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Seizure disorders

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Approach to seizures in a child
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Seizure disorders

  1. 1. SEIZURE DISORDER Dr. Wassihun T.
  2. 2. Cntd…..  outline • Defn • Classication • Management
  3. 3. Definition • A seizure the clinical expression of abnormal, excessive, synchronous discharges of neurons residing primarily in the cerebral cortex • Epilepsy has been defined as recurrent convulsive or nonconvulsive seizures • The tendency to have recurrent, unprovoked seizures.
  4. 4. TERMINOLOGIES • Acute symptomatic seizures -occur 20 to an acute problem eg; electrolyte imbalance or meningitis • Unprovoked seizure- is seizure with out precipitating factor • Remote symptomatic seizure- is 20 to a distant brain injury such as an old stroke
  5. 5. Pathophysiology • Inhibitory circuits (GABA) limits synchronous discharge. • When GABA receptors blocked Rhythmic and repetitive hypersynchronus discharge of neurons  seizures • Excitatory NT  Ach , Aspartate and Glutamate also involved to develop seizures •  inhibitory system +  excitation   genesis of seizures • Abnormalities in Ion Channels (Na+, K+, Ca-) may cause seizures. (Prolongation of depolarization state)
  6. 6. Classification of seizures Partial seizures Primarily generalized seizures Unclassified seizures Simple partial seizures Absence (petit mal) Neonatal seizures Complex partial seizures Tonic-clonic (grand mal) Infantile spasms Partial seizures with secondary Tonic , Atonic, Myoclonic
  7. 7. Focal • For seizures: – originating within networks – limited to one hemisphere.
  8. 8. A, Simple Partial Seizures characterized by: • Motor, sePsory, autonomic, or psychic symptomatology • Consciousness is preserved • Postictal (Todd's) paralysis that can last minutes or hours
  9. 9. B, Complex Partial Seizures • Last 1-2 min and are often preceded by an aura • With an alteration of consciousness • Seizures often begin with a motionless stare or arrest of activity followed by automatisms
  10. 10. C, Secondary generalized seizure • Start as simple or complex partial seizures with subsequent clinical generalization • Most such seizures last 1-2 min • Tongue biting, urinary and stool incontinence, vomiting with risk of aspiration
  11. 11. II, Generalized seizures A, Absence Seizures 1-Typical absence seizures  Usually start at 5-8 yr of age  They do not have an aura  Usually last for only a few seconds  Do not have a postictal period  Hyperventilation for 3-5 min can precipitate the seizures
  12. 12. 2-Atypical absence seizures Have associated myoclonic components and tone changes of the head and body Also usually more difficult to treat They are precipitated by drowsiness
  13. 13. 3-Juvenile absence seizures  Are similar to typical absences but occur at a later age  Are accompanied by 4-6 Hz spike–and–slow wave discharges  These are usually associated with juvenile myoclonic epilepsy
  14. 14. B, TONIC-CLONIC SEIZURES  Consciousness is lost immediately  Massive sustained contractions of the entire musculature  This tonic phase lasts 10 to 20 seconds and is followed by the clonic phase, which lasts about 30 seconds
  15. 15. Cont,  During the tonic phase, marked autonomic phenomena are evident  The complete tonic-clonic sequence is rare in infants and young children
  16. 16. C, MYOCLONIC SEIZURES  Characterized by short duration  Rapid, bilaterally symmetric muscle contractions  When severe, the myoclonus may cause the patient to fall  The ketogenic diet may be effective in children with myoclonic seizures resulting from brain damage
  17. 17. III, Unclassified seizures A, Neonatal Seizures 1) -Subtle seizures occur more commonly in premature  Include transient eye deviations  Bicycling, pedaling, and stepping  Hypertension episodes, and apnea
  18. 18. Cont, 2) -can be focal or multifocal  Multifocal are migratory in nature  Generalized clonic seizures are uncommon due to incomplete myelination
  19. 19. Cont, 3) -can be focal or generalized Generalized tonic seizures are bilateral tonic limb extension or tonic flexion of upper extremities Focal tonic seizures include persistent posturing of a limb or posturing of trunk or neck in an asymmetric way often with persistent horizontal eye deviation
  20. 20. Cont, B, Infantile spasms • Are sudden generalized jerks lasting 1-2 sec. • Are distinguished from generalized tonic spells by their shorter duration • As peak activity is reached, hundreds of spasms may occur in a 24-hour period • Usually involve the muscles of the neck, trunk, and extremities
