The Child With Seizure

Pediatric Neur olo g y Ca se s Case 3 .

The Child with a Seizure

Sa li ent 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.

Salie nt P oin ts: 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

Ex amin atio n on admissi on: 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

Ne ur o Exam    

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

Is ther e a n eur olo gic dise ase ?  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. 

Se izu r e T ypes:  Partial seizures Simple partial-(as seen in this patient) Jacksonian seizure Complex Partial seizures- behavioral manifestations, with impairment of consciousness.

Se izu r e t yp es  Generalized seizures Tonic Clonic Gran mal (tonic clonic) Myoclonic Absence Atonic  Unclassified seizures

Is ther e a n eur olo gic dise ase ?  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 si mple f ebrile se izu r e? 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 Co mp le x febril e se izu r e?  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 Epil epsy?  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.

Dia gnost ic possib il it ies:  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.

W her e is the le si on?  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.

W hat is th e le sio n?  The acute course should make us consider: infectious vascular trauma paroxysmal

Dia gnostic A ppr oach  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.

T her apeutic A ppr oach  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

Pr ognosis  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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