20 common pediatric epilepsy scenarios with treatment approaches.
1. Typical Absence Epilepsy (7-year-old)
- First: Ethosuximide
- Second add-on: Valproate
- Third add-on: Lamotrigine
- Replacement options: Levetiracetam if both fail
2. Juvenile Myoclonic Epilepsy (14-year-old male)
- First: Valproate
- Second add-on: Levetiracetam
- Third add-on: Topiramate
- Replacement: Lamotrigine, Zonisamide
3. Juvenile Myoclonic Epilepsy (13-year-old female)
- First: Levetiracetam
- Second add-on: Lamotrigine or valproate
- Third add-on: Topiramate
- Replacement: Zonisamide
4. Benign Rolandic Epilepsy (8-year-old)
- First: Oxcarbazepine or valproate if there is paradoxical worsening
- Second add-on: Levetiracetam
- Third add-on: Carbamazepine
- Replacement: Gabapentin
5. West Syndrome (6-month-old)
- First: ACTH/Vigabatrin
- Second add-on: Topiramate
- Third add-on: Levetiracetam
- Replacement: Valproate, clobazam
6. Lennox-Gastaut Syndrome (5-year-old)
- First: Valproate
- Second add-on: Clobazam
- Third add-on: Rufinamide
- Replacement: Lamotrigine
7. Focal Epilepsy with Normal MRI (10-year-old)
- First: Oxcarbazepine
- Second add-on: Levetiracetam
- Third add-on: Lamotrigine
- Replacement: Carbamazepine
8. Focal Epilepsy with Cortical Dysplasia (4-year-old)
- First: Levetiracetam
- Second add-on: Oxcarbazepine
- Third add-on: Topiramate
- Replacement: Lacosamide
9. Dravet Syndrome (2-year-old)
- First: Valproate
- Second add-on: Clobazam
- Third add-on: Stiripentol
- Replacement: Topiramate, Fenfluramine
10. Childhood Absence Epilepsy with Myoclonic Components (8-year-old)
- First: Valproate
- Second add-on: Levetiracetam
- Third add-on: Lamotrigine
- Replacement: Topiramate
11. Post-traumatic Epilepsy (12-year-old)
- First: Levetiracetam
- Second add-on: Carbamazepine
- Third add-on: Lacosamide
- Replacement: Oxcarbazepine
12. Tuberous Sclerosis with Focal Seizures (3-year-old)
- First: Vigabatrin
- Second add-on: Levetiracetam
- Third add-on: Topiramate
- Replacement: Oxcarbazepine
13. GLUT-1 Deficiency Syndrome (2-year-old)
- First: Ketogenic Diet
- Second add-on: Levetiracetam
- Third add-on: Zonisamide
- Replacement: Topiramate
14. Juvenile Absence Epilepsy (12-year-old)
- First: Valproate
- Second add-on: Lamotrigine
- Third add-on: Levetiracetam
- Replacement: Topiramate
15. Focal Epilepsy with Language Dysfunction (6-year-old)
- First: Levetiracetam
- Second add-on: Lamotrigine
- Third add-on: Oxcarbazepine
- Replacement: Topiramate (avoid phenytoin/phenobarbital)
16. Myoclonic-Atonic Epilepsy (Doose Syndrome) (4-year-old)
- First: Valproate
- Second add-on: Lamotrigine
- Third add-on: Clobazam
- Replacement: Levetiracetam
17. Early Myoclonic Encephalopathy (2-month-old)
- First: Phenobarbital
- Second add-on: Levetiracetam
- Third add-on: Topiramate
- Replacement: Valproate
18. KCNQ2 Encephalopathy (neonate)
- First: Carbamazepine/Oxcarbazepine
- Second add-on: Levetiracetam
- Third add-on: Topiramate
- Replacement: Phenobarbital
19. Rasmussen Encephalitis (7-year-old)
- First: Levetiracetam
- Second add-on: Carbamazepine
- Third add-on: Clobazam
- Replacement: Consider immunotherapy/surgery
20. Focal Epilepsy with Autism (5-year-old)
- First: Levetiracetam (though may need to monitor behavior)
- Second add-on: Oxcarbazepine
- Third add-on: Lamotrigine
- Replacement: Valproate (if no behavioral worsening)
Key Considerations for All Cases:
- Monitor side effects closely
- Consider drug interactions
- Adjust based on comorbidities
- Consider ketogenic diet in refractory cases
- Evaluate for surgical candidacy in focal cases
- Regular EEG monitoring
- Growth monitoring
- Development/cognitive monitoring
- Quality of life assessment
1. Typical Absence Epilepsy (7-year-old)
- First: Ethosuximide
- Second add-on: Valproate
- Third add-on: Lamotrigine
- Replacement options: Levetiracetam if both fail
2. Juvenile Myoclonic Epilepsy (14-year-old male)
- First: Valproate
- Second add-on: Levetiracetam
- Third add-on: Topiramate
- Replacement: Lamotrigine, Zonisamide
3. Juvenile Myoclonic Epilepsy (13-year-old female)
- First: Levetiracetam
- Second add-on: Lamotrigine or valproate
- Third add-on: Topiramate
- Replacement: Zonisamide
4. Benign Rolandic Epilepsy (8-year-old)
- First: Oxcarbazepine or valproate if there is paradoxical worsening
- Second add-on: Levetiracetam
- Third add-on: Carbamazepine
- Replacement: Gabapentin
5. West Syndrome (6-month-old)
- First: ACTH/Vigabatrin
- Second add-on: Topiramate
- Third add-on: Levetiracetam
- Replacement: Valproate, clobazam
6. Lennox-Gastaut Syndrome (5-year-old)
- First: Valproate
- Second add-on: Clobazam
- Third add-on: Rufinamide
- Replacement: Lamotrigine
