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By

Dr Muhammad Saleem LaghariMBBS(KEMU), MCPS, FCPS (Paeds)

Gold Medalist FCPS-I

Associate ProfessorDepartment of pediatrics

SMC,RYK

SEIZURES OR CONVULSIONS

What is a Seizurea transient occurrence of signs and/or symptoms resulting from abnormal excessive or synchronous neuronal activity in brain.

Seizure disorderIt is a general term used to include any one

of several disorder like epilepsy, febrile seizures, possibly single seizure seizures secondary to metabolic ,infections.

MCQA 1 ½ year old boy brought to emergency

department having convulsions. Temperature of patient was 104oF, no signs of Meningeal irritation. Patient recover of fit after treatment, and was discharged from ER after 4 hour. What is most likely diagnosis.

a. Acute Pyomeningitisb. Epilepsyc. Cerebral Malaria.d. febrile seizuree. Encephalitis

SEQ 1 year old boy brought to causality in a

convulsive state. Examination of baby revealed Temp 104oF, Anterior fontanel normal, SOMI –ve, Patient was managed and after few hours he recovered & became active & playful.

1- What is the most likely diagnosis ?(1)

2- Write 4 steps of management of this child. (2)

3- Mention 4 risk factors for epilepsy in this

condition (2)

Key: 1- Febrile fits / Febrile convulsions 2- (i) Maintain A,B,C.

(ii) Measures to control fever (iii) Measures to control seizures (iv) Treatment for cause of fever (v) Counseling of parents and prophylaxis

3- (i) An abnormal Neurologic status before the

occurrence of seizures (Cerebral palsy, & Mental retardation).

(ii) Early onset of febrile seizures (iii) A family history of epilepsy (iv) Complex febrile fits.

A 3 year old girl brought in OPD with complaint of fits (Generalized tonic colonic) since the age of 6 months. Examination revealed no stigmata of any neurocutaneous disease. She is not taking any regular treatment. Her one cousin having seizure disorder and is under treatment.

1- What is most likely diagnosis?(1)

2- Write 3 investigations to reach final diagnosis? (1.5)

3- Write 5 principles of anticonvulsant therapy. (2.5)

Key:

1- Epilepsy2- (i) EEG, (ii) CT Scan Brain, (iii) MRI Brain

3- (i) Treat with the drug appropriate to the clinical type of epilepsy

(ii) Do not use the anticonvulsant drug used previously without any success.

(iii) Start with the one drug of choice in appropriate dosage. Increase the dose until seizures are well controlled or signs of toxicity appear.

(iv) If seizures are not controlled with one drug of choice, second drug of choice is added. Do not stop first drug suddenly. Withdraw it gradually.

Advise the parents and the patient that the therapy will be prolonged but it will not produce any mental slowing. Changes in medications or their dosages should not be made without the advice of the physician. Sudden withdrawal of anticonvulsants may precipitate the seizures or even status epilepticus.

Follow up of the patient and periodic neurologic re-evaluation is important.

If signs of toxicity appear, then reduce the drug by 25% or add another drug.

Get frequent blood levels of anticonvulsant drugs as required.

After 2-3 years of fits free interval, consider withdrawal of the anticonvulsant drug.

EPILEPSY

Epilepsy is defined as recurrent seizures(2 or more unprovoked seizures) unrelated to fever or to an acute cerebral insult in a time frame of >24 hr.

Febrile convulsions or seizures

Febrile convulsions or seizures are defined as

seizures that occur between 6-60m,

associated with fever(38C or higher),

in the absence of detectable CNS infection,

Or any metabolic imbalance

and occur in the absence of a history of prior

afebrile seizures.

Criteria for febrile convulsions

Age of 6 months to 6 years. Most febrile seizures occur between

the ages of 12-24 months.Fever of 38.8oC.Non-central nervous system

infection.

Exclusion to the diagnosis

A history of previous afebrile seizures.

CNS infection or inflammation.Acute systemic metabolic

abnormality causing convulsions.

Incidence

These are most common cause of childhood convulsive disorder

occur in 2-5% of children. These are twice as common in

boys than girls.

Febrile convulsions are simple:

when generalized,

duration less than 15 minutes and

do not recur within 24 hours.

Febrile convulsions are complex:

when focal,

prolonged more than 15 minutes

and/or recurs within 24 hours period

Febrile Status Epilepticus :when seizure lasting > 30 minutes.

