Cases fits transcript — SMP305 lecture transcript

Hello. Hi, it's, it's Christi here. I'm just trying to sort out this IT here. I've plugged my laptop into the HDMI cable, selected data, tried laptop, but nothing's appearing on the screen that I can see. Um. Um, if I go to date, there's, I mean, there's visual, video, there's data. Oh, I could try. Oh, so HDMI, is that the one we need to use, right, OK, that would make sense, wouldn't it? Yeah, OK, perfect. Thank you very much. OK, cheers, thanks, bye. Hi, welcome. I think everybody's. Mostly here then. OK, great. Um, we've got, uh, about just under an hour to talk about bits playing some funny turns in children. Uh, have you done any adult neurology at all? Yeah? So you've done the epilepsy bit in the, in the adult one. So, OK. So this is much more interesting, well. If you're interested in epilepsy, uh, paediatric epilepsy is much more interesting than adult epilepsy is, but, uh, what I will try not to do is to replicate too much of what you've heard before, but I guess we still need to go through it. So I'm gonna take you through a sort of an approach to looking at the child who's having a, a fit or a faint or a funny do of some sort, um, how to think about it. Show you some videos because probably that's the the the one thing you can't get out of books. Um, and talk a little bit about management and about complications, uh, and we hopefully will manage to achieve that in the time. So, as with everything in, in medicine, effective management depends on accurate diagnosis. If you don't diagnose accurately, you're not going to treat it. Uh, and if you're seeing a child who's having a paroxysmal event, there are broadly 4 questions to, to ask yourself. First of all, is this paroxysmal event likely to be epileptic, or is it something else? Secondly, because we're really concentrating on epilepsy here, if we think it is epileptic, first of all, what kind of seizure or seizures is the child having? Does that tell us what kind of epilepsy they have? Because actually epilepsy isn't a single entity, it's it's a collection of a number of different entities. And really importantly, why? What's the cause? Because as with everything else, epilepsy's not an end diagnosis, it, it's a symptom of something that's happening within the brain. Not in the same way that cough is a symptom of something. Always happening in the chest, but essentially it's a symptom. So if we start with the first question, the reason that I'm telling you about it is that people get it wrong. And people get it wrong quite a lot of the time. Um, in, in a study done in the 1960s in Birmingham, they looked at a paediatric clinic and looked at very carefully the children who had a diagnosis of epilepsy and found that if you actually really unpicked it, about 1 in 4 of those children turned out not to have epilepsy at all. Now that's the 60s, you could argue it's a long time ago, we were much less advanced. The reality is that every single study that's been done since then, perhaps up until more recently, replicated those results. And indeed there were some European studies that suggested that the misdiagnosis rate could be as high as 40% in some centres. So it's easy to get it wrong. And people get it wrong, I think, for one of 3 or more than one of 3 reasons. First of all, and probably the single most importantly, they don't take an accurate history. The second is they may rely unduly on EEG on the electrical recording from the brain. And then thirdly, and, and my get out of jail free card is, is it's sometimes really difficult. So, let's go through those, so let's start with this, this issue of history. And the history of a child who's having a paroxysmal event needs to be complete. Parents, and the great thing about dealing with children is that by and large you have an observer, you generally have a parent or a teacher, somebody who's seen the event happening. But parents in particular will want to focus on what happened at the time they were most scared. The bit when the child was either shaking or convulsing or went blue or stopped breathing. But what you need to know is what happened right the way from the time the child was completely well all the way until the child was completely well again. The whole sequence of events and sometimes it's helpful to talk to parents and say, well, let's think of this like a video running in slow motion. Let's take it step by step. How did it, what was the child like before it started? How did it start? How did it progress? What was the child like during that? Um, how did it come to an end? How did the child recover? Uh, and sometimes you need to go over that over and over again, because the first time the the parent comes or uh whoever comes actually. They may not know all of that information. They may not have thought to look. So sometimes you have to say, well, if it happens again, these are the things I want to know. Because it's safer not to make a diagnosis incorrectly. Than to defer a correct diagnosis. Finally, So those are the things you want to know, and I'll give you an example um of how that could be important, particularly the last bit which is the question the child bit. And that's no different from the adult. Ask the person who's experienced the event because they may have some really important insights that they can