Can post‑ictal drowsiness in children be associated with an extensor plantar (Babinski) response?

Post-Ictal Extensor Plantar Response in Children

Yes, post-ictal drowsiness in children can present with extensor plantar responses (Babinski sign), and this is a recognized transient phenomenon that occurs after epileptic seizures, particularly tonic-clonic seizures. 1

Frequency and Clinical Significance

• Extensor plantar responses (EPRs) occur after approximately 27% of all epileptic seizures and are found in 42% of patients with epilepsy. 1
• After tonic-clonic seizures specifically, EPRs are present in 52% of cases, making this a common post-ictal finding. 1
• These responses represent temporary pyramidal tract dysfunction that resolves as the post-ictal state clears. 2

Lateralization Value

• Unilateral extensor plantar responses are usually contralateral to the side of seizure onset, providing valuable lateralizing information during the post-ictal examination. 1
• This lateralizing sign can help identify the epileptogenic hemisphere in patients being evaluated for focal epilepsy. 3, 1

Mechanism and Pathophysiology

• The Babinski sign indicates dysfunction of pyramidal tract fibers, which can be structural or functional. 4, 2
• Babinski himself recognized in 1896 that the extensor plantar response transiently appears in epilepsy, distinguishing it from permanent pyramidal lesions. 2
• The post-ictal EPR represents temporary pyramidal tract dysfunction from the seizure discharge, not a structural lesion. 4, 2

Differentiation from Psychogenic Seizures

• Extensor plantar responses are NOT found after psychogenic (non-epileptic) seizures, making this a useful distinguishing feature. 1
• This can help differentiate true epileptic seizures from psychogenic events during the post-ictal period. 1

Clinical Management Implications

• Children should be monitored for at least 5-10 minutes after seizure activity stops to ensure return to baseline mental status. 5
• The presence of an extensor plantar response during this period is expected and does not require emergency intervention unless accompanied by other concerning features. 5, 1
• If the child does not return to baseline within 5-10 minutes after the seizure stops, emergency services should be activated. 5

Important Caveats

• The extensor plantar response should resolve as the post-ictal state clears; persistent EPR beyond the immediate post-ictal period warrants further neurological evaluation. 5, 6
• In children under 18 months with post-ictal drowsiness and EPR, lumbar puncture should be strongly considered to rule out meningitis, as these children may have unduly prolonged drowsiness from central nervous system infection. 5
• Increased deep tendon reflexes and abnormal plantar reflexes together suggest upper motor neuron dysfunction and require differentiation between transient post-ictal changes versus structural pathology. 5, 7