Approaching a child that presented with involuntary movements or abnormal behavioural change suddenly

1. • Dr.C.S.N.Vittal
Approach to
Seizure Disorders
in
Children

2. Seizure
(Latin sacire, “to take possession of”)
A transient occurrence of signs
and/or symptoms resulting
from abnormal excessive or
synchronous neuronal activity
in the brain.

3. Epilepsy
Epilepsy is a disorder
characterized by two or more
unprovoked seizures occurring
more than 24 hours apart
beyond neonatal period.

4. • A seizure is the event
Seizure vs Epilepsy
• Epilepsy is the disease
associated with spontaneously
recurring seizures

5. Convulsion
A convulsion is any seizure
(not necessarily epileptic)
characterized by excessive,
abnormal muscle
contractions, which are
usually bilateral.

6. Some terminology
• Dr Neeta Naik, Guidelines for Diagnosis and Management of Childhood Epilepsy; Expert Committee On Pediatric Epilepsy, IAP; Ind Ped, Vol 46 Aug 17, 2009:
681-698

7. Epilepsy – new definition
Epilepsy is a disease of the brain defined by any of the following:
1. A least two unprovoked (or reflex) seizures occurring >24 h
apart
2. One unprovoked (or reflex) seizure and a probability of
further seizures similar to the general recurrence risk (at
least 60%) after two unprovoked seizures, occurring over
the next 10 years
3. Diagnosis of an epilepsy syndrome
• Robert S fisher et al; A practical clinical definition of epilepsy: Epilepsia, 55($):475-482, 2014

8. Questions to Ask
2. What type of seizure?
3. Cause of seizure?
1.Was the spell in question a seizure?
A detailed account of the event or spell from a witness in order to answer the three questions:

9. Pre-ictal
• Was there any warning before the spell? If so, what was the warning?
• Did the child complain of abdominal discomfort, fear or any other unpleasant
sensations before the spell?
• What was the child doing before the spell?
• Was the child asleep or awake prior to the event?
• Was the child sleep deprived prior to the spell?
• Were there any triggers for the spell?
• Was the child well before the spell or was there a fever or illness?

10. Ictal
• Was the child responding during the spell or was consciousness impaired?
• Did the child remember anything that occurred during the spell?
• Were there any repetitive behaviors during the episode, such as lip smacking,
pulling at clothing, and constant rubbing of objects.
• Did any body movements occur?
• Was there any perioral cyanosis?
• How long did the spell last?
• How many episodes has the child experienced?

11. Post-ictal
• How did the patient feel after the spell?
• Did the child seem confused and tired after the spell?
• How long did it take for the child to get back to baseline condition?
• Did the child suffer from a headache after the spell?

12. Other questions to ask:
• Has the child ever had any seizures before? Febrile seizures?
• Ask about past medical history, developmental history and current
medications to rule out a symptomatic seizure.
• Is there any family history of seizures?

13. Motor
tonic-clonic
clonic
tonic
myoclonic
myoclonic-tonic-clonic
myoclonic-atonic
atonic
epileptic spasms2
Non-Motor (absence)
typical
atypical
myoclonic
eyelid myoclonia
Unknown Onset
Motor Onset
automatisms
atonic2
clonic
epileptic spasms2
hyperkinetic
myoclonic
tonic
Non-Motor Onset
autonomic
behavior arrest
cognitive
emotional
sensory
focal to bilateral tonic-clonic
Generalized Onset
Focal Onset
Aware
Impaired
Awareness
Motor
tonic-clonic
epileptic spasms
Non-Motor
behavior arrest
ILAE 2017 Classification of Seizure Types Expanded Version
Unclassified3
2 These could be focal or generalized, with or without alteration of awareness
3 Due to inadequate information or inability to place in other categories
From Fisher et al. Instruction manual for the ILAE 2017 operational classification of seizure types. Epilepsia doi: 10.1111/epi.13671

14. Seizure
Evaluation
on
First Visit
1 Seizure / seizure mimic ?
2 Is it unprovoked / provoked seizure?
3 Generalized / focal seizure?
4 Etiology?
5 Any associated comorbidities?
6 Treatment received till now?

