clinicalepilepsy

clinicalepilepsy内容摘要：

CSlide 44 Status Epilepticus Treatment (cont.) Time post onset Treatment 10 min. Can repeat lorazepam or diazepam if seizures ongoing 3060 min. EEG monitoring unless status ended and patient waking up 40 min. Phenobarbital 20 mg/kg at  5 mg per minute ( mg/kg per minute) continued Reference: Lowenstein DH, Alldredge BK, Status Epilepticus. NEJM 1998。 338: 970976. CSlide 45 Status Epilepticus Treatment (cont.) Time post onset Treatment 70 min. Pentobarbital 35 mg/kg load, 1 mg/kg per hour infusion, increase to burst suppression OR Propofol 35 mg/kg load, 510 mg/kg/hr initial infusion then 103 mg/kg/hr OR Midazolam mg/kg load, .252 mg/kg infusion Reference: Lowenstein DH, Alldredge BK, Status Epilepticus. NEJM 1998。 338: 970976. CSlide 46 Neonatal Seizures  Incidence: – per 1000 live births  Major risk factors are prematurity, lowbirth weight, HIE  Association with increased morbidity and mortality  May be symptomatic of treatable, serious condition (hypoglycemia, meningitis)  Diagnosis: observation with vs. without EEG References: Ronen, J Pediatr, 1999。 Lanska, Neurology, 1995。 Saliba, Am J Epidemiol, 1999. CSlide 47 Recognition of Neonatal Seizures  Observation of abnormal, repetitive attacks of movements, postures or behaviors  Classification • subtle • tonic • clonic • myoclonic • autonomic  Evaluation for cause(s) of seizures  Confirmation/support by EEG CSlide 48 Examples of Acquired Conditions That May Provoke Neonatal Seizures  Hypoxiaischemia  Physical trauma  Toxicmetabolic  Inborn errors of metabolism  Systemic or CNS infections  Intracranial hemorrhage CSlide 49 Acute Treatment of Neonatal Seizures  Phenobarbital loading dose: 20 mg/kg  Fosphenytoin loading dose: 20 mg/kg PE@ 1  Diazepam first dose about mg/kg  Lorazepam first dose about to mg/kg CSlide 50 Selected Pediatric Epilepsy Syndromes  Epileptic Encephalopathies • West Syndrome — infantile onset, hypsarrhythmic EEG, tonic/myoclonic seizures。 idiopathic vs. symptomatic • LennoxGastaut Syndrome — childhood onset, slow spikewave EEG, tonic, atypical absence, atonic and other seizure types • Myoclonic epilepsies of infancy and early childhood — heterogeneous CSlide 51 Selected Pediatric Epilepsy Syndromes (cont.)  Febrile convulsions — 6 yrs. • Simple: Duration less than 15 minutes, generalized, and do not recur within 24 hours • Complex: Duration longer than 15 minutes, focal in nature or recur within 24 hours  Febrile convulsions: Risk Factors for development of epilepsy: • Complex febrile seizures • Neurodevelopmental abnormalities • Afebrile seizures in firstdegree relatives • Recurrent febrile seizures • Febrile seizures following brief and low grade fever • Febrile seizure onset in first year CSlide 52 Selected Pediatric Epilepsy Syndromes (cont.)  Benign epilepsy with centrotemporal spikes — nocturnal oropharyngeal simple partial, rare secondarily generalized seizures  Childhood epilepsy with occipital paroxysms — visual phenomena, at times with secondary generalization CSlide 53 Selected Pediatric Epilepsy Syndromes (cont.)  Idiopathic generalized epilepsies • Childhood absence epilepsy — absence, occasionally with tonicclonic seizures • Juvenile myoclonic epilepsy — myoclonic, tonicclonic, at times absence CSlide 54 AEDs in Pediatrics  Extrapolation of efficacy data from adult studies  Importance of adverse effects relative to efficacy  Susceptibility to specific adverse effects (valproate hepatotoxicity, lamotrigine rash)  Agerelated pharmacokiic factors  Neonate: low protein binding, low metabolic rate, possible decreased absorption if given with milk/formula  Children: faster metabolism CSlide 55 Differential Diagnosis of Nonepileptic Events  Syncope  Migraine  Cerebral ischemia  Movement disorder  Sleep disorder  Metabolic disturbance  Psychiatric disturbance  Breathholding spells CSlide 56 Psychogenic Nonepileptic Seizures  1045% of patients referred for intractable spells  Females males  Psychiatric mechanism — disassociation, conversion  Common association with physical, emotional, and sexual abuse  Spells with nonepileptic etiology  Nonictal patern on EEG CSlide 57 Psychogenic Nonepileptic Seizures (cont.)  Represents psychiatric disease  Once recognized, approximately 50% respond well to specific psychiatric treatment  Epileptic and nonepileptic seizures may coexist  VideoEEG monitoring often required for diagnosis CSlide 58 Syncope  Characteristic warning, usually gradual (except with cardiac arrhythmia)  Typical precipitants (except with cardiac arrhythmia)  Minimal to no postictal confusion/somnolence  Convulsive syncope — tonicclonic manifestations, usually 30 sec。 usually from disinhibited brainstem structures (only rarely from cortical hypersynchronous activity) CSlide 59 Pregnancy and Epilepsy  Most pregnancies in mothers with epilepsy produce normal children  Fetal anomalies (up to 10% of pregnancies) are multifactorial • Drug effects • Consequences of the mother’s underlying diseases • Consequence of maternal seizures during pregnancy  All antiepileptic drugs carry teratogenic risks  Polytherapy increases risk Reference: Practice Parameter: Management issues for women with epilepsy (summary statement): Report of the Quality of Standards Submittee of the American Academy of Neurology. Neurology 1998。 51: 944948. CSlide 60 Pregnancy and Epilepsy Guidelines for Management  All women of。