Posterior Reversible Encephalopathy Syndrome in Pediatric Hematologic- Oncologic Disease: Literature Review and Case Presentation

Mohammad Thaghi ARZANIAN, Bibi Shahin SHAMSIAN*, Parvaneh KARIMZADEH, Mohammad KAJIYAZDI, Fatima MALEK, Mohammad HAMMOUD

Iranian Journal of Child Neurology, Vol. 8 No. 2 (2014), 22 April 2014 , Page 1-10

How to Cite This Article: Arzanian MT, Shamsian BSh, Karimzadeh P, Kajiyazdi M, Malek F, Hammoud M. Posterior Reversible Encephalopathy Syndrome in Pediatric Hematologic-Oncologic Disease: Literature Review and Case Presentation. Iran J Child Neurol. 2014 Spring 8(2):1-10.


Posterior reversible encephalopathy syndrome (PRES) is a cliniconeuroradiological disease entity, which is represented by characteristic magnetic resonance imaging (MRI) findings of subcortical/cortical hyperintensity in T2-weighted sequences. It is more often seen in parietaloccipital lobes, and is accompanied by clinical neurological changes. PRES is a rare central nervous system (CNS) complication in patients with childhood hematologic-oncologic disese and shows very different neurological symptoms between patients, ranging from numbness of extremities to generalized seizure.
In this article, we will review PRES presentation in hematologic-oncologic patients. Then, we will present our patient, a 7-year-old boy with Evans syndrome on treatment with cyclosporine, mycophenolate mofetil (MMF) and prednisone, with seizure episodes and MRI finding in favour of PRES.



1. De Laat P, Te Winkel ML, Devos AS, Catsman-Berrevoets CE, Pieters R, van den Heuvel-Eibrink MM. Posterior reversible encephalopathy syndrome in childhood cancer. Ann Oncol 2011;22(2):472-8.

2. Siebert E, Spors B, Bohner G, Endres M, LimanTG. Posterior reversible encephalopathy syndrome in children: radiological and clinical findings - a retrospective analysis of a German tertiary care center. Eur J Paediatr Neurol 2013;17(2):169-75.

3. Lucchini G, Grioni D, Colombini A, Contri M, De Grandi C, Rovelli A, et al. Encephalopathy Syndrome in Children With Hemato-Oncological Disorders Is Not Always Posterior and Reversible. Pediatr Blood Cancer 2008;51:629–33.

4. Kim SJ, Im SA, Lee JW, Chung NG, Cho B, Kim HK. Predisposing Factors of Posterior Reversible Encephalopathy Syndrome in Acute Childhood Leukemia. Pediatr Neurol 2012;47(6):436-42.

5. Endo A, Fuchigami T, Hasegawa M, Hashimoto K, Fujita Y, Inamo Y , et al. Posteriorreversible encephalopathy syndrome in childhood: report of four cases and review of the literature. Pediatr Emerg Care 2012;28(2):153-7.

6. Won SC, Kwon SY, Han JW, Choi SY, Lyu CJ. Posterior Reversible Encephalopathy Syndrome in Childhood with Hematologic/Oncologic Diseases. J Pediatr Hematol Oncol 2009;31(7):505-8.

7. Legriel S, Pico F, Azoulay E. Understanding Posterior Reversible Encephalopathy Syndrome. Annual update in intensive care and emergency medicine. Springer; 2011.P.631-653.

8. Malbora B, Avcı Z, Donmez F, Alioğlu B, Alehan F, Alehan F, et al. Posterior reversible leukoencephalopathy syndrome in children with hematologic disorders. Turk J Hematol 2010;27(3):168-76.

9. Komur M, Delibas A, Arslankoylu AE, Okuyaz C, Kara E.. Recurrent and atypical posterior reversible encephalopathy syndrome in a child with hypertension. Ann Indian Acad Neurol 2012;15(3):208-10.

10. Dzudie A, Boissonnat P, Roussoulieres A, Cakmak, Mosbah K, Bejui FT, et al. Cyclosporine-Related Posterior Reversible Encephalopathy Syndrome After Heart Transplantation: Should We Withdraw or Reduce Cyclosporine?: Case Reports. Transplant Proc 2009;41(2):716-20.

11. Fuchigami T, Inamo Y, Hashimoto K, Yoshino Y, Abe O, Ishikawa T, et al. Henoch-schönlein purpura complicated by reversible posterior leukoencephalopathy syndrome. Pediatr Emerg Care 2010;26(8):583-5.

12. Incecik F, Hergüner MO, Altunbasak S, Erbey F, Leblebisatan G. Evaluation of nine children with reversible posterior encephalopathy syndrome. Neurol India 2009;57(4):475-8.

13. Chandramohan V, Nagarajan VP, Sathyamoorthi MS, Kumar S, Shanmugasundaram C, Periakaruppan G, et al. Posterior reversible encephalopathy syndrome in a child with autoimmune lymphoproliferative syndrome: Case report and review of literature. J Pediatr Neurosci 2012;7(3):221-4.

14. Wright KL, Polito MH, French AE. Posterior Reversible Encephalopathy Syndrome: A Case Study. Am J Nurs 2012;112(5):36-40.

15. Pedraza R, Marik PE, Varon J. Posterior Reversible Encephalopathy Syndrome: A Review.Crit Care & Shock 2009;12:135-43.

16. Morris EB, Laningham FH, Sandlund JT, Khan RB. Posterior reversible encephalopathy syndrome in children with cancer. Pediatr Blood Cancer 2007;48(2):152-9. 

Efficacy of Chloral Hydrate-Hydroxyzine and Chloral Hydrate-Midazolam in Pediatric Magnetic Resonance Imaging Sedation

Razieh FALLAH, Nafiseh FADAVI, Shekofah BEHDAD, Mohammad FALLAH TAFTI*

Iranian Journal of Child Neurology, Vol. 8 No. 2 (2014), 22 April 2014 , Page 11-17

How to Cite This Article: Fallah R, Fadavi N, Behdad Sh, Fallah Tafti M. Efficacy of Chloral Hydrate-Hydroxyzine and Chloral Hydrate-Midazolam in Pediatric Magnetic Resonance Imaging Sedation. Iran J Child Neurol. 2014 Spring 8(2):11-17.


Magnetic resonance imaging (MRI) is a useful diagnostic tool for the evaluation of congenital or acquired brain lesions. But, in all of less than 8-year-old children, pharmacological agents and procedural sedation should be used to induce
motionless conditions for imaging studies. The purpose of this study was to compare the efficacy and safety of combination of chloral hydrate-hydroxyzine (CH+H) and chloral hydrate-midazolam (CH+M) in pediatric MRI sedation.

Materials & Methods
In a parallel single-blinded randomized clinical trial, sixty 1-7-year-old children who underwent brain MRI, were randomly assigned to receive chloral hydrate in a minimum dosage of 40 mg/kg in combination with either 2 mg/kg of
hydroxyzine or 0.5 mg/kg of midazolam. The primary outcomes were efficacy of adequate sedation (Ramsay sedation score of five) and completion of MRI examination. The secondary outcome was clinical side-effects.

Twenty-eight girls (46.7%) and 32 boys (53.3%) with the mean age of 2.72±1.58 years were studied. Adequate sedation and completion of MRI were achieved in 76.7% of CH+H group. Mild and transient clinical side-effects, such as vomiting of one child in each group and agitation in 2 (6.6 %) children of CH+M group, were also seen. The adverse events were more frequent in CH+M group.

Combinations of chloral hydrate-hydroxyzine and chloral hydrate-midazolam were effective in pediatric MRI sedation; however, chloral hydrate-hydroxyzine was safer.



1. Lehman RK, Schor NF. Neurologic Evaluation. In:Kliegman RM, Stanton BF, Schor NF, St. Geme JW,Behrman RE, editors. Nelson Textbook of Pediatrics.19th ed. Philadelphia: Saunders; 2011. p. 2013-7.

2. Sahyoun C, Krauss B. Clinical implications of pharmacokinetics and pharmacodynamics of procedural sedation agents in children. Curr Opin Pediatr 2012;24:225-32.

3. Mason KP, Prescilla R, Fontaine PJ, Zurakowski D. Pediatric CT sedation: comparison of dexmedetomidine and pentobarbital. AJR Am J Roentgenol 2011;196(2):W194-8.

4. Schulte-Uentrop L, Goepfert MS. Anaesthesia or sedation for MRI in children. Curr Opin Anaesthesiol 2010;23(4):513-7.

5. Freeman JM. The risks of sedation for electroencephalograms: data at last. Pediatrics 2001; 108(1):178.

6. Cortellazzi P, Lamperti M, Minati L, Falcone C, Pantaleoni C, Caldiroli D. Sedation of neurologically impaired children undergoing MRI: a sequential approach. Paediatr Anaesth 2007;17(7):630-6.

