Gan

Seizures

Definition: is a clinical event in which there is a sudden disturbance of neurological function in association with an abnormal or excessive neuronal discharge. Divided : a. Febrile seizure: Seizure associated with fever in the absence of another cause and not due to intracranial infection from meningitis or encephalitis b. Afebrile seizure (Epilepsy) : Recurrent seizure other than febrile convulsion in the absence of an acute cerebral insult

Type of Seizure
Epilepsy

Idiopathic Secondary cerebral dysgenesis/cerebral damage Cerebral tumour Neurodegenerative disorder Neurocutaneous syndromes

Non epilepsy

Febrile convulsion Metabolic eg. Hypoglycaemia, electrolyte imbalance Head trauma Meningitis / encephalitis Poisons / toxins

Febrile Seizure
Definition and clinical features
Accompany

by fever Between 3 month and 6 years of age Not symptomatic of any acute neurological illness Not preceded by a non febrile seizure

 Occur

in about 3% of children Genetic influence plays a role Usually occur early in viral infection when the temperature is rising rapidly Commonly triggered by URTI, otitis media and occasionally flu and AGE

Type of Febrile Seizure

Simple febrile seizure
15 minutes Primary generalized seizure and no focal features

Complex febrile seizure

> 15 minutes Focal features, either focal seizure and / or Todd paralysis

No recurrence within 24 hours Recurrence within 24 hours Interictal period- normal Normal neurological examination Residual neurological deficit after seizure (include Todds paralysis)

Complication
Epilepsy -family history of epilepsy -neurodevelopmental abnormality. (cerebral palsy) -recurrence

Differential Diagnosis
Infection- meningitis,encephalitis,UTI Trauma- Brain Lesion Metabolic-hypoglycemia, hypocalcemia,

Prognosis
Slightly increased risk of unprovoked afebrile seizure Certain subgroup have an increased risk of epilepsy:

Neurological abnormality (including

developmental delay) Family history of afebrile seizure Complex febrile seizures

Earlier the first seizure, the greater the chance of recurrence

Physical Examination
All organ systems Vital sign (PR, RR, BP, Temperature) Neurological assessment Development assessment

Investigation
1.Lumbar puncture

All febrile fit patient MUST RULE OUT MENINGITIS esp 18 years old Must be done esp if : o Sign of suspected intracranial infection o First febrile fit <18 months old o Complex febrile fit

2.Urine analysis and culture 3.Blood culture 4.Skull x-rays (if suspect significant head injury) 5.Blood glucose level

Management
Control fever 2. Do not start antibiotic unless bacterial infection is suspected 3. > 10 minutes: IV rectal diazepam 4. > 30 minutes: treat as status epilepticus
1.

Status Epilepticus
Continuous seizures lasting for 30 minutes or more, or Recurrent seizures at brief intervals, without recovery of consciousness in between attacks

Classification
Convulsive Generalised - Tonic-clonic Non-convulsive
Absence (petitmal)

Partial

- Tonic - Myoclonic - Clonic - Epilepsia partialis - Non-motor simple continua/ partial motor partial SE - Complex partial SE

Epilepsia partialis continua

Recurrent motor epileptic seizures that are focal Without loss of consciousness Affect a single group of muscle/ several Distal muscle group (e.g. hands) more frequently involved More proximal muscle group (e.g. facial muscles) can be affected as well

Non-motor Simple partial SE (with somatosensory components)

Involves subjective sensory disturbances focal or unilateral paresthesias or numbness focal visual obscuration or focal colorful hallucinations olfactory or gustatory hallucinations atypical rising abdominal sensations

Complex partial SE
Bizarre behaviours, confusional states Main symptoms long-lasting stupor, staring, emotional disturbance, disorientation, irritability, delayed reaction time Automatism repetitive lip-smacking, fumbling, swallowing movement

Aetiology
Prolonged febrile seizures Idiopathic status epilepticus in absence of an underlying CNS lesion or insult Symptomatic status epilepticus underlying neurologic disorder / metabolic abnormality

