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DEFINITION
Epileptic seizures occurring at any age especially in infants and
toddlers as an answer of the CNS to an acute insult ( alteration
of homeostatic constants temperature, glycemia, acid-base
equilibrium, phospho-calcemia, etc), in the absence of any
epileptogenic lesion.
frequently due to extracerebral changes, rather than to
intracerebral ones
CLASSIFICATION
1. OCCASIONAL SEIZURES DUE TO EXTRACEREBRAL INSULTS :
Febrile seizures;
Hypocalcemic seizures;
Hypoglycemic seizures;
Acute dehydration -induced seizures;
Acute poisoning ( intoxication) induced seizures;
Pyridoxine-deficiency induced seizures;
2. OCCASIONAL SEIZURES DUE TO INTRACEREBRAL INSULTS:
ILAE
FEBRILE SEIZURES
ETIOPATHOGENESIS:
- insufficiently known;
- various factors with impact on cortical excitability:
1. Fever ;
2. Age ;
3. Inheritance ;
FEBRILE SEIZURES
1.
FEVER
etiology: upper respiratory airways infections, eruptive
disease, urinary infections, gastroenteritis;
FS occur at sudden body core temperature rising;
75% at >39,5 C;
FEBRILE SEIZURES
2.
AGE:
very important;
rarely < 6 mo & > 4-5 yrs;
FEBRILE SEIZURES
3. HEREDITARY FACTORS:
-
FEBRILE SEIZURES
CLASSIFICATION:
SIMPLE FEBRILE SEIZURES (SFS)
COMPLEX ( COMPLICATED) FEBRILE
SEIZURES (CFS)
unique episode in first 24 hours of a febrile episode ( body ext temp > 38C );
in children without neurologic deficits ( no pre-, peri- or postnatal brain damage, normal
psychomotor development, no afebrile seizure previously );
DIAGNOSIS OF FS
Rigorous history;
LUMBAR PUNCTURE:
PUNCTURE
+ meningeal signs
patients < 6 mo (obligatory);
patients under antibiotic therapy
patients < 18 mo (recommended);
strong suspicion of CNS infection
in CFS.
DIAGNOSIS OF FS
EEG:
- limited value
- in CFS: high dg value in viral encephalitis !
- epileptiform abn may be expression of genetic
predisposition (not future epilepsy indicator).
Blood chemical tests (glycemia, calcemia) and other
investigations if the clinical picture is suggestive!!
NEUROIMAGING: CT & MRI - not routinely.
DIFFERENTIAL DIAGNOSTIC :
CNS infections meningitis, encephalitis (40% cases
do not have meningeal signs);
anoxic seizures ( cerebral syncope) may be triggered
by fever, fear, emotion, heart pathology;
Shuddering, dystonic seizures
Breath holding spells
FEBRILE SEIZURES
TREATMENT
1. ACUTE INTERVENTION;
SFS > 3 min
CFS
2. PREVENTION AND RECURRENCE RISK ;
1. ACUTE INTERVENTION
Supportive measures: lateral decubitus position, removal of airway
obstruction, venous access, O2.
iv Diazepam: 0,5 mg/kg;
antipyretics: acetaminophen, ibuprofen, lukewarm baths DO NOT !!!
use cold packs or ice. May cause shivering, increasing temperature
etiological treatment if the case;
Calm the scared, anxious parents
CALM, DO NOT PANIC
2. PROPHYLACTIC TREATMENT:
a. Intermittent treatment various regimes:
1. classical : at temp > 38C: antipyretics, Diazepam, 0,2-0,5
mg/kg/day per os during the febrile illness and 2 more days
after fever resolution
2. if the FS recurs the family will administrate Diazepam ir
0,4-0,5mg/kgc , repeated 1 more time if there is still fever > 8
hours, max x3/24 hrs
2. PROPHYLACTIC TREATMENT:
b. Continuous treatment:
- does not prevent epilepsy
- ! side-effects of the AEDs (irritability, lethargy,
cognitive impairment, liver/ pancreatic insufficiency )
some may be permanent
- Phenobarbital 3-5mg/kg/day,
- Valproate 20-30 mg/kg/day;
2. PROPHYLACTIC TREATMENT
When? :
- children with high risk ( 3FS in 6 mo, 4 in 1yr),
- duration FS>15 min,
- FS requiring pharmacological intervention to be stopped
- frequent recurrences,
- abnormal psychomotor development
- frighten, anxious parents
OUTCOME
Mortality very low
PREDICTORS OF RECURRENCE (33-40%):
- familial history + for FS (Ist degree relatives) ;
- short duration of fever prior to FS;
- overall duration;
- low temperature;
- lateralized seizure;
- age at onset : < 15 mo: 50-65%;
- 50-75% recurrences in the Ist year;
- infancy associates multiple recurrences (x3);
OUTCOME
Risks of neurological/ cognitive impairment :
- low in previously normal, healthy chidren;
- after some CFS: hemiplegia, diplegia, coreoatetosis
- frequent:
- minor neurologic signs,
- behaviour disorders (hyperkinetic sdr);
- learning disabilities;
OUTCOME
PREDICTORS FOR EPILEPSY :
FS > 15 min;
More FS in 24 ore;
Familial history + for epilepsy
Neurologic abnormalities;
FS & EPILEPSY
Approximate history of FS in specific epileptic
sindromes:
BRE - 8%
BOE 15%
CAE 15%
JME 8%
Myoclonic-astatic epilepsy 28%
Febrile seizures plus 90%
Current Opinion in Neurology, 1998