SEIZURE

An occasional excessive and disordered discharge of nerve tissue

Manifestation of transient hypersynchronous abnormal neuronal behavior

Seizure transient manifestation of abnormal hypersynchronous discharge of cortical neurons
Epilepsy disorder characterized by the occurrence of at least 2 unprovoked seizures
Epileptic syndrome a disorder consisting of a cluster if signs and symptoms plus its typical EEG

Mechanism of seizure generation

Seizure :

Paroxysmal disorder
Altered neurological function
Abnormal cortical electrical discharge
Beginning and an end
Involuntary
Classification of seizure

Partial
Simple partial
Complex partial
Partial generalized Tonicclonic

Generalized
Absence
Tonic-Clonic
Myoclonic,clonic,tonic,atoni
c

Unclassified
Neonatal seizures
Rhythmic eye movements
Chewing, swimming

INTERNATIONAL LEAGUE AGAINST EPILEPSY (ILAE) classification of seizure type

I.
Partial seizure
A. Simple partial seizure (consciousness not impaired)
B. Complex partial seizure (with impairement of consciousness)
C. Partial secondarily to generalized
II.
Generalized seizures (bilaterally symmetrical and without local onset)
A. Absence seizure
B. Myoclonic seizure
C. Clonic seizure
D. Tonic seizure
E. Tonic-clonic seizure
F. Atonic seizure (astatic)
III.
Unclassified epileptic seizure (inadequate or incomplete data)

Partial seizure
Abnormal flow of electrical discharge from a specific or single focus

Simple partial seizures

With motor symptoms
-Focal motor without march
-Focal motor with march (Jacksonian)
-Phonatory (vocalization or arrest of speech)
With somatosensory or special sensory symptoms
-Somatosensory
-Visual
-Auditory
-Olfactory
-Gustatory
-Vergitinous

-Versive
-Postural

Simple partial seizures

Epigastric sensation
Erythema
Pallor
Genital sensations/orgasm
Sweating
Hyperventilation
Flushing
Lacrimation
Piloerection
Miosis/mydriasis
Pupillary dilatation
Pilomotor excitation
Apnea
Palpitation
Arrhythmias/bradyarrhythmias
Tachycardia
Chest pain
Urinary urgency/incontinence
Cyanosis
Vomiting
With psychic symptoms:

Dysphasic

Dysmnesic (deja vu, jamais vu, memory recall, memory gaps/amnesia)

Cognitive (dreamy states, distortions of time sense)

Affective (fear, anger, sadness, pleasure, sexual emotion, emotional distress)

Illusions (macropsia)

Structured hallucinations (music, scenes, visual, auditory, olfactory)

Other (change in reality, depersonalization, feeling of a presence (as if someone is nearby),

forced thinking, distortion of body image)

Partial epilepsi with secondary generalization

Starts off as simple seizure which later evolves into generalized seizure

Complex partial epilepsy

appears to be in a dream like state

unaware or unresponsive to questioning
may perform unusual actions such as picking of clothings, grimacing, contorting to one side,
chewing
feel confused for several minutes
no recollection of the event

Cardinal point impairement of consciousness

Limbic lobe is affected
Characterized by affective and perceptual disturbance, motor manifestations and automatisms
Automatism
Oro-alimentary

Chewing, lip smacking

Mimicry

Anger, joy
Gestural

Clapping, scratching

Ambulatory

Walking, riding a bicycle

Verbal automatism

Generalized seizures

Begin throughout both hemispheres, more or less simultaneously

Do not have localized onset
Reflect generalized disturbance of cortical function
May cry out or gasp, fall down, become rigid
Muscle may jerk, breathing becomes shallow
May lose bladder and bowel control

May drool, bite the tongue or lips and may turn blue
Post ictal maybe confused, drowsy, sleep for a while or have headache

Absence seizures
Onset

5 years old

5-15 years old

15 years old

24 %
8.3 %
7%

Common between 5-9 years old

Rare below 3 years old and above 15 years old
EEG result : 3hz Spike Wave

Differential diagnosis for loss of consciousness

Syncopal attacks (vaso-vagal)

Hyperventilation
Drom attacks
Migraine
Menieres disease
Cardiac disease
Hypoglycemia

Features helpful in differentiating between phychogenic seizures and true

epileptic seizures
Feature
Sex
Age
Precipitating factors
Loss of consciousness
Precipitant
Occurence
Circumstances in sleep when
alone
Onset
Incontinence
Tongue biting
Consciousness

