CONVLUSIVE DISORDERS
CONVULSIVE DISORDERSA convulsion or seizure is a transient
disturbance of brain function, manifested by involuntary, motor,
sensory, autonomic or psychic phenomenon alone or in any
combination usually having associated alteration or loss of
consciousness.
Convulsions are relatively more common in infancy and
childhood.
Several times, a child may present with a condition that can
mimic or be misinterpreted as a seizure. These conditions include
convulsive syncope with or without cardiac dysarhythmia,
decerebrate posturing, psychogenic events, dystonia migraine and
many other depending upon the age of the patient. A seizure has to
be differentiated from these conditions as misdiagnosis can have
significant therapeutic implications.
Neonatal seizures often present with twitching of the limbs,
fluttering of the eyelids, sucking movements, and conjugate
deviation of the eyes. These should be distinguish from
jitteriness, tremors, startle response to stimuli, sudden jerks on
awakening and tremulousness of the hungry child.CAUSES OF
CONVULSIONS IN CHILDHOOD: -
Early Neonatal Period: -
i. Birth asphyxia, difficult obstructed labor.
ii. Intraventricular intracerebral hemorrhage.
iii. Pyridoxine dependency, hypoglycemia, and hypocalcema, hypo
or hypernatremia
iv. Inborn errors of metabolism.
v. Maternal withdrawl
vi. Accidental injection or local anesthetic into the fetal
scalp during the paracervical block given to the mother.
Neonatal period: -
i. Hypocalcemia, hypomagnesemia, hypoglycemia,
dyselectrolytemia.ii. Kernicteerus.
iii. Developmental malformations, microcephaly, proncephaly,
arteriovenous fistualae, agensis of corpus callosum.
iv. Meningitis, septicemia.
v. Intrauterine injfections (TORCH)
vi. Tetanus neonatorum
vii. Inborn metabolic errors PKU, MSUD, Gala atosemia,
homocysteinemia, urea cycle disorders.
From One Month to three years: -
i. Simple febrile convulsions.
ii. Injections of the central nervous system
a. Acquired Bacterial meningitis tuberculous, meningitis,
aseptic meningitis, encephalitis, cerebral malaria, tetanus, mumps
encephalopathy, measles encephalopathy and Reyes syndrome
b. Intrauterine injections.
iii. Postinfectious or postvaccinal encephalopathy: - Following
acute viral infections, pertusis, vaccination, subacuite selerosing
panencephalitis post-measles / chicken pox.
iv. Metabolic cause: - Dehydration, dyselectrolytemia,
alkalosis, hypocalcemia, hypomagnesemia and inborn errors of
metabolism.v. Space occupying lesions in the brain: Neoplasm, brain
abscess, tuber culoma, cysticerosis.
vi. Vascular: - Arteriovenous malformations, intracranial
thrombosis or hemorrhage and consumptive coagulopathies.
vii. Miscellaneous causes: - The stroke, acute brain swelling
poisoning, lead encephalopathy, hypertensive encephalopathy, breath
holding spells, residua of birth trauma and birth asphyxia, gray
matter degeneration and storage disorders.
viii. Drugs and poisons: - Toxic doses of phenothiazine
salicylate, diphenylhydantion, strychnine, carbon monoxide etc.
ix. Epilepsy.
3 years to 6 years: -
Idiopathic epilepsy, febrile convulsions uncommon, rest as ,
previously enumerate at B.
Classification of Seizures:-
1. Bebrile Convulsions
i. Typical febrile convulsions
ii. Atypical febrile convulsions
2. Chronic/ Recurrent convulsions
3. Status Epilepticus
4. Neonatal seizures
i. Subtle seizures
ii. Multifocal clonic seizures without Jacksonian pattern.
iii. Focal clonic seizures
iv. Tonic seizures
v. Myoclonic seizures.
International Classification of Epileptic seizures: -1. Partial
seizures
i. Simple partial seizures
Motor
Sensory
Autonomic
Psychic
ii. Complex partial seizures
Simple partial followed by impaired consciousness, consciousness
impaired at onset.
Partial seizure with secondary generalization2. Generalized
seizures
i. Absences
Typical
Atypical
ii. Generalized tonic clonic
Tonic
Clonic
Myclonic
Atonic
Infantile spasms
Types of Convulsions: -
I. FEBRILE CONVULSIONS: -
The term denotes seizures associated with fever but excluding
those due to CNS infections.
It is one of the most common disorders of infancy and early
childhood.
