Academic journal article International Journal of Child Health and Human Development

Adolescence and Neurologic Disorders

Academic journal article International Journal of Child Health and Human Development

Adolescence and Neurologic Disorders

Article excerpt

Introduction

Adolescence can in itself provide major challenges, which can be further burdened when in addition neurological disorders appears. Clinical care for neurological disorders in adolescence can be provided by pediatric or adult neurologists and it is important that the health care provider has a holistic approach, which also involve the family in question.

Epilepsy

A seizure is "a transient, involuntary alteration of consciousness, behavior, motor activity, sensation, or autonomic function caused by an excessive rate and hypersynchrony of discharges from a group of cerebral neurons" (1). Epilepsy is defined as more than one unprovoked seizure.

Epidemiology

It is estimated that 4-10% of children suffer at least one seizure by age 16 years. The lifetime risk of one seizure (febrile seizures included) is about 8-10%. The ratio of children with a first unprovoked seizure to those who develop epilepsy is about 5:1 (1,2).

Classification

Distinction is made between a seizure type and epilepsy syndrome. The seizure type is determined by the patients behavior and EEG pattern during the actual seizure event (see tables 1 and 2). On the other hand, the epilepsy syndrome is defined by the seizure type, natural history, EEG findings (ictal and interictal), response to anticonvulsant (AED) treatment, etiology and outcome.

Differential diagnosis

The differential diagnosis includes syncope (see chapter 28), cardiac arrhythmias, migraine and its variants, behavioral events (such as nonepileptic staring spells, jitteriness, self-stimulation, or stereotypies), movement disorders (such tics, benign myoclonus, dyskinesias, or dystonias),sleep disorders (such as night terrors, narcolepsy, sleep myoclonus or confusional arousals [see chapter 26]) and psychogenic conditions (such as non-epileptic seizures, rage attacks or panic attacks).

Management

Only about 27% to 44% of patients who present with their first unprovoked seizure will have a second one (3-9). A majority of the recurrences occur early (within the first 1 to 2 years). Risk factors for recurrence: Abnormal EEG, focal seizure or exam, remote symptomatic, positive family history, young age (1st year of life), and history of prior febrile seizure (10-18).

There is no evidence of a difference when treatment is started after the first seizure versus after a second seizure in achieving a 1-or 2-year seizure remission (19). Even though a decision to treat is made on an individual basis after weighing the risks versus the benefits of treatment, generally speaking, prophylactic treatment is recommended after a second unprovoked seizure since at this point, the risk of recurrence is deemed to be higher. In most cases, children who have been seizure-free on medications for 2 or more years have a higher chance of remaining seizure free after coming off anticonvulsant therapy (20-21).

Seizure prophylaxis

Identifying the right seizure type and epilepsy syndrome is important when choosing an anticonvulsant for seizure prophylaxis (see figure 1). For generalized epilepsies, "broad-spectrum" anticonvulsants are the best option. In addition, Ethosuximide is an excellent choice for childhood absence epilepsy. This drug however will not prevent other types of generalized seizures. Therefore, if a patient is at risk for a generalized convulsive seizure, other broad-spectrum agents need to be considered either in combination with or as a replacement for ethosuximide.

The "narrow spectrum" drugs are a good choice for partial epilepsies but they may exacerbate generalized epilepsies. Therefore, when the seizure type is unclear, use a broad-spectrum agent. A number of anti-seizure medications are reviewed.

Valproic acid

Initial starting dose is 10 to 15mg/kg/day divided twice a day to three times a day. One can raise the dose by 5 to 10 mg/kg/day with a goal maintenance dose range of 20 to 50mg/kg/day. …

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