Epileptic seizure
Male or female
Any age
Variable, lack of sleep,
hypoglycemia, fever, etc.
Common
Usually none
Common
Common

Psychogenic seizures
Mostly female
Adolescence or early adult
Emotional

Usually abrupt, may have short

aura
Common
Common
Usually totally lost

Maybe gradual with increasing

emotional symptoms
Rare
Rare
Maybe unresponsive often
possible to communicate during
an attack
Maybe gradual, maybe
prolonged, often with emotional
display
Unusual
unusual

Duration of seizure

Usuall short (but with

automatism sometimes)

Conrfusion
Drowsiness/sleep

Common
Common

No loss of consciousness
Often and emotional precipitant
Rare
Less common

Most common causes of elipectic seizures according to age of onset

First week
Second week
o Perinatal asphyxia
-Early CNS infection
o Perinatal trauma (often with intracranial bleeding)
-Hypocalcemia
(alimentary)
o Very early CNS infection
-Kernicterus
o Cerebral malformation
-Cerebral malformations
o Hypocalcemia
o Hypoglycemia

4 months to 2 years
o Febrile convulsions
o CNS infection
o Residual epilepsy due to early CNS damage (cerebral palsy)
o Cerebrovascular problems; arterial occlusion, venous thrombosis
o Inborn errors of metabolism
o Neurocutaneous disorders

3 to 10 years
11 to 20 years
o Benign Rolandic epilepsy
-Primary Generalized epilepsy
o
o
o
o

Primary generalized epilepsy

Residual epilepsy due to early CNS damage
CNS damage
Trauma
Inborn erros of metabolism

-Trauma
-Residual due to early
-CNS infection
-Arteriovenous malformations

o
o
o

Above
o
o
o

Neurocutaneous disorders
CNS infection
CNS poisoning (e.g, Lead)

60 years
Cerebral arteriosclerosis
Brain tumor, primary
Brain tumor, metastatic

Common precipitating factors for seizures in young patients

-Fever
-Fatige
-Drug abuse
-Photic stimulation

-stress
-sleep deprivation
-menstrual cycle
alcohol

Factors lowering seizure threshold

Common
-Sleep deprivation
-Alcohol withdrawal
-Dehydration
-Systemic infection
-Trauma
-Malnutrition

Occasional
-barbiturate withdrawal
-hyperventilation
-flashing lights
-diet and missed meals

Risk of persistent seizure

Progressive neurologic damage

Worsening seizures

Adverse cognitive and psychosocial effects

Cumulative drug toxicity

Principle of treatment

Establish the dx and the rule out underlying cerebral pathology

Classify seizure type using EEG and clinical criteria

Select AED of first choice for seizure type

Increase dose slowly until end-point is reached:

o Complete seizure control
o Optimum plasma drug level
o Toxic side effects appear

If poor seizure control gradually withdraw first drug while replacing with second drug of choice for seizure type

Monotherapy is preferable to polypharmacy

Continue treatment to achieve minimum seizure free period of 3-5 years

If best medical therapy is unsuccesful, refer to a neurologist

Common anti-epileptic drugs
Generic name
Trade name
Phenobarbital
Luminal
absence
Phenytoin
Epilepticus
Carbamazepine
Seizure
Valproic Acid
Clonazapam

Dilatin
Tegretol
Epival
Rivotril

Principal therapeutic indication

Tonic-clonic seizure, simple and complex
partial seizure
Tonic-clonic seizure simple complex partial
seizure status
Tonic-clonic seizure complex partial seizure
and simple partial
Tonic-clonic seizure complex partial seizure,
absence seizure, myoclonic
Myoclonic seizure

Some AED drug interaction

Drugs that raise its level
Valproate
Primidone
Phenobarbital
Ethosuximide
Carbamazepine

Sallcylates
Carbamazepine
Dicumarol
Ethosuximide
Valproate, MAO inhibitors
Chlorampenicol
Erythromycin,
Cimetidine, Calcium channel
blockers,
Isoniazid, propoxyphene

Drugs that lower its

level
Ethosuximide

Phenytoin
Phenobarbital
Phenytoin

Anti-epileptic drugs/dosages
Generic name
Trade name
Phenobarbital
Phenytoin
Carbamazepine
Clonazepam
Valproate NA
Diazepam
ACTH
Gabapentin
Oxcarbazepine