7. Haselkorn T, Whittemore AS, Udaltsova N, Friedman GD. Short-term chloral hydrate administration and cancer in humans. Drug Saf 2006; 29(1):67-77.

8. Costa LR, Costa PS, Brasileiro SV, Bendo CB, Viegas CM, Paiva SM. Post-Discharge Adverse Events following Pediatric Sedation with High Doses of Oral Medication. J Pediatr 2012;160(5):807-13.

9. da Costa LR, da Costa PS, Lima AR. A randomized double-blinded trial of chloral hydrate with or without hydroxyzine versus placebo for pediatric dental sedation. Braz Dent J 2007;18(4):334-40.

10. Klein EJ, Brown JC, Kobayashi A, Osincup D, Seidel K. A randomized clinical trial comparing oral, aerosolized intranasal, and aerosolized buccal midazolam. Ann Emerg Med 2011;58(4):323-9.

11. Johnson E, Briskie D, Majewski R, Edwards S, Reynolds P. The physiologic and behavioral effects of oral and intranasal midazolam in pediatric dental patients. Pediatr Dent 2010;32(3):229-38.

12. Wetzel RC. Anesthesia, Perioperative Care, and Sedation. In: Kliegman RM, Stanton BF, Schor NF, St. Geme JW, Behrman RE, editors. Nelson Textbook of Pediatrics. 19th ed. Philadelphia: Saunders; 2011. p. 359-60.

13. Cote CJ, Wilson S. Guidelines for monitoring and management of pediatric patients during and after sedation for diagnostic and therapeutic procedures: an update. Pediatrics 2006;118(6):2587-602.

14. Ramsay MA, Savege TM, Simpson BR, Goodwin R. Controlled sedation with alphaxalone-alphadolone. Br Med J 1974;2(5920):656-9.

15. Fallah R, Jalili Sh, Golestan M, Akhavan Karbasi S, Jarahzadeh MH. Efficacy of chloral hydrate and promethazine for sedation during electroencephalography in children; a randomised clinical trial. Iran J Pediatr 2013;23(1):27-31.

16. Fallah R, Nakhaei MH, Behdad S, Moghaddam RN, Shamszadeh A. Oral chloral hydrate vs. intranasal midazolam for sedation during computerized tomography. Indian Pediatr 2013;50(2):233-5.

17. Mason KP, Sanborn P, Zurakowski D, Karian VE, Connor L, Fontaine PJ, et al. Superiority of pentobarbital versus chloral hydrate for sedation in infants during imaging. Radiology 2004;230(2):537-42.

18. Chowdhury J, Vargas KG. Comparison of chloral hydrate, meperidine, and hydroxyzine to midazolam regimens for oral sedation of pediatric dental patients. Pediatr Dent 2005;27(3):191-7.

19. Roach CL, Husain N, Zabinsky J, Welch E, Garg R.Moderate sedation for echocardiography of preschoolers. Pediatr Cardiol 2010;31(4):469-73.

20. Avalos-Arenas V, Moyao-García D, Nava-Ocampo AA, Zayas-Carranza RE, Fragoso-Ríos R. Is chloral hydrate/ hydroxyzine a good option for paediatric dental outpatient sedation? Curr Med Res Opin 1998;14(4):219-26.

21. Torres-Pérez J, Tapia-García I, Rosales-Berber MA, Hernández-Sierra JF, Pozos-Guillén Ade J. Comparison of three conscious sedation regimens for pediatric dental patients. J Clin Pediatr Dent 2007;31:183-6.

22. Lee YJ, Kim do K, Kwak YH, Kim HB, Park JH, Jung JH. Analysis of the appropriate age and weight for pediatric patient sedation for magnetic resonance imaging. Am J Emerg Med 2012;30(7):1189-95.

23. Kannikeswaran N, Sethuraman U, Sivaswamy L, Chen X, Mahajan PV. Children with and without developmental disabilities: sedation medication requirements and adverse events related to sedation. Pediatr Emerg Care 2012;28(10):1036-40.

24. Fávero ML, Ponce FA, Pio MR, Tabith Junior A, Carvalho e Silva FL. Chloral hydrate to study auditory brainstem response. Braz J Otorhinolaryngol 2010;76(4):433-6. [Article in English, Portuguese]

25. Heistein LC, Ramaciotti C, Scott WA, Coursey M, Sheeran PW, Lemler MS. Chloral hydrate sedation for pediatric echocardiography: physiologic responses, adverse events, and risk factors. Pediatrics 2006;117(3):e434-41.

Acquired CNS Demyelinating Syndrome in Children Referred to Shiraz Pediatric Neurology Ward

Soroor INALOO*, Saeedeh HAGHBIN, Mehrpoor MORADI, Hassan DASHTI, Nazila Nazila SAFARI

Iranian Journal of Child Neurology, Vol. 8 No. 2 (2014), 22 April 2014 , Page 18-23

How to Cite This Article: Inaloo S, Haghbin S, Moradi M, Dashti H, Safari N. Acquired CNS Demyelinating Syndrome in Children Referred to Shiraz Pediatric Neurology Ward. Iran J Child Neurol. 2014 Spring; 8(2):18-23.

Incidence of CNS acquired demyelinating syndrome (ADS), especially multiple sclerosis (MS) in children, appears to be on the rise worldwide. The objective of this study was to determine prevalence, clinical presentation, neuroimaging
features, and prognosis of different types of ADS in Iranian children.

Materials & Methods
During the period 2002-2012, all the patients (aged 1-18 years) with ADS, such as MS, acute disseminated encephalomyelitis (ADEM), optic neurotic (ON), Devic disease, and transverse myelitis (TM), referred to the pediatric neurology ward, Nemazee Hospital, Shiraz University of Medical Sciences, were included
in this study. Demographic data, clinical signs and symptoms, past and family history, preclinical findings, clinical course, and outcome were obtained.

We identified 88 patients with ADS in our center. The most prevalent disease was MS with 36.5% (n=32), followed by AEDM 26.1% (n=31), ON 17% (n=13), TM 15.9% (n=14), and Devic disease 4.5% (n=4). MS, ON, TM were more
common among females while ADEM was more common in males. Children with ADEM were significantly younger than those with other types of ADS.
Family history was positive in 10% of patients with MS.
Previous history of recent infection was considerably seen in cases with ADEM.
Clinical presentation and prognosis in this study was in accordance with those in previous studies on children.

In this study, the most common type of ADS was MS, which was more common in female and older age cases. ADEM was more common in male and younger children. ADEM and ON had the best and Devic disease had the worst prognosis.


1. Longer-Gould A, Zhaug JL, Chung J, Yeung Y, Wanbant E, Yao J. Incidence of acquired CNS demyelinating syndrome in a multiethnic cohort of children. Neurology 2011;27(12):1143-8.

2. Banwell B, Kennedy J, Sandovnick D, Arnold DL, Magalhaes S, Wambera K. Incidence of acquired demyelination of the CNS in Canadian children. Neurology 2009;72(3):232-9.

3. Canellas AR, Gols AR, Izquierdo J.R, Subirana MT, Gairin XM. Idiopathic inflammatory demyelinating disease of central nervous system. Neuroradiology 2007;49(5):393-409.

4. Renoux C, Vukusic S, Mikaeloff Y. Natural history of multiple sclerosis with childhood onset. N Engl Med 2007;356(25):2603-13.

5. Krupp LB, Banwell B, Tenembaum S; International Pediatric MS Study Group. Consensus definition proposed for pediatric multiple sclerosis and related disorders. Neurology 2007;68(16 Suppl 2):S7-12.

6. Ebers GC. Environmental factors and multiple sclerosis. Lancet Neurol 2008;77(3):268-77.

7. Banwell B, Ghezzi A, Bar-OrA, Mikaeloff Y, Tordieu M. Multiple sclerosis in children, clinical diagnosis, therapeutic strategies and future directions. Lancet Neurol 2007;6(10):887-902.

8. Absound M, Lim MJ, Chorg Wk, Goede CGs Foster K, Counny R. Pediatric acquired demyelinating syndromes: incidence, clinical and magnetic resonance imaging features. Mult Scler 2012;19(1):76-86.

9. Banwell B, Krupp L, Kennedy J. Clinical features and viral serology in children with multiple sclerosis: a multinational observation study. Lancet Neurology 2007;6(9):773-81.

10. Jin Y, Depedro-Cusesta J, Söderströ, M. Stawiarz L, Link H. Seasonal pattern in optic neuritis and multiple sclerosis. A meta-analysis. J Neurol Sci 2000;1(181):56-64.

11. Ghobai M, Omrani H, Rosta ئzadeh M. Epidemiology of multiple sclerosis. Tehran Univ Med J 2008;65:74-7.

12. Etemadifar M, Hosseini A, Khodabanehlou R, Maghzi AH. Childhood-onset multiple sclerosis: report of 82 patients from Esfahan, Iran. Arch Iranian Med 2007;10(2):152-6.

