1. Seizures / Febriles Seizures
Dr. Kalpana Malla
MD Pediatrics
Manipal Teaching Hospital
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2. Topics
• Seizure***
• Causes / Classification
• Neonatal seizures
• Febrile seizures***
• Epilepsy & Specific epileptic syndromes***
• Status epilepticus
• Drug therapy in epilepsy

3. Seizures in children
• Common neurological disorder in children
• Do not constitute diagnosis-Is symptom of
underlying CNS disorder

4. Definition- Seizure :
• Paroxysmal alteration in behavior due to any
transient brain pathology-cerebral
dysrhythmias, Transient ischemic or anoxic
attacks (faints) - excessive and abnormal
discharge from cortical neurons
**May be manifested as Transient, involuntary
alteration or loss of consciousness, abnormal
motor activity, behavioral abnormalities,
sensory disturbance or autonomic dysfunction

5. • 10% of children have seizure
• Most seizures are provoked by somatic
disorders originating outside brain – like –
high
fever, toxins, hypoxia, arrhythmias, psychogeni
c etc.
• Less than 1/3rd of seizures are caused by
epilepsy

6. Terminology
• Fit :-
Clinical manifestation of cerebral
dysrhythmia
- Maybe convulsive-GTC
- Maybe nonconvulsive –
absence or complex partial

7. Terminology
• Convulsion:-
• Tonic clonic motor component of seizure
• When child shows sudden episode of
decerebrate posturing which is followed
by clonic jerking-
**all convulsions are not epilepsy

8. Terminology
• Epilepsy : Two 0r more unprovoked seizure occurring at
an interval greater than 24 hrs apart
– recurrent fits due to repeated primary
cerebral dysrhythmias

9. • What are nonepileptic conditions
that may mimic seizures?

10. Seizure Mimicers
1. Breath-holding spells 1. Benign paroxysmal vertigo
2. Cough Syncope 2. Benign paroxysmal
torticollis of infancy
3. Tics
3. Hereditary chin trembling
4. Acute dystonia 4. Narcolepsy
5. Pseudoseizures 5. Day dreaming
6. Benign myoclonus
6. Hysteria
7. Night terrors
7. Migraine

11. Mimicking seizures
Jitteriness
– Absence of abnormal gaze movements
– Provoked by passive flexion or extension
– Movement to and fro shorter duration
– Normal EEG
– No increase in blood pressure or heart rate
• No postictal phase after these episodes

12. Mechanisms
• Exact cause unknown
• Basis-Failure of mechanism that aborts S
1. Excessive persistent excitation - by
excitatory neurotransmitters --
glutamate, aspartate, acetylcholine also N-
methyl-d-aspartate (NMDA)
2. Ineffective recruitment of inhibition -
dominant inhibitory neurotransmitter
gamma aminobutyric acid (GABA)

13. Mechanisms
3.Significant neuronal burst discharge-
usually by voltage dependent calcium
currents
4.Arise from areas of neuronal death-
these regions promote development of
hyperexcitable synapses that promote
seizure

14. Causes of seizures
1. Febrile convulsions**
2. Epilepsy**
3. Infections- Meningitis**, encephalitis*, brain
abscess**,Cerebral malaria
4. ICSOL**
5. Cerebral ischemia, trauma

15. Causes
6. Metabolic –
Hypocalcemia, Hypoglycemia, Hypomagne
semia, Dyselectrolytemia, Inborn errors of
metabolism
7. Toxic –
Uremia, Hepatic encephalopathy, Reye’s
syndrome, Lead ,phenothiazine
Strychnine poisoning, Shigelosis, Tetanus

16. Causes
8.Renovascular-
Acute nephritis, Hypertensive
encephalo[athy, Hemolytic –Uremic syndrome
9.Arterio-venous malformation
10. Hysterical conversion reaction

17. Febrile Seizures

18. Febrile Convulsion
**Most common seizure disorder with excellent
prognosis
• Definition:-
Seizure occurring with temp ≥38oC in absence
of detectable CNS infections but there may be
association of acute extra cranial infections
and high environmental temperatures

19. Febrile Convulsion
• Incidence – 3-5%
• Autosomal dominant pattern of inheritance
• Chromosome 19p & 8q.
• Thus , family history imp.

