Seizures
From Holoprosencephaly
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Definition of Seizure
A seizure is a sudden attack caused by abnormal electrical discharges from the brain’s neurons. Depending upon the origin of the activity in the brain, one may experience a single attack or recurrent attacks of convulsive movements (which are involuntary muscular contractions and relaxation), motor, sensory or behavior abnormalities, altered autonomic function or involuntary loss of consciousness.
In children, the risk of seizure is highest from birth to 2 years old; between the ages of 5 and 7 years old; and at the onset of puberty.
Epilepsy refers to a pattern of recurrent or chronic seizure episodes. Seizures can be caused by a specific area of the brain that is injured or inflamed, or they can be due to stress on the brain from a more widespread systemic process Seizure disorders have numerous and varied causes. These may be the result of congenital brain defects, malformations or conditions; acquired causes such as brain injury, hemorrhage, infections, hypoxia, poisonings, drug/alcohol toxicity, sudden medication withdrawal, high fever, severe biochemical irregularities or unknown causes.
Classifications of Seizures Neonatal seizures Febrile Convulsions Partial Seizures
- Simple Partial Seizures
- Complex Partial Seizures
Generalized Seizures
- Tonic Clonic (grand mal) Seizures
- Myoclonic
- Infantile spasms
- Atonic or Akinetic (also known as drop attacks)
- Absence (also known as petit mal or lapse seizures)
NEONATAL SEIZURES
These occur within 28 days of birth. Most occur soon after the child is born. They may be due to a large variety of conditions such as anoxia, infection, traumatic injury, post-surgical complications, fever or congenital brain abnormalities. It may be difficult to determine if a newborn is actually seizing, because they often do not have convulsions. Instead, their eyes appear to be looking in different directions. They may have lip smacking or periods of no breathing.
FEBRILE CONVULSIONS
These type seizures are triggered by a high fever.
Occurrence:
Such convulsions may occur without any underlying brain or spinal cord infection or other neurologic cause. However, children with congenital brain disorders are at higher risk for developing these type seizures. About 3-5% of otherwise healthy children between the ages of 9 months and 5 years will have a seizure caused by a fever. Toddlers are most commonly affected.
Causes:
Most febrile seizures are triggered by a rapid rise of body temperature over 102.2°F. Most occur well within the first 24 hours of an illness, not necessarily when the fever is highest. It is the quickness of the rise in temperature, not the actual height of the fever, which appears to trigger the seizures. The seizure is often the first sign of a fever. Most febrile seizures are triggered by fevers from viral upper respiratory infections, ear infections, or roseola. Meningitis causes less than 0.1% of febrile seizures but should ALWAYS be considered, especially in children less than one year old or those who still look ill when the fever comes down.
Symptoms:
A febrile seizure may be as mild as the child's eyes rolling or limbs stiffening. Quite often a fever triggers a full-blown convulsion that involves the whole body. The movements are the same as in a grand mal seizure.
A simple febrile seizure stops by itself within a few seconds to 10 minutes, usually followed by a brief period of drowsiness or confusion. A complex febrile seizure is one that lasts longer than 15 minutes, occurs in an isolated part of the body, or recurs during the same illness.
Treatment:
Medical attention should be sought from a health care provider. In infants and young children, it is important to rule out other causes for a first-time seizure, especially meningitis.
Initial treatment focuses on bringing the fever down. Usually acetaminophen or ibuprofen are administered and cool compresses are used on the entire body. Anticonvulsant medicines are generally not needed.
PARTIAL SEIZURES
Partial seizures are the most common type of seizure experienced by people with epilepsy. These are caused by an electrical disturbance in a specific area of one side of the brain. Any movement, sensory, or emotional symptom can occur as part of a partial seizure, including complex visual or auditory hallucinations. Partial seizures may spread to cause a generalized seizure.
Partial seizures are subdivided into simple partial seizures (in which consciousness is retained); and complex partial seizures (in which consciousness is impaired or lost).
- Simple Partial Seizures
Simple partial seizures have sensory or motor components, depending on where the electrical disturbance has occurred in the brain. These are categorized as focal sensory seizures or focal motor seizures. Consciousness is usually retained during this event.
A focal sensory seizure may produce a variety of sensations. These include numbness, tingling, prickling, warmth or pain in one area or body part.
The sensation may be localized initially but often spreads to other parts of the body.
There may also be visual, auditory, taste or olfactory disturbances
A focal motor seizure produces a tonic (muscle stiffening) and clonic (rapid alternate muscle contraction and relaxation) movements of a body part, such as the face, arm, leg, thumb or hand.
During the event, the child may involuntarily turn their eyes or head away from the part that is moving, have increased salivation, arrested speech or facial grimace.
This episode may occur alone or preceding a tonic clonic seizure. It originates unilaterally but may spread to other parts of the brain and body.
- Complex Partial Seizure
Most often these are observed in children ages 3 to 12 years old.