  21. 21. Cont, • Flexor spasms -sudden flexion of the neck, trunk, arms, and legs, and contraction of the abdominal muscles • Extensor spasms —abrupt extension of the neck and trunk, with abduction or adduction of the arms or legs • Mixed spasms —Mixture of flexor-extensor spasms
  22. 22. Febrile Seizures Seizures that occur between the age of 6 - 60 months with a temperature of >38 OC Occur in 2 to 4 percent of children younger than five years of age That are not the result of central nervous system infection or any metabolic imbalance That occur in the absence of a history of prior afebrile seizures
  23. 23. Simple febrile seizure Is a primary generalized Usually tonic-clonic attack Lasting for a maximum of 15 min Not recurrent within a 24-hour period
  24. 24. Complex febrile seizure Is more prolonged (>15 min) Is focal in type Recurs within 24 hr
  25. 25. Risk factor for recurrence of febrile seizure • Family history of febrile seizures • Family history of epilepsy • Complex febrile seizure • Age <1 yr • Duration of fever <24 hr
  26. 26. RISK FACTORS FOR OCCURRENCE OF SUBSEQUENT EPILEPSY RISK FACTOR RISK FOR SUBSEQUENT EPILEPSY Simple febrile seizure 1% Neurodevelopmental abnormalities 33% Focal complex febrile seizure 29% Family history of epilepsy 18% Fever <1 hr before febrile seizure 11% Complex febrile seizure, any type 6%
  27. 27. Approach to the patient • Detailed history • Thorough general and neurologic examination  INVESTIGATIONS • Lumbar puncture • CBC • Random blood sugar • Electrolyte • Blood film
  28. 28. Diagnostic modalities of seizure • Random blood sugar, • lumbar puncture, • VDRL • Metabolic study (Urine for quantitative organic acids) • Complete blood count , • Electrolyte • Renal function test, • Liver function test • EEG, MRI, CT scan
  29. 29. CONTD…. • EEG : – Recommended in all patients with paroxysmal event. – Helps to distinguish seizure from non- seizure, classification of seizure type & syndrome, deciding treatment & focus localization. – Video EEG needed for differentiating true seizures from non- seizure paroxysmal disorders & pre- surgical evaluation. • Time to do EEG : – Ideally should be done 3-4 days after seizure to avoid post ictal slowing. – Sleep deprived EEG increases the yield. – Photic stimulation & hyper- ventilation helps • No need to stop AED before EEG.
  30. 30. Status Epilepticus  Continuous seizure activity or recurrent seizure activity without regaining of consciousness lasting for >5 MIn  Febrile status epilepticus is the most common type of status epilepticus in children
  31. 31. Cont, Nonconvulsive status epilepticus-  Manifests as a confusional state, dementia, hyperactivity with behavioral problems  Fluctuating mental status, confusional state, hallucinations, paranoia
  32. 32. Cont, Convulsive status epilepticus  The most common type  Generalized tonic, clonic, or tonic-clonic
  33. 33. Cont, Refractory status epilepticus  Is status epilepticus that has failed to respond to therapy  Usually with at least 2 (although some have specified 3) medications of treatment
  34. 34. Treatment of status epilepticus • ABC of life • Intravenous lorazepam or diazepam • Phenobarbital 20 mg/kg loading dose • Or phenytoin 20 mg/Kg loading dose • Valproate as a third-line medication • Monitor for respiratory depression
  35. 35. Treatment of Infantile Spasm • Is best treated with adrenocorticotropic hormone (ACTH) • ACTH is gradually tapered over the next 9 wk • Predinsolon 2mg/kg • Ketogenic Diet
  36. 36. Treatment • Basic life supporting care • Diazepam or lorazepam • Antipyretics-paracetmpol • Council the parent
  37. 37. SYSTEMIC COMPLICATIONS OF STATUS EPILEPTICUS • Hypoxemia • Academia • Rhabdomyolysis • Hyperkalemia • Myoglobinuria • Acute renal failure
  38. 38. Therapeutic Considerations • Therapy should always begin with a single agent • The selection of the preferred drug is based on the type of seizure and on the potential toxicity of the drug • Cautious in using valproate in preschool children because of the increased risk of liver damage
  39. 39. Cont, • Anticonvulsant medication should be withdrawn gradually • Surgical therapy should be considered in children with medically intractable epilepsy
  40. 40. Selection of Antiepileptic Drugs Generalized Tonic-Clonic Partial Absence Atypical Absence, Myoclonic, Atonic Valporic acid Phenytoin Valproic acid Valproic acid Phenobarbit ol Carbamazepin e Ethosuximide Lamotrigine Phenytoin Valproic acid Clonazepam
  41. 41. Discontinuation of AED Therapy • Discontinuation of AEDs is usually indicated when children are free of seizures for at least 2 yr • Most relapses occur within the first 6 mo
  42. 42. CONT…. THANKS