Epilepsy in Children
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Transcript Epilepsy in Children
NEUROLOGY FOR
NURSES
ANDREA VAN LIEROP RN BSN
Arkansas Children’s Hospital
Children with Epilepsy
School Issues
Children with poor seizure control are more
likely to have trouble making friends.
Taking medication at school may be
associated with a significant decrease in
social and peer relationships. Even in
children with self reported good seizure
control.
DEFINITION
A seizure is a sudden and stereotyped
alteration in motor activity, sensation,
behavior or consciousness due to an
abnormal electrical discharge of neurons
Epilepsy is a chronic neurological condition
characterized by recurrent, unprovoked
seizures.
Epilepsy
Recurrent seizures produced by abnormal
repetitive neuronal firing in the brain
Occurs in 1-2% of the population
Seizure Classification
Partial (Focal)
Simple
Complex
Primary Generalized
Absence Myoclonic Atonic Convulsive
Tonic
May secondarily generalize
Clonic
Tonic-clonic
Tonic-clonictonic
Evaluation of Epilepsy
EEG & Epilepsy
– Awake only ( 30-40% abnormal)
– Awake and asleep ( 60-70% abnormal)
– Photic stimulation
may induce generalized spike and wave or occipital
spikes
– Hyperventilation
may induce 3/sec. spike and wave (absence)
Evaluation of Epilepsy
Neuroimaging
– Indicated with:
Abnormal neurological exam
Focal onset seizures
Uncertain if focal or primary generalized onset
Onset of seizures after adolescence
– MRI is the gold standard (not CT)
– CT is helpful in the acute setting
i.e. persistent alteration of consciousness or abnormal
neurologic exam
General Guidelines for
Therapy:
Correct classification of seizures leads to
correct AED selection
Treat when the benefit of therapy outweighs
the risk
Avoid polypharmacy
Monotherapy usually results in better
seizure control and less side effects
General Guidelines for
Therapy:
Maximize one medication before changing
to the second
Treat the patient, not the EEG or the AED
level
Use rational polypharmacy when indicated
IF IT’S NOT BROKEN, DON’T TRY TO
FIX IT!!!!!!!!!!
“Women” of Child
Bearing Age on AED’s:
All should receive folic acid
supplementation with a minimum of
1mg/day, or 4mg/day if they are pregnant or
actively trying to become pregnant
Development of AED’s
1993
1993
– Phenobarbital
– Felbamate (Felbatol)
– Other barbiturates
– Gabapentin (Neurontin)
Primidone
– Lamotrigine (Lamictal)
– Phenytoin (Dilantin)
– Tiagabine (Gabatril)
– Ethosuxmide (Zarontin)
– Topiramate (Topamax)
– Carbamazepine (Tegretol)
– Oxcarbazepine (Trileptal)
– Valproate (Depakote,
– Levetiracetam (Keppra)
Depakene)
– Zonisamide (Zonegran)
Natalie
3-week-old infant with no apparent
perinatal complications
Hypotonia
Slow feeder, poor suck
Several spells per day of staring with slight
jerking movements
Neonatal Seizure
Samuel
7-month-old infant with cerebral injury
from “shaken baby” syndrome
Now with episodes described as “startle
reflexes” commonly occurring in clusters
Not responsive to maintenance
phenobarbital
Infantile Spasms
Infantile Spasms
Flexion or extension spasms
Tend to occur in clusters
Cryptogenic vs. symptomatic
– Many potential causes
Onset: Birth to 2 years
– Peak onset: 5-6 months
80% develop mental retardation
60-70% have lifelong epilepsy
Hypsarrhythmia pattern on EEG
Hypsarrhythmia
Electrodecremental
Seizure
Fp1-F3
F3-C 3
C 3-P3
P3-O1
Fp2-F4
F4-C 4
C 4-P4
P4-O2
Fp1-F7
F7-T3
T3-T5
T5-O1
Fp2-F8
F8-T4
T4-T6
T6-O2
1 s ec
50 µV
Charlie
9-year-old boy with long-standing history of
intractable epilepsy with tonic-clonic, tonic,
myoclonic, atypical absence and atonic
seizures
Moderate mental retardation