13. Ruggior M, Polizzi A, Pervon L, Grimoldi LM. Multiple sclerosis in children under 6 years of age. Neurology 1999;53(3):478-4.

14. Handefield FA. Characteristic of childhood multiple sclerosis. Int MS J 1995;3:91-8.

15. Selcen D, Anlar B, Renda Y. Multiple sclerosis in children. Report of 16 cases. Eur Neurol 1996;36(2):79-84.

16. Inaloo S, Yavari MJ, Sabori S. Multiple sclerosis in children: A review of clinical and paraclinical features in 26 cases. Iran J Child Neruol 2008;2(4):41-6.

17. Hynson JL, Kornberg AJ, Coleman LT, Shield L, Harvey AS, Kean MJ. Clinical and Neuroradiologic feature of acute disseminated encephalomyelitis in children. Neurology 2001;56(13):8-12.

18. Murthy KSN, Faden HS, Cohen ME, Bakshi R. Acute disseminated encephalomyelitis in children. Pediatric 2002;110(2):1-8.

19. Collard RC, Koehler RP, Mattson DH. Frequency and significance of antinuclear antibodies in multiple sclerosis. Neurology 1997;49(3):857-61.

20. Barned S, Goodman AD, Mattson AD. Frequency of antinuclear antibodies in multiple sclerosis. Neurology 1995;45(2):384-5.

21. Sri-Udomkajorn S, Pongwatcharaporn K. Clinical feature and outcome of childhood optic neuritis at Queen Sirikit National Institute of Child Health. J Med Assoc Thai 2011;94(Suppl 3):S189-94.

22. Absoud M, Cummins C, Desai N, Gika A, McSweeney N, Munot P, et al. Childhood optic neuritis clinical features and outcome. Arch Dis Child 2011;96(9):860-2.

23. Thomas T, Branson HM, Verhey LH, Shroff M, Stephens D, Magallhaes S, et al. The demographic, clinical, and magnetic resonance imaging (MRI) features of transverse myelitis in children. J Child Neurol 2012;27(1):11-21

The Etiology, Clinical Type, and Short Outcome of Seizures in Newborns Hospitalized in Besat Hospital/Hamadan/ Iran

Mohammad Kazem SABZEHEI, Behnaz BASIRI, Hassan BAZMAMOUN*

Iranian Journal of Child Neurology, Vol. 8 No. 2 (2014), 22 April 2014 , Page 24-28

How to Cite This Article: Sabzehei MK, Basiri B, Bazmamoun H. The Etiology, Clinical Type, and Short Outcome of Seizures in Newborns Hospitalized in Besat Hospital/ Hamadan/Iran. Iran J Child Neurol. 2014 Spring 8(2):24-28.

Seizures in neonates are very different from those of older children and adults.
The aim of this study was to determine the etiology, clinical presentation, and outcome of seizures in hospitalized neonates of Besat Hospital, Hamadan, Iran.

Material & Methods
In this retrospective study, we evaluated all neonates with seizures (aged 0-28 days) admitted to the Besat hospital, Hamadan, over a period of three years from September 2008 to September 2011. The data were obtained from hospital records and analyzed using SPSS 12.

Seizures were reported in 102/1112 (9.1%) neonatal admissions. Among neonates with seizures, 57% were male and 23.5% were preterm. The mean birth weight was 2936±677 grams and the mean gestational age was 37.60±1.94 weeks. 16.7% of them were LBW and 2.9% VLBW. In terms of seizure type, subtle seizures were observed in 38.2%, tonic in 29.4%, clonic in 26.4%, and
myoclonic in 5.9% of cases. The main diagnosis in neonates with seizures included hypoxic-ischemic encephalopathy (HIE) (34.3%), infections (24.4%), intracranial hemorrhage (6.9%), hypoglycemia (5.9%), hypocalcemia (2.9%), inborn error of metabolism (1%), and unknown cause (24.5%). The mortality rate was 14.7%.

Neonatal seizures indicate a significant underlying disease. HIE was the most common cause of neonatal seizures in our study. Therefore, efforts should be made to improve care during childbirth.


1. Mwaniki M, Mathenge A, Gwer S, Mturi N, Bauni E, Newton CR, et al. Neonatal seizures in a rural Kenyan District Hospital: aetiology, incidence and outcome of hospitalization BMC Medicine 2010;8:16.

2. Digra SK, Gupta A. Prevalence of seizures in hospitalized neonates. JK Science 2007;9(1):27-9.

3. Faiz N, Malik M, Azam M, Afzal U. Etiology and type of neonatal seizures, Ann Pak Inst Med Sci 2009;5(2):77-86.

4. Aftab R. Neonatal seizures: Etiology, Clinical types and outcome. Professional Med J 2007;14(2):199-203.

5. Fakhraee SH. Neonatal seizures: A Review. Iran J child Neurol 2007:1(4):7-11.

6. Sheth RD, Hobbs GR, Mullett M. Neonatal seizure: Incidence, onset and etiology by gestational age. J Perinatol 1999;19(1):40-3.

7. Saliba RM, Annegera Jf, waller DK, Tyson JE. Incidence of Neonatal seizures in harris county, American Journal of epidemiology 2000,150(7):763-9.

8. Moayedi AR, Zakeri S, Moayedi F. Neonatal seizures: Etiology and type. Iran J child Neurol 2007:23-6.

9. Ronen GM, Penney S, Andrew W. The epidemiology of clinical neonatal seizure in new found land, a populationbased study. J Pediatr 1999;134(1):71-5.

10. Arpino C, Domizio S, Carrieri MP, Brescianini DS, Sabatino MH, Curatolo P. Prenatal and perinatal determinants of neonatal seizures occurring in first week of life. Abs J child Neurol 2001:16(9):651-6.

11. Tekgul H, Gauvrea K, Soul J, Murphy L, Robertson R, stewart J, et al. The current etiology profile and neurodevelopmental outcome of seizures in term newborn infants. Pediatrics 2006;117(4):1270-80.

12. Udani V. Long-term prognosis of neonatal seizure – where are we? Indian pediatr 2008;45(9):739-41.

13. Ross AL, Lombroso CT.Neonatal seizures state. A study of clinical, pathological, and electroencephalographic features in 137 full-term babies with a long-term followup. Pediatrics 1970;45(3):404-25.

14. Taksande A, Vilhecar K, Jain M, Lakra M. Clinico-Biochemical Profile of Neonatal Seizures. Indian J Pediatr 1995;52:424-7.

15. Legido A, Clancy RR, Berman PH. Neurologic outcome after electroencephalographically proven neonatal seizures. Pediatrics 1991;88(3):583-96.

16. Malik BA, Butt MA, Shamoon M, Tehseen Z, Fatima A, Hashmat N. Seizures etiology in the newborn period. J Coll Physicians Surg Pak 2005;15(12):786-90.

17. Nunes ML, Martins MP, BareaBM, Wainberg R C, Costa da Costa J. Neurological outcome of newborns with neonatal seizures. Arq Neuropsiquiatr 2008;66(2A):168-74.

18. Taghdiri MM, Emadi M, Tavasoli AR. Plain CT Scan in neonatal convulsion. Iranian Red Crescent Medical Journal 2005;7(3):43-45.

19. Taghdiri MM, Eghbalian F, et al. Auditory Evaluation of high risk newborn by automated auditory brain stem response. Iranian J Pediatric 2008 Dec; 18(4):330-334.

Prevalence of Epileptiform Discharges in Children with Sensori-Neural Hearing Loss and Behavioral Problems Compared to Their Normal Hearing Peers


Iranian Journal of Child Neurology, Vol. 8 No. 2 (2014), 22 April 2014 , Page 29-33

How to Cite This Article: Amirsalari S, Radfar Sh, Ajallouyean M, Saburi A, Yousefi J, Noohi S, Tavallaie SA, Hassanalifard M, Ghazavi Y. Prevalence of Epileptiform Discharges in Children with Sensori-Neural Hearing Loss and Behavioral Problems Compared to Their Normal Hearing Peers. Iran J Child Neurol. 2014 Spring 8(2):29-33.

Overactivity and behavioral problems are common problems in children with prelingually profound sensorineural hearing loss (SNHL). Data on epileptiform electroencephalography (EEG) discharges in deaf children with psychological
disorders are so limited. The primary focus of this study was to determine the prevalence of epileptiform discharges (EDs) in children with SNHL and overactivity or behavioral problems.

Materials & Methods
A total of 262 patients with prelingually profound SNHL who were referred to our cochlear implantation center between 2008 and 2010 were enrolled in this study. Children with SNHL who had diagnosis of overactivity and/or behavioral
problems by a pediatric psychiatrist, underwent electroencephalography (EEG).
EEG analysis was carried out by a board-certified pediatric neurologist. The control group consisted of 45 cases with overactivity or behavioral problems and normal hearing.

