In this fast-paced guide, pediatric neurologist Jennifer Yuen, DO, makes sense of the many seizure types and epilepsy syndromes, so that primary care providers can efficiently reach a likely diagnosis and determine which patients need a workup (including when and how to work up a febrile seizure). She offers tips on getting parents to describe seizures in useful ways, the typical appearance and onset age range for various epilepsies, and pearls of wisdom regarding drug use and how to improve medication compliance, especially for teenagers.
And share. So I'm gonna be talking about seizures and hopefully this works, you know, in terms of things that just kind of updating you as well as um you know, learning some new things about seizures. So, all right. So, so no disclaimers and then basically, we're gonna talk about seizures, bed seizures and the very types of epilepsies that you may see or encounter and then just other seizure considerations. So what are seizures, abnormal neuronal activity in the brain? Um And so, basically describe it a little short circuit of what's happening in the brain. Um And that's what the seizures are clinically speaking. So these are other terms that I just kind of found in terms of um what patients have said or I've read, you know, convulsions and twitches, ticks and absent and absentee seizures like that comes up a lot. Um episodes attack, spasm fits and then the Grand Mall petit mall that everybody hears and nobody seems to ever get correct. Um in terms of what they're saying. So whenever you hear these terms, I always say it's great that you're describing them in terms of these, you know, um using these words but a really good description in terms of what you're asking your patients to give you is like painting a picture, you want to know all the little bits and pieces of what occurred um during the event that they had. Um and so different types of seizures. Uh There's a tonic clonic. And so, um everyone hears about the generalized tonic clonic seizure. That's just kind of big seizure is what they call it. So that's your grand mal seizure is your generalized tonic clonic seizure. Um And so basically, it's a tonic phase is the part that's like stiff and the clonic phase is the part that's moving. So if you have the tonic clonic, um and that's really what it is. Um And you can have a focal tonic clonic as well. It doesn't have to be both sides. Um And so, um I will uh and why it's important to, to, it's nice that we have these terms that I've listed here, but it's also good to have a, have a description because some parent, some sometimes you'll hear um also generalized tonic sonic, but it really is just a tonic seizure. And I will let you know, I had, I had an IC U doctor tell me a kid was, had a generalized tonic clonic seizure and I had them describe it to me and the kid was in a piston and was herniating completely different treatment. Completely different urgency. And that's why I, I'm ok with using some of these words. But if you're really wanting to give me a better picture of what's happening, the, the smaller words are fine, like stiffening, shaking, jerking. I'm fine with all of that because then I can get a better picture of what's happening with the kid. So tonic is that stiffening and they can have that shaking, right. So you can be stiff and shaking and some people will call that generalized tonic clonic because they're like, well, it's just shaking, but they're really just kind of tense and stiff. Um And then you have the Maya Clan which is really quick, really rapid jerk of, you know, and of an extremity really rapid um atonic um is loss of tone. Uh And so basically what you see and certain kids, you know, parents are really concerned. They like my kids having a head drop and their head is dropping and that's an atonic seizure. Um And then we have the absence and I will tell you I have had absence used for all sorts of different types of seizures, including tonic clonic seizures. It is a specific type of seizure, um oftentimes involving its absence, epilepsy. And so oftentimes triggered by hyperventilation, uh kids are staring off, sometimes there's eyelid, fluttering, sometimes they have like mouth chewing mo motions, sometimes they've got like automatisms of their fingers and they'll kind of move their fingers a little bit, but it really is just kind of a stare off and then they'll come back. Um And then a spasm which are, which a lot of people like, well, what's the difference between a myoclonic and spasm? So, hold on one second. So a mayo. So myoclonic I I said was really quick. Correct. A spasm is a lot. Um It's a little bit longer. So my Atlantic is here. Spasm is you, you have this jerk, but there's a little bit of a linger underneath and particularly concerning when we talk about infantile spasms. Um and I'll talk about it later, but it is that, that quick movement and that hold and that's what a spasm is. So again, it's really important to get a good description um of the event and no, no need to use these big words. You can. Um But I always have my patients tell me in the, the whatever words they have they can give me, don't need to impress me with the fact that they know what Grand Mall is. I just want to know what their description of the um movement is. All right. So, focal and generalized seizures, it's really just kind of plain and simple segregation of the different types of seizures. We have um we have focal, so basically one part of the brain has abnormal activity. Um And so uh uh you