Download Pediatric Neurology Cases

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.
Good Morning !