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Neuroimaging Evaluation for First Attack of Unprovoked Nonfebrile Seizure in Pediatrics: When to Order?

Neuroimaging Evaluation for First Attack of Unprovoked Nonfebrile Seizure in Pediatrics: When to... Original Paper Received: December 28, 2014 Med Princ Pract 2016;25:56–60 Accepted: October 20, 2015 DOI: 10.1159/000441847 Published online: November 13, 2015 Neuroimaging Evaluation for First Attack of Unprovoked Nonfebrile Seizure in Pediatrics: When to Order? a a b c Hussain Sadeq   Jumanah Karim   Yousef Marwan   Talal AlSaleem   a b   Department of Pediatrics, Al-Adan Hospital,   Department of Orthopedic Surgery, Al-Razi Orthopedic Hospital, and   Department of Pediatrics, Mubarak Al-Kabeer Hospital, Kuwait City, Kuwait Key Words Introduction Neuroimaging studies · Pediatrics · Nonfebrile seizure Witnessing a child in seizure is an unpleasant experi- ence for parents. The challenge is for the pediatrician to Abstract detect structural brain abnormalities associated with the Objective: To assess the value of neuroimaging studies in seizure. Seizure among children is quite a common con- evaluating pediatric patients presenting with a first attack dition, accounting for 4–10% of all pediatric neurological of nonfebrile seizure. Method: We reviewed the medical disorders [1] . In the USA, it is estimated that 10% of the records of pediatric patients aged 28 days to 12 years who population will experience at least one attack of seizure were admitted between 1 January and 31 December 2013 once in their lifetime [2] . The importance of neuroimag- with a first attack of unprovoked, afebrile seizure. These pa- ing studies for pediatric patients presenting with nonfe- tients had undergone neuroimaging studies. The exclusion brile seizure is still a debatable issue in the literature [3] . criterion was patients with known predisposing conditions One meta-analysis study showed that findings on neuro- for seizure. The computed tomography (CT) scan and mag- imaging were abnormal in up to one third of children netic resonance imaging (MRI) results were either normal or with a first attack of seizure; however, most of these ab- abnormal, and the abnormal ones were further classified normalities did not require any immediate medical or into clinically insignificant or significant. Descriptive analysis surgical intervention [4] . Focal neurological deficits and was performed to summarize the data. Result: Fifty children the presence of predisposing conditions to seizure among were identified with a mean age of 5.2 ± 3.8 years. Of the 50 this group of patients are reported to be the strongest pre- subjects, 29 (58.0%) were males and 21 (42.0%) were fe- dictors of abnormal computed tomography (CT) scan males. Sixteen patients (32.0%) had abnormal neuroimaging findings [5, 6] . studies (CT scan, MRI or both); however, only 1 was consid- The current guidelines of the American Academy of ered to have a clinically significant abnormality, later diag- Neurology (AAN) do not support the routine use of neu- nosed as Moyamoya disease. Conclusion: In this study, the roimaging studies in such circumstances because of the neuroimaging studies were found not to be useful in evalu- lack of sufficient evidence of any benefit from such stud- ating pediatric patients presenting with a first attack of un- ies [4] . In Kuwait, there are no well-established guidelines provoked, nonfebrile seizures. © 2015 S. Karger AG, Basel regarding the use of neuroimaging studies for pediatric © 2015 S. Karger AG, Basel Hussain Sadeq 1011–7571/15/0251–0056$39.50/0 Department of Pediatrics Al-Adan Hospital E-Mail karger@karger.com Th is is an Open Access article licensed under the terms of the Kuwait City (Kuwait) www.karger.com/mpp Creative Commons Attribution-NonCommercial 3.0 Un- E-Mail drhsadeq   @   icloud.com ported license (CC BY-NC) (www.karger.com/OA-license), applicable to the online version of the article only. Distribu- tion permitted for non-commercial purposes only. Assessed for eligibility (n = 153) Excluded (n = 103) 1. Neuroimaging study was not done (n = 23) 2. Not meeting inclusion criteria (n = 80) a. Febrile seizure b. Known epileptic disorder c. History of status epilepticus d. History of fits shortly after head trauma e. Neonates or patients aged >12 years presenting with a seizure attack Included (n = 50) Patients aged between 28 days and 12 years presenting with 1st attack of unprovoked, nonfebrile convulsions for whom neuroimaging studies were done Fig. 1. Selection of patients. patients with a first attack of nonfebrile seizure, although normal movement, loss of consciousness and fainting were written in the