have, you know, like your right arm, they get jerking or your leg um or just even kind of, you know, head twitching and things like that. So the focal focal um seizures generally uh don't have complete uh loss of awareness, generalized seizure, the whole brain goes all off at once. Having abnormal activity. There is loss of consciousness with this type of seizure. Um and then uh you have focal with secondary generalization. So basically, one part of the brain starts having it and then it just kind of triggers an avalanche and the entire brain goes. So you might have patients that um have some awareness at the beginning and they're like, I don't know what happened and their family members like no, they fell to the ground, they were shaking. So that's likely focal with secondary generalization, important to know these um or important to ask these questions in terms of, you know, like, oh, do you have any idea? Was it, was it one part of your body that started to first, did you feel anything funny beforehand? Because it does uh um change work up um in terms of looking at um the brain and see if there's anything structurally wrong. Um I know we're in pediatrics, but even more important for adults. If it's vocal, you, you really have to scan them. Um And then um Feb so I'm gonna go straight into febrile seizures. It's not an epilepsy. So, epilepsy is two or more unprovoked um seizures and febrile seizure is provoked. Um So, onset from six months to six years. Um Roughly speaking, there's two different types. There's simple febrile seizures and complex febrile seizures, simple febrile seizures. They're generalized less than 15 minutes in length. I know that sounds really long but it's less than 15 minutes in length and there's one in a 24 hour period and the fever can be at any time during that kind of 24 hour period of time. Um, so does it have to be right at the, right at the time? You know, they're like, well, they didn't have a fever when Ems came and they came to the, er, and like an hour later they're spiking a tap and it's 40 °C, right? Febrile seizure. Um complex. It means that it's focal, it can be focal, secondary, generalized and it's greater than 15 minutes and you have two or more in a 24 hour period. The reason to really kind of figure out if it's simple or complex febrile seizure because it changes your management. So simple febrile seizures. No neurologic work up reassurance. It may happen again again, six months to six years that it can occur. You can always give them um a rescue medication uh for those because our rescue medicines talk to you about later. Um Pardon me? Sorry. Um. Mhm. Here you go. Um rescue medicines. We like to give them for seizures longer than 3 to 5 minutes. So it's totally ok to give a rescue medication for these um febrile seizures. And the complex febrile seizures, particularly if it's focal really deserves a work up. So, eeg and an MRI and then again, reassurance. So if, if egeg is normal, MRI is normal, still reassurance can still occur six months to six years. Um So if there, if there are kids that are less than six months and have a fever with a seizure, you need to do a full work up, you know, sub sex work up plus other work up for the potential for the kid is having an un. There's an underlying cause for them to have epilepsy and just because they got sick, it kind of just kind of brought that back up. Um It just kind of kicked it into gear and then again, if they're over six years and with a, a seizure with or without a fever needs a work up. I would say if your first febrile seizure is at five, probably deserves more of a work up. The peak age of febrile seizures to start is 22 months. So two years is the typical time that um a kid would have it. And then again, whenever we talk about febrile seizures, I'm always concerned about the cause of the fever in terms of if they're really young, they need a septic work up. Are there any other signs, meningeal signs, things like that? Um important to have? All right. And so here we are to epilepsy. Um So epilepsy again, I said two or more unprovoked seizures. Um, and then again, the seizure is a symptom. I always, you know, worried and she was like, oh, the seizure, well, the seizure was caused by something some of the time we don't know, but it doesn't mean that we don't go looking. And so, um, I always tell families, you know, we are two roads that we travel and sometimes they're together and sometimes I kind of merge off and sometimes we kind of travel one more than the other. And it's really um the diagnosis and treatment. And so at the very beginning, diagnosis and treatment for epilepsy tend to kind of run parallel. Um And so, you know, some parents are like, well, I really just want to just know why they have epilepsy but not treat like you're having a seizure once every two weeks, we're gonna treat you and then let's talk about doing a work up. So we have to follow both pathways, they're separate, but they kind of um are right next to each other. All right, types of epilepsy. So um I'm gonna talk about generalized epilepsies, common types that you may see in clinic and focal epilepsies, common types that you see in clinic childhood types, um ones with unknown etiology and known etiology of focal epilepsies that you um may run into, have already run into um and hear about. So if you have any questions about or heard of any of those types of sy you can feel free to ask. Um this presentation I made for um child neurology residency. So I like the tail end. I have