SEIZURES, BRAIN DEVELOPMENTAND THEIR CONSEQUECES

Agus SoedomoDepartment Of Neurology Faculty Of Medicine Sebelas

Maret University / Dr. Moewardi General HospitalSurakarta

Outline

Introduction Definition Etiology Pathogenesis Consequence / Influences Tackling / Prevention Summary

Introduction Seizures occur in 1-5% of infants Seizures are triggered by an acute illness Seizure in the new born signal brain pathology Neonates seizures sign of acute neonatal

encephalopathy major risk factor for death and subsequent neurologic disability

Neurologist & neonatologist face a number in resolved facts & some controversies : define, monitor, treat seizures,& consequences

INFANT : neonates seizures – febrile seizures & status epilepticus

Seizures and Epilepsy

Secondary•Symptomatic•Partial •Age disease related

Primary•Idiopathic •Partial General•Age Related

Transient•Symptomatic•Metabolic•Toxic

Non recurrent Recurrent ( Epilepsy )

Definition

Definition of seizures Time limited paroxysmal, that result from

sudden, temporary change in brain dysfunction caused by abnormal, rhythmic, involuntary neuronal discharge (Clancy&Geyer, 2010)

Seizures are usually unpredictable Seizures usually brief (<5 minutes) self

terminating or stop spontaneously Convulsion ictus, event, spell, attack, fit

Definition of Epilepsy

A disease as paroxysmal of cerebral dysfunction, characterized by spontaneous recurrence of unprovoked seizures ( at least 2 time per year ), ILAE, 1993

Seizures are symptoms, while epilepsy is a disease

Epilepsy is seizures disorderEpilepsy is a syndrome disease

Each Epilepsy Syndrome is Determine Based on :

Type of seizureAge at seizures onsetFamily historyPhysical examinationEEG findingsNeuroimaging findings

Definition of Febrile Seizures

A simple febrile seizure is generalized seizure occurring in infant or child between age of six months and five years, lasting less than 15 minutes and occurring only once in 24 hours. The child should not have an intracranial infection or a severe metabolic disturbances ( American Academy of Pediatrics Practice Parameter, 1999)

A seizure occurring in childhood after one month of age, associated with a febrile illness not caused by an infection of central nervous system, without previous neonatal seizures or previous unprovoked seizures and not meeting criteria for other acute symptomatic seizures ( ILAE, 1993 )

Three Critical Element of Febrile Seizures

Age of first seizures onsetTemperature of feverType seizures

Neonatal Seizures

Under recognized Especially in sick neonates Often difficult to treat Manifestation of underlying neurological

conditions Most common caused by HIE : 50 – 60%

Epidemiology Seizures are common in human Incidence ± 80 / 100.000 population Overall risk of epilepsy of 1% - 3% 3% - 4% at least one FS before 7 years Incidence FS depend of regional variation

Cumulative Incidence of FS

United State : 2 – 5%South America : 2 – 5%Western Europe : 2 – 5%India : 5 – 10%Japan : 8,8%Guam : 14%( Hauser WA at Liu at al, 2010 )

Prevalence of Neonates Seizure (Jkt)

RS Ciptomangunkusuma : 0,9%RS Harapan Kita : 0,3%RS Padmawati : 0,3%

Daisy et al, 2006

EtiologyToxic / metabolic cause of seizures

Drug intoxication Drug withdrawal Electrolyte Heavy metals : lead and mercury Hyperosmolarity Hypoxia

Causes of Fever in Febrile Seizures

Upper Respiratory Tract Infection : 38%Otitis Media : 23%Pneumonia :15%Gastroenteritis : 7%Roseola Infantum : 5%Non Infectious Illness : 12%

Genetic Causes of Epilepsy

Aminoacidurias Channelopathies Lisosomal Storage Disease Phakomatosis Phenylketonuria Sturge Weber Syndrome

Pathogenesis

Seizure arise secondary to a number etiologiesIdiopathicCryptogeneticSymptomatic

Idiopathic

No apparent causeNo brain lesionPresumably - genetic alterations in brain

excitabilityKnowledge about the cause of epilepsy

increase the number of idiopathic cases will diminished

Cryptogenic

Cases of epilepsy where the cause is unknown, but lesion & dysfunction pathogenesis are presumed

The lesion of temporal lobe epilepsy is mesial temporal sclerosis but the cause of the lesion is unknown

Symptomatic

Cases of epilepsy in known which the disorder is due to a cause some but not all, symptomatic cause are also lesional, meaning that an identified structural brain abnormality or lesion is present

TraumaEarly Post Traumatic Seizures :Intracranial hemorrhageFocal neurological deficitsPost traumatic amnesia > 24 hoursLinier skull fracturesLate post traumatic seizuresSome as above, but :Depressed skull fracturesInjury after age 16 years

Congenital Malformations

Structural anomaliesGenetic cause of epilepsy ( table )Not associated with structural

malformations

Infection

Meningitis, encephalitis feverBacterial abscess formationsHSV, seizures & catastrophicCMV, various viral, fungal & toxoplasmosis

Developing seizures

Cerebral ischemiaCommon cause of seizures in the neonates

but uncommon in older pediatric populationsTumor slow growing seizures

Supratentorial more frequently than cerebellar or brain stem tumor

Toxic metabolic Table The derengement can cause seizures can

worsen pre-existing epilepsy

The Pathophysiology of Febrile Seizure Unknowns

Possible three pictures interact :Immature brainFeverGenetic predisposition

Consequences / InfluencesDirect effect of seizures in human brain

are difficult to detectRecently :

Animal studiesNeuroimaging examinationAmplitude integrated EEG or video

EEG monitoring

Influence of Neonatal Seizures

Recurrent neonatal seizures reduced cell number, but not causing cell death

Recurrent seizures during early life pronounced effect on brain development are different from those occurring in mature brain

Brain of neonatal seizures are smallerThe long term functional consequences can

be detrimental

Influence of Febrile Seizures

Recurrent febrile seizuresRecurrent later epilepsy

Risk Factors for Recurrent Febrile Seizures

Young age of onset, the earlier, the greater

Relative low fever, the lower, the greater

Family history : first degree relativeDuration between fever onset &

seizure onset, the shorter, the greater

Risk Factors for Later Epilepsy

Abnormal neurological or development status prior to onset

Family history of a febrile seizuresComplex febrile seizuresOnset FS after the age of 5 years no risk15% of children with epilepsy have one or

more preceding FSLess 7% FS developed epilepsyThe risk were higher : family history of

epilepsy, cerebral palsy, or low APGAR score

Tackling / PreventionNeonatal seizures and complex febrile seizures

may have a global effect on brain development, especially in immature brain

Neonatal seizure must early detect and be able effective therapy especially for underlying etiologies

Febrile seizure are usually brief and self limited but if the convulsion is prolonged, airway & oxygenation should be kept

After resolution of neonatal seizures still be needed less frequent and shorter phenobarbital treatment, although there remains considerable variation in practice

SummarySeizure in infant : neonatal seizures, febrile seizures

and status epilepticusSeizures are symptom, while epilepsy is a diseaseIncidence FS depend on regional variationEtiologies seizures : toxic / metabolic, and genetic

causesPathogenesis is divided into : idiopathic,

symptomatic, and cryptogenicConsequence of seizures are detected by animal

study, neuroimaging examination and video EEG monitoring

Neonatal seizure and complex febrile seizure may have a global effect on brain development

Neonatal seizures must early detected and treated

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