Pediatric Neurology Cases Case 3 . The Child with a Seizure

Salient Points: R.R., 5 yrs old, male brought to the ER because of convulsions. 1 day pta, had colds and mild fever Few hours later. On waking up, had twitchings of the left face followed by clonic movements of the hand and left leg for 2 min. After the episode he was awake with headache and dizziness.

Salient Points: Past History: (-) trauma; at 2 yrs old , had febrile convulsions (2 x) (Dx. Benign febrile seizures, acute tonsillopharyngitis) (+) febrile seizures – sibling 2 months ago – he was diagnosed to have Primary TB and given anti Koch medications

Examination on admission: P.E. Temp=37.6’C; RR= 35/min; CR = 94/min Weight = 42 lbs Congested posterior pharyngeal wall Heart and Lungs unremarkable No hepatosplenomegaly

Neuro Exam Awake, alert, active, playful No cranial deficits DTR= ++; No pathological reflexes (-) Kernigs, (-) Brudzinski

Is there a neurologic disease? The description of event appears to be a seizure. Seizures refer to excessive neuronal discharge with change in motor activity or behavior. Seizures may be due to non-neurologic causes as: metabolic disorders, electrolyte imbalance, hypoglycemia, hypoxia, fever, systemic infections, toxins, drug-related.

Seizure Types: Partial seizures Simple partial-(as seen in this patient) Jacksonian seizure Complex Partial seizures- behavioral manifestations, with impairment of consciousness.

Seizure types Generalized seizures Tonic Clonic Gran mal (tonic clonic) Myoclonic Absence Atonic Unclassified seizures

Is there a neurologic disease? Neurologic causes of seizures include: 1. Tumors 2. CNS malformation 3. Vascular disorders 4. Idiopathic epilepsy

What is the neurologic disease? In this patient, the seizures are ushered in by fever and respiratory infection. Benign Febrile Seizures should be ruled out. The typical benign FS is characterized by: 1. Grand mal lasting for <15 min 2. Occurring once in the same illness 3. Age incidence: 3 months to 5 years 4. Occurs at temperature 380 C and above 5. Normal neurological examination 6. Family history (+) for FS 7. CNS infection absent

Is this a simple febrile seizure? Although the patient was previously diagnosed to have simple febrile seizure, the present episode does not appear to be BFC. 1st -Seizures happened at a very low temperature. (37.6’C); 2nd – focal seizures

Is it a Complex febrile seizure? Complex febrile seizures are febrile seizures which are atypical. They may occur more than once in an illness, a focal seizure, more than15 minutes May need investigation to rule out epilepsy.

Is this Epilepsy? Epilepsy is defined as recurrent unprovoked seizures. No fever nor any provoking factors as electrolyte imbalance, hypoglycemia, anoxia A small percentage of patients with simple febrile seizures may later develop epilepsy.

Diagnostic possibilities: A seizure disorder is considered in the absence of a provoking factor. A CNS infection should always be ruled out especially with a history of mild fever. The P.E. however did not show any meningeal signs.

Where is the lesion? The presence of seizures tell us that the cerebral cortex is affected. The focal seizures over the left suggests a lesion over the right. The absence of abnormal neuro findings make it difficult to pinpoint specific area. Lesion must be on the right cerebral hemisphere.

What is the lesion? The acute course should make us consider: infectious vascular trauma paroxysmal

Diagnostic Approach An electroencephalogram is indicated. Epileptiform patterns may be seen over the right hemisphere. A normal EEG does not rule out a seizure disorder. If the EEG is abnormal, a cranial CT scan or MRI may be done to rule out structural causes. Seizure disorders with no clear cause, and negative tests are labeled idiopathic.

Therapeutic Approach The first episode of afebrile seizure may not need any anticonvulsant drugs. Commonly used drugs in epilepsy are: Phenobarbital Phenytoin Valproic Acid Carbamazepine Oxcarbazepine Topiramate

Prognosis Depends on the etiology of the seizures. Benign epileptic syndromes as the Rolandic seizures are of good prognosis. Seizures from inherited metabolic disorders and degenerative diseases are usually intractable.

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