One hundred thirty-eight children with mean age of 3.5±1.23 year were enrolled in the case group, of whom 88 cases (63.7%) were boy. The control group consisted of 45 cases with mean age of 3.2±1.53 years, of whom 30 (66.6%)
cases were male. EDs were detected in 28 (20.02%) children of the case group (with SNHL) in comparison with 4 (8.88%) in the control group (without SNHL), which was statistically significantly different.

In this study, we obtained higher frequency of EDs in deaf children with overactivity and/or behavioral problem compared to the children without SNHL. Further studies are required to evaluate the possible association of SNHL with
EDs in overactive children.


1. Matsuura M, Okubo Y, Toru M, Kojima T, He Y, Hou Y, et al. A cross-national EEG study of children with emotional and behavioral problems: a WHO collaborative study in the Western Pacific Region. Biol Psychiatry 1993;34(1-2):59-65.

2. Hindley P, Kroll L. Theoretical and epidemiological aspects of attention deficit and overactivity in deaf children. J Deaf Stud Deaf Educ 1998;3(1):64-72.

3. [No author listed] . Clinical practice guideline: diagnosis and evaluation of the child with attentiondeficit/ hyperactivity disorder. American Academy of Pediatrics. Pediatrics 2000;105(5):1158-70.

4. Klinkerfuss GH, Lange PH, Weinberg WA, O’Leary JL. Electroencephalographic abnormalities of children with hyperkinetic behavior. Neurology 1965;15(10):883-91.

5. Millichap JJ, Stack CV, Millichap JG. Frequency of epileptiform discharges in the sleep-deprived electroencephalogram in children evaluated for attention-deficit disorders. J Child Neurol 2011;26(1):6-11.

6. Fonseca LC, Tedrus GM, Moraes C, Vicente Machado A, Almeida MP, Oliveira DO. Epileptiform abnormalities and quantitative EEG in children with attentiondeficit/ hyperactivity disorder. Arq Neuropsiquiatr 2008;66(3A):462-7.

7. Venkatesh C, Ravikumar T, Andal A, Virudhagirinathan BS. Attention - deficit/Hyperactivity Disorder in Children: Clinical Profile and Co-morbidity. Indian J Psychol Med 2012 ;34(1):34-8.

8. Monastra VJ, Lubar JF, Linden M. The development of a quantitative electroencephalographic scanning process for attention deficit-hyperactivity disorder: reliability and validity studies. Neuropsychology 2001;15(1):136-44.

9. Monastra VJ, Lubar JF, Linden M, VanDeusen P, Green G, Wing W, et al. Assessing attention deficit hyperactivity disorder via quantitative electroencephalography: an initial validation study. Neuropsychology 1999; 13(3):424-33.

10. Barry RJ, Johnstone SJ, Clarke AR. A review of electrophysiology in attention-deficit/hyperactivity disorder: II. Event-related potentials. Clin Neurophysiol 2003;114(2):184-98.

11. Magee CA, Clarke AR, Barry RJ, McCarthy R, Selikowitz M. Examining the diagnostic utility of EEG power measures in children with attention deficit/hyperactivity disorder. Clin Neurophysiol 2005;116(5):1033-40.

12. Loo SK, Barkley RA. Clinical utility of EEG in attention deficit hyperactivity disorder. Appl Neuropsychol 2005;12(2):64-76.

13. Venkateswaran S, Shevell M. The case against routine electroencephalography in specific language impairment. Pediatrics 2008;122(4):e911-6.

14. Amirsalari S, Ajallouyean M, Saburi A, Haddadi Fard A, Abed M, Ghazavi Y. Cochlear implantation outcomes in children with Waardenburg syndrome. Eur Arch Otorhinolaryngol 2012; 269(10):2179-83.

15. Amirsalari S, Yousefi J, Radfar S, Saburi A, Tavallaie SA, Hosseini MJ, et al. Cochlear implant outcomes in children with motor developmental delay. Int J Pediatr Otorhinolaryngol 2012;76(1):100-3.

16. Holtmann M, Becker K, Kentner-Figura B, Schmidt MH. Increased frequency of rolandic spikes in ADHD children. Epilepsia 2003;44(9):1241-4.

17. Richer LP, Shevell MI, Rosenblatt BR. Epileptiform abnormalities in children with attention-deficithyperactivity disorder. Pediatr Neurol 2002;26(2):125-9.

18. Socanski D, Herigstad A, Thomsen PH, Dag A, Larsen TK. Epileptiform abnormalities in children diagnosed with attention deficit/hyperactivity disorder. Epilepsy Behav 2010;19(3):483-6.

19. Fonseca LC, Tedrus GM. [Somatosensory evoked spikes and epileptiform activity in “normal” children]. Arq Neuropsiquiatr 2003;61(3B):793-5. [Article in Portuguese]

20. Borusiak P, Zilbauer M, Jenke AC. Prevalence of epileptiform discharges in healthy children--new data from a prospective study using digital EEG. Epilepsia 2010;51(7):1185-8.

21. Daneshi A, Hassanzadeh S. Cochlear implantation in prelingually deaf persons with additional disability. J Laryngol Otol 2007;121(7):635-8.

22. Dye MW, Bavelier D. Attentional enhancements and deficits in deaf populations: an integrative review. Restor Neurol Neurosci 2010;28(2):181-92.


A Study of Methadone-Poisoned Children Referred to Hamadan’s Besat Hospital/Iran

Hassan BAZMAMOUN, Afshin FAYYAZi*, Ali KHAJEH, Mohammad Kazem SABZEHEI, Fuzieh KHEZRIAN

Iranian Journal of Child Neurology, Vol. 8 No. 2 (2014), 22 April 2014 , Page 34-37

How to Cite This Article: Bazmamoun H, Fayyazi A, Khajeh A, Sabzehei MK, Khezrian F. A Study of Methadone-Poisoned Children Referred to Hamadan’s Be’sat Hospital Iran. Iran J Child Neurol. 2014 Spring 8(2):34-37.

Increasing use of methadone in withdrawal programs has increased methadone poisoning in children. This research aimed to study the causes of incidence of poisoning in children and its side-effects.

Materials & Methods
In this research, The hospital records of all methadone-poisoned children referred to Hamadan’s Be’sat Hospital from June 2007 to March 2013, were studied. Children with a definite history of methadone use or proven existence
of methadone in their urine, were studied.

During 5 years, 62 children with the mean age of 53.24±29.50 months were hospitalized due to methadone use. There was a significant relationship between
delayed referral to hospital and increased bradypnea. According to their history, 25.8% and 58.1% of the children had been poisoned by methadone tablet and syrup, respectively. The most common initial complaint expressed by parents, was decreased consciousness (85.5%). During the initial examination, decreased consciousness, meiosis, and respiratory depression were observed in 91.9%,
82.3%, and 69.4% of the cases, respectively. Nine patients required mechanical ventilation. There was a significant relationship between the need for mechanical ventilation and seizure with initial symptom of emesis. There were two cases of death (3.2%), both of which were secondary to prolonged hypoxia and brain death. There was a significant relationship between poor patient prognosis (death) and presence of cyanosis in early symptoms, seizure, hypotension, duration of decreased consciousness, and duration of mechanical ventilation.

This research indicated that the occurrence of seizure, hypotension, and cyanosis in the early stages of poisoning is associated with an increased risk of sideeffects and death and are serious warning signs. Early diagnosis and intervention can improve outcomes of methadone-poisoned children.


1. Nazari H. Clinical approach to methadone intoxication. J Addict 2007;2:18-20.

2. Fayyazi A, Bagheri M, Khajeh A, Ahmadi S. Acute hydrocephaly following methadone intoxication in a child. Iran J Child Neurol. 2012;6(1):35-8.

3. Binchy JM, Molyneux EM, Manning J. Accidental ingestion of methadone by children in Merseyside. BMJ.1994; 308(6940):1335-6.

4. Li L, Levine B, Smialek JE. Fatal methadone poisoning in children: Maryland 1992–1996. Subst Use Misuse 2000;35(9):1141-8.

5. Riascos R, Kumfa P, Rojas R, Cuellar H, Descartes F. Fatal methadone intoxication in a child. Emerg Radiol 2008;15(1):67-70.

6. Milroy CM, Forrest AR. Methadone deaths: a toxicological analysis. J Clin Pathol 2000;53(4):277-81.

7. Farnaghi F, Jafari N, Mehregan FF. Methadone Poisoning among Children Referred to Loghman-Hakim Hospital in 2009. Pajoohandeh Journal 2012;16(6):299-303.

8. Zamani N, Sanaei-zadeh H, Mostafazadeh B. hallmarks of opium poisoning in infants and toddlers. Trop Doct 2010;40 (4):220-2.

