Febrile Seizures

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Slide 1 :

Febrile Seizures Amy Kao, MD 2005-2006 Division of Pediatric Neurology Oregon Health & Science University Stirred, Not ShakenGetting Comfortable with Neurology

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Learning Objectives Review basic definitions and classification of seizures Discuss the specific epilepsy syndrome of febrile seizures Review the neurologic exam in the context of the concept of anatomical localization of neurologic symptoms and deficits

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The Basics Definition of a Seizure sudden event caused by abrupt, uncontrolled, hypersynchronous discharges of neurons

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More Definitions Epilepsy condition characterized by the tendency for recurrent seizures that are unprovoked by an immediate cause Status epilepticus > 30 minutes long OR Back-to-back without return to baseline

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Seizures—Differential Dx Loss of tone or consciousness Abnormal heart rhythm Vasovagal syncope (classic fainting) Attention deficit disorder Disorders of breathing Breathholding spells Hyperventilation Other medical disorders Hypoglycemia Gastroesophageal reflux

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Seizures—Differential Dx (2) Unusual” movements Benign sleep myoclonus Shuddering attacks Migraine (torticollis, ataxia, confusional) Tics “Pseudoseizures” Behavioral or Self-stimulation Night terrors Sleep walking Rocking Head banging Infantile masturbation

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Seizures—Etiology V(ascular): AVM, stroke, hemorrhage, HTN I(nfectious): meningitis, encephalitis T(raumatic) A(utoimmune): SLE, vasculitis, ADEM M(etabolic/toxic): electrolyte imbalance, tox I(diopathic): “idiopathic epilepsy” N(eoplastic) S(tructural): cortical malformation, prior stroke, “other causes of CP” S(yndrome): genetic disorder

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Classification of Seizures By Onset Generalized Begins simultaneously in both hemispheres Generalized-tonic-clonic = “grand-mal” Absence = “petit-mal” Myoclonic Tonic Atonic

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Classification by Onset, continued Partial (=Focal) Onset in a focal region of the brain Simple partial Complex partial Secondarily generalized

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Classification of Seizures By Cause Acute Symptomatic Shortly after an acute insult Infection Hypoglycemia, low sodium, low calcium Head trauma Toxic ingestion

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Classification by Etiology, continued Remote Symptomatic Pre-existing brain abnormality or insult Brain injury (head trauma, low oxygen) Meningitis Stroke Tumor Developmental brain abnormality

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Classification by Etiology, continued Idiopathic No history of preceding insult Likely “genetic” component

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Classification by Syndromes Definition of a syndrome Cluster of symptoms, signs, and lab findings (EEG) Consistent Implies diagnosis, treatment, or prognosis There are syndromes specific to children

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Febrile Seizures Definition “a seizure in association with a febrile illness in the absence of a CNS infection or acute electrolyte imbalance in children older than 1 month of age without prior afebrile seizures”

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Febrile Seizures Epidemiology 2 to 5 % of children in the US Most common form of childhood seizures Peak at 18 months Simple = isolated, brief, generalized Complex = focal, multiple, or prolonged

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Simple Febrile Seizures < 15 minutes Generalized-tonic-clonic Fever > 100.4 rectal to 101 F (38 to 38.4 C) No recurrence in 24 hours No post-ictal neuro abnormalities (e.g. Todd’s paresis) Most common 6 months to 5 years Normal development No CNS infection or prior afebrile seizures

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Risk Factors for 1st Feb Sz Febrile seizure in 1st/2nd degree relative Day care Neonatal nursery stay of >30 days Developmental delay Height of temperature

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Risk Factors for Recurrent FS 1/3 will have a recurrence 10% will have 3 or more FH of febrile seizures Age <18 months Height of temperature Duration of fever

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Risk Factors for Epilepsy 2 to 10% will go on to have epilepsy Developmental delay Complex FS (possibly > 1 complex feature) 5% > 30 mins => ¼ of all childhood status FH of epilepsy Duration of fever

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Evaluation in Febrile Seizures Exclude acute etiologies HCT, lytes/cbc if history/PE suggests Strongly consider LP < 12 months old Prior antibiotic therapy Suspicious findings on history/PE Not absolutely necessary in > 18 mos

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Evaluation in FS (2) EEG Does NOT predict recurrence or epilepsy More likely to be abnormal in: Older children Neurodevelopmental abnormalities Family history of febrile seizures Complex febrile seizure

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Febrile Seizures—Treatment May reduce short-term recurrence But NO effect on occurrence of epilepsy AND the side effects ! The approach is based on epidemiological data that FS are benign, so Prevent status epilepticus

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FS—Treatment (2) Antipyretics No data that this reduces risk FS at onset of fever => highest recurrence Benzodiazepines Rectal diazepam (Valium) 2-5 y/o 0.5 mg/kg 6-11 y/o 0.3 mg/kg (round up to 2.5, 5, 10 mg) Oral diazepam 0.33 mg/kg q8 hrs x 48 hrs during illness

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FS—Treatment (3) Daily medications NOT recommended Phenobarbital Drowsiness, sleep problems, hyperactivity, IQ Valproic acid Hepatotoxicity Phenytoin and carbamazepine Not effective

