Seizure
Provoked: symptomatic of an acute underlying pathology: Gastro, RTI, meningitis, toxin, tumour, hypoglycaemia
Definition
Epid: 3% will experience an unprovoked seizure
Recurrence 50% for first unprovoked seizure (usually within 6m)
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Focal = one hemisphere
Generalised = both hemispheres
Unknown
12% of first seizures present in Status
Infection
Hx
first seizure OR first presentation with seizure i.e. Epilepsy =
Ix
Syndromes
Neonatal period
Mx
Education
Safety (water, driving), BLS
Treatment: depends on syndrome
reduces recurrence but dose not alter long term prognosis or risk of SUDEP
Gen Paed within 2 weeks
Recording
Neuropsychology (25% of first seizures have deficit) should be monitored / assistance provided
Treat comorbidities: Anx, dep, ADHD
Prognosis
Anxiety/Depression
Anticonvulsants
Visual field constriction (difficulty seeing at night): Vigabactrin (30%)
Levels useful: phenytoin, carbamazepine, phenobarbitone
HLA-B*1502 allele is recommended prior to starting carbamazepine in patients with Asian ancestry due to the risk of Stevens-Johnson syndrome
See
NSW CPG
NICE
PENNSW
ILAE classification
- GIT have low recurrence
- RTI, UTIs have similar to unprovoked
- >1mo with no previous, and no acute provocation
Definition
Epid: 3% will experience an unprovoked seizure
Recurrence 50% for first unprovoked seizure (usually within 6m)
----
Focal = one hemisphere
- Focal with maintained awareness (previously simple partial)
- Focal with loss of awareness (previously complex partial)
- Focal evolving to bilateral convulsive (previously with secondary generalisation)
Generalised = both hemispheres
- Generalised tonic clonic (previously Grand Mal)
- Tonic phase: brief axial flexion, then prolonged extension
- Intermediate vibratory tremor
- Clonic phase: alternative tone and atonia
- Brief second tonic (tongue biting)
- Post-ictal phase
- Absence (previously petit mal)
- Myoclonic
- Clonic
- Tonic
- Atonic
Unknown
- Epileptic spasms (previously infantile)
12% of first seizures present in Status
Infection
Hx
first seizure OR first presentation with seizure i.e. Epilepsy =
- 2 unprovoked seizures 24 hours apart
- 1 unprovoked with >60% risk of recurrence
- 1 unprovoked with recognised syndrome
Ix
- LP if ?meningitis/encephalitis
- EEG within 24 hours OR
- sleep deprived EEG with photic and hyperventilation
- BOTH have 50% diagnostic rate for syndromes i.e. 50% sens, 98% spec i.e. 2% on normal kids have focal spike, generalise spike and wave, or photo paroxysmal discharges
- NB sleep deprivation can trigger BRE, Gen Seiz in JME, + ?others
- BenRolEp, JuvMyoEp, Ben OccEp (Panay), Mes Temp Lobe Ep have characteristics
- Imaging abnormal in ⅓ of first seizures, 2% of these require immediate action (tumour), mainly effect Rx/Prog
Syndromes
- Juvenile Myoclonic Epilepsy. 12y-18y, absence/myoclonic seizure early morning, generalised spike wave with 4-6 Hz polyspikes. Avoid sleep deprivation, OH, strobe/neon lights, also premenstrual (?OCP), generally lifelong
- Nocturnal Frontal lobe epilepsy: <1 min, cluster in night, St2 sleep (soon post), sterotyped posturing, recall.