Sometimes called a temporal lobe or psychomotor seizures, they are characterized by brief, 1 to 2 minute episodes when the person appears to be staring or daydreaming with rapidly fluttering eyelids.
This may be accompanied by:
Inability to respond to the environment Odd or unpleasant odors or taste Auditory or visual hallucinations Strange feeling rising from stomach into the throat Feelings of anxiety, fear, elation or strangeness Lip smacking or chewing motion
Automatism- repetition of purposeless acts like running in place or in circles, kicking or laughing
Immediately after the seizure, the person may fall asleep or feel drowsy. In addition they may experience:nausea; oral symptoms such as lip smacking, chewing, drooling or swallowing; muscle stiffness; confusion; and staring spells. Most likely they will have no recollection of the event.
GENERALIZED SEIZURES
Generalized seizures affect both cerebral hemispheres of the brain from the beginning of the seizure. These are caused by abnormal electrical activity at multiple locations in the brain and/or over a large area of the brain. They may occur in people of any age, as a single episode or as a repeated, chronic condition, epilepsy.
They are sub-categorized into several major types:
Generalized Tonic Clonic (also known as grand mal) Myoclonic Infantile spasms Atonic or Akinetic (also known as drop attacks) Absence (also known as petit mal or lapse seizures)
- Generalized Tonic Clonic Seizures (also known as Grand Mal)
These are the most common and dramatic type of seizures. They begin abruptly and last several minutes. Often before the seizure begins, the person will experience an “aura” that manifests as a change in mood, confusion, a floating sensation, visual or taste disturbances, GI distress or sudden overwhelming fear/anxiety.
Tonic Phase
Usually lasting 10-30 seconds, the tonic phase may begin with the person giving a loud cry or scream caused by air rushing from the lungs through the vocal cords. Followed by or simultaneously occurring:
Immediate loss of consciousness Eyes roll upward If standing, the person will suddenly fall All muscles stiffen in a generalized, symmetric contraction Back arches Arms flex Legs, head and neck extend Foaming or increased salivation of the mouth
Clonic Phase
The clonic phase may last 30 seconds to 30 minutes or longer. During this period, muscles experience rhythmic contraction and relaxation producing violent jerking movements. There may also be incontinence of urine or feces, increased salivation, tongue biting, increased heart rate and increased blood pressure. As the attack ends, movements become less intense, occur less frequently then end entirely.
Postictal State
This refers to the period immediately after the seizure episode in which the body relaxes. This may only last a few minutes but could continue for an hour or more. The person may be semi-conscious, appear to be sleeping and difficult to arouse. After awakening the person may experience: confusion, poor coordination, mild fine motor impairments, mild vision and speech problems, nausea and vomiting, mild to severe headache. These symptoms may last for several hours accompanied by sore muscles and fatigue. There is usually no recollection of this event.
Status Epilepticus
This refers to a state in which the person experiences a rapid succession of seizures without regaining consciousness between the events. This is an emergency situation that requires immediate intervention to stop the seizure. Without treatment this leads to respiratory failure, cerebral oxygen deprivation, irreversible brain damage and possible death.
- Myoclonic Seizures
Myoclonic seizures are characterized by sudden brief involuntary muscle jerks of the body or extremities which occur as single or multiple episodes. These may be isolated and benign or occur with other seizure forms. This may affect entire or isolated muscle groups. There is usually no loss of consciousness.
- Infantile Spasms
These usually occur between 6 and 18 months of age. The child may experience numerous seizures throughout the day without postictal drowsiness or sleep, frequently upon awakening. These may occur with or without loss of consciousness. They are often associated with mental retardation.
Symptoms include: Brief, sudden, symmetric spasms of muscle groups Head flexed, arms extended and legs drawn up Eyes may roll inward and/or upward May be preceded or followed by crying or giggling May appear pale, flushed or bluish
- Atonic or Akinetic Seizures (also known as drop attacks)
The onset of these type seizures usually occurs between 2 and 5 years of age. Most often these occur in the morning shortly after awakening but attacks may recur throughout the day. These are characterized by sudden loss of muscle tone and postural control accompanied by temporary loss of consciousness. This loss causes the child to fall to the ground without the ability to break their fall. As a result, head, facial and arm injuries may occur during these episodes.
These type seizures may be less severe for some children who may only experience a brief sudden loss of consciousness causing them to drop or nod their head with a quick recovery.
- Absence Seizures (also known as petit mal or lapse seizures)
The onset of these type seizures usually occurs between 4 and 12 years of age. Absence seizures produce a brief lapse of awareness, usually lasting 10 to 30 seconds. These appear without warning or aura. Like partial complex seizures, the person may appear to be staring or daydreaming. They simply stops moving or speaking, stare straight ahead blankly, and do not respond to questions. Symptoms such as lip smacking, twitching, slight hand movements and slight loss of muscle tone without loss of postural control may also occur.
