MCQsIn Pediatric Seizures

Q 1:

A 6-year-old boy experiences a first generalized tonic-clonic seizure upon awakening. He recovers completely. There is no family history of epilepsy. Upon presentation at the office, the child is afebrile, and findings are normal on general and neurologic examinations. Electroencephalographic findings also are normal.

Of the following, the MOST appropriate management is administration of:

A. carbamazepine

B.  gabapentin

C.  no medication

D.  phenobarbital

E.   valproic acid

Answer

C

Most neurologists would not initiate treatment with an antiepileptic drug following a child’s first afebrile seizure if there is a negative family history and findings on the neurologic examination and electroencephalography are normal.

            Anticonvulsant treatment for a child who has had recurrent seizures begins with a single drug that is matched to the seizure type, based on history and electroencephalographic findings.

Drug choice also is designed to provide efficacy with the fewest possible side effects. For generalized tonic-clonic seizures, carbamazepine, valproic acid, or sometimes phenytoin is selected. Phenobarbital generally is reserved for infants who have had generalized tonic-clonic seizures. For absence seizures, therapy is initiated with ethosuximide or valproic acid. Valproic acid also is used for myoclonic seizures, mixed seizures, and the syndrome of juvenile myoclonic epilepsy.

            Gabapentin is indicated as a second or add-on therapy for refractory partial seizures. The newer drugs, lamotrigine, topiramate, tiagabine, and zonisamide, typically are reserved for add-on or substitution therapy for children whose seizures are recalcitrant

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Q 2

While sitting in an emergency department waiting room, a 5-year-old girl begins to have a generalized tonic-clonic seizure. You are unable to establish intravenous access, and the seizure persists.

Of the following, the MOST appropriate treatment is:

A.  diazepam rectally

B.  lorazepam sublingually

C.  phenobarbital intraosseously

D.  phenytoin intramuscularly

E.  valproic acid rectally

Answer

A

A benzodiazepine is administered first because it is absorbed rapidly into the nervous system. Intravenous lorazepam (0.05 to 0.1 mg/kg) is preferable to diazepam (0.2 to 0.5 mg/kg) because of its longer half-life in the central nervous system. There is no evidence to endorse sublingual administration of these medications. In contrast, there is considerable experience documenting the efficacy of rectal administration of diazepam at the same dose used for intravenous administration. The drug can be administered rectally by syringe with the available intravenous formulation or via a commercially available gel. Both formulations are well absorbed into the bloodstream. Midazolam occasionally is administered intramuscularly, but absorption is variable, and length of effect is unpredictable.

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Q 3:

An 8-year-old child who has complex partial seizures and has been receiving an anticonvulsant for the past year has declining school performance. His parents request counseling about his seizure management.

The statement you are MOST likely to include in your discussion is that:

A.  carbamazepine causes cognitive side effects less frequently than other anticonvulsants

B.   intellectual impairment seldom is associated with epilepsy alone

C.   phenobarbital causes cognitive impairment only when taken at a dosage causing sedation

D.   the ketogenic diet is associated with long-term decline in school performance

E.   valproic acid can cause rage attacks

Answer

A

Certain drugs appear to be especially associated with behavioral and cognitive difficulties. For example, decline in intelligence quotient, decreased attention, depression, or hyperactivity has been reported in 50% or more of patients receiving phenobarbital. Sedation is dose-related, but cognitive impairment can be idiosyncratic. Primidone is metabolized to phenobarbital and may result in similar effects, especially aggressive behavior or personality changes. Benzodiazepines, such as clonazepam or clorazepate, can produce significant behavioral abnormalities as well as drowsiness and irritability. Valproic acid and carbamazepine are associated with fewer cognitive adverse effects. Valproic acid does not produce rage attacks; in fact, it has been used for their treatment. 


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Q 4

A 13-year-old girl has experienced brief, shock-like jerks of her arms and has sometimes inadvertently thrown objects in her hand. This morning she had a generalized tonic-clonic seizure after awakening. Subsequent electroencephalography shows 4 to 5 cycle per second generalized spike and wave discharges with normal background activity.

