A 4-year-old girl is brought to the emergency room due to seizures. Two hours ago, the patient reported a headache and was given acetaminophen; an hour later, she suddenly had a generalized tonic-clonic seizure that lasted 5 minutes. While en route to the hospital, the patient had another seizure that manifested as right arm shaking. She has no history of prior seizures, recent trauma, or recent infectious illness. The patient is up to date on vaccinations, has no medical conditions or developmental delay, and takes no medications. Temperature is 36 C (96.8 F), blood pressure is 92/60 mm Hg, pulse is 88/min, and respirations are 15/min. Oxygen saturation is 98% on room air. On examination, the patient is lethargic but opens her eyes to voice. She follows commands and answers questions with a single word. The head is normocephalic and atraumatic. The pupils are equal, round, and reactive to light. The neck is supple without meningeal signs. Muscle strength is decreased in the right upper and lower extremities. Point-of-care blood glucose is normal. CT scan of the head without contrast reveals no abnormalities. Complete blood count and serum electrolytes are normal. Appropriate seizure therapy is initiated, and electroencephalography is requested. What is the most appropriate next step in management of this patient?

Question

A 4-year-old girl is brought to the emergency room due to seizures.  Two hours ago, the patient reported a headache and was given acetaminophen; an hour later, she suddenly had a generalized tonic-clonic seizure that lasted 5 minutes.  While en route to the hospital, the patient had another seizure that manifested as right arm shaking.  She has no history of prior seizures, recent trauma, or recent infectious illness.  The patient is up to date on vaccinations, has no medical conditions or developmental delay, and takes no medications.  Temperature is 36 C (96.8 F), blood pressure is 92/60 mm Hg, pulse is 88/min, and respirations are 15/min.  Oxygen saturation is 98% on room air.  On examination, the patient is lethargic but opens her eyes to voice.  She follows commands and answers questions with a single word.  The head is normocephalic and atraumatic.  The pupils are equal, round, and reactive to light.  The neck is supple without meningeal signs.  Muscle strength is decreased in the right upper and lower extremities.  Point-of-care blood glucose is normal.  CT scan of the head without contrast reveals no abnormalities.  Complete blood count and serum electrolytes are normal.  Appropriate seizure therapy is initiated, and electroencephalography is requested.  What is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

This patient's right-sided weakness and aphasia (eg, single-word answers in a developmentally normal child age 4) are concerning for acute ischemic stroke (AIS). In young children (eg, age <6), AIS often presents differently than in older children and adults. In particular, young children are more likely to have nonlocalizing symptoms such as headache (25%-50%), generalized or focal seizures (15%-25%), and altered mental status (eg, lethargy), in addition to the classic focal neurologic deficits. In this pediatric patient with suspected AIS, MRI with MR angiography (MRA) should be urgently performed. Although a noncontrast CT scan of the head may be obtained initially to rule out hemorrhagic stroke, MRI/MRA is more sensitive than CT scan in the diagnosis of AIS. Obtaining an MRI/MRA is particularly important in pediatric patients because stroke mimics (eg, Todd paralysis, complicated migraine) are common and the etiology of stroke is more varied than in adults. Rapid diagnosis of AIS is essential for determining eligibility for time-dependent reperfusion therapies such as intravenous thrombolysis or mechanical thrombectomy. etiology of stroke (Choice A) Sickle cell disease, which is diagnosed using hemoglobin electrophoresis, is a common cause of pediatric stroke; however, it is unlikely in a previously healthy 4-year-old with a normal hemoglobin level and no family history of sickle cell disease. (Choice B) CNS infections such as meningitis, which is diagnosed using lumbar puncture, can cause headache, lethargy, and seizures. However, meningeal signs, as well as a history of febrile illness for up to several days prior to development of severe symptoms, are commonly present. This patient has no meningeal signs or fever, and her symptom onset was more acute (eg, over 2 hr). (Choice D) Todd paralysis, which requires no additional testing, can manifest as transient focal deficits (eg, aphasia, unilateral weakness) following a seizure. However, it is a diagnosis of exclusion that requires first ruling out AIS (eg, with MRI). (Choice E) Serum prolactin levels, which are usually elevated immediately following seizure, are used primarily to differentiate seizure from pseudoseizure (psychogenic nonepileptic seizure) in adults; they are not recommended in the routine evaluation of patients with suspected AIS. Educational objective: Young children (eg, age <6) with stroke often have nonfocal symptoms (eg, headaches, seizures, lethargy), in addition to classic focal neurologic deficits. Urgent MRI/MR angiography should be obtained to confirm the diagnosis and determine eligibility for potential reperfusion therapies. References: A systematic review of the use of opioid medication for those with moderate to severe cancer pain and renal impairment: a European Palliative Care Research Collaborative opioid guidelines project. (http://www.ncbi.nlm.nih.gov/pubmed/21708859) Opioid management in older adults with chronic kidney disease: a review. (http://www.ncbi.nlm.nih.gov/pubmed/31295441)

A 4-Year-Old Girl Is Brought to the Emergency Room Due