7. Focal Epilepsy with Normal MRI (10-year-old)
- First: Oxcarbazepine
- Second add-on: Levetiracetam
- Third add-on: Lamotrigine
- Replacement: Carbamazepine
8. Focal Epilepsy with Cortical Dysplasia (4-year-old)
- First: Levetiracetam
- Second add-on: Oxcarbazepine
- Third add-on: Topiramate
- Replacement: Lacosamide
9. Dravet Syndrome (2-year-old)
- First: Valproate
- Second add-on: Clobazam
- Third add-on: Stiripentol
- Replacement: Topiramate, Fenfluramine
10. Childhood Absence Epilepsy with Myoclonic Components (8-year-old)
- First: Valproate
- Second add-on: Levetiracetam
- Third add-on: Lamotrigine
- Replacement: Topiramate
11. Post-traumatic Epilepsy (12-year-old)
- First: Levetiracetam
- Second add-on: Carbamazepine
- Third add-on: Lacosamide
- Replacement: Oxcarbazepine
12. Tuberous Sclerosis with Focal Seizures (3-year-old)
- First: Vigabatrin
- Second add-on: Levetiracetam
- Third add-on: Topiramate
- Replacement: Oxcarbazepine
13. GLUT-1 Deficiency Syndrome (2-year-old)
- First: Ketogenic Diet
- Second add-on: Levetiracetam
- Third add-on: Zonisamide
- Replacement: Topiramate
14. Juvenile Absence Epilepsy (12-year-old)
- First: Valproate
- Second add-on: Lamotrigine
- Third add-on: Levetiracetam
- Replacement: Topiramate
15. Focal Epilepsy with Language Dysfunction (6-year-old)
- First: Levetiracetam
- Second add-on: Lamotrigine
- Third add-on: Oxcarbazepine
- Replacement: Topiramate (avoid phenytoin/phenobarbital)
16. Myoclonic-Atonic Epilepsy (Doose Syndrome) (4-year-old)
- First: Valproate
- Second add-on: Lamotrigine
- Third add-on: Clobazam
- Replacement: Levetiracetam
17. Early Myoclonic Encephalopathy (2-month-old)
- First: Phenobarbital
- Second add-on: Levetiracetam
- Third add-on: Topiramate
- Replacement: Valproate
18. KCNQ2 Encephalopathy (neonate)
- First: Carbamazepine/Oxcarbazepine
- Second add-on: Levetiracetam
- Third add-on: Topiramate
- Replacement: Phenobarbital
19. Rasmussen Encephalitis (7-year-old)
- First: Levetiracetam
- Second add-on: Carbamazepine
- Third add-on: Clobazam
- Replacement: Consider immunotherapy/surgery
20. Focal Epilepsy with Autism (5-year-old)
- First: Levetiracetam (though may need to monitor behavior)
- Second add-on: Oxcarbazepine
- Third add-on: Lamotrigine
- Replacement: Valproate (if no behavioral worsening)
Key Considerations for All Cases:
- Monitor side effects closely
- Consider drug interactions
- Adjust based on comorbidities
- Consider ketogenic diet in refractory cases
- Evaluate for surgical candidacy in focal cases
- Regular EEG monitoring
- Growth monitoring
- Development/cognitive monitoring
- Quality of life assessment
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ITP approach.
Petechiae are pinpoint hemorrhages <2 mm in size, purpura are 2 mm to 1 cm, and ecchymoses are >1 cm.
patient has all three. These lesions are the result of extravasation of blood from the vasculature into skin/mucosa and do not blanch.
platelet disorder could explain these symptoms and physical findings.
But is the platelet issue qualitative (platelets are normal in number but abnormal in function) or quantitative (platelets are normal in function, but abnormal in number)?.
There's a test for that.
Immature platelets = newly released platelets.
The immature platelet fraction If low/normal, there is decreased platelet production; if elevated, there is increased platelet destruction.
The elevated immature platelet fraction tells us we are dealing with a process causing platelet destruction.
The degree of thrombocytopenia narrows our differential to TMA and ITP. The absence of concomitant hemolytic anemia points us to the right diagnosis:
Petechiae are pinpoint hemorrhages <2 mm in size, purpura are 2 mm to 1 cm, and ecchymoses are >1 cm.
patient has all three. These lesions are the result of extravasation of blood from the vasculature into skin/mucosa and do not blanch.
platelet disorder could explain these symptoms and physical findings.
But is the platelet issue qualitative (platelets are normal in number but abnormal in function) or quantitative (platelets are normal in function, but abnormal in number)?.
There's a test for that.
Immature platelets = newly released platelets.
The immature platelet fraction If low/normal, there is decreased platelet production; if elevated, there is increased platelet destruction.
The elevated immature platelet fraction tells us we are dealing with a process causing platelet destruction.
The degree of thrombocytopenia narrows our differential to TMA and ITP. The absence of concomitant hemolytic anemia points us to the right diagnosis:
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