Frequent injuries from falls
Head Drops
Lennox-Gastaut Syndrome
Onset in early childhood
Multiple seizure types including
– Atypical absence, generalized convulsive,
atonic, myoclonic, partial
Negative neurodevelopmental impact
– Mental retardation
Slow spike and wave (2 hertz)
Atonic
No warning; abrupt onset
Loss of muscular tone results in sudden fall
Brief duration
Injuries common
Very difficult to treat
Atonic
Terry
2-year-old boy with 3-week history of
recurrent episodes of sudden fear or panic
Initial frequency of 2-3 per day, now
increased to 1 per hour or more
Maintenance of consciousness
LMD felt these could not be seizures
Simple Partial Seizure
Gabrielle
12 y/o hispanic girl with 1-year history of
frequent spells with several daily
Diagnosed with “pseudoseizures”
Maintenance of consciousness
Events are stereotypical with extension of
the right arm and turning to the left,
followed by agitated movements and
vocalization with an abrupt recovery
Frontal Lobe Seizure
Simple Partial
Focal onset
Aura is common
No alteration of consciousness
May secondarily generalize
William
12-year-old boy with intractable seizures
with episodes of confusion and
disorientation
Ash leaf spots noted on Wood’s lamp exam
Intractable seizures despite numerous
AED’s
Complex Partial Seizure
Complex Partial
Focal onset
Aura is common
Alteration of consciousness
Automatisms
Postictal confusion
May secondarily generalize
Chelsea
9-year-old girl with 2 seizures during the
last 4 months
First episode occurred during sleep
consisting of a brief generalized convulsion
Second seizure occurred during
wakefulness and involved the right face and
arm with subsequent secondary
generalization
Bilateral Centrotemporal Spikes
Fp1-F3
F3-C 3
C 3-P3
P3-O1
fp2=f4
F4-C 4
C 4-P4
50 µV
1 s ec
P4-o2
Benign Focal Epilepsy of
Childhood
Rolandic (centrotemporal) or occipital
spikes
Nocturnal seizures are common
Seizures are usually infrequent
Remits by 15-16 years of age or earlier
Benign Focal Epilepsy of
Childhood: Treatment
*Treatment may not be warranted for uncomplicated,
infrequent seizures.
If seizures are frequent or tend to secondarily
generalize, treatment should be considered.
Tina
13 y/o girl with frequent staring episodes
described as a blank stare with
unresponsiveness, noted daily at school
Decreasing school performance
Key question: Is there an acute arrest of
activity?
Absence
Absence
Brief staring episodes with unresponsiveness
Sudden onset with an arrest of activity
No aura or postictal confusion
May have associated eye flutter or simple
automatisms
Generalized 3 per second spike and wave
80% will have resolution with age
20% also have convulsive seizures.
Absence: Treatment
1st Choice AED’s
– Ethosuximide (Zarontin)
– Valproate (Depakote,
Depakene)
Phenytoin, Phenobarbital, Carbamazepine, Gabapentin, Topiramate
May even exacerbate seizures
Absence Followed by
Clonic-Tonic-Clonic
Primary Generalized
Convulsive
No warning; abrupt onset
Tonic, clonic, tonic-clonic or clonic-tonicclonic activity
Bowel and bladder incontinence common
Postictal unresponsiveness or confusion
Generalized spike and wave
Primary Generalized
Convulsive: Treatment
1st Choice AED’s
– Valproate (Depakote,
Depakene)
Primary Generalized
Convulsive & Absence:
Treatment
1st Choice AED’s
– Valproate (Depakote,
Depakene)
– Lamotrigine (Lamictal)
2nd Choice AED’s
– Topiramate (Topamax)
– Ethosuximide +
Valproate
– Zonisamide
– Levetiracetam (Keppra)
– Felbamate (Felbatol)
Bubba
13-year-old boy who had a single
generalized convulsion 3 weeks ago
No previous history of seizures
Key question: Do you ever have small jerks
of your arms, especially early in the
morning?