admission slip from the pediatric emergency room. Key- magnetic resonance imaging (MRI) has been found to be words such as abnormal movement, fainting and loss of conscious- of value [7–9] . Emergency neuroimaging studies should ness were also considered as a provisional diagnosis because in be considered in any child of any age presenting with some of the patients, such symptoms could be related to seizure Todd’s paresis [10, 11], and several investigations world- disorders. Exclusion criteria were subjects with febrile seizure, a wide have addressed the importance of neuroimaging known epileptic disorder, a history of status epilepticus or fits oc- curring shortly after head trauma as well as neonates or patients tests in evaluating pediatric patients with this presenta- older than 12 years. Any patient who did not have a neuroimaging tion [12–14] . test as part of the evaluation of the seizure was excluded ( fig. 1 ). The aim of this study was to assess the usefulness of The medical records were thoroughly examined to retrieve data neuroimaging studies in pediatric patients presenting regarding the demographic characteristics and features of the sei- with a first attack of unprovoked, nonfebrile seizure. zure of each patient. This included gender, age, the type and dura- tion of the seizure, the presence of chronic disorders, the family medical history, exposure to toxins and developmental history. In Materials and Methods addition, physical examination findings, investigations and imag- ing results were documented. Seizure types (i.e. partial or general- This retrospective study was conducted at the Mubarak Al-Ka- ized) were defined based on the latest guidelines of the Interna- beer Hospital, Kuwait. The hospital was selected randomly from 5 tional League against Epilepsy [15] . The CT scan and MRI results general hospitals that have Departments of Pediatrics. The study were considered either normal or abnormal by the consultant ra- involved pediatric patients aged between 28 days and 12 years, who diologist, pediatric neurologist and pediatric neurosurgeon. Ab- were admitted for a first attack of unprovoked, nonfebrile seizure. normal neuroimaging studies were further classified as clinically It included patients admitted between 1 January and 31 December insignificant or clinically significant based on the need for imme- 2013. diate medical or surgical intervention. The medical records of the patients were reviewed to identify This study was reviewed and ethically approved by the Review those who had undergone neuroimaging. These radiological tests Board of the Ministry of Health of Kuwait. Moreover, permission were done immediately following admission to the hospital; no to review and collect data from the patients’ records was obtained patient was discharged before undergoing the studies. A consul- from the administration of the hospital involved in our study. The tant radiologist had assessed the images which were then evaluated collected data were entered and analyzed using the Statistical Pack- by pediatric neurologists or neurosurgeons. During our chart re- age for Social Sciences (SPSS v17.0, IBM Inc., Chicago, Ill., USA). view, provisional diagnosis of a first attack of unprovoked, nonfe- Frequencies and proportions were used to describe the demo- brile seizure (as in the medical records) was considered if keywords graphic, clinical and neuroimaging data of the patients, which such as epilepsy, fit, seizure, convulsion, afebrile, nonfebrile, ab- were then summarized in the form of tables. Med Princ Pract 2016;25:56–60 Neuroimaging for First-Attack Nonfebrile 57 DOI: 10.1159/000441847 Seizure Table 1. Demographic characteristics and history of the partici- Table 2. Findings of the physical examination pants Physical examination findings n (%) Characteristics n (%) Mental status Gender Normal 49 (98.0) Male 29 (58.0) Disturbed 1 (2.0) Female 21 (42.0) LOC/coma 0 Age Dysmorphic features 1 – 6 months 7 (14.0) Yes 2 (4.0) 6 – 12 months 3 (6.0) No 48 (96.0) 1 – 5 years 18 (36.0) Neurological skin features 5 – 12 years 22 (44.0) Yes 2 (4.0) Mean ± SD 5.2 ± 3.8 No 48 (96.0) Developmental history Focal neurological deficit Normal 45 (90.0) Yes 3 (6.0) Motor delay 2 (4.0) No 47 (94.0) Global delay 3 (6.0) Family history LOC = Loss of consciousness. Yes 20 (40.0) No 30 (60.0) Seizure type Focal 17 (34.0) Generalized 33 (66.0) Seizure duration ed with focal seizures. In addition, 32 (64.0%) children <5 min 32 (64.0) presented with a brief (<5 min), unprovoked, nonfebrile 5 – 30 min 18 (36.0) seizure. Chronic conditions The findings of the physical examination are shown in Yes 11 (22.0) table 2 ; 1 patient (2%) was admitted to the