid
 Infantile spasm
steroids
vigabatrin
 Partial seizures
carbamazepine
 ABSENCE EPILEPSY
ethosuxamide
valproic acid
lamotrigine

41. Treatment
 MOST OF AEDs
start small dose then increase
if max dose reached no response serum
level
routine drug level discouraged
 MONOTHERAPY
avoide interaction
better compliance
 BEFORE switching to another drug reconsider
DX

42. Treatment
SIDE EFFECT
 Most are idiosyncratic
 Skin rash
 Steven johonson syndrome
 Hepatotoxicity
 pancreatitis

43. Medication
Phenytoin (Dilantin)
 Gingival hyperplasia occuring in approximately 20% of
patients.

45. Guidelines for discontinuation
AEDs
 seizure free 2-5 years on AEDs mean 3.5 years
 single type of partial generalized seizures
 normal neurological and IQ examination
 EEG normalized with treatment

46. Vagus Nerve Stimulator
 Limited for localization related epilepsy
 Implanted device
 Stimulates the left vagus nerve for 30 seconds every
five minutes
 30% experiences 50% reduction in seizure activity

47. Surgical
 First surgery in 1886
 Only utilized when medication cannot achieve
satisfactory control
 INDICATIONS:
 intractable partial seizures
 intractable hemiepilepsy
 Mesial temporal sclerosis

48. Dietary
Ketogenic diet (Metabolic shift-Ketosis state)
 High fat and oils
 High calorie
 Low in proteins
 Low in carbohydrates

49. THANK YOU