Prolonged febrile seizure

Febrile seizure lasting more than 30 minutes Particularly in child younger than 3 years of age Most common cause of status epilepticus

Idiopathic status epilepticus

Sudden

withdrawal of anticonvulsants (especially benzodiazepines & barbiturates) in epileptic patients Epileptic children who are given anticonvulsants on irregular basis/ who are non-compliant Initial presentation of epilepsy Sleep deprivation & intercurrent infection in epileptic patients

Symptomatic status epilepticus

Severe anoxic encephalopathy Meningitis/encephalitis Congenital malformation of brain Inborn errors of metabolism Electrolytes imbalance Hypoglycemia Traumatic brain injury (e.g. intracranial hemorrhage) Reyes syndrome Drug intoxication Extreme hyperpyrexia Brain tumor, neurocutaneous syndrome

Pathophysiology
Phase 1 Increase in cerebral metabolic demand Rise in cerebral blood flow (CBF) Anaerobic respiration to maintain cerebral demand Systemic & cerebral lactate levels rise Lactic acidosis Increase in BP, HR, temperature & other autonomic activities

Phase 2 Decompensated status BP falls Cerebral autoregulation ceases, CBF is compromised by hypotension Cerebral hypoxia If untreated permanent brain damage Autonomic dysfunction such as arrhythmia & neurogenic pulmonary edema

Clinical Manifestations

Most common : generalised tonic-clonic, purely clonic seizures

Autonomic manifestation: Tachycardia Hyperpnoea Mydriasis As seizures persist: Respiratory depression Hypotension Dehydration Hyperpyrexia Hypoglycemia

Complications
Metabolic Lactic acidosis Hypercapnia Hypoglycemia Hyperkalemia CSF/serum leukocytosis

Autonomic Hyperpyrexia Permanent brain damage

Cardiac/respiratory Hypoxia Arrhythmia High output failure Aspiration pneumonia Neurogenic pulmonary edema Renal Acute renal failure from rhabdomyolysis Myoglobinuria

Investigations
Full blood count Blood glucose Urea & Electrolytes, including Ca & Mg Arterial blood gases Blood culture Lumbar puncture Metabolic and toxicology study CT scan of the brain EEG

Management
Medical emergency Maintain the vital function (airway, breathing& circulation) Maintain hydration and electrolyte balance, treat acidosis Terminate the seizure (anticonvulsant) - diazepam, phenytoin, phenobarbitone - intravenous route

Meningitis

Meningitis is inflammation of the protective membranes covering the brain and spinal cord, known collectively as meninges.

Inflammation may be caused by infection with viruses, bacteria, or other micro-organism and less commonly by certain drugs.
It is classified as Medical emergency.

Causative Agents
Type Bacterial Viral infection Pathogen (most Common) Strep pneumoniae, E-coli, Neisseria meningitis Coxsackie Virus, Echovirus, Enterovirus, Arbovirus, HIV, HSV-2

TB meningitis
Protozoal Infection Fungal infection

M. Tuberculosis
Toxoplasma Gondii (toxoplasmosis) Cryptococcus neoformans
(cryptococcal meningitis)

Classification

Acute pyogenic (bacterial) meningitis Acute aseptic (viral) meningitis Chronic bacterial infection (tuberculosis).

Causes/ Pathogens:
In neonatal period- Escherichia coli, Streptococcus pneumonae,Salmonella species,Pseudomonas aeruginosa,Streptococcus fecalis and Staphylococcus aureus. 3 months to 3 years: Hemophilus influenza, S.pnemoniae and meningococci(Neisseria meningitidis). Beyond 3 years: S.pnemoniae and Neisseria meningitis. Other: Accidental wound infection and iatrogenic cause. Mode Of Transmission: The bacteria are spread by direct close contact with the discharges from the nose or throat of an infected person.

Predisposing Factor:
Prematurity Low birth weight baby Complicated labor Prolonged rupture of membrane Maternal sepsis Babies in artificial respiration or intensive care.

BACTERIAL MENINGITIS
Inflammation of meninges caused by bacteria. Should be taken seriously. Can be life threatening if not treated right away.