Phenobarbital
Dilantin
Tegretol
Rivotril
Depakene
Epival
Valium
Acthargel
Neurontine
Trileptal

Adult dose
(mg/day)
100
300
400-800
4-6
750-1500

Pediatric dose
(mg/kg/day)
3-5
4-8
10-20
0.05-0.2
15-60

20-50

0.5-1.5
10-80 units

900-1800
300-900

Effective blood level

(mg/ml)
10-40
10-20
4-10
0.01-1.07
50-100

10-20

Criteria for starting anti-epileptic drug therapy

Diagnosis of epilepsy must be firm

Selection of an anti-epileptic drug: Factors to consider

Risk recurrence of seizures must be sufficient

Seizures must be sufficiently troublesome

Control of seizures
o Types of seizure

Tolerability
o Frequency of seizure

Pharmacokinetic properties
o Severity of seizure

Patient characteristics
o Timing of seizure
o Precipitation of seizure

Good compliance must be likely

Patient has been fully counselled

Anti-epileptic drugs
First generation
Phenobarbital
Phenytoin
Carbamazepine
Valproate
Clonazepam
Primidone
Ethosuximide

Second generation
Gabapentine
Lamotrigine
Topiramate
Tiagabine
Felbamate
Vigabatrin

Pharmacologic properties
Anti-epileptic drug
Glutamate antagonist
Phenobarbital

Third generation
Oxcarbazepine
Levetiracetam
zonisamide

GABA agonist

Na+ channel blocker

Ca+ channel blocker

Phenytoin

Carbamazepine

Valproic acid

Gabapentin
topiramate

Spectrum of AED activity

Generalized Seizures

Partial
seizure
CBZ,OXC,P
HT

GTC

Tonic

Myocloni
c
CLZ

VGB,GBP,T
GB

Atoni
c

I.S.
ACTH,
VGB

Absence
ESM

__________________________________________________________________________________
VPA, LTG, TPM
FBM, ZNS, LEV
CBZ carbamazepine; OXC oxcarbazepine; PHT phenytoin; VGB - vigabatrin;
GBP gabapentin; TGB - tisgabine; CLZ clonazepam; ACTH adenocorticotriphic
hormone;
ESM ethosuximide; PB phenobarbital; VPA valproic acid; LTG lamotrigine;
Non Pharmacologic Treatment and other Treatment Modalities of Epilepsy
Objectives
TPM
topiramate;
felbamate;
ZNS zonisamide;
LEV
- levetiracetam
1. Give
a brief
overviewFBM
on the
non-conventional
treatments for
epilepsy
Not antiepileptic drugs
Diet
Surgery
2.

Enumerate & discuss briefly on the other non-pharmacologic management of epilepy

Lifestyle changes
herbal
Psychological
acupuncture

Introduction

Seizure control with anti-epileptic drugs 75%

Increase concern with unwanted side effects/toxicity

Role in intractable seizures

Non-conventional anti-epileptic drug treatment of epilepsy

Alternative approaches
to conventional antiepileptic drugs

1.

in the management of pediatric

Non-AED medical treatment
Steroids
IV Immunoglobulins
Vitamins (pyridoxine, pyridoxal phosphate, biotin, folinic acid
Melatonin

2.

Dietary Manipulation
Ketogenic diet
Classical ketogenic diet
MCT diet
Atkins diet
Oligoantigenic diet

3.

Epilepsy surgery techniques

a. Lesional surgery tumor, amygdalohippocampectomy,
temporal lobectomy, extra-temporal resections
2. Psychological approaches
b. Anatomical hemispherectomy or functional hemispherotomy
a) Techniques to abort seizures or reduce
c. removal of cortical seizure foci
seizure frequency
d. Specific surgical techniques (sub-pial transection
for Landau-Kleffner
syndrome
b) Promotion
of emotional
wellbeing
e. Palliative surgery (callostomy, vagus nerve stimulator
VNS )
implantation
Yoga
Reduction of psychiatric comorbidity
Non-pharmacological treatment of epilepsy
(anxiety or depression)
1. Lifestyle changes
c) Coping strategies for living

Exercise

Avoidance of sleep deprivation

with epilepsy
Avoidance of excessive alcohol
consumption
d)
Educational interventions
3.
4.