9. Malloy S, Soh C, Williams TL Reversible delayed post hypoxic leukoencephalopathy. Am J Neuroradiol 2006; 27(8):1763–5.

10. Geibprasert S, Gallucci M and KringsT. Addictive Illegal Drugs: Structural Neuroimaging. Am J Neuroradiol 2010;31(5):803-8.


Iron-deficiency Anemia in Children with Febrile Seizure: A Case-Control Study

Fateme GHASEMI, Fateme VALIZADEH*, Nadere TAEE

Iranian Journal of Child Neurology, Vol. 8 No. 2 (2014), 22 April 2014 , Page 38-44

How to Cite This Article: Ghasemi F, Valizadeh F, Taee N. Iron-deficiency Anemia in Children with Febrile Seizure: A Case-Control Study. Iran J Child Neurol. 2014 Spring 8(2):38-44.

Considering the recurrence of febrile seizure and costs for families, many studies have attempted to identify its risk factors. Some recent studies have reported that anemia is more common in children with febrile convulsion, whereas others have reported that iron deficiency raises the seizure threshold. This study was done to compare iron-deficiency anemia in children with first FS with children having febrile illness alone and with healthy children.

Materials & Methods
This case-control study evaluated 300 children in three groups (first FS, febrile without convulsion, and healthy) in Khoramabad Madani Hospital from September 2009 to September 2010. Body temperature on admission was
measured using the tympanic method. CBC diff, MCV, MCH, MCHC, serum iron, plasma ferritin and TIBC tests were performed for all participants. Data were analyzed by frequency, mean, standard deviation, ANOVA, and chi-square statistical tests. Odds ratios were estimated by logistic regression at a confidence level of 95%.

Forty percent of the cases with FS had iron-deficiency anemia, compared to 26% of children with febrile illness without seizure and 12% of healthy children. The Odds ratio for iron-deficiency anemia in the patients with FS was 1.89 (95% CI, 1.04-5.17) compared to the febrile children without convulsion and 2.21 (95% CI, 1.54-3.46) compared to the healthy group. 

Children with FS are more likely to be iron-deficient than those with febrile illness alone and healthy children. Thus, iron-deficiency anemia could be a risk factor for FS.


1. Østergaard J R. Febrile Seizures. Acta Pædiatr 2009;98(5):771-3.

2. Jones T, Jacobsen SJ. Childhood Febrile Seizures: Overview and Implications. Int J Med Sci. 2007; 4(2):110-4.

3. Flury T, Aebi C, Donati F. Febrile Seizures and Parental Anxiety: Does Information Help? Swiss Med Wkly 2001;131:556–60.

4. Kliegman RM, Stanton BF, St Geme JW, Schor NF, Behrman RE. Nelson Textbook of Pediatrics. 19th ed. Philadelphia (PA): WB Saunders Company; 2011. p.2017.

5. Pisacane A, Sansone R, Impagliazzo N, Coppola A, Rolando P, D’Apuzzo A, et al. Iron Deficiency Anemia and Febrile Convulsions: Case-control Study in Children under 2 Years. BMJ 1996;313 (7053):343.

6. Lozoff B, Beard J, Connor J, Barbara F, Georgieff M, Schallert T, et al. Long-lasting Neural and Behavioral Effects of Iron Deficiency in Infancy. Nutr Rev 2006;64(5 Pt 2):34–43.

7. Parks YA, Wharton BA. Iron Deficiency and the Brain. Acta Paediatr Scand 1989;361:(Suppl 1):71–7.

8. Ur-Rehman N, Billoo AG. Association between Iron Deficiency Anemia and Febrile Seizures. J Coll Physicians Surg Pak 2005;15(6):338-40.

9. Daoud AS, Batieha A, Abu-Ekteish F, Gharaibeh N, Ajlouni S, Hijazi S. Iron Status: A Possible Risk Factor for the First Febrile Seizure. Epilepsia 2002;43(7):740-3.

10. Hartfield DS, Tan J, Yager JY, Rosychuk RJ, Spady D, Haines C, et al. The Association between Iron Deficiency and Febrile Seizures in Childhood. Clin Pediatr (Phila) 2009;48(4):420-6.

11. Momen A, Nikfar R, Karimi B. Evaluation of Iron Status in 9-month to 5-year-old Children with Febrile Seizures: A Case-control Study in the South West of Iran. Iran J

Child Neurol 2010;4(2):45-50.

12. Talebian A, Momtazmanesh N. Febrile Seizures and Anemia. Iran J Child Neurol 2007;31-3.

13. Kobrinsky NL, Yager JY, Cheang MS, Yatscoff RW, Tenenbein M. Does Iron Deficiency Raise the Seizure Threshold? J Child Neurol 1995;10(2):105–9.

14. Salehi Omran MR, Tamaddoni A, Nasehi MM, Babazadeh H, Alizadeh Navaei R. Iron Status in Febrile Seizure: A Case-control Study. Iran J Child Neurol 2009:3(3):40-3.

15. Amirsalari S, Keihanidost Z, Ahmadi M, Sabouri A, Kavemanesh Z, Afshar P, et al. Relationship between Iron Deficiency Anemia and Febrile Seizures. Iran J Child Neurol 2010;14(1):27-30.

16. Bidabadi E, Mashouf M. Association between Iron Deficiency Anemia and First Febrile Convulsion: A Case–control Study. Seizure 2009;18:347-51.

17. Oski FA, Brugnara C, Nathan DG. A Diagnostic Approach to the Anemic Patients. In: Nathan DG, Orkin SH, editors. Nathan and Oski’s Hematology of Infancy and Childhood. 7th ed. Philadelphia: WB Saunders Company; 2008. Appendix 11.

18. Vaswani RK, Dharaskar PG, Kulkarni S, Ghosh K. Iron Deficiency as a Risk Factor for First Febrile Seizure. Indian Pediatr 2009;47(5):437-9.

19. Sadeghzadeh M, Khoshnevis P, Mahboubi E. Iron Status and Febrile Seizure- A Case Control Study in Children Less Than 3 Years. Iran J Child Neurol 2012;6(4):27-31.

20. Idro R, Gwer S, Williams TN, Otieno T, Uyoga S, Fegan G, et al. Iron Deficiency and Acute Seizures: Results from Children Living in Rural Kenya and a Metaanalysis. PLoS One 2010;5(11):e14001.

21. Auvichayapat P, Auvichayapat N, Jedsrisuparp A, Thinkhamrop B, Sriroj S, Piyakulmala T, et al. Incidence of Febrile Seizures in Thalassemic Patients. J Med Assoc Thai 2004:87(8):970-3.


Associations between Manual Abilities, Gross Motor Function, Epilepsy, and Mental Capacity in Children with Cerebral Palsy

Ewa GAJEWSKA*, Magdalena SOBIESKA, Włodzimierz SAMBORSKI

Iranian Journal of Child Neurology, Vol. 8 No. 2 (2014), 22 April 2014 , Page 45-52

How to Cite This Article: Gajewska E, Sobieska M, Samborski W. Associations between Manual Abilities, Gross Motor Function, Epilepsy, and Mental Capacity in Children with Cerebral Palsy. Iran J Child Neurol. 2014 Spring 8(2):45-52.

This study aimed to evaluate gross motor function and hand function in children with cerebral palsy to explore their association with epilepsy and mental capacity. 

Material & Methods
The research investigating the association between gross and fine motor function and the presence of epilepsy and/or mental impairment was conducted on a group of 83 children (45 girls, 38 boys). Among them, 41 were diagnosed
with quadriplegia, 14 hemiplegia, 18 diplegia, 7 mixed form, and 3 athetosis.
A neurologist assessed each child in terms of possible epilepsy and confirmed diagnosis in 35 children. A psychologist assessed the mental level (according to
Wechsler) and found 13 children within intellectual norm, 3 children with mild mental impairment, 18 with moderate, 27 with severe, and 22 with profound.
Children were then classified based on Gross Motor Function Classification System and Manual Ability Classification Scale.

The gross motor function and manual performance were analysed in relation to mental impairment and the presence of epilepsy. Epilepsy was found to disturb conscious motor functions, but also higher degree of mental impairment was
observed in children with epilepsy.

The occurrence of epilepsy in children with cerebral palsy is associated with worse manual function. The occurrence of epilepsy is associated with limitations in conscious motor functions. There is an association between epilepsy in children with cerebral palsy and the degree of mental impairment.
The occurrence of epilepsy, mainly in children with hemiplegia and diplegia is associated with worse mental capacities.


