Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

Her body. My name is uh Katrina Harris and I'm a pediatrician. I'm a develop neuro developmental pediatrician who works in North London. Um As part of my responsibility is looking after Children with epilepsies um in the UK um epilepsy clinics at the secondary here uh provision. So in uh the sort of hospitals where pediatrics are part of the sort of service delivery, if you have an epilepsy clinic, uh the National Institute for Clinical Guidelines uh states that Children should be looked after by pediatrician with the special interest in the condition. And that means that you have to have some training, some formal training and then you have to participate in specific sort of educational courses through your career and to make sort of out lapses your interest and to uh you have it as a part of the developmental sort of plan. Sorry guys, really, uh let's just go back to out with. And so um you, you can be a pediatrician just with a special interest in epilepsy really as a condition. Uh We have specific guidelines which sort of say when we should refer to child to a pediatric neurologist. And really as we're such a little bit waiting for people to join. Um I can just very briefly talk about. So all Children under the age of two, strictly speaking should be referred for a review by a pediatric neurologist. But it a little bit depends on the ready because sometimes you have a child and you know that the prognosis is good really. And then other times you know that the child perhaps already have a much more complex condition. And uh therefore sort of referral to pediatric neurology should be quicker because what can they offer what we can offer? They can definitely offer a much better quality scanning, which is important in a sort of early assessment of particularly focal seizures. If you think that a child actually should be referred for um for epilepsy surgery, for example. So in focal epilepsy, sometimes you can have a lesion, a developmental lesion content, a lesion. And as Children, actually, if they're referred early for the epilepsy surgery, they tend to have a very good outcome uh because the development is not affected by uh the search of epilepsy and they have a pretty high rate of achieving seizure freeze um status. Um So such of under two Children really with the sort of uh way you suspect that there's maybe an underlying lesion should be referred to neurology, but also in general, all Children um in whom epilepsy is not fully controlled on two medications again, should be referred for a sort of further assessment with colleagues from pediatric neurology. And uh for example, some of those Children will be referred for the genetic testing, which we sort of s pediatricians don't have really access to. There will be uh perhaps a more detailed imaging um undertaken and consideration of the epilepsy surgery and generally sort of looking with that and they can look at the underlying causes. So um let's just move on. So, epilepsy really as a disorder is a disorder of the brain and um the 10 that tend to be a recurrence of the seizures. Now, the fact that the seizures have to re occur and happened more than once is a very fundamental key issue to the diagnosis of epilepsy. So one of seizure does not mean that child has epilepsy. In fact, a one of seizure doesn't even justify. Um is it Sitra from um I just further investigations, we never really um under it is a river Children for E G after one of seizure. And pretty much so, hardly ever, you would treat uh with the medication, one of seizures, perhaps um the exception from that room would be a status epilepticus, particularly if a child didn't have it on the background of uh infection and uh fever. Um and in some very, very rare cases, when you have very clear indicators that actually there will be more seizures coming three and sort of as time goes by a small and more um experienced, you're in dealing with the condition. Um You obviously get more and more awareness which Children you should expect to have more seizures. But general rule, we do not treat and we do not investigate by seizure. We call it a past seizure. Now, um is there any difference between a seizure and a statement and epileptic seizure? And then if so how can we define an epileptic seizure? And if you can write on the screen, you already? Very welcome to do that. So, a difference between a seizure and then epileptic seizure, anybody can write or even say we're only 11 people on the screen. Just go for it. Well, don't be shy. You're 50 50 chance of already being correct. Yes or no. Uh So a seizure is a single, uh it happens only like a single occurrence. Uh with epilepsy, you can have more than one seizures at the name. Yes. Yes. Yes. Yes. Yes, yes. And also there's more to it really because obviously we're sort of differentiating seizure in versus epileptic seizure in an epileptic seizure. There is no provocation in the beginning. Um Yes. But such of your, it's not entirely and not entirely because uh sleep deprivation is a really very well known provocation. Okay. Let's well, because I asked the question that obviously there has to be a difference really because otherwise I wouldn't ask the question but your all of the such a bright truck getting there. So when we talk about a seizure, a seizure really as such, it is a southern clinical event, but it doesn't necessarily come from the brain. So a faint, a cardiac collapse, uh sort of behavior or night terror breath holding attack in a little care. In a little kid, they are all seizures. So they're just sudden sort of events really which happened. Um We also have something what we call non epileptic seizures. And these can look like really seizures really, sometimes it is