Pediatric Neurology Cases
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Transcript 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.
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