Pediatric Neurology Pediatric Neurology Cases Cases

Case 3 . Case 3 . The Child with a SeizureThe Child with a Seizure

Salient Points:Salient Points:

R.R., 5 yrs old, male brought to the ER R.R., 5 yrs old, male brought to the ER because of convulsions.because of convulsions.

1 day pta, had colds and mild fever1 day pta, had colds and mild fever Few hours later. On waking up, had twitchings Few hours later. On waking up, had twitchings

of the left face followed by clonic movements of of the left face followed by clonic movements of the hand and left leg for 2 min.the hand and left leg for 2 min.

After the episode he was awake with After the episode he was awake with headache and dizziness.headache and dizziness.

Past History:Past History: (-) trauma; at 2 yrs old , had febrile (-) trauma; at 2 yrs old , had febrile

convulsions (2 x) (Dx. Benign febrile convulsions (2 x) (Dx. Benign febrile seizures, acute tonsillopharyngitis)seizures, acute tonsillopharyngitis)

(+) febrile seizures – sibling(+) febrile seizures – sibling 2 months ago – he was diagnosed to 2 months ago – he was diagnosed to

have Primary TB and given anti Koch have Primary TB and given anti Koch medicationsmedications

Salient Points:Salient Points:

Examination on admission:Examination on admission:

P.E.P.E. Temp=37.6’C; RR= 35/min; CR = 94/minTemp=37.6’C; RR= 35/min; CR = 94/min

Weight = 42 lbsWeight = 42 lbs Congested posterior pharyngeal wallCongested posterior pharyngeal wall Heart and Lungs unremarkableHeart and Lungs unremarkable No hepatosplenomegalyNo hepatosplenomegaly

Neuro ExamNeuro Exam

Awake, alert, active, playfulAwake, alert, active, playful No cranial deficitsNo cranial deficits DTR= ++; No pathological reflexesDTR= ++; No pathological reflexes (-) Kernigs, (-) Brudzinski(-) Kernigs, (-) Brudzinski

Is there a neurologic Is there a neurologic disease?disease?

The description of event appears to be a The description of event appears to be a seizureseizure.. Seizures refer to excessive neuronalSeizures refer to excessive neuronal discharge with change in motor activity ordischarge with change in motor activity or behavior.behavior. Seizures may be due to non-neurologic Seizures may be due to non-neurologic

causes as: metabolic disorders, causes as: metabolic disorders, electrolyte imbalance, hypoglycemia, electrolyte imbalance, hypoglycemia, hypoxia,hypoxia,

fever, systemic infections, toxins,fever, systemic infections, toxins, drug-related.drug-related.

Seizure Types:Seizure Types:

Partial seizuresPartial seizures

Simple partial-(as seen in this patient)Simple partial-(as seen in this patient)

Jacksonian seizureJacksonian seizure

Complex Partial seizures- behavioralComplex Partial seizures- behavioral

manifestations, with impairment ofmanifestations, with impairment of

consciousness.consciousness.

Seizure typesSeizure types

Generalized seizuresGeneralized seizures

TonicTonic

ClonicClonic

Gran mal (tonic clonic)Gran mal (tonic clonic)

MyoclonicMyoclonic

AbsenceAbsence

AtonicAtonic Unclassified seizuresUnclassified seizures

Is there a neurologic Is there a neurologic disease?disease?

Neurologic causes of seizures include:Neurologic causes of seizures include: 1. Tumors1. Tumors

2. CNS malformation2. CNS malformation

3. Vascular disorders3. Vascular disorders

4. Idiopathic epilepsy4. Idiopathic epilepsy

In this patient, the seizures are ushered in by In this patient, the seizures are ushered in by fever and respiratory infection.fever and respiratory infection.

Benign Febrile SeizuresBenign Febrile Seizures should be ruled out. should be ruled out. The typical benign FS is characterized by:The typical benign FS is characterized by:

1. Grand mal lasting for <15 min1. Grand mal lasting for <15 min 2. Occurring once in the same illness2. Occurring once in the same illness 3. Age incidence: 3 months to 5 years3. Age incidence: 3 months to 5 years 4. Occurs at temperature 384. Occurs at temperature 380 0 C and aboveC and above 5. Normal neurological examination5. Normal neurological examination 6. Family history (+) for FS6. Family history (+) for FS 7. CNS infection absent 7. CNS infection absent

What is the What is the neurologic neurologic disease?disease?

