epilepsy%20(pediatric)
EPILEPSY (PEDIATRIC)
Epileptic seizure is a transient occurrence of signs or symptoms that is due to abnormal excessive or synchronous neuronal activity in the brain.
Epilepsy is a disorder that is characterized by a persistent predisposition of the brain to generate epileptic seizures.
This condition may cause neurobiologic, cognitive, psychological and social disturbances.
It is recommended that all patients having a first seizure be referred to a specialist as soon as possible.

Diagnosis

  • It is recommended that all patients having a first seizure be referred to a specialist as soon as possible
  • Diagnosis of epilepsy should be made by a pediatric neurologist or a child physician w/ expertise in childhood epilepsy
  • History should include but is not limited to: Age of onset, family history, social history, alcohol & drug use, & past medical history including head injury, febrile convulsions, diseases in other organ systems

Seizure Description

  • Pertinent details to be obtained from patient: Frequency of attacks, triggering factors, symptoms before, during & after the attacks, duration of symptoms, injury incurred & incontinence
  • Pertinent details to be obtained from witness: Frequency of attacks, detailed observations before & during the attacks (eg physical symptoms, psychic symptoms & level of consciousness) & symptoms following the attacks

Classification

Seizure types

May be self-limited type, as focal or generalized, or continuous type, as in status epilepticus; precipitating factors should also be determined

Focal

  • Simple partial (no loss of consciousness)
  • Complex partial [loss of consciousness, may start w/ loss of awareness or may follow a simple partial seizure, w/ or w/o automatism (eg lip smacking, rubbing hands, walking, running w/ no recollection)]
  • Partial developing to secondary generalization (w/ tonic, tonic-clonic or clonic features)

Generalized

Consciousness is lost at onset except in myoclonic seizures; motor features bilateral

  • Absence (last for seconds; w/ or w/o automatism)
  • Myoclonic (simple or multiple jerks, often upper limbs)
  • Tonic
  • Tonic-clonic
  • ClonicAtonic (sudden loss of head posture, limbs &/or body)

Unclassified (Usually used when an adequate description is not available)

  • Eg seizures during sleep, no eyewitness

Epilepsy Syndrome

Is classified based on seizure types, age of onset, electroencephalogram (EEG) & imaging

  • The types of epileptic syndromes should be defined
  • The distinction between a focal & idiopathic generalized epilepsy should be made

Focal Epilepsy

  • History of potential cause
  • Aura
  • Focal motor activity during seizure
  • Automatism

Idiopathic Generalized Epilepsy

  • Childhood or teenage onset
  • Tonic-clonic seizures & myoclonic jerks in the early morning
  • Short-absence seizures
  • Photoparoxysmal response on EEG
  • Generalized 3 per seconds spike & wave or polyspike & wave on EEG 

Epilepsies Undetermined Whether Focal or Generalized 

Situation-Related

  • Seizures occurring only when there is an acute metabolic or toxic event (eg alcohol, drugs, eclampsia, non-ketotic hyperglycemia)

Physical Examination

  • Detect signs of disorder associated w/ epilepsy (eg sign of head trauma, ear or sinus infection, congenital abnormalities, focal or diffuse neurologic abnormalities, diseases in other organ systems)

Laboratory Tests

  • Blood glucose level
  • Creatinine & electrolytes
  • Liver function tests (LFTs)
  • Serum Ca & Mg levels
  • Serum prolactin (PRL) level
    • Obtained at 10-20 minutes after a suspected seizure may differentiate generalized tonic-clonic seizures or complex partial seizures from psychogenic non-epileptic seizures among older children
    • Serum PRL determined more than 6 hours after a suspected seizure should represent the baseline PRL level

Imaging

Electroencephalography (EEG)

  • Presence of abnormal electric activity
  • Location of seizure focus
  • Type of seizure disorder
  • Must be performed only after clinical evaluation by an expert in epileptic disorders

Limitations

    • EEG abnormalities are somewhat common in the elderly, migraine patients & in patients w/ psychotic illness, psychotropic medication
    • Abnormal EEG should therefore not be interpreted as confirming a diagnosis of epilepsy
    • EEGs may be normal in a number of epileptic patients
    • A normal EEG should not be interpreted as excluding a diagnosis of epilepsy
    • All children w/ recurrent epileptic seizures should have EEGA repeat EEG & a sleep EEG should be done in children w/ recurrent epileptic seizures & normal standard EEG
    • An ictal EEG should be performed when diagnosis is uncertain
  • In children, an initial work up of presumed ‘idiopathic generalized epilepsy’ syndrome should include an EEG
  • Consider video EEG for refractory epilepsy w/ “normal EEG”

Brain Imaging

  • Computed tomography (CT) scan, magnetic resonance imaging (MRI)
    • MRI is brain imaging of choice in patients w/ epilepsy
    • CT may be used if urgent assessment of seizures is necessary or MRI is contraindicated

Recommended Diagnostic Testing in Patients <25 years old

  • EEG should be performed to assist in classification of seizures & epilepsy
  • Most children w/ epilepsy should have an elective MRI scan
  • Brain imaging is not required if firm diagnosis of ‘idiopathic generalized epilepsy syndrome’ is made based on clinical history & EEG, there is complete & rapid response to 1st-line anticonvulsant medication
  • If firm diagnosis of ‘idiopathic generalized epilepsy syndrome’ is not made, both EEG & brain imaging are necessary
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