Sign and Symptoms:

The sign and symptoms of meningitis vary and depend both on the age of the child and on the cause of the infection. Because the flu-like symptoms can be similar in both types of meningitis, particularly in the early stages, and bacterial meningitis can be very serious, it's important to quickly diagnose an infection. The first symptoms of bacterial or viral meningitis can come on quickly or surface several days after a child has had a cold and runny nose, diarrhea and vomiting, or other signs of an infection. Common symptoms include: fever lethargy (decreased consciousness) irritability headache photophobia (eye sensitivity to light) stiff neck skin rashes seizures

In newborns and infants, the typical symptoms of fever, headache, and neck stiffness may be hard to detect. Other signs in babies might be inactivity, irritability, vomiting, and poor feeding.

symptoms of meningitis in infants can include: jaundice (a yellowish tint to the skin) stiffness of the body and neck (neck rigidity) fever or lower-than-normal temperature poor feeding a weak suck a high-pitched cry bulging fontanelles (the soft spot at the top/front of the baby's skull) Viral meningitis tends to cause flu-like symptoms, such as fever and runny nose, and may be so mild that the illness goes undiagnosed. Most cases of viral meningitis resolve completely within 7 to 10 days, without any complications or need for treatment.

Acute Pyogenic Bacterial

Investigation:

Physical Examination:
Brudzinskis & Kernigs sign Nuchal rigidity

Laboratory Investigation:
Specimen: CSF Chemistry - glucose and protein. Cytology WBC and %PMN Gram stain or Rapid diagnostic tests Polymerase chain reaction: (N.meningitidis, S. pneumoniae, H. influenzae, S. agalactiae, L. monocytogenes & enteroviruses). Non- specific tests: including C-reative protein, lactic dehydrogenase, and CSF lactic acid level . Culture for pathogens.

Blood, Urine, & Sputum Cultures

CSF Finding
Changes in CSF Normal Pyogenic (Bacterial)

Appearance WBC

Crystal-clear < 5 mm3

Turbid/purulent > 1000 mm3

Mononuclear cells
Polymorph cells

< 5 mm3
Nil

<50 mm3
200-300/ mm3

Protein
Glucose

0.2- 0.4 g/L

40-80 mg/dl

0.5-2.0 g/L
<40 mg/dl

Empirical Therapy For ABM

Age Common Pathogen Anti microbial < 1 month Streptococcus agalactiae, Escherichia coli, Listeria monocytogenes, Klebsiella species Ampicillin plus cefotaxime or ampicillin plus an aminoglycoside

4-12 weeks

Streptococcus pneumoniae, Haemophilus influenzae, Group B streptococcus,Listeria monocytogenes.

Ampicillin plus either cefotaxime or ceftriaxone.

12 weeks and older

H. influenza, N. meningitidis, S. pneumoniae

Ceftriaxone or cefotaxime or ampicillin plus chloramphenical.

Duration of Antibiotic
Microorganism Neisseria meningitidis Haemophilus influenzae Streptococcus pneumoniae Streptococcus agalactiae Aerobic gram-negative bacillia Listeria monocytogenes Duration of therapy, days 7 7 10-14 14-21 21 >21

Adjunct Steroid Therapy for Infants, Children

Dexamethasone is given in a dose 0.5 mg/kg/6hourly for 4 days .The dose should be administered intravenously 15 minutes before first parenteral antibiotic dose. Adjunctive dexamethasone should not be given to the patients who have already received antimicrobial therapy, because administration of dexamethasone in this circumstance is unlikely to improve patient outcome

Complication:

Subdural effusion or empyema Ventriculities Arachnoiditis Brain abscess Hydrocephalous Hemiplegia Aphasia Ocular palsies Hemianopsia Blindness Deafness Mental retardation Shock Status epilepticus

Outcome:
The majority of children recover without permanent deficits. Subdural hematomas develop in approximately 50% of children under 18 months, but most resolve without treatment. Headaches may persists for varying period of time. 15-20% of children may develop auditory nerve deficit. Even when children have defects,many children have no evidence of the defects 2 years after discharge.