like slides on other like rarer type of epilepsies. I don't think we had time to go into that today. So here we have the primary generalized epilepsies. Um And the ones that you might see often are childhood absence, epilepsy. There's a juvenile absence, epilepsy, juvenile myoclonic epilepsy. And then this one you may or may not have seen or heard in terms of generalized epilepsy, febrile seizures plus which is gets plus. But in part to the because I talked a lot about febrile seizures because some of these kids end up with febrile, they start off with febrile seizures and then they have a unprovoked seizure and then we have to start worrying about this. All right. So as I said, it doesn't actually become a concern if it, if it, unless it falls outside of typical febrile seizure category. All right. So absence epilepsy. So there's two childhood and juvenile childhood absence epilepsy. This is um parents come to you and like, oh, they're staring, sometimes the parents actually don't know until they get into school and they're like, yeah, the teachers noticing that they're just kind of staring off um typical onset 5 to 8 years and the seizures absence. So they're staring off. Sometimes they have eyelid, fluttering, sometimes they have these mal chewing motions and they just kind of stare off and then they'll come on and it's almost like nothing happened. Um The typical eeg findings, three Hertz they can wave um gold gold standard treatment is ethosuximide. Um And so, um I this is, we don't have a whole lot of epilepsies with the gold standards and this is one of them. Um And so I always like to um treat it with the gold standard. There are other medicines that will work for this in terms of generalized broad spectrum anti-seizure medicines. But Eco su is it's old standards. So if you um have um seen a patient and I know that we're in a bigger city and I, but I practiced in Arizona and I had some pediatricians that were out um on the reservations and things like that and they couldn't come in to see child neuro child neurologist. I said if you're really convinced and you can, uh this is something that you will, you can actually provoke in clinic. It kind of stopped a little bit with COVID because nobody wants anyone breathing um hyperventilating around them. But prior to COVID, you would just have them hyperventilate. And if you, if you to them for three minutes, they will have an absence seizure. So you can actually trigger one in clinic and then you your diagnosis. And I, I've done this before again, less since COVID, but I've done it where I'm like, you know what parents I'm going to just, you know, have your child lie down. I'm gonna have the hyperventilate for three minutes. And if they have a seizure, we have a proven diagnosis. I will still do the work up. We will still get the eeg I'll do all this, but I will start treatment right now today. Um So if you were so inclined and say you can't get them in to see a child neurologist for a month or two and you trigger an episode in clinic, you can go ahead and you can call us and we can advise you. But ethosuximide is the medicine of choice. Um It is a medicine of choice. Um And this is one where, you know, parents were like, oh, this is the one that you can outgrow. So I don't love that term, but it's one that doesn't necessarily continue into adulthood, but if it goes untreated. So I see when people say, well, they'll outgrow it. I don't have to treat my kid. No, this one you need to treat because they are having 50 plus seizures a day and you can't lay down a good foundation of all the education that their teachers are giving them um when you're having 50 plus seizures a day. So I tell them if it goes untreated, you are going to notice a definite decrease in their ability to attend, to be able to learn to comprehend and their development just kind of goes down. I've had pen parents to say, well, you know, the teacher was complaining of staring spells and they were getting A's and now they're getting D's and F's and I'm like, ok, this sounds very much like absence epilepsy. Let's get you, let's get you diagnosed and treated and sure enough their grades go right back up. Um, so just an important thing as parents, if they say, well, they'll grow and I started to decide not to start them with seizures. No, the brain is still very much developing brain isn't developed till the 23 25. And so if this is starting at five years of age, that's 222 decades of brain growth that is affected by absence, epilepsy. So the next one is juvenile, absence, epilepsy. And so this one a little bit older and onset um and they have absence but they also have generalized tonic clonic seizures. This one, their eeg finding is a little bit different than the three hear spike and wave. Um And this one you can use, this one doesn't actually have a gold standard. Now, if um if at first we, you know, they have um absence seizures and we start on the ethosuximide like, oh, let's try it out. But once they have a generalized tonic clonic seizure, you have to start a different treatment. The ethosuximide only works on the absences. Sometimes I've had it where I'll put them on the, I'll keep them on the ethosuximide because if their absences are completely treated and then I'll start them on a different medicine for the generalized tonic clonic cure. So, Depakote, Keppra, lamoTRIgine, those are all good medications for these medic uh for these patients, typically these don't outgrow. So most of the time they are um lifelong and then