Seizures in children

Seizures in Children

  • Overview presented by MUDr. Gabriela Kiss, Faculty of Medicine, UPJS

Seizures in Pediatrics

  • Most common neurological disorder in children

  • Affects 4-10% of pediatric population; at least one seizure event in a lifetime

  • Various conditions, different etiology and character

Definition of an Epileptic Paroxysm

  • Transient, time-limited impairment of neurological functions

  • Symptoms arise from excessive or synchronous neuronal activity

  • Symptoms may include motor, sensory, psychic, or autonomic signs, with or without altered consciousness

Definition of Epilepsy

  • Condition in which the brain shows persistent tendency to recurrent seizures

  • Criteria:

    1. At least 2 unprovoked seizures >24 hours apart

    2. 1 unprovoked seizure with likelihood of another within 10 years

    3. An identified epileptic syndrome

Classification of Seizures

  1. Beginning of Seizure: Location of the brain

  2. Level of Consciousness: Impairment during seizure

  3. Other Features: Various manifestations

Manifestations of an Epileptic Seizure

  • Seizures can exhibit various symptoms including:

    • Myoklonus

    • Tonic and clonic symptoms

    • Spasm, dystonia, automatism

    • Atonic signs (astatic), akinesis

    • Version (eye deviation), speech disorder, vomiting

Seizure Onset Localization

  • Important for treatment choices, including:

    • A) Focal/Partial

    • B) Generalized

    • C) Unknown localization

    • D) Focal seizure progressing to generalized tonic-clonic seizure

Consciousness Status

  • Focal seizures may present with:

    • A) No impairment of consciousness

    • B) With impairment of consciousness

  • Generalized seizures typically show consciousness impairment

Description of Motor Symptoms in Focal Seizures

  • A) Focal motor seizures may include specific movement types:

    • Twitches, tonic movements, automatisms (lip licking, hand movements)

  • B) Focal seizures without motor features include:

    • Subjective changes in emotions, feelings, or thoughts

  • C) Includes both motor and non-motor features

  • D) Auras may occur

Description of Generalized Seizures

  • A) Generalized motor seizure is characterized as tonic-clonic (grand mal)

  • B) Generalized seizures can also manifest as absence (petit mal)

Clinical Aspects During Seizures

  • Physiological changes occur during seizures:

    • Increased cerebral blood flow and glucose consumption

    • Increased lactate and CO2 production

  • Objective signs in children:

    • Tachycardia, hypertension, increased body temperature, hyperglycemia, hypoxemia

Additional Clinical Symptoms During Seizures

  • Breathing difficulties (dyspnea, hyperventilation)

  • Vegetative symptoms (nausea, vomiting)

  • Irritability or fatigue

  • Disorientation, confusion

  • Incontinence (urine or bowel)

Short vs. Prolonged Seizures

  • Brief seizures rarely lead to permanent neurological damage

  • Prolonged seizures can cause permanent damage, may lead to:

    • Rhabdomyolysis, hyperkalemia, hypoglycemia, hyperthermia

Tonic-Clonic Seizures

  • Initial tonic phase includes:

    • Paleness, mydriasis, eye deviation, muscle contraction, incontinence

  • Clonic phase involves:

    • Rhythmic twitches and impaired mental status

Stages of a Seizure

  • Comprises:

    • Hallucination, confusion, stiff body, amateur cry, frothy saliva

    • Tonic stage, clonic stage, postictal stage

Myoklonus

  • Characterized by violent, shock-like muscle twitches

  • Involves simultaneous contraction of muscle agonists and antagonists

  • Can occur physiologically (e.g., while falling asleep)

Atony

  • Sudden loss of muscle tone with impaired consciousness

  • Can manifest as drooping eyelids or inability to hold objects

Absences

  • Sudden cessation of motor activity with unresponsiveness

  • Accompanied by amnesia

Etiology of Epileptic Seizures/Epilepsy

  • Febrile conditions (febrile convulsions)

  • Idiopathic, genetic epilepsy syndromes

  • Structural brain lesions (focal cortical dysplasias)

  • Neuroinfections, expansive processes, intracranial hypertension

  • Systemic infections, diseases, intoxications, congenital disorders

Further Etiological Factors

  • Metabolic disorders (hypoglycemia, hyperglycemia)

  • Mineral imbalances

  • Kidney or liver failure

  • Endocrine disorders and vitamin deficiencies

Non-Epileptic Paroxysmal Events

  • Events mimicking seizures include:

    • Disorders with altered consciousness (syncope)

    • Mental disorders like ADD/ADHD, hysteria

    • Sleep disorders (nightmares, somnambulism)

Differential Diagnosis of Non-Epileptic Events

  • Gastroesophageal reflux (GER)

    • Sandifer's syndrome can mimic seizures in infants

Epileptic Encephalopathies

  • Characterized by:

    • Drug-resistant seizures, cognitive deficits, poor prognosis

    • Epileptic activity contributing to cognitive decline

Types of Epileptic Encephalopathies in Infants

  • Otahara syndrome, West syndrome, Dravet syndrome, Lennox-Gastaut syndrome

Genetic Syndromes Affecting Epilepsy

  • Rett syndrome (affects girls), Angelman syndrome, tuberous sclerosis

  • FOXG1 syndrome, Dup15q syndrome, KBG syndrome

Other Epileptic Syndromes in Children

  • Rassmusen syndrome: characterized by pharmacoresistant seizures

  • Opsoclonus-myoclonus syndrome in neuroblastoma

Epilepsies with Spontaneous Remission

  • Benign, self-limited forms such as epilepsy with centrotemporal spikes

  • Often outgrow by adolescence

Age-related Epileptic Seizures

  1. Newborn-3 months: Congenital malformations, metabolic errors

  2. 4 months-4 years: Peak incidence of seizure types

  3. 4-12 years: Manage seizures, limit to benign forms

  4. 12-18 years: Increased generalized seizures from triggers

Typical Seizure Events in Newborns

  • Characteristic tonic and clonic seizures

  • Common causes include:

    • Hypoxic-ischemic encephalopathy and intracranial hemorrhage

Non-Epileptic Events in Newborns

  • Benign neonatal myoclonus: harmless and resolves within months

Infant Age Seizures

  • Febrile seizures: complication of fever, manageable under certain criteria

    • Onset typically between 6 months and 5 years

Characteristics of Febrile Seizures

  • Often arise from rapid temperature rise exceeding 39 degrees Celsius

  • Most children experience simple febrile seizures, but complicated can lead to long-term risks

Infantile Spasms

  • Sudden muscle contractions forming series, typical feature of West's syndrome

Affective Respiratory Attacks

  • Loss of consciousness triggered by negative emotion or crying

Preschool Age Epileptic Forms

  • Epilepsy with myoclonic-astatic seizures (Doose syndrome)

  • Lennox-Gastaut syndrome characterized by various seizure types

School Age and Adolescence Seizures

  • Child absences: brief loss of awareness during activity

  • Juvenile myoclonic epilepsy: onset between age 12-18

  • Benign partial epilepsy with centrotemporal spikes: common partial epilepsy

Non-Epileptic Differential Diagnosis

  • Includes syncope, tics, psychogenic seizures (related to stress)

Diagnostics for Seizures

  • Careful evaluation includes patient history:

    • Age of onset, event description, time of day, precipitating factors

Minimum Diagnostic Standards

  1. Complete pediatric examination

  2. Neurological assessment

  3. Lab tests (CBC, glucose, ions)

  4. EEG and possibly CT/MRI

Status Epilepticus

  • Generalized seizures typically last <2 min.

  • Important to treat seizures lasting >5-10 minutes

  • Mortality rate for generalized tonic-clonic is 10-20%

Management/Treatment of Epileptic Seizures

  1. First-choice meds: Benzodiazepines (e.g., Diazepam)

  2. Second-line: Fenobarbital (Luminal)

  3. Treatment causes (e.g., antipyretics for febrile seizures)

Management of Epilepsy

  • Proper classification essential for treatment success

  • Antiepileptic drugs from various generations:

    • I: Older (e.g., valproate, carbamazepine)

    • II and III: Newer generation drugs with specific properties

Anticonvulsant Treatment Strategies

  • Pharmacological and non-pharmacological options:

    • Ketogenic diet, neurosurgery for drug-resistant cases

Comorbidities Associated with Epilepsy

  • Include behavioral, psychological problems, and autistic spectrum disorders

  • Important for early identification and appropriate management

Relevant Information Concerning Epilepsy

  • Considerations regarding driving, pregnancy, and occupational restrictions

Case Report Example

  • 7-year-old boy with atypical presentation, nocturnal vomiting, later diagnosed with focal epilepsy

Conclusion

  • Thank you for attention!