Alternative therapy/ Herbal medicine

Others:

Aromatherapy/hypnosis

Acupuncture
Seizure alert dogs

Corticosteroids
Indications:
1. Drug resistant epilepsy syndromes
2. Exacerbation of seizures
Mechanism of action:
-Unknown
Dose, treatment regime

example: West syndrome

-ACTH
-Prednisone
-Predisolone 2-3 mkd
- 2 weeks course then taper over 1-2 week
Disadvantages:
Potential side effects

Immunoglobulins
Indications:
1. Drug resistant epilepsy syndrome
2. Exacerbation of seizures
examples : west syndrome, Rasmussen syndrome
Mechanism of action:
-Unknown
Dose, treatment regime:
-100 mg - 1000 mg/day
-For 1,2,3 days then repeated afters 1,2,3 weeks
Disadvantages:
-Potential side effects - expensive
Vitamins
Indications:
1. Replacement therapy
- inherited metabolic defects
2. Pyridoxine dependent seizures
3. Biotinidase deficiency
4. Folinc acid resposive neonatal seizures
Mechanism of action:

May reduce seizure frequency through presumed anticonvulsant role

Resetting GABA & glutaminergic system

Examples:
a. Vitamin E
b. Folic acid
c. Pyridoxal phosphate
Vitamins: Pyridoxine (B6)

Pyridoxine dependent seizure

Considered in all babies <18 months

Intractable seizures
Children with epilepsy due to mutations in

100 mg IV or 3 week course oral pyridoxine at 100-200 mg daily

GLUT-1 (class III)
Pyruvate dehydrogenase (PDH) deficiency
Ketogenic diet
(class III)
Indications: refractory and intractable seizure
Infantile spasms (class II)
1. Effective in children generalize seizure
Dravet syndrome (aka. Severe myoclonic
2. Mimics fasting
epilepsy of infancy). (Class III)
3. High fat diet and low carbohydrate content
Myoclonic-astatic epilepsy (Doose syndrome).
----------promote ketone production
(class III)
Mechanism of action
b) 2 types :
a) Classical
b) Modified (medium chain triglyceride)
The ketogenic diet: Uses in Epilepsy and Other Neurologic Illnesses

Traditionally used in cases of intractable

epilepsy
Established as a first line agent in a few
specific epilepsy syndromes

Disadvantages: Curr Treat Options Neurol. 2008

a. Difficulty implementation strict adherence
b. Frequent blood/urine monitoring
c. Parental commitment
d. Patient compliance unpalatable

e.
f.
g.
h.
i.

GIT upset & weight loss

Risk of dehydration
Hypernatremia
Kidney stones
Vitamin & trace element deficiency

ATKINS Diet
Similar with KD
Lower fat
Higher protein
No fluid or calorie restriction
No fasting

N=6
Refractory epilepsy
N-3 --- 90% reduction in seizure frequency
reduction in AED
more data needed

Surgical treatment
1. Neurostimulation
2. Lesionectomy
3. Hemispherectomy
4. Corpus colostomy
Neuro stimulation therapy for epilepsy:
Current modalities and future directions
a. Deep brain stimulation

Stimulations of the Centromedian Nucleus of the thalamus

Stimulation of the Anterior Nucleus of the thalamus

Stimulation of the Subthalamic Nucleus

Cortical stimulation
b. Vagus nerve stimulation
Non-pharmacological treatment of epilepsy
1. Lifestyle changes
Sleep hygiene
exercise
o Avoidance of sleep
- quality of life & socia inclusion
Deprivation
- No RCT
o Regular & consistent sleep
- prospective study n-21 --- no difference
o Teenagers
Avoidance of excessive alcohol consumption
o Teenagers
o Disturbed sleep & interaction with AEDs
2. Psychological approaches
a. technique to abort seizures or reduce seizure frequency
Avoidance
Photosensitivity epilepsy
Avoid triggers : flickering,
immersion
in hot
b. promotion oflights,
emotional
well being
water
Video games
- television
Yoga
-

3.

