A practical approach to uncomplicated seizures in children.

Uncomplicated seizures and epilepsy are common in infants and children. Family physicians should be aware of certain epilepsy syndromes that occur in children, such as febrile seizures, benign focal epilepsy of childhood, complex partial epilepsy, juvenile myoclonic epilepsy and video game-related epilepsy. Not all uncomplicated childhood seizures require neuroimaging or treatment. Febrile seizures, rolandic seizures and video game-related seizures are childhood epileptic syndromes that are typically not associated with brain structural lesions on computed tomography or magnetic resonance imaging, and are often not treated with anticonvulsant drugs. Juvenile myoclonic epilepsy does not require neuroimaging but does require treatment because of a high rate of recurrent seizures. Complex partial epilepsy often requires both neuroimaging and treatment. Although seizures are diagnosed primarily on clinical grounds, all children with a possible seizure (except febrile seizures) should have an electroencephalogram. Interictal EEGs may be normal. Computed tomography has demonstrated abnormalities in 7 to 19 percent of children with new-onset seizures. The yield of magnetic resonance imaging for specific childhood seizure types is not known, but it is the preferred modality of neuroimaging for many clinical presentations. Most children's seizures treated with anticonvulsants are controlled by the first drug selected. The value of "therapeutic' serum drug levels is questionable in the management of uncomplicated childhood seizures.

Prolonged survival with hydranencephaly: report of two patients and literature review.

Infants with hydranencephaly are presumed to have a reduced life expectancy, with a survival of several weeks to months. Rarely, patients with prolonged survival have been reported, but these infants may have had other neurologic conditions that mimicked hydranencephaly, such as massive hydrocephalus or holoprosencephaly. We report two infants with prenatally acquired hydranencephaly who survived for 66 and 24 months. We reviewed published reports to ascertain the clinical and laboratory features associated with survival of more than 6 months. This review demonstrates that prolonged survival up to 19 years can occur with hydranencephaly, even without rostral brain regions, with isoelectric electroencephalograms, and with absent-evoked potentials. Finally, the ethical aspects of these findings, as they relate to anencephaly and organ transplantation, are discussed.

Tourette syndrome associated with unilateral cystic changes in the gyrus rectus.

Brain magnetic resonance imaging of an 11-year-old male with Tourette syndrome demonstrated multicystic changes predominately in the gyrus rectus of the left frontal lobe. Other brain regions, including the basal ganglia, were normal. He did not have any symptoms of the comorbid conditions associated with Tourette syndrome, such as attention-deficit disorder or obsessive-compulsive disorder. The possible neurobiologic connection between Tourette syndrome and the gyrus rectus and its interconnecting pathways is discussed.

Osteopathic physicians and expert medical testimony.

The US Supreme Court addressed the issue of expert medical and scientific testimony in the 1993 case Daubert v Merrell Dow Pharmaceuticals, Inc. The guidelines to be used as a standard for expert medical witnesses under Daubert differ from earlier standards used by many courts for more than 70 years. This commentary reviews the history of previous and current standards used to determine admissibility of medical testimony in legal proceedings and discusses the ramifications of these standards for osteopathic physicians involved in the medical malpractice process.

Intracranial hematoma in experienced teenage equestrians.

Intracranial hematoma in pediatric equestrians is rare, notwithstanding the lack of uniform standards and requirements for the use of protective headgear during equestrian events. We report two teenage helmeted equestrians who sustained severe head trauma with intracranial hematoma due to falls during equestrian events. Current recommendations for the use of equestrian headgear are reviewed.

Complete heart block in nonfamilial hyperekplexia.

An infant with nonfamilial hyperekplexia had multiple episodes of tonic spasms that mimicked tonic seizures. They were accompanied by complete heart block and apnea. These episodes did not correlate with electroencephalographic epileptiform changes and were partially responsive to clonazepam, valproic acid, and cardiac pacemaker. Sudden death in hyperekplexia may be related to complete heart block and apnea during seizurelike episodes.

Value of MRI in pediatric migraine.

Twenty four pediatric migraineurs were prospectively evaluated to determine if white matter hyperintensities were present on magnetic resonance imaging (MRI). None had white matter findings or brain abnormalities. Five had mucoperiosteal thickening of the paranasal sinuses, which were unrelated to the patients' clinical course. MRI white matter findings are probably not a common occurrence in pediatric migraineurs. In addition, MRI sinus findings are not necessarily related to a child's headache complaints.

Resolving MRI lesions in lupus erythematosus selectively involving the brainstem.

An adolescent girl with systemic lupus erythematosus presented with selective brainstem dysfunction as the initial sign of central nervous system involvement. Although computed tomography was initially normal, magnetic resonance imaging demonstrated multiple, large brainstem lesions. Serial magnetic resonance imaging, which revealed resolution of most of these lesions, correlated with a good clinical outcome. We postulate that this magnetic resonance imaging pattern represents microinfarction with surrounding edema.

Results of computed tomography in "neurologically normal" children after initial onset of seizures.

A combined retrospective and prospective study assessed the results of computed tomographic (CT) scans in infants and children without neurologic deficit who presented with initial onset of seizures. Of 101 pediatric patients, 81 had afebrile seizures and 20 had complicated febrile seizures (i.e., focal, multiple, or prolonged). Seven children (7%), 6 with afebrile and 1 with a febrile seizure, had CT abnormalities. Four patients (4%) required further diagnostic workup including angiography and/or surgery. Children with afebrile focal seizures were more likely to have an abnormality than those with afebrile generalized seizures without focal components (13% and 4.9%, respectively). This study demonstrated a lower percentage of overall CT abnormalities, yet a similar percentage of "therapeutically important" abnormalities, in neurologically normal children with new onset of seizures when compared to previous reports of children with chronic seizures. Although an abnormal CT was more likely to be associated with an abnormal electroencephalogram, a normal result did not eliminate the possibility of an abnormal CT.