hospital with No 39 (78.0) Toxin exposure a disturbed level of consciousness and a lethargic appear- Yes 0 ance, dysmorphic features were noted in 2 (4%) and 2 No 50 (100.0) others (4%) had evidence of significant skin features (i.e. hypopigmented macules and café-au-lait spots; both of these patients had normal brain MRI results). Subtle or gross focal neurological deficits at the time of admission Results were noted in 3 patients (6%) only. The findings of the investigations and neuroimaging During the study period, 153 children were admitted studies are summarized in table 3 . An elevation in white with a first attack of nonfebrile seizure. Of these, 50 blood cell count was noted in 4 patients (8%), while se- (32.7%) met the inclusion criteria, i.e. 29 males (58.0%) rum calcium abnormal levels were noted in 5 (10%). Lac- and 21 females (42.0%; table 1 ). Their mean age was 5.2 tate and/or amino acid level tests were ordered for 18 ± 3.8 years, with 40 children (80%) between 1 and 12 patients (36%), but significant abnormalities were only years old and 10 children <1 year (20%). Global or motor found in 1 subject (2%). Lumbar puncture was conduct- delay was noticed in 5 patients (10.0%). Of the 50 chil- ed in 3 patients (6%); all of them had normal cerebrospi- dren, 11 (22.0%) had a history of preexisting chronic nal fluid findings. Electroencephalography was done for conditions; 6 of these were preterm patients, and the re- 30 patients (60.0%), and 17 of them (34%) had abnormal maining 5 were cases of neonatal hypocalcemia, atten- findings such as high-amplitude sharp waves or spike tion-deficit hyperactivity disorder, glucose-6-phosphate complexes found at the frontal, temporal and/or parietal dehydrogenase deficiency, autism spectrum disorder leads. Head CT scan was done for 34 patients (68%), and recurrent otitis media. Moreover, a first- or second- brain MRI for 6 (12%) and 10 patients (20%) had both degree positive family history of epileptic disorder was of these neuroimaging studies. The CT and MRI studies noted in 20 patients (40.0%). Thirty-three patients did not reveal any abnormalities in 34 of the patients (66.0%) presented to the Emergency Department with (68%). Sixteen (32%) were found to have abnormal neu- generalized tonic-clonic seizures and 17 (34.0%) present- roimaging scan results; however, only 1 of these was con- Med Princ Pract 2016;25:56–60 58 Sadeq/Karim/Marwan/AlSaleem DOI: 10.1159/000441847 Table 3. Findings of the investigations Investigations n (%) CBC abnormalities Yes 4 (8.0) No 46 (92.0) Electrolyte abnormalities Calcium 5 (10.0) 2 Magnesium 0 Sodium 0 Glucose 0 Mild brain Small foci of Mild Pineal cyst Arachnoid atrophic hyper-/hypo- ventricular cyst None 45 (90.0) changes density dilatation Lactate and amino acid abnormalities Yes 1 (2.0) No 17 (34.0) Not done 32 (64.0) Fig. 2. Insignificant findings in neuroimaging studies. Lumbar puncture Normal 3 (6.0) Abnormal 0 Not done 47 (94.0) Electroencephalography Discussion Normal 13 (26.0) Abnormal 17 (34.0) Not done 20 (40.0) In this study, 32.0% of the patients had abnormal neu- Neuroimaging modality roimaging findings, and only 1 (6.2%) had clinically sig- CT head 34 (68.0) nificant abnormal CT scan and MRI findings. This 1-year- MRI brain 6 (12.0) old child was diagnosed with Moyamoya disease after Both 10 (20.0) presenting with disorientation and focal attack of seizure, Neuroimaging findings Normal 34 (68.0) and was moved to the Pediatric Neurosurgery Care Unit Abnormal 16 (32.0) where she received antiplatelet therapy and was followed up for possible surgical intervention in the future. CBC = Complete blood count. This low finding of 6.2% of the subjects having signif- Only 1 subject out of 16 was considered to have an abnormal icant neuroimaging findings requiring medical or surgi- CT/MRI scan that was clinically significant. cal management confirmed the finding of 4% in the study of Aprahamian et al. [16] that involved 319 patients. Equally important, Maytal et al. [3] reported that <10% of children with new-onset, nonfebrile seizures had abnor- sidered to have clinically significant abnormal CT scan/ mal emergency neuroimaging findings, but that they did MRI findings. The CT scan of the head of this patient not require any medical or surgical intervention. Taken showed hypodensity in the right temporal and frontal together, all of these findings seem to indicate that the lobes, and the brain MRI revealed a high signal intensity routine use of neuroimaging studies in this group of pe- in the right frontal and occipital lobes with attenuation diatric patients is not useful. of the postcerebral artery (more in the right and middle However, several