share with you. And I'll give you an example, a, a child that I saw quite a long time ago now, but, uh, he was about 7 at the time that he was referred to me, and he'd been having paroxysmal events since about the age of 4.5. And he'd been referred to me by one of the very good general paediatricians who'd been treating him for epilepsy for the last 2.5 years, and he was still having attacks from time to time. And the referral letter mentioned that when he first came, the, the doctor wondered about the possibility of something called reflex anoxic seizures, which is effectively a kind of convulsive syncope. OK, so it's a heart problem or a rhythm problem rather than a brain. But he concluded this boy has had a number of unprovoked attacks from sleep, and so I've concluded that these were epileptic. And so we went through the story, and the first event had actually happened when this boy was climbing a tree. And I could quite see where the problem was, Mum said. Doctor E's asked me this loads of times. I don't know whether he fell out the tree because he had the convulsion. Or he convulsed because he fell out the tree. I can't tell you. All I know is he fell out the tree and he was convulsed. So I said to the boy, well, can you remember the event? And he said, oh yeah, he said, like. He never asked me that, but yeah, I remember, he said I was crawling along a branch. And the branch broke. And I fell and I hit my elbow on the ground really, really hard, and then I felt hot and everything went black and that. And suddenly this this uncertainty was resolved, because this was a provoked attack with the child feeling hot and going, and things going black. Sounds very much like a syncope rather than an epileptic. But there is still a problem about the nighttime events, these attacks from sleep. And Mum said, well, actually, do you know what, I actually never saw these events. They happened when he was on a And the cub leader told me that that he'd seen children having epileptic seizures before and he was absolutely certain that that's what it was. So again, I just said to the boy, well, can you remember that? And he said, oh yeah, he said. He said that we were, we weren't really camping, he said. Shame faced at that point. So we were in bunks. We were in dormitories. And I was in the top bunk and I woke up and Pitch black And I couldn't see anything and I sat up. And I didn't realise how close the ceiling was, and I sat up and I hit my head on the ceiling really hard, and then I felt really hot, and I don't. And again this unprovoked attack from sleep was actually a provoked. From And actually it turned out the reason this boy wasn't responding to anti-epileptic drugs because he didn't have epilepsy at all. And the only thing that was missing from the history was asking the boy about it. So really key to think about all of those factors. The other thing people sometimes get wrong, and less so now, and I think probably one of the reasons that that diagnosis is better now than it was perhaps even 10 years ago, is that people used to rely not on the And the EEG is a useful tool. But an EEG between events. Can't tell you whether a person has or has not at. It can tell you about what kind of epilepsy sometimes. But actually the reality is that if we look at EEGs in people who do not have A substantial proportion of them have abnormalities. So up to 10% of the general population will have some sort of abnormality on their. And of those, up to 3% will have frankly, epileptic form. So relying on an EEG to tell you whether a person does or doesn't have epilepsy is fraught with danger. If 1 in 10 people have Um, abnormal EEGs, but only 1 in 100 have epilepsy. There's an awful lot of people with abnormal. That that. Put that against the fact that some people who do have epilepsy, if you just record an EEG with them awake, will have no abnormality. Actually, the chance of finding something is much smaller. So Let's move on from that, because actually what I want to focus on is, is the issue of epilepsy, and this is a a a definition of epilepsy, it was produced by the International League Against Epilepsy in 2016, and it's the current best. Diagnostic um criteria for for epileps. You don't need to remember it. You'll get the slides in due course, but in a sense you either have to have two unprovoked epileptic attacks more than 24 hours apart. And that gets rid of the the the sort of situation where a person may have epileptic seizures because they've got a low blood sugar or. Abnormal sodium Um, or you have to have one seizure, but there is something about you that makes it highly likely that you will have a second. So for example, in a child who has cerebral palsy. And who has a hemiplegic cerebral palsy, so they have an abnormality affecting their brain on the other side of the brain. They have a focal seizure affecting their hemiplegic side. You can say there is, they have a much higher risk of having a second In the general population. So after a single seizure, you could make a diagnosis. doesn't mean you're treated. Just means you could make the diagnosis. And then thirdly, and the one that used to cause people a lot of problems was, what about reflex epilepsies, because we've talked about unprovoked seizures, but there are types of epilepsy where by the nature of it, the event is. So Flickr, for