Relaxation
-

1 RCT children
6 weeks treatment
Recognize pre seizure signs
Result: fewer seizure

Reduction of Psychiatric Co-morbidity

- stress
anxiety, depression, psychosis
c. Coping strategies for living with epilepsy
- Incidence in children unknown
- counselling & psychotherapy
precipitant of seizure
a. individual group family counselling
b. patient support group
- Sham &
sahaya yoga RCT
d. educational
intervention
A. educational programs
B. improvement
knowledge and understanding of epilepsy
no usefullin
conclusion
Alternative therapy
Herbal medicine
No RCT
2 open label studies : Chinese medicine literature
a. N: 239 adults
6 months - years
human placenta & peach flower buds
result: seizure reduction in > 75 % in 2/3 of patients
b. N: 100 children
8 months
13 hurbo

Status Epilepticus

Seizure lasting more than 30 minutes or recurrent seizures lasting more than 30 minutes from which the patient
does not regain consciousness ILEA
A condition characterized by an epileptic seizure that is so frequently repeated or so prolonged as to create a fixed
and lasting condition
WHO
Annual estimated incidence
- 18 to 28 cases per 100.000 population
- occur most commonly in
a. children
b. people with learning difficulties
c. those with structural cerebral pathology
(Shorvon, Handbook of Epilepsy Treatment 2000)
- 50 % of cases of SE occurs under the age of 3 yrs
(Shinnar, Epilepsia 1995)
Most seizures are brief - >90% lasts less than 2 minutes
Seizures lasting longer than 10 minutes are likely to be prolonged
(Theodore, Neurology 1983)

Pathophysiology
Mechanisms remain unclear
A failure of inhibitory mechanisms that ordinarily terminate a seizure
Neuronal metabolism is not able to keep up with the demand of continuing ectal activity
The role of glutamate in depolarization
(Pellock, Pediatric Epilepsy: Diagnosis and Therepy
Classification of Status Epilepticus
Conclusive
Nonconclus
ive
Generalized
Tonic-clonic Absence
Tonic
Myoclonic
Partial
Partial
Complex
Partial
Motor
(EPC)
Who is
-

at risk for Status Epilepticus?

Px with acute symptomatic seizures
Status Epilepticus in Aduts vs Children
Those with pre-existing neurologic abnormalities
The very young

Compared to adults with SE, children have unique

The very old
differences:
Those with prior history of prolonged seizures
- Etiology

Immature vs Adult Brain

- Intravenous
access
Seizure-induced
Neuronal
Injury

- Drug epilepticus
side effectsin the mature animals
- Developing brain is more prone to

Status
Precipitants
of
SE:
Based
on
Review
of
SE
cases
in
Richmond,
Virginia
seizures
Treatmentloss
response
-- Neuronal
in the hippocampal fields
- Developing brain is less affected
CA1, CA3,
and dentate hilus
by seizures
- Mortality
- Aberrant growth (sprouting) of granule
cell axons in
the supragranular zone of the
fascia dentata and
CA3 and sprouting of CA1

Physiological changes in SE
Phase 1 - Phase of Compensation
Cerebral metabolism is greatly increased
Physiological mechanisms are sufficient to meet the metabolic demands
Massive autonomic and cardiovascular changes
Phase 2 Phase of Decompensation
Cerebral metabolism is greatly increased
Metabolic demand not fully met
Hypoxia and altered cerebral and systemic metabolic patterns
Autonomic changes persist and cardiorespiratory functions may progressively fail to maintain homeostasis
Priorities in Managing SE

(A) maintain airway

(B) ensure breathing ventilation

(C) maintain circulation (obtain IV access)

Provide oxygen and glucose

Order laboratory studies (electrolytes, BUN, creatinine, glucose, calcium, magnesium, drug levels)

Obtain history, perform physical and neurological examination

Administer antiepileptic drugs

Order further laboratory studies and provide additional treatment as needed

Summary of 5 treatment protocols in the management of SE in children (KCHC, Boston Childrens Hospital,
Pellock, Shorvon, Dodson)

Management of Status Epilepticus

The Goals of treating status epilepticus include:
Stopping the seizure safely and timely
Minimizing treatment-related morbidity
Management of Status Epilepticus in Children

Treat fast and treat hard

- longer delays mean more refractory status epilepticus

Etiology of SE must be sought out

Recognize medical complications and treat concomitant diseases

Consider prehospital treatment of seizures

- the role of rectal diazepam

- prophylaxis treatment of febrile seizures with oral/rectal diazepam

Globalize the evidence

Localize the decision

Clinical Practice Guideline on Simple Febrile Seizures

1998- American Academy of Paediatrics CPG

2000- CNSP Task Force reviewed AAP recommendations
2nd CNSP convention
2002- Consensus of experts
1st congress of PLAE
2004- Joint PPS CNSP CPG development
- Systematic evidence based search and review of literature
- multisectorial participation
- adapted for the Filipino child/practitioners
PPS convention 2004, 2005
Objective

