The role of brain computed tomography in evaluating children with new onset of seizures in the emergency department

BACKGROUND: The purpose of neuroimaging of a patient with new onset of seizures is to demonstrate cause and explore the prognosis. It was recently recommended that emergency brain computed tomography (CT) be performed only in adult seizure patients with an increased likelihood of life-threatening lesions, i.e., those with new focal deficits, persistent altered mental status, fever, recent trauma, persistent headaches, history of cancer, history of anticoagulation, or suspicion of acquired immunodeficiency syndrome. The objective of this study was to determine the diagnostic utility of emergency brain CT in children who present to the emergency department with new onset of seizures. METHODS: A 1-year retrospective chart review of all children who presented to the emergency department of the Schneider Children's Hospital with a new onset of seizures and who underwent CT of the brain, excluding children with simple febrile seizures. RESULTS: 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 CT results and 14 patients (21.2%) had abnormal CT results. Seizure cause was considered cryptogenic in 33 patients, of whom 2 (6%) had abnormal CT results; neither patient required intervention. Seizure cause was considered symptomatic in 20 patients, of whom 12 (60%) had abnormal CT results (p < 0.0001). In two patients with abnormal CT scans (both acute symptomatic), the imaging findings were of immediate therapeutic significance and were predictable from the clinical history and the physical examination. None of the 13 patients with complex febrile seizure cause had an abnormal CT scan. Patients with partial convulsive seizures were more likely to have abnormal CT scans than patients with generalized convulsive seizures, but the difference was not statistically significant. CONCLUSIONS: The routine practice in many pediatric emergency departments of obtaining brain CT scans for all patients with new onset of nonfebrile seizures is unjustified. History and physical examination are sufficient to identify those patients for whom such studies are likely to be appropriate. Emergent CT is not indicated for patients with no known seizure risk factors, normal neurological examinations, no acute symptomatic cause other than fever, and reliable neurological follow-up. For these patients, referral to a pediatric neurologist for further workup, including electroencephalography and the more diagnostically valuable magnetic resonance imaging, would be more appropriate.     

HIPDM single photon emission computed tomography brain imaging in partial onset secondarily generalized tonic-clonic seizures

HIPDM-Single photon emission computed tomography brain imaging was performed during interictal and ictal stages in three patients with complex partial seizures and secondarily generalized tonic-clonic seizures. In all three patients, interictal studies demonstrated decreased regional cerebral perfusion (rCP) and ictal studies showed increased rCP in the epileptogenic region. The demonstration of focal hyperperfusion by SPECT performed during secondarily generalized tonic-clonic seizures suggests that rCP in the epileptic focus remains higher than in other cerebral regions during immediate postictal stages, even in secondarily generalized seizures.     

CT in simple partial seizures in children: a clinical and computed tomography study

Introduction – Therapeutic relevance of computed tomography (CT) in children with simple partial seizures (SPS) is reported to be remarkably low (1–2%). There are no studies, however, from the developing countries where neuroinfections are among important causes of seizures. The present study from India is aimed at evaluating the significance of CT in the management of SPS in children and to determine the difference in clinical features of children with and without focal brain lesions in CT. Patients and methods – CT scans of all patients aged 15 years or younger with SPS, seen over a period of 15 months, were reviewed. The clinical features of the patients with focal lesions in the CT were compared with those of children without focal abnormalities. Results – Focal structural lesions were present in 117 (59.09%) of 198 children. These included: solitary contrast enhancing CT lesion – 16.16%, focal calcification – 12.12%, cysticercosis – 10.10%, focal atrophy – 9.59%, tuberculoma – 6.56% and infarction – 6.06%. Neuroinfections or their sequelae were responsible for seizures in 89 children (44.94%). There were no statistically significant differences in clinical features of patients with and without focal lesions in CT. Conclusion – CT study in children with SPS in developing countries has significant therapeutic relevance. It is not possible to clinically differentiate children with focal lesions from those without focal lesions in CT.     

Age at onset of seizures in young children

Age at onset of seizures in young children and its relationship to factors such as prior neurological status and neurological outcome were examined. Of 52,360 children, 39,270 of whom were followed for the full 7 years, a total of 2,635 experienced one or more seizures between birth and 7 years of age. The incidence of nonfebrile convulsions was highest in the first year of life, especially in the first month. Children with neonatal seizures who later developed nonfebrile seizures did so early, two-thirds by 6 months and three-quarters by 1 year of age. Children with neurological or developmental abnormality assessed in the first year of life did not have their first seizure earlier than children without abnormality. Neurological abnormality in the first year of life before any seizure, and the presence of minor motor seizures, were associated with an increased rate of mental retardation and cerebral palsy at age 7, but early age at onset appeared to have little prognostic value regarding intellectual function, cerebral palsy, and epilepsy.     