20. PATHOGENESIS
• Due to temporary impairment of the balance
between the convulsant and anticonvulsant
system of brain
• Threshold level of anticonvulsant system in
these genetically predisposed children is lower

21. PATHOGENESIS
• Studies in children suggests – that the
cytokine network is activated and may have a
role in the pathogenesis of febrile seizures
• Other suggestion - endogenous
pyrogens, such as interleukin 1, increasing
neuronal excitability & causing seizures

22. Causes - Febrile Convulsion
1.ARI-URTI(Otitis media )
2.LRTI
3.Viral fever- Roseola and Influenza A , other
fever with rash
4.UTI
5. Gastroenteritis

23. Typical F. Convulsion
1. Age- 6months – 5 yrs peak 14 - 18 months
2. With rapid rise of temp ≥38oC ,within 24 hrs
of onset of fever
3.Should not last more than 10 min
4. Generalized not focal

24. Typical F. Convulsion
5. Positive family history ( 50%) - AD in some
families
6. One seizure attack at each episode
7. No residual weakness of limb or disability
except a brief period of drowsiness
8.EEG between and after seizure is normal
9.Extracranial infection may be + but no CNS
infection

25. Criteria for Diagnosis
• Above features plus
• M>F
• Infections: 90% of the cases are due to viral
infections, Common infections are URTI, Otitis
Media, Pneumonia, UTI and Roseola
• Recurrence: 30- 50% under 1 year. Frequency
decreases after 5 yrs of age.

26. Classification
• SIMPLE
- Age group-6months – 5 yrs peak 14 - 18 months
- GTCS
- <10 MIN
- Single in 24 hrs1 fit per febrile episode
- Brief / no post ictal phenomenon
- EEG - N

27. Classification
• ATYPICAL/ COMPLEX
- > 15 MIN
- >1 Episode per fever - Occurs more than once in 24 hrs
- Focal
- + family history
- Pre existing CNS disorder
- Delayed devl or regression
- - Followed by Todd paralysis, but no significant other
- reason or CNS infection can not be found
- EEG may remain abnormal for 2wks or more
• Continuous prophylaxis therapy may be given

28. Risk factor for 1st episode
• + family history
• After immunization – DPT , MMR.
• INFECTIONS esp Herpes virus
• Fe def

29. Risk Factors for Recurrent Febrile
• Younger than 18 months
• Duration of fever (i.e., shorter duration of fever
before seizure - higher risk of recurrence)
• Complex febrile seizure at onset
• Family history of epilepsy
• Family history of febrile seizures
• Height of fever (i.e., the lower the peak fever, the
higher the rate of recurrence)

30. Risk factors for devp of epilepsy
1.+ family history
2. 1st F .seizure before age 9 month
3. Atypical F. seizure
4. Delayed milestones
5. Abnormal neurological findings
Risk of epilepsy increases to 9% from 1% if
above factors are ++

31. AAP Practice Parameter
• Lab testing - identifying source of fever
- part of routine evaluation
• Do blood glucose in all patients
• Blood Studies: No indication for routine testing of
electrolytes, calcium, magnesium, CBC
• Neuroimaging: No need to perform in routine
evaluation of first febrile seizure

32. Investigations - AAP Practice Parameter
• EEG: not needed for first simple febrile seizure
but done in complex febrile seizure
• LP: should be “strongly considered” in < 12
mos and “considered” between 12-18 mos.
• If older than 18 mo, rely on meningeal S&S
• Also consider LP if prior antibiotic treatment

33. Hospital care
1.Position –semi prone –ABC
2. Control fever-antipyretics, tepid sponge
3.Control convulsion-Diazepam IV/PR
4. Infection should be looked for and treated
- LP?
- CBC?
• Parents reassurance

34. Treatment
• Home management
• Reduction of body temp-
- PCM/Ibuprofen
-Tepid water sponging

35. Treatment
5.prophylaxis-
- Intermittent with oral diazepam -0.3mg
/kg/ dose TID
clobazam, midazolam –effective
- Long term prophylaxis- sodium valproate

36. SEIZURE PROPHYLAXIS
• Intermittent • Continuous
• Diazepam • Valproate
• Clobazam • No role of
• Midazolam phenytoin/CBZ/Ph
enobarbitone

37. • Criteria for Prophylactic anticonvulsant
therapy:
1. <18mo with previous abnormal
development or abnormal neurological
signs
2. Atypical febrile seizure
3. Recurrent febrile seizure
4. High level of parental anxiety

38. • Continuous daily prophylaxis given with
Sodium Valproate 30- 60mg/kg/day in two
divided doses to be continued for at least 2 fit
free years or until child is 6 yr old, whichever
comes earlier.

39. Patient Education
• Counsel on the benign nature of febrile seizures
• Reassured that simple febrile seizures do not lead to
neurological problems or developmental delay
• If their child has another seizure -
• To call for assistance if the seizure lasts longer than 10
minutes or if the postictal period lasts longer than 30 minutes

40. Prognosis
• 50% with single F. convulsion have no
recurrence even if untreated
• 30-50% have recurrence
• 40% in 1st episode have > one or more further
convulsions,10% will have multiple attacks
• 1% with no risk factors and 9% with risk
factors develop epilepsy by age 7 yrs

41. Thank you
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