CONVULSIONS (SEIZURES)

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CONVULSIONS (SEIZURES)

• PROF. DR. SHAHENAZ M. HUSSEIN

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Seizures
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• Definition-
• A seizure is the clinical event that
  result from abnormal excessive neuronal activity.
  
• Etiology-
• -Alteration of consciousness, motor activity,
  behavior, sensation or autonomic function.
• -It may be viewed as a symptom of an underlying
  disease process.
• Classification-
• Acute non recurrent convulsions-
• One or more convulsive fits that occur during the
  same acute illness do not recur after
  recovery-
• Febrile convulsions. hypertensive
  encephalopathy.
• CNs infections- meningitis, encephalitis.
• Intra cranial Hemorrhage spontaneous, or
  traumatic
• Toxic- e.g tetanus. Intracranial tumors.
• Anoxic- sudden severe asphyxia.
• Metabolic- hypoglycemia, hypocalcaemia, hypo or
  hypernateremia.

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• Chronic recurrent convulsions-
• Recurrent attacks of convulsions with symptoms
  free intervals-
• Epilepsy
• -- Idiopathic.
• --Neurocutaneous synd. Such as Sturge-weber,
  neurofibromatosis, tuberous scelosis.
• Organic secondary to brain insult- post-
  infection, post- traumatic, post- hypoxic, post-
  toxic.
• Benign neonatal convulsions.
• Degenerative brain disease.
• Congenital cerebral malformation.

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Electrical rhythm in epilepsy
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• Epilepsy
• Defined as Increased Neuronal Excitability
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• Partial- Epileptic focus start localized and
  remain localized
• Classified according to level of
  consciousness
• No loss of consciousness
• Motor Sensory Autonomic.
• Loss of Consciousness Temporal lobe epilepsy.
• Generalized- Epileptic focus start localized
  then become generalized.
• Grandmal Febrile - Status epilepticus
  Myoclonic
• Clonic Atonic.-- Petite mal (typical and
  atypical) Tonic.
• Unclassified

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• Generalized tonic clonic
• (grand-mal epilepsy)
• The commonest form of childhood convulsions 60-
• -An aura- unusual behaviors recognized by the
  mother.
• -Tonic phase- powerful sustained contraction(5
  minutes)-
• The patient falls to the ground stiff due to
  powerful sustained contraction of all muscles.
• Arm flexed - Legs extended.
• -Clonic phase- Rhythmical contraction and
  relaxation of muscles of limbs and face- Biting
  the tongue and incontinence may occur during the
  clonic phase.
• -Duration of attack is variable but if exceed 20
  minutes it considered status epilepticus.

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• -Post epileptic phase- The child falls in deep
  sleep and afterwards he may be confused or
  irritable.
• Grand-mal epilepsy has good prognosis if the
  first attack start after the age of 3years and
  the mental development is normal.
• Febrile convulsion
• Definition- Generalized tonic clonic convulsions
  which occasionally occur at the onset of acute
  extra-cranial infections.
• Incidence- 3-5 in all children.

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• Etiology-
• At the onset of acute extra-cranial infections
  such as tonsillitis.
• - Febrile seizures may signify a serious
  underlying acute infections.
• - In association with high environmental temp.
• Clinical picture-
• Criteria for diagnosis of simple febrile
  convulsions-
• Patient type- Age 6month to 6years. - Sex
  male more than female.
• Family history Strong positive.
• - Neurologically metabolically
  free.

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• Seizures stages-
• Pre- Ictal- Convulsions occur at the onset of
  temperature 39o c or more.
• Ictal- Generalized tonic clonic.
• Short duration- 5-15 minutes.
• Course- Usually one convulsive fit during the
  same illness.
• Post-ictal- Short postictal stupor.

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• Investigation
• Laboratory-
• CSF analysis Indicated if any doubt exist
  regarding the possibility of meningitis.
• EEG- Indicated in atypical febrile seizure
  persists for more than 15 minutes or recurrent
  more than 3 time/day, or focal seizures.
• A child at risk for developing epilepsy-
• Positive family history of epilepsy
• Initial febrile seizures before the age of 6
  months.
• A febrile seizure.
• Delayed developmental milestone.
• Associated Respiratory manifestation (cyanosis).

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• Prognosis- Risk for developing epilepsy is 1 in
  children without risk factors,9 with risk
  factors.
• Treatment-
• Immediate first aid measures.
• Measures to lower the temperature-
• Cold fomentation / Antipyretics.
• Treatment of the cause of fever e.g Antibiotics
  for acute tonsillitis.
• Short acting anticonvulsant- Diazepam (valium)
  0.25mg/kg/dose.

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• Generalized absence petit-mal epilepsy
• - The commonest age 5-9 years.
• - Rare below 2years and never continue after 15
  years.
• - Short sudden loss of consciousness.
• - The child suddenly stops talking and stares for
  few seconds.
• - Recovery is immediate and child resumes
  talking.
• - Not associated with limb movement.
• - Recurrent up to more than 100 times/day.
• May affect school performance.

