Pediatric Seizures: Clinical Case, Presentations, and Viva Questions

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1. Clinical Case of Seizures in Children

Clinical Case: Febrile Seizure in a 2-year-old

A 2-year-old boy, previously healthy, is brought to the emergency department by his parents. They report that 30 minutes ago, the child suddenly became unresponsive, his eyes rolled back, and his entire body began to shake. The episode lasted approximately 2 minutes, after which the child appeared confused and sleepy.

History:

  • No previous history of seizures
  • Developed a fever (39.5°C / 103.1°F) earlier in the day
  • No recent head trauma or ingestion of toxins
  • Up-to-date on vaccinations
  • No family history of epilepsy

Physical Examination:

  • Temperature: 39.2°C (102.6°F)
  • Heart Rate: 130 bpm
  • Respiratory Rate: 28/min
  • Blood Pressure: 90/60 mmHg
  • Oxygen Saturation: 98% on room air
  • Appears lethargic but arousable
  • No focal neurological deficits
  • Tympanic membranes slightly erythematous bilaterally

Assessment and Plan:

  1. Diagnosis: Simple Febrile Seizure
  2. Immediate management:
    • Ensure airway patency and adequate oxygenation
    • Antipyretic medication (acetaminophen or ibuprofen)
    • Close monitoring of vital signs and neurological status
  3. Investigations:
    • Complete blood count
    • Basic metabolic panel
    • Urinalysis
  4. Patient education:
    • Explain febrile seizures to parents
    • Discuss home management of fever and seizure recurrence
  5. Follow-up:
    • Schedule follow-up with pediatrician in 1 week
    • Provide guidelines for when to seek immediate medical attention
2. Varieties of Clinical Presentations of Seizures in Children

Clinical Presentations of Seizures in Children

  1. Generalized Tonic-Clonic Seizures

    • Sudden loss of consciousness
    • Rigid muscle contractions (tonic phase)
    • Followed by rhythmic jerking movements (clonic phase)
    • May be accompanied by tongue biting, urinary incontinence
    • Post-ictal confusion and sleepiness

  2. Absence Seizures

    • Brief episodes of staring and unresponsiveness
    • May have subtle eye blinking or mouth movements
    • Typically last 5-10 seconds
    • Abrupt onset and cessation
    • No post-ictal confusion

  3. Focal Seizures (Simple Partial)

    • Preserved consciousness
    • Localized motor, sensory, or autonomic symptoms
    • May involve jerking of one limb or face
    • Can progress to secondary generalization

  4. Complex Partial Seizures

    • Altered consciousness or awareness
    • May involve automatisms (lip smacking, picking at clothes)
    • Often preceded by an aura
    • Post-ictal confusion common

  5. Febrile Seizures

    • Occur in children 6 months to 5 years old
    • Associated with fever (typically >38°C or 100.4°F)
    • Can be simple (generalized, <15 minutes) or complex
    • Usually self-limiting and benign

  6. Infantile Spasms

    • Typically occur in infants 4-8 months old
    • Brief, sudden flexion or extension of trunk and limbs
    • Often occur in clusters
    • Associated with developmental regression

  7. Atonic Seizures (Drop Attacks)

    • Sudden loss of muscle tone
    • May cause falls and injuries
    • Brief duration, typically <15 seconds
    • Common in Lennox-Gastaut syndrome
3. Viva Questions and Answers Related to Seizures in Children

Viva Questions and Answers

  1. Q: What is the definition of a seizure?

    A: A seizure is a paroxysmal, time-limited change in motor activity and/or behavior that results from abnormal electrical activity in the brain.

  2. Q: How do you classify seizures?

    A: Seizures are primarily classified into two main categories:

    1. Focal seizures (originating in one area of the brain)
    2. Generalized seizures (involving both hemispheres from the onset)

    Each category is further subdivided based on specific characteristics and symptoms.

  3. Q: What is the difference between epilepsy and a seizure?

    A: A seizure is a single event of abnormal electrical activity in the brain, while epilepsy is a chronic condition characterized by recurrent, unprovoked seizures. Epilepsy is typically diagnosed when a person has two or more unprovoked seizures occurring more than 24 hours apart.