The statement you are MOST likely to include in your discussion with the family is that:

A.  absence epilepsy frequently resolves after 1 year

B.   ketogenic diet is the treatment of choice

C.   lifelong treatment with valproic acid is likely necessary

D.   no treatment is indicated

E.   rolandic seizures never should be treated with carbamazepine

Answer

The child described in this vignette has juvenile myoclonic epilepsy (myoclonic epilepsy of Janz), which usually begins with epileptic myoclonic jerks between 12 and 16 years of age. A small number of patients may have had antecedent absence seizures. The myoclonic jerks are especially prevalent upon awakening, and the child sometimes inadvertently throws objects during the morning routine, such as reported for the girl in the vignette. The generalized tonic-clonic seizures that also occur in this disorder are of greater concern. Findings on neurologic examination in this disorder are normal, and electroencephalography will show 4 to 6 per second generalized spike or polyspike and wave activity that is enhanced with photic stimulation. Background electrical rhythm is normal. The onset of generalized convulsions clearly mandates treatment. Juvenile myoclonic epilepsy typically responds well to valproic acid, but lifelong treatment usually is required. The ketogenic diet is reserved for use in younger children who have seizures that are recalcitrant to a number of antiepileptic drugs; it is not appropriate for treatment of juvenile myoclonic epilepsy.

The prognosis for remission of seizures in childhood epilepsy relates closely to the etiology of the condition. In general, tapering and stopping anticonvulsant medication should be considered for a child who has been seizure-free for approximately 2 years. A number of risk factors that increase the likelihood of recurrence have been identified in clinical investigations. The most prominent are neurologic dysfunction (motor handicap or mental retardation), seizure onset after age 12 years, history of neonatal seizures, and multiple seizures before control is attained.

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Q 5


A mother brings her 3-year-old boy to the emergency department. She explains that the boy
suddenly stopped paying attention, stared, and had jerking of his arms and legs for about 1
minute. His lips turned blue, and he became incontinent of urine. After the episode, he appeared
confused and became very sleepy. On physical examination, he has a temperature of 104°F
(40°C). Following administration of acetaminophen, his temperature has decreased to 98.6°F
(37°C). He is alert, interactive with his parents, and has normal findings on physical examination.

Of the following, the MOST appropriate next step is to

A. begin therapy with carbamazepine
B. obtain magnetic resonance imaging
C. obtain sleep-deprived electroencephalography
D. perform a lumbar puncture
E. provide the family with education

Answer

E


The family should be educated about febrile seizures. The key components of this education
are: 1) seizure first aid, 2) seizure precautions, 3) risk of recurrence of seizures, and 4)
prognosis.

First aid: If the child has another seizure, he should be placed on the floor on his side, away
from furniture. Some families worry that the child may swallow his tongue and may want to place
a spoon or other object in the mouth to prevent this. Parents should be told that tongue
swallowing cannot and does not occur, and no object should be placed in the child’s mouth. The
parent should time the seizure to be able to report to the doctor its duration. If the seizure lasts 5
minutes, the family should call 911 for emergency assistance.
Precautions: Seizure precautions in children prior to driving age involve “wheels and water.”
This common sense advice includes the wearing of helmets when the child is “on wheels” and
adult supervision whenever the child is in water, including bath water. The child can sleep in his
or her own bed and does not need to sleep with a parent.
Recurrence risk: In an otherwise healthy child who experiences a single, simple febrile
seizure, the recurrence risk for febrile seizures is about 33%.
Prognosis: There is no evidence that simple febrile seizures cause brain damage. The
family should be reassured that the risk of epilepsy, ie, recurrent nonfebrile seizures, is less
than 5%.

For a 3-year-old child who has a febrile seizure, the focus of the diagnostic evaluation is on
the cause of the illness, not on the brain. Neuroimaging is not needed. In the absence of
encephalopathy and at age 3 years, lumbar puncture is not recommended routinely. Lumbar
puncture is recommended in children younger than 18 to 24 months of age and based on clinical
judgment in other settings. There is no role for electroencephalography in the evaluation of a
child who has a febrile seizure because it does not provide information that affects management.
Daily anticonvulsant medications such as carbamazepine are not prescribed after one or a
few febrile seizures. Some physicians prescribe rectal diazepam or intranasal midazolam to all
children after a single seizure to be used in the future should a prolonged seizure occur. This is
especially important for a child who had a febrile seizure lasting more than 5 minutes, is
medically fragile, or has limited access to medical facilities

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Q 6:


Which of the following drugs could cause hyponatremia?

(A) carbamazepine
(B) phenytoin
(C) oxcarbazepine
(D) felbamate
(E) topiramate
(F) A, C, and D


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Q 7:


Which anticonvulsive drug treatment has a higher incidence of kidney stones?

(A) phenytoin
(B) carbamazepine
(C) topiramate
(D) tiagabine