General objective:
Provide recommendations for the performance of diagnostics tests and treatment of healthy normal
infants of 3 months to 6 years with a firs simple febrile seizure

Specific objectives:
o Clarify the role of neurodiagnostic procedure lumbar puncture and neuroimaging (diagnosis)
o Evaluate effectiveness of antipyretics and antiepileptic drugs (treatment)
o clarify the role of EEG in predicting risk for epilepsy (prognosis)
Practice setting
Intended for

Healthy normal infants aged 3 months to 6 years

First simple febrile seizure

o Axillary temperature of 37.8 C or greater
o Generalized tonic clonic seizures
o Lasts less than 15 minutes
o Does not recur within the same febrile illness
Clinical Issues for Discussion

Diagnostic test
I.
Lumbar puncture for CSF analysis
II.
Neuroimaging studies

Therapeutic intervention
I.
Antipyretics
II.
Continuous antiepileptic drugs
III.
Intermittent antiepileptic drugs

Prognostic tests
I.
EEG

Summary for evidence

I.
Burden of illness
II.
Accuracy of the test/ availability of effective treatment
III.
Recommendation of others
IV.
Consideration for the Philippines CPG recommendations

Grades of recommendation
Grade A: based on the current evidence, the consensus is that the test SHOULD BE USED for screening or diagnosing the
disease in interest/medication is used to treat the disease interest
Grade B: the test MAY OR MAY NOT BE USED for screening of diagnosing the disease in interest, either because the
evidence in lacking, equivocal or conflicting, or a consensus could not be reached
Grade C: based on the current evidence the consensus is that the test SHOULD BE USED for screening or diagnosing the
disease of interest/ or medication should not be used to treat the disease of interest
Level of evidence
1. Effectiveness of treatment for the asymptomatic condition must have been assessed by well-designed RCT
evaluating the effect of treatment on clinical outcomes
2. The prevalence of the symptomatic condition must be based on locally conducted community based studies
3. The accuracy and reliability of the screening test must be based on validation studies done in the community
4. Cost effectiveness of the screening test and the treatment should be evaluated in properly conducted economic
analysis

CLINICAL ISSUES 1 (To do LP or not)

Among children with a first febrile seizure, is lumbar puncture recommended to rule out meningitis?
Summary of evidence: Burden of Illness

Prevalence of Meningitis
7 retrospective studies in urban emergency room hospitals in USA with 2100 cases of febrile seizures
1.2%
2 hospitals based studies in Denmark 7%
1 hospitals based study in Saudi Arabia 7%

Local studies on prevalence of meningitis

Mangubat & Robles

Retrospective study of 19. Children aged 3 months to 6 years with new onset febrile seizure
1% prevalence
Dilangalen & Perez

Cotabato regional and Medical center

Retrospective study of 339 children 7% prevalence

Summary of Evidence: Accuracy of the test

CSF analysis is not the test that confirms the diagnosis of febrile seizure per se

CSF analysis is the gold standard for the alternative diagnosis of meningitis

AGE plays a crucial role decision to do lumbar puncture

Discriminate factors in the clinical signs and symptoms that differentiate children with meningitis
o Presence of major signs of meningitis (nuchal rigidity, coma, petechiae) 70% identified
o Presence of at least one of the features of complex febrile seizure (partial, multiple, prolonged
seizures) 74 identified
Recommendation Statement
Lumbar puncture is strongly recommended for children below 18 months for a first simple febrile seizure. For
those children >/= 18 months of age, lumbar should be performed in the presence of clinical signs of meningitis
(meningeal signs, sensorial changes
*Grade of recommendations: A
*Level of evidence: 3
Basis of recommendation

Emphasizes the value of not missing the alternative diagnosis of meningitis

Population at risk is the low income group, poor nutrition, no access to anti-meningitis vaccinations

Practice setting intended for health providers with varying clinical acumen, skills, training and
experience
CLINICAL ISSUE 2 (To do imaging or not)

Among children with a first febrile seizure, do we need to perform neuroimaging studies (cranial ultrasound, CT scan,
and MRI)?
Summary of the evidence: Accuracy of the test

No studies done on utility of neuroimaging for simple febrile seizures

Recommendation statement
Neuroimaging studies should not be routinely performed for children for children with a first simple febrile seizure
*Grade of recommendation: C
*Level of Evidence: 4
Basis for Recommendation