  4. Q: What are the most common causes of seizures in children?

    A: Common causes include:

    • Fever (febrile seizures)
    • Genetic factors
    • Structural brain abnormalities
    • Infections (meningitis, encephalitis)
    • Metabolic disturbances
    • Head trauma
    • Hypoxic-ischemic injury
    • Toxins or drug exposures

  5. Q: What is the typical age range for febrile seizures?

    A: Febrile seizures typically occur in children between 6 months and 5 years of age, with a peak incidence at 18 months.

  6. Q: How do you differentiate between simple and complex febrile seizures?

    A: Simple febrile seizures are:

    • Generalized (not focal)
    • Last less than 15 minutes
    • Do not recur within 24 hours

    Complex febrile seizures have one or more of the following features:

    • Focal onset
    • Duration >15 minutes
    • Recurrence within 24 hours

  7. Q: What is the emergency management of an actively seizing child?

    A: The emergency management includes:

    1. Ensure airway patency and adequate oxygenation
    2. Place the child in a lateral decubitus position
    3. Monitor vital signs
    4. Administer anticonvulsant medication if seizure persists (e.g., benzodiazepines)
    5. Treat underlying causes (e.g., fever, hypoglycemia)
    6. Prepare for potential respiratory support

  8. Q: What investigations would you consider for a child presenting with a first-time seizure?

    A: Investigations may include:

    • Complete blood count
    • Serum electrolytes, glucose, calcium, magnesium
    • Electroencephalogram (EEG)
    • Neuroimaging (CT or MRI), especially if focal seizure or abnormal neurological exam
    • Lumbar puncture if suspicion of CNS infection
    • Toxicology screen if ingestion suspected

  9. Q: What is status epilepticus and how is it managed?

    A: Status epilepticus is a prolonged seizure or recurrent seizures without recovery of consciousness between episodes, typically lasting more than 5 minutes. Management includes:

    1. ABC's (Airway, Breathing, Circulation)
    2. Benzodiazepines (e.g., lorazepam, midazolam)
    3. If seizures persist, second-line agents such as fosphenytoin or valproic acid
    4. Continuous EEG monitoring
    5. Intubation and mechanical ventilation if necessary
    6. Treatment of underlying causes

  10. Q: What are the long-term effects of recurrent seizures on a child's development?

    A: Potential long-term effects include:

    • Cognitive impairment
    • Learning difficulties
    • Behavioral problems
    • Motor deficits
    • Increased risk of sudden unexpected death in epilepsy (SUDEP)
    • Psychosocial issues

    However, many children with well-controlled epilepsy have normal development and quality of life.

  11. Q: How do absence seizures present, and how are they diagnosed?

    A: Absence seizures present as brief episodes of staring and unresponsiveness, often with subtle eye blinking or mouth movements. They are diagnosed through:

    • Clinical history
    • EEG showing characteristic 3 Hz spike-and-wave discharges
    • Hyperventilation test (can provoke absence seizures)

  12. Q: What is the role of neuroimaging in pediatric seizures?

    A: Neuroimaging (CT or MRI) is used to:

    • Identify structural abnormalities (e.g., tumors, malformations)
    • Evaluate for signs of increased intracranial pressure
    • Detect evidence of trauma or infection
    • Guide surgical planning in refractory epilepsy

    It is not routinely required for simple febrile seizures or typical absence seizures.

  13. Q: What are the main classes of antiepileptic drugs (AEDs) used in children?

    A: Main classes of AEDs include:

    • Sodium channel blockers (e.g., carbamazepine, oxcarbazepine)
    • GABA enhancers (e.g., valproic acid, clobazam)
    • Calcium channel modulators (e.g., ethosuximide)
    • Synaptic vesicle protein 2A (SV2A) modulators (e.g., levetiracetam)
    • Multiple mechanism drugs (e.g., topiramate, zonisamide)

  14. Q: How do you approach the management of a child with newly diagnosed epilepsy?

    A: The approach includes:

    1. Accurate diagnosis and seizure classification
    2. Selection of appropriate AED based on seizure type and patient factors
    3. Patient and family education about epilepsy and medication
    4. Regular follow-up to assess efficacy and side effects
    5. Counseling on safety precautions and lifestyle modifications
    6. Consideration of non-pharmacological treatments if appropriate

  15. Q: What are the indications for EEG in pediatric seizure evaluation?

    A: Indications for EEG include:

