In this lecture we are going to discuss seizures
What are seizures?
Seizures are uncontrolled firing of nerves in the brain.
If involing both cerebral hemispheres, seizures are generalized.
it's the whole body.
If it is involing one hemisphere or one area, it may be focal
involving one extremity or one simple area of the body.
In young infants,
seizures maybe vey subtle
and my look very different than in older folks.
They can just be little jittery movements
and sometimes they are missed by doctors and parents alike.
Let's talk first about Status Epilepticus.
Status Epilipticus is frequent or recurrent or prolonged seizures
without returning to baseline in a 30 minute period.
It can be convulsive,
or non-convulsive with few symptoms and usually focal.
So, seizures in general affect about 1 percent of the population
but Febrile seizures, which we will get ino the end of this talk
affect a much larger part of the population;
4-10 percent of children.
and 15 percent of the children who have a first seizure
have another within the next year.
So, recurrence
actually isn't that common, at least not right away.
Many children have one seizure
and never have another one and we never know why it happened.
Seizures are different depending on where they are on the brain.
A frontal lobe seizure
may result in bizarre behavior.
A temporal lobe seizure
may result in depression or mood affect changes.
But a generalized seizure is what we expect to see
with motor movements predominantly appearing.
Alteration of vital signs and respiratory suppression
are absolutely possible during seizures.
And after seizures, they may be a period of sleepiness. postictal period.
This is especially true for generalized seizures.
Also after seizures,
patient may develop a paralysis transly of one side of the body
even if it's a generalized seizure
and that's called Todd's paralysis.
patients feel that they report they feel absolutely
lousy after a seizure.
so we know seizures are no fun to have and would like to prevent them.
the types of seizures can be categorized in many different ways.
Tonic-clonic seizures are the ones which you classically see on television.
an initial atonic phase
of stiffening and then a clonic phase of shaking.
Patients usually fall down
the may have loss of lower bladder or bowel function
and then may be very sleepy afterwards.
or have Todd's paralysis
they may just have a tonic phase
in their seizure or they may just have a clonic phase in their seizures.
myotonic jerks are unique type of seizure
that happens in children.
They will happen up to say 100 times a day.
and it will be a sudden jerking spasm of one arm or one extremity.
Atonic-akinetic seizures
are literally a drop spell,
where there is a complete loss of tone and patients will collapse to the floor.
and absence seizures are unique
and the children will
what we call space out.
there will be a complete lack of awareness of the world
and they will pop right back in again
without any postictal phase.
It may be so subtle that children
don't even know they're doing it but are simply
confused in the classroom
because for them the teacher is jumping forward in time.
if you detect a seizure in a child,
especially a tonic-clonic seizure
we have to be concerned that there may be other causes to the seizure
infectious causes are innumerable
and include brain abscesses, encephalitis
again they might just have a febrile seizure
meningitis,
Neurocystercercosis is an unusual cause from eating raw beef
tuberculosis may cause calcified lesions in the brain that cause seizure,
toxoplasma, same thing
and HIV can cause an encephalitis that can cause seizures.
the birth injuries can result in damage
to the brain that can cause seizures
congenital anomalies the brain such as
polymicrogyria can cause seizures.
degenerative cerebral disease
hypoxic ischemic encephalopathy
tuberous sclerosis of the brain these tumors can cause seizures
neurofibromatosis can cause seizures
patients who have shunts to drain excessive fluid
may have misfunction of that drainage
patients may get acute hydrocephalus and may present the seizure
and hydrocephalus untreated can certainly present with seizure.
many metabolic conditions
that can present procedures such as hypercarbia
and then the hypos
hypocalcemia
hypoglycemia
hyponatremia
and hypomagnesemia.
think of the hypos, calcium glucose sodium and magnesium.
inborn errors of metabolism
may leave children prone to seizures
especially some of the metabolic disorders
that are mitochondrial in nature
like mirth.
or MELAS syndrome
paradoxine deficiency can also cause seizures
and sometimes a dose of vitamin B6 is the cure, especially with newborns.
in traumatic or vascular disease
patients can get seizures from cerebral contusions
child-abuse, trauma
or any cause of intracranial hemorrhage.
toxins can also cause seizures.
Drugs of abuse such as cocaine
and methamphetamine cause vasoconstriction which can cause
ischemia of the brain and seizure.
Lead poisoning can do it in severe
cases as can rarely organophosphates
salicylates,
sympathomimetics
tricyclic antidepressants,
or withdrawal from drugs of abuse.
Those can all cause seizures
and then once we've gone through
all these causes including oncologic causes could it be a tumor
or obstetric causes. Is the patient
have a baby inside them?
and now they have a problem with their liver.
and are getting seizures of results like preeclampsia.
and then after we ruled out all these other causes
we're left with epilepsy.
So, epilepsy is really a diagnosis of exclusion
after you've ruled out all these other potential causes.
also keep in mind
there are things that children do that
look a lot like seizures but it
breath holding spells can be truly remarkable.
These start around six months of age
and go from to go for several years
they usually happen when a child is upset
or displeased or terrified.
they just hold their breath
and they can hold their breath
until they turn blue and literally pass out unconscious.
children tend to eventually outgrow this
they have no long-term sequelae at all.
but there's a lot of counseling needed for the families
syncope can look like a seizure.
panic attacks are often mistaken as seizures.
especially since when patients breathe very quickly
they get a respiratory alkalosis
and that can cause a carpal pedal spasm of the hands
if you see a patient looks scared and has clenching of the fist
but almost always a panic attack
and all that's required is calm.
Tic disorders may look like a focal seizure.
Keep in mind, tics can be fairly complex.
We have another talk about Tics later
Benign myoclonus is common in babies
and parents may bring up videos of their child
doing shaking movements
that they are concerned might be a seizure.
Remember it's common for babies to have an exaggerated startle reflex
when their arms come out and they shake
And commonly these children
will have brief shaking episodes or twitches of the arms and legs
as they're falling asleep.
People, adults do that to.
Dystonic reaction is a
unusual side effect to certain medications.
for example Reglan
or some medicines for nausea
The dystonic reaction is a sudden spasm
of the muscles that is relieved by IV Benadryl.
It really is not a seizure.
Patients may fake seizures
in outright desire to get more attention
or they maybe so stressed out
that their body is seizing
even though they're not actually having true seizures.
We call these pseudo seizures and their very common in adolescents.
likewise night terrors, sleepwalking, narcolepsy
all of these things can be mistaken for seizures.