example. Or there are reading epilepsies, there's even a thinking. Um, so there are, there are lots of different types of provoked. And if you have a recognised provoked epilepsy, and two seizures, um, that, that would constitute a diagnosis. So that's what epilepsy is. Also importantly, remember that what we're talking about is those seizures have to be epileptic seizures. So they have to be events, electroclinical events, so something where there is a change in the way the person behaves or acts or something occurs which is in association with increased firing of neurons either in an area of the cortex or across the both sides of the. So epileptic seizures are cortical events with increased neuronal firing. Um, faints, for example, where you may have a motor event. There is reduced neuronal firing because there's a reduction in provision. Oxygen and blood supply to the brain. So that's what an epileptic seizure is. Epilepsy can go away, just as it can come, uh, but it's to to say that somebody no longer has epilepsy, there's a, there's a pretty high bar. So you have to be seizure free for 10 years off anti-seizure medication. Or you've got a recognised childhood epilepsy and you're past the age that that epilepsy will. And there are a number of epilepsies that occur in childhood that are clearly age. And if you're past that age, you can say you no longer It's a common disorder. It's slightly more common in the third world than it is in the first world, and that probably reflects things like CNS infection, malnutrition, lots of acquired insults. In the first world, it probably has an incidence of around 1 in 1000 and a prevalence of between 1. So it's quite a common disorder, which means that in a secondary school of say 2000 people, you might expect around 10 to 15 people. So quite a lot of people People have tried, so let's move on from this first question about is this epilepsy or not? The second question is, well, what kind of seizures and what kind of epilepsy? And people have tried over the years to, to classify epilepsy. From very simplistic um approaches in the in the 19th century by um Gers um in Hospital, all the way to incredibly complicated uh classification schemas in the late 2010s. So It gives you a kind of a flavour that that this is complicated. The most recent one is really useful for people like me who deal with epilepsy day in and day out, but for most people it just becomes incredibly complicated and broadly we can think about epilepsy as either as epileptic seizures, as either having a focal onset, so they start and In the brain, or they could have a bilateral onset, which we call generalised, or we just don't know. And then if they're focal, um, you can have a retention of awareness or you can have impairment of awareness, and then broadly, these are the kind of events that can occur. And if you think about it, what they look like is going to depend on where in the brain they most predominantly manifest. Not always where they start, because seizures that start, for example, in the parietal lobe. May start in a relatively silent area of the brain, so they may only manifest when they get to your temporal lobe or your frontal lobe, or occasionally. So what what they look like depends on So if they happen in your Occipital cortex, you'll have elementary visual. If they occur in your temporal lobe, you may have changes in memory, things like deja vu. You may have abnormal smell, you may have experiential symptoms, you may see things the way that the the temporal lobes very involved in kind of processing what things look like. What they are, but what they look like, so you may get things that could look almost eagerness with microbes. If they're in the frontal lobe, if they involve the motor strip, they will have motor phenomena. If they involve um the more um anterior parts of the frontal lobe, there may be emotional components and so on. By contrast, seizures that occur on both sides of the brain. Just varies All the way from what we call absences in which you just stare, you're unresponsive to bilateral convulsive seizures where you stiffen. And jerk, that's plot. And I'm gonna show you some examples of all of these on the video, um, in a little while. And then as I say there are ones where we just don't know. So have a look at this video I'll I'll probably try and kind of pause as we go through it.

Some of these are. That's logs, isn't it? Uh, so this is a little girl actually who was treated for epilepsy for quite a long time. And again, the report was that she sometimes had attacks that were provoked and sometimes had attacks that weren't provoked. And she could have them if she was told off or if she was upset or she hurt herself, but sometimes there was no obvious reason. But usually there was, actually, if you asked about it. Uh, and this is, this is a non-epileptic seizure. This is what we call a reflex anoxic seizure. OK. So reflex means it's a, a response to some sort of trauma or upset or. Something unpleasant, Anoxic means there's a reduction in Essentially oxygen supply to the brain, but it's blood and oxygen supply, and seizure makes it. So yeah, so this girl here. But to gain. End of this month goes on sale. Wait, I can't even see her body though. get the back of them. the calendar to. Have a good afternoon. That's what we wish we're knackered.

