11 neurological events that aren’t epilepsy

By Dr. Andrew Mower, CHOC Children’s neurologist

You open the exam room door to find an anxious mother pacing with her baby. Her son has been displaying sudden shivering moments, she says. She’s frightened that these episodes were epileptic seizures.

Indeed, watching a child shake and tremble suddenly is worrisome for any parent. But not every paroxysmal event is a seizure or neurological event.

Dr. Andrew Mower, pediatric neurologist at CHOC Children’s

Here are 11 such examples, and a guide to help pediatricians understand what the differential diagnosis is for seizures and other neurological events; recognize elements in the history that helps differentiate whether the paroxysmal spell is a seizure or neurological event or not; and learn what initial diagnostic workup is needed to guide management.

  1. Breath holding

During these episodes, a child appears to stop breathing and may collapse, typically after a startling, frustrating or painful event. The child’s skin may be pale or purple in color, and he may show mild tonic or tonic-clonic movements. Recovery occurs in minutes. The behavior surfaces typically in children between ages 6 months and 2 years.

Though they may appear to be a seizure, these episodes are a physiological response, and not caused by electrical impulses in the brain.

Some factors to consider, however, that would call into question whether this is something other than breath-holding spells include a questionable or unclear trigger, progressively more frequent episodes, movements much more suggestive of a seizure, a very young age of onset, and a child with a developmental delay.

Children showing these red flags may require an EEG. For most, however, a workup is not typically needed, nor is treatment.

Almost all children outgrow breath holding and there is no neurological consequence.

2. Benign paroxysmal vertigo

During these episodes, a child, typically between 1 to 2 years of age, may become suddenly unsteady and fall. The child may become pale, vomit or cry, but retain consciousness. Events last minutes.

These events are considered an early migraine manifestation. Differential diagnoses include labyrinthitis, CNS tumor, epilepsy, unwitnessed head trauma and concussion, near-syncope, cardiac dysrhythmia

More worrisome are events that are unremitting and not episodic; include a loss of consciousness; show other neurological signs such as seizures, weakness or hearing loss; or are experienced by a child with a developmental delay can be more worrisome.

Workup for children exhibiting these events could include a brain MRI, ENT evaluation or EEG.

These episodes are typically not progressive or degenerative, but do indicate a likelihood for migraines in teen and adult years.

3. Shuddering attacks

Patients experiencing these events have shivering moments that last seconds, which can occur sporadically or multiple times a day. They occur most typically in infants ages 6 to 15 months, and they do not lose consciousness.

These events are behavioral, and differential diagnoses include seizure or tics.

Longer episodes; rhythmic twitching; a change of awareness or consciousness; and color change are red flags, as is an event experienced by a child with developmental delay or abnormal exam.

A video captured at home is often sufficient for diagnosis, and no workup is needed. No treatment is necessary for these events, and a child’s prognosis is excellent.

4. Infant gratification

This is a normal phenomenon, more commonly known as masturbation, that can include dystonic posturing, grunting, rocking, eidetic imagery and sweating. Typically experienced by children 2 months to 5 years of age, these events can occur sporadically or multiple times a day.

Children’s skin may change color and they may seem tired afterward. The event can be stopped in progress, but a child may get upset if the parents stop the behavior.

Red flags for this behavior include unresponsiveness, tonic-clonic movements or cyanosis, and a differential diagnosis is partial seizures.

A video captured at home is often sufficient for diagnosis, and no workup is needed. Treatment is behavioral based, and prognosis is excellent.

5. Staring spells

These episodes occur in children of any age, but are common in children with autism. The spells may look like day dreaming or inattention, but are often redirectable.

Often, the events are behavioral or related to frontal lobe processing. Differential diagnoses include absence or complex partial seizures. Episodes wherein children are not redirectable, show a change in coloring or behavior, or have a cognitive decline are more worrisome.

Workups include EEG, ADHD evaluation, neuropsychological evaluation for learning disabilities and cognitive abilities, or a psychological evaluation.

Treatment can include psychology or behavioral therapy, neuropsychology and appropriate educational setting, or stimulant medication as needed.

