Case 1: Vertigo and Episodes of Slurred Speech in a 5-year-old Girl

1. Ashwin Malhotra, MD* 2. Louis Manganas, MD, PhD* 3. Traci Downs, MD† 4. Sunny Chang, MD† 5. Latha Chandran, MD, MPH† 1. Departments of *Neurology and 2. †Pediatrics, Stony Brook University School of Medicine, Stony Brook, NY A 5-year-old girl presents with symptoms of vertigo and intermittent episodes of slurred speech for 1 day. This morning she had a “popping” headache localized bilaterally to the sides and the back of the head. Her headache spontaneously resolved within 20 minutes, although she later experienced “a spinning sensation” and her knees buckled, causing her to fall backward. There is no history of ataxia, visual changes, weakness, or fatigue before the fall. Similarly, there is no history of altered mental status or evidence of injury afterward. Six months earlier, she had been diagnosed as having localization-related epilepsy. It was likely that her epilepsy was of genetic origin and considered benign because of normal brain magnetic resonance imaging (MRI) findings, electrographic abnormalities noted on video electroencephalography (EEG), and semiology that was noted during 3 witnessed episodes of tonic-clonic movements. Her epilepsy was initially well controlled with levetiracetam and oxcarbazepine therapy. In the preceding months, she would experience episodes of “spacing out” during which she would see colors in the air or smell things, “freeze up” (ie, have behavioral arrest), and then be unable to recall what happened. Her birth, developmental, and immunization history is noncontributory. Her mother has a history of depression, anxiety, and migraines with aura. Evaluation in the emergency department reveals episodic dysarthria without aphasia. She is alert and oriented, with normal vital signs and …