Epileptic seizures as presenting symptom of the shaken baby syndrome

Clinical history: A 5-month-old boy, born at term after normal delivery, was admitted after onset of focal seizures with secondary generalization. He appeared to be drowsy. The parents reported that the child had lost consciousness after bumping his head on a baby chair and that his father had immediately shaken the boy with the intent of bringing him back to consciousness. Examination: On initial evaluation, the child was alert and responsive, with no neurological signs. Special studies Routine laboratory investigations were normal. Computerized tomography (CT) of the brain showed acute subdural hematomas along the posterior cerebral falx and posterior fossa and in the posterior surface of the occipital lobes (Fig.1 a, b). Phenobarbital was introduced, with consequent control of generalized seizures, but persistence of subclinical multifocal seizure activity on the EEG. Follow-up: Brain magnetic resonance imaging (MRI), performed 4 days later, revealed extensive areas of low intensity signal of the cortex and white matter in the frontal and temporal lobes (Fig. 2b). Extensive restriction of diffusion in the white matter, suggestive of severe ischemia, was seen using diffusion-weighted sequences (Fig. 2a). Ophthalmologic examination revealed retinal hemorrhages confined to the posterior pole and rare flame-shaped hemorrhages. Video-EEG monitoring on the fifth day after onset of symptoms demonstrated alternating ictal activity originating from either the left or the right frontocentro-temporal area, without any clinical symptoms (Fig. 3a, b). Due to persisting seizure, activity carbamazepine was introduced, which terminated seizures. Follow-up MRI, 17 days later, showed residual left hemispheric and basal occipital hematomas, with recent internal bleedings and subcortical atrophy (Fig. 2c). Therefore the hematoma was drained and a subdural-peritoneal shunt placement was performed. Two months after admission, the boy was discharged from hospital with a clinical picture including spastic quadriparesis, defective eye tracking, irritability, and impaired social interaction and communication.