CONVULSIONS

(SEIZURES)
PROF. DR. SHAHENAZ M.
HUSSEIN

Seizures

Definition:-

A seizure is the clinical event that result from

abnormal excessive neuronal activity.

Etiology:-

-Alteration of consciousness, motor activity, behavior,

sensation or autonomic function.

-It may be viewed as a symptom of an underlying disease
process.

Classification:-

Acute non recurrent convulsions:One or more convulsive fits that occur during the same
acute illness & do not recur after recovery:-

Febrile convulsions. hypertensive

encephalopathy.
CNs infections:- meningitis, encephalitis.
Intra cranial Hemorrhage: spontaneous, or
traumatic
Toxic:- e.g tetanus.
Intracranial tumors.
Anoxic:- sudden severe asphyxia.
Metabolic:- hypoglycemia, hypocalcaemia, hypo or
hypernateremia.

 Chronic recurrent convulsions:Recurrent attacks of convulsions with symptoms free

intervals:*Epilepsy:
-- Idiopathic.
--Neurocutaneous synd. Such as Sturgeweber, neurofibromatosis, tuberous scelosis.
Organic secondary to brain insult:- postinfection, post- traumatic, post- hypoxic,
post- toxic.
Benign neonatal convulsions.
*Degenerative brain disease.
*Congenital cerebral malformation.

Electrical rhythm in epilepsy

Epilepsy
Defined as Increased Neuronal Excitability

Partial:- Epileptic focus start localized

and remain localized:
Classified according to level of consciousness:
No loss of consciousness:
Motor Sensory Autonomic.
Loss of Consciousness: Temporal lobe epilepsy.

Generalized:- Epileptic focus start

localized then become generalized .
Grandmal Febrile - Status epilepticus Myoclonic
Clonic Atonic.-- Petite mal (typical and atypical)
Tonic.

Unclassified

Generalized tonic clonic

(grand-mal epilepsy)
The commonest form of childhood convulsions 60%:-An aura:- unusual behaviors recognized by the mother.
-Tonic phase:- powerful sustained contraction(5
minutes): The patient falls to the ground stiff due to
powerful sustained contraction of all muscles.
Arm flexed - Legs extended.
-Clonic phase:- Rhythmical contraction and relaxation
of muscles of limbs and face:- Biting the tongue and
incontinence may occur during the clonic phase.
-Duration of attack is variable but if exceed 20 minutes it
considered status epilepticus.

-Post epileptic phase:- The child falls in

deep sleep and afterwards he may be
confused or irritable.
Grand-mal epilepsy has good prognosis if the
first attack start after the age of 3years
and the mental development is normal.

Febrile convulsion
Definition:- Generalized tonic clonic
convulsions which occasionally occur at
the onset of acute extra-cranial infections.
Incidence:- 3-5% in all children.

Etiology:At the onset of acute extra-cranial infections

such as tonsillitis.
- Febrile seizures may signify a serious
underlying acute infections.
- In association with high environmental temp.

Clinical picture:Criteria for diagnosis of simple febrile convulsions:-

free.

Patient type:- Age: 6month to

6years. - Sex: male more than
female.
Family history: Strong positive.
- Neurologically & metabolically

Seizures stages:Pre- Ictal:- Convulsions occur at the

onset of temperature 39o c or more.
Ictal:- Generalized tonic clonic.
Short duration:- 5-15 minutes.
Course:- Usually one convulsive fit
during the same illness.
Post-ictal:- Short postictal stupor.

Investigation
Laboratory:CSF analysis: Indicated if any doubt exist
regarding the possibility of meningitis.
EEG:- Indicated in atypical febrile seizure persists
for more than 15 minutes or recurrent more than
3 time/day, or focal seizures.

A child at risk for developing

epilepsy: Positive family history of epilepsy
Initial febrile seizures before the age of 6
months.
A febrile seizure.
Delayed developmental milestone.
Associated Respiratory manifestation
(cyanosis).

Prognosis:- Risk for developing epilepsy

is 1% in children without risk factors,9%
with risk factors.

Treatment: Immediate first aid measures.

Measures to lower the temperature:Cold fomentation / Antipyretics.
Treatment of the cause of fever e.g
Antibiotics for acute tonsillitis.
Short acting anticonvulsant:Diazepam (valium) 0.25mg/kg/dose.

Generalized absence = petit-mal

epilepsy
- The commonest age 5-9 years.
- Rare below 2years and never continue after
15 years.
- Short sudden loss of consciousness.
- The child suddenly stops talking and stares
for few seconds.
- Recovery is immediate and child resumes
talking.
- Not associated with limb movement.
- Recurrent up to more than 100 times/day.
- May affect school performance.

Myoclonic epilepsy
- Occurs at any age but is more seen in infants and
young children.
- Usually associated with mental retardation.
-The attack which is very frequent, present with
sudden symmetrical mass jerking involving all
limbs.