In general, a child’s prognosis is typically excellent. Children with ADHD have a generally good prognosis, but may have variable response to treatment with stimulant medications. A prognosis for those with learning disabilities depends on the severity, classroom setting and educational factors.

6. Reflux

Shown in younger infants from birth to age 6 months, these events look like twisting and writhing movements that aren’t typically sudden. However, patients may show some sudden flexion and extension of the body, arms or legs. Children’s skin may redden.

Children exhibiting these events may have low muscle tone that contributes to relaxed muscle at esophageal-gastric junction.

Differential diagnoses include seizures, infantile spasms or movement disorders, and red flags include no association with feeding, stereotyped movements like jack-knifing or sudden flexion in clusters, or cyanosis.

Workup includes clinical diagnosis, further investigation following a finding of low tone on exam, sometimes upper GI or other GI studies, EEG or video-EEG monitoring.

Treatment includes H2 blockers or proton pump inhibitors.

Patients’ prognoses are generally excellent with symptoms resolving over time. However, for children with significant GI pathology or neuromuscular conditions, the prognosis is guarded.

7. Tics/Tourette’s syndrome

These episodes include the twitching of one muscle or a group of muscles, but rarely involve larger muscle groups. Though repetitive, they are not typically rhythmic or prolonged. They do not cause falling, and do not typically restrict activities.

They can occur in a variety of ages, and older children may describe a feeling that they must make the movement. Vocal tics include grunting, humming, clicking and sniffling, but rarely formed words.

As pathophysiology, structural and functional neuroimaging studies have shown the involvement of the basal ganglia and related cortico-striato-thalamo-cortical circuits, and the dopaminergic neuronal system.

Differential diagnoses include myoclonic seizures. A change of consciousness, inability to suppress, onset in sleep, and episodes that are rhythmic and repetitive are red flags.

Workup includes a clinical diagnosis, EEG or screening for the presence of ADHD, OCD or other behavioral disorders.

Most children do not need treatment for tics, unless the behavior is disturbing physically or socially. Central alpha agonist medications (Clonodine, Tenex) or dopamine antagonist drugs (Haldol, Risperdal, ORAP, Pimozide) can be useful.

Most children outgrow tics, and up to 15 percent of people diagnosed with Tourette’s outgrow the condition.

8. Stereotypies

Typically shown in early childhood after age 1, these episodes are marked by repetitive stereotyped movements that may or may not be rhythmic. They are self-stimulatory and otherwise without purpose. Examples include hand flapping or rocking. Events may persist into adulthood, especially in patients with autism or an intellectual disability.

These events are behavioral in nature, but a differential diagnosis is automatisms with complex seizures.

Red flags include a change in awareness, which can be difficult to detect in children with autism, and events that are rhythmic and repetitive.

Workup includes and EEG, and treatment is applied behavior analysis or therapy from a psychologist. For children who can be taught not to exhibit the behavior, prognosis is good.

9. Night terrors

These episodes are more common in children around age 3, but can surface earlier and persist into teenaged years and adulthood.

A patient may awake from deep sleep with a terrified look, screaming and showing decreased responsiveness. They may tremble, and episodes may occur several times a night.

Their exact mechanism is unknown, but night terrors may be genetic.

Differential diagnoses include nightmare, seizure, arousal disorder or parasomnia. Episodes are more worrisome if they occur many times a night, include strange repetitive movements like pelvic thrusting or bicycle pedaling motions, or are accompanied by progressive academic or developmental decline.

Workup includes a history and clinical diagnosis, polysomnogram or video EEG sometimes combined with polysomnogram.

Most children grow out of night terrors and do not require treatment, but can benefit from counseling on sleep habits or psychology. Though rarely, medications like clonazepam or amitriptyline can be helpful.

10. Syncope

These events are more common in teenaged patients. They include a sudden and brief loss of consciousness typically with associated loss of muscle tone. Patients may fall or slump forward or backward, and have mild twitching. They might also have a light-headed, giddy feeling or blackening of vision.

