What further investigations are warranted in a child who experienced a generalized tonic-clonic (Grand mal) seizure following a common cold (upper respiratory tract infection) with fever, now presenting as afebrile?

From the Guidelines

For a child who experienced a Grand mal seizure associated with fever during a common cold but is now afebrile, the most appropriate next step is to perform an MRI of the head, as it is more sensitive than CT in detecting brain abnormalities, which can help identify underlying causes of the seizure, such as developmental abnormalities, hemorrhage, neoplasm, or gliosis 1. This approach is supported by the fact that MRI has been shown to detect focal brain abnormalities in 55% of children with seizures, whereas CT was positive in only 18% of children 1. Additionally, MRI is superior to CT in identifying peri-ictal cortical abnormalities that might explain clinical deficits after acute seizure 1. The child's presentation with a Grand mal seizure, even if associated with a fever, warrants further investigation to rule out underlying neurological conditions, such as epilepsy or structural brain abnormalities. While simple febrile seizures typically don't require extensive workup, a Grand mal seizure is a more significant concern, and an MRI can help guide management decisions. Some may argue that an EEG should be the first step, but given the higher sensitivity of MRI in detecting brain abnormalities, it is a more appropriate initial investigation in this case. Basic labs to rule out metabolic causes may also be considered, but the primary focus should be on neuroimaging to identify any underlying structural abnormalities. It's worth noting that the guidelines for managing febrile seizures suggest that simple febrile seizures do not require extensive workup, but this child's presentation with a Grand mal seizure necessitates a more thorough evaluation 1. The use of anticonvulsant therapy may be considered if the MRI or EEG reveals underlying epilepsy or other neurological conditions, but this should be determined on a case-by-case basis. In terms of specific protocols, an optimized epilepsy protocol with adequate spatial resolution and multiplanar reformatting is essential for detecting epileptogenic lesions 1. The region of onset should be identified by clinical and EEG findings to guide the selection of specific protocols. Overall, the priority should be to identify any underlying causes of the seizure and to guide management decisions, with a focus on minimizing morbidity, mortality, and improving quality of life.

From the Research

Further Investigations for a Child with a Generalized Tonic-Clonic Seizure

Following a common cold with fever, now presenting as afebrile, several factors should be considered for further investigations:

• The child's age, as the risk of febrile seizure recurrence decreases linearly with increasing age 2
• The type of seizure, as simple febrile seizures have a higher likelihood of causing temporal lobe epilepsy than complex febrile seizures 3
• Electroencephalography (EEG) findings, as abnormal EEG results can be an independent risk factor for febrile seizure recurrence 2
• Neuroimaging studies, as they can be critical in determining the etiology and syndrome of the seizure 4, 5
• Family history, as idiopathic generalized epilepsies with pure grand mal have a high concordance rate within the syndrome 6
• Developmental and neurologic status, as predictors of poor neurodevelopmental outcome and problematic seizures can be identified at diagnosis 4

Potential Diagnostic Tests

• EEG to assess for abnormal activity or epileptiform discharges 2, 4, 6
• Neuroimaging studies, such as computed cerebral tomography scans (CCT) or magnetic resonance imaging (MRI), to rule out any underlying structural abnormalities 4, 6
• Genetic testing, as it can be a high-yield endeavor in early-life epilepsies 5
• Metabolic, hematologic, and chemistry tests to rule out any underlying metabolic or systemic disorders 4