And people thought that this was an epileptic. Was that she stiffened and she jerked. And nobody asked the question, Well, tell me a bit more about the jerking. Because if you ask Mum, she said, well, she'll have 2 or 3 jokes. Now that wouldn't be consistent with a tonic-clonic seizure. Um, those jokes, these little things that we could see there, but nobody had asked that question. And so that's why she'd actually had about 7 different epilepsy medications. She came to a neurology centre. Um, And then she took a long time to recover. Sick as the proverbial if he doesn't get this answer right. Cry crackers, Friday 6:30 on Yorkshire. This is a psychogenic, non-epileptic seizure. Um, Which is pretty dramatic, isn't it? But you can see that although there's a convulsing element to it, it's much more kind of sinusoidal, it's much more sort of Rocking than it is jerking, OK, um, and this is, this is a a psychogenic. What do you think would happen if we took that pillow away? Do you think she'd carry on? can stop How many do you think she'd carry on? 2. How many do you think she'd stop? And the rest of you are going to hedge your bets. enough The reality is this is, although this is psychogenic, so it has a psychological cause, she's not choosing to do it. It's, it's a manifestation of psychological trauma, and actually if you take the pillow away, she'll carry on. Those of you who put your hand up saying you should stop. You're in the the the the nurses in the hospital thought that she would, they thought she would. And so they took the She smashed it The dental hospital. So the reality is it's it's important that that just because it's not epileptic doesn't mean it's not serious and it's not a significant issue. The next lot are all epileptics, these are generalised seizures, so this is a child having a And although you can't really see the EP that well, you'll see it changes. And she'll have eye opening She's staring. If you look, you can see some subtle twitching of her eyes. Um, her eyes deviate. rocking And as soon as it's over. Eyes shut and she goes straight back to where she was before. She has no recollection of that. This boy has exactly the same, except it's much more subtle, much more difficult to see. Again, just like the last girl, it's triggered by asking him to overbreathe, so he's hyperventil. And is now stopped. But unlike the other girl where the eye opening was immediate. His eye opening is much slower. But again, when he opens his eyes, you'll see his eyes are straight ahead. Completely unresponsive, his dad was And he does a little bit of rocking. Then you'll see in a minute He'll abruptly close his eyes and go straight back to overbreathing. It would be really difficult to know that was an absence if we didn't have He doesn't have it on there, but we did. But very difficult to recognise. The next is a myoclonic seizure. I'm afraid that this video is degraded with time, but just watch her eyes, you'll see just a little subtle jerk of her eyelids, can you see that? Easier to see on the next one, which is a little boy who has a reflex mic on him. Uh, it's easier we tap him. Has a series of brief jokes. Can you see those, those are my plums. Tonic means a stiffening seizure, so this girl will suddenly abruptly stiffen. See that? This is what most people think of as an epileptic seiz. You can have a seizure with a loss of tone. So this boy, we're asking him to hold his arms up in the air. Um, and he will do so. Until the seizure starts. And then abruptly they dropped down and actually if we weren't all flo So that's an A2 And all of these are what we call generalised seizures, so they're affecting both sides of the body. But the, the brain. The next lot are all focal motor seizure or focal seizures, so this is a motor seizure, rising in In the motor strip in the frontal lobe, and if you watch her right side, this is a left focal motor seizure, you can see she's got flexion of her hip, she'll have flexion into her shoulder. And she'll have subtle jerking. Can you see that? So that's a focal motor seizure. She actually has retained awareness. The the the sound is off, but when people talk to her, she tells you. The next is a focal seizure arising in the temporal lobe. You'll see quite a lot of similarities to the absence. Um, again, there's uh. Eye opening. Which is slow, but when her eyes open, you'll see her eyes are deviated to the side. And you'll see that her face is asymmetrical, so her head turns to the right, her eyes when they open would turn to the right. You can see her face is asymmetrical, um, she's having some chewing moves. You Her mouth is very asymmetric. Perhaps a drooling of the Completely unresponsive. F. Um It's over, she sits up and she starts. Seizure over. It's just This is a seizure rising in the front.