Loss of consciousness lasts only seconds, and patients may hear people around them before vision returns. They may feel groggy afterward, but not confused.

Recovery is quick, and episodes typically have a trigger: standing up too quickly, standing in place too long with legs locked, dehydration on a hot day, emotional fright, valsalva including defecation or urination, hair traction, or venipuncture.

These episodes are not a primary neurological event, and a common feature is reduced cerebral perfusions. They stimulate the vagus nerve, which causes bradycardia. Decreased venous tone allows venous pooling and decreased blood return to the heart. Valsalva prevents venous return to heart

Differential diagnoses are complex partial or other types of seizures, or postural orthostatic tachycardia syndrome.

Red flags include no provoking factor, prolonged and prominent tonic-clonic movements or hemi-clonic movements, cyanosis, or occurrence in very young children or those with a neurological or developmental disorder.

Workup includes diagnosis based on clinical history; orthostatic blood pressures; EEG if any red flags are present; and KG/Holter study, tilt-table testing, or cardiology consult if the patient’s clinical history is suggestive of dysrhythmia.

Treatment includes counseling on how to avoid symptoms, including standing up slowly, drinking water and avoiding triggers.

Looking forward, a predisposition to fainting may continue into adulthood. The episodes don’t cause neurologic injury, but a patient could get injured from a fall.

11. Cyclic vomiting

These episodes entail one to five days of copious vomiting, followed by asymptomatic periods. The average age of patients is 5, but episodes can span from infancy to adulthood.

They usually start in early morning or late afternoon. Abdominal pain, anorexia, lethargy, pallor, sweating and salivation accompany the episodes.

Triggers include emotional stress, energy-depleting states, some foods and menstrual cycles.

To diagnose, the patient must have stereotypic episodes of vomiting with at least two acute-onset episodes in the past six months, each occurring at least one week apart and persisting for less than one week.

Red flags include periods of unresponsiveness, tonic-clonic movements, visual changes, other neurological symptoms such as hemiparesis, hematemesis and melena.

Workup includes MRI or GI referral and endoscopy.

IV fluids, anti-nausea medication, pain relief medication is common treatment. Periactin; amitriptyline; antiepileptic medications with migraine indications (Depakote, Topamax, others); and propranolol can be used as prophylactics.

Learn how to refer to a CHO Children’s neurologist.

Patients Say the Darndest Things – Happy Doctor’s Day!

In celebration of Doctor’s Day, we asked a few of our physicians what’s the funniest thing a patient has ever told you?

Dr. Mary Jane Piroutek

Dr. Mary Jane Piroutek, emergency medicine specialist

Q: What’s the funniest thing a patient has ever told you?

A:  Kids say funny things all the time. One of my favorites was a little 4 -year-old girl who had ingested coins and they were stuck in her esophagus. When I asked her what happened she shrugged her shoulder and with a mischievous look in her eyes said, “I ate the money, I’m not supposed to eat the money.”  Also recently a patient told me I looked like Snow White (which I don’t) and she called me Dr. Snow White the whole time I took care of her.

 

Dr. Gary Goodman

Dr. Gary Goodman, medical director, pediatric intensive care unit, CHOC Children’s at Mission Hospital

Q: What’s the funniest thing a patient has ever told you?

A: Just recently, I had a patient, who has a mild developmental delay, call me “the boy.”  I would stop in the patient’s room each morning, at which point I’d get asked, “What do YOU want?”

 

Dr. Kenneth Kwon

Dr. Kenneth Kwon, emergency medicine specialist

Q: What’s the funniest thing a patient has ever told you?

A: An adage in pediatric emergency care is when a child comes in with a nosebleed, you don’t ask if he picks his nose, you ask him which finger he uses. When I asked this question to one of my pint-sized patients, he answered that he used all of them, and then proceeded to demonstrate by sticking each of his 10 fingers in his nose individually. It was priceless.

 

Dr. Maryam Gholizadeh

Dr. Maryam Gholizadeh, general and thoracic surgeon

Q: What’s the funniest thing a patient has ever told you?

