DR SUNIL SABLE,MD

Fellow Paediatric Neurology

Consultant Paediatric Neurologist
INTRODUCTION
Epilepsy is common disorder constituting 60-
70% of all pediatric neurological disorders.

Of all the epilepsies, 70% have onset in

paediatric age group.
DEFINITION
CONVULSION- Attack of involuntary muscle
contraction,either sustained(tonic) or
interuppted(clonic)
SEIZURE- Abnormal clinical events due to
excessive and abnormal electrical activity
of cerebral neuron
EPILEPSY- 2 or more unprovked seizure 24
hr apart. A cluster of seizures within 24
hours is considered as single episode.
APPROCH TO CHILDHOOD
EPILEPSY
STEP1-HISTROY TAKING
STEP2-RULE OUT SEIZURE-MIMIC
STEP3-FOCAL OR GENERALISED
STEP4-SYNDROMIC CLASSIFICATION
STEP5-ETIOLOGY
STEP6-TREATMENT
STEP1-HISTROY TAKING
Eye witness
Awake or sleep
Precipitating factors
Aura
Clinical description of events-focal or
generalized, consciousness
Post ictal state
post ictal neurological deficit
family history
Birth history and milestone
STEP2-Rule out seizure-
mimic
Benign sleep myoclonus
Benign Myoclonus Of Infancy
Breath holding spasm
Startle disease
Spasmas nutans
Night terror
Narcolepsy and cataplexy
Syncope
Suddering attack
Open eyes, eye deviation, head deviation, incontinence,
tounge bite are fairly specific for seizures
Unresponsiveness,confusion,clonic/tonic movements are
suggestive
STEP3-FOCAL OR GENERALISED
A} FOCAL SEIZURE
1) Simple partial seizure- consciousness not impaired
2) Complex partial seizure- consciousness impaired
3) Partial seizure evolving to secondary generalization
B} GENERALISED SEIZURE
1) Tonic seizure
2) Clonic seizure
3) Generalized Tonic-Clonic seizure
4) Absence seizure
5) Myoclonic seizure
6) Atonic seizure
7) Infantial spasm
C} Unclassified epileptic seizure
SIMPLE PARTIAL SEIZURE
Motor
Sensory
Auonomic
Psychic
SPS----CPS
SPS---GENERALISED SEIZURE
COMPLEX PARTIAL
SEIZURE
Impairment of consciousness
Aura
Automatism
a) Alimentary- chewing, salivation
b) Mimetic- movement of face-fear, vacant look,
laughing,crying
c) Gestural- repetitive movements of hands and
fingers and sexual gesture
d) Ambulatory phenomenon- wandering, running
e) Verbal phenomenon- short
phrases,expletiveCPS----GENERALISED SEIZURE
GENERALISED TONIC CLONIC
SEIZURE
Five phases total duration 5 to 15 minutes
1) Aura
2)Tonic phase- 10 to 30 seconds,flexion followed by
extension,apnea
3)Clonic phase- 30 to 50 seconds
4)Autonomic phenomenon- begins in preictal phase max at the
end of tonic phase decreases abruptly at onset of clonic phase.^
HR,^ BP,^ spincture
tone,flushing,cynosis,piloerection,perspiration,salivation,bronchial
secretion
5)Post-ictal phase- 1 to 5 min., ^ muscle tone followed by
decrease tone,bladder sphincer muscle relax-
incontinence,respiration return,loss of consiousness remain
complete,BP normal,tachycardia,cynosis changes to palor
6)Late post-ictal phase- 2 to 10 min,flaccidity,HR normal,DTR
absent,planter extenser,awaken by passing through stages of
coma,confusional state,drowsiness or may directly sleep without
awakening
ABSENCE SEIZURE
Starts abruptly without aura,loss of
consciousness lasts for few second to half
minute
A) Typical Absence Seizure
a) Simple-impairment of consiousness only
b) Complex-clonic,
tonic,automatism,autonomic component
B) Atypical Absence Seizure- onset and
cessation not abrupt, changes tone more
pronounced
MYOCLONIC SEIZURE
Sudden,brief,shocklike contraction

Less than 350 microsecond

Focal,segmental,generalised
TONIC SEIZURE
Sudden onset of increased tone in extensor
muscle.

If standing fall
ATONIC SEIZURE
Loss of muscle tone.

If confined to group of muscle such as neck-

head drop

IF involve trunk-fall
CLONIC SEIZURE
Occur exclusively in neonate and young
children
INFANTILE SPASM
STEP5-SYNDROMIC
CLASSIFICATION
Cluster of signs and symptoms together.
Based on age,semiology,etiology,anatomy,precipitating
factor,severity,chronicity,diurenal variation,prognosis and response to treatment
A} Localisation related epilepsies and epileptic syndrome
1)Idiopathic:e.g. BECTS,BEOP
2)Symptomatic or probably symptomatic:e.g.migrating partial epilepsy of early
infancy,MTS,Rasmussens syndrome,HHE syndrome
B} Generalised epilepsies and syndrome
1)Idiopathic:BNFC,BNIC,BMEI,CAE,JAE,JME,epilepsy with GTC on awakenening
2)Cryptogenic or symptomatic:West syndrome,LGS,MAE,epilepsy with myoclonic
absence
3)Symptomatic:EME,EIEE or Otahara syndrome
C}Epilepsies and epileptic syndrome undetermined as focal generalised: neonatal
seizure,SMEI,epilepsy with CSWS,LKS
D)Special syndrome
Situation related seizure
febrile sz
Isolated sz or isolated status epilepticus
Acute symptomatic sz e.g. alcohol withdral sz,eclamsia,uremia
STEP5-Etiology
1)Symptomatic:known CNS dissorder