    • Diagnosis and classification of seizure type
    • Evaluation of suspected epilepsy syndromes
    • Monitoring of treatment response
    • Investigation of cognitive or behavioral changes
    • Evaluation of status epilepticus
    • Pre-surgical evaluation in refractory epilepsy

  16. Q: What is West syndrome and how is it managed?

    A: West syndrome is an epileptic encephalopathy characterized by:

    • Infantile spasms
    • Hypsarrhythmia on EEG
    • Developmental regression

    Management includes:

    1. First-line treatments: ACTH, oral corticosteroids, or vigabatrin
    2. Second-line options: topiramate, zonisamide, valproic acid
    3. Ketogenic diet in refractory cases
    4. Early intervention and developmental support
    5. Treatment of underlying etiology if identified

  17. Q: How do you counsel parents about the risk of recurrence after a first unprovoked seizure in a child?

    A: Counseling should include:

    • Overall recurrence risk is about 40% within 2 years
    • Risk factors for recurrence:
      • Abnormal EEG
      • Neurological abnormalities
      • Nocturnal seizures
      • Family history of epilepsy
    • Discussion about whether to start AED treatment
    • Safety precautions and first aid for seizures
    • Importance of follow-up and reporting any recurrence

  18. Q: What are the potential side effects of common antiepileptic drugs in children?

    A: Common side effects include:

    • Valproic acid: weight gain, hair loss, thrombocytopenia, hepatotoxicity
    • Carbamazepine: rash, hyponatremia, leukopenia
    • Phenytoin: gingival hyperplasia, hirsutism, cerebellar ataxia
    • Levetiracetam: irritability, behavioral changes
    • Topiramate: cognitive slowing, weight loss, kidney stones
    • Ethosuximide: gastrointestinal upset, headache

  19. Q: What is Lennox-Gastaut syndrome and how does it differ from other childhood epilepsies?

    A: Lennox-Gastaut syndrome is a severe epileptic encephalopathy characterized by:

    • Multiple seizure types (tonic, atonic, atypical absence)
    • Cognitive impairment and developmental delays
    • Characteristic EEG pattern with slow spike-and-wave complexes

    It differs from other epilepsies in its:

    • Resistance to treatment
    • Poor prognosis
    • Association with significant cognitive and behavioral problems

  20. Q: How do you approach the management of refractory epilepsy in children?

    A: Management of refractory epilepsy includes:

    1. Re-evaluation of diagnosis and seizure classification
    2. Optimization of current AED regimen
    3. Trial of new or combination AEDs
    4. Consideration of non-pharmacological options:
      • Ketogenic diet
      • Vagus nerve stimulation
      • Epilepsy surgery
    5. Addressing comorbidities (e.g., cognitive, behavioral issues)
    6. Psychosocial support for child and family

  21. Q: What is the ketogenic diet and how is it used in pediatric epilepsy?

    A: The ketogenic diet is a high-fat, low-carbohydrate diet that induces a state of ketosis. In pediatric epilepsy:

    • It's primarily used for refractory epilepsy
    • Particularly effective in certain conditions (e.g., GLUT1 deficiency, infantile spasms)
    • Requires strict medical supervision and dietary planning
    • Can lead to seizure reduction or freedom in some patients
    • Potential side effects include constipation, kidney stones, growth retardation

  22. Q: How do you diagnose and manage autoimmune epilepsy in children?

    A: Diagnosis and management of autoimmune epilepsy involves:

    1. Clinical suspicion based on presentation (e.g., refractory seizures, encephalopathy)
    2. Testing for neuronal antibodies (e.g., anti-NMDA receptor, anti-LGI1)
    3. Neuroimaging (MRI) to look for characteristic changes
    4. CSF analysis for inflammation markers
    5. Treatment:
      • First-line: corticosteroids, IVIG, or plasmapheresis
      • Second-line: rituximab, cyclophosphamide
      • Antiepileptic drugs for seizure control
    6. Long-term follow-up and monitoring for relapses

  23. Q: What are the considerations for transitioning adolescents with epilepsy to adult care?

    A: Key considerations include:

    • Gradual process starting in early adolescence
    • Education about epilepsy self-management
    • Discussion of lifestyle factors (e.g., driving, alcohol use, contraception)
    • Addressing psychosocial and educational/vocational needs
    • Ensuring continuity of care with adult epilepsy services
    • Reviewing and updating treatment plans
    • Addressing any comorbid conditions
    • Providing resources for adult epilepsy support services
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