Seizures – Childhood

Seizures – Childhood: Excerpt from In A Page: Pediatric Signs and Symptoms

Febrile seizures occur in 3–4% of all children; they often do not require long-term treatment. Each year, between 25,000 and 40,000 children in the U.S. have a first unprovoked afebrile seizure. Most of these children will not have a second seizure and do not require prophylaxis. The neurologic exam and the EEG help guide the evaluation and treatment.

Differential Diagnosis

• Febrile seizure
• Cerebral dysgenesis: Disorders of neuronal migration, heterotopias, lissencephaly
• Epilepsy syndromes
  –Childhood absence
  –Juvenile absence
  –Juvenile myoclonic epilepsy (JME)
  –Benign rolandic epilepsy (BRE)
• Meningitis/encephalitis (e.g., HSV)
• Cerebral abscess
• Postinfectious (e.g., ADEM)
• Hyponatremia
• Hypernatremia
• Hypocalcemia
• Hypoglycemia
• Toxins: Ingestions or sedative withdrawal
• Trauma
• Pyridoxine deficiency
• Neoplasm
• Degenerative
  –Alpers disease
  –Rett syndrome
  –Unterricht-Lundborg disease
  –Lafora disease
  –Neuronal ceroid lipofuscinosis
• Genetic
  –Angelman syndrome
  –Aicardi syndrome
• Metabolic
  –Medium chain acyl-CoA dehydrogenase deficiency (MCAD)
  –Myoclonus epilepsy and ragged-red fibers syndrome (MERRF)
  –Sialidosis
  –Glucose transporter deficiency
  –Urea cycle defects
• Vascular: Stroke, hemorrhage, vasculitis
• Hashimoto encephalitis
• Seizure mimics
  –Breath-holding spells
  –Syncope, convulsive syncope
  –Gastroesophageal reflux
  –Cardiac arrhythmia
  –Movement disorder
  –Migraine
  –Benign paroxysmal vertigo
  –Parasomnia
  –Pseudo-seizure
  –Rage attack

Workup and Diagnosis

• History: Detailed description of the spell, loss of consciousness, eye deviation, time of onset, other suspicious spells (jerking, staring, day-dreaming), birth and developmental history, previous history of head trauma, encephalitis, febrile seizures, medications at home, recent infections
• Physical exam: Dysmorphic features, skin rash, retinal exam for cherry-red spot, macular degeneration, hepatosplenomegaly, meningismus
• Full neurologic examination: Postictal weakness can provide clues to the focus of seizures (Todd paralysis)
• Labs: Glucose, electrolytes, calcium, toxicology screen, ammonia, lactate, pyruvate, genetic testing for specific disorders (MECP2 mutation for Rett, FISH on chromosome 15 for Angelman)
• Lumbar puncture to rule out infection (including HSV PCR), glucose transporter deficiency
• EEG can help make the diagnosis of focal vs generalized epilepsy
  –Crucial for decisions of treatment choices
• MRI can help determine any structural abnormalities, including cerebral dysgenesis, abscess, neoplasm, temporal lobe sclerosis
• For other specific etiologies, one can follow up with skin biopsy, CSF amino acids, biotinidase level, TSH, anti-thyroglobulin antibodies, rheumatologic workup

Treatment

• In the acute setting: First evaluate and secure airway, breathing, and circulation
  –IV benzodiazepines (lorazepam) is first line of treatment; in the absence of IV access, rectal diazepam may be used
  –IV fosphenytoin is the second line of treatment and provides longer seizure suppression
  –If not sufficient, phenobarbital can be added
  –Constant evaluation of the airway during treatment, and, if necessary, intubation is critically important

• If the seizure continues despite these medications, anesthesia with pentobarbital, midazolam, or propofol may be used to suppress the refractory seizures
• Long-term prophylaxis can be obtained by one or a combination of anti-epileptic medications
  –Focal seizures: Carbamazepine, oxcarbazepine, gabapentin, levetiracetam, or valproate
  –Absence seizures: Ethosuximide or valproate

Book Source Details

• Book Title: In A Page: Pediatric Signs and Symptoms
• Author(s): Jonathan E. Teitelbaum, Kathleen O. Deantonis, Scott Kahan
• Year of Publication: 2007
• Copyright Details: In A Page: Pediatric Signs and Symptoms, Copyright © 2007 Lippincott Williams & Wilkins.

More About Myoclonus epilepsy

• Back to disease: Myoclonus epilepsy: Introduction
• Next Book Extract About Myoclonus epilepsy: Seizures – Neonatal (In A Page: Pediatric Signs and Symptoms)
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: In A Page: Pediatric Signs and Symptoms Authors: Jonathan E. Teitelbaum, Kathleen O. Deantonis, Scott Kahan Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 1-4051-0427-9

 » Next page: Seizures – Neonatal (In A Page: Pediatric Signs and Symptoms)

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