New onset focal seizures in 5 year old

[Javalavashiloh]

Hello - my 5 year old daughter had 2 seizures on May 17.  One at preschool while falling asleep for nap, and the 2nd at home while falling asleep at bedtime.  Both were similar: noticed b/c she was making a gurgling noise -about 30 seconds of severe drooling, mouth jerking to the left, eyes glazed.  Was normal afterward.  No seizures since.  Was seen by peds neurology that Monday and neuro exam normal. Discussed possibilities (BRE) and need for EEG and MRI as well since her sz were partial.  EEG performed May 23 - neurologist called to report that it did not look like benign rolandic epilepsy.  Placed her on Keppra and MRI is being scheduled.

Details of sleep deprived EEG: Frequent high-amplitude monomorphic spike & wave complexes in the left occipital head region that are highly focal. Also somewhat frequent independently occuring right hemisphere spikes, max in the centro-temporal region.  When she fell asleep, spikes in L & R hemisphere continue independently and sometimes rhythmically. L occipital spikes rhythmic 2-4 seconds. R hemisphere spikes 30-60 seconds.   Interpretation: independent spike foci in L occipital region and R centro-temporal regoin.  Occur rhythmically on some occasions but are not sufficiently sustained and do not evolve, so are not particularly suspicious for electrographic seizures.

We are in contact with our neurologist, and understand we need to wait for an MRI, but I am just trying to find as much info as possible.  Of course our fear is that there is something in her brain causing this due to the focal occipital spikes.  If the MRI is normal would the reading based on her seizures and the EEG be a variant of childhood epilepsy?  Have you ever seen an EEG reading like this that did not represent something structural in the brain?  I also don't completely understand what the last sentence of the EEG interpretation means. If the activity is not "suspicious for seizures", then why is she now on Keppra?  
Thank you so so much.  

[Christopher R Newey, DO]

Thanks for using the forum. I am happy to address your questions, and my answer will be based on the information you provided here. Please make sure you recognize that this forum is for educational purposes only, and it does not substitute for a formal office visit with a doctor.

Without the ability to examine and obtain a history, I can not tell you what the exact cause of the symptoms is. However I will try to provide you with some useful information.

Without the ability to examine and obtain a history and view the EEG myself, (EEGs can be different based on the experience of the person reading the EEG), I cannot tell you what the exact cause of the symptoms is. However I will try to provide you with some useful information.

A sharp wave (or spike) is a transient high-voltage waveform that when found in certain clinical contexts are called “epileptiform discharges” suggestive of a region of the brain, particularly the temporal lobe, that is susceptible to seizure. There are several ways electrophysiologists use to elicit epileptiform discharges. These include sleep deprivation, photic stimulation, and hyperventilation.

It sounds like your child has bilateral spikes, which makes it suspicious for a generalized epilepsy. However, if it is a focal epilepsy, the concern would be for a structural cause such as a mass or malformation (to name a few). The MRI would be useful to determine this. If someone has a seizure (especially more than one) and there are abnormalities on the EEG that suggests epilepsy (i.e., spikes or sharp waves), then treating with an antiepileptic is typical.

Has her development and birth history been unremarkable? Is she neurologically “normal”? Has she ever had a febrile seizure? Is there a family history of seizures? Has she ever had head trauma or meningitis?

You should continue following up with the pediatric neurologist.

Thank you for this opportunity to answer your questions, I hope you find the information I have provided useful, good luck.

[Javalavashiloh]

Dear Dr. Newey - thank you so much for your response.  My daughter's MRI is scheduled for Thursday of this week.

No family hx of seizures.  No febrile sz. No meningitis or head trauma.  Her birth was normal except that her heart rate had dropped and they almost performed an emergency c-section.  Her development has been normal except for growth (0% weight on the chart, 15% for height) which was eventually attributed to functional constipation (with an admission to hospital at 10 months old with poor feeding, night-time vomiting, and weight loss) - xrays showed that she was packed with stool.  She is bright and school reports (pre-K) are normal.  I do notice some OCD-like behavior with her - namely, smelling things.  She smells everything and over the past 2 weeks has been smelling her hands a lot of the time.   She has had no further seizures (that we have seen) since starting Keppra, but last night I did notice that while outside playing, she came over to me, looked a little weird, I saw some twitching of her left eye and mouth - but she remained conscious and after a few moments went back to playing.  I'm not sure what that was?  But her seizures were limited to her face, mostly to the left.

Thank you so much for the info - extremely helpful!