2)Idiopathic: no known cause

3)Cryptogenic(probably
symptomatic):presumed to be symptomatic
but no known cause
INVESTIGATION
EEG
Less than 24 hours-pick up rate 55-70%
After 7 days:35%
First recording-40-50% normal
Yield increased by repeated recording,prolonged recording,sleep
deprivation
EEG helps in classifying sz type and diagnosis of various syndrome
EEG recommended for diagnostic evaluation of first unprovoked sz
3-4 days after sz.
NEUROIMAGING
CT/MRI with epilepsy protocol
Done in suspected symptomatic sz,sz cluster,focal deficit,altered
consiousness,focal EEG
Blood investigation
Lumber puncture
STEP6-TREATMENT
Risk of recurrance after first sz-40%,in majority of cases sz recur
only few times or not at all
Risk of recurrance after second sz-70%-justified treating
Risk factor for sz recurrance
Preexisting static brain abnormalities
focal neurological deficit
Abnormal EEG
Tumor or other progressive lesion
Status epileptics
Family history of epilepsy
Previous febrile sz
Abnormal neuroimaging
DRUG TREATMENT
Acute symptomatic sz-
Epilepsy in 10-15%.
AED do not influence
Short term AED
Benign epilepsy syndrome
Withhold treatment
But if sz frequent,prolonged,parental
anxiety, medical help away-consider
treatment
If no treatment-Advise rectal
diazepam,buccal or nasal midazolam
CHOICE OF AED
Epilepsy syndrome
Type of sz
Age and gender
Premorbid condition
Cost
Epilepsy syndrome
West $-
ACTH,Vigabatrin,valparin,clonazepam,
nitrazepam
LGS- VPA,LTG,CLB,TPM,Zonisamide
CAE-VPA,CLB,LTG Contra-CBZ
BECTS-CBZ,VPA,CLB
LKS-Steroid,VPA,CLB
IGE-VPA,LTG,Acetazolamide Contra-
PTH,CBZ
Partial sz-PTH,CBZ,OXZ,TPM,LEV
Generalised sz-VPA,CLB,LTG
Age and Gender
Infant-PB,CLB,LTG
Do not use CBZ,PTH,VPA,VGB
School Age-CBZ,VPA.
Avoid PB,BZD,VGB-neurobehavioral side
effect
Adolescents: Preferabally sustained
release preparation VPA,CBZ,CLB,PHT
PTH avoided in female due to cosmetic
reasons
VPA-wt. gain,PCOD
Premorbid condition
Childrens with behavioral and school problem-
Avoid PB,VGB,BZD
Drolling-worsened by BZD
Obesity-Avoid VPA,VGB,CLB
Sleep disturbance-Avoid BZD,PB
Metabolic disorders-Avoid VPA
How to use antiepileptic
drug
Drug introduction
Start with minimum dose-titrate dose till sz
controlled or side effect occur
Do not increase the dose with increase in wt. if sz
is under controlled
Side effect can be avoided with slow titration
CBZ,PB,BZD-start low dose increase gradually to
avoid sedation
LTG-slowly increase to avoid rash
VPA can be introduced at maintaince dose without
significant problem
DOSE INTERVAL
Compliance-once or twice daily doses optimal
PB-OD,BID
PHT-TDS
VPA,CBZ,CLP-TDS
VPA SR,CBZ SR-BD
CLB,TPM,VGB,LTG-BD
Give drug at meal time
MONITERIG
Clinical monitoring of sz and adverse effect
Follow up after 1,3,6,12 months
Sz not controlled-frequent
CBC for CBZ,LFT for VPA-not recommended
TDM-status epilepticus,toxicity,non compliance
Sz diary
EEG-Routinely not required, done if sz control poor
or deterioration in school performance and
language or other cognitive skill to rule out
epileptic encephalopathy
MONOTHERAPHY
Less side effect, more compliance
Introduce small dose-titrate till sz controlled
No sz controll with maximum dose-introduce
new drug and taper out first drug
Sz reduced but not stopped-add on second
drug
RATIONAL
POLYTHERAPHY
Using not more than two drugs at time and
avoiding drugs with similar mech. of action
e.g. PB & BZD,PHT & CBZ
VPA & CLB or LTG-synergetic
SIGNIFICANT INTERACTION
PB,CBZ,PHT-enzyme inducer
VPA decreases clearance of PB and LTG
VPA & CBZ- increases CBZ epoxide-toxicity
DRUG WITHDRAL
Most epilepsies-2 yr sz free
Adoloscent onset,remote symptomatic
epilepsy,abnormal EEG-3 to 4 yr sz freedom
JME-life long treatment
Drug withdral over 3-6 months and one drug
at time in case of polytheraphy
HOME TREATMENT
Rectal Diazepam-0.5 mg/kg

Nasal or buccal midazolam-0.3 mg/kg