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Neuroscience版 - 侄女发热后抽搐,癫痫治疗
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相关话题的讨论汇总
话题: febrile话题: seizures话题: children话题: epilepsy话题: seizure
进入Neuroscience版参与讨论
1 (共1页)
l****y
发帖数: 130
1
快5周岁。体重60斤。
侄女发热后抽搐共发生了4次。昨天是因为扁桃体发炎,发热到39度。
之前有过3次,前一次是15个月前,当然查了CT和24小时脑电图,未见异常。
国内问过一些医生,认为是癫痫。但是一些医生说需要吃药治疗。但是药是激素药,会
影响卵巢发育。另外一些医生觉的保守治疗就好。
我的问题是:
1)倒底是不是癫痫呢?
2)如果是,根据这个情况,美国这边是保守治疗还是吃药
3)如果吃药的话,有没有什么好的药可以不影响发育的
谢谢!
f**d
发帖数: 768
2
在高烧情况下小孩很容易产生癫痫,癫痫有时几秒,有时十几秒,不容易捕捉到
要注意的就是尽量避免高烧--只要体温低于39度,癫痫基本就不会发生。
---这是我目前知识能解释的范畴
临床方面请参考医生

【在 l****y 的大作中提到】
: 快5周岁。体重60斤。
: 侄女发热后抽搐共发生了4次。昨天是因为扁桃体发炎,发热到39度。
: 之前有过3次,前一次是15个月前,当然查了CT和24小时脑电图,未见异常。
: 国内问过一些医生,认为是癫痫。但是一些医生说需要吃药治疗。但是药是激素药,会
: 影响卵巢发育。另外一些医生觉的保守治疗就好。
: 我的问题是:
: 1)倒底是不是癫痫呢?
: 2)如果是,根据这个情况,美国这边是保守治疗还是吃药
: 3)如果吃药的话,有没有什么好的药可以不影响发育的
: 谢谢!

w******y
发帖数: 4871
3
Febrile seizures
Author
Marvin A Fishman, MD
Section Editor
Douglas R Nordli, Jr, MD
Deputy Editor
Janet L Wilterdink, MD
Last literature review version 19.1: January 2011 | This topic last updated:
February 3, 2011 (More)
INTRODUCTION — Febrile seizures are a common cause of convulsions in young
children. They occur in 2 to 4 percent of children younger than five years
of age, but the incidence is as high as 15 percent in some populations. This
incidence has been attributed to closer living arrangements among family
members making detection more likely, but racial and geographic variations
may also be important.
The generally accepted criteria for febrile seizures include:
•A convulsion associated with an elevated temperature greater than 38&
ordm;C
•A child younger than six years of age
•No central nervous system infection or inflammation
•No acute systemic metabolic abnormality that may produce convulsions
•No history of previous afebrile seizures
Febrile convulsions are divided into two categories, simple (benign), or
complex, based upon clinical features. Simple febrile seizures are the most
common and are characterized by seizures that last less than 15 minutes,
have no focal features, and, if they occur in a series, the total duration
is less than 30 minutes. Complex febrile seizures are characterized by
episodes that last more than 15 minutes, have focal features or postictal
paresis, and occur in a series with a total duration greater than 30 minutes
[1,2].
ETIOLOGY AND PATHOGENESIS — It is not known how or why seizures are
generated in response to fever; it may be that fever-induced factors (eg,
interleukin-1beta) are proconvulsant in individuals who are susceptible
based upon the stage of brain development and genetic susceptibility [3,4].
Certain ion channels in the brain are temperature sensitive and may generate
fever-associated synchronized neuronal activity [5,6]. There is also
evidence to suggest that hyperthermia-induced hyperventilation and alkalosis
may play a role [7].
Infections — Febrile seizures can occur during both viral and bacterial
infections. In one hospital based study, the incidence of febrile seizures
was similar with influenza, adenovirus, and parainfluenza infections (6 to
18 percent), and somewhat less common with respiratory syncytial virus and
rotavirus (4 to 5 percent) [8]. No specific virus was associated with risk
of complex febrile seizures or later recurrence. Other studies have reported
higher rates of febrile seizures (36 percent) in human herpesvirus (HHV)-6
infections and also a higher rate of complex features and recurrence [9,10].
(See "Human herpesvirus 6 infection in children: Clinical manifestations;
diagnosis; and treatment".)
Immunizations — The risk of febrile seizures is increased after
administration of diphtheria, tetanus toxoid, and whole-cell pertussis (DTP)
and measles, mumps, and rubella (MMR) vaccine. (See "Standard immunizations
for children and adolescents".) In a large cohort study, febrile seizures
were significantly increased on the day of DTP vaccination and 8 to 14 days
following MMR vaccination (adjusted relative risks 5.7 and 2.83,
respectively) [11]. The risk for subsequent seizures or neurodevelopmental
disabilities was comparable in children with febrile seizures whether or not
they were associated with vaccination.
Predisposing factors — Susceptibility to febrile seizures has been linked
with abnormalities in neurotransmitters. However, whether observed
abnormalities were primary events or were secondary to the convulsions is
unclear. As an example, the cerebrospinal fluid (CSF) concentration of gamma
-aminobutyric acid (GABA), an inhibitory transmitter, was reduced in one
series of children who were studied after their first or second febrile
seizure; the samples were obtained after the convulsion and, thus, may be
the effect rather than the cause of the seizure [12]. Furthermore, low CSF
GABA was not confirmed in other studies of children with febrile seizures [
13].
CSF neopterin concentrations may be elevated in children with febrile
seizures [14]. Because neopterin is secreted by activated macrophages, this
observation suggests immune activation within the central nervous system [14
].
Iron insufficiency may play a role in pathogenesis. In a prospective study
of 150 children, mean ferritin levels were significantly lower in children
with a first febrile seizure than in matched controls with febrile illness
but no convulsions (29.5 versus 53.3 mcg/L) [15]. Plasma ferritin levels ≤
30 mcg/L occurred in a significantly greater proportion of children with
seizures than controls (65 versus 32 percent). Further studies will be
required to confirm this preliminary finding.
Genetic susceptibility — Genetic and familial factors appear to be
important factors in the expression of febrile convulsions and the
subsequent development of epilepsy in some children [2,16]. Among first-
degree relatives of children with febrile seizures, 10 to 20 percent of
parents and siblings also have had or will have febrile seizures. In
addition, monozygotic twins have a much higher concordance rate than do
dizygotic twins, in whom the rate is similar to that of other siblings.
Susceptibility to febrile seizures has been linked to several genetic loci
in different families, including the long arm of chromosome 8q13-21 (FEB1) [
17], chromosome 19p (FEB2) [18,19], chromosome 2q23-24 (FEB3) [20],
chromosome 5q14-15 (FEB4) [21,22], chromosome 6q22-q24 (FEB5) [23],
chromosome 6q16.3-22.31 [24], chromosome 21q22 [25], and perhaps chromosome
18p11.2 [26]. The trait is transmitted in an autosomal dominant fashion.
However, susceptibility genes have not been identified in most patients with
febrile seizures [3].
Genetic factors are also believed to be important in nonmendelian forms of
febrile seizures. One study suggests that common polymorphism in a sodium
channel gene (splice site variant SCN1A) is a common risk factor for febrile
seizures [27]. However, this finding was not replicated in a follow-up
study [28].
A syndrome of generalized epilepsy with febrile seizures plus (GEFS+) also
has been described [29,30]. The most common phenotype consists of children
who had seizures with fever in early childhood that, unlike typical febrile
seizures, continued beyond six years of age or were associated with afebrile
tonic clonic seizures as well as other seizure types [29]. The epilepsy
typically remitted by mid-adolescence. This disorder is usually autosomal
dominantly inherited. Family members who inherit the mutation may only have
nonfebrile seizures [31].
Among different families with GEFS+, a variety of gene loci and mutations
have been identified, including chromosome 19q with mutations in the beta-1-
subunit of the neuronal sodium channel [29-32], chromosome 2q with mutations
in the alpha-1-subunit of the neuronal sodium channel [26,33-36],
chromosome 8p23-p21 [37] and a mutation in the gamma-2 subunit of the GABA-A
receptor [38-40]. A mutation in the last gene has also been identified in a
family with febrile seizures without associated epilepsy [41].
These observations link febrile seizures with afebrile seizures in some
families in an autosomal dominant fashion. In addition, previous studies
have shown that siblings and parents of patients with febrile seizures have
a 4 to 10 percent incidence of epilepsy.
Hippocampal lesions — Another approach linking febrile seizures and
epilepsy was suggested from an evaluation of two families with familial
febrile convulsions [42]. Magnetic resonance imaging (MRI) was performed in
family members who had no seizures, febrile convulsions only, and febrile
convulsions with the subsequent development of temporal lobe epilepsy. All
subjects with febrile convulsions who did not develop epilepsy and six
clinically unaffected relatives showed asymmetry in the size of the
hippocampi. In addition to a difference in the size between the right and
left hippocampi were changes in the internal architecture of the hippocampal
bodies. The authors concluded that a subtle preexisting hippocampal
malformation that was present may facilitate febrile convulsions and
contribute to the development of subsequent hippocampal sclerosis, which was
seen in the patients who developed temporal lobe epilepsy. (See 'Subsequent
temporal lobe epilepsy' below.) Furthermore, the hippocampal malformation
did not appear to be a consequence of the febrile convulsions and, therefore
, may have been a predisposing factor associated with the development of
epilepsy.
In another study, the effect of prolonged febrile seizures was evaluated in
the immature rat [43]. Prolonged hyperthermia-induced seizures did not lead
to spontaneous seizures in adult rats. However, the experimental animals,
but not control animals, developed hippocampal seizures after systemic
administration of a low dose of kainate, a chemical convulsant, indicative
of a reduced seizure threshold. An analogous situation may exist in humans.
Individuals predisposed to developing epilepsy, by a variety of factors, may
become symptomatic in later years after having their thresholds modified by
febrile seizures in infancy.
CLINICAL FEATURES — Febrile seizures occur in children between the ages of
six months and six years, with the majority occurring in children between 12
to 18 months of age. Febrile seizures have been reported in children over
six years of age, but in older children, febrile seizures should be
considered a diagnosis of exclusion, as they are more likely than younger
children with febrile seizures to have subsequent afebrile seizures [44].
Simple febrile seizures are the most common type encountered in children.
Generalized seizures are mainly clonic, but other forms include atonic and
tonic spells. The facial and respiratory muscles are commonly involved.
Complex febrile seizures (focal features longer than 15 minutes or multiple
episodes within 24 hours) are unusual; prolonged convulsions occur in fewer
than 10 percent and focal features in fewer than 5 percent of children with
febrile seizures. An initial simple febrile seizure may be followed by
complex seizures, but the majority of children who develop complex febrile
seizures do so with their first seizure. However, an initial complex febrile
seizure does not necessarily indicate that all subsequent seizures will be
complex.
Some patients present in febrile status epilepticus, ie, continuous seizures
or intermittent seizures without neurologic recovery, either lasting for a
period of 30 minutes or longer. (See 'Febrile status epilepticus' below.)
The majority of children have their febrile seizures on the first day of
illness and, in some cases, it is the first manifestation that the child is
ill. The degree of fever associated with febrile convulsions is variable,
and approximately 25 percent of events occur when the temperature is between
38ºC and 39ºC. They are often seen as the temperature is
increasing rapidly but may develop as the fever is declining. Recurrent
febrile seizures do not necessarily occur with the same degree of fever as
the first episode and do not occur every time the child has a fever.
DIFFERENTIAL DIAGNOSIS — Involuntary movements can occur in sick children
and be confused with seizures. Shaking chills are usually readily
distinguished from seizures. Chills are common and are characterized by fine
rhythmic oscillatory movements about a joint. They rarely involve facial or
respiratory muscles, which frequently occur during febrile seizures. In
addition, chills usually involve both sides of the body simultaneously and
are not associated with loss of consciousness, in contrast to children with
generalized seizures. Thus, bilateral manifestations without apparent
unconsciousness strongly suggest that the movements are not convulsive.
An underlying metabolic disorder presenting as a seizure in a febrile child
is rare. In such children, the history and physical examination yield clues
of an underlying problem. Infants with a history of vomiting, diarrhea, and
altered fluid intake may have electrolyte abnormalities (eg, hypernatremia,
hyponatremia) that can lead to seizures.
Meningitis and encephalitis are the main concerns in a child presenting with
fever and seizures. A thorough evaluation by an experienced clinician
almost always will detect the child with meningitis. Although as many as 40
percent, particularly younger infants, who have seizures as an initial
manifestation of meningitis do not have meningeal signs, they have other
symptoms and findings that strongly suggest the correct diagnosis.
It is exceedingly rare for bacterial meningitis to be detected on the basis
of doing a "routine" evaluation of the CSF after a febrile seizure. When the
only indication for performing a lumbar puncture is the seizure, meningitis
will be found in less than 1 percent of patients and less than one-half of
these will have bacterial meningitis [45].
Children with status epilepticus (SE) and fever are more likely to have
bacterial meningitis than those with a short seizure. Meningitis must be
considered as a diagnostic possibility in children with SE and fever (see '
Febrile status epilepticus' below).
The emergent evaluation and management of the child with suspected
meningitis is discussed separately. (See "Epidemiology, clinical features
and diagnosis of acute bacterial meningitis in children", section on '
Evaluation'.)
DIAGNOSTIC EVALUATION
Lumbar puncture — The need for a lumbar puncture (LP) with CSF examination
to exclude meningitis or encephalitis in children with a febrile seizure is
uncertain. A retrospective cohort review of 704 patients aged 6 to 18 months
who presented with a first simple febrile seizure revealed that 38 percent
underwent LP [46]. There were no diagnoses of bacterial meningitis made in
children in whom this was not otherwise suspected clinically; leukocytosis
was present in 3.8 percent. CSF cultures revealed no pathogens, but in 10
cases (3.8 percent) a contaminant grew. A separate study in children with
complex febrile seizures revealed similar findings [47].
While routine performance of LP in all children with febrile convulsions
does not seem warranted, the American Academy of Pediatrics (AAP)
recommendations regarding the performance of LP in the setting of febrile
seizures are the following [48]:
•LP should be performed when there are meningeal signs or symptoms or
other clinical features that suggest a possible meningitis or intracranial
infection.
•LP should be considered in infants between 6 and 12 months if the
immunization status for Haemophilus influenzae type B or Streptococcus
pneumoniae is deficient or undetermined.
•LP should be considered when the patient is on antibiotics because
antibiotic treatment can mask the signs and symptoms of meningitis.
Once a decision to perform an LP has been made, blood culture and serum
glucose testing should be performed concurrently.
LP should also be considered when febrile seizures occur after the second
day of illness, or when, based on history or examination, the clinician
remains concerned about possible central nervous system infection. Based on
case series, but not included in the AAP guidelines, febrile status
epilepticus may be another possible indication for lumbar puncture (see '
Febrile status epilepticus' below) [49-51].
Other tests — A complete blood count and measurement of serum electrolytes
[52], blood sugar, calcium, and urea nitrogen is of very low yield; these
parameters should be measured only when the patient has a history of
vomiting, diarrhea, and abnormal fluid intake, or when physical findings of
dehydration or edema exist [48].
Neuroimaging with computed tomography (CT) or MRI is not required for
children with simple febrile seizures [48,51,53]. Urgent neuroimaging (CT
with contrast or MRI) should be done in children with abnormally large heads
, a persistently abnormal neurologic examination, particularly with focal
features, or signs and symptoms of increased intracranial pressure [51,53,54
].
Routine electroencephalography (EEG) is not warranted, particularly in the
setting of a neurologically healthy child with a simple partial febrile
seizure [48]. Abnormalities are more likely to be found when the test is
performed shortly after the seizure and when convulsions are of long
duration and have focal features. An abnormal EEG cannot predict the
likelihood of recurrent febrile seizures or the development of afebrile
seizures.
TREATMENT OPTIONS
General considerations — Febrile seizures that continue for more than five
minutes should be treated. The airway, respiratory status, and circulatory
status must be assessed before treatment is initiated. Blood should be
obtained for electrolytes and glucose determination, if indicated.
Antiepileptic drugs should be administered intravenously, if possible,
starting with a short-acting benzodiazepine such as lorazepam (0.05 to 0.1
mg/kg). If the seizure persists, an additional dose may be given. The child'
s respiratory status needs to be monitored carefully and intubation
undertaken if the ventilatory status becomes inadequate. (See "Emergent
endotracheal intubation in children".)
Persistence of the seizure is rare. When it does, the child can be treated
with fosphenytoin (15 to 20 mg/kg IV) (see 'Febrile status epilepticus'
below). If intravenous access is not possible or if the child is being
treated at home, diazepam rectal gel may be used (0.5 mg/kg). (See '
Recurrent febrile seizures' below.)
The fever should be treated as the seizures are controlled. (See "
Pathophysiology and treatment of fever in infants and children".)
Recurrent febrile seizures — One strategy for the treatment of a recurrent
febrile seizure is the use of rectal diazepam gel if the episode lasts
longer than five minutes [55]. Parents can be taught to safely give the
medication at home, and one dose administered rectally will not lead to
respiratory depression.
One factor helpful in predicting a prolonged febrile seizure is focality. A
strong correlation appears to exist between focality and a prolonged
duration of both first and recurrent febrile seizures [56]. In children with
recurrent febrile seizures, those with long duration, defined as lasting
longer than 10 minutes, tend to have similar features in repeat episodes.
Similarly, children who have multiple risk factors for recurrent febrile
seizures (focal onset, multiple seizures during the episode) and have a
prolonged febrile seizure often have prolonged recurrent febrile seizures [
56]. This may be a group of children for whom rectal therapy at the time of
occurrence should be strongly considered.
PROGNOSIS — The prognosis for children with febrile seizures is favorable.
While early reports had suggested that febrile seizures were associated with
sudden death, the results from a large population-based study indicate that
the small excess in mortality among children with febrile seizures is
restricted to those with complex febrile seizures. Furthermore, the
increased risk in those patients is explained, at least in part, by pre-
existing neurologic abnormalities and subsequent epilepsy [57].
Recurrent febrile seizures — Children with febrile seizures are at risk for
developing recurrent febrile seizures. The overall recurrence rate is
approximately 30 to 35 percent [58,59]. However, the values vary with age
from as high as 50 to 65 percent in children who are younger than one year
of age at the time of the first seizure to as low as 20 percent in older
children [60]. A major factor influencing the recurrence rate is the age of
the infant at the time of the first seizure.
A prospective cohort study of 428 children with a first febrile seizure
defined other features and factors influencing recurrences [58].
Approximately one-third of the children had at least one recurrence, 17
percent had one recurrence, 9 percent had two recurrences, and approximately
6 percent had three or more recurrences. The majority of recurrences (50 to
75 percent) took place within one year of the initial seizure and almost
all occurred within two years [61]. Four factors in the prospective cohort
study increased the recurrence risk [58]:
•Young age at onset
•History of febrile seizures in a first-degree relative
•Low degree of fever while in the emergency department
•Brief duration between the onset of fever and the initial seizure
Children who had all four factors were much more likely to have a recurrent
febrile seizure than were those with none (≥70 versus ≤20 percent).
Complex features were not associated with the risk of recurrence. These
findings were confirmed in another prospective study [62].
Other factors identified in different studies have been abnormal development
before the first febrile seizure, a history of afebrile seizures in parents
and siblings, recurrence of seizures within the same illness, and the
number of subsequent febrile illnesses [59,61-63]. Among children who have
had one recurrence, younger age at the time of the first recurrence and a
family history of epilepsy are predictors of subsequent recurrences [58,62].
Another risk factor is an unprovoked seizure after a febrile seizure; such
children are at substantial risk for further seizures with fever (rate ratio
3.47 after adjusting for the above risk factors, p = 0.0015) [64].
Neurologic sequelae — Neurologic sequelae, including new neurologic
deficits, intellectual impairment, and behavioral disorder, are rare
following febrile convulsions.
Reports documenting neurologic complications have been anecdotal and derived
from biased populations consisting of children assessed in hospitals or
clinics; in some cases, they may reflect preexisting abnormalities. When new
deficits were reported, they occurred only after complex or prolonged
febrile seizures.
Population-based studies do not corroborate anecdotal reports of neurologic
complications. In the National Collaborative Perinatal Project,
approximately 5 percent of children had febrile seizures lasting longer than
30 minutes. None of these children sustained permanent motor deficits and
none had impaired mental development unless they developed afebrile seizures
[63]. Similar findings were noted in a population-based study of children
with febrile convulsions in the United Kingdom [65]. The children were
assessed when they were ten years old, and children who had neurologic and
developmental problems prior to the first febrile seizure were excluded. No
difference was found in measurements of academic progress in children with
febrile convulsions, whether simple, complex, or recurrent, compared to a
controlled cohort. There was also no difference in behavior between the two
groups. Finally, among 18 thousand Danish conscripts aged 18 to 20 years,
there was no association found between febrile seizures and cognitive
function [66].
Subsequent epilepsy — Epilepsy occurs more frequently in children who have
had febrile seizures than in the general population. In a normal child with
a simple febrile seizure, the risk is only slightly above that of the
general population [67]. Epidemiologic studies have identified risk factors
for epilepsy among children with febrile seizures:
•In the National Collaborative Perinatal Project, children with
abnormal neurologic development and whose first seizure was complex (focal,
multiple, or longer than 15 minutes) had a 9.2 percent incidence of afebrile
seizures by seven years of age; a risk 18 times higher than that in
children with no history of febrile seizures (0.5 percent) and more than
eight times higher than that in normal children with a noncomplex first
febrile seizure (1.1 percent) [67].
•In Rochester, Minnesota, 687 children with a history of febrile
seizures were observed into adulthood [68]. Three risk factors for
developing epilepsy were identified: focal seizures, prolonged seizures, and
repeated episodes within 24 hours during the same illness. The risk of
developing epilepsy was 2.4, 6 to 8, 17 to 22, and 49 percent in children
with no, one, two, or three of these risk factors, respectively.
•A population-based study in Denmark also followed children with
febrile seizures into adulthood [69]. The cumulative incidence of epilepsy
was 6.9 percent at 23 years, and the relative risk associated with febrile
seizures was 5.4. The risk of epilepsy was higher in those with a family
history of epilepsy, cerebral palsy, or low Apgar scores at five minutes.
Subsequent temporal lobe epilepsy — Although a variety of seizure types
follow febrile convulsions, whether prolonged febrile convulsions lead to
the development of temporal lobe epilepsy is controversial. Reports of
patients with refractory temporal lobe epilepsy considered for surgery often
find an association with febrile convulsions in infancy, particularly
prolonged seizures [70]. In addition, studies assessing hippocampal volume
in adults with epilepsy have found an association between a smaller
hippocampus and a history of febrile seizures [71,72]. Data are conflicting
as to whether a correlation exists between the duration of epilepsy and a
reduction in hippocampal volume. As noted above, hippocampal abnormalities
have also been associated with familial febrile seizures [42]. (See '
Hippocampal lesions' above.)
The possibility of hippocampal injury induced by febrile seizures was
assessed by MRI in infants who had had complex febrile seizures [73].
Abnormalities were found in the children with focal and prolonged complex
febrile seizures but not in those with generalized febrile convulsions. In a
few children who had significantly longer seizures, MRI suggested acute
edema of the hippocampus, a finding noted in other case series as well [74-
76]. Follow-up imaging studies in these children may show hippocampal
atrophy or abnormal apparent diffusion coefficient measurements. Another
study found that hippocampal atrophy and other MRI characteristic of
hippocampal sclerosis were more common in adults with a history of febrile
seizures in childhood than those without [77]. Although these observations
suggest acute injury to the hippocampus during a febrile seizure, the
possibility of preexisting lesions leading to susceptibility to injury is
not excluded.
Studies based mainly upon imaging results and patients being considered for
epilepsy surgery suggest an association between febrile seizures and
temporal lobe epilepsy. Some clinical studies reached a similar conclusion.
In one, patients presenting to an epilepsy clinic because of a previous
diagnosis of epilepsy or recent onset of seizures were prospectively
questioned about febrile convulsions and their characteristics [78]. Febrile
convulsions were reported by 13.2 percent of the patients. Temporal lobe
epilepsy was more likely to be preceded by febrile convulsions than by other
types of epilepsy (25.2 percent versus 5.6 percent, respectively).
Prolonged duration was the most common feature of the complex febrile
seizure associated with temporal lobe epilepsy, although patients with
generalized epilepsy were more likely to have had simple febrile convulsions.
However, carefully performed community-based epidemiologic studies have not
been able to confirm this association. In one, the characteristics of
epilepsy were evaluated in 524 children who were one year of age or older at
the onset of epilepsy [70]. Febrile seizures were present in 14 percent of
the patients. Complex febrile seizures were associated with a younger age at
onset of the epilepsy, but there was no specific association with
localization-related forms of epilepsy. No evidence that focal or prolonged
febrile seizures were associated with temporal lobe epilepsy was found;
three children had hippocampal atrophy demonstrated on their initial MRI,
but none had a history of febrile seizures.
In summary, febrile seizures do not appear to cause temporal lobe epilepsy.
The association may represent an inherent susceptibility in some children
who are predisposed to prolonged febrile seizures and epilepsy
simultaneously.
FEBRILE STATUS EPILEPTICUS — A prolonged febrile seizure (febrile status
epilepticus [FSE]) is a concern for both physicians and parents. A
multicenter prospective cohort study described the characteristics of
prolonged (>30 minutes) febrile seizures in 119 children, aged one month
through five years [79]. The following findings were noted:
•The median duration was 68 minutes
•The seizures were convulsive in all but one child
•The seizures were continuous in 52 percent and intermittent in 48
percent
•Two-thirds of seizures were partial
•This was the first febrile seizure in 76 percent of children
Chart reviews suggested that status epilepticus was often not recognized by
the emergency department staff, perhaps contributing to the long duration of
the seizures.
The clinical setting in which FSE is not clearly different than shorter
febrile seizures. In the multicenter cohort described above, the median peak
temperature was 103ºF (39.4ºC), most patients had a defined viral
or bacterial illness, and there was a higher than expected family history
of epilepsy [79].
In another series, patients with FSE were more likely to have a family
history of epilepsy than children who presented with briefer febrile
seizures; they also had a higher prevalence of baseline neurologic disease
and a personal history of epilepsy [80].
Some reports suggest that children with status epileptics and fever are more
likely to have bacterial meningitis than those with a short seizure. A
group of 24 children with status epilepticus in the setting of fever were
identified over a six month period through a British surveillance study of
children with SE [49]. Lumbar puncture was performed in nine patients, four
of whom had findings characteristic of bacterial meningitis. The incidence
of bacterial meningitis in this report is quite high and may be due, in part
, to the small sample size. In another series 11 of 95 children with status
epilepticus and fever (11.6 percent) had acute bacterial meningitis [50].
Thus, meningitis must be considered as a diagnostic possibility in children
with presumed FSE.
The distribution of seizure durations suggests that the longer a febrile
seizure continues the less likely is it to stop without treatment [79].
Patients with FSE should be treated with anticonvulsant medication as are
other patients with status epilepticus and efforts should be made to lower
fever using antipyretics and a cooling blanket. (See "Management of status
epilepticus in children" and "Pathophysiology and treatment of fever in
infants and children".)
The long term consequences of FSE have not been defined. Clinical follow-up
of the above mentioned cohort is in progress [79]. Another study followed 44
children with FSE, most of whom were identified prospectively [81]. After a
mean follow-up of 28 months, the risk of recurrent seizures (febrile and
afebrile) was increased only in those who had prior neurologic abnormalities
. This finding is similar to that seen in patients with febrile seizures
without status. Other case series have found that EEG studies, performed
within one week after FSE, show focal slowing in one-third [82]. While some
have found that this is associated with a higher risk of epilepsy, this
association has not been consistently reported and requires further study. (
See 'Subsequent epilepsy' above.)
ROLE OF PREVENTIVE THERAPY
Antiepileptic therapy — Children with febrile seizures are at increased
risk for recurrent febrile as well as the development of afebrile seizures,
suggesting a role for prophylactic treatment with chronic antiepileptic
medications (AEDs). However, there is increasing consensus that risks of AED
treatment outweigh potential benefits for most patients [83,84].
The effectiveness of AEDs was evaluated in a meta-analysis of studies for
the prevention of recurrent febrile seizures; treatment with either
phenobarbital or valproate were associated with reduced odds of recurrent
febrile seizures (OR 0.54 and 0.09, respectively) [85]. There was no benefit
for the use of intermittent diazepam. The latter finding is in contrast to
a controlled trial in which oral diazepam (0.33 mg/kg every eight hours
during the first few days of a febrile illness) was as effective as was the
continuous administration of phenobarbital in reducing episodes of recurrent
febrile seizures [86]. Another observational study found that diazepam PR
was associated with a reduced incidence of recurrent febrile seizures (2
versus 15 percent) compared with patients not so-treated [87].
The potential benefit of AED prophylaxis in reducing the usually benign
recurrence of febrile seizures within the same illness must be balanced with
the potential adverse effects of treatment, which include ataxia, lethargy,
irritability, and others occurring in as many as 40 percent of patients [86
,88,89].
There is no available evidence that the use of chronic AEDs or the
prevention of recurrent febrile seizures is associated with a reduced risk
of epilepsy [84].
The Committee on Quality Improvement, Subcommittee on Febrile Seizures of
the AAP concluded that "Based on the risk and benefits of effective
therapies, neither continuous nor intermittent anticonvulsive therapy is
recommended for children with one or more simple febrile seizures [84]. The
American Academy of Pediatrics recognizes that recurrent episodes of febrile
seizures can create anxiety in some parents and their children and as such
appropriate educational and emotional support should be provided".
There is no data upon which to base a recommendation regarding AED
prophylaxis in children with complex febrile seizures [89]. Treatment in
such cases is individualized based upon underlying risk factors.
Antipyresis — For children who have had febrile seizures, treatment with
antipyretics at the time of a febrile illness may be helpful in overall
management but does not appear to affect the recurrence rate of febrile
seizures [84,89-91]:
•A study in which low dose acetaminophen or a placebo was administered
for fever failed to demonstrate a decrease in febrile seizures [91].
However, the fact that the patients also received diazepam or a placebo and
the fact that all patients apparently received acetaminophen if temperature
reached 40 C (104 F) makes the data difficult to interpret.
•A systematic review of 12 trials (1,509 patients) of acetaminophen
versus placebo or sponging for treatment of fever concluded that there was
insufficient evidence to show whether or not acetaminophen influenced the
risk of febrile convulsions [90].
•A subsequently published clinical trial randomly assigned 231
children with febrile seizures to receive either rectal diclofenac or
placebo at onset of a subsequent febrile episode; patients were
simultaneously randomized into one of three subsequent treatment groups (
oral placebo versus acetaminophen versus ibuprofen) to begin eight hours
after initial treatment [92]. In this study, antipyretics were not effective
at lowering body temperature or preventing the recurrence of febrile
seizures (overall incidence 23 percent).
(See "Pathophysiology and treatment of fever in infants and children".)

【在 l****y 的大作中提到】
: 快5周岁。体重60斤。
: 侄女发热后抽搐共发生了4次。昨天是因为扁桃体发炎,发热到39度。
: 之前有过3次,前一次是15个月前,当然查了CT和24小时脑电图,未见异常。
: 国内问过一些医生,认为是癫痫。但是一些医生说需要吃药治疗。但是药是激素药,会
: 影响卵巢发育。另外一些医生觉的保守治疗就好。
: 我的问题是:
: 1)倒底是不是癫痫呢?
: 2)如果是,根据这个情况,美国这边是保守治疗还是吃药
: 3)如果吃药的话,有没有什么好的药可以不影响发育的
: 谢谢!

h******e
发帖数: 1385
4
如果在国内,建议去找这个大夫。
http://www.haodf.com/doctor/DE4r08xQdKSLBVk4FYSdpUn-8HdJ.htm
他对偶发惊厥和癫痫病的区分比较有把握
i****s
发帖数: 729
5
5岁的小孩保守治疗更优吧,成年后自愈的case多了。

【在 l****y 的大作中提到】
: 快5周岁。体重60斤。
: 侄女发热后抽搐共发生了4次。昨天是因为扁桃体发炎,发热到39度。
: 之前有过3次,前一次是15个月前,当然查了CT和24小时脑电图,未见异常。
: 国内问过一些医生,认为是癫痫。但是一些医生说需要吃药治疗。但是药是激素药,会
: 影响卵巢发育。另外一些医生觉的保守治疗就好。
: 我的问题是:
: 1)倒底是不是癫痫呢?
: 2)如果是,根据这个情况,美国这边是保守治疗还是吃药
: 3)如果吃药的话,有没有什么好的药可以不影响发育的
: 谢谢!

S*****s
发帖数: 287
6
今天刚和老板讨论过,Febril seizure 不算癫痫。癫痫是在无刺激状态下自发产生
seizure。小儿大脑发育不完全,容易产生 seizure。很多在成年后就消失了,不需要
太激进的治疗。我老板是神经科的医生,他遇到这样的病人肯定是保守治疗。

【在 l****y 的大作中提到】
: 快5周岁。体重60斤。
: 侄女发热后抽搐共发生了4次。昨天是因为扁桃体发炎,发热到39度。
: 之前有过3次,前一次是15个月前,当然查了CT和24小时脑电图,未见异常。
: 国内问过一些医生,认为是癫痫。但是一些医生说需要吃药治疗。但是药是激素药,会
: 影响卵巢发育。另外一些医生觉的保守治疗就好。
: 我的问题是:
: 1)倒底是不是癫痫呢?
: 2)如果是,根据这个情况,美国这边是保守治疗还是吃药
: 3)如果吃药的话,有没有什么好的药可以不影响发育的
: 谢谢!

l****y
发帖数: 130
7
谢谢大家的回复。
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