these are just the type of, this is the eegs that you would see and absence epilepsy. But I like to say asth epilepsy, eegs are, are pretty and looks a little bit like wallpaper. It's a real nice pattern, you know. So therefore, these are very rhythmic, very rhythmic. This is what their eeg looks like. All the other primary generalized epilepsies. You have the juvenile myoclonic epilepsy. So again, happened in adolescence and as its name sake says it's myoclonic. So you have those myoclonic jerks. These are the kids are, you know, they're 14, 15 and they, they come in, they come into the, er, because they um were sleeping over at a friend's house and then they had a seizure in the morning and then neurology comes in consults or you guys see them in clinic and a good question to ask a teenager who may have been, you know, maybe study up up late playing video games. What have you um is, hey, have you noticed that when you're like, you know, if you're showering in the morning or you're holding your cereal bowl that suddenly, you know, your, your hand just jerks and you drop things. It's really kind of are you, are you kind of a Butterfingers in the morning? You're just dropping things and they're like, yeah, that actually may just kind of be that my iconic jerk that they're like, oh, that's happening coupled with the generalized tonic clonic seizure and you have your um suspicion of a juvenile myoclonic epilepsy. Their eeg findings a little bit faster than the absences. So 4, 4.5 Hertz poly spike and wave. It is not as pretty as the um absence eegs. Um this um treatment you can use any kind of broad spectrum um anti seizure medication, deo Keppra, lame trine. Um This one can be lifelong. Um and it is a definite push that I tell families and patients, I'm like alcohol, sleep deprivation, recreational drugs, including marijuana will make this worse. Um I always tell them they're like, yeah, even no matter what social media tells you and you can have your marijuana for your ow, this is not the one I've had patients that I had treated on lamoTRIgine doing really well. They had breakthrough seizure and guess what they did. I smoke pot. I'm like, well, here you are. What did I tell you? This is what happens? Um So very much so important to um just kind of educate the patients. I mean, we want to educate that we don't want any of this like you shouldn't drink, you know, we are pediatrics, right? Like none of this is legal, but definitely for sure if you have juvenile my clinic, epilepsy, you can't. And I often prefer it. Like, do you want to drive? Like, yes. Ok. Well, then if you have a seizure, you can't drive for a certain period of time. Um And so sometimes that's a nice little push to kind of help them, like over the hump of, I need to take my medicine and then we have Gus plus again, I kind of dabbled in that. Um you can have um if they have febrile seizures and suddenly have non febrile seizures, something to look into is a genetic type of epilepsy. Again, broad spectrum anti seizure medication. So when I talk about primary generalized epilepsies, I wrote on here specifically F plus, there's no carBAMazepine, no Oscar Bazin, no Fenty toin any medication or uh lacosamide, anything that is specifically for a focal epilepsy. So, channel acting medication, you probably shouldn't use it for any generalized epilepsies because it will make it worse. Um All right. And so these are some of the eegs for us. See again, it's there and it's not as pretty as the absence epilepsies, but that's just kind of what it looks like. Um focal epilepsy. So we have childhood type of epilepsies that you guys might run into or see or just kind of hear about um from patients. And then we have other ones. So childhood epilepsies, let me tell you the international league against epilepsy loves to change names. So what was known before is benign romantic epilepsy during my period of of being a a resident into my my first decade of child neurology, it ended up being benign epilepsy of childhood central temple spikes or Becks and very most recently 2022 2021 something like that is now self limiting epilepsy with central temporal spi flex. So any of all that is still benign Rolan epilepsy is kind of what most people have been trained on and what they hear. And then you have um benign focal epilepsy with occipital paroxysms or benign childhood occipital epilepsy or Paoli syndrome. Um And then we have other ones based on their um locations in the brain and I'll go over all of them. So here we have select so school age to older school. Um So in the tweens, um this is vocal. Usually what happens is you get a story that they parents like, oh, they had a seizure. What happened? Well, I sent them to bed and I think that they were drifting off to sleep and then they come into my room and one part of the face is twitching and they're slurred speech and I don't know what happened and then they, you know, they either stopped or they went to the ground shaking all over. Um And so that's typically early onset is uh or onset is early stages of sleep and then sometimes when they wake up as well. Um And the eeg shows central, central temple spikes this, um the treatment for his observation versus treatment, 98% of them outgrow it. Now there's some controversy as to whether or not to treat all of them um before it was, well, if they're having really rare seizures don't treat and, and some neurologists like, well, their eg is abnormal, go ahead and treat for two years um to just to decrease the chances