Absence of evidence

Tests are not readily available for clinicians

Test may be costly

CLINICAL ISSUE 3 (To give antipyretic or not)

In children with a simple febrile seizure, can prophylactic treatment with antipyretic drugs decrease the likelihood of
recurrence of febrile seizure?
Summary of Evidence: Availability of Effective Treatment

Pursell 2000

Sporadic (prn) or regular dosing of antipyretic did not show difference in the number of febrile
convulsions, range of temperature or mean duration of fever

Van Stujivenberg 1998

RCT on intermittent (prn) ibuprofen in 230 children did not prevent febrile seizure recurrence in
children at increased risk

Van Esch 1995

Randomized, non-placebo, multidose, double blind crossover study on acetaminophen and

ibuprofen, seizure prophylaxis not evaluated
Recommendation of statement
Antipyretic drugs are used to lower fever and should not be relied upon to prevent the recurrence of febrile seizure
*Grade of Recommendation: C
*Level of Evidence: 2
Basis for Recommendation

Emphasizes the role of antipyretic just to control the fever to give comfort to the child

Recognizes that there is evidence that the prophylactic use of antipyretic cannot be relied upon to prevent
seizure recurrence in children at risk

CLINICAL ISSUE 4 (To give AEDs or not)

In children with a simple febrile seizure, can prophylactic treatment with antiepileptic drugs (whether continuous or
intermittent) decrease the likelihood of recurrent febrile seizures?
Summary of Evidence: Burden Illness

Two important outcomes of untreated febrile seizures

Occurrence of subsequent febrile seizures

Occurrence of afebrile seizures or epilepsy

Recurrence of febrile seizures varies with age

First sz < 12 months 50 %

First sz < 12 months - 30 %

Occurrence of afebrile seizures by age 7

Comparable to general population 1%

First sz < 12 months and multiple sclerosis FC 2.4 %

Complex febrile seizure 6 to 27 %

Summary of Evidence: availability of effective treatment (continuous anticonvulsant)

Prevention of recurrent febrile seizures

Pooled data of 4 non-British RTCs with continuous phenobarbital

o Odds ratio 0.45 (95% CI 0.33-0.90)
o NNT: 8-27

Pooled data of 7 British RCTs on continuous phenobarbital

o Odds ratio: 0.8

1 RCT on continuous valproic acid

o Odds ratio 0.99 (95% CI 0.01-0.78)

Prevention of Epilepsy
No studies that show that treatment of febrile seizure can prevent epilepsy
Summary of Evidence: Availability of effective treatment (intermittent diazepam)

Prevention of recurrent febrile seizures

Pooled data of 3 RCTs with intermittent diazepam
o Odds ratio 0.81 (95% CI 0.54-1.22 p = 0.31)

Local studies
2 RCT but with methodological flaws
Recommendation Statement
The use of continuous anticonvulsants is not recommended in children after the first simple febrile seizure. Although
anticonvulsants can reduce the recurrence of febrile seizures, the adverse side effects of these drugs do not warrant
their use in this benign disorder
*Grade of recommendation: C
*Level of Evidence: 2
CLINICAL ISSUE 5 (To do EEG or not)

Among children with a first simple febrile seizure, is EEG recommended to predict the risk epilepsy or afebrile seizure?
Summary of evidence: Accuracy of the Test

Limited studies on the ability of EEG to predict future afebrile seizure or epilepsy
Most studies where paroxysmal EEG changes were recorded including children with complex febrile seizure
and pre-existing neurologic abnormalities
Heijbel, 1980
o Limited studies to simple febrile seizures
o 2 children who developed epilepsy had normal EEGs

Summary of recommendations
1. Lumbar puncture should be performed in all children below 18 months for a first simple febrile seizure. For
those children >/= 18 month of age, lumbar puncture should be performed in the presence of clinical signs of
meningitis (e.g., presence of meningeal signs, sensorial changes
2. Neuroimaging studies should be routinely performed in children for a first simple febrile seizure
3. Antipyretic drugs are used to lower fever and should not be relied upon to prevent the recurrence of febrile
seizure
4. The use of anticonvulsants are not recommended in children after a first simple febrile seizure. Although
anticonvulsants can reduce the recurrence of febrile seizure, the adverse effects of these drugs 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. Electroencephalogram should not be routinely requested in children with a first simple febrile seizure