it. OK. Yes. Yes. I did. That Bye Oops. I, I probably So, That boy has a genetic focal epilepsy arising in his frontal lobe, but you can see the strong emotional component of it. You can also see how difficult it might be to make a diagnosis, certainly without a video, because what the parents described was that he'd wake up in the night screaming in distress. And what they didn't say was that he always had posturing of his hand. If you asked them about it, if you said, does he do anything with his arms or his legs. They would say, oh yeah, he brings his one arm up and his, his leg bends up at the hip, but they wouldn't tell you that unless you specifically asked the question. And that's a frontal lobe seizure. In very young children, you can have focal seizures that only present with vegetative phenomena. So this baby that you're about to see now presented to the respiratory team because of apnea. that he would just stop breathing. Um, but they recognised quite quickly that there was something else going on. So this is, this is the, the CG here, and you need to listen to. I've got just the recipe for keeping the winter goes

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Sometimes if there's a unilateral cause, as in this child, may be asymmetric and you can see it's only his right arm that's involved here, and this boy actually had a low grade tumour in his left temporal lobe. that DC has went away. So That's seizure types. The problem is, if A child only had one kind of seizure, or if the same kind of seizure always occurred in the same kind of epilepsy, that would be dead straightforward. But the problem is that children can have more than one kind of seizure, and there's more than one kind of epilepsy, and this is the kind of way of thinking of it, um, that seizure types tell you about the types of epilepsy, and epilepsies can be focal or generalised or a combination of the two, or uncertain. And some of those constitute what we call epilepsy syndromes because they're well recognisable. Underneath that is an aetiology, which you can see there could be structural, genetic, infective, uh, inflammatory, metabolic, and so on. And beside it are the comorbidities. So what I want to do is just briefly kind of talk you through a little bit about epilepsy syndrome, just to, don't, you don't need to remember any of this, but, but recognise that in children, and this is what makes it so much more interesting than than adults. There are numerous different types of efforts. And the different types of epilepsy present at different ages, and some of those may start at one age and then change into something else as the child gets older. So you have neonatal onset attacks, you have attacks that start in infancy, some that start in childhood, uh, and then some that start in adolescence. And many of the adolescent epilepsies are very similar to the epilepsies we see in, in adulthood. So I'm just gonna give you one example, we'll skip past the other, but just to give you an idea of what we mean by an epilepsy syndrome. So an epilepsy syndrome is constituted of seizure type or seizure type. An EEG characteristic, demographics about the child and something about um the the child's um neurodevelopment. So for example, what we call childhood absence epilepsy used to be called petit mal, but isn't anymore. The adult neurologists still do call it that. typically starts in childhood. Between the ages of 4 and 10, likely to affect boys and girls, typically associated with a normal neurodevelopmental profile, and it's characterised by absences. Do you remember those ones where the child suddenly stops, stares and is unresponsive? EEG has a very characteristic picture with um 33 spiking wave bursts in every second and in the vast majority, The epilepsy remits and in general it responds well to treatment. So knowing about the epilepsy syndrome is important because right at the onset, it helps you with decision making about your treatment, it helps you with the advice that you give to parents, and it helps you with looking at knowing what to look out for in the future. So And there are many, many, many more, but I'm not going to bore you with. Fascinating to me, but substantially less fascinating. Um, so the next question when we're dealing with epilepsy is the why. And the things that have really radically changed our understanding of aetiology in epilepsy has been the improvements in MRI technology and the advances in, um, molecular genetics. Those are the two that have changed, but there are other things that are important. Um, but for example, um, MR imaging can pick up things that we would previously not have seen. It doesn't usually come beautifully labelled with an arrow. Um, an MR radiologist gives us that. But you can see here, if you look at this, um, this structure on the, on the, on the left hand side, so this is, it's always a mirror image, you can see this nice chunky rolled up looking thing that's called the hippocampus. And it has a nice chunky look. On the right hand side you can see it's shrivelled. And shrunken and scarred, and that's what we call hippocampal sclerosis, and that's an important cause of temporal lobe epilepsy. Here's another lesion in the temporal lobe, um, and you can see there there's low, um, Uh, signal lesion. In the right temporal lobe, and that has all the characteristics of a developmental tumour called a D net, which is sort of hematomatous lesion. And