Special Features: -
Some of the remaining salient features are: -
(A) Typical Features: -
These are generally associated with fever of 38o C or more at
the time of attack
Generalized rather than focal convulsions are nearly a rule. The
first febrile seizure usually occurs between 6 months and 3 years
of age. Family history of seizures is frequently present, also
higher incidence occurs in twins and children of consanguinous
parents. This has led to the speculation that, as a result of
genetic susceptibility, immature neuronal membrane responds to the
temperature elevation by breaking down. The attack lasts less
than10 to 20 minutes. There is no recurrence before 12 to 18 hours
of the attack that accompanies rapid rise in body temperature.
There is no residual paralysis of a limb following the attack. CSF
after the attack is normal. EEG after the attack is normal(B)
Atypical Febrile Convulsions: -
A proportion of children may have focal convulsions of greater
than 20 minutes duration even without significant fever and/or with
persistently abnormal EEG for two weeks or more after the
attack.
All these cases (in fact all case of febrile seizures not
satisfying the criteria laid down for typical febrile seizures) are
labelled atypical febrile convulsion cases. They are basically
predisposed to idiopathic epilepsy.
(II) CHRONIC & RECURRENT CONVULSIONS: -
Under this heading are covered epilepsy, epilepsy stimulating
states and epilepsy equivalents such as narcolepsy, hysteria,
breath holding spills, syncope and migraine.
Epilepsy is defined as a symptom complex characterized by
recurrent, paroxysmal attacks of unconsciousness or impaired
consciousness, usually with a succession of tonic or clonic
muscular spasms or other abnormal behaviour. It may be idiopathic
or organic.
The salient details of types of idiopathic epilepsy are given
below:
i. Grandmal Commonest, generalized tonic clonic convulsions are
its hallmark.
ii. Petitmal Momentary loss of consciousness.
iii. Jacksonian or focal seizures Starting from one part and
spreading to other parts in a fixed pattern.
iv. Psychomotor (temporal lobe) Visceral symptoms like nausea,
vomiting or epigastric sensation followed by short periods of
increased muscular tonicity and, later, semi - purposive movements
during a period of impaired consciousness or amnesia. The syndrome
of periodic headache in association with abdominal pain , nausea
and vomiting has been termed abdominal epilepsy or abdominal
migraine.
v. Myoclonic: - Involuntary violent contractons of limbs or
groups of muscles with or without loss of consciousness. In
infantile myoclonic epilepsy, also called sallam seizures or West
Syndrome, the baby (usually under 6 months) has massive attacks of
flexion of the head, once or as may as 100 times a day. In the
primary type child is microcephalic and mentally retarded. EEG
shows typical hypsarrhythmia.
Treatment is preferably with ACTH though steroids, diazepam,
valproate and pyridoxie may also prove effective.
ORGANIC EPILEPSY: -
It is frequently accompanied by cerebral palsy, mental
retardation and EEG abnormalities. Its main causes are: -
i. Post traumatic Direct damage to brain tissue as followed head
injury.
ii. Post hemorrhagic Injury to brain at birth or afterwards,
bleeding diathesis, rupture of miliary aneurysm,
pachymeningitis.
iii. Post infections Meningitis, ancephalitis cerebral abscess,
sinus thrombophlebitis.
iv. Post toxic Kernicterus chronic poisoning (lead arsenic)
v. Degenerative Intracranial neurofibromatosis., cerebromascular
digeneratation , subacute selerosing panecephalitis.
vi. Congenital Arteriovenous aneurysm, strurgeweber type of
vascular anomaly, cerebral aplasia, porencephaly, hydrocephalus,
tuberous sclerosis.
vii. Parasitosis Cysticercosis, hydatid disease, ascariasis,
toxoplasmosis.
(III) STATUS EPILEPTICUS: -
Definition: -
Status epilepticus means any true convulsion lasting more than
30min or a series of convulsions extending over such a period wit
or without recovery of consciousness between spells.
