The Role of Brain Computed Tomography in Evaluating Children with New Onset of Seizures in the Emergency Department

Abstract

Summary: Ruc~ltgroiintl:The purpose of ncuroiniaging of a patient with new onset of seizures is to demonstrate cause and explore thc prognosis. It was recently recommended that eincrgcncy brain coinputcd tomography (CT) be performed only in adult seizure patients with an increased likelihood of lifethreatening lesions, i.c., those with new focal deficits, persistent altcred mental status, lever, recent trauma, persistent headaches, history of cancer, history of anticoagulation, or suspicion of acquired immunodcl'iciency syndrome. The objective of this study was to determine the diagnostic utility of emergency brain CT in children who present to (he emergency deparlment with new onset of seizures.Methods: A I -year retrospective chart review of all children who presented lo thc emergency department of the Schneidcr Children's Hospital with a new onset of seizures and who underwent CT of the brain, excluding children with simple febrile scimrcs.Kesiilts: Sixty-six patients, 34 boys and 32 girls with a mean age of 4.9 years, qualified for inclusion in the study. Fifty-two patients (78.8%) had normal C T results and 14 patients (21.2%) had abnormal CT results. Seizure cause was considered cryplogenic i n 33 patients, of whoin 2 (6%) had abnormal CT results; ncither patient required intervention. Seizure cause was considered symptomatic in 20 patients, of' whom I2 (60%~) had abnormal CT results (p < 0.0001). In two patients with abnormal CT scans (both acutc symptomatic), the imaging findings were of immediate therapeutic significance and were predictable from the clinical history and the physcial examination. None of the 13 patienls with complex febrile seizure ciiusc had an abnormal CT scan. Patients with partial convulsive seizures were more likely to have abnormal CT scans than paticnts with generalized convulsive seizures, but the difference was not statistically significant.Conclusions: The routine practice in many pediatric emcrgency departments of obtaining brain CT scans for all patients with ncw onset of nonfebrile seizures is un.justified. History and physical examination are sufficient to identify those patients for whom such studies arc likely to be appropriate. Emergent CT is not indicated for patients with no known seizure risk factors, normal neurological examinations, no acutc symptomatic cause other than fever, and reliable neurological follow-up. For these patients, referral to a pediatric neurologist I'or further workup, including electroencephalography and the more diagnostically valuable magnetic resonance iinaging, would be more appropriate. Key Words: Seizure diagnosis-CT scanEmergency department.Adults and children presenting to emergency departments (EDs) with a new onset of seizures are often evaluated with computed tomography (CT) ( 1-4). Previous neuroradiological studies have demonstrated that approximately one-third of children with epilepsy have CT abnormalities (5-7); however, fewer than 3% of these

Prevalence of and Risk Factors for Intracranial Abnormalities in Unprovoked Seizures

“…[4][5][6][7][8]12,16,17,19 In 2 large previous prospective studies, in which patients were evaluated by neurologists, the risk of any clinically relevant abnormalities on imaging ranged from 21% to 31%, with the higher estimate noted in a study that exclusively used MRIs. 5,12 We identified a somewhat lower estimate of emergent/urgent intracranial abnormalities on neuroimaging than previous studies.…”

“…[5][6][7][8][9][10][11][16][17][18] Most previous studies, however, have been retrospective, have not included standardized evaluations of patients, or the clinical findings were not elicited by acute care providers. [4][5][6][7][8][9][10][11][12][16][17][18][19][20][21] Existing guidelines provide only weak recommendations regarding which children might benefit from prompt neuroimaging. [9][10][11] Our primary aim was to determine the prevalence of, and risk factors for, clinically relevant intracranial abnormalities on neuroimaging in a well-described group of children who presented to medical care for the first time after having sustained unprovoked seizures.…”

“…[1][2][3] Approximately 8% to 31% of children with first, unprovoked seizures have abnormalities upon neuroimaging and ,1% to 8% have abnormalities warranting intervention. [4][5][6][7][8][9][10][11][12] The wide range of estimates results from the varying populations studied, differing outcome definitions, and the varied use of MRI. [4][5][6][7][8][9][10][11][12] The majority of patients undergo acute neuroimaging, most frequently computed tomography (CT).…”

“…We chose the clinical findings on the basis of an extensive review of the literature and through detailed discussions with faculty physicians who were expert in pediatric and adult neurology. [5][6][7][8][9][10][11] To assess interrater reliability of clinical findings, a second clinician performed an independent evaluation within 30 minutes of the first assessor on a convenience sample (47%) of those enrolled (details published previously). 22 Clinician assessors were asked to complete the data form before they had knowledge of cranial CT or MRI results, if obtained.…”

Evaluation of the acute symptomatic seizures during central nervous system infections

“…Uyaran olmadan fokal nöbet geçiren, anormal fizik muayene bulguları olan veya EEG'de fokal anormallikleri olan hastalara beyin görüntülemesinin yapılması önerilmektedir [14][15][16]. Çalışmamızda merkezi sinir sistemi enfeksiyonu nedeniyle hastaların tümüne beyin görüntülemesi yapılmış ve %54,1'inde anormallik görülmüştür.…”