this one here, if you look on the left-hand side, you can see how nicely the, the cortex, which is the grey, the darker colour, um, the white matter interdigitates into the cortex in the temporal lobe, but on the, on the side labelled with an arrow, you can see that it's chaotic and disorganised, and that's also very epileptic genic. So structural abnormalities can be important, but increasingly we're recognising, particularly in early onset childhood epilepsies. An explosion of of of genetic understanding. And the early epilepsies that we identified all were problems with with neurotransmitters and neurotransmitter pathways, but increasingly there's a much, much broader range of abnormalities that cause epilepsy. And now in a young child who we refer for whole genome sequencing, we expect a hit rate of around 30 to 40%, which for any investigation you'll discover is. But at the end of the day, Diagnosis, while hugely important, isn't the end of it. If, if all we did was say to parents, yeah, congratulations, we've told you that your child has epilepsy, they have these kinds of seizures, this is the kind of epilepsy they have, and this is how it's going to behave, thank you very much. It's been a pleasure meeting you. Not many of them are going to go away happy. Because most parents. Even most people with athletic impact, almost all want them to stop. Want the attacks to stop. So we need to be looking at how we manage epilepsy, and that's far more than just giving drugs. It's about how we deliver the service, how we deal with the comorbidities, and how we deal with those epilepsies that don't respond well to medication. But the good thing is that about 3/4 of people who present with epilepsy will respond well to an anti-seizure medication, so they will become seizure-free. On a single drug. But of the remaining 30%, about half of those will get pretty good seizure control, um, but they might need. Drugs? And the other 10 to 20% have uncontrolled epilepsy, and those are the ones that come and see somebody like. As an So that means that when we're treating people with epilepsy, what we need to be saying is for the vast majority they'll only be on the. Appropriate. We need to therefore be thinking about what's the best drug for this kind of epilepsy. Be aware of side effects that may occur and have a, a low threshold for saying if we genuinely believe this person is experiencing adverse effects from their anti-epileptic drug, there is an alternative. To look at what alternatives there are. Um, and recognising that what we're not doing with our treatment is curing the epilepsy. No more than treating diabetes with insulin is curing diabetes, or treating asthma with inhaled steroids is curing asthma, we're simply suppressing symptoms. And it's really important that people understand that because they need to continue their treatment. There are numerous treatments available to Although the kind of advent of of what we now think of as anti-epileptic drugs really dates from the 19th century when bromide came on, there were anti-epileptic interventions for centuries before that. Hippocrates thought that castration In Roman times it was thought that if you bathed in the blood enslaved gladiator, that would help your There are endless numbers of of of uh um Chinese and and and Asian treatments that have been tried. The vast majority of which unfortunately, have been shown to be ineffect. Um, but with the onset of proper drugs from the late 19th century and certainly through the 20th century, we have a whole range of options open. But even despite that, we still have about 10 to 20% of children who still continue to have seizures. Just a quick point that two of the most effective drugs that we Um, that we used to use. largely prescribed. We currently use sodium valproate except in extreme circumstances. can't use topiramate for both of those, it's because of the effect of foetus, but with sodium valproate, there is some evidence, um, quite weak evidence, but there is some evidence that it has an effect on male fertility. But it also can affect, um, there's enough of it in semen. that if you Father a child while you're on Valpro that could cause developmental abnormalities. The child. So we're advised not to use operate at all. Please don't try and read all of this. This is just to give a sense of, this is what NICE tells us about how to, to look at um drug treatment for, for people with epilepsy. But the important thing is that what NICE is saying is sense. It says, look at the age of the child, look at their gender, look at what kind of seizures they have, what kind of epilepsy they have, um, do they need treatment? Some epilepsies don't need to be treated. There are certain types of epilepsy that. Occur in childhood that are going to remit come what may, and actually you may only ever may have one or two seizures, so you may not ever want to treat. Um, look at what the, the family wants. Do they want these Sometimes Say, well, I think The down Look at what drugs they're on already. look at comorbidities, look at Things like education, what about um pregnancy and so on, and these are the things we need to think about when we're choosing a drug. What Nice also says is We should always be using a single drug unless there's no alternative. Um, but remember that if the first one doesn't work, try a second one, but be aware that things may go wrong when you change over. There's really