of learning disabilities. A DH D and things like that. And so um oftentimes it's hard to talk families into starting a medicine after one seizure. But if they have two, I'm more in line of, you know, if you have frequent enough, I'm gonna treat you regardless of whether or not you outgrow this um a little different than ab ab you're having like 50 seizures a day. This one is not. Um So there's a little bit of uh difference there. So you may notice that you have some patients that have it and some are on treatment and some are not. And this is kind of the thought process for that, but they do outgrow it. And then we have the benign childhood um occipital epilepsy or panopo syndrome. Um This one occurs in younger kids, 5 to 7 years old and these are the kids that come in, they have vision changes, hallucinations, vomiting, sometimes headaches. So this one is kind of a, the stranger one where, you know, where we, they'll come in and we're like, well, maybe they have headaches, maybe they have migraines. Um, but if I get, you know, if they're really just, you know, episodic and don't last very long and otherwise it just doesn't sound a whole lot like actual, like headaches or migraines. This is something to think about. Are they having occipital epilepsy? Um, eeg shows uh occipital spikes in sleep or when the eyes are closed on the eeg. Um So treatments um uh anti-seizure medicines that work really well for focal epilepsy. So, carBAMazepine, Oscar baze pine, um lacosamide works fine with us. Um And then we have focal epilepsies by location of brain. Um So those in the frontal lobe um tend to be really short seizures and they cluster and sleep. And these are the ones that if you hear the story, you're like, are they, are they, are these really epileptic or these non epileptic? Are these psychogenic or functional type of seizures? Uh because they're like, you're like, they don't sound, they don't sound like seizures. But um but these are ones where um if able to, to capture one on eeg just because it can't because it can be difficult to diagnose unless you capture it on eeg. Um um There have been a few times, you know, the time I've been a child neurologist and particularly my 1st 1st 1 during residency, my attending and I very much convinced that this, that whatever this kid was having was non epileptic routine, eeg is normal and the kid was not having enough to put in the epilepsy monitoring unit. But then as they start to happen more, because I always say epilepsies are going to present itself. It's not going to just see you without any treatment. If it's gonna be an epilepsy, it's going to, it's going to present itself, it's going to continue to happen. Finally got to the point of having enough episodes capture one, sure enough frontal lobe, frontal lobe seizure. Um So um oftentimes it's nice to capture on eeg and then um treatment, I'm gonna say the treatment for a lot of these are the ones I'm gonna talk about. Next are the in terms of Colonostomy, oscopy, lacosamide. You can use broad spectrum anti-seizure medicines with this as well. And we have other options that aren't um pharmacological. So uh VNS or an RNS. Now we have non lesion surgery or leal surgery if you find a lesion that's causing you to have the seizures, um temporal lobe seizures, they're repetitive. You have automatism. So, lip smacking, rubbing their hands together. Deja vu fear, anxiety and odd smell and odd chest sensation, right. So a lot of these things that you hear and if they only give you one, you're like, oh you know, it doesn't really sound like a seizure. The odd smell generally is um smelling of burning rubber and then the taste that they can have is like a copper penny um that they can have. So it's very particular. So they say hear an odd smell and you're like, ask them what they smell and they're like, oh, it's, it smells like, you know, like a pumpkin spice candle. Probably not, probably not it, but it's, it's, you know, if they tell you like, oh, I smell something funny and each and every time is the same thing, then you start thinking, OK. It's a temporal lobe doesn't mean that every time it happens is a temporal lobe seizure, but it definitely should ring some kind of like alarm bells to be like, oh maybe you need to see a neurologist, maybe needs to do some imaging. Um again, treatment um similar to that of all the other um focal epilepsies. Um All right. So we have parietal lobe. So I for so we have we had our frontal and our temporal lobe and parietal lobe now. So we have our Jacksonian March and I'm sure that you guys have he heard about sensory changes. So the feeling of the sensation marching so face to, you know, in terms of face to leg, um they can have vertigo, visual ha um illusions, distortions of the reels or hallucinations that are not real, typically, hallucinations and seizures are not formed hallucinations. So if they tell you, no, I definitely saw a figure and they were standing there and they were, you know, coming at me or if I'm hearing something and they're talking words to me, unlikely to be a seizure is going to be the hallucination. Whether it's auditory or visual um is going to be less formed, it's distorted, it doesn't look real. Um or sometimes they see colors um just kind of wavy colors. Whooshing sounds um things like that. So if they tell you that my, the whoever is talking to me was actually, I could hear what they were saying. They were calling my name and telling me stuff, probably not a seizure. Um And then occipital lobe visual