1. Pediatric Neurology Cases
Case 3 . The Child with a Seizure

2. 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.

3. 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

4. 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

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

6. 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.

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

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

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

10. 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

11. 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

12. 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.

13. 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.

14. 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.

15. 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.

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

17. 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.

18. 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

19. 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.

20. Good Morning !