Development of color association in normal and neurologically impaired children

Color association, defined as the ability to identify the characteristic color of familiar objects, was studied in 2 groups of brain-damaged children with language or nonlanguage impairment and in a group of control patients. The performance of the 16 control children, 3.5-4.5 years of age, was compared with that of 31 patients, 4.5-5.5 years of age; their scores were 52.4 +/- 31.3 (mean +/- SD) and 85.9 +/- 13.1, respectively (p less than 0.005). Seventeen dysphasic, brain-damaged children and 11 age-matched children with neurologic deficits but without language delay were examined. Their scores were 57.7 +/- 11.7 and 70.6 +/- 21.9, respectively (p less than 0.05). Finally, each of the brain-damaged groups was compared with age-matched controls. Although the control children performed far better than the dysphasic children (77.6 +/- 20.9 and 57.5 +/- 11.7, respectively, p less than 0.001), there was no significant difference between controls and neurologically impaired children without language delay (77.6 +/- 20.9 and 70.6 +/- 21.9, respectively). We conclude that color association in normal children is already operative at 3.5 years and approaches maturity by 4.5-5.5 years. This function was preserved in neurologically impaired children without language delay but was significantly distrubed in the dysphasic children; therefore, the use of color should be assessed in the habilitation of children.     

Brain perfusion single photon emission computed tomography in children after acute encephalopathy

We studied single photon emission computed tomography (SPECT) of 15 children with acute encephalopathy after more than 1 year from the onset, using technetium-99 m-L, L-ethyl cystinate dimer (99mTc-ECD) and a three-dementional stereotaxic region of interest template. Regional cerebral blood flow was evaluated and divided in three groups according to the severity of disability: absent or mild, moderate, and severe. There was no abnormality on SPECT in the patients without disability or with mild disability. Diffuse hypoperfusion was shown in the groups with moderate and severe disability. The patients with severe disability showed hypoperfusion in the pericallosal, frontal and central areas which was more pronounced than in the patients with moderate disability.     

Seizure recurrence risk following a first seizure in neurologically normal children

Purpose: To define seizure recurrence rates in normal children who had had a single seizure and to define electroencephalography (EEG) or magnetic resonance imaging (MRI) utility in predicting seizure recurrence. Methods: We studied 150 children (6 to 14 years) with a first afebrile, unprovoked seizure. Inclusion criteria were: Normal physical and neurological examination, undergone EEG and MRI studies of the brain, and followed for at least 27 months. These children participated in an ongoing prospective study of new onset seizures in childhood. Results: The seizure recurrence rate was 66.4%. An abnormal EEG had no association with seizure recurrence at 9, 18, or 27 months (p = 0.1806, p = 0.2792, and p = 0.2379, respectively). A “significant” MRI abnormality, which occurred in 16.0% of patients, was associated with an increased seizure recurrence risk at 9 months (p = 0.0389) but not at 18 or 27 months. Discussion: EEG findings poorly predict recurrence after a single seizure. The high rate of MRI abnormalities suggests that MRI may need consideration as a routine test to evaluate epilepsy in normal children.     

Partial epilepsy in neurologically normal children: clinical syndromes and prognosis

A clinical and electroencephalographic study of 107 neurologically normal children with partial seizures was undertaken to verify the existence and determine the frequency of epileptic syndromes reported in selected populations. Sixty-three children had simple partial seizures, 39 had complex partial seizures, and 5 children were unclassifiable. The syndrome of benign partial epilepsy of children with rolandic spikes (BPEC, 38 cases) was clearly identified and its uniformly benign final prognosis was confirmed even if some of these children had at times severe or poorly controlled seizures. Among the children with simple partial seizures outside the BPEC (25 cases) and complex partial seizures (39 cases), no homogeneous clinical or electroclinical subgroup could be found. Two children with benign partial epilepsy and myoclonic-astatic seizures ("atypical benign partial epilepsy of childhood") and one child with "benign epilepsy with occipital spike-waves" were identified. 74% of children with epilepsy with complex partial seizures (ECP) had a 1-year seizure-free interval, and many children with epilepsy with simple partial seizures outside the BPEC group (ESP) had no more than two seizures. A benign course is thus not limited to the BPEC but is difficult to predict. Prospective studies are necessary to confirm the existence of well-defined benign syndromes among the idiopathic partial epilepsies of childhood, which appear quite rare outside the BPEC.     

