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Introduction To Epilepsy Semiology diagnosis Treatment

Objectives. Recognize different types of seizures.Discuss workup for new onset seizuresLearn classification of epilepsy types based on history, seizure type, MRI, and EEG findingsReview common treatments used in epilepsyLearn prognosis based on epilepsy typeBriefly review some frequently asked

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Introduction To Epilepsy Semiology diagnosis Treatment

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    1. Introduction To Epilepsy Semiology diagnosis Treatment M. Scott Perry, M.D. Emory University April 18, 2007 September 18, 2006

    2. Objectives Recognize different types of seizures. Discuss workup for new onset seizures Learn classification of epilepsy types based on history, seizure type, MRI, and EEG findings Review common treatments used in epilepsy Learn prognosis based on epilepsy type Briefly review some frequently asked questions

    3. Spells

    4. Case 1

    6. Seizure Imitators Benign Neonatal Sleep Myoclonus Myoclonic jerks are focal, multifocal, unilateral or bilateral 1-5 hz, distal>proximal Begins in first weeks, diminishes by 2nd month, generally gone by 6 months Episodes may be exacerbated by benzos

    7. Seizure Imitators Breath Holding Spells Incidence: 4.6% (population study, N=4980) Onset: 6-18 months 90% resolve by age 6y cyanotic and pallid

    8. CYANOTIC BREATH-HOLDING SPELLS 60 % are cyanotic stimulus triggered (anger, frustration) short cry breathing interrupted in expiration cyanotic, limp, LOC +/- sleep

    9. COMPLICATED BREATH-HOLDING SPELLS Breath-holding spells + seizure-like activity usually more prolonged 15% have complicated features clonic activity follows LOC stiffening

    10. Seizures: What information is useful? What was the patient doing when it started? Unresponsive?...are you sure? Asleep or awake? Tell us exactly what you saw: E.R.B.S.A.O? Does it make anatomical sense? Same side, both sides, just arms, etc. How long did it last?

    15. Seizure Types

    16. Simple partial

    17. Partial Secondarily Generalized

    18. Partial Seizure Clues Contralateral Head Deviation, Eye Deviation, Dystonic Posturing, Unilateral Clonic Activity, Postictal Paralysis Ipsilateral Automatisms, Eye Blinking, Nose Wiping

    19. Differentiating Seizure Types - Semiology

    20. What do you see?

    21. Seizure Types

    22. Generalized Seizure

    23. See the Difference?

    25. Generalized Seizure Semiology

    26. Review So Far Common seizure imitators in pediatrics Seizures come in two basic types. You have to ask the right questions to distinguish them Now...how do you diagnose epilepsy (i.e. when is EEG/MRI necessary) and why do we care?

    34. Symptomatic Partial Epilepsy Abnormal MRI (stroke, dyplasia, etc.) or abnormal EEG without classic pattern History not consistent with primary partial epilepsy Prognosis varies

    35. Secondary Partial Epilepsy - MRI

    52. Choosing an AED Type of epilepsy

    53. Treatment of Epilepsy: AEDs

    54. Choosing an AED Type of epilepsy Type of formulation (IV, capsule, sprinkle, etc.)

    55. Choosing an AED Formulation IV: Benzos, phenytoin, phenobarbital, valproic acid, levetiracetam Sprinkles: valproate, topiramate Liquids: carbazepine, oxcarb, levetiracetam, valproate, dilantin. zonegran,lamictal,topiramate will dissolve in H20 Extended release: valproate, carbamazepine

    56. Choosing an AED Type of epilepsy Type of formulation (IV, capsule, sprinkle, etc.) Time to onset

    57. Choosing an AED Time To Onset Rapid onset: Any IV form Onset in 24 hours: Levetiracetam Onset in Days: carbamazepine, oxcarb, dilantin, valproate, zarontin. Slow titration: Topiramate, zonisamide Really slow: Lamictal

    58. Choosing an AED Type of epilepsy Type of formulation (IV, capsule, sprinkle, etc.) Time to onset Side Effects

    59. Choosing An AED Side Effects

    60. Choosing an AED Type of epilepsy Type of formulation (IV, capsule, sprinkle, etc.) Time to onset Side Effects Dosing Schedule

    61. Choosing An AED Dosing Schedule QD: Depakote ER, Zonisamide TID: Depakene, Neurontin, Tegretol, Phenytoin (neonates) BID: Everything else

    62. Febrile Seizure 3 types (simple, complex, status) NIH consensus: Febrile seizure is an event in infancy or childhood, usually 3m-5 years, associated with fever but without evidence of intracranial infection or defined cause. Seizures with fever in children who have suffered a previous nonfebrile seizure are excluded. incidence- 4%: absolute risk increased with family hx (1 relative 10%, 2-32%), daycare (7%), dev delay (10%) Risk of recurrence: 1 in 24 risk of future epilepsy: 2-10% workup - MRI/EEG does not predict recurrence treatment

    63. Practice Parameter Febrile Seizures Current Recommendations AAP [Pediatrics 97(5), May 1996, 769-71.] Age 6-12 months with febrile seizure should strongly consider LP Age 12-18 months should consider >18 months may use physical exam, associated symptoms to drive need Based recommendations on 4 studies reporting 13-15% of children will present with seizures as the initial manifestation of seizures with 30-35% having no meningeal signs. More recent reviews have suggested the presence of meningitis in the absence of associated signs is rare (1/200), with a large percentage of such patients with normal CSF at presentation. The introduction of the H.Flu vaccine has significantly altered the epidemiology of infantile bacterial meningitis making present treatment different from that 30 years ago (which the AAP based their recommendations). Most physicians would agree that LP in children outside the range of febrile convulsions is necessary, as well as children within the range with sign or symptoms of CNS infection, such as nuchal rigidity, altered mental status, etc.

    64. Practice Parameters First Unprovoked Seizure Laboratory investigations (CBC, CMP, tox screens) should be considered based on historic and clinical findings LP is of limited value in first unprovoked afebrile seizure EEG is recommended to dx epilepsy syndromes and provide for prognosis MRI is preferred modality and should be considered in children with cognitive/motor impairment that is unexplained, focal onset seizures, or in children < 1y. Emergenat imaging should be performed in children with prolonged todd’s, or prolonged (several hours) postictal state. Treatment: 46% have recurrence in 10years, 19% > 4 seizures, and 10%>10 seizures

    65. FAQ (the ED) I have a 14 month old with a febrile seizure and a “raging otitis,” do I need to do a LP? (3a.m.) Hey, how are you? I have a kid here with known epilepsy that had a breakthrough seizure (like he does once every 3 months or so), do you want to increase his medicine? Do I need to CT this kid? I have a patient of Dr. Flamini’s here, how do you want to treat him?

    66. FAQ (the parents) Why does my child have seizures? Will my child be stupid? How long does my child need treatment? What do I do when my child has a seizure?

    67. Case 16 year old female with first unprovoked seizure, described as generalized tonic clonic

    68. Case 8 y/o with frequent episodes of staring, at times associated with lip smacking

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