CHILDHOOD SEIZURES AND

MENINGITIS
(PART-1)

DR.M.ASHFAQ. BURNEY

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 Case No. 1
6 year old male child brought to the clinic
with history of seizures, 2 days back.
– What further questions would you like to ask
in the history?
– How would you proceed further with the
investigations and management?

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 “What to ask”?
Age
Sex
History of presenting complaint
– Was there an aura?
– How did the seizure start?
– Were there palpitations or a preceding feeling of light-
headedness?
– Were there symptoms of a "partial complex seizure" (also
sometimes seen in an "absence seizure")?
– Was the person able to respond to any outside stimulus?
– Were there stiffening ("tonic") and/or later harsh jerking
("clonic") movements?
– Was the jaw clenched or was the tongue bitten?

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 “What to ask”? Cont:
– Was there any color change or breathing problem?
– How long did the actual seizure last?
– Was there a "post-ictal" state of confusion? How long
did it last?
– Was there a headache after the episode?
– Was there any incontinence?
– Was there any identifiable trigger? What was
happening at that time?
– Have there been any previous quick startle-like
movements of the hands ("myoclonus"), typically in
the morning hours?
– Have there been any symptoms of night-time
seizures?
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 Past History:
•Maternal drug use (hypnotics,
narcotics, analgesics)
•Maternal infection, bleeding, or
ANTENATAL trauma
•Maternal blood pressure, toxemia,
pre eclampsia, eclampsia
•Fetal movement ---- decreases or
paroxysmal increases
•Polyhydramnios/oligohydramnios
NATAL •Duration,
complication
•Fetal monitoring
•Fetal heart rate and
reactivity •Meconium
•Need for oxygen and
POSTNATAL resuscitation
•Nuchal cord
•Prolonged or precipitous
•Forceps or trauma
•Apgar scores 5
Family history:
Family history of seizures, especially in newborn
period.
Developmental history:
Milestones achieved at the right time or not?

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 General Physical Examination
•Temperature
•Breathing
Vital signs: Blood pressure

Weight and length

Head circumference
Unusual odor of sweat and urine
Dysmorphism •Musty (phenylketonuria)
•Maple syrup (branched
chain ketonuria)
•Sweaty feet (isovaleric
acidemia)

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 Systemic Examination
•Scalp
•Fontanels
HEENT: •Cranial bruits
•Eyes

•Facial angioma
(trigeminal distribution)
SKIN: •Café-au-lait spots
•Vesicles
•Erythematous bulla
•Jaundice
•Mental status
•Cranial nerves
•Motor functions
•Tendon reflexes
•Infantile reflexes
Neurologic examination: •Sensory focal deficits

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 SEIZURES

Abnormal, excessive, synchronous

discharges of neurons.
Intermittent abnormal paroxysmal activity
usually self-limiting, lasting seconds to a
few minutes.

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 Epilepsy
Recurrent seizures without obvious
precipitants.
A condition arising from a variety of
pathological insults involving the cortex.

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 Etiology
•Pre-natal hypoxia and
Neonates ischemia
•Intracranial hemorrhage
and trauma
•CNS infections
•Metabolic disorders
•Genetic disorders
•Drug withdrawal
Infants and children
•Idiopathic
•Genetic disorders
•CNS infection
•Trauma
•Developmental disorders
•Fever

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 CLINICAL CHARACTERISTICS
Stereotyped
– Each one is like the previous one
Random
– Occur at any time of the day or night
Precipitated by specific environmental,
psychological, or physiological events.
– seizures only during sleep
– upon awakening in the morning
– Catamenial seizures
– Reflex seizures

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 Classification
Partial (or focal)
– Simple partial seizures
– Complex partial seizures
– Partial seizures evolving to secondarily
generalized seizures •With motor signs (including jacksonian,
versify, postural).
•With sensory symptoms (including visual,
•Simple partial onset
somatosensory, auditory, olfactory, gustatory
followed by impaired and vertiginous).
consciousness •With psychological symptoms (including
•With impairment of dysphasia, dysmnesic, hallucinatory and
consciousness at onset affective changes).
•With automatism •With autonomic symptoms (including
epigastric sensation, pallor, flushing and
papillary changes). 13
Generalized
– Absence seizures
– Myoclonic seizures
– Tonic-clonic seizures (may include clonic-
tonic-clonic seizures)
– Tonic seizures
– Atonic seizures
Unclassified epileptic seizures

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Distinguishing characteristics of partial and
generalized seizures
Characteristics Partial Seizures Generalized
Seizures
Consciousness Altered in complex Lost
partial seizure
Normal in simple
partial seizure
Focal neurological Common None
symptoms or signs
during or after seizure
Interictal EEG findings Normal or focal Normal or
epileptiform generalized
discharges Epileptiform
discharges
Ictal EEG findings Focal, but may generalized
become generalized 15
Characteristics that distinguish absence and
complex partial seizures