changes. Um you have loss of vision, um illusions, hallucinations, abnormal eye movements. Um And so the same treatment um categories with this. And so whenever you're, whenever you're getting a history of seizures or episodes that kids are having, if they are episodic, if they are always the same, start worrying about seizures, even if it doesn't sound like a seizure. If you're like, huh every single time this kid is telling me exactly the same thing that's happened five times in a row, then start thinking, but start thinking um epileptic seizure. All right. And then we have our epilepsy syndromes um with syndrome, infantile spasms, Lex Gusto syndrome and L dole. Not that you're necessarily going to um diagnose any of these, but you might come into them and, and, and, and, and see these kids or send into us. So when to be concerned, sent to us. Um All right. So epilepsy syndrome. So we have we syndrome. So try out of infantile spasms. So remember I told you it's the spasm is that kind of quick jerk and that kind of like um that subtle kind of cold and then down. So if they are infancy, so 4 to 6 months, if, if you have a 18 month old and you're like, oh, they're having spasms and if they were totally normal before, not infantile spasms um could be something else but not typical infantile spasms. Um So if you see any of them, you know, in terms of flexion spasm or extensive spasms and sometimes they can cluster, they can cry and oftentimes um in the morning times and they are of that age, get concerned, you know, call your local neurologist, send us a video, send us to the er um we can definitely get a work up their eeg at the bottom uh corner there. It's, it's not very pretty. You've seen some of the other egs before? This one is, is, is a, is a kind of a big mess. So it's very messy, disorganized brains. That's what it is. It's a very disorganized eeg this little portion here that I'm circling with mouse, you can see that the part that looks like it's not disorganized kid had a seizure. So it's a electrode. That's their um the eg finding. So when they have an electro decrement where the brain actually looks like it's organized is actually when they have a seizure. So the brain just kind of shuts off has a seizure and it goes back to being disorganized. Um So that is included with the West syndrome. Hips arrhythmia is the name of the eeg abnormalities and they had developmental regression or delays. Um Typically 4 to 6 months is when I see it. Um But, you know, 3 to 12 months of age, uh usually younger in the infancy. Um And then the etiology, the cause of it is there's many different types of causes and sometimes it becomes unknown, it remains unknown. Um treatment for them. Ac th that's like gold standard, it's so expensive and not everybody has it. And sometimes parents don't want to give their kids injections. So high dose predniSONE it is um and then by gr and there's other anti seizure medicines that other people use but steroids is where it's at. So we have just kind of immunosuppressants is really what um what we start them with while looking for the cause. And um there's some kids whose infantile spasms um end up turning into Lana Gusteau syndrome. So sometimes they can just kind of, it's on a spectrum. So we have like in neonates is Otara syndrome that turns into West syndrome that turns into Lana Caste. So there's a big spectrum of where these kids end up. Some of them do some of the kids just kind of pop in here and there. But a lot of kids, they'll have this whole spectrum that they've, they've written and the name changes because of their age and the type of seizures. So Lus Castillo Syndrome, you have multiple different types of seizures that are different, difficult to control. And so they can have generally sonic clonic seizures. They get myoclonic seizures, tonic seizures and the F MS atonic seizures. So, if you've got a kid with multiple different types of seizures, they've got developmental disabilities and suddenly they have atonic seizures. You probably, you know, in terms of LG is probably what they have um eeg findings, it is pretty, it's still like the absences because, but it is slower, it's 2, 2.5 Hertz. Um And this is kind of younger, 3 to 5 years of age. Um again, various causes most um unknown. But now we have a lot more genetic testing and genetic type of epilepsies that we run genetic panels. So we're finding out more, but there's still a vast number that are unknown or what they call it, cryptogenic idiopathic um type epilepsies. And then again, patients with meta spasms can develop into lexa still. And then this one just various different types of medications for generalized epilepsies. We just kind of broad spectrum, hope hope for the best. Um In terms of um some of these medicines, there are some medicines that have been studied that uh people use specifically Vla syndrome um like cloBAZam or Amy. Um Rofin Amide um forgot the brand name for Raffin Amide, but phenom is one of them. Um Felbamate. That's an old one. I used that early on in my career and I don't use it very much anymore, but that used to be a leg on medication. Um So you might see these patients in your clinic and then the next one. So Land Kloner syndrome rarer. Um but something to think about when you see kids and suddenly they have a speech communication difficulties um in comprehension can comprehension can affect uh their expressive language regression and development in a kid. That's 3 to 7. You start thinking, oh, is it autism? Right? But if, if