recommendations have been made cerebral artery) along with abnormal vascular anasto- regarding the indication of neuroimaging evaluation for mosis around the circle of Willis; these were consistent first attacks of nonfebrile seizure in pediatric patients [4, with Moyamoya disease. The clinically insignificant 17–19] . Khodapanahandeh and Hadizadeh [17] suggest- findings ( fig. 2 ) observed in the other 15 patients were: ed the use of neuroimaging studies for children who mild brain atrophic changes in 2 (4%), small foci of present with focal seizures, abnormal neurological find- hypo-/hyper-density or intensity in 6 (12%), mild ven- ings or who are younger than 2 years of age. The AAN tricular dilatation in (5 (10%), pineal cyst in 1 (2%) and guidelines [4] recommend the use of emergency neuro- arachnoid cyst in 1( 2%). All of these findings were con- imaging for any child of any age who exhibits a postictal sidered insignificant by the pediatric neurologist or the focal deficit (i.e. Todd’s paresis) that does not resolve neurosurgeon. quickly or who has not returned to baseline within sev- Med Princ Pract 2016;25:56–60 Neuroimaging for First-Attack Nonfebrile 59 DOI: 10.1159/000441847 Seizure Number of patients eral hours after the seizure. In other reports [4, 18, 19] A major limitation of this study was the small number nonurgent MRI should be considered for any child with of patients. Also, due to its retrospective nature, it could a significant cognitive or motor impairment of unknown not provide a causal relationship between the findings of etiology, unexplained abnormalities on neurological ex- neuroimaging studies and the clinical picture of the pa- amination, a seizure of focal onset with or without sec- tients. ondary generalization, an electroencephalography result that does not represent a benign partial epilepsy of child- hood or primary generalized epilepsy, or in children Conclusion <1 year of age. Unfortunately, following the AAN guide- lines, neuroimaging studies were ordered for 47 of the In this study, neuroimaging studies were not useful in patients (94%) despite the absence of Todd’s paresis. This evaluating pediatric patients who presented with a first resulted in performing unnecessary, expensive and, in attack of unprovoked, nonfebrile seizures. We therefore some cases, high-radiation tests on the children based on recommend that neuroimaging should not be routinely our findings. It seems that pediatricians in Kuwait do not performed in this group of patients unless there is evi- follow any specific guidelines about when to order a neu- dence of focal neurological deficits. roimaging study for this group of patients, but rather that their decision to do so seems to be based on their own experience. These issues should be thoroughly investi- Disclosure Statement gated and addressed in future studies in order to improve pediatric care in Kuwait. There were no conflicts of interest. References 1 Booth TN: Imaging strategies for new onset 8 Resta M, Palma M, Dicuonzo F, et al: Imaging 14 Warden CR, Brownstein DR, Del Beccaro seizures. Pediatr Radiol 2009; 39:S236–S238. studies in partial epilepsy in children and ad- MA: Predictors of abnormal findings of com- 2 Long L, Adams C: Evaluation of a single sei- olescents. Epilepsia 1994; 35: 1187–1193. puted tomography of the head in pediatric pa- zure: guidelines for advance practice nurses. J 9 Shinnar S, O’Dell C, Mitnick R, et al: Neuro- tients presenting with seizures. Ann Emerg Am Acad Nurse Pract 2000; 12: 141–145. imaging abnormalities in children with an ap- Med 1997; 29: 518–523. 3 Maytal J, Krauss JM, Novak G, et al: The role parent first unprovoked seizure. Epilepsy Res 15 Engel J Jr; International League against Epi- of brain computed tomography in evaluating 2001; 43: 261–269. lepsy (ILAE): A proposed diagnostic scheme children with new onset of seizures in the 10 Vining EP, Freeman JM: Management of for people with epileptic seizures and with emergency department. Epilepsia 2000; 41: nonfebrile seizures. Pediatr Rev 1986; 8: 185– epilepsy: report of the ILAE Task Force on 950–954. 190. Classification and Terminology. Epilepsia 4 Hirtz D, Ashwal S, Berg A, et al: Practice pa- 11 Berg AT, Shinnar S, Levy SR, et al: Early de- 2001; 42: 796–803. rameter: evaluating a first nonfebrile seizure velopment of intractable epilepsy in children: 16 Aprahamian N, Harper MB, Prabhu SP, et al: in children: report of the quality standards a prospective study. Neurology 2001; 56: Pediatric first time non-febrile seizure with subcommittee of the American Academy of 1445–1452. focal manifestations: is emergent imaging in- Neurology, the Child Neurology Society, and 12 Al-Rumayyan AR, Abolfotouh MA: Preva- dicated? Seizure 2014; 23: 740–745. the American Epilepsy Society. Neurology lence and prediction of abnormal CT scan in 17 Khodapanahandeh F, Hadizadeh H: Neuro- 2000; 55: 616–623. pediatric patients presenting with a first sei- imaging in children with first afebrile sei- 5 Hirtz DG: Generalized tonic-clonic and fe- zure. Neurosciences (Riyadh) 2012; 17: 352– zures: to order or not to order? Arch Iran Med brile seizures. Pediatr Clin North Am 1989; 356. 