Some children have a chronic seizure disorder with more seizures during fever. These are not febrile seizures, but are referred to as seizures with fever.

General considerationMore than 90% febrile seizures are generalized, are

less than 5 minutes duration, and occur early in an illness (e.g. otitis media, pharyngitis, adenitis, or UTI)

A strong family history of febrile convulsions in siblings and parents suggests a genetic predisposition(gene on chromosome 19p). An autosomal dominant pattern of inheritance may be present.

Complex febrile seizures have more risk of epilepsy or recurrent non-febrile seizures.

Risk factors for recurrence of febrile seizures

Major:Age < 1yrDuration of fever <24 hrFver 38-390CMinor: Family h/o febrile seizureFamily h/o EpilepsyComplex febrile seizuresDay careMale gender

Factors leading to epilepsy in febrile

convulsion patients. An abnormal neurologic status before the

occurrence of seizures (e.g. cerebral palsy, mental retardation)

Early onset of febrile seizures (i.e. before 1 year of age)

A family history of epilepsyComplex febrile convulsion. The incidence of epilepsy is >9% when several

risk factors are present, compared with an incidence of 1% in children who have febrile convulsions and no risk factors.

Etiology:

A rapid increase in body temperature has been postulated but exact pathogenesis is unknown.

Viral rather than bacterial infections cause disturbance of cerebral electrical activity.

Clinical Features:Febrile convulsions mainly occur between 6 months and 5 years of

age with a peak in the second year. Fever is thought to trigger seizures in genetically predisposed

children as 30-50% first-degree relatives have a history of febrile convulsions.

Respiratory infection is the predisposing cause. These are usually brief, bilateral clonic or tonic-clonic fits.

Sixty to seventy % have single seizure.

prolonged febrile convulsions may cause mesial temporal sclerosis and may be responsible for later afebrile fits.

Meningitis must be ruled out.

Lumber puncture should be performed in children: With any suspicion of meningitis. Under 1 years of age With a first febrile convulsions When recovery from a febrile convulsion is slow.

A blood count may help to decide whether to use antibiotics or not. The child should be hospitalized when meningitis is suspected or febrile convulsions are severe or multiple.

Investigations

1. Blood count

2. Lumber puncture if required

3. Blood sugar, calcium, phosphorus, urea and electrolytes

4. An EEG is indicated if febrile seizure is complicated. EEG should be done at least a week after the illness to prevent transient findings in EEG due to fever or seizure itself.

5. Neuroimaging

Treatment

Measures to control fever, and appropriate antibiotics (if a bacterial illness is suspected or found) are the mainstay of treatment.

Lower the temperatureBy tepid water sponging and antipyretics like paracetamol

60mg/kg/day in dd.

Control seizure: diazepam

Family should be reassured.

Parental education

Prolonged Anticonvulsant ProphylaxisHighly controversialNo longer recommended in childrenPhenytoin & Carbamazepine

Do not prevent febrile seizuresPhenobarbitone

Prevents recurrenet febrile seizuresDecrease Cognitive functionNo longer recommended

Prophylactic anticonvulsants

These are not generally indicated in uncomplicated febrile seizures.

Prophylactic anticonvulsants are indicated. If febrile seizures are complicated or prolonged. If medical reassurance fails to relieve the anxiety of

parents. Diazepam is used at the onset of fever and continued

for the duration of the febrile illness.

Alternatively, phenobarbitone 3-5 mg/kg/day is given as a single dose. It cuts the recurrence by two third and may be recommended for 2 years in:

Patients under 18 months with abnormal development.Complex seizures.Positive family history of febrile convulsions

Sodium valproate may also be used as a prophylaxis.

Phenytoin and carbamazepine are not effective as prophylaxis of febrile seizures.

Prognosis

It is good in simple febrile convulsions but infant with complex febrile seizure may develop epilepsy later in life.

About 6% children develop psychomotor epilepsy following prolonged unilateral fits before the age of 3 years.

The younger the child, the more likely it is that febrile convulsions will recur.

About 50-75% of recurrences take place within 1 year of initial seizure, and about 90% occur within 2 ½ years.

Recurrence is 30% after one febrile seizure & 50% after 2 or more episodes.

Recurrence rate can be influenced by the intermittent use of

rapid acting anti-epileptic drugs or continuous prophylactic treatment.

THANK YOU VERY MUCH