A: There was a young child around 8-9 years old and we were going to remove his appendix with laparoscopy. I was standing on his left side because with laparoscopy we make our incision on the left side. Just before he went to sleep he looked up at me and said, “Why are you standing on my left? My appendix is on the right.” I was amazed at how knowledgeable this kid was!

 

Dr. Jennifer Ho

Dr. Jennifer Ho, hospitalist

Q: What’s the funniest thing a patient has ever told you?

A: “I want to be a doctor like you … but only for unicorns and fairies.”

 

Dr. Andrew Mower

Dr. Andrew Mower, neurologist

Q: What’s the funniest thing a patient has ever told you?

A: “I don’t eat apples, doctor.”

“Why?”

“Because they keep the doctor away, and I like you, Dr. Mower.”

 

Dr. Laura Totaro

Dr. Laura Totaro, hospitalist

Q: What’s the funniest thing a patient has ever told you?

A: I was examining the mouth of my patient when he proudly showed me his loose tooth and whispered to me that his family had a secret. He then excitedly admitted that his mom was the tooth fairy!  His mother looked at me quizzically and then burst out laughing when she realized what had taken place. Earlier she had admitted to him that she played the role of tooth fairy at home but her son took this quite literally and believed it to actually be her secret full time job for all children.

 

Dr. Mustafa Kabeer

Dr. Mustafa Kabeer, general and thoracic surgeon

Q: What’s the funniest thing a patient has ever told you?

A: A patient asked me what my first name was, and I told him it was Mustafa. He then promptly told me that was the name of his pet lizard!

 

Dr. Sharief Taraman

Dr. Sharief Taraman, neurology

Q: What’s the funniest thing a patient has ever told you?

A: One of my patients told me that I look like the character Flint Lockwood from Cloudy With A Chance of Meatballs and another one thinks I look like the character Linguini from the movie Ratatouille, both of which I found very funny.  Apparently, I give off the nerdy guy vibe.

ROSA Robot Assists in CHOC Patient’s Successful Epilepsy Surgery

Five-year-old Ian Higginbotham recently enjoyed his best summer yet.  He experienced his first family vacation. He learned to swim and ride a bike. He got himself ready for kindergarten.  These are milestones most kids and parents, alike, eagerly welcome.  But there was a time when Ian’s parents weren’t certain their son, who was born seemingly healthy, would enjoy such happy pastimes.

Ian began talking and walking in his sleep as a toddler.  When the episodes, including night terrors, increased in frequency and severity, his mom Lisa made an appointment with the pediatrician.  One day, Lisa knew something just wasn’t right and didn’t want to wait for the appointment to get Ian checked out.  She and her husband Derek took him to the Julia and George Argyros Emergency Department at CHOC Children’s Hospital.  To her surprise, doctors diagnosed her son with epilepsy.    Ian’s “sleepwalking” and “night terrors” were actually seizures.

The family was referred to CHOC’s comprehensive epilepsy program.  A national leader in pediatric epilepsy care, CHOC’s comprehensive epilepsy program offers cutting-edge diagnostics, innovative medical approaches and advanced surgical interventions.  CHOC was the first children’s hospital in the state to be named a Level 4 epilepsy center by the National Association of Epilepsy Centers, signifying the highest-level medical and surgical evaluation and treatment for patients with complex epilepsy.

CHOC Children's

Ian’s neurologist Dr. Andrew Mower suspected he was experiencing complex partial seizures, which was confirmed by video EEG monitoring.  Complex partial seizures start in a small area of the temporal or frontal lobe of the brain, and quickly involve the areas of the brain affecting alertness and awareness.  The pattern of Ian’s seizures suggested they were originating from the right frontal lobe.  Dr. Mower knew Ian and his family were in for a tough journey.

“I really don’t think the general public understands the impact epilepsy has on a child and his family.  Its effects are multifaceted and extensive.  Our team’s goal is to reduce or eliminate our patients’ seizures, helping improve their quality of life,” explains Dr. Mower, who placed Ian on a series of medications.