really the only thing is a speech and you have this regression and they're typically a little bit on the older side than a kid with autism with progression. Think about this. Um So it's an acquired epileptic aphasia. So 2 2020 22 I said it it changes a lot. The International League against epilepsy, which I really think is like the coolest name for uh a group of people of doctors. Um They recommend that Landof is a subtype of a developmental epileptic encephalopathy with spike wave activation and sleep. So you can have um electrical status epileptic in sleep or just continue a spike in slow wave during sleep, slow wave sleep. So you don't even have to have a seizure occur during this. You just grab an eeg hope they uh you know, get it, get it 24 hour, have your sleep. And if you have this with the clinical di with the clinical picture, you have your diagnosis. Um and so the eg can't be normal during a week. So you want to sleep. Um and again, this one, you can various uh anti seizure medicines, immunosuppressants uh may be able to help um with this including in Ivig can help um surgery. VN srn S those type of things uh that we have. And so this is kind of the eeg awake eg this is awake, eg is not normal, but in here, we have our continuous uh slow wave to spike and slow w sleep zero. All right. So other con seizure considerations, I'm watching the time um status epilepticus. So this one status epilepticus definition changes a little bit over, you know, over the over time. So it's greater than five minutes. So continuous clinical and or electric graphic seizure activity, you can also have multiple seizures that cluster without regaining consciousness for longer than five minutes. So if, if you guys had, you know, in terms of learned about seizures a while ago, it used to be three seizures in 30 minutes without regaining consciousness, we've changed this and it can be uh convulsive. So one that you can see in terms of clinical or nonconvulsive So, um, oftentimes the, uh, kids say they, they come into the, er, and they're like, oh no, they have generalized tonic chronic seizure and, you know, suddenly it stops but the kid is tuned, they're not responding, they're not, you know, they're there. It's just like, oftentimes it's like, well, are we now concerned that they're having noncoms status, you know, versus, um, being post single? Um, so eeg can be helpful in that standpoint and then again, medical emergency that last longer than five minutes, it's likely to continue if not treated. So, this is one where, um, we give our rescue medicines. Um, you know, seizure over 3 to 5 minutes. Most seizures are under five, the majority of those are under two minutes long. Um, although it seems like forever, um, when we see them, um, that, um, I always tell parents, I'm like, it's not, you know, I give you seizure medicine to stop it. It's not because suddenly your brain is going to be damaged or something bad's gonna happen. I'm like, if it's gonna last longer than five minutes, it may actually last, it may continue and then you're gonna pile on even more medications. And oftentimes the, the reason why a kid needs to be intubated or given oxygen in the, er, for status epileptic because is because us, um, right, we give them Ativan, we give them fuss, we give them, you know, Keer de Fen of art. What have you um, all of that is what's gonna cause the apnea and we're gonna protect their airways, so we're gonna intubate them. Um, and so I always tell parents it's not that something bad is gonna happen. It's just that if I can get it stopped early, I don't have to pile on more medications. Um, so that kind of helps them realize like, ok, all right. So that's why I want to give my medicine honestly, with the, with the rescue medicine, I'm like, you know what if you're freaking out? And it's only been a minute and they continue of the seizure, go ahead and give it to them. It's not gonna hurt, right. It's shallow breathing, they're gonna be tired. But if it stops the seizure from continuing, go ahead and I'm not stopping you. Um But again, if you're a parent with a kid, if you have a parent with kid who has seizures, um you know, daily, they might not want to use a Benzo every day for it, you know, say they're on four medicines and they have a VNS and this is kind of their life. Now we say, you know what that's, you may not want to use the Benzo every day. So maybe do keep time um for these seizures or however many clusters. Um So side effects of seizures, we have um short term, we have post the postictal phase of post seizure phase, tired, lethargic, grumpy, aggressive, confused, dazed, some don't even have a postictal phase. Um, many have no side effects in the long term. Um, you can have, um, I didn't write it on here. You can have weakness. So Todd's paralysis after a focal seizure. Um, so weakness on one side that resolves after a couple of hours. Um, if, if all that is, you know, they come into the, er, and say parents don't, they're like, oh, maybe they had a seizure and then they have weakness and of course, you know, they're like, oh, is it a stroke and things like that? But sometimes, and then it's like, oh no, just resolve that for an hour. It can be Todd's paralysis and that can be a post picked up phase. Um And then, as I said before, frequent seizures in young developing brain can cause learning and memory issues. So there are higher rates of A DH D and learning disorders. One of the gold standards for kids with epilepsy is to see neuropsychology. But as you