Answer: “Oh yeah, I’ve been doing that for
a couple of years”
Myoclonic Seizure
Myoclonic
Sudden single jerks of the arms and head
May occur in clusters
No alteration in consciousness
May progress to a clonic-tonic-clonic
seizure
Generalized multispike wave
Valproate, Clonazepam, Zonisamide
Juvenile Myoclonic Epilepsy:
Treatment
1st Choice AED’s
– Valproate (Depakote,
Depakene)
Juvenile Myoclonic Epilepsy
Autosomal dominant inheritance
– Chromosome 6
Myoclonic seizures with onset in late
childhood or adolescence
May develop generalized convulsive or
absence seizures
The Rescue Drug
Diastat Acudial is a diazapam rectal gel intended
for the management of seizure patients who
require intermittent use of Diazepam for seizure
activity greater than 5 min.
10mg diastat Acudial can be dialed to 5mg 7.5mg
or 10mg
20mg Diastat Acudial can be dialed to 12.5mg
15mg 17.5mg and 20mg
2.5mg diastat is still available
MAD
Nasal Drug Delivery System
Fast and Effective
Controlled Delivery
No Needles
Midazolam/ Versed
Dosage .2mg/Kg up to max of 10mg
50kg = 10mg/2ml
Deliver slowly in one side of nostril,
hold other side closed
WHEN DO YOU CALL 911
If a patient has been given Diastat or versed
and is not recovering after 3 min.
If the patient has turned cyanotic and is not
breathing
If the patient is having cycles of seizures
even after receiving rescue medication.
Alternative Therapy for
Epilepsy
Ketogenic diet
Vagus nerve stimulator
Epilepsy surgery
Ketogenic Diet
First described by Wilder, Mayo Clinic Bulletin,
1921
Mark 9:29 “This kind can come forth by nothing,
but by prayer and fasting.”
Typically reserved for children with severe,
debilitating and intractable seizures
4:1 (Fat: Protein + Carbohydrates)
– 75-90% of caloric intake as fat
Urinary ketosis 80- 160 millimolar
Ketogenic Diet: Efficacy
150 children prospectively evaluated
Age range: 4 months - 16 years
Average of 410 seizures per month
Results after 1 year:
– 55% remained on the diet
– 1/2 had > 50% reduction in seizures
– 1/4 had > 90% decrease in seizures
Freeman, Vining, et.al. Pediatrics, December, 1998
Vagus Nerve Stimulator:
Rule of Thirds
1/3 - marked improvement
1/3 - some improvement
1/3 – little/no improvement
Potential benefits
– fewer seizures, less severe seizures, shorter
recovery period, decreased meds and side effects,
less fear and anxiety, more control
Epilepsy Surgery:
Criteria for Consideration
Seizures must be medically intractable
Seizures must be debilitating
There should be no chance for spontaneous
resolution
Epilepsy
Surgery
Temporal lobectomy
– 75-90% seizure free
Extratemporal lesional
resection
– 50-75% seizure free
Extratemporal nonlesional resection
– < 50% seizure free
Functional
hemispherectomy
Corpus callosotomy
– Especially for atonic and
brief tonic seizures
Monica
14 year old girl with 1 week history of new
onset convulsive seizures
Hospitalized and loaded with phenytoin
with worsening seizures
Normal EEG
Is it Real or is it Memorex?
Pseudoseizure
NES in Children:
Psychosocial Stressors
#1 Sexual or physical abuse
Others:
– Death of a family member
– Forced separation from family members
– Physical disability or illness of a parent
– Significant family conflict
– Major illness
– Financial stressors
– Moving
– Relational difficulties
CASE HISTORY
An 8 year old girl in 3rd grade has recently
been noted to have staring episodes at
school. She also has a recent decline in
grades.
Case history 2
A 9th grader has a generalized convulsion in
the school lunch room. He had been very
stressed with exams and was extremely
tired. Upon questioning you learn that he
also has jerks of his arms, especially in the
morning.
Case history 3
A 6 year old has experienced 2 seizures.
The first occurred 3 months ago during sleep. His
parents took him to the ER. His CT and labs were
normal. He was scheduled for an outpatient EEG
but did not keep apt. His second seizure happened
during nap time, his kindergarten teacher noticed
he had initial twitching of the right face and arm
followed by a brief generalized convulsion.
ANY QUESTIONS?