Characteristics Absence Seizures Complex partial

seizures
Patient age Child, rarely adult All ages

Seizure Duration Few seconds 30–50 sec

Automatism Uncommon unless Common

prolonged seizure
Post ictal confusion Absent Present

Seizure frequency Up to 100 per day Usually weekly to

monthly
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Seizure classification algorithm

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 Laboratory Evaluation
Complete blood count
Serum electrolytes
Calcium, magnesium, phosphorus
Glucose
Toxicology screen
Hepatic function
Renal function
BUN
Creatinine
Tests for infectious diseases
Lumbar puncture

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 Electroencephalography
Sustained, abnormal electrical activity that
has a relatively discrete beginning and
end, goes through an evolution
characterized by changing morphology
and amplitude (voltage) of the abnormal
discharges

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 Differential Diagnosis
Febrile seizures
Infectious etiologies
Metabolic
Syncope
Head trauma
Congenital cerebral malformations
Ischemic or hemorrhagic strokes
Inflammatory disorders

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 Whether syncope or seizure?
Assessment of patients with recurrent
unexplained blackouts is expensive, and is cost
ineffective unless guided by a good history and
examination

Patient history and witness account is

paramount

Scoring scheme by Sheldon and colleagues

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 Whether syncope or seizure?
Characteristics Risk
Wake with tongue cutting?
2
Wake with out tongue cutting?
1
Emotional stress associated with loss of consciousness?
1
Head turning during a spell
1
Unresponsive, unusual posture, limb movement, or amnesia
1
of spells? (any one of these)
Confusion after a spell
1
Lightheaded spells
-2
Sweating before spell
-2
Spell associated with prolonged sitting or standing
-2
If point score is >1 the likelihood is seizure or if <1 the likelihood is syncope 22
 MANAGEMENT

Non-pharmacological education:
What Should You Do?
– Stay calm.
– Lay the child down with head and body to the
side.
– Loosen tight clothing.
– Place something soft under the head.
– Clear the area of sharp or dangerous objects.
– Do not place anything in the child’s mouth.
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 Non Pharmacological Rx
Be cautious:
CPR is typically not needed
– Don't panic! or helpful.

– Do not hold the person down or try to stop his

movements as it may lead to muscular injury
or even fractures.
– Don't put anything in the child's mouth--they'll
just break a tooth. They're not going to
swallow their tongue.
– Do not restrain the child--it won't be helpful.

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 Pharmacological Therapy

Type of Seizure
Simple and complex partial: Carbamazepine, Sodium Valproate, Gabapentin,
Lamotrigine, Topiramate, Oxcarbazepine,
Zonisamide, Levetiracetam, Phenytoin,
Pregabalin, Primidone, Phenobarbital

Secondarily generalized: Carbamazepine, Sodium Valproate, Gabapentin,

Lamotrigine, Topiramate, Oxcarbazepine,
Zonisamide, Levetiracetam, Phenytoin,
Pregabalin, Phenobarbital, Primidone

Primary generalized seizures:

Tonic-clonic Sodium Valproate, Lamotrigine, Topiramate,

Zonisamide, Carbamazepine, Oxcarbazepine,
Phenytoin

Absence Sodium Valproate, Lamotrigine, Ethosuximide,

Zonisamide

Myoclonic Sodium Valproate, Clonazepam, Levetiracetam

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 New AEDs
For last couple of years, following new
AEDs approved by FDA:
– Gabapentin
– Lamotrigine
– Topiramate
– Tiagabine
– Oxcarbazepine
– Levetiracetam
– Zonisamide

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 Drugs of choice by seizure type
Seizure type Drug of choice Alternative
Absence Ethosuximide, Lamotrigine,
Sodium Valproate Topiramate,
Zonisamide
Atypical absence/ Sodium Valproate Lamotrigine,
atonic Topiramate,
Zonisamide
Myoclonic Sodium Valproate Lamotrigine,
Clonazepam,
Clorazepate
GTC/tonic/clonic Carbamazepine, New AEDs probably
Phenytoin, valproate useful
Partial onset (all All conventional All new AEDs (most
types including AEDs except are approved only
secondarily ethosuximide as add-on)
generalized) 27
Anticonvulsants Target Dose in
Ataxia, blood dyscrasias,

mg/kg/day Steven Johnsons,

hepatotoxic

Carbamezapine 10-20
Dependence
Clonazepam 0.05-0.2
Gastrointestinal upset
Ethosuxamide 10-20
Weight gain, leg edema
Gabapentin 20-40
Rash, Increased
Lamotrigine risk with
Valproate
5-15
Cognition, Sedation
Phenobarbital Hirsutis, 5-10
gingival

Phenytoin hyperplasia,
teratogenicity, 5-10 Cognitive S/E, renal stones,
rash
acidosis, glaucoma, weight loss
Topiramate 1-9
Weight gain, alopecia,
hepatotoxicity, PCOs,
Valproic Acid 10-20 Pancreatitis
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