Clinical predictors of computed tomography in epileptic children

The purpose of this study was to determine which clinical characteristics correlated with abnormal computed tomographic (CT) scans in epileptic children. Thirty variables were examined. Of these, four variables (presence of inherited or congenital disease, focal motor findings, developmental delay, and early onset of seizures) correlated with CT scan outcome. Partial seizures per se were not highly associated with abnormal CT scans. A crude decision rule based on these results correctly classified the CT scan result in 94% of the patients who were clinically predicted not to have a parenchymal abnormality.     

Value of neuroimaging in the evaluation of neurologically normal children with recurrent headache

Headache is one of the most frequent physical complaints in children. Although headaches in children are generally benign, neuroimaging studies are frequently performed in clinical practice for the fear of missing a serious underlying disease. Despite this, limited data exist about the utility of neuroimaging in recurrent headache of children with a normal neurologic examination. This prospective study was planned to determine the value of neuroimaging in neurologically normal children with migraine and tension-type headache. Among 95 consecutive patients presenting with headache, 72 patients receiving a diagnosis of migraine or tension-type headache were included in the study. Neuroimaging procedures were performed in 83%. Magnetic resonance imaging (MRI) was abnormal in 11 of 49 cases. Abnormalities consisted of foci of gliosis in four, sinusitis in two, pineal cyst in one, periventricular leukomalacia in one, arachnoid cyst in one, old traumatic changes in one, and cervical syrinx in one. Two of the 11 computed tomographic (CT) scans revealed sinus disease. The percentage of findings causally related to headache was about 10. None of the patients had undergone surgery because of neuroimaging results. In conclusion, the yield of neuroimaging in recurrent headaches of children with a normal neurologic examination is low, and neuroimaging should not be part of a routine initial examination of these patients.     

Hypodense extracerebral images on computed tomography in children

External hydrocephalus (EH) was identified in 58 infants under 3 years of age during the period 1 June 1986 to 28 February 1990. Radiological images and clinical features were compared with 11 cases of cerebral atrophy (CA). Significant differences were found in delivery, head circumference, and the incidence of motor and developmental abnormalities. The population with EH was found to be quite heterogeneous, with a male preponderance. Intracranial pressure was normal in 15 cases in which lumbar puncture was done. The flow of cerebral spinal fluid was considered to be within the normal range in 6 cases. The results of a few cases examined with metrizamide cisternography are presented. The prognosis in our cases was not as benign as previously published, and use of the name EH is questioned. The less committal term hypodense extracerebral images is proposed when computed tomography (CT) is the only study done. The hypothesis that encephalocranial disproportion is the basic underlying entity for the CT images is proposed.     

Ictal single photon emission computed tomography in seizures induced by eye closure

Ictal single photon emission computer tomography (SPECT) studies were performed on a 12 year old child with reflex seizures induced by eye closure. EEGs had shown generalised polyspike waves during eye closure. A magnetic resonance head scan was normal. There was no photosensitive induction of the seizure. Comparison between ideal and post treatment (ethosuximide) interictal SPECT revealed increased ictal perfusion in the basal ganglis, lateral frontal region and superior temporal lobe in the left hemisphere. It is suggested that the reflex epilepsy in this case was triggered by sensory afferents from the orbicularis oculi and mediated via the thalamus.     

Assessment of craniocerebral asymmetries in children by computed tomography

Computed tomographic (CT) scans of 32 children (mean age 2.8±2.5 years) with a wide range of craniocerebral asymmetry (CCA) were analyzed. Hemiparesis and epilepsy were the main clinical presentations. Two-thirds of the patients had brain infarcts. The degree of cerebral and ventricular asymmetry was evaluated by ratios obtained by linear measurements. The patients were divided into two groups according to the index of maximal asymmetry. The incidence of hemiparesis and the width of the cerebral ventricles did not differ in the two groups. This may be due to the fact that most of our patients suffered from perinatal insult to the brain, allowing time for remodeling and palstic changes to occur. The use of measurable structural parameters in craniocerebral asymmetry offers a basis for comparable radiological assessment.     

Nonepileptic events in normal and neurologically handicapped children: a video-EEG study.

Nonepileptic episodic phenomena are reported in 27 of 124 children (21.8%) who had video-electroencephalographic studies performed. Mean age was 7.4 years (S.D.: 6.0; range: 0.1-19). Nineteen (70%) were neurologically impaired (Group 1) and 8 (30%) neurologically normal (Group 2). The final diagnoses included movement sequences (48%), conversion disorder (22%), behavioral staring (18%), sleep disorder (11%), behavioral episodes (8%), and central apnea (8%). In Group 1, abnormal movements (58%) and staring (26%) were most common; conversion disorder (62.5%) was most common in Group 2. Unnecessary medication therapy was prevented in many children. Video-electroencephalography is valuable in preventing over-medication and misdiagnosis.     

