Pediatric Neurology: Seizures--History Taking

Front 1

What is the first question a clinician should ask him/herself when evaluating a patient for seizures?

Why?

Back 1

Are the episodes REALLY seizures at all?

20-40% of patients referred to seizure clinics do not really have seizures

Front 2

Using the patient and available observers as our eyes and ears, what 6 critical areas in the history do we we need to understand as thoroughly as possible?

Back 2

1. What happened at the beginning of the event? Was there an aura? Was there a spell of confusion?

2. What symptoms happened in the middle--the ictal event?

3. What happened at the end (postictal)?

Also:

4. Age of patient when event occurred

5. Time of day (early morning, coming out of sleep)

6. Were there possible triggering factors at work?

Front 3

Name 7 disorders that can mimic seizures.

Back 3

1. Syncope/convulsive syncope

2. Non-epileptic seizures (psychogenic)

3. Pain reactions (fainting)

4. Panic symptoms (fainting)

5. Dissociative episodes, other psychiatric states

6. Sleep disorders

7. Narcolepsy

Front 4

If we indeed are dealing with seizures, what is the first question to settle?

Back 4

Are the seizures partial-onset (focal), or are they generalized?

Front 5

What are partial-onset or focal seizures?

Back 5

They ORIGINATE from a localized, discrete area of brain tissue (though over time the rest of the brain might become involved.)

Front 6

What are generalized seizures?

Back 6

These do not have a focal origin but affect both hemispheres of the brain SIMULTANEOUSLY.

Front 7

Name 3 partial seizure types.

Back 7

1. Simple partial

2. Complex partial

3. Partial evolving to secondary generalized seizures (with convulsions)

Front 8

Name 6 generalized seizure types

Back 8

1. Absence (petit mal)

2. Myoclonic

3. Clonic

4. Tonic

5. Tonic-clinic (grand mal)

6. Atonic

Front 9

As for simple partial seizures:

1. What do the signs and symptoms depend upon?

2. What 4 groups of signs/symptoms can be involved?

3. What condition distinguishes all cases of simple partial seizures?

Back 9

1. They depend on the location of the seizure focus.

2. Signs can include:

a. Motor

b. Sensory

c. Autonomic

d. Psychic

3. THERE IS NO IMPAIRMENT OF CONSCIOUSNESS

Front 10

Concerning complex partial seizures:

1. What must be present?

2. What else is commonly present?

Back 10

1. CONSCIOUSNESS IS IMPAIRED

2. Automatisms: involuntary motor activity during impaired consciousness (from chewing motions or fumbling to commiting crimes)

Front 11

Name 7 examples of sensory symptoms seen with partial seizures

Back 11

1. Numbness

2. Tingling

3. Prickling

4. Strange smell

5. Strange taste (e.g. "rust")

6. Visual distortions

7. Transient blindness

Front 12

Name 5 examples of autonomic symptoms or signs associated with partial seizures of all kinds.

Back 12

1. Sudden sweating

2. Blushing

3. "Rising epigastric sensation"

4. Vomiting

5. Sudden tachycardia (look for "anxiety attacks" in 6-year olds)

Front 13

Allahu akbar! What is "rising epigastric sensation?"

Back 13

A difficult-to-describe sensation of nausea, "indigestion," or belly pain that won't simply stay in the stomach but will seem to progress up the body.

Front 14

1. What is an aura?

2. What kind of seizure is it always found with?

3. What kind of seizures have NOTHING WHATSOEVER TO DO with auras?

Back 14

1. They are the symptoms perceived at the very onset of the seizure.

2. They are the harbinger of partial seizures

3. Never found with primary generalized seizures

Front 15

What brain area does an aura of "déjà vu" localize to?

Back 15

Temporal lobe (as in, temporal lobe epilepsy)

Front 16

What brain area does "rising epigastric sensation" correspond to as an aura?

Back 16

Temporal lobe

Front 17

What part of the brain produces the aura of parasthesias--tingling or pricking?

Back 17

Parietal lobe

Front 18

In which brain area will a localized epileptic seizure cause visual distortions or even temporary blindness?

Back 18

Occipital lobe

Front 19

Name 5 features of generalized tonic seizures.

Back 19

1. NO aura

2. Sudden onset of increased tone in extensor muscles

3. Last < 60"

4. Impaired consciousness

5. Postictal impairment: confusion, fatigue, HA

Front 20

Name 5 distinguishing features of atonic generalized seizures.

Back 20

1. No warning

2. Sudden loss of POSTURAL MUSCLE TONE

3. Very brief, last 1-2"

4. Consciousness briefly impaired

5. Usually no postictal confusion

Front 21

Name 3 distinguishing features of generalized clonic seizures.

Back 21

1. Rhythmic or semi-rhythmic contractions of a GROUP of muscles

2. Arms , neck, facial muscles most commonly involved

3. NO tonic phase

Front 22

1. Which seizures occur more commonly in the pediatric years?

2. Which seizures predominate after adolescence?

Back 22

1. Generalized seizures

2. Partial-onset seizures

Front 23

Name 4 distinguishing features of tonic-clonic generalized seizures.

Back 23

1. No aura

2. Two phases of the seizure:

a. Tonic--generalized stiffening of flexor OR extensor muscles

b. Clonic--generalized muscle jerking

3. Loss of consciousness occurs suddenly and simultaneously with the tonic phase

4. Almost always followed by deep postictal sleep

Front 24

Tonic-clonic generalized seizures represent the main seizure type in how many people with epilepsy?

Back 24

About 20%

Front 25

What is the most common seizure type associated with metabolic derangements?

Back 25

Tonic-clonic

Front 26

Name 8 factors that can trigger seizures?

Back 26

1. Sleep deprivation

2. Flickering lights

3. Menses

4. Alcohol consumption

5. Stress

6. Fever

7. Exercise

8. Not taking seizure meds

Front 27

Name 4 characteristics of absence seizures.

Back 27

1. No aura

2. Sudden, brief lapses of consciousness WITHOUT LOSS OF POSTURAL CONTROL

3. Lasts a few seconds

4. No postictal confusion

Front 28

What is the easiest way to discover the presence of absence seizures, especially in younger children?

Back 28

Ask family members whether the child stops and stares all of a sudden while doing a favorite or pleasurable activity.

Front 29

What 3 epilepsy syndromes are associated with myoclonic seizures?

Back 29

1. Juvenile myoclonic epilepsy

2. Lennox-Gastaut syndrome

3. Progressive myoclonic epilepsy

Front 30

What 5 features characterize myoclonic seizures?

Back 30

1. Sudden very short bursts of body jerks

2. One part of the body or the entire body can be involved

3. Often an early AM episode, unlike the jerks that happen as we fall asleep

4. Consciousness usually not impaired

5. Jerking varies in intensity among people: from dropping stuff to almost minimal body twitching.

Front 31

What time of the day are myoclonic seizures more common?

Back 31

Early in the morning or upon awakening

Front 32

What time of the day are tonic-clonic seizures more common?

Back 32

Upon awakening or early in the AM

Front 33

Which kind of seizures are more common at nighttime, during sleep?

Back 33

Frontal lobe seizures

Front 34

Name 2 psychic symptoms associated with focal seizures

Back 34

1. Déjà vu

2. A feeling of impending doom, that something very bad is about to happen.