2006; 9: 156–158. 36: 365–382. 13 Gaillard WD, Chiron C, Cross JH, et al: 18 Nordli DR Jr, Bazil CW, Scheuer ML, et al: 6 Reinus WR, Wippold FJ 2nd, Erickson KK: Guidelines for imaging infants and children Recognition and classification of seizures in Seizure patient selection for emergency com- with recent-onset epilepsy. Epilepsia 2009; 50: infants. Epilepsia 1997; 38: 553–560. puted tomography. Ann Emerg Med 1993; 22: 2147–2153. 19 King MA, Newton MR, Jackson GD, et al: Ep- 1298–1303. ileptology of the first-seizure presentation: a 7 Yang PJ, Berger PE, Cohen ME, et al: Com- clinical, electroencephalographic and mag- puted tomography and childhood seizure dis- netic resonance imaging study of 300 consec- orders. Neurology 1979; 29: 1084–1088. utive patients. Lancet 1998; 352: 1007–1011. Med Princ Pract 2016;25:56–60 60 Sadeq/Karim/Marwan/AlSaleem DOI: 10.1159/000441847 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Medical Principles and Practice Pubmed Central

Neuroimaging Evaluation for First Attack of Unprovoked Nonfebrile Seizure in Pediatrics: When to Order?

Medical Principles and Practice , Volume 25 (1) – Nov 13, 2015

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Abstract

Original Paper Received: December 28, 2014 Med Princ Pract 2016;25:56–60 Accepted: October 20, 2015 DOI: 10.1159/000441847 Published online: November 13, 2015 Neuroimaging Evaluation for First Attack of Unprovoked Nonfebrile Seizure in Pediatrics: When to Order? a a b c Hussain Sadeq   Jumanah Karim   Yousef Marwan   Talal AlSaleem   a b   Department of Pediatrics, Al-Adan Hospital,   Department of Orthopedic Surgery, Al-Razi Orthopedic Hospital, and   Department of Pediatrics, Mubarak Al-Kabeer Hospital, Kuwait City, Kuwait Key Words Introduction Neuroimaging studies · Pediatrics · Nonfebrile seizure Witnessing a child in seizure is an unpleasant experi- ence for parents. The challenge is for the pediatrician to Abstract detect structural brain abnormalities associated with the Objective: To assess the value of neuroimaging studies in seizure. Seizure among children is quite a common con- evaluating pediatric patients presenting with a first attack dition, accounting for 4–10% of all pediatric neurological of nonfebrile seizure. Method: We reviewed the medical disorders [1] . In the USA, it is estimated that 10% of the records of pediatric patients aged 28 days to 12 years who population will experience at least one attack of seizure were admitted between 1 January and 31 December 2013 once in their lifetime [2] . The importance of neuroimag- with a first attack of unprovoked, afebrile seizure. These pa- ing studies for pediatric patients presenting with nonfe- tients had undergone neuroimaging studies. The exclusion brile seizure is still a debatable issue in the literature [3] . criterion was patients with known predisposing conditions One meta-analysis study showed that findings on neuro- for seizure. The computed tomography (CT) scan and mag- imaging were abnormal in up to one third of children netic resonance imaging (MRI) results were either normal or with a first attack of seizure; however, most of these ab- abnormal, and the abnormal ones were further classified normalities did not require any immediate medical or into clinically insignificant or significant. Descriptive analysis surgical intervention [4] . Focal neurological deficits and was performed to summarize the data. Result: Fifty children the presence of predisposing conditions to seizure among were identified with a mean age of 5.2 ± 3.8 years. Of the 50 this group of patients are reported to be the strongest pre- subjects, 29 (58.0%) were males and 21 (42.0%) were fe- dictors of abnormal computed tomography (CT) scan males. Sixteen patients (32.0%) had abnormal neuroimaging findings [5, 6] . studies (CT scan, MRI or both); however, only 1 was consid- The current guidelines of the American Academy of ered to have a clinically significant abnormality, later diag- Neurology (AAN) do not support the routine use of neu- nosed as Moyamoya disease. Conclusion: In this study, the roimaging studies in such circumstances because of the neuroimaging studies were found not to be useful in evalu- lack of sufficient