{
  "abstract": "A previously healthy female toddler was transferred to the emergency department with acute-onset febrile seizures that lasted for more than 80 min. On arrival, the patient was unresponsive and experienced intermittent right-sided clonic seizures. Vital signs were as follows: heart rate of 186/m, respiratory rate of 40/m, temperature of 39.4℃ and oxygen saturation of 100% (oxygen mask 6 L/min). There was a bilateral leftward deviation of the eyes, and the pupils were dilated with reduced papillary reaction to light. The seizures were successfully treated with a total of 0.45 mg/kg of intravenous midazolam. After 1 hour, the patient regained responsiveness. Neurological deficits, such as hemiparesis, were absent. The patient’s mother had a history of COVID-19 exposure, and the patient’s rapid SARS-CoV-2 antigen detection test results were positive. Emergent non-contrast brain CT revealed a slightly hyperdense oval-shaped lesion measuring 15 mm in the left frontal lobe adjacent to the Sylvian fissure ( figure 1A). Brain CT angiography (figure 1B) and magnetic resonance (MR angiography (figure 2A) depicted an arteriovenous malformation (AVM) with a nidus and an associated aneurysm, 15 mm in diameter, fed by the left middle cerebral artery branches in the left frontal lobe. Two months after the AVM diagnosis, the patient underwent endovascular embolisation using a coil combined with a liquid embolic agent (figure 3A,B). MR angiographic follow-up 13 months later revealed that the aneurysm had disappeared, and the nidus had decreased in size (figure 2B). 16 months after the procedure, the patient remained seizure free while on an anticonvulsant. No neurodevelopmental symptoms were observed. It is crucial to diagnose unruptured brain AVMs in children because these congenital lesions carry a lifelong risk of intracranial haemorrhage, which may result in high rates of neurological morbidity and mortality.1 In addition, an aneurysm-associated brain AVM, as observed in this patient, is a major risk factor for haemorrhage. Seizures are the second most frequent presenting symptom, followed by spontaneous haemorrhage. Cortical AVMs in the frontal lobe are more likely to present with seizures.2 However, febrile seizures have rarely been associated in children with brain AVMs. Although diagnostic imaging studies are not routinely recommended in children with febrile seizures, the prolonged and focal seizure activity suggested an intracranial pathology herein; thus, an emergency brain CT was performed. We found an abnormal oval-shaped lesion in the left frontal lobe, and angiographic imaging confirmed the diagnosis of an unruptured brain AVM with an associated aneurysm. Consequently, endovascular embolisation was performed with a good clinical outcome, and neurological sequelae were absent. Our observations suggest that, although rare, paediatric unruptured brain AVMs may present as febrile seizures. Despite febrile seizures being the most common neurological complications in children with COVID-19,3 intracranial structural abnormalities requiring therapeutic intervention, such as unruptured AVMs, should be considered in children with COVID-19-associated febrile status epilepticus.",
  "authors": [
    {
      "affiliations": [
        "Department of Pediatrics, Asahi General Hospital, Asahi, Cihba, Japan"
      ],
      "name": "Kazuma Komori"
    },
    {
      "affiliations": [
        "Department of Pediatrics, Asahi General Hospital, Asahi, Cihba, Japan"
      ],
      "name": "Katsuhiko Kitazawa"
    }
  ],
  "title": "Unruptured brain arteriovenous malformation presenting with COVID-19-associated febrile status epilepticus in a toddler",
  "uid": "575d692a-021d-5b91-acd5-fe83beb3f591"
}