00:01
Let's move on to generalized seizures.
00:05
In a patient with generalized seizures, i
it's important to control the seizure
but you probably got about five minutes
remember most pediatric seizures
will stop of their own accord
within five minutes.
00:18
An EEG after a seizure is done maybe useful
for identiyfing underlying seizure syndromes.
00:25
Let me give you an example.
00:28
Lennox Gastaut Syndrome
has an onset between typically three
and five years of age.
00:34
These patients have mixed varieties
of seizure
and they may develop mental
retardation.
00:41
And severe behavioral problems.
00:44
Lennox Gastaut has a very typical
EEG pattern.
00:48
It is not so important for a medical
student or a resident
or even
a fellow would probably need to know it
if there is a neurology fellow.
00:58
But most of us don't really need
to know how to read EEGs
But we should be aware that there are
certain patterns in them
that give away certain diagnosis.
01:07
And Lennox Gastaut does have
a typical EEG appearance.
01:11
The reason why it is important to make
the diagnosis of Lennox Gustaut is because
it is a difficult to manage disease
and will require the guidance
of a pediatric neurologist.
01:22
Here is an example of an EEG.
01:25
What you see here is a patient
with Lennox-Gastaut
You can here that there are intermittent
periods of independent polywave spikes
lasting for roughly one to eight seconds.
01:36
And that is classic and emblematic
of that disease.
01:42
We've got Levetiracetam (commonly called Keppra), Dilatin or Phenytoin.
01:48
We've got Phenobarbital and Ethosuximide.
01:52
These are all drugs that we are going to use to place a child on all the time to help prevent them from getting recurrent seizures,
when their seizures are frequent.
02:01
Keppra is our most commonly used drug, and we use it as a common first-line agent to prevent seizures in children,
both with ongoing seizure disorders, and sometimes temporarily for a period of time
after serious brain injury to prevent seizures from happening as a prophylaxis measure.
02:16
An important side effect of this med, especially in babies, is irritability,
and this can be counteracted somewhat by providing Vitamin B-6 as well.
02:26
Other side effects can include diastolic hypertension and nausea or vomiting.
02:32
Dilantin is good for partial or generalized seizures.
02:37
The problem is you need to know the serum drug levels of the patients on this drug and over time they can develop side effects.
02:43
The side effects that you are going to be asked about on your tests is probably Gingival hypertrophy.
02:48
They get excessively growing gums around their teeth.
02:51
They also have increased body hair.
02:53
Usually in the arms you can see it very easily.
02:56
And long term, they can have neurotoxic effects with actually a loss of IQ points over time.
03:02
So in general we like to avoid seizure drugs unless we need them.
03:06
Phenobarbital generally used and better on children under one year of age, although it has been largely replaced by Keppra.
03:13
It is good for partial or generalized seizures, and again, we are going to have to follow drug levels.
03:19
This can cause a loss of IQ points over time.
03:22
It has a general sedating effect, which mitigates somewhat over time as they get used to the drug.
03:27
But be careful to warn the parents that for the next week or two, their child may be excessively sleepy.
03:33
Ethosuximide is our first line anti-seizure medicine for children with absence seizures.
03:38
So, I threw it in here as an alternative example of a seizure medication that you will see children being on.
03:43
The side effects of Ethosuximide are drowsiness, behavioral changes, nausea and they can get an Aplastic anemia or a lupus-like syndrome.
03:51
The general principle here is that there are lots of drugs we use in children
we need to know what the side effects are and we need to know which drugs are most effective in which seizure syndromes.
04:01
It's really a matter of what the side effect profile what are your monitoring needs and what the seizure type is.
04:10
Let's switch goals to focal seizures.
04:14
Now remember,
only children with focal seizures are
going to have auras warning them
of an impending seizure.
04:23
Auras are unique things for each child.
Sometimes they will see certain colors
or just get a sense that a seizure is coming
on.
04:31
Focal seizures usually affect one area of the
body.
04:35
Let's say an arm or a face.
04:37
The child may be fully awake
during the event.
04:41
If we diagnose it with EEG,
but an MRI is absolutely indicated in
a child with a first time focal seizure
because we need to rule out
a focal abnormality in the brain.
04:53
We're going to treat focal seizures
with AEDs, implanted devices
and in bad cases, ketogenic
diet or surgercal removal of the lesion.
05:04
Infantile spasms are a severe and
very sad disease that happens
to infants and can have terrible progrnosis.
05:16
These look really unique.
05:18
And I urge you to go online and
get to Youtube
and find a video of infantile spasms.
They are all over the place.
05:26
It is important to be able to recognize them
because diagnostically,
It is important to make this
diagnosis.
05:32
These children have generalized myoclonic
jerks of the neck, trunk and limbs.
05:38
It generally begins between 3
and 7 months of age.
05:42
The specific etiology of the majority
are unknown or they're genetic or syndromic.
05:49
Children who are not actively seizing
will start off with having a normal
neurologic exam and the typical
EEG finding is something called
hypsarrhythmia.
06:00
You should probably remember that
that might show up on a test.
06:05
Infantile spasms have a very
bad diagnosis.
06:08
And it is a very bad prognosis.
06:11
The death occurs for
about 1/3 within 3 years of diagnosis.
06:15
These children have profound cognitive
effects from their recurring seizures
These seizures are profoundly hard
to control.
06:22
and in survivors,
they gradually turn
into other types of seizures
which can persist into adulthood.
06:31
Another type of seizure that is much less
concerning is
Benign Rolandic Epilepsy.
06:38
This is also called Benign Epilepsy with
Centrotemporal spikes or BECTS.
06:45
That's because
these patients tend to have
Centrotemporal spikes on their EEG.
06:51
This present as several partial seizures
usually in the face and in the hand.
06:56
It begins a little bit older
between 5 and 12 years of age.
07:00
And usually with normal children
who are developing normally.
07:04
What is key is they usually occur
during sleep.
07:07
or within an hour of falling asleep.
07:11
Almost all are outgrown during adolescence.
07:14
They have those specific EEG findings,
and treatment is optional because they
are asleep while having the problem.