1.
Motor activity is the most important symptom, tonic or clonic tend to involve the
2. Typical absence seizures (petit mal) are characterized by a sudden cessation of motor activity or speech
with a blank facial expression and flickering of the eyelids. Patients do not lose body tone, but their head may
fall forward slightly.
5. Rarely persist longer than 30 sec and may experience countless seizures daily, and are not associated
with a postictal state, Immediately after the seizure, patients resume activity.
1. Have associated motor components consisting of myoclonic movement of the face, fingers, or extremities
and, on occasion, loss of body tone
2. These seizures produce atypical EEG spike and wave, accompanied by 1- to 2-Hz spike-and–slow-wave
discharges.
1. Similar to typical absences but occur at a later age. These are usually associated with juvenile
myoclonic epilepsy
2. Accompanied by 4- to 6-Hz spike-and–slow-wave and polyspike and–slow-wave discharges.
1. Benign myoclonus begins during infancy and consists of clusters of myoclonic movements
confined to the neck, trunk, and extremities. The myoclonic activity may be confused with infantile
spasms.
2. The EEG is normal in patients with benign myoclonus
3. The prognosis is good, with normal development and the cessation of myoclonus by 2 yr of age.
An anticonvulsant is not indicated.
1. The mean age of onset is ≈2 yr, but the range spreads from 6 mo to 4 yr. Have unremarkable
pregnancy, labor, and delivery and intact developmental milestones
2. A few patients have febrile convulsions or generalized tonic-clonic afebrile seizures that
precede the onset of myoclonic epilepsy. Variable frequency\ days or weeks.
3. The EEG is abnormal , 1\3rd + F\H of epilepsy.
4. Mental retardation develops in the minority, Learning and language problems and emotional and
behavioral disorders occur and >50% are seizure-free several years later.
Uses of EEG in epilepsy:
1. Demonstration of paroxysmal discharge on EEG
during a clinical seizure is diagnostic of epilepsy.
2. A normal EEG dose not exclude the diagnosis of
epilepsy, because the interictal recording is normal in
about 40% of patient.
3. Activation procedure such as hyperventilation, eye
closure, photic stimulation and sleep deprivation
may increase the positive yield.
1. Usually begin between the ages of 4 and 8 mo and are characterized by brief
symmetric contractions of the neck, trunk, and extremities.
1. Flexor spasms: occur in clusters or volleys and consist of sudden flexion of the neck,
arms, and legs onto the trunk.
2. Extensor spasms: produce extension of the trunk and extremities and are
the least common form of infantile spasm.
3. Mixed infantile spasms: consisting of flexion in some volleys and extension in
others, is the most common type of infantile spasm.
1. Cryptogenic (idiopathic): account for 10–20% of cases.
Prognosis: Infants with cryptogenic infantile spasms have a good
prognosis.
2. Symptomatic infantile spasms are related directly to:
A. Several prenatal, perinatal, factors. Like hypoxic-ischemic encephalopathy, congenital
infections, inborn errors of metabolism, tuberous sclerosis, lissencephaly and schizencephaly
and prematurity.
B. Postnatal conditions include CNS infections, head trauma and hypoxic-ischemic
encephalopathy.
Prognosis: The symptomatic type 80–90% risk of mental retardation.
4. The spasms occur during sleep or arousal but have a tendency to develop while
patients are drowsy or immediately on awakening. A cry may precede or follow an
infantile spasm, accounting for the confusion with colic in a few cases.
5. EEG: hypsarrhythmia
6. Pathogenesis:
1. One hypothesis implicates corticotropin-releasing hormone (CRH) overproduction, resulting in
neuronal hyperexcitability and seizures.
2. The number of CRH receptors reaches maximum in an infant's brain followed by spontaneous
reduction with age, perhaps accounting for the eventual resolution of infantile spasms, even
without therapy.
3. Exogenous ACTH and glucocorticoids suppress CRH synthesis, which may account for their
effectiveness in treating infantile spasms.
1. This is uncommon before age 5 yrs., more prevalent in girls.
3. Never associated with an aura. Typical abscence
4. Automatic behavior frequently found.
6. Hyperventilation for 3–4 min routinely produces an absence seizure. The EEG shows a typical 3
spike /sec and generalized wave discharge
Atypical abscence
Jeuvenile abscence
1. These seizures are common ,may follow focal seizure or occur de novo
2. Suddenly lose consciousness and, in some cases, emit a shrill, piercing cry. eyes roll back, entire body musculature
undergoes tonic contractions, become cyanotic in association with apnea.
The clonic phase of the seizure is heralded by rhythmic clonic contractions alternating with relaxation of all muscle
groups. Persists for a few minutes, children may bite their tongue but rarely vomit. Loss sphincter control, particularly
the bladder.
3. Postictally, children are initially semicomatose and typically remain in a deep sleep from 30 min to 2 hr. The
postictal phase is often associated with vomiting and an intense bifrontal headache
4. During the seizure: Tight clothing and jewelry around the neck should be loosened, the patient should be placed on
one side, and the neck and jaw should be gently hyperextended to enhance breathing.
Benign myoclonus of infancy
This disorder is characterized by repetitive seizures consisting of brief,
often symmetric muscular contractions with loss of body tone and falling
or slumping forward, which has a tendency to cause injuries to the face
and mouth
Typical myoclonus
face, neck and extremities. Versive seizures consisting of head turning and conjugate
eye movements are particularly common
2. No automatisms
3. Positive aura (chest discomfort, headache), may be the only manifestation of the
Focal aware
seizure.
4. The average seizure persists for 10–20 sec. Patient is conscious and mey verbalize
during the seizure. No post ictal phenomenon
5. The EEG may show spikes or sharp waves unilaterally or bilaterally or a multifocal
spike pattern.
1. Brief blank stare or a sudden cessation or pause in activity.
-In infants: Alimentary automatisms, including lip smacking,
chewing, swallowing, and excessive salivation.
2. Automatisms are a common feature of focal unaware seizure in infants and children, 50–75% of cases -In older children: semi-purposeful, incoordinated, and
(increase with age). Automatisms develop after the loss of consciousness and may persist into the unplanned gestural automatisms, including picking and pulling
postictal phase at clothing or bedsheets, rubbing or caressing objects and
walking or running in a nondirective, repetitive and often fearful
fashion.
3. With or without an aura. An aura: unpleasant feelings, epigastric discomfort, or fear, the presence of
Focal unaware an aura always indicates a focal onset of the seizure.
2. Types Focal 40% of
4. The average duration of focal unaware seizure is 1–2 min. The aura is usually followed by impaired
childhood seizures consciousness or the onset may start with an impaired state of consciousness.
In those with normal routine interictal
EEG we use the following:
5. EEG may be able to identify the abnormal event in 80% but approximately 20% of infants and children 1- A sleep-deprived EEG study.
with focal have a normal routine interictal EEG. CT scanning and especially MRI are most likely to identify 2- Zygomatic leads during EEG
an abnormality in the temporal lobe. 3- Prolonged EEG recording.
4- Video EEG study of the hospitalized
3. Etiology patient weaned from anticonvulsants.
Infantile spasms 1. BPEC is a common type of focal epilepsy in childhood. Typically starts during childhood (ages 3-10 yr) in normal
children with an unremarkable history and normal neurologic examination. There is often a positive family history of
epilepsy.
2. The seizures are usually focal, the motor signs and somatosensory symptoms are often confined to the face.
Oropharyngeal symptoms include tonic contractions and parasthesia of the tongue, unilateral numbness of the
cheek (particularly along the gum), gutteral noises, dysphagia and excessive salivation. Focal seizure may proceed to
secondary generalization.
Unilateral tonic-clonic contractures of the lower face frequently accompany the oropharyngeal symptoms, as do
clonic movements or paresthesias of the ipsilateral extremities.
Rolandic
3. BPEC occurs during sleep in 75% of patients. consciousness may be intact or impaired
4. Has an excellent prognosis since it is outgrown by adolescence. 1\4th have repeated clusters of seizures and
anticonvulsants are necessary for patients who have frequent seizures.
Epilepsy in children Carbamazepine is the preferred drug, which is continued for at least 2 yr or until 14–16 yr of age, when spontaneous
remission of BPEC usually occurs.
5. The EEG pattern is diagnostic, characterized by a repetitive spike focus localized in the centrotemporal or
Rolandic area with normal background activity
1st step:
1. Ensure that the patient has a seizure disorder and not a condition that mimics epilepsy.
2. 1st afebrile convulsion, negative family history, normal results of a physical
examination and EEG, and a cooperative and compliant family, antiepileptics should not
be used. Approximately 50% will not experience another convulsion.
3. A recurrent seizure, particularly if it occurs in close proximity to the 1st seizure, is an
indication to begin an anticonvulsant.
2nd step:
1. Choosing an anticonvulsant depends on the classification of the seizure, determined
by the history and EEG findings.
Abscence 2. The goal for every patient should be the use of only one drug with the fewest possible
side effects for the control of seizures. The drug is increased slowly until seizure control
Treatment is accomplished or until undesirable side effects develop.
A minimum of two seizure-free years is an adequate and safe period of treatment for a
patient with no risk factors. When the decision is made to discontinue the drug, the
weaning process should occur over 3–6 mo because abrupt withdrawal may cause
status epilepticus.
3. Recurrence is ≈20–25%, particularly in the 1st 6 mo after discontinuation of the
anticonvulsant
Common antiepileptic medications:
1- Carbamazepine (Tegretol): for Generalized tonic-clonic ,focal
seizures.
2- Ethosuximide (Zarontin): for Absence seizure.
3- Phenobarbital: for generalized tonic- clonic seizure.
Tonic clonic Generalized 4- Phenytoin (Dilantin): for Generalized tonic-clonic, focal
seizure, status epileptics.
5- Valproic: for generalized tonic-clonic ,absence and myoclonic
seizures.
6- ACTH: is the preferred drug of infantile spasm, prednisolone is
equally effective.
Myoclonic