Loss of consciousness though a prominent feature of status
epilepticus with grandmal epilepsy, may be absent in petitmal,
psychomotor or myoclonic status. In the latter category,
consciousness is generally only impaired status convulsions refer
to status epilepticus with preservation of
consciousness.PATHOPHYSIOLOGY: -
The relationship between the neurologic outcome and the duration
of status epilepticus is unknown in children and adults. Some
evidence shows that the period of status epilipticus that produces
neuronal injury in a child is less than that for an adult. In
primates pathologic changes can occur in the brain of ventilated
animals after 60 min of constant seizure activity when metabolic
homeostasis is maintained. Thus, cell death may result from
excessively increased metabolic demands by continually discharging
neurons. The most vulnerable areas of the brain include the
hippocampus amygdlala, cerebellum, middle cortical area, and
thalamus. Characteristic acute pathologic changes consist of venous
congestion, small petechial hemorrhages and oedema. Ishemic
cellular changes are the earliest histologic findings, followed by
neuronophagia, microglieal proliferation, cell loss and increased
numbers of reactive astrocytes. Prolonged seizures are associated
with lactic acidosis an alteration in the blood brain barrier and
elevation of ICP and temperature. A series of complex, poorly
understood hormonal and biochemical changes ensues. Circulating
levels of prolactin, ACTH, cortisol, glucagons, growth hormne,
insulin, epinephrine and cyclic nucleotides are elevated during
status epilepticus in the animal. Neuronal concentrations of Ca,
arachidonic acid and prostaglandins rise and my promote cell death.
Initially, the animal may be hyper glycemic, but hypoglycemia
ultimately occurs. Inevitably dysfunction of the autonomic nervous
system develops and may lead to hypotension and shock. These series
of biochemical changes are not unique to status epilepticus because
they may also follow severe mechanical and stress injuries.Constant
tonic clonic muscle activity during a seizure may produce
myoglobnuria and acute tubular necrosis.
Several investigations have shown significant increase in
cerebral blood flow and metabolic rate during status epilipticus.
In animals approximately 20 min of status epilepticus produces
regional oxygen insufficiency, which promotes all damage and
necrosis. The studies have led to the concept of a critical period
during status epilepticus when irreversible neuronal changes may
develop. This transitional period varies between 20 & 60 min in
animals during constant seizure activity.
(4) NEONATAL SEIZURES:-
i. SUBTLE SEIZURES: -
They account for over 50% of all cell seizures and are more
common in preterm babies. They can be easily overlooked. Jerking of
the eyes (with or without conjugate deviation), blinking or
fluttering of eyelids, starting look, sucking, chewing, or smacking
oro buccal movements apneic attacks or included among subtle
seizures. Oral, facial & lingual phenomenon are common due to
advanced maturation of the limbic system. There is tachycardia at
the onset followed by bradycardia after apnea and hypoxemia.
(II) Multifocal clonic seizures without Jacksonian patterna:
-
Tonic convulsive movements migrate haphazardly from one limb to
another. The twitchings may be predominantly limited to one side of
the body. They may occur due to hypoxic ischemic encephalopathy and
birth trauma.
(III) Focal clonic seizures: -
They are well localized and often associated with loss of
consciousness . Even focal seizures in a newborn baby are a
manifestation of bilateral cerebral disturbance. They are common
due to metabolic disorder, birth trauma and cerebral infarction.
Right sided clonic seizures are most commonly due to blockage of
left middle cerebral artery.(IV) Tonic Seizures: -
There is generalized stiffening similar to decerebrate (tonic
extension of all limbs) or decorticate (flexion of upper limbs and
extension of lower limbs) posturing and may be associated with
stertorous breathing and eye signs or occasional clonic jerks. They
may be associated with intraventricular hemorrhage and
kernicterus.
(V) Myclonic seizures: -
Sudden jerk movements produced by episodic contractions of a
group of muscles are rare in the newborn. These are more common in
babies with developmental defects including anencephaly. Typical
hypsarrhythmic electroencephalogram and massive myoclonic spasm may
develop during infancy.
International Classification of Epileptic Seizures: -
1. PARTIAL SEIZURES: -
Partial seizures account for a large proportion of childhood
seizures up to 40% in some series. Partial seizures may be
classified as simple and complex, consciousness is maintained with
simple seizures and is impaired in patients with complex
seizures.
Simple Partial Seizures (SPS): -
Motor activity is the most common symptom of SPS. The movements
are characterized by asynchronous clonic or tonic movements, and
thy tend to involve the face, neck and extremities. Versive
seizures consisting of head turning and conjugate eye movements are
particularly common in SPS. Automatisms do not occur with SPS, but
some patient complain of aura (e.g. chest discomfort and headache),
which may be the only manifestation of a seizure. The average
seizures persists for 10-20 sec.Complex Partial Seizures (CPS):
-
A CPS may begin with a simple partial seizure with or without an
aura, followed by impaired consciousness conversely the onset of
the CPS may coincide with an altered state of consciousness. An
aura consisting of vague, unpleasant feelings, epigastric
discomfort or fear is present in approximately one third of
children with SPS and CPS. The presence of an aura always indicates
a focal onset of the seizures because partial seizures are
difficult to document in infants and children, the frequency of
their association with CPS may be underestimated. Impaired
consciousness in infants and children is difficult to appreciate.
Automalisms are a common feature of CPS in infants and children
occurring in approximately 50 75% of cases, the older the child,
the greater is the frequency of automatisms. Automatisms develop
after the loss of consciousness and may persist into the postical
phase but they are not recalled by the chld. The automatic
behaviour observed in infants is characterized by alimentary
automatisms, including up smacking, chewing, swallowing and
excessive salivation. Those movement can represent normal infant
behaviour and are difficult to distinguish from the automatisms of
CPS.
Automatic behaviour in older children consist of semipurposeful,
inco-ordinated and unplanned gestural automatisms, including
picking and pulling at clothing or the bed sheets, rubbing or
caressing objects, and walking or running in a nondirective,
repetitive, and often fearful fashion.
Spreading of the epileptiform discharge during CPS can result in
secondary generalization with a tonic clonic convulsion. During the
spread of the ictal discharge throughout the hemisphere,
contralateral, versive turning of the head, dystonic posturing and
tonic or clonic movemtns of the extremities and face including eye
blinking may be noted. The average duration of a CPS is 1 - 2 min,
which is considerably longer than an SPS or an absence seizure.
Benign Partial Epilepsy with centrotemporal spikes (BPEC) :-
BPEC is a common type of partial epilepsy in childhood and has
an excellent prognosis. The CIF, EEG findings (rolantic foci) and
lack of a neuropathologic lesion are characteristic and readily
separate BPEC from CPS, BPEC occurs between the ages of 2 and 14
and has a peak age of onset of 9-10 yrs. The disorder occur in
normal children with an unremarkable past history and normal
neurologic exam. There is often a positive family history of
epilepsy. The seizures are usually partial and motor sign and
somatosensory symptoms are often confined to the face.
Oropharyngeal symptoms include tonic contractions and paresthesis
of the tongue, Unilateral numbness of the cheek, guttural noises,
dysphagia and excessive salivation. U/L tonic- clonic contractures
of the lower face frequently accompany the oropharyngeal symptoms,
as do clonic movements or paresthesias of the ipsilateral
extremities, consciousness may be intact or impaired, and the
partial seizure may proceed to secondary generalization.2.
GENERALIZED SEIZURES: -
Absence Seisures: -
Simple (typical), absence (petitmal) seizures are characterized
by a sudden cessation of motor activity or speech with a blank
facial expression and flickering of the eylids. These seizures,
which are uncommon before age 5 yrs. are more prevalent in girls,
they are never associated with an aura, they rarely persist longer
than 30 sec and they are not associated with a postictal state.
Children with absence seizures may experience countless seizures
daily, whereas complex partial seizures are usually less frequent.
Patient do not lose body tone, but their head fall forward
slightly. Immediately after the seizure, patients resume
preseizures activity with no indication of postictal
impairment.Generalize Tonic clonic seizures: -
These seizures are extremely common and may follow a partial
seizure with a focal onset. They may be associated with an aura,
suggesting a focal origin of the epileptiform form discharge. It is
important to inquire about the presence of an aura, because its
presence and site of origin may indicate the area of pathology.
Patients suddenly lose consciousness and in some cases emit a
shrill, piercing cry. Their eyes roll back their entire body
musculature undergoes tonic contractions, and they rapidly become
cyanotic in association with apnea. The clonic phase of the seizure
is heralded by rhythmic clonic contractions alternating with
relaxation of all muscle group. The clonic phase slows toward the
end of the seizure, which usually persists for a few minutes, and
patients often sigh as the seizures comes to an abrupt stop. During
the seizure, children may bite their tongue but rarely vomit. Loss
of sphincter control, particularly the bladder is common during a
generalized tonic clonic seizures.
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 hyper extended to enhance breathing. The mouth
should not be opened forcibly by an object or by a finger because
patients teeth may be dislodged and aspirated, or significant
injury to the oropharyngeal cavity may result.Myoclonic Epilepsies
of Childhood: -
This disorder is characterized by repetitive seizures consisting
of brief, often symmetric muscular contraction with loss of body
tone and falling or slumping forward, which has a tendency to cause
& injuries to the face and the mouth.