  1. Richards CL, Malouin F. Cerebral palsy: definition, assessment and rehabilitation. Handb Clin Neurol 2013;111:183-95.
  2. Sellier E, Uldall P, Calado E, Sigurdardottir S, Torrioli MG, Platt MJ, et al. Epilepsy and cerebral palsy: characteristics and trends in children born in 1976-1998. Eur J Paediatr Neurol 2012;16(1):48-55.
  3. Wallace SJ. Epilepsy in cerebral palsy. Dev Med Child Neurology 2001;43(10):713-7.
  4. Bax MCO. Cerebral palsy. In: Aicardi J, editor. Disease of the nervous system in childhood. 2nd ed. London: Mc Keith Press; 1998. p. 210-39.
  5. Reid A, Imrie H, Brouwer E, Clutton S, Evans J, Russell D, et al. “If I knew then what I know now”: parents’ reflections on raising a child with cerebral palsy. Phys Occup Ther Pediatr 2011;31(2):169-83.
  6. Rosenbaum P, Paneth N, Leviton A, Goldstein M, Bax M, Damiano D, et al. A report: the definition and classification of cerebral palsy April 2006. Dev Med Child Neurology 2007;109:8-14.
  7. Palisano R, Rosenbaum P, Bartlett D, Livingston M. Content validity of the expanded and revised Gross Motor Function Classification System. Dev Med Child Neurology 2008;50(10):744-50.
  8. Öhrvall AM, Eliasson AC. Parents and therapists perceptions about the content and construct of Manual Ability Classification System, MACS. Scand J Occup Ther 2010;17(3):209-16.
  9. Marszał E.Występowanie, diagnostyka i leczenie padaczki u dzieci z mózgowym porażeniem dziecięcym. Neurologia dziecięca;2006:15, 30:65-8.
  10. Blair E, Watson L. Epidemiology of cerebral palsy. Semin Fetal Neonatal Medicine 2006;11(2):117-25.
  11. Meberg A, Broch H. Etiology of cerebral palsy. J Perinat Med 2004;32(5):434-9.
  12. Blair E. Epidemiology of the cerebral palsies. Orthop Clin North Am 2010;41(4):441-55.
  13. Hellbrűge T, Fritz L, Menara D, Schamberger R, Rautenstrauch T. Monachijska Funkcjonalna Diagnostyka Rozwojowa. Kraków: Antykwa; 1994. p. 80-130.
  14. Arnould C, Penta M, Renders A, Thonnard JL. Abilhand-Kids: a measure of manual ability in children with cerebral palsy. Neurology 2004;63(6):1045-52.
  15. Carnahan KD, Arner M, Hägglund G. Association between gross motor function (GMFCS) and manual ability (MACS) in children with cerebral palsy. A population-based study of 359 children. BMC Musculoskeletal Disorders 2007;21:50.
  16. Bax MC, Keith Brown J. The spectrum of disorders known as CP. In: Scrutton D, Damiano D, Mayston M, editors. Management of the Motor Disorders of Children with CP. Clinics in Developmental Medicine London: Mac Keith Press; 2004. p. 83-140.
  17. Kwong KL, Wong SN, So KT. Epilepsy in children with cerebral palsy. Pediatr Neurol 1998 ;19:31-6.
  18. Odding E, Roebroeck ME, Stam HJ. The epidemiology of cerebral palsy: incidence, impairments and risk factors. Disabil Rehabil 2006;28(4):183-91.
  19. Sugiura C, Shiota M, Ieshima A, Ohno K. [Epilepsy in patients with cerebral palsy--analysis of frequency and clinical prognosis]. No To Hattatsu 2003;35(6):478-83.
  20. McLellan A. Epilepsy – an additional risk factor for psychological problems in cerebral palsy. Dev Med Child Neurology 2008;50(10):727.
  21. Kulak W, Sobaniec W, Smigielska-Kuzia J, Kubas B, Walecki J. A comparison of spastic diplegic and tetraplegic cerebral palsy. Pediatr Neurol 2005;32(5):311-7.
  22. Rossman BS, Ashwal S. Evaluation of the child with cerebral palsy. Seminars in Pediatr Neurol 2004;11(1):47-57.


Study on MRI Changes in Phenylketonuria in Patients Referred to Mofid Hospital/Iran


Iranian Journal of Child Neurology, Vol. 8 No. 2 (2014), 22 April 2014 , Page 53-56

How to Cite This Article: Karimzadeh P, Ahmadabadi F, Jafari N, Shariatmadari F, Nemati H, Ahadi A, Karimi Dardashti S, Mirzarahimi M, Dastborhan Z, Zare Noghabi J. Study on MRI Changes in Phenylketonuria in Patients Referred to Mofid Hospital. Iran J Child Neurol. 2014 Spring 8(2):53-56.

Phenylketonuria is one of the most common metabolic disorders and the first known cause of mental retardation in pediatrics. As Screening for phenylketonuria (PKU) is not a routine neurometabolic screening test for neonates in Iran, many PKU cases may be diagnosed after developing the clinical symptoms. One of the findings of PKU is myelination disorders, which is seen as hypersignal regions in T2-weighted (T2W) and FLAIR sequences of brain MRI. The aim of our study was to assess MRI changes in PKU patients referred to Mofid Children’s Hospital, 2010-2011.

Materials & Methods
We studied all PKU cases referred to our clinic as a referral neurometabolic center in Iran for brain MRI and assessed the phenylalanine level at the time of Imaging. The mean phenylalanine level (in one year), clinical manifestations,
and MRI pattern based on Thompson scoring, were evaluated.

The mean age of our study group was 155±99 months and the mean diagnosis age was 37±27.85 months. There were 15 patients with positive and 15 with negative family history. The mean phenylalanine level at the time of imaging was 9.75±6.28 and the mean 1 year phenylalanine level was 10.28±4.82. Seventy percent of our patients had MRI involvement, in whom 20% showed atrophic changes, in addition to white matter involvement. Based on modified Thompson scoring, the score for our study group was 4.84.
The maximum involvement in MRI was in occipital region, followed by parietal, frontal, and temporal zones. There was not any correlation between MRI score and patients’ age. But we found significant relationship between MRI score and
the age of regimen cessation. No correlation was seen between phenylalanine level (at the time of Imaging) and MRI score. But there was a relationship between mean 1 year phenylalanine level and MRI score.

According to the results of this study, brain MRI and white matter involvement can be used for evaluation of long-term control of phenylalanine level in PKU cases.



1. Blau Nenad. Phenylketonuria and BH4 Deficiencies. London: UNI-MED; 2010.

2. Buck PS. The child who never grew. Woodbine House; 1992.

3. Rezvani I, Melvin JJ. Defects in metabolism of amino acids. In: Kliegman RM, Stanton BF, St. Geme J, Behrman RE, editors. Nelson Textbook of Pediatrics. 19th ed. USA: Elsevier; 2011. p. 418-22.

4. Menkes J, Wilcox WR. Inherited Metabolic Diseases of nervous system. In: Menkes JH, editor Child neurology. 7th ed. Philadelphia: Lippincott Williams&Wilkins; 2006. p. 34-36.

5. Aicardi J. Diseases of the nervous system in childhood. London: Mac Keith press; 2009.

6. Enns GM, Cowan TM, Klein O, Packman S. Aminoacidemias and organic acidemias. In: Swaiman KF. Swaimans Pediatric Neurology principle and practice. 5th ed. China: Saunders; 2012. p. 330-7.

7. Barkovich J. Toxic and Metabolic Brain disorders. In: Barkovich J, editor Pediatric Neuroimaging. 4th ed. USA: Lippincott William&Wilkins;2005. p. 88-92.

8. Van der knaap MS. Phenylketonuria. In: Van der knaap MS, Valk J, editor. Magnetic resonance of Myelination and Myelin Disorders. 3rd ed. Germany: Springer; 2005. p. 285-90.

9. Manara R, Burlina AP, Citton V, Ermani M, Vespignani F, Carollo C, et al. Brain MRI diffusion-Weighted imaging in patients with classical phenylketonuria: Neuroradiology (2009)51:803-12.

10. Möller HE, Weglage J, Bick U, Wiedermann D, Feldmann R, Ullrich K. Brain imaging and proton Magnetic Resonance Spectroscopy in Patients with Phenylketonuria Pediatrics 2003;112(6 Pt 2):1580-3.

11. Phillips MD, McGraw P, Lowe MJ, Mathews VP, Hainline BE. Diffusion-Weighted Imaging of White Matter Abnormalities in Patients with Phenylketonuria. AJNR Am J Neuroradiol 2001 Sep;22(8):1583-6.

12. Cleary MA, Walter JH, Wraith JE, Jenkins JP, Alani SM, Tyler K, et al. Magnetic resonance Imaging of the Brain in Phenyl ketonuria. Lancet 1994;344(8915):87-90.

Levatiracetam for the management of Lance-Adams syndrome

Faik ILIK*, Mustafa Kemal ILIK, İlker ÇOVEN

Iranian Journal of Child Neurology, Vol. 8 No. 2 (2014), 22 April 2014 , Page 57-59

How to Cite This Article: Ilik F, Ilik MK, Çöven I. Levatiracetam for the management of Lance-Adams syndrome. Iran J Child Neurol. 2014 Spring 8(2):57-59.


Chronic post-hypoxic myoclonus, also known as Lance-Adams syndrome (LAS) is a neurological complication characterized by uncontrolled myoclonic jerks following cardiac arrest. In this article, clinical manifestation and symptomatic treatment options are discussed especially concerning the rationale of use of levatiracetam in patients with Lance-Adams syndrome. Clinical presentation is action myoclonus associated with cerebellar ataxia, postural imbalance, and very mild intellectual deficit.

An 18-year-old female patient was admitted to our intensive care unit in a coma. She had a cardiorespiratory arrest after a splenectomy in a local hospital. Then, myoclonic movements were continuously observed over the entire body, including the face.

On day 14 of hospitalization, we started levatiracetam 1000 mg daily. The frequency of convulsion movements was reduced. The patient level of consciousness was 15 on the Glasgow coma scale (GCS) on the Mini-Mental State Examination (MMSE) score was 23 out of 30. She was later transferred to the rehabilitation department.

Vigilance is required to ensure early diagnosis and timely intervention for the myoclonic jerks. In conclusion, we would like to emphasize that LAS should be considered in patients with the myoclonic jerks following cardiac arrest and that levatiracetam therapy may be useful as treatment.


1. Lance JW, Adams RD. The syndrome of intention or action myoclonus as a sequel to hypoxic encephalopathy. Brain 1963; 86: 111-136.

2. Guo XH, Yu SY, Liu J, Wu WP, Pu CQ, Zhu K. Posthypoxic myoclonus treated with 5-hydroxytryptophan: a case report. J Clin Neurol 2002; 15: 313-6.

3. Arpesella R, Dallocchio C, Arbasino C, Imberti R, Martinotti R, Frucht SJ. A patient with intractable posthypoxic myoclonus (Lance-Adams syndrome) treated with sodium oxybate. Anaesth Intensive Care 2009; 37:314-8.

4. Werhahn KJ, Brown P, Rompson PD, Marsden CD. The clinical features and prognosis of chronic post-hypoxic myoclonus. Mov Disord 1997; 12: 216-20.

5. Frucht SJ, Trost M, Ma Y, Eidelberg D. The metabolic topography of post-hypoxic myoclonus. Neurology 2004; 62: 1879-1881.

6. Frucht S, Fahn S. The clinical spectrum of post-hypoxic myoclonus. Mov Disord 2000; 15 (Suppl 1): 2-7.

7. Matsumoto RR, Truong DD, Nguyen KD, Dang AT, Hoang TT, Vo PQ, Sandroni P. Involvement of GABA(A) receptors in myoclonus. Mov Disord 2000; 15(Suppl1):47-52.

The Acrocallosal Syndrome in A Neonate With Further Widening of Phenotypic Expression

Ravish SINGHAL*, Sadbhavna PANDIT, Ashok Saini, Paramjit SINGH, Neeraj DHAWAN

Iranian Journal of Child Neurology, Vol. 8 No. 2 (2014), 22 April 2014 , Page 60-64

How to Cite This Article: Singhal R, Pandit S, Saini A, Singh P, Dhawan N. The Acrocallosal Syndrome in A Neonate With Further Widening of Phenotypic Expression. Iran J Child Neurol. 2014 Spring;8(2):60-64.


The presentation of the typical characteristics of the acrocallosal syndrome (ACLS) are hypoplasia/agenesis of corpus callosum, moderate to severe mental retardation, characteristic craniofacial abnormalities, distinctive digital
malformation, and growth retardation in a neonate.
An Indian neonate presented on day 1 of life (youngest in the literature to be reported) with combination of abnormalities consistent with the acrocallosal syndrome and some additional findings. The baby, born to non-consanguineous, healthy parents, presented with macrocephaly, prominent forehead, hypertelorism, polydactyly of the hands and feet, duplication of hallux, hypotonia, recurrent cyanotic episodes, rib anomalies, dextro-positioning of heart, and delayed fall
of umbilical cord.
As the mode of inheritance of ACLS is autosomal recessive, the risk of recurrence is 25%. Genetic counselling is of prime importance, Polydactyly, and central nervous system malformations can be detected by ultrasonography in the second trimester, but due to variability of presentation, prenatal diagnosis may not always be possible.


1. Schinzel A. Postaxial polydactyly, hallux duplication, absence of corpus callosum, macencephaly and severe

mental retardation: a new syndrome? Helv Paediatr Acta 1979:34:141-146.

2. Schinzel A. The acrocallosal syndrome: expansion of the phenotypic spectrum. Clin Dysmorphol 1994;3:31-34.

3. Schinzel A, Schmid W. Hallux duplication, postaxial Polydactyly, absence of corpus callosum, severe mental retardation and additional anomalies in two unrelated patients: a new syndrome. Am J Med Genet 1980;6:241-249.

4. Moeschler JB, Pober BR, Holmes LB, Graham JM Jr. Acrocallosal syndrome: new findings. Am J Med Genet 1989;32:195-199.

5. Schinzel A, Kaufmann U. The acrocallosal syndrome in sisters. Clin Genet 1986;30:399-405.

6. Koenig R, Bach A, Woelki U, Grzeschik KH, Fusch S. Spectrum of acrocallosal syndrome. Am J Med Genet 2002;108:7-11.

7. Schinzel A. The acrocallosal syndrome in first cousins: widening of the spectrum of clinical features and further support for automal inheritance. J Med Genet 1988;25:332-336.

8. Hendriks HJE, Brunner HG, Haagen TAM, Hamel BCJ. Acrocallosal syndrome. Am J Med Genet 1990;35:443-446.

9. Yuksel M, Caliskan M, Ogur G, Ozmen M, Dolunary G, Apak S. The acrocallosal syndrome in a Turkish Boy. J Med Genet 1990;27:48-49.

10. Casamassima AC, Beneck D, Gewitz MH, Horowitz MA, Woolf PK, Pettersen IM, Shapiro LR. Acrocallosal Syndrome: additional manifestation. Am J Med Genet 1989;32:311-317.

11. Courtens W, Vamos E, Christophe C, Schinzel A. Acrocallosal syndrome in an Algerian boy born to consanguineous parents: review of the literature and further delineation of the syndrome. Am J Med Genet 1997;69:17-22.

12. Bassam R Ali, Jennifer L Silhavy, Nadia A Akawi, Joseph G Gleeson Lihadh Al-Gazali. A mutation in KIF7 is responsible for te autosomal recessive syndrome of macrocephaly, multiple epiphyseal dysplasia and distinctive facial appearance. Orphanet J Rare Dis 2012 May 15;7:27.

A Rare presentation of neurobrucellosis in a child with Recurrent transient ischemic attacks and pseudotumor cerebri (A case report and review of literature)


Iranian Journal of Child Neurology, Vol. 8 No. 2 (2014), 22 April 2014 , Page 65-69

How to Cite This Article: Akhondian J, Ashrafzadeh F, Beiraghi Toosi M, Hashemi N. A Rare Presentation of Neurobrucellosis in A Child with Recurrent Transient Ischemic Attacks and Pseudotumor Cerebri (A Case Report and Review of Literature). Iran J Child Neurol. 2014 Spring; 8(2):65-69.


Brucellosis is a multi-system infectious disease that presents with various manifestations and complications. Neurobrucellosis is an uncommon but serious presentation of brucellosis that can be seen in all stages of the disease. High
index of suspicion, especially in endemic areas is essential to prevent morbidity from this disease.
The case was an 11- year -old female patient who was admitted with a severe headache that was worsening over a period of 2 months. The day after each attack, she experienced transient right hemiparesia that was lasting less than one hour (TIA) as well as blurred vision and bilateral papilledema. Laboratory findings revealed serum agglutination Wright test positive at 1/320 and 2ME test positive at 1/160. A lumbar puncture showed a clear CSF with increased opening pressure (32 cmH2O), CSF examination was within normal range (pseudotumor cerebri).To our knowledge, there has been no report for recurrent TIA in pediatric neurobrucellosis in the base of pseudotumor cerebri.
In endemic areas like Iran, unexplained neurological signs or symptoms should be evaluated for brucellosis.



1. Pappas G, Akritidis N, Bosilkovski M, Tsianos E. Brucellosis. N Engl J Med 2005; 352 2325-2336.

2. Young EJ, Mandel GL, Bennett JE, et al. Principles and practice of infectious diseases. Philadelphia: Churchill Livingstone; 2002; Pp:23 86-93.

3. Gul HC, Erdem H, Bek S. Overview of neurobrucellosis: a pooled analysis of 187 cases. Int J Infect Dis. 2009;13(6):339-343.