A correlative study of electroencephalography and computed tomography in partial complex seizures in adults

To further elucidate relationships between the EEG and computed tomography (CT) in partial complex seizures (PCS), we retrospectively reviewed the EEGs and CT scans in nonselected, predominantly male patients with refractory PCS. We further correlated EEG and CT results with clinical data. All 78 patients in the study had EEGs and CT scans. The time span between the two procedures was 6 months or less. The ages of the patients ranged from 25 to 80, with an average of 51 years. Seizure chronicity ranged from 1 to 60 years, with an average of 15 years. Statistical analysis revealed a trend for unilateral CT and EEG abnormalities to be on the same side. There was no significant relationship between the location of abnormalities on EEG and on CT. The greatest degree of disagreement between CT and EEG occurred in patients with normal findings or diffuse atrophy on CT. There was no significant difference in the age between groups defined by different EEG categories (normal, right-sided, left-sided, or bilateral). The average age of patients with bilateral CT lesions was greater than that of patients with other CT lesions. This observation may reflect the influence of aging rather than the epileptic process on CT findings in PCS. We conclude that surface EEG and neuroimaging measure complementary aspects of cerebral pathology in PCS.     

Video-EEG monitoring differences in children with frontal and temporal onset seizures

The objective of this study was to explore the clinical manifestations and electroencephalogram (EEG) features in children with frontal and temporal onset seizures. The method used was video-EEG monitoring that was conducted for 24 h in children with seizure disorders. The results were as follows: There were fewer children with temporal EEG onset seizure (TOS) than with frontal EEG onset seizure (FOS) (p = 0.132). Within the TOS category, PTOS was most frequent, and ATOS was rare (p = 0.001). The mean duration of ATOS was longer than that of TOS and PTOS (p < 0.05). There were no significant differences in seizure frequency and nocturnal attacks between children with TOS and children with FOS. Furthermore, we observed the interictal EEG from three aspects: the background, the location of discharges, and the time of discharges. The frequency of the multi-focal and bilateral discharges of FOS was higher than that of TOS (p < 0.01). The FOS discharged easily and quickly spread to the bilateral hemisphere and formed secondary bilateral synchrony. Focal discharges predominated in TOS, and rarely showed the paroxysm of bilateral synchronous rhythm. Bursts of fast rhythms predominated in the onset of TOS. In contrast, there were a variety of ictal EEG in FOS. Finally, it was concluded that in the group of children studied, the clinical and EEG characteristics of TOS were different from those of FOS.     

Psychogenic seizures after head injury in children

A total of 148 patients with a history of probable seizure disorder were studied prospectively with long-term video electroencephalography over a 1-year period. Sixteen (11%) were identified with psychogenic seizures. Eleven (69%) of 16 were boys, with a mean age of 10.5 years. Seven (44%) of the 16 had an antecedent history of head injury prior to the development of these episodes; of these patients 85% were boys. Our results suggest that contrary to findings in the adult population, psychogenic seizures can be commonly seen in boys. The prevalence of antecedent head injury suggests that it is a notable risk factor in children as well as adults in the occurrence of psychogenic seizures.     

Results of muscular x-ray computed tomography in 145 cases of neuromuscular disease

CT Scan examination in 145 cases of neuromuscular diseases yielded the following results: Diagnosis between myogenic and neurogenic process is inconstant and cannot be considered as absolute. In myogenic diseases the X ray density of muscle is early decreased with a preservation of muscle outline. In neurogenic diseases muscle volume is early decreased. Coexistence of atrophic and hypertrophic muscles indicates primarily muscle disease. Some patterns of involvement appear to be frequent. In Duchenne's dystrophy a contrast exists between atrophic "empty" or hypertrophic muscles during the ambulatory period and "ghostly" muscles during the terminal period. In facio-scapulo-humeral muscular dystrophy, tibialis anterior and hamstring muscles have often a decreased density and psoas muscles are normal or hypertrophic. In myotonic dystrophy a hypodense perifemoral crescent is frequently observed. Diagnosis between limb-girdle myopathy ("empty" muscles with preserved limits, hypertrophic muscles, hypodense gastrocnemius medialis muscles) and chronic spinal amyotrophy (irregular and atrophic muscles without selective involvement and hypertrophic muscles) is tentatively proposed but is not considered to be clear-cut. Muscle involvement has an asymmetric distribution in amyotrophic lateral sclerosis and is rather symmetric in peripheral neuropathies.     

Gastroesophageal reflux in neurologically impaired children

We present here the indication, procedure and results of surgical treatment of gastroesophageal reflux (GER) for neurologically impaired children. We decide its indication based on clinical symptoms and findings of upper GI series, esophