Etiology of Seizures & Epilepsy:

• Infants, Children: Prenatal or Birth injury vs. Inborn Errors of Metabolism vs. Congenital Malformation
• Children, Adolescents: Idiopatchi or Genetic vs. CNS Infection vs. Trauma
• Adolescents, Young Adult: Head Trauma vs. Drug Intoxication or Withdrawal 

Seizure Type: determed by patient's behavior and EEG pattern during the event

Epilepsy Syndrome: defined by age at onset, seizure types, EEG patterns and family history 

Case 1:

• HPI: 5 month old with no past medical history presents with concerns for jerking movements of head and arms
• Exam: healthy child, mild truncal hypotonia 
• EEG: Hypsarrhythmias
• Diagnosis: West Syndrome (Infantile Spasms)
• Sudden, symmetric, tonic muscle contraction production flexion/extension of truck and extremities 

Case 2:

• HPI: 4 year old history of birth related HIE and resultant static encephalopathy presents with episodes of head drops & staring spells & occasional falls 
• Exam: Microcephaly, cognitive delays, spasticity 
• EEG: shows diffuse 2-2.5 Hz spike wave (slow spike & wave activity)
• Diagnosis: Lennox-Gastaut Syndrome 
• Frequent seizures, mental retardation, resistance to drug therapy, mixed seizure disorder (atonic, tonic, atypical absence)
• Onset peaks at 3-5 years of age 

Case 3:

• HPI: 9 year old presents with first time seizure. Nocturnal, speech arrest, drooling followed by left face and arm clonic activity
• Exam: non-focal & normal development
• EEG: EKG like morphology of waves with this type of epilpesy (sharp spike & slow wave); normal back ground with centrotemporal spokes activated by drowsiness and sleep ipsilateral to side of body with clonic activity 
• Diagnosis: Benign Rolandic Epilepsy
• Age of onset is late childhoold (~3-10 years of age)
• Low frequency of seizures thus don't treat the first seizure!
• 25% of patients have 1 seizure; 50% of patients have < 5 seizures 
• Epilepsy usually remits by 16 years of age 
• Speech involved & if occurs upon waking up at night, think Benign Rolandic Epilepsy
• Seizure Type: simple partial motor in ~75%, involving face, oropharyngeal muscles and upper limb with retained conciousness 
• Some patients have Learning Disabilities 
• Management: unclear if truly necessary but patients get a good repsonse with Carbamazepine & Oxcarbamazepine 

Case 4:

• HPI: 6 year old with declining school performance, staring spells. Normal birth history and development
• Exam: normal 
• EEG: bursts of 2.5 to 3.5 Hz spike and wave induced by hyperventilation with brief unresponsiveness; normal background
• Diagnosis: Absence Epilepsy
• Occurs around age 4 to 8 years old but can also start during puberty 
• More common in females 
• Simple: brief, staring episodes, unresponsive, motor arrest
• Complex: oral or motor automatisms, autonomic phenomenom, incontinence
• abrupt onset and offset, NO POSTICTAL STATE, which is how you differentiate from complex partial seizures 
• Management: Ethosuximide or Valproate 

Case 5: 

• HPI: 15 year old healthy teenager with first "grand mal" seizure occured in setting of sleep deprivation. Sometimes "clumsy" in the morning, drops things, sometimes jerks after awakening. 
• Exam: normal along with normal labs and MRI
• Diagnosis: Juvenile Myoclonic Epilepsy
• Precipitated by fatigue, alcohol, sleep deprivation; 40% have a family history 
• Seizures recur in 80-90%; minority have seizure remission 

Epilepsy Mimics:

• Syncope
• Metabolic Derangements
• Migraine
• Cerebral Vascular Disorders
• Sleep Disorders
• GI Disorders
• Psychiatric Disorders (such as PNES)
• Respiratory Conditions