Juvenile myoclonic epilepsy

-Occurs during adolescence
A.D.
-Chromosome No. 6
The hallmark is morning myoclonus within 90
minutes after awakening.
-Resolved with Valporic acid therapy for life.

Atonic (a kinetic) epilepsy

- It is a type of myoclonic epilepsy.
- Transient loss of consciousness and falling on the
ground.
- Then immediately the child gets up and resumes
activity.
- The condition may be confused with petit mal.

Benign neonatal convulsions

-A.D.
- Chromosome No. 20
-Generalized clonic seizures
-Occurs toward the end of the 1st week of life.
-Called familial 5th day fits.
-Favorable prognosis.

Infantile spasm ( West syndrome)

Brief convulsion of the neck, trunk and arm muscles
followed by sustained muscle contraction lasting 2 to 10
seconds.
Occurs when the child awakening or going to sleep.
Each jerk is followed by a brief period of relaxation, many
clusters occurs each day.
EEG showed Hypsarrhythmia ( high- voltage slow waves,
spikes and polyspikes).
Peak age 3-8 months. - It could be mistaken for infantile colic.
Treatment by ACTH,or oral steroids, or benzodiazepines,or
valproic acid and vigabatrinis also promising.

Status epilepticus
Definition:Continuous convulsion or repeated
convulsions without return of the level of
consciousness more than 20 min.
Causes:-Sudden withdrawal of anticonvulsant.
-Febrile convulsion in poorly controlled
epileptic patient.
-Metabolic or toxic.

Management:
1-Stop the convulsion by:- Diazepam 0.2 0.4mg / kg / dose I.V. or 0.5mg/kg/dose
rectally.
- Chloral hydrate or paraldehyde:- 0.15 mg/kg diluted in
saline I.V or 0.5ml/kg/dose rectally
- If failed give general anesthesia (short acting
barbiturates).
2-Long-term anticonvulsant: Phenobarbitone 3-5mg/kg/day.
Diphenylhydantoin 5-8mg/kg/day.
3-Evaluation of the patient:
After the attack
Todd's paralysis may occur and then resolve completely.

Partial (focal) seizures

Motor :

Jacksonian epilepsy
(simple partial motor seizures): Involve the motor area of the brain and the
patient is alert.
Consists of clonic movements in a localized
group of muscles. Commonly at the Corner
of mouth, Thumb, and Great toe.
Jacksonian march:- The neuronal discharge
may spread to other parts on the same side
or become generalized.
Rarely may continue for hours or day
(epilepsia partialis continue).
After the attack, there may be weakness of
the part involved (Todd's) paralysis.

 Sensory seizures:-

(simple partial

sensory seizures): Localized or spreading parasethesia:tingling, coldness, numbness electricity or

even pain.

Autonomic seizures-

(simple partial

autonomic seizures):Autonomic manifestation:

-Sweating. - Tachycardia.
Diarrhea or Constipation.
Hypertension.
Abdominal pain (abdominal epilepsy).
Pupillary dilatation or constriction.

Temporal lobe (psychomotor)

Partial complex epilepsy
Sequence of events: Aura:- blinking of eyes, abnormal sound, taste,
smell or movement.
Absence:- loss of consciousness.
Automatism:- automatic movements e.g:
chewing, smacking of lips.
Amnesia:- recent amnesia for all events during
the attack.

Treatment of epilepsy
Duration of therapy: 3 or 4 years after the last convulsions in grandmal or petit mal epilepsy in an otherwise
normal child.
Longer period or even life long for those with
associated neurological problems.

Advice to parents & child: Give full information about the drug
therapy and stress on not to stop the
drug without medical advice.
Allow normal activities:- the child
should be attended by a responsible
adult while bathing or swimming.
Give clear instructions about the firstaid measures in case the seizures:
1. Ensure patent airway.
2. Avoid biting the tongue
3. Putting the child in the prone or side
position with head down.

 Anticonvulsants:
Type of
seizures

Drug of
choice

Daily dose

Side effects

Neonatal

Phenobarbito
ne

3-5 mg/kg

Irritability,overacti
vity

Grand-mal

Na-Valproat,
Phentoin,

10-20mg/kg -Hepatic
dysfunction
4-Ataxia,gum
8mg/kg
hypertrophy.
-Rash, Leucopenia,
hepatic
10-20mg/kg dysfunction

Carpamazepi
ne

Focal motor

Carpamazepi
ne

4-8mg/kg

Rash, Leucopenia,
hepatic
dysfunction

Psychomotor

Carpamazepi
ne

4-8mg/kg

Rash, Leucopenia,
hepatic
dysfunction

Myoclonic,

Clonazepam

0.05-

Drowsiness,

New drugs used for treatment of

epilepsy:
-For generalized seizures:
Lamotrigine
Topiramate
Zonisamide
-For partial seizures:
*Gabapentine
-For Infatile spasm:
*Topiramate
*Vigabatrin