evidence of any benefit from such stud- ating pediatric patients presenting with a first attack of un- ies [4] . In Kuwait, there are no well-established guidelines provoked, nonfebrile seizures. © 2015 S. Karger AG, Basel regarding the use of neuroimaging studies for pediatric © 2015 S. Karger AG, Basel Hussain Sadeq 1011–7571/15/0251–0056$39.50/0 Department of Pediatrics Al-Adan Hospital E-Mail karger@karger.com Th is is an Open Access article licensed under the terms of the Kuwait City (Kuwait) www.karger.com/mpp Creative Commons Attribution-NonCommercial 3.0 Un- E-Mail drhsadeq   @   icloud.com ported license (CC BY-NC) (www.karger.com/OA-license), applicable to the online version of the article only. Distribu- tion permitted for non-commercial purposes only. Assessed for eligibility (n = 153) Excluded (n = 103) 1. Neuroimaging study was not done (n = 23) 2. Not meeting inclusion criteria (n = 80) a. Febrile seizure b. Known epileptic disorder c. History of status epilepticus d. History of fits shortly after head trauma e. Neonates or patients aged >12 years presenting with a seizure attack Included (n = 50) Patients aged between 28 days and 12 years presenting with 1st attack of unprovoked, nonfebrile convulsions for whom neuroimaging studies were done Fig. 1. Selection of patients. patients with a first attack of nonfebrile seizure, although normal movement, loss of consciousness and fainting were written in the admission slip from the pediatric emergency room. Key- magnetic resonance imaging (MRI) has been found to be words such as abnormal movement, fainting and loss of conscious- of value [7–9] . Emergency neuroimaging studies should ness were also considered as a provisional diagnosis because in be considered in any child of any age presenting with some of the patients, such symptoms could be related to seizure Todd’s paresis [10, 11], and several investigations world- disorders. Exclusion criteria were subjects with febrile seizure, a wide have addressed the importance of neuroimaging known epileptic disorder, a history of status epilepticus or fits oc- curring shortly after head trauma as well as neonates or patients tests in evaluating pediatric patients with this presenta- older than 12 years. Any patient who did not have a neuroimaging tion [12–14] . test as part of the evaluation of the seizure was excluded ( fig. 1 ). The aim of this study was to assess the usefulness of The medical records were thoroughly examined to retrieve data neuroimaging studies in pediatric patients presenting regarding the demographic characteristics and features of the sei- with a first attack of unprovoked, nonfebrile seizure. zure of each patient. This included gender, age, the type and dura- tion of the seizure, the presence of chronic disorders, the family medical history, exposure to toxins and developmental history. In Materials and Methods addition, physical examination findings, investigations and imag- ing results were documented. Seizure types (i.e. partial or general- This retrospective study was conducted at the Mubarak Al-Ka- ized) were defined based on the latest guidelines of the Interna- beer Hospital, Kuwait. The hospital was selected randomly from 5 tional League against Epilepsy [15] . The CT scan and MRI results general hospitals that have Departments of Pediatrics. The study were considered either normal or abnormal by the consultant ra- involved pediatric patients aged between 28 days and 12 years, who diologist, pediatric neurologist and pediatric neurosurgeon. Ab- were admitted for a first attack of unprovoked, nonfebrile seizure. normal neuroimaging studies were further classified as clinically It included patients admitted between 1 January and 31 December insignificant or clinically significant based on the need for imme- 2013. diate medical or surgical intervention. The medical records of the patients were reviewed to identify This study was reviewed and ethically approved by the Review those who had undergone neuroimaging. These radiological tests Board of the Ministry of Health of Kuwait. Moreover, permission were done immediately following admission to the hospital; no to review and collect data from the patients’ records was obtained patient was discharged before undergoing the studies. A consul- from the administration of the hospital involved in our study. The tant radiologist had assessed the images which were then evaluated collected data were entered and analyzed using the Statistical Pack- by pediatric neurologists or neurosurgeons. During our chart re- age for Social Sciences (SPSS v17.0, IBM Inc., Chicago, Ill., USA). view, provisional diagnosis of a first attack of unprovoked, nonfe- Frequencies and