4. McLean DR, Russell N, Khan MY. Neurobrucellosis: Clinical and therapeutic features. Clin Infect Dis. 1992; 15:582-90.

5. Young EJ, Douglas M. Brucella species. Bennett’s principles and practice of infectious diseases. 6th ed. Churchill Livingstone Co. 2005; 6: 2669-73.

6. Fatima ZO, Samer Z, Ropert A. Neurobrucellosis in children. Developmental Medicine & Child Neurol.1997;39:762-765.

7. Habib YKR, AL – Najdi AKN, Sadek SAH. Paediatric Neurobrucellosis: Case Report and Literature Review. J Infection 1998; 37:59-62.

8. Bucher A, Gaustad P, Pape E. Chronic neurobrucellosis due to Brucella melitensis. Scand J Infect Dis 1990; 22:223-6.

9. Al Deeb SM, Yaqub BA, Sharif HS, et al. Neurobrucellosis: clinical characteristics, diagnosis, and outcome. Neurology 1989; 39:498-501.

10. Shakir RA, Al-Din ASN, Araj GF, et al. Clinical categories of neurobrucellosis; a report on 19 cases. Brain. 1987;110: 213-223.

11.Haji-Abdolbagi M, Rasooli-Nejad M, Jafari S, et al. Clinical and laboratory findings in neurobrucellosis: Review of 31 Cases. Arch Iranian Med 2008; 11 (1): 21-25.

12. Ranjbar M, Rezaiee AA, Hashemi SH, et al. Neurobrucellosis: report of a rare disease in 20 Iranian patients referred to a tertiary hospital. Eastern Mediterranean Health Journal. 2009; 15(1): 143-148.

13. Sturniolo G, Mondello P, Bruno S, et al. Neurobrucellosis associated with syndrome of inappropriate antidiuretic hormone with resultant diabetes insipidus and hypothyroidism. Journal of clinical microbiology. 2010; 48(10): 3806-3809.

14. Trifiletti RR, Restivo DA, Pavone P, et al. Diabetes insipidus in neurobrucellosis. Clin Neurol Neurosurg. 2000; 102: 163- 165.

15. Zaidan R, Al Tahan AR. Cerebral venous thrombosis: a new manifestation of neurobrucellosis. Clin Infect Dis.1999; 28: 399 - 400.

16. Namiduru M, Karaoglan I, Yilmaz M. Guillain-Barre syndrome associated with acute neurobrucellosis. Int J Clin Pract. 2003; 57: 919 - 920.

17. Tuncer-Ertem G, Tülek N, Yetkin MA. Case report: subdural hemorrhage in neurobrucellosis. Mikrobiyol Bul. 2004; 38: 253 - 256.

18. Tena D, Gonzáles-Praetorius A, López- Alonso A, Peña JL, Pérez-Pomata MT, Bisquert J. Acute meningitis due to Brucella spp. Eur J Pediatr 2006; 165:726-727.

19. Salih M A, Abdel G M. Abdel G, et al. Infectious and in ammatory disorders of the circulatory system as risk factors for stroke in Saudi children. Saudi Med J. 2006;27: 41-52.

20. Sayyahfar Sh, Karimi A, Fahimzad A , et al. Rare presentation of neurobrucellosis. Pak J Med Sci. 2008; 24(3): 464-467.

21. Hernandez MA, Anciones B, Frank A, et al. Neurobrucellosis and cerebral vasculitis. Neurologia 1988; 3:241-243.

22. Adaletli I, Albayram S, Gurses B, et al. Vasculopathic changes in the cerebral arterial system with neurobrucellosis. Am J Neuroradiol 2006; 27:384-386.

23. Bingöl A, Togay-Isıkay C. Neurobrucellosis as an exceptional cause of transient ischemic attacks. Eur J Neurol 2006; 13:544-548.

24.Elrazak MA. Brucella optic neuritis. Arch Intern Med 1991;151:776-8.

25. Karakurum G B, Yerdelen D, Karatas M, et al. Abducens nerve palsy and optic neuritis as initial manifestation in brucellosis. Scand J Infect Dis 2006; 38:721-5.

26. Karapinar B, Yilmaz D, Vardar F, et al. Unusual presentation of brucellosis in a child: Acute blindness. Acta Paediatrica. 2005;94:378-80.

27. Marques R, Martins C, Machado I, et al. Unilateral optic neuritis as a presentation of neurobrucellosis. Pediatric Reports. 2011; 3(11): 36-38.

28. Tali ET, Keskin T, Oznur II, et al. MRI of brucella polyneuritis in a child. Neuroradiology. 1996; 38(1): 190-2.

29. Yilmaz M, Ozaras R, Mert A, et al. Abducent nerve palsy during treatment of brucellosis. Clin Neurol Neurosurg 2003; 105:218-20.

30. Balcer LJ. Optic neuritis. N Engl J Med 2006; 354:1273-1280.

31. Dirge KB. Idiopathic intracranial hypertension. BMJ 2010; 341:109-110.

32. Emadoleslamia M, Mahmoudianb T. A case of pseudotumor cerebri and brucellosis. Pediatr Infec Dis J .2007;2: 251-253.

33. Yasar anlar F, yalcin S, Secmeer G. Persistant hypoglycorrhachia in neurobrucellosis. pediatr infec j. 1994;13(8):747-8.

34. Erdem H, Ulu-Kilic A, Kilic S, et al. Efficacy and tolerability of antibiotic combinations in neurobrucellosis: results of the Istanbul study. Antimicrob Agents Chemother. 2012; 56(3):1523-8.



A Report of Guillain–Barré Syndrome With Myalgia and Mild Weakness


Iranian Journal of Child Neurology, Vol. 8 No. 2 (2014), 22 April 2014 , Page 70-72

How to Cite This Article: Aminzadeh V, Hassanzadeh Rad A. A Report of Guillain–Barré Syndrome With Myalgiaand Mild Weakness. Iran J Child Neurol. 2014 Spring; 8(2):70-72.


We report a rare case that revealed severe myalgia as the chief complaint that is not mentioned in the list of frequent symptoms of Guillain Barré.
Guillain-Barré syndrome (GBS) is an acute inflammatory demyelinating polyneuropathy (AIDP).Required features for diagnosis of GBS are progressive motor weakness of more than one limb and areflexia. We report an 11-yearold
boy who was referred to the emergency department with complaints of generalized body pain and gate problem.
It seems that if myalgias are the chief complaint and weakness is mentioned as a less important symptom, clinicians should consider GBS after ruling out other
reasons for myalgia especially inflammatory myositis.



1. Landaverde JM, Danovaro-Holliday MC, Trumbo SP, Pacis-Tirso CL, Ruiz-Matus C. Guillain-Barré syndrome in children aged <15 years in Latin America and the Caribbean: baseline rates in the context of the influenza A (H1N1) pandemic. J Infect Dis 2010 Mar;201(5):746-50.

2. Edward J. Filipponea, D Mitul Kanzariaa Rodney Bellb Eric Newmana, D John L. Farber. Secondary Membranous Nephropathy Associated with Guillain-Barré Syndrome. Case Rep Nephrol Urol 2013;3:34–39.

3. Kuwabara S. Guillain-Barré syndrome: epidemiology, pathophysiology and management. Drugs 2004;64(6):597-610.

4. Hughes RAC, Swan AV, Raphael JC, Annane D, van Koningsveld R, van Doorn PA. Immunotherapy for Guillain-Barré syndrome: a systematic review. Brain 2007;130:2245-2257.

5. Dy M, Leshner RL, Crawford JR An Unusual Case of Recurrent Guillain-Barre Syndrome of a Different Subtype Five Years after Initial Diagnosis.Case Rep N eurol Med 2013; 2013: 356157.

6. McLean S, Sheng F, Oon SF. Childhood Guillain-Barre Syndrome: Comparing Intravenous

immunoglobulin Treatment with Supportive Care.Trinity Student Medical Journal. 2005; 6:60–7.

7. Swaimann K. Ashwal S. Ferriero D. Pediatric neurology: principles and practice. 4th ed. Philadelphia: Mosby-Elsevier 2006.p 1920.

8. Sejvar JJ, Kohl KS, Gidudu J, et al. Guillain-Barré syndrome and Fisher syndrome: case definitions and guidelines for collection, analysis, and presentation of immunization safety data. Vaccine 2011;29:599-612.

9. Hicks CW, Kay B, Worley SE, Moodley M. A clinical picture of Guillain-Barré syndrome in children in the United States. J Child Neurol 2010 Dec;25(12):1504-10.

10. Borade A, Lad S, Ansari N, Dhongade R. Guillain-Barré syndrome in child with prolongintubation. Indian J Med Sci 2010 Jul;64(7):325-8.

11. Roodbol J, de Wit MC, Walgaard C, de Hoog M, Catsman-Berrevoets CE, Jacobs BC. Recognizing Guillain-Barré syndrome in preschool children. Neurology 2011 Mar 1; 76(9):807-10.