The medications reduced Ian’s seizures, but did not control them.  Dr. Mower was concerned about the seizures affecting Ian’s development, and presented his case to the epilepsy team.   The multidisciplinary team agreed Ian was a candidate for epilepsy surgery.  For children who fail at least two medications, surgery may be considered early in treatment versus as a last resort.  Surgery can result in an improvement in seizure control, quality of life, and prevent permanent brain damage.  Ian’s surgery was going to be performed by CHOC neurosurgeon Dr. Joffre Olaya.

While the thought of surgery was frightening to Lisa and her husband, they were confident in the team and comforted to know their son was going to benefit from innovative technology, like the ROSA™ Robot. Considered one of the most advanced robotized surgical assistants, ROSA includes a computer system and a robotic arm.  The computer system offers 3D brain mapping to aid surgeons in locating the exact areas they need to reach and planning the best surgical paths.  The robotic arm is a minimally invasive surgical tool that improves accuracy and significantly reduces surgery/anesthesia time.

Dr. Olaya used ROSA to accurately place electrodes in the area of Ian’s brain suspected to be the source of his seizures.  By using the robot, Dr. Olaya avoided performing a craniotomy.

“ROSA is an amazing tool that yields many benefits for our patients, including less time under anesthesia in the operating room.  It reduces blood loss and risk of infections.  Patients tend to recover faster than they would if they had craniotomy,” says Dr. Olaya.

Lisa was amazed at the outcome. “I couldn’t believe how great Ian looked after the placements of the electrodes with ROSA.  He wasn’t in any pain, there was no swelling.  It was wonderful!”

She and her husband were also amazed at how well Ian did following his epilepsy surgery.

“We got our boy back,” says Lisa. “There were no more side effects from medication and, more importantly, no more seizures!  He started developing again and doing all the things a child his age should do.”

Ian’s care team isn’t surprised by his recovery.

“Children are resilient, and their brains are no different.  In fact, the plasticity of a young brain allows it to adapt to changes and heal more easily than an adult brain,” explains Dr. Mower.

Learning to ride a bike and swim were among the first of many milestones Ian quickly reached following surgery.  He enjoys playing with his younger brother and his friends.  And, whether inspired by his experience with ROSA or not, Ian loves robots.

Meet Dr. Andrew Mower

CHOC Children’s wants its referring physicians to get to know its specialists. Today, meet Dr. Andrew Mower, a pediatric neurologist.

Dr.Andrew_Mower_0699_2

Q: What is your education and training?
A: I attended medical school at St. George’s University School of Medicine in Grenada, West Indies. My residency in pediatrics was at Maimonides Medical Center in New York.  My residency in child neurology was at State University of New York Downstate (SUNY Downstate) in New York. My fellowship in clinical neurophysiology was at Columbia University in New York.

Q: What are your administrative appointments?
A: Quality Improvement Committee since 2016; Ancillary and Diagnostic services since 2015.

Q: What are your special clinical interests?
A: Epilepsy and epilepsy surgery

Q: How long have you been on staff at CHOC?
A: Two years

Q: What are some new programs or developments within your specialty?
A: Stereotactic EEG for epilepsy surgery

Q: What are your most common diagnoses?
A: Epilepsy and headaches

Q: What would you most like community/referring providers to know about you or your division at CHOC?
A: We take on the most challenging epilepsy cases to search for cures, and, if not, at least an improvement in the child and family’s quality of life. We work together as a team to use all of our expertise to help the child and family.

Q:  What inspires you most about the care being delivered here at CHOC?
A: I feel that we offer families hope when hope had been abandoned before.

Q: Why did you decide to become a doctor?
A: I decided to become a doctor to help people in need. I chose neurology as my specialty because I had a fascination with the nervous system and wanted to break misperceptions that little can be done for patients with neurological problems.

Q: If you weren’t a physician, what would you be and why?
A: Farmer. I love the accomplishment of creating a garden and growing produce.

Q: What are your hobbies/interests outside of work?
A: Gardening, running and hiking

Q: What was the funniest thing a patient told you?
A: “I don’t eat apples, doctor.”

“Why?”

“Because they keep the doctor away, and I like you, Dr. Mower.”