Armando Hasudungan
Biology and Medicine videos

Non-Febrile Seizures (Epilepsy)

This section will mainly focus on Paediatric Epilepsy (NOT FEBRILE SEIZURES)

Remember Children and Adults can have seizures because of metabolic disturbances, trauma or being in a febrile state. This does mean they have epilepsy. Epilepsy is a condition characterised by the tendency for recurrent seizures. Presents when at least 2 unprovoked seizures occur >24 hours apart.

 

Overview

Overview Seizures are a common occurrence in children. 8% will have at least one seizure by 15 years of age. A seizure is the result of an abnormal paroxysmal discharge by cerebral neurons. Many underlying conditions and neurological challenges may provoke seizures, and in over 50% of children seizures are isolated events associated with either a fever (febrile seizures/convulsions) or minor head injury in early childhood. Thus, Seizures can be broadly divided based on:

  • Fever (febrile seizure)
  • Non-febrile seizures

There are many….many causes of non-febrile seizures, one of which is epilepsy.

Overview

Seizures can be classified as focal or generalised

Definition
Seizure: sudden attack of altered behaviour, consciousness, sensation or autonomic function produced by a transient disruption of brain function. The result of this altered brain function is most commonly a tonic (stiffening) or tonic-clonic (stiffening-jerking) seizure.
Epilepsy: common set of variable conditions with recurrent seizures. Presents when at least 2 unprovoked seizures occur >24 hours apart.
Convulsions: a seizure with motor accompaniments
Non Febrile convulsion (seizures): These are seizures occuring without presence of a fever. There are many causes one of which is epilepsy.
Febrile Convulsions: a seizure without other known cause occurring between 6 months and 6 years of age with fever
Remember Children with a fit and fever may have meningitis

Classification of Epilepsy

  • Partial (Focal) Seizures – Retained consciousness seizure
    • Simple
    • Complex
    • Status epilepticus
  • Generalised Seizures – Immediate loss of conciousness
    • Absence
    • Tonic-Clonic
    • Myoclonic
    • Status epilepticus
Side note Epilepsy and febrile seizures have different classifications
SEIZURES TYPES
Partial (focal) Generalised
Simple Tonic & Clonic
Complex Absence
 Status Epilepticus Myoclonic
Atonic
Infantile Spasms (West Syndrome)
Status Epilepticus

Signs and Symptoms

Definition
Tonic: Stiffening
Clonic: Jerking
Tonic Clonic: Stiffening and jerking
Convulsion: a seizure with motor accompaniments
Preictal: Before seizure
Ictal: During seizure
Postictal: after seizure

 

Remember There is no reliable diagnostic test for a seizure. A good first and eye-witness account is essential

 

Remember Prolonged seizure and or repeated disease of antiepileptic’s may lead to airway compromise and breathing difficulty.

Differential Diagnosis

Differential Diagnosis of Seizures in general (VITAMIN)

  • Vascular – Hypoxic-Ischaemic encephalopathy
  • Infection – Meningitis/Encephalitis
  • Temperature – Febrile Seizure
  • Abnormality of the CNS
  • Metabolic Disturbance – Hypoglycemia, Hypocalcemia, Hypomagnesiumea, Hyper/Hyponaturemia
  • Intracranial Haemorrhage/infarction
  • Neoplastic or CNS lesion

Neonatal epilepsy Differential Diagnosis

  • Behavioral events – tics, shuddering, breath-holding, inattention
  • Dystonia’s
  • Cardiovascular events – prolonged QT syndrome
  • Psychogenic
DIFFERENTIATING FEATURES BETWEEN SEIZURE AND SYNCOPE 
Seizures Syncope
Age  Any 8-15 years
Timing Whenever Day
Situation Commonly during activity Standing
Prodrome Brief (twitching, hallucinations) Long (dizziness, sweats, nausea)
Duration Variable Under 5 minutes
Tonic-clonic movement Common Rare
Colour change Maybe be cyanosis Pallor
Injury Common Rare
Incontinent of urine Common Rare
Recovery Drowsiness, confusion or headache Quick Recovery
Think What happens after the “event” is a big differentiating factor between syncope (quick recovery) and seizure (drowsy, confused, headache, fatigue)

Investigations

Identify the cause of seizure if epilepsy has not been diagnosed

  • EEG
  • CT/MRI – Tumours, hydrocephalus
  • FBC – sepsis
  • EUC
  • Calcium/Magnesium/Phosphate (CMP)
  • Lumbar Puncture – meningitis
  • Serum Calcium

