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FEBRILE SEIZURES

Febrile seizure – seizure occurring in healthy children ages 3 months to 6 years, with
axillary temperature of 37.8 C or greater, without evidence of CNS infection. Seizures
with fever in children with previous nonfebrile seizures, a previous diagnosis of
neurologic insult or abnormality, and an abnormal neurologic examination are excluded.

SIMPLE FEBRILE SEIZURE


A. DEFINITION
Simple febrile seizure is seizure characterized as generalized (usually tonic-clonic),
lasting for <15 minutes and which does not recur within the same febrile illness.

B. TREATMENT
The current recommendation is not to routinely treat children with simple febrile
seizures with anticonvulsants. One should weigh the side effects of the drug versus
therapeutic effects. The only medications effective in controlling seizures are
benzodiazepines and valproic acid.
For recurrent febrile seizures, one may opt to give diazepam 0.5mg/kg/dose q12 hrs
to a maximum of 4 doses during febrile states of 38C and above.

Summary of Recommendations
Philippine Clinical practice Guidelines on first Febrile Seizure
Philippine Pediatric Society-Child Neurology Society Philippines, Inc

1. Lumbar puncture should be performed in all children below 18 months for a first
febrile seizure. For those children >/= 18 months of age, lumbar puncture should
be performed in the presence of clinical signs of meningitis (eg. (+) meningeal
signs, sensorial changes).
2. Neuroimaging studies should not be routinely performed in children for a first
simple febrile seizure.
3. Antipyretic drugs are used to lower the fever and should not be relied upon to
prevent the recurrence of febrile seizures.
4. The use of continuous anticonvulsants is not recommended in children after a
first simple febrile seizure.
Although anticonvulsants can reduce the recurrence of febrile seizures, the
adverse side effects of these do not warrant their use in this benign disorder.
5. The use of intermittent anticonvulsant (whether Phenobarbital or diazepam) is
not recommended for the prevention of recurrent febrile seizures.
6. EEG should not be routinely requested in children with a first simple febrile
seizure.
COMPLEX FEBRILE SEIZURE

A. DEFINITION
Complex febrile seizure with partial onset, prolonged duration (lasting >10 or >15
minutes, both have been used) and recurrent (more than 1 seizure in a single
illness episode, generally in a 24-hour period). It occurs in 20-38% of all children
with febrile seizures, 4-15% of children with complex febrile seizures develop
epilepsy.

B. TREATMENT
Unlike simple febrile seizures, no guidelines have been proposed for the
management of the first complex febrile seizure. The role of EEG, neuroimaging
studies and treatment are still unclear. Based on some studies, majority of which
are retrospective, the following may be considered:

1. Just like patients with the first simple febrile seizure, a child with the first
complex febrile seizure <2 years old should undergo lumbar tap in order to
rule out the presence of meningitis, unless a contraindication in doing the
procedure is present such as signs of increased intracranial pressure.
2. Doing a routine EEG is not recommended. However, there are some
predictive factors of abnormal EEGs in children with complex febrile
seizures:
Age > 3 years
EEG performed between 7-10 days
Abnormal neurological examination
3. No studies have shown that the presence of abnormality on CT scan/MRI
could predict seizure recurrence in patients with the first complex febrile
seizures. However, a study has shown that abnormal neuroimaging
studies are more likely to be seen in patients with abnormal EEG findings.
4. In terms of epilepsy prevention, there are no studies yet showing that
treatment of febrile seizure, whether simple or complex, can prevent
epilepsy.

NEURODIAGNOSTIC EVALUATION IN PATIENTS WITH SEIZURES


The extent of the laboratory work-up for patients with seizure problems is
dependent on the suspected etiology of the seizures. The following are commonly
requested laboratory tests:

A. ELECTROENCEPHALOGRAM (EEG)
• To confirm clinical diagnosis of epilepsy, to accurately determine seizure
type, and to determine focus of seizure (localization)
• Indicator of cerebral dysfunction and measure of severity disturbance
• Maturational pattern of background activity
• Monitoring of response to treatment
B. NEUROIMAGING
Neuroimaging is done in evaluating patients suspected of having structural
lesions

1. CRANIAL ULTRASOUND is safe and easily available tool to check for


hydrocephalus, complications of CNS infections such as subdural
effusion/empyema and ventriculitis, acute intracranial bleed and cerebral edema
in neonates and infants with open anterior fontanelle.

2. SKULL X RAY has limited value in the evaluation of seizures.

3. CRANIAL CT (Computed Tomography) SCAN is the preferred imaging modality


of choice if one is looking for calcifications (TORCH), acute bleed, acute
infections. Contrast studies should always be requested unless contraindicated.

4. SPIRAL CT (3-D CT) is the preferred imaging for evaluating craniosynostosis

5. MAGNETIC RESONANCE IMAGING (MRI) is preferred over CT scan in


evaluating for parenchymal anomalies and other malformation as in the ff:
a. mesial temporal sclerosis
b. cortical dysplasia and other migration disorders
c. vascular malformations
d. neoplasia
e. posterior fossa lesions

6. MRA and ANGIOGRAPHY are usually reserved for patients suspected of


vascular anomalies

7. SPECT (Single Photon Emission Computed Tomography) is used to measure


cerebral blood flow and for presurgical evaluation patients with refractory
seizures who arte candidates for epilepsy surgery

8. POSITRON EMISSION TOMOGRAPHY (PET) uses positron-emitting isotopes


like fluorodeoxyglucose (FPG) which reflects alteration in metabolic demands of
neurotransmitter activity.

C. CSF ANALYSIS
Contraindications:
o Infection at site of puncture
o Coagulopathies
o Increased intracranial pressure
o Cervical cord lesions
o Suspected or known intracranial mass
o Severe cardiovascular compromise
D.VIDEO EEG MONITORING
Indications:
o Confirmation of clinical diagnosis of epilepsy in patients with
suspicion of pseudoseizures.
o Accurate determination of seizure type
o Determination of sleep cycles.

DRUG THERAPY

Principles of drug therapy


Objective:
- To prevent recurrence by prescribing the appropriate anticonvulsant

Drug of Choice In The Treatment of Seizure

Seizure Type First Choice Second Choice

Partial
Simple Partial Carbamazepine Gabapentin
Phenytoin Lamotrigine
Valproic Acid Phenobarbital
Oxacarbazepine Topiramate
Complex Partial Carbamazepine Gabapentine
Phenytoin Lamotrigine
Valproic Acid Phenobarbital
Oxacarbazepine Topiramate
Generalized SZ
GTC Carbamazepine Gabapentin
Phenytoin Lamotrigine
Valproic Acid Phenobarbital
Phenobarbital (phils) Topiramate
Absence Ethosuximide Lamotrigine
Valproic Acid Topiramate
Myoclonic Valproic Acid Clonazepam
Phenobarbital
Clonic Valproic acid Phenobarbital
Tonic Valproic acid Carbamazepine
Lamotrigine
Phenytoin
Topiramate
Atonic Valproic acid Lamotrigine
Topiramate