Benign Myoclonus of Infancy: -
Benign myoclonus begin during infancy and consist of clusters of
myoclonic movements confined to the neck, trunk and extremities.
The myoclonic activity may be confused with infantile spasm.
Cessation of myoclonus by 2 yrs. of age. An anticonvulsant is not
indicated.Typical Myoclonic Epilepsy of Early Childhood: -
Children who develop typical myoclonic epilepsy are near normal
before the onset of seizures with and unremarkable pregnancy,
labour an delivery and developmental milestones. The mean age of
onset is approximately 2 years but the range spread from 6 months
to 4 years.
The frequency of myoclonic seizures varies, they may occur
several times daily, or children may be seizure free for weeks. A
few patients have febrile convulsions or generalized tonic clonic
afebrile seizure that precede the onset of myoclonic epilepsy. At
least one third of the children have a positive family history of
epilepsy, which suggests a genetic etiology in some cases. The long
term outcome is relatively favorable. Mental retardation develops
in the minority and more than 50% are seizures free several years
later. However, learning and language problems and emotional and
behavioral disorders occur in a significant number of these chidren
and require prolonged follow up by a multidisciplinary team.
Complex Myoclonic Epilepsies: -
These consist of a heterogeneous group of disorders with a
uniformly poor prognesis. Focal or generalized tonic clonic
seizures beginning during the 1st year of life typically antedate
the onset of myoclonic epilepsy. The generalized seizure is often
associates with an upper respiratory tract infection and a low
grade fever and frequently develops into status epilepticus. A
history of hypoxi ischemic encephalopathy in the perinatal period
and the finding of generalized upper motor neuron and period and
extrapyramidal sign with microcephaly constitute a common pattern
among these children. A family history of epilepsy is much less
prominent in this group compared with typical myoclonic epilepsy.
Some children display a combination of frequent myoclonic and tonic
seizures.Treatment with valproic acid or the benzodiazepines may
decrease the frequency or intensity of the seizures. The Ketogenic
diet should be considered for those patients whose seizures are
refractory to anticonvulsants.
Juvenile Myoclonic Epilepsy (Janz Syndrome): -
Juvenile myoclonic epilepsy usually begins between the age of 12
and 16 yrs. and accounts for approximately 5% of the epilepsies.
Patients not frequent myoclonic jerks on awakening, making hair
combing and tooth brushing difficult. As the myoclonus tends to
abate later in the morning most patients do not seek medical advice
at this stage and some deny the episodes. A few years later, early
morning generalized tonin clonic seizures develop in association
with the myoclonus. The neurologic exam is normal and the majority
responds dramatically to valproate, which is required lifelong.
Discontinuance of the drug causes a high rate of recurrence of
seizures.Progressive Myoclonic Epilepsies: -This heterogeneous
group of rare genetic disorders uniformly has a grave prognosis.
These condition include Lafora disease, myclonic epilepsy with
ragged red fibers (MERRF). Lafora disease presents in children
between 10-18 yrs. with generalized tonic clonic seizures.
Ultimately, myoclonic jerks appear, these become mere apparent and
constant wit progression of the disease. Mental deterioration is a
characteristic feature and becomes evident within one year of the
onset of seizures. Neurologic abnormalities, particularly
cerebeller and extrapyramidal signs, are prominent findings. The
myoclonic jerks are difficult to control, but a combination of
valproic acid and a benzodiazepine (e.g. clonazepam) is effective
in controlling the generalized seizures.
INFANTTLE SPASM: -Infantile spasm usually begin between the ages
of 4 and 8 month and are characterized by brief symmetric
contractions of the neck, trunk and extremities.There are three
types of infantile spasm: -i. Flexor spasm
ii. Extensor spasm
iii. Mixed spasm
i. Flexor spasm: -
It occurs in clusters or volleys and consist of sudden flexion
of the neck, arms and legs onto the trunk.
ii. Extensor spasm: -
Extensor spasm produce extension of the trunk and extremities
and are the least common form of infantile spasm.
iii. Mixed spasm: -
Mixed infantile spasm, consisting of flexion in some volleys and
extension in others, is the most common type of infantile
spasm.