15. Symptomatic seizures are caused by:
• CNS Infection
• Meningitis
• Encephalitis
• Abscess
• CNS Trauma
• Acute trauma
• Previous trauma may lead to scar tissue formation
• Cerebrovascular
• Infarction
• Hemorrhage
• Arteriovenous malformation
• Venous thrombosis
• Hypoxic
• Hypoxic ischemic encephalopathy
• Metabolic
• Hypoglycemia
• Electrolyte disturbances
• Inborn errors of metabolism
• Neurologic effects of systemic disease
• Toxic
• Drugs
• Drug withdrawal
• Alcohol
• Alcohol withdrawal
• Lead poisoning
• Tumour
• Congenital CNS malformations
• Cortical dysplasia
• Lissencephaly
• Neurocutaneous syndromes (e.g. tuberous
sclerosis)
• Fever – febrile seizures are discussed elsewhere

16. Differential Diagnosis
• Syncope
• Breath holding spell
• GERD
• Panic attack
• Conversion or pseudoseizures
• Benign sleep myoclonus
• Benign paroxysmal vertigo
• Motor tics
• Decorticate posturing
• Jitteriness in newborn

17. Physical Examination
• Vitals, including temperature
• Height, weight and head circumference
• Developmental stage of child in gross motor, fine motor, language
and social domains.
• Signs of trauma
• Signs of increased intracranial pressure
• Skin lesions – may suggest a neurocutaneous diseases
• Fundoscopy – look for papilledema – suggests an increase in
intracranial pressure (link to Signs of inc ICP)
• Neurologic exam

18. Blood tests
• Gen:
• CBC and differential
• Electrolytes
• Calcium, phosphorus, magnesium
• Blood glucose level
• Hemorrhagic basis – INR, PTT
• Toxic basis – blood levels of suspected drugs and metabolites
• Genetic disease – possible karyotype and other tests specific to illness
• Metabolic disease
• Ammonia, Lactate, Pyruvate, Amino acids, Urine organic acids

19. Differentiation of Seizures from Nonconvulsive Movements
• Jitteriness – Tremor
• No associated ocular movements or autonomic phenomena,
• Stimulus sensitivity,
• Tremor that is suppressed by flexing the limb.
• Benign neonatal sleep myoclonus
• Occurs in healthy newborns
• Only during sleep. Jerking ceases on wakening
• Apnea of prematurity
• In Preterms, apnea and bradycardia

20. Diagnosis
• History:
• Maternal drug abuse, Intrauterine infection, metabolic disease, natal history,
etc.
• Complete Hemogram
• Blood:
• Sugar, Calcium, Magnesium, Na+, K+ & HCO3 , Elevated Ammonia, Lactate
Levels, Culture & Sensitivity, plasma aminoacids, drugs

21. Lumbar puncture
• Infants <12 months with a first time febrile seizure to rule out meningitis
• Infants 12 to 18 months with a simple febrile seizure
• Any child with meningeal signs
• CSF:
• Analysis, Biochemical & C/s.

22. Imaging
• Cranial U/s.:
• hemorrhage, cysts, abnormal ventricles
• CT scan – indicated if head trauma is present/suspected
• MRI – indicated if the child has new or focal neurological deficits,
recurrent seizures and/or papilledema

23. EEG
• EEG when abnormal can suggest the nature of the seizure tendency as focal or
generalized, but does not determine whether or not a spell was a seizure or whether
or not to treat,.
• 50% of patients with partial seizures show focal spikes (or slowing), up to 75% after
repeat studies or sleep deprivation.
• 90% of patients with generalized seizures show generalized spikes, more with sleep
deprivation, hyperventilation, or photic stimulation.
• A normal EEG would favor partial onset seizures in a patient with epilepsy.
• 1-2% of nonepileptics have spikes on their EEGs.
• 20% of patients with spikes on the EEG do not have epilepsy.

24. Step 6
Switch to another
monotherapy or
addon
Management Strategies
Step 1
Step 4
Select AED
Step 3
Evaluate need for Tt
Step 2
Establish seizure type/syndrome
Confirm Diagnosis
Step 5
Start monotherapy

25. Management Strategies
First Seizure
Generalized
No deficits
normal EEG
Wait and
watch
No deficits
High rec risk
AED trial
Focal deficit
Neuroimaging
treat
accordingly

26. • Dr.C.S.N.Vittal