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• Myoclonic epilepsy
• - Occurs at any age but is more seen in infants
  and young children.
• - Usually associated with mental retardation.
• -The attack which is very frequent, present with
  sudden symmetrical mass jerking involving all
  limbs.
• Juvenile myoclonic epilepsy
• -Occurs during adolescence
• A.D. -Chromosome No. 6
• The hallmark is morning myoclonus within 90
  minutes after awakening.
• -Resolved with Valporic acid therapy for life.

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• Atonic (a kinetic) epilepsy
• - It is a type of myoclonic epilepsy.
• - Transient loss of consciousness and falling on
  the ground.
• - Then immediately the child gets up and resumes
  activity.
• The condition may be confused with petit mal.
• Benign neonatal convulsions
• -A.D. - Chromosome No. 20
• -Generalized clonic seizures
• -Occurs toward the end of the 1st week of life.
• -Called familial 5th day fits.
• -Favorable prognosis.

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Infantile spasm ( West syndrome)

• Brief convulsion of the neck, trunk and arm
  muscles followed by sustained muscle contraction
  lasting 2 to 10 seconds.
• Occurs when the child awakening or going to
  sleep.
• Each jerk is followed by a brief period of
  relaxation, many clusters occurs each day.
• EEG showed Hypsarrhythmia ( high- voltage slow
  waves, spikes and polyspikes).
• Peak age 3-8 months. - It could be mistaken for
  infantile colic.
• Treatment by ACTH,or oral steroids, or
  benzodiazepines,or valproic acid and vigabatrinis
  also promising.

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• Status epilepticus
• Definition-
• Continuous convulsion or repeated
  convulsions without return of the level of
  consciousness more than 20 min.
• Causes-
• -Sudden withdrawal of anticonvulsant.
• -Febrile convulsion in poorly controlled
  epileptic patient.
• -Metabolic or toxic.

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• Management
• 1-Stop the convulsion by-
• - Diazepam 0.2 0.4mg / kg / dose I.V. or
  0.5mg/kg/dose rectally.
• - Chloral hydrate or paraldehyde- 0.15 mg/kg
  diluted in saline I.V or 0.5ml/kg/dose rectally
• - If failed give general anesthesia (short acting
  barbiturates).
• 2-Long-term anticonvulsant-
• Phenobarbitone 3-5mg/kg/day.
• Diphenylhydantoin 5-8mg/kg/day.
• 3-Evaluation of the patient After the
  attack Todd's paralysis may occur and then
  resolve completely.

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• Partial (focal) seizures
• Motor Jacksonian epilepsy
• (simple partial motor seizures)-
• Involve the motor area of the brain and the
  patient is alert.
• Consists of clonic movements in a localized group
  of muscles. Commonly at the Corner of mouth,
  Thumb, and Great toe.
• Jacksonian march- The neuronal discharge may
  spread to other parts on the same side or become
  generalized.
• Rarely may continue for hours or day (epilepsia
  partialis continue).
• After the attack, there may be weakness of the
  part involved (Todd's) paralysis.

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• Sensory seizures- (simple partial sensory
  seizures)-
• Localized or spreading parasethesia- tingling,
  coldness, numbness electricity or even pain.
• Autonomic seizures- (simple partial autonomic
  seizures)-
• Autonomic manifestation
• -Sweating. - Tachycardia.
• Diarrhea or Constipation.
• Hypertension.
• Abdominal pain (abdominal epilepsy).
• Pupillary dilatation or constriction.

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• Temporal lobe (psychomotor)
• Partial complex epilepsy
• Sequence of events-
• Aura- blinking of eyes, abnormal sound, taste,
  smell or movement.
• Absence- loss of consciousness.
• Automatism- automatic movements e.g chewing,
  smacking of lips.
• Amnesia- recent amnesia for all events during
  the attack.
• Treatment of epilepsy
• Duration of therapy-
• 3 or 4 years after the last convulsions in
  grand-mal or petit mal epilepsy in an otherwise
  normal child.
• Longer period or even life long for those with
  associated neurological problems.

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• Advice to parents child-
• Give full information about the drug therapy and
  stress on not to stop the drug without medical
  advice.
• Allow normal activities- the child should be
  attended by a responsible adult while bathing or
  swimming.
• Give clear instructions about the first-aid
  measures in case the seizures
• Ensure patent airway.
• Avoid biting the tongue
• Putting the child in the prone or side position
  with head down.

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• Anticonvulsants

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• New drugs used for treatment of epilepsy
• -For generalized seizures
• Lamotrigine
• Topiramate
• Zonisamide
• -For partial seizures
• Gabapentine
• -For Infatile spasm
• Topiramate
• Vigabatrin