Clusters or volleys of seizures my persist for minutes with
brief intervals between each spasm. A cry may precede or follow an
infantile spasm, accounting for the confusion with colic in a few
cases. The spasm occur during sleep or arousal but have a tendency
to develop while patients are drowsy or immediately on
awakening.Infantile spasms are typically classified into two
groups: -
i. Cryptogenic
ii. Symptomatic
i. Cryptogenic: -
A child with cryptogenic infantile spasms has an uneventful
pregnancy and birth history as well as normal developmental
milestones before the onset of seizures. The neurologic examination
and the CT and MRI scans of the head are normal, and there are no
associated risk factors. Approximately 10-20% of infantile spasms
are classified as cryptogenic and the remainder is classified as
symptomatic.ii. Symptomatic: -
Symptomatic infantile spasm are related directly to several
prenatal, perinatal and postnatal factors. Prenatal and perinatal
factors include hypoxic ischemic encephalopathy with
periventricular leukomalacia, congenital infections inborn errors
of metabolism. Post natal conditions include CNS infections, head
trauma (especially subdural hematoma and intraventricular
hemorrhage), and hypoxic ischemic encephalopathy.
In the past, immunization particularly with the pertusis antigen
had been implicated as a cause of infantile spasms. Infants with
cryptogenic infantile spasms hava a good prognosis, whereas those
with the symptomatic type have an 80 -90% risk of mental
retardation. DIAGNOSIS: -
The investigation of a seizure depends on many factors,
including the age of the patient, the type and frequency of the
seizure, and the presence or absence neurologic findings and
constitutional symptoms.
First line Investigations: -
Check hemotocrit, blood, glucose, calcium, phosphorus,
magnesium, sodium. Venous pH and base excess. CSF examination and
blood culture should be taken in all cases to exclude pyogenic
meningitis. Cranial ultrasound and EEG should be done once
metabolic disorders are excluded.Second line investigations: -
When convulsions persist and first line investigations are
unable to identify the cause, MRI or CT scan is advised to exclude
structural or developmental defects like cerebral dysgenesis,
lissencephaly and neuronal migration disorders. Appropriate tests
including serology for TORCH infections should be undertaken to
exclude intrauterine infections. Screening tests for exclusion of
inborn error of metabolism include ABG, blood ammonia, lactate/
pyruvate level, plasma and urinary amino acid profile etc. If
facilities exist mothers urine and babys meconium should be
screened for maternal drug abuse.
Electroencephalography: -
Prolonged EEG monitoring with simultaneous closed circuit video
recording is reserved for complicated cases of protracted and
unresponsive seizures. It provides an invaluable method for
recording ictal seizure event that are rarely obtained during
routine EEG studies. This technique is extremely helpful in the
classification of seizure because it can accurately determine the
location and frequency of seizures discharges while recording
alterations in the level of consciousness and the presence of
clinical signs. Patient with pseudo seizures can be readily
distinguished from those with true epilepsy, and seizures type can
be more precisely identified.
MANAGEMENT OF EPILEPSYS/No.DRUGINDICATIONS(Seizure type)DOSE
1CarbamazepinePartial, tonic clonic, atonic, akinetic.10 30
mg/kg Start with low dose
2PhenobarbitoneTonic clonic, akinetic, Partial fibrile
convulsions.3 5 mg/kg/24hr. bid
3Diphenylhydation(Phenytoin) (Dilantin)Tonic clonic, atonic
akinetic, akinetie partial3 9 mg/kg/24 hr. bid.
4Ethosuximide (Zarontin)Absence may increase tonic clonic
seizuresBegin 20 mg/kg/24hr increase to maximum of 40 mg
/kg/24hr.
5ACTH (Semacthen)Myoclonus20 40 units per day 4 6 weeks then 1/3
dose for 3 6 months
6PredinisoloneMyocloness2 mg/kg/day in 2 doses
7NitrazepamMyoclonus & PartialBegin 0.2 mg/kg/24hr increase
slowly to 1mg/kg/24hr.
S/No.DRUGINDICATIONS
(Seizure type)DOSE
8DiazepamIn status epilepticus0.2 mg/kg/dose IV in children
9ClonazepamAtonic, akinetic0.03 mg/kg/day 2 divided doses (0.25
1 mg/kg/24hr bid or tid)
10Sodium ValproateBroad Spectrum20 50 mg/kg/day divided
doses
11Valproic AcidGeneralized tonic clonic
- Myoclonic
- Partial
Begin 10 mg/kg/24hr increase by 5 10 mg/kg/week. Usual dose 30
60 mg/kg per 24 hr tid or bid
12AcetazolamideResistant cases10 20 mg/kg
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