The seizure is so short and hard to even notice that a person can have 50 or 100 absence seizures a day, without them being detected. When the seizure ends, the person goes back to his or her normal activities without realizing that anything has happened; he or she also does not have any memory of the seizure.
Diagnostic Evaluation of Seizures
Most children with first seizures should be evaluated in a hospital's emergency department. Any child with repeated or prolonged seizures, trouble breathing, or who has been significantly injured should go to the hospital by ambulance. However, if the seizure lasted less than 2 minutes, if there were no repeated seizures, and if the child had no difficulty breathing, it may be possible to have the child evaluated at the pediatrician's office.
The physician needs ascertain the type of seizure and understand the cause so that effective treatment may be provided.
Careful intake of medical history, including detailed description of seizure episode is very important.
Physical examination and blood analysis may be performed prior to diagnostic evaluation using EEG, a study looking at the brain waves or electrical activity of the brain; or neuroimaging studies such as CT, MRI or PET scans to identify brain defects.
If the child has had his or her first febrile seizure, then the doctor may want to perform a lumbar puncture (spinal tap) to test for possible meningitis, especially if the child has a VP or VA shunt. The lumbar puncture should be performed in children younger than 6 months, and some doctors perform them in children as old as 18 months.
Treatment of Seizures
Immediate treatment
In addition to protecting the child from injury, it is important that caregivers do not try to give food, liquid, or medications by mouth to a child who has just had a seizure. For children with chronic seizure disorders, physicians may prescribe the rectal form of some anti-seizure medications to keep on hand for emergencies. It is important for caregivers to call 911 and retrieve medical assistance immediately if a child has status epilepticus.
They will be treated very aggressively with anti-seizure medications, admitted to the intensive care unit, and possibly be placed on a breathing machine.
Long term treatment
Long term, the goal is to control the seizures and to protect the child from injury. Each child requires individualized plans for treatment based on their specific circumstances
Medication, surgery, or changes in diet may be required. Some children may also use a special electrical device to stop seizures called a VNS.
The type of treatment prescribed will depend on several factors including the frequency and severity of the seizures as well as the person's age, overall health and medical history.
Many drugs are available to treat epilepsy, several of which have only recently been released.
Older, classic medications used to treat epilepsy include: Dilantin or Phenytek (For more info, see: Medication Index/Dilantin) Phenobarbital (For more info, see: Medication Index/Phenobarbital) Tegretol or Carbatrol (For more info, see: Medication Index/Tegretol) Mysoline Zarontin Depakote, Depakote ER (For more info, see: Medication Index/Depakote) Valium Ativan Tranxene Klonopin
Newer drugs to treat epilepsy include: Felbatol Gabitril Keppra (For more info, see: Medication Index/Keppra) Lamictal Neurontin Topamax (For more info, see: Medication Index/Topamax) Trileptal Zonegran Lyrica
The doctor will follow the drug levels, which require frequent blood tests, and will watch closely for side effects (including damage to child’s teeth and liver). Often, it takes weeks to months to adjust the medications, and sometimes more than one medicine is needed.
What research is being done?
Scientists are studying potential antiepileptic drugs with goal of enhancing treatment for epilepsy. Scientists continue to study how neurotransmitters interact with brain cells to control nerve firing and how non-neuronal cells in the brain contribute to seizures. One of the most-studied neurotransmitters is GABA, or gamma-aminobutryic acid. Researchers are working to identify genes that may influence epilepsy. This information may allow doctors to prevent epilepsy or to predict which treatments will be most beneficial. Doctors are now experimenting with several new types of therapies for epilepsy, including transplanting fetal pig neurons into the brains of patients to learn whether cell transplants can help control seizures, transplanting stem cells, and using a device that could predict seizures up to 3 minutes before they begin. Researchers are continually improving MRI and other brain scans. Studies have show that in some case, children may experience fewer seizures if they maintain a strict diet - called the ketogenic diet - rich in fats and low in carbohydrates.
Sources: http://www.nlm.nih.gov/medlineplus/ency/article/000695.htm http://www.emedicinehealth.com/seizures_in_children/article_em.htm http://www.intelihealth.com/IH/ihtIH/WSIHW000/9339/9400.html http://www.nlm.nih.gov/medlineplus/ency/article/000980.htm http://www.epilepsyfoundation.org/answerplace/Medical/treatment/treatfirst.cfm http://www.ninds.nih.gov/disorders/epilepsy/epilepsy.htm http://www.virtualpediatrichospital.org/patients/cqqa/epilepticseizure.shtml
Resources: -National Institute of Neurological Disorders and Stroke: http://www.ninds.nih.gov/ -American Academy of Neurology (AAN): http://www.thebrainmatters.org/ -Epilepsy Foundation of America (EFA): http://www.epilepsyfoundation.org/ -Epilepsy Foundation: http://www.efa.org/
If you have any concerns, please don't hesitate to discuss your concerns with your child's doctor(s).
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