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Seizures—Exam Temp, BP, HC Skin (rash, neurocutaneous lesions), Neck Evidence of dysmorphisms, developmental delay Evidence of increased intracranial pressure Bulging anterior fontanelle Depressed level of consciousness Pupillary asymmetries Downgaze/sunsetting eyes Abducens palsy Papilledema

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Seizures—Exam (2) Evidence of focal deficits Weakness Intracranial lesion versus Todd paresis Tone or reflex asymmetry ? Chronic versus acute

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Seizures—Evaluation Lumbar puncture “Strongly consider” in patient <12 mo with first febrile seizure Kernig’s, Brudzinski’s, nuchal rigidity low sensitivity (Thomas 2002) But usually more than isolated seizure History of irritability/lethargy Complex febrile seizure Slow postictal clearing of mentation

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Seizures—Evaluation (2) Neuroimaging “Emergent” HCT Concern of acute focal lesion, mass effect I.e. persistent paresis or change in MS MRI (nonurgent) Focal sz Cognitive/motor impairment Focal EEG findings EEG Not if simple febrile seizure

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Location, Location, Location

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Overview of the Neuro Exam Mental Status Cranial Nerves Motor Gait Coordination Reflexes Sensory “General”

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General Growth parameters (HC) Vital signs (temp, BP) Anterior fontanelle Flattening of the occiput Dysmorphic features Cardiac abnormalities Hepatosplenomegaly Cutaneous lesions

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Mental Status Change in mental status = brain is not working correctly Level of consciousness Lethargy Stupor Coma Attentive/interactive Language (receptive, expressive)

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Cranial Nerves = Brain stem or nerve CN2 = optic nerve Funduscopic exam Visual fields/blink to threat Visual acuity/color vision CN3, 4, 6 = oculomotor, trochlear, abducens Eyelids Pupils Extraocular movements

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Cranial Nerves (2) CN5 = trigeminal Sensation Masseter function Corneal reflex (comatose or focal brain stem) CN7 = facial Wide palpebral fissure and flat nasolabial fold Both upper and lower face = LMN Only lower face weak = UMN

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Cranial Nerves (3) CN8 = vestibulocochlear nerve Finger rub Weber’s—louder ear = conduction deafness Rinne—confirms above ear (air < bone) CN9, 10 = glossopharyngeal and vagus Palate elevation, gag CN11 = spinal accessory L SCM turns head to R, ear to ipsi clavicle CN12 = hypoglossal Tongue in cheek

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Motor Hypotonia = LMN or UMN, cerebellum Hypertonia = UMN lesion, basal ganglia Bulk/Fasciculations Tone Resistance to passive ROM Traction response, horizontal/vertical suspension Power 0 to 5 grading scale Techniques to bring out asymmetry Pronator drift, finger tapping, gait

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Gait Motor cortex, corticospinal tracts, basal ganglia, cerebellum, vestibular system, nerves, muscles, vision, proprioception Good screening test Natural gait Toe walk, heel walk, tandem walk Romberg (proprioception, vestibular) Sit to stand

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Coordination Limb ataxia = cerebellar hemispheres Gait ataxia = midline cerebellum Finger-to-nose testing/reaching for toys Rapid rhythmic alternating movements Titubation (truncal ataxia)

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Reflexes Hyperreflexia = UMN lesion Hyporeflexia = LMN lesion 0 to 5+ grading scale Babinski’s sign = UMN lesion Correspond to spinal roots Primitive reflexes

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Sensation Stocking-glove = nerve Vibration/proprioception = dorsal columns Pain/temp = spinothalamic tracts Extinction = cortex Localization of stim Purposeful withdrawal to painful stim Spinal level

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Questions re:Neuro Exam? http://medstat.med.utah.edu/pedineurologicexam/home_exam.html

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Bibliography Baumann RJ and Duffner PK. Treatment of children with simple febrile seizures: The AAP practice parameter. Pediatr Neurol 2000;23:11-17. Hirtz D et al. Practice parameter:evaluating a first nonfebrile seizure in children. Neurology 2000;55:616. Knudsen FU. Febrile seizures: Treatment and prognosis. Epilepsia 2000;41:2-9. Prensky AL. An approach to the child with paroxysmal phenomena with emphasis on nonepileptic disorders. In: Pellock JM, ed. Pediatric epilepsy diagnosis and therapy. New York: Demos Medical Publishing, 2001:97.

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Bibliography Provisional committee on quality improvement, subcommittee on febrile seizures. Practice parameter: the neurodiagnostic evaluation of the child with a first simple febrile seizure. Pediatrics 1996;97:769. Shinnar S and Glauser TA. Febrile seizures. J Child Neurol 2002;17:S44-52. Thomas KE et al. The diagnostic accuracy of Kernig’s sign, Brudzinski’s sign, and nuchal rigidity in adults with suspected meningitis. Clin Inf Dis 2002;35:46. Warden CR et al. Evaluation and management of febrile seizures in the out-of-hospital and emergency department settings. Ann Emerg Med 2003;41:215.

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Division of Pediatric Neurology. Oregon Health & Science University .... Neurology 2000;55:616. Knu more Division of Pediatric Neurology. Oregon Health & Science University .... Neurology 2000;55:616. Knudsen FU. Febrile seizures: Treatment and prognosis. ... less
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