very well know, that's hard to get into, to see neuropsychologists or if they, or it can be costly if they go outside. Um you know, in terms of self pay, but if, if this were, you know, the gold standard world, I would love it for every patient with epilepsy to see a neuropsychologist um routinely, you know, at the very beginning of their epilepsy and then on routine um throughout however long, um they will be seen um and then prolonged seizures can cause brain cell death. Um And so just because of the, the brain cells just tire out. So when they tire out, they quit working and if they can't recover, if they don't get enough rest and recover, they'll die. And um and brain cells don't regenerate. And so, but this is usually hours long, but you start seeing kind of brain cell death, sued up sudden and unexplained death and epilepsy. So kids, kids or adults, people with a history of epilepsy, it's sudden death. It's unexpected unexplained. Despite investigative um efforts including autopsy, um risk factors include those with generalized tonic clonic seizures. Um If you've had three or more generalized tonic clonic seizures in a year, your risk goes up, uh frequent uncontrolled seizures, uh patients who are on multiple medications, those that are non compliant with their medications. I have unfortunately had two of my patients um ended up being sued up and both of them decided not to take their medications. Um And so that's, it was really unfortunate um for it. Um And then um the younger they are at onset um can increase the risk. Um and also many years living with epilepsy. Now, the rate of cab is actually higher in adults than it is in kids, but the younger they are onset does increase the risk of it. And then of course, risk factors include etiology if you have a genetic cause of, of epilepsy, you're a higher risk um for it and then seizure threshold. Um we all have a threshold. Um We could all potentially actually have a seizure. Um There are things that provoke um like illness, dehydration, low blood sugar, even high blood sugars can cause it. Um changes in electrolytes above or below normal changes in blood pressure, stress, medications, drugs. Um and then patients with epilepsy, they are even at higher risk um for a seizure beca due to any of these things. So when you know, patients like I had a breakthrough seizure, were you ill? Did you miss medications? Those are, you know, some of the things that we ask because those are really common for them to have a breakthrough seizure due to and um medication compliance, important to discuss with um our patients and their families important as a medication compliance. So missing doses cause increased seizure, um risk, um changing the doses without physician approval can have consequences. And then teenagers, teenage population compliance can be as low as 50 to 75%. And then of course, I've had it many times. I was like, well, who gives them the medicine? Well, you know, my, my kid is 12 and I want them to take responsibility. So I am letting them take care of their medication. I'm like, that's ok for you to have them draw their medicine or take them out of the bottle, but you should be watching them and you should be there, um, being there because their brain is not mature, right? As I said earlier, 2023 to 25 is when their frontal lobes are completely mature. So at 12, not a whole lot is mature. I think your auditory auditory centers are mature by that time. Um, now whether or not they, they choose to actually listen to what you're saying is different because they're teenagers. But again, the frontal lobes are not mature at that time. So, um definitely a reminding parents, I'm sure that you guys do with all the other medications and you pre uh prescribe that parents should be the ones monitoring their medication compliance, seizure first aid. Um So you want to lay, you know, just to kind of reiterate some of the things to tell parents, I lay the child on their side, any side doesn't really matter. It's just to allow um anything coming out of the mouth to come out and not into blocking their airway. Um and then don't stick anything in their mouth and just introduces objects in their airway. And many of times I have parents be like, oh, I have a band aid. You stuck your finger in their mouth. Yes, I'm like you won't do it again. No. So lesson learned um and then rescue medicines, intranasal versed um um Diastat um oral Ativan clonazePAM Wafers rescue medicines, you know, parents was like, well, which one works the best, whichever one you're gonna be comfortable giving is going to work the best as much as, you know, some parents are like, you know, be like, well, maybe, you know, internasal verset is quicker. But if they're like, well, I don't, I don't really love to shove anything up their nose and I'm like, then it's not gonna work, you know, if, if parents are concerned that they're sticking their fingers, um, in their mouth, granted, when the clonazePAM Wafer goes in, I say, put it in the cheek, don't go past the teeth but some people, you know, sort of, they, they're like, oh, I don't really want to put anything in their, their cheek or I don't wanna give a depository, then it's not going to work no matter. So all of these are going to work, um, relatively the same, whichever one you're going to be comfortable giving is the one that you, that, that I will prescribe to you done and done. Um, and then of course, calling Ems, um, sending to the, er,
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