Seizures and Epilepsy

More documents

Recommendations

Info

Mg++, and liver function tests (LFTs) is important for both the search for a potential cause of the seizures and for medication selection. Urine drug screening should be obtained for patients with new-onset seizures. TREATMENT Physicians and families often agonize over the decision about whether to initiate therapy after a single seizure. In the absence of a structural cause for the seizures or a typical syndrome of epilepsy, most patients do not require long-term treatment with an antiepileptic medication. The patient selection criteria for treatment after a single seizure are listed in Table 3-8. 48,49 Stopping the antiepileptic medication can also be a challenge. The prognostic factors used for making the decision regarding discontinuation are listed in CHAPTER 3 Seizures and Epilepsy ■ 35 Table 3-9. Components of a Seizure History Aura Birth and developmental history CNS infections Exacerbating factors (sleep, emotion, stress, menstrual cycle, substance abuse) Family history of epilepsy Head trauma Postictal state Seizure description by an eyewitness Table 3-9. 49 The selection of a particular antiepileptic medication for a given subtype of epilepsy has long been the subject of controversy. When selecting a given drug, the concomitant medical disorders such as headache, bone marrow dysfunction, and liver insufficiency should be considered. Guidelines for the selection of antiepileptic drugs, the pharmacology of the common Table 3-8. Characteristics of Frontal Lobe Seizures by Region of Onset Anteromedial Frontal Contralateral eye and head version Frequent generalization Somatosensory aura Tonic posture Cingular Amnesia Facial expressions of fear and anger “Psychotic” appearance Dorsolateral frontal Simple partial Tonic eye and head contraversion Frontopolar Loss of tone Rapid generalization Opercular/Insular Complex seizures include gagging, swallowing, chewing, amnesia, genital manipulation Seizures include gustatory sensation, salivation, gagging Orbitofrontal Blinking or staring Complex automatisms Supplementary Motor Area Contralateral tonic posture Simple motor seizure Somatosensory aura Tonic eye and head contraversion Vocalizes antiepileptic drugs, and potential interactions are reviewed in Tables 3-10 to 3-13. 50-53 Surgery for epilepsy is an important but often underutilized treatment option. The surgical option provides an opportunity for some patients to become seizure free. However, this is a complex discussion and beyond the scope of this book. Table 3-10. Patient Selection Criteria for Treatment After a Single Seizure Probably AVM Brain tumor CNS infection Immediate family history of epilepsy Probably Not Acute febrile illness Drug withdrawal or intoxication Electrolye imbalance EtOH withdrawal Hyper/hypoglycemia Immediate posttraumatic seizure Severe sleep deprivation–related seizure
36 ■ Section 2: Common Pediatric Neurologic Problems Table 3-11. Prognostic Factors for Stopping AEDs Favorable Unfavorable Primary generalized epilepsy Partial epilepsy Idiopathic epilepsy Identifiable lesions Childhood onset Adult onset Easy to control Difficult to control Normal neurological examination Abnormal neurologic examination Normal intelligence Mental retardation More than 2–3 years seizure-free Less than 3 years seizurefree Normal EEG Epileptiform EEG From Geyer J, Keating J, Potts D, Carney P, eds. Neurology for the Boards. 3rd ed. Philadelphia: Lippincott Williams & Wilkins; 2006. Non-epileptic Events Non-epileptic events are unusual in the pediatric population, especially in the younger child. Several categories of non-epileptic events (thrashing, staring, etc.) have different natural histories and variable prognosis. Etiologies include conversion disorder, malingering, and medical conditions, especially cardiac disorders. Symptoms suggesting non-epileptic events include closed eyes, resisted eyelid opening, non-physiologic progression, pelvic thrusting, lack of cyanosis, lack of tongue biting, variable semiology, crying, and rapid reorientation following the event. 54-56 Neonatal Seizures Neonatal seizures are poorly classified, under-recognized, especially in sick neonates, and often difficult to treat. Table 3-12. Antiepileptic Drug Selection a Neonatal seizures are often the presenting clinical manifestation of underlying neurological conditions such as hypoxic-ischemic encephalopathy, stroke, intraventricular or intraparenchymal hemorrhages, meningitis, sepsis, or metabolic disorders. Of these, hypoxic ischemic encephalopathy is the most common etiology, accounting for 50% to 60% of patients with neonatal seizures. 57 The neonatal brain is particularly vulnerable to seizure activity as a result of an imbalance of excitatory to inhibitory circuitry. The imbalance favors excitation, and does so to facilitate important developmental processes that occur during the neonatal period (synaptogenesis, apoptosis, progressive integration of circuitry, synaptic pruning). The imbalance occurs anatomically and physiologically by an overexpression of NMDA receptor in the hippocampus and neocortical regions of the neonatal brain, a delay in the maturation of the inhibitory system, and neurons in such regions as the hippocampus are excited rather than inhibited by the neurotransmitter GABA (normally the primary inhibitory neurotransmitter in the brain). Clinical presentation Subtle. Subtle seizures are more common in premature infants. As the name suggests, the seizures may be difficult to identify with only tonic horizontal eye movements, sustained eye opening, chewing, or apnea. In some cases there may be “boxing” movements. These seizures may have limited EEG changes correlating with the seizure activity. 58-61 Clonic. Clonic seizures typically present as rhythmic, slow movements. The movements have a frequency of 1 to 3 Hz. Focal clonic seizures involve one side of the body, and the infant is not clearly unconscious. Seizure Type VPA LTG TPM LVT ETX ACTH GBP CBZ PHT PHB Infantile spasms 1 2 Absence 2 2 1 Tonic-clonic 1 2 2 2 3 2 4, 1 bb Myoclonic 1 2 Atypical absence 1 2 Simple partial 3 2 2 2 1 2 1 bb Complex partial 2 2 2 2 2 1 2 1 bb aNumbers refer to order of preference for use in specific seizure types. bb Infants. From Geyer J, Keating J, Potts D, Carney P, eds. Neurology for the Boards. 3rd ed. Philadelphia: Lippincott Williams & Wilkins; 2006.
Page 1 and 2: CHAPTER 3 DEFINITIONS AND EPIDEMIOL
Page 3 and 4: 32 ■ Section 2: Common Pediatric
Page 5: 34 ■ Section 2: Common Pediatric
Page 9 and 10: 38 ■ Section 2: Common Pediatric
Page 11: 40 ■ Section 2: Common Pediatric

Seizures and Epilepsy

Create successful ePaper yourself

Delete template?

Save as template?