- Panay
- Ep with GenTonClo Seiz Alone
- Childhood Absence Epilepsy
- 10% of epilepsy, 2-10y, usually resolves by 12yo, ?polygenetic
- Brief, impaired consciousness, interrupting activity, 10-100/day
- Occasional mild myoclonic elements of eyes, eyebrows and eyelids at onset
- Automatisms in 2/3
- EEG normal background, 3Hz spike and wave with event, accentuated by hyperventilation
- Rx first line: ethosuximide, others lamotrigine or valproate monotherapy
- Avoid Vigabatrin, tiagabine, carbamazepine, and gabapentin >worsen absence
- Childhood Epilepsy with Centrotemporal Spikes (previously Benign Rolandic Epilepsy)
- 3-14y, 15% of epilepsy, spontaneous remission in adolescence
- 1-2mins, numb buccal/speech arrest(guttural noises)/pooling of saliva/Ton-Clo Face
- can have loss of awareness/spread to arm/bilat convulsive
- 80% nocturnal, 20% on waking
- normal imaging (i.e. structure)
- EEG: normal background, centro-temporal spikes with accentuation in sleep (3% of normal children CTS)
- 20% have 1 seizure, 60% have 2-10, 20% have >10. Seizures stop before EEG normalises,
- Rx not always required, usually only for 1-2 years.
- if GTC, low evening dose of carbamazepine first line
- Can have memory and language delay, intervention helps, usually improves with time
- Epileptic spasms AKA West Syndrome (previously Infantile spasms but can persist beyond or start after 1y)
- Spasms
- EEG: chaotic
- Associated with cognitive decline
Neonatal period
- Benign familial neonatal epilepsy (BFNE)
- Early myoclonic encephalopathy (EME)
- Ohtahara syndrome
- Epilepsy of infancy with migrating focal seizures
- West syndrome
- Myoclonic epilepsy in infancy (MEI)
- Benign infantile epilepsy
- Benign familial infantile epilepsy
- Dravet syndrome
- Myoclonic encephalopathy in nonprogressive disorders
- Febrile seizures plus (FS+) (can start in infancy)
- Panayiotopoulos syndrome
- Epilepsy with myoclonic atonic seizures (previously astatic) aka Doose Syndrome
- Benign epilepsy with centrotemporal spikes (BECTS)
- Autosomal-dominant nocturnal frontal lobe epilepsy (ADNFLE)
- Late onset childhood occipital epilepsy (Gastaut type)
- Epilepsy with myoclonic absences
- Lennox-Gastaut syndrome
- Epileptic encephalopathy with continuous spike-and-wave during sleep (CSWS)
- Landau-Kleffner syndrome (LKS)
- Childhood absence epilepsy (CAE)
- Juvenile absence epilepsy (JAE)
- Juvenile myoclonic epilepsy (JME)
- Epilepsy with generalized tonic–clonic seizures alone
- Progressive myoclonus epilepsies (PME)
- Autosomal dominant epilepsy with auditory features (ADEAF)
- Other familial temporal lobe epilepsies
- Familial focal epilepsy with variable foci (childhood to adult)
- Reflex epilepsies
- Mesial temporal lobe epilepsy with hippocampal sclerosis (MTLE with HS)
- Rasmussen syndrome
- Gelastic seizures with hypothalamic hamartoma
- Hemiconvulsion–hemiplegia–epilepsy
Mx
Education
Safety (water, driving), BLS
- Bikes: always helmet, bike tracks not roads
- Adolescents in shower (not bath) with unlocked door (younger supervised)
- Swimming: outer lane with dedicated spotter, avoid surf/openwater/rivers must be reachable MUST be compliant Rx
- No driving until 2 years seizure free
Treatment: depends on syndrome
reduces recurrence but dose not alter long term prognosis or risk of SUDEP
Gen Paed within 2 weeks
Recording
Neuropsychology (25% of first seizures have deficit) should be monitored / assistance provided
Treat comorbidities: Anx, dep, ADHD
Prognosis
- Brain damage/death from seizures rare
- Cognitive deficits ofter comorbidity of underlying pathology rather than caused by seizures
- 40% for unprovoked (? brain damage/death)
- increased after second/third.., structural anomaly, focal neurology/seizure + EEG changes (80% at 2y), nocturnal seizures, FHx
- reduced with normal neuro ex + EEG (25% at 2y)
- most are early, the long without recurrence the better
Anxiety/Depression
Anticonvulsants
Visual field constriction (difficulty seeing at night): Vigabactrin (30%)
Levels useful: phenytoin, carbamazepine, phenobarbitone
HLA-B*1502 allele is recommended prior to starting carbamazepine in patients with Asian ancestry due to the risk of Stevens-Johnson syndrome
See
NSW CPG
NICE
PENNSW
ILAE classification