Is this a simple febrile Is this a simple febrile seizure?seizure?

Although the patient was previouslyAlthough the patient was previously diagnosed to have simple febrile seizure, diagnosed to have simple febrile seizure, the present episode does not appear to bethe present episode does not appear to be BFC.BFC. 11stst -Seizures happened at a very low -Seizures happened at a very low

temperature. (37.6’C);temperature. (37.6’C); 22ndnd – focal seizures – focal seizures

Is it a Complex febrile Is it a Complex febrile seizure?seizure? Complex febrile seizures are febrile Complex febrile seizures are febrile

seizures which are atypical.seizures which are atypical.

They may occur more than once in an They may occur more than once in an illness, a focal seizure, more than15 illness, a focal seizure, more than15 minutes minutes

May need investigation to rule out May need investigation to rule out

epilepsy.epilepsy.

Is this Epilepsy?Is this Epilepsy?

Epilepsy is defined as recurrent Epilepsy is defined as recurrent unprovoked seizures.unprovoked seizures.

No fever nor any provoking factors as No fever nor any provoking factors as electrolyte imbalance, hypoglycemia, electrolyte imbalance, hypoglycemia, anoxiaanoxia

A small percentage of patients withA small percentage of patients with simple febrile seizures may later develop simple febrile seizures may later develop

epilepsy.epilepsy.

Diagnostic Diagnostic possibilities:possibilities: A seizure disorder is considered in the A seizure disorder is considered in the

absence of a provoking factor.absence of a provoking factor.

A CNS infection should always be ruled A CNS infection should always be ruled out especially with a history of mild fever. out especially with a history of mild fever. The P.E. however did not show any The P.E. however did not show any meningeal signs.meningeal signs.

Where is the lesion?Where is the lesion?

The presence of seizures tell us that the The presence of seizures tell us that the cerebral cortex is affected.cerebral cortex is affected.

The focal seizures over the left suggests The focal seizures over the left suggests a lesion over the right.a lesion over the right.

The absence of abnormal neuro findingsThe absence of abnormal neuro findings make it difficult to pinpoint specific area.make it difficult to pinpoint specific area. Lesion must be on the Lesion must be on the right cerebral right cerebral

hemisphere.hemisphere.

What is the lesion?What is the lesion?

The acute course should make us The acute course should make us consider:consider:

infectiousinfectious

vascularvascular

traumatrauma

paroxysmal paroxysmal

Diagnostic ApproachDiagnostic Approach

An electroencephalogram is indicated.An electroencephalogram is indicated.

Epileptiform patterns may be seen over theEpileptiform patterns may be seen over the

right hemisphere. A normal EEG does notright hemisphere. A normal EEG does not

rule out a seizure disorder.rule out a seizure disorder. If the EEG is abnormal, a cranial CT scan or If the EEG is abnormal, a cranial CT scan or

MRI may be done to rule out structural causes.MRI may be done to rule out structural causes. Seizure disorders with no clear cause,Seizure disorders with no clear cause,

and negative tests are labeled idiopathic.and negative tests are labeled idiopathic.

Therapeutic ApproachTherapeutic Approach

The first episode of afebrile seizure may not The first episode of afebrile seizure may not need any anticonvulsant drugs.need any anticonvulsant drugs.

Commonly used drugs in epilepsy are:Commonly used drugs in epilepsy are: PhenobarbitalPhenobarbital PhenytoinPhenytoin Valproic AcidValproic Acid CarbamazepineCarbamazepine OxcarbazepineOxcarbazepine TopiramateTopiramate

PrognosisPrognosis

Depends on the etiology of the seizures.Depends on the etiology of the seizures. Benign epileptic syndromes as the Benign epileptic syndromes as the

Rolandic seizures are of good prognosis.Rolandic seizures are of good prognosis. Seizures from inherited metabolic Seizures from inherited metabolic

disorders and degenerative diseases disorders and degenerative diseases are usually intractable.are usually intractable.

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