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Emergent Neuroimaging Is Not Needed in Most New-Onset Afebrile Seizures

Question

  • In children with new onset afebrile seizures, who should have neuroimaging?

Clinical Bottom Lines

  1. Children who are well-appearing and meet low risk criteria can be safely discharged from the ER without emergent neuroimaging, provided follow up can be assured.
  2. Children <33 mo old presenting with focal seizures and children with predisposing conditions (sickle cell disease, bleeding disorders, cerebral vascular disease, malignancy, HIV infection, hemihypertrophy, hydrocephalus, closed head injury and travel to areas endemic for cysticercosis) were at increased risk for having a clinically significant abnormality on head CT or MRI


Summary of Key Evidence

  1. Retrospective chart review of 500 consecutive cases of children (ages 0-21) seen in the ED of a tertiary care children's hospital.1
  2. 475 patients (95%) were imaged with CT or MRI.
  3. Clinically significant abnormal neuroimaging was noted in 38/475 (8% of patients imaged). Operative intervention was required in 5/38. Acute operative intervention was required in <1% of children overall. (3/475).
  4. Recursive partition analysis identified 2 criteria for high-risk for clinically significant abnormal neuroimaging: 1) presence of a predisposing condition, and 2) <33 mo old presenting with a focal seizure.

Additional Comments

  • Practice parameter endorsed by the AAP states that there is insufficient evidence to support routine neuroimaging, laboratory studies or lumbar puncture of all patients with new-onset afebrile seizures. These studies were recommended based on specific clinical circumstances.2
  • Current costs of evaluating a child is > $3,000 per child. More judicial use of neuroimaging and laboratory studies could reduce the cost of a basic ER visit to about $800.3
  • Other studies have come to the same conclusion that emergent neuroimaging is rarely indicated.4,5

Citation

  1. Sharma S, Riviello JJ, Baskin MN. The role of emergent neuroimaging in children with new-onset afebrile seizures. Pediatrics 2003; 111:1-5.
  2. Practice Parameter: evaluating a first nonfebrile seizure in children. Report on the Quality Standards Subcommittee of the American Academy of Neurology, the Child Neurology Society, and the American Epilepsy Society. Neurology 2000;55:616-3.
  3. Freeman JM. Commentary: Less testing is needed in the emergency room after a first afebrile seizure. Pediatrics 2003;111:194-6.
  4. Landfish N, Gieron-Korthals M, Weibley RE, Panzarino V. New onset childhood seizures. Emergency department experience. J Fla Med Assoc 1992;79:697-700.
  5. Maytal J, Krauss JM, Novak G, et al. The role of brain computed tomography in evaluating children with new onset of seizures in the emergency department. Epilepsia 2000;41: 950-4.

CAT Author: Kelly M. Harte, MD

CAT Appraisers: Eugene Golding, MD

Date appraised: March 10, 2003

Last updated December 24, 2003
Department of Pediatrics and Communicable Diseases
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