really, really difficult to distinguish the two because and they look just so so similar really, you have this rhythmical jerking and so topa you would really think indeed this is it and yet it isn't. And the main difference is that if you have any of these other events that you do not call an epileptic seizure, they do not originate from the nerve cells from the neurons. And um when you have these nonepileptic seizures, sometimes some of them are pretty obvious that they are not epileptic, but sometimes the only way to evidence that they actually are not epileptic is to put the electrons and to record electrical activity in the brain. I tell you in a little anecdote. Um many, many years ago, when I worked in the children's hospital at the neurology ward, we had a young um teenager who came several times to the neurology department because of the prolonged seizures. And for whatever reason, the neurophysiologist at that time was always arguing that this boy has nonepileptic seizures. He knew that boy really, really well and he had several recordings of E G S and so really various treatments and all together. And yet really, people couldn't make up their mind because he just had such uh they looked so much like rail seizures on one occasion. Um This boy was admitted in the middle of the night. The neuro philosophy ologist came in the middle of the knowledge to put the electrodes to evidence that actually what he suspected was a non epileptic seizure. Uh Was that what it was? And it didn't originate from the such of from the nurses. The support to sort of these conditions is through child psychiatry and really through other uh such of method than just uh the medication. Nevertheless, as I say, sometimes they can be really, really looking like. So they're not pretended they're not really conscious events really on behalf of the of the Children. And also one has to remember that uh many of those non epileptic events, nonepileptic seizures, they exist side by side with the really seizures. So then obviously, you have a big problem, okay, but let's just go back to epileptic seizures because that is supposed to be our sort of main aspect of the talk today. So an epileptic seizure is a manifestation of excessive and sort of hyper synchronous, usually self limited activity of the neurons of the brain. Um They set of the nerve cells, they produce, produce really electrical discharges. And these discharges, we all have electrical activity going through the brain. And I will just sort of showing a little picture of these sort of E G in a child in a minute. But then suddenly sometimes we have these sort of uh big voltage discharges and these big voltage of discharges are causing an epileptic seizure. And we, if we are lucky to capture that on E G, we can see the such of specific buttons. Now, when we have the electrical discharge in the brain, depending on where it happens in the brain, we can have different responses. So we know that there is a part of the brain, there, there are a couple of central sulcus is which are responsible for the motor activity, they control the motor movement. So if you're unlucky, and if you get an electrical discharge in that part of the brain, that obviously the response will be what we all know a seizure, jerking seizure. If you, for example, get the sort of electrical activity, let's say in the temporal lobe, which such of often is responsible for behavior and sensation, then you can have these such of odd uh such of uh when you sort of experience, you feel like you've seen things before or your behavior is totally erratic and sort of unusual. Or if you have it in the occipital part of the lobe, you can see things. Now, um when the seizures happen, um it a little bit depends on what you experience. Uh It depends on it. Firstly, in which part of the brain it happens, which we've already spoke about. But also whether the electrical activity happens all over the brain and we call it a generalized seizure. And really the main difference in generalized seizure is that it happens in both sides of the hemisphere and, and the person has no preserved consciousness. The person is unconscious during the seizure or opposite to the general seizure. You can have a focal seizure. So you have a seizure which happens in one part of the brain and you have two possibilities in that situation. So you have this electrical activity happening in one side of the brain, it stays in this one side of the brain and you will have the symptoms which are related to that one side of the brain, but only on half of the body uh only in one part of the body. However, this other part of the brain is actually functioning okay. And because of that, you have preserved consciousness. So that's the reason why sometimes you have her Children who will come and say that let's say right hand was jerking, but they were able to speak and they knew what was going on and they had full consciousness of the activity going on in there, right handwritten. However many seizures they start on one side of the brain and they then secondary generalized. So the electrical activity goes through carpet skull is um to the other side of the brain. And resulting from that you have something that started on one side of the body and then ends up with the sort of a generalized type seizure. And I hope that by sort of going into the, all these details, I just start to give you sense of importance of a getting from the parents when you meet them first time. Very good description of what actually happened and really go bit by bit because old pants are home, the child cause you know, eyes rolled back and my child was jerking all over. This is really what they tell you and they're petrified and they're scared. Really most people appreciate that an epileptic seizure is quite dangerous. So they're really, really scared. But actually, if you bit by bed methodically ask them what happened where it happened, how it happened. They can give you um very good description or they can show you that even better. They immediately will show you with their arm or with the whatever parts of the body. What's that? What's happening? And importance of that is for the treatment because as we speak about the treatment of procedures, you see that sort of there are different medications that we use in different situations. So um I sort of use that picture on the left side. Despite that, it talks about the partial seizures. We don't, we do. No, we don't do that any longer already. We don't talk about these sort of precious seizures again. But I actually quite like the fact that sort of uh you have uh you have a brain, you have these such a focus there and then you have such a approximate a drawing of E G recording which such a so nicely shows what you sort of can see if you're lucky. So the seeds can take many forms. And such of we started to talk about that they can present with jerking all over or in one part of the body or you know, people can such of have arrested behavior or stare into space, etcetera depending on whether where it happens. And um when you sort of are lucky that you have E G recording during the activity, you can see um the change in the electrical activity sometimes very, very clearly either across all the 20 electrodes apply to the head or just one side of the body. We have different types of seizures depending on what happens. Really. Let's start with these sort of talking about the generalized seizures. So, seizures which comes from such of activation of both sides of the brain. Really. The most common one is tonic clonic seizure and that is the seizure, which is uh old, sometimes still old literature of people remember is grand mal seizure, great attack. Really. That is 1/19 century description and what does they mean? Um The they mean a typical seizure which everybody knows it's a seizure and which consists of the tonic and clonic face Tomic face is a stellar motor seizure which sort of causes the stiffness of the body change of the muscle tone. And then it goes into a jerking phase of the muscles and the claw tonic seizure, we can have them together, tonic clonic, uh tonic clonic seizures. But we also can have separately. There are some Children who only have tonic seizures or they have only joking to clonic seizures. Uh We have Children who, who lose the control of the body tongue and they drop drop attacks and they are called a tonic seizures. So they just lose the control of the time. We can have my clonic seizures. My clonic seizures are little jerks really. They just happen like that really. And and they sort of against the generalized seizures. But the very, very brief ones, we can have absences. And now you have to be careful about the absences because we have uh absences typical for childhood absence epilepsy, which has a very characteristic E E G A recording. And I will show you the picture but very common epilepsy in young Children. It's a generalized the epilepsy, but you can have a presentation of an absence um in focal seizures. If they originate really from uh the particular temporal aspect of the brain, really. Sometimes Children present with the upsets and their focal seizures. And the, again, the sort of importance of that. So that is sometimes something which sometimes you need E G four to differentiate is because you can treat them differently, different medication will apply. And so one medication which is very good for the focal seizures can actually make generalized absences much worse and we can have sparse. Um and the, the, the, the epileptic spasm has generalized seizures. While in the focal seizures, we will have you in that sort of uh sort of uh activation of one part of the brain depending on from which part it comes, you can either have the motor sort of activity. As I said, for example, you can have the really just jerking in in the hand. Sometimes it spreads to one part of the body, for example, but you can have sensory one so that people smell or hear things if they come from these sort of uh the temporal aspects of visual ones. Now something to remember is I already said, the thing I start from the bottom that one seizure doesn't make the diagnosis of epilepsy. Because when we look really at the epidemiology, you will see that actually many people will have only one seizure and it doesn't happen and you have 50 50 chance ready of having another one. But we'll also have to remember and I hope that you already got to the idea. Yeah, but actually epilepsy is not a single condition. It's a group of disorders and some can classify for epilepsy syndrome statement. But what it really means, it means simply that they have very specific changes which you can see on E G and E G is very good for such of differentiating different types of epilepsy. And um really um depending on how they present, they will um have such a very unique sort of uh complex of signs and symptoms. But the importance of these sort of understanding that there are different um syndromes and that it's a sort of medical conditions. It's the fact that there will be different etiology. And actually many times that the cure comes with dealing with their theology because even when you treat the seizures, you prevent really the event, you prevent the event yet, but you're not really curing it really, you're just suppressing thresholds for the discharge and really, it doesn't happen in a clinical manifestation. But for example, if you understand the geology, let's say tuberous sclerosis where you have the seizures because you have the uh hematoma. So you have these sort of lumps in the brain. If you remove these, you have a good such a possibility of the curing the etiology of the seizure causes of epilepsy. I put this slide only because I think it's just so much of it really, so many things and we're not going to talk about all of them, but few of them. So I sort of would like to point out to the second box on the left hand side from the top ready idiopathic. We, we have no clue why the child has it. In the recent years, we have had a massive expansion of the genetic discoveries and understanding that many of the genetic changes um can cause epilepsy and that they can cause uh yes, seizures. And actually, we know that more and more is sort of related to sort of genetics really. But another one which I really would like you guys to sort of uh remember is that seizures can be provoked and sleep deprivation is a really enormously important trigger to a seizure. Um not even to epilepsy, but Children who don't sleep, they tend to have problems with controlling seizures if they have epilepsy. And then a long enough sleep deprivation can give this one of seizure in your lifetime, regardless drugs. Here, there's a whole sort of uh selection of the sort of uh complicated medication, etcetera. But cocaine is a really very common, very common, maybe not common. That's the wrong word. It's a very important drug, recreational drug that we have to remember as association with seizures. And in Children, particularly important because many Children will be exposed to passive smoke of crack cocaine that is misused by their parents. And the passive uh exposure in Children can cause a very rapid rays of the blood levels of the metabolites ready because Children have very limited capacity to metabolize already crack cocaine metabolites. So, just being possibly exposed to the smoke can be so bad that they can actually have a seizure really. So, very important one to remember now, developmental um uh aspects really. So uh neuronal migration, focal cortical displays is one of the most common sort of uh brain abnormalities. We're seeing Children and drug withdrawal. Yes. Absolutely. Metabolic abnormalities. Yes, particularly that's why we do bloods in Children. Um hypoglycemia in metabolic conditions or in Children when they have poorly controlled diabetes, etcetera. But not only that really, hypocalcaemia, a very common cause of the uh of a sort of one of seizures, low vitamin D really in their kids. Then obviously infections really another very important one. Now, uh tuberous sclerosis. Yes, just condition developmental conditions, brain uh brain tumours, etcetera really. So head injury, brain trauma, like density, however, they can cause really seizures, maybe not completely epilepsy. But what sort of, I think it's important about that is just to know that actually a one of can be caused by many factors. A little bit of these facts really. And it's not really something to sort of uh you know, learn by heart. It just really more to know why I'm going on about that. One. Uh seizure doesn't, uh of course, uh it's not called epilepsy because it's actually very common to have one seizure. One in five people. Uh teenagers who drink too much don't eat or don't sleep or take drugs really. Um in sort of in the UK, which has population of 60 million people, approximately um 600,000 people have epilepsy. So it's one in 100. So it's quite a common condition really. Now, we have four, two different types of seizures. Really. Massive. Number 12% of those ethnic clonic seizures. So the most common, 13% are focal seizures, absence seizures, my chronic etcetera. So this is just a little bit of the general numbers really. Um Now uh one in five people have the focus is here with secondary generalization. Uh Now, interesting 11 in 500 Children will have uh epilepsy under the age of four ready and one inch of 100 such of under 18. Everything that's such a record number ready for planning of the services obviously. But uh the classification of seizures is a sell job, very confusing one because sort of there are so many depending on the word they start or what they cause and sort of all of them are good. There is also because they have sort of understanding really the condition. Um There's also a lot of such of old fashioned know meant later is still around really as I was saying, sort of grand mal petite smile, they're old 19th centuries, sort of uh sort of descriptions which people still actually use. But for us, in the medical practice, we tend to sort of stick to the classification provided by the International League against the epilepsy. And in 2017, they sort of set up these four criterias for the classification. So um they try to get us to say, where does the seizure start in the brain onset? Now, does the person has a preserved awareness or not a really? So, is it with consciousness or without consciousness? So, is it focal or generalized, is it focal with the such a secondary generalization? Now, um they want us to specify in the diagnosis whether or not seizure involves other symptoms. So, is the seizure associated with the movement? So, is it a motor seizure or not? And does this say if the seizure doesn't involve movement, do we have uh an event of arrested behavior? So an absence and do we have a sensory component to it or sort of affected emotions? And then again, depending on whether they start. So the seizures are described as focal onset, generals onset or unknown answer, but sometimes, maybe we just simply don't know really just from the history really. It isn't really that clear as then obviously, there is such a really, we go further and sometimes we know that the epilepsy symptomatic but in far far majority, as I said at the beginning, two thirds of the cases, we, I do not know um about any underlying brain and normality. And uh we know that they can be such a genetic uh the seizures can be genetic in their origin. But those types of epilepsy, we call idiopathic. So we don't know where they originally. However, if we have an idea, then we talk, call them symptomatic such of epilepsy. And we know that it is the result of the, for example, congenital malformation and they, by far the most common sort of congenital malformation Children we expect is a focal kat ical displays. Um what happens is that in the embryonic age, really, when um the we have the migration of the such of the neurons to the surface, you know, sort of a sort of uh all inside the brain. And then they sort of through the embryonic progression, they migrate to the surface and they sort of build up the gray matter, really gray matter in the brain is sort of the cells of the newer really. Uh sometimes there's an abnormality um either in this process how they migrate and they're called migration disorders. But they sometimes are actually that these cells are either formed in an incorrect way or that sort of something else such of happens nevertheless, have the epilepsy have the seizures to present. It just gives us an idea that actually we are dealing with something um congenital. And on the MRI scan, we will get a typical picture which is described this focal cortical dysplasia. So in the cortex, we have this sort of space which is sort of abnormal. But Children sometimes also may have a head injury and post that really they, they will have a scar tissue and for example, seizures lasting seizures. Uh Children have stroke, just the normal common stroke, which most people associated with the elderly population. It does happen in Children. They can also have some other underlying brain malformations. Uh for example, neurocutaneous disorders. So, tuberous sclerosis are nura fiber disease or stage Weaver syndrome where you have a Hammond Juma which tends to cause seizures. So, symptomatic epilepsy, epilepsy which comes from another symptom which hopefully will detect by doing an MRI scan and then post infectious causes of course as well. Manji itis or encapsulitis, etcetera. Now, uh taking history in epilepsy is really, really important because there is no good test which can sort of um confirm whether the child has efficacy or not. And really the scale is in uh such uh taking detailed history. Um So you can sort of imagine that the misdiagnosis is common. It's very common because sometimes it's not easy to depreciate between these sort of events really. And uh the studies which indicate that in a neurology clinic and the 30% of misdiagnosis really. And um you have a description, it sounds like the sound, uh the child has a sort of Southern events, etcetera. So what can it be if it isn't a seizure? Well, we can have a cardiac event and we can have a sink up as a paint, just normal paint but we also can have a basil vagal event which results from a painful stimuli. When you are task specific history and detailed history, you will hear that the child was hurt or hit, argument, had an event and really they experienced Spain and after that, they sort of drop on the ground and started jerking. Um Sometimes you will also have a history that they may be aware very pale or just, you know, sweaty or whatever really. But that is not an unusual history. And obviously it is not an epileptic event really, which has happened. Well, you can have behavioral incidents and they can be daydreaming, they can be anxiety attacks, etcetera, etcetera. And you can have sleep problems. For example, night terrors really, there can be sometimes quite tricky to differentiate from, from the lobe epilepsy which is appealing in sleep. So being very such of uh you know, just going into the detail is really, really important. Uh Now what's the problem really with the clinical diagnosis? Well, you can over diagnosed. And as I said, these such of this is unfortunately really, really common really because um it isn't always clear really and uh what the problem you will over treat, um the treatment will be unnecessary. Um and the medical treatment has lots of side effects, it's very good, but a lot of side effects really. So the benefit has to be really clear. But then also if you overdiagnosed there stigma and there's still, unfortunately quite a lot of stigma, there is a lot of anxiety about having another such an attack. And then there comes restrictions, for example, uh the teenagers become older really, you have to be seizure free for two years, really not to be able to drive. Now, what are you worried really about uh under diagnosing, really missed diagnoses? Really? And we all sort of worry about the aspect that the child has. Uh for example, absence seizures, they underperformance school, they have undertreated seizures. And actually, if they were treated there sort of attention at school and performances, school would be much better really. But we also worry that they may have uh tonic clonic seizures which becomes prolonged and then that may cause even death rated stow. Uh why do we struggle with the diagnostic such uh aspect of the epilepsy? Simply because there is no good test. Um We will talk about the issues really with the E G. But one has to remember that E G does not diagnose epilepsy. You really have to get it from the history. What is very helpful when you take really very accurate and detailed history. It is really helpful to ask the parents to take a video recording of the event. And that tends to create quite a lot of distress because the parents come after the first seizure, they're very sort of stress, then someone and then you ask them to record it. So then they say, oh my God, I haven't thought about it and blah, blah, blah, all together. But uh if you, if you explain to the parents why you need the video, the video is really very, very effective way of showing you what actually happened and what you tend to get in an epileptic seizure rather than any other event. There is this arithmetical uh regularity really and sort of like the history that every time exactly the same stuff happens really. And that's what the video is very, very good when you have the rhythmical joking of one side of the face, you know, that actually there's nothing else than sort of epileptic seizure. So why, what's the E G good for into what we can do? So we know that the brain cells we spoke about, they generate such of uh electrical current, electrical activities and um and such of the E G is able to record this background activity which is sort of going on that's sort of in the brain. And then just so that their little blobs really, let me just see because I put actually and all love. Okay. So what I want you to look at is the top picture in the left hand corner because that is a normal electrical activity in a child. So you have these sort of different rates and depending on which part of the brain really, and it's very regular and such of it's a low voltage activity. Yep. And then, and we will have the paroxysmal um outburst of activity. So we will have the sudden sort of spikes of the activity, which is completely different. And then that is why I sort of put this sort of uh picture from the internet because you can have these such uh look really where on the background of the normal activity, you have the spike wave activity going on and that's what the E G records. But E G only records what happens in the brain when the buttons are attached to your brain. So if there is a normal activity at the time when the recording goes on, there might be a representation of that on the picture you get. But if the activity is completely normal, then obviously the E G will come back with no result really which you want. And we know that at least half of the people who have established epilepsy, they actually have completely normal E G between the epileptic um event. And that is actually a good thing because you want to have a normal activity between these seizures. But it doesn't help really to diagnose epilepsy. Um Yeah. So such of that's such of that the people have completed normal such of uh activity. On the other hand, we can have um abnormal eeg e in completely normal people who don't have epilepsy. Um Just giving an example. Um working really in neuro developmental world, really ideal with Children with autism and many Children with autism will have abnormal um E E G S, but they don't have seizures. And um well, the neuro developmental abnormalities obviously come from the brain. So there will be this sort of abnormal activity really there. But that doesn't necessarily mean that sort of uh you know, the that is epilepsy. And because of that, you do not treat E D, even if it was abnormal. If you do not have a, a clinical picture of the seizures that you want to treat, then you don't sort of treated, you don't get the medical treatment. E G can help and it's very helpful in specific situations. But you have to be aware that when you order it, it may not, it may confuse the situation even more. Now, what the E G is very good is to decide what type of epilepsy. A childhoods. I started to talk a little bit about syndromic epilepsies. So there are specific epilepsies which have specific characteristics and I think that the such a thing knowing about them is important because some treatments are particularly good for some specific epilepsies. And and because of that, knowing that you're dealing with that is really useful. For example, childhood absence, epilepsy is very specific appearance on the E G and as the sex um I'd is the drug of choice, you can have electrical stages of electric is during slow wave sleep PSEs and that needs to be treated with a very specific medication, you're gonna have uh language uh regression and you can think it's autism. But in true fact, if you complete E G, you might find out that the child has Landau Kleffner syndrome, very rare epilepsy, but actually, it's fully treatable with the steroids really. So, um I think that's such a classifying syndromic epilepsy can be important for the outcome and for use of most appropriate medication. As I say, some of the anticonvulsants, they can make uh some types of seizures worth. For example, carBAMazepine is contraindicated in childhood absence epilepsy because it makes it worse. So yes, just with the general sort of uh example, I put these pictures um at the slide on. So the normal background activity in Children quite a regular such a low vaulted. Then on the second picture, on the right hand side, we have absolutely typical appearance of three house per second discharges which are typical for chart hold ups and seizures. And then we have this very disorganized, very upper neck, normal, high amplitude intra active interictal activity. So, activity between the seizures, which actually is typical for hips arrhythmia and West syndrome in Children where you treat them with the high dose of steroids. Now, um when do we do the MRI scans at the next step of our a sort of investigations in a child who comes to passenger clinic, we do not do them in generalized epilepsies in general already. However, when we have the history of the focal seizure, that is the general recommendation of doing an MRI scan because a focal seizure can represent an abnormality which is focal and for example, it may be eligible for surgery. This is just an example of the focal lesion causing seizure, which is in the hippocampus, hippocampus, sclerosis with the arrow and that removing the section can they're sort of procure the epilepsy. Now, I was mentioning the uh these sort of focal uh cortical dysplasia. And um so such of that's another really one of the most common reasons for focal seizures and that's where the MRI scans are very useful. Now, um the MRI scan has to be really quite detailed and it has to be esper epilepsy protocol. And in the general pediatric hospitals, we are not necessarily always able to such a complete them. So that can be one of the reasons for referral to the colleagues in uh neurology department. But you get the inclination that you're dealing with the vocal dysplasia already when you start treating really the child. And again, sometimes they are really good for uh surgical treatment and that's really changes really outcome. There's another aspect as well, which one has to remember that in the hospitals, the MRI scans are reported by adult radiologist, they do not have all uh at times experience of reporting children's um MRI S. So sometimes it's worth to send the scan to the pediatric radiology because they can sort of get the idea about the changes visible. So the big question which comes to light is treat or not to treat. And because if you start the treatment, then obviously you need to think about the benefits versus unwanted effect really. So the general rule is to use one drug to the it's full dose and see whether it controls the seizure, 80% of Children become seizure free, but they also grow out of there a plexi and it is sometimes tricky to know whether it's your drive, which is controlling it or whether it's the actually that the child grows out of the treatment. The general rule is to treat the child for two years and once they have been seizure free for two years, then you win the medication. Um obviously, there's a lot of aspects of uh the such of epilepsy which impact on life and that is particularly difficult for teenagers because it's about pleasure. It's about the safety really. It's about such of always having an adult in swimming, telling everybody around. That's just sort of the child has this uh sort of uh seizure. It's about such a supervision and height, it's about supervision on the roads. Um It's about really not a bad thing but shoring, etcetera, etcetera, epilepsy can be associated with other conditions. So, thinking about it like uh tuberous sclerosis is really our neuro by um neurofibromatosis, etcetera. Um Children with autism have about 40% of epilepsy. Now, teenagers, this is particularly difficult time really to think about the epilepsy because alcohol is a known trigger factors. You need to think about the contraception and the sort of impact of epilepsy drugs on contraception and really a contraception not being really as effective really if you're on an anticonvulsive medication. And then a big, big worry for us all southern unexpected death in epilepsy where when you speak to the parents and, and really making sure that you make them aware. But the biggest problem is really that there is nothing what can really prevent it apart from improving control of seizures so very quickly about this souder and it's a sued up. It's a sudden unexpected death in epilepsy. It's a very, very serious matter because it's much more common than in uh in uh people without epilepsy. And there are people who die suddenly unexpectedly for no other reason with or without evidence of having seizure. And it happens really when than witnesses, there's no explanation for death and um often in sleep and what is it is not fully understood, why should it occurs. But we really sort of believe that the electrical activity in the brain spreads to the areas that control the heartbeat and, and that way sort of the cause of the arrhythmia and then the child dies, risk factors, young adults, particularly male, poor control tonic clonic seizures, seizures in sleep, uh polypharmaceutical, which obviously means that the seizures are not controlled abrupt changes in medication and learning disability. Now, website very good with English website for information for the parents about the epilepsy. If you have access, a really, really good one with lots of information, I'm just heading towards ending uh more websites with fantastic information about the epilepsy. Quick, think about the federal convulsions. They occur in Children between three months and five years. They're not epilepsy, simple febrile convulsions, 70% 30% are classified this complex. Simple ones are shorter than 10 minutes. If there longer than 10 minutes, they're complex. Um Simple ones are also when they do not re occur in 24 hours. But if you have more than um two seizures in 24 hours, you call them complex over there or the risk of re occurrences of to 30%. And which of the risk factors when they start in a young child under the age of 18, family is straight. And when they happen with the lower temperature than the 40 degrees or even 39 when the seizure happens faster than the temperature comes later, really, it's a high risk factor for re occurrence but complexities such it's not really risk factors. It is the number of the risk factors that tells you that it will happen again, really? 3% have the risk to develop epilepsy and then a number of risk factors. Really. So what advice you gave uh prevent temperature using antipyretics rigorously and to regularly when the child is unwell. But before they have temperature, uh common use medications, we have nice guidelines. I need to finish because the next lecture start. Really? You're very welcome to look at that usual medication for different types of seizures. And in England, we use uh battle Midazolam as a manager's medication. But otherwise diazePAM is used for seizures lasting longer than 20 minutes. Thank you. Thank you very much. 11 o'clock.