Investigations are not necessary for febrile convulsions


Diagnosis of epilepsy

Tests are not performed to determine if a child has epilepsy or not. This is a clinical judgement made by a specialist. However, in general epilepsy is two unprovoked seizures (not related to infection, inflammation or metabolic changes) occurring >24hours apart

Epilepsy - Partial (Focal) Seizure

Partial or Focal seizures is now known as retained consciousness seziures. Partial seizures start in a focus in the brain. The focus may be the site of previous cerebral damage. Partial seizures may be motor, sensory, automatic or psychic. Partial seizures may occur with or without impairment of consciousness and awareness. Partial seziures are divided into simple partial or complex partial.

Remember Partial epileptic seizures are classified as either simple partial or complex partial. Whereas, febrile seizure is classified as either simple (generalized seizure) or complex (partial or generalised). GETS CONFUSING!

Simple

  • Asynchronous tonic or clonic movements; most of the face, neck and extremities, average duration 10-20seconds
  • +/- aura; no postictal period

Complex 

  • Impaired consciousness at some point
  • +/- aura
  • Automatisms common after loss of consciousness
Partial with secondary Generalized Begins focal and spreads around brain to become generalized seizure

Epilepsy - Generalized Seizures

Generalized seizures the whole brain is involved characterized by immediate loss of consciousness. It can be defined by a variety of seizures:

Tonic-clonic seizures (Grand Mal) These fits comprise of  a:

  • Tonic phase (muscle spasm) which may start with a cry – if prolonged to cyanosis THEN
  • Clonic phase (jerking) +/- tongue biting and frothing at the mouth THEN
  • Relaxation and unconsciousness FOLLOWED BY A
  • Period of drowsiness and/or confusion

Flashing lights can be triggers. Seizures can last from less than 1minutes to over 30minutes (status epilepticus)

Absence Seizures (petit mal) Sudden cessation of motor activity or speech with blank stare and blinking. uncommon <5 years of age. No aura and lasts usually <30seconds with no postictal period.

Myoclonic Seizure Repetitive seizures – brief, symmetric muscle contraction and loss of body tone with falling over.

Remember Single jerks as we fall asleep are normal (physiological myoclonus)

Atonic Seizure Known as drop attacks. Sudden decrease in muscle tone makes a child lose postural control and drop to the floor.

Infantile Spasms Rare and serious form of seizure occurring usually at age 1-6months. Associated developmental delay is common. The single most common cause is tuberous sclerosis. Treatment: ACTH + Prednisone + anticonvulsants if no response

Idiopathic infantile spasms “West syndrome”: a severe epilepsy syndrome composed of the triad: infantile spasms, hypsarrhythmia on EEG and mental retardation.

Management

Seizures lasting a few minutes and are self-limiting only need monitoring

  • Anticonvulsants (antiepileptic drug) – usually one and titrated slowly
  • Titrate
  • Monitor
  • Review
Side note Depending on the type of epilepsy, one to several years free of seizure are generally required before anti convulsants are withdrawn.

Pharmacology - Antiepileptics

Watch Pharmacology – Antiepileptic 

Acute Management

  • Seizures lasting a few minutes and are self-limiting only need monitoring.
  • Seizures lasting 5minutes need to be managed with ABCDEFG

pathway

Prolonged seizure and or repeated disease of antiepileptic’s may lead to airway compromise and breathing difficulty.

Discharge

  • Regained full consciousness
  • Provide clear management for any recurrences
  • Provide education, support and follow up with GP

Complications and Prognosis

Prognosis of epilepsy

  • 50% of childhood epilepsy have a favourable course
  • 25% gradually improve
  • 25% are refractory to treatment
Remember after the first afebrile seizure, only 1/3 of children experience further episodes.

Neonatal Seizures (fits)

Overview Seizures are common in the first month as a result of birth injury, metabolic and infective causes or developmental abnormalities. Hypoxic ischemia encephalopathy is the most common cause; seizure usually present within 12-24 hours after birth.

Cause Presentation Association
Hypoxic ischemia encephalopathy 12-24 hours Term, cerebral palsy
Intraventricular haemorrhage 1-7 days Preterm
Metabolic Variable Infant of Diabetic mother, inborn errors of metabolism
Infection Variable TORCH, maternal fever, sepsis, meningitis

References

Royal Children Hospital Melbourne