proportions were used to describe the demo- brile seizure (as in the medical records) was considered if keywords graphic, clinical and neuroimaging data of the patients, which such as epilepsy, fit, seizure, convulsion, afebrile, nonfebrile, ab- were then summarized in the form of tables. Med Princ Pract 2016;25:56–60 Neuroimaging for First-Attack Nonfebrile 57 DOI: 10.1159/000441847 Seizure Table 1. Demographic characteristics and history of the partici- Table 2. Findings of the physical examination pants Physical examination findings n (%) Characteristics n (%) Mental status Gender Normal 49 (98.0) Male 29 (58.0) Disturbed 1 (2.0) Female 21 (42.0) LOC/coma 0 Age Dysmorphic features 1 – 6 months 7 (14.0) Yes 2 (4.0) 6 – 12 months 3 (6.0) No 48 (96.0) 1 – 5 years 18 (36.0) Neurological skin features 5 – 12 years 22 (44.0) Yes 2 (4.0) Mean ± SD 5.2 ± 3.8 No 48 (96.0) Developmental history Focal neurological deficit Normal 45 (90.0) Yes 3 (6.0) Motor delay 2 (4.0) No 47 (94.0) Global delay 3 (6.0) Family history LOC = Loss of consciousness. Yes 20 (40.0) No 30 (60.0) Seizure type Focal 17 (34.0) Generalized 33 (66.0) Seizure duration ed with focal seizures. In addition, 32 (64.0%) children <5 min 32 (64.0) presented with a brief (<5 min), unprovoked, nonfebrile 5 – 30 min 18 (36.0) seizure. Chronic conditions The findings of the physical examination are shown in Yes 11 (22.0) table 2 ; 1 patient (2%) was admitted to the hospital with No 39 (78.0) Toxin exposure a disturbed level of consciousness and a lethargic appear- Yes 0 ance, dysmorphic features were noted in 2 (4%) and 2 No 50 (100.0) others (4%) had evidence of significant skin features (i.e. hypopigmented macules and café-au-lait spots; both of these patients had normal brain MRI results). Subtle or gross focal neurological deficits at the time of admission Results were noted in 3 patients (6%) only. The findings of the investigations and neuroimaging During the study period, 153 children were admitted studies are summarized in table 3 . An elevation in white with a first attack of nonfebrile seizure. Of these, 50 blood cell count was noted in 4 patients (8%), while se- (32.7%) met the inclusion criteria, i.e. 29 males (58.0%) rum calcium abnormal levels were noted in 5 (10%). Lac- and 21 females (42.0%; table 1 ). Their mean age was 5.2 tate and/or amino acid level tests were ordered for 18 ± 3.8 years, with 40 children (80%) between 1 and 12 patients (36%), but significant abnormalities were only years old and 10 children <1 year (20%). Global or motor found in 1 subject (2%). Lumbar puncture was conduct- delay was noticed in 5 patients (10.0%). Of the 50 chil- ed in 3 patients (6%); all of them had normal cerebrospi- dren, 11 (22.0%) had a history of preexisting chronic nal fluid findings. Electroencephalography was done for conditions; 6 of these were preterm patients, and the re- 30 patients (60.0%), and 17 of them (34%) had abnormal maining 5 were cases of neonatal hypocalcemia, atten- findings such as high-amplitude sharp waves or spike tion-deficit hyperactivity disorder, glucose-6-phosphate complexes found at the frontal, temporal and/or parietal dehydrogenase deficiency, autism spectrum disorder leads. Head CT scan was done for 34 patients (68%), and recurrent otitis media. Moreover, a first- or second- brain MRI for 6 (12%) and 10 patients (20%) had both degree positive family history of epileptic disorder was of these neuroimaging studies. The CT and MRI studies noted in 20 patients (40.0%). Thirty-three patients did not reveal any abnormalities in 34 of the patients (66.0%) presented to the Emergency Department with (68%). Sixteen (32%) were found to have abnormal neu- generalized tonic-clonic seizures and 17 (34.0%) present- roimaging scan results; however, only 1 of these was con- Med Princ Pract 2016;25:56–60 58 Sadeq/Karim/Marwan/AlSaleem DOI: 10.1159/000441847 Table 3. Findings of the investigations Investigations n (%) CBC abnormalities Yes 4 (8.0) No 46 (92.0) Electrolyte abnormalities Calcium 5 (10.0) 2 Magnesium 0 Sodium 0 Glucose 0 Mild brain Small foci of Mild Pineal cyst Arachnoid atrophic hyper-/hypo- ventricular cyst None 45 (90.0) changes density dilatation Lactate and amino acid abnormalities Yes 1 (2.0) No 17 (34.0) Not done 32 (64.0) Fig. 2. Insignificant findings in neuroimaging studies. Lumbar puncture Normal 3 (6.0) Abnormal 0 Not done 47 (94.0) Electroencephalography Discussion Normal 13 (26.0) Abnormal 17 (34.0) Not done 20 (40.0) In this study, 32.0% of the patients had abnormal neu- Neuroimaging modality roimaging findings, and only 1 (6.2%) had clinically sig- CT head 34 (68.0) nificant abnormal CT scan and MRI findings. This 1-year- MRI brain 6 (12.0) old child was diagnosed with Moyamoya disease after Both 10 (20.0) presenting with disorientation and focal attack of seizure, Neuroimaging findings Normal 34 (68.0) and was moved to the Pediatric Neurosurgery Care Unit Abnormal 16 (32.0) where she received antiplatelet therapy and was followed up for possible surgical intervention in the future. CBC = Complete blood count. This low finding of 6.2% of the subjects having signif- Only 1 subject out of 16 was considered to have an abnormal icant neuroimaging findings requiring medical or surgi- CT/MRI scan that was clinically significant. cal management confirmed the finding of 4% in the study of Aprahamian et al. [16] that involved 319 patients. Equally important, Maytal et al. [3] reported that <10% of children with new-onset, nonfebrile seizures had abnor- sidered to have clinically significant abnormal CT scan/ mal emergency neuroimaging findings, but that they did MRI findings. The CT scan of the head of this patient not require any medical or surgical intervention. Taken showed hypodensity in the right temporal and frontal together, all of these findings seem to indicate that the lobes, and the brain MRI revealed a high signal intensity routine use of neuroimaging studies in this group of pe- in the right frontal and occipital lobes with attenuation diatric patients is not useful. of the postcerebral artery (more in the right and middle However, several recommendations have been made cerebral artery) along with abnormal vascular anasto- regarding the indication of neuroimaging evaluation for mosis around the circle of Willis; these were consistent first attacks of nonfebrile seizure in pediatric patients [4, with Moyamoya disease. The clinically insignificant 17–19] . Khodapanahandeh and Hadizadeh [17] suggest- findings ( fig. 2 ) observed in the other 15 patients were: ed the use of neuroimaging studies for children who mild brain atrophic changes in 2 (4%), small foci of present with focal seizures, abnormal neurological find- hypo-/hyper-density or intensity in 6 (12%), mild ven- ings or who are younger than 2 years of age. The AAN tricular dilatation in (5 (10%), pineal cyst in 1 (2%) and guidelines [4] recommend the use of emergency neuro- arachnoid cyst in 1( 2%). All of these findings were con- imaging for any child of any age who exhibits a postictal sidered insignificant by the pediatric neurologist or the focal deficit (i.e. Todd’s paresis) that does not resolve neurosurgeon. quickly or who has not returned to baseline within sev- Med Princ Pract 2016;25:56–60 Neuroimaging for First-Attack Nonfebrile 59 DOI: 10.1159/000441847 Seizure Number of patients eral hours after the seizure. In other reports [4, 18, 19] A major limitation of this study was the small number nonurgent MRI should be considered for any child with of patients. Also, due to its retrospective nature, it could a significant cognitive or motor impairment of unknown not provide a causal relationship between the findings of etiology, unexplained abnormalities on neurological ex- neuroimaging studies and the clinical picture of the pa- amination, a seizure of focal onset with or without sec- tients. ondary generalization, an electroencephalography result that does not represent a benign partial epilepsy of child- hood or primary generalized epilepsy, or in children Conclusion <1 year of age. Unfortunately, following the AAN guide- lines, neuroimaging studies were ordered for 47 of the In this study, neuroimaging studies were not useful in patients (94%) despite the absence of Todd’s paresis. This evaluating pediatric patients who presented with a first resulted in performing unnecessary, expensive and, in attack of unprovoked, nonfebrile seizures. We therefore some cases, high-radiation tests on the children based on recommend that neuroimaging should not be routinely our findings. It seems that pediatricians in Kuwait do not performed in this group of patients unless there is evi- follow any specific guidelines about when to order a neu- dence of focal neurological deficits. roimaging study for this group of patients, but rather that their decision to do so seems to be based on their own experience. These issues should be thoroughly investi- Disclosure Statement gated and addressed in future studies in order to improve pediatric care in Kuwait. There were no conflicts of interest. References 1 Booth TN: Imaging strategies for new onset 8 Resta M, Palma M, Dicuonzo F, et al: Imaging 14 Warden CR, Brownstein DR, Del Beccaro seizures. 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Medical Principles and PracticePubmed Central

Published: Nov 13, 2015

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