good evidence that That there's a law of diminishing returns the more drugs you've tried. So if you try one anti-epileptic drug and a person doesn't respond, their chance of responding to the second anti-epileptic drug drops to about 40% and the third drops to about 5%. So actually What we now think of as being refractory epilepsy is a failure to respond to two appropriate anti-epileptic drugs, because if you've tried two drugs to an appropriate dose that's right for that kind of epilepsy, the chance of success with the third is pretty small. I'm just not going to go through all of this, but you'll get to see this. So What about those that don't respond? How do we deal with those? And the reality is that we need to be paying really careful attention to, is this truly refractory? In other words, has the person been given. A drug for the right reason. Do they have epilepsy? Or if they have epilepsy, were they given the right the right drug. Had they been given it to the right dose? Or is this epilepsy really not going to And there are certain epilepsies that we can recognise from very early on are not going to respond. ile p s y treatment We need to be aware that there are patient related things that may impact as well. Most of them are doctor. Or medically related things, but patients or parents may not adhere to the treatment regime that you've advised, so they may Not remember to take it. Or the child may spit it out. Or particularly in adolescence, there may be lifestyle issues that get in the way. There are certain kinds of epilepsy, generalised epilepsies that occur in adolescence in which sleep deprivation is a Powerful trigger for seizures and teenagers who, for example, may stay up till all hours um on their phones um and then have to get woken up for school in the morning, may have seizures because they've not had adequate sleep. So we need to think about all of those things. We need to think about if it is a truly refractory epilepsy, well, why? Is there a structural abnormality? Have they got a progressive disorder underneath? Have they got a particular kind of epilepsy that we know is going to be refrain. But sometimes we just don't know why the epilepsy isn't responding to. And that's really difficult both for the doctor and for the family. It's much easier if you can say to somebody, Your child's epilepsy isn't responding to treatment, and this is for why. It's much more difficult Tell people why. In the last 10 minutes, I just want to think about comorbidities or complications. I'm not going to cover all of them, but I'm going to look at education, I'm going to look at behaviour and Um, so start with education. We know that epilepsy has a major impact. OK From an educational point And actually if you look at all children with epilepsy, About half of them will underachieve. So you look at their IQ and you look at their performance in school and they don't. that we'd expect And there are really two quite important factors that come into that. One is attention. And we know that children with epilepsy are likely to have disordered attention, and some of them will actually have frank. Attention deficit And if you can't pay attention in school, you're not going So recognising that and giving teachers the the understanding of that, and families and children the tools to be able to say, well, these are the things you can do to help your child attention is really important. But if you have a focal epilepsy, and you have an abnormality in a, in a part of your brain which is important for, for learning, and that may also lead to a specific. So for example, if you have a lesion. Um, your dominant temporal. You may have Verbal. Memory It may be difficult for the child to really retain information that's given to them purely in spoken form. So you may need to support that with a lot of visual learning as well. And remember that this is not really visual learning, this is still verbal. Words done, but that's not So, so, so saying to teachers you need to support them with, with visual And things, doesn't mean just write it down and It needs to be visual, so that they can use their non-dominant hemisphere to learn. Does that make sense? Um, but remember that actually a substantial proportion of children with epilepsy do have a frank learning disability. So that's important to recognise at the outset as well. Why? Well, the single most important thing is whatever causes your epilepsy. So if you've had injury to your brain or you have a structural change in your brain or you have a genetic disorder, that's probably what's going to cause your, your learning. Disability, but uncontrolled seizures, Uncontrolled epileptic discharges, um, the medications that we use, people's attitudes, really importantly, and mental health problems all impact as well. So when you're dealing with a child who's not doing as well at school as they should do, you need to be paying attention to all of those things. And the same thing applies when we start to look at behaviour. Um, a really nice study in the 1990s looked at the impact of behaviour or it looked at the impact of chronic disease on behaviour. And two disorders were chosen, diabetes and epilepsy, because they're common. And what that study showed was that both Groups of children had problems with behaviour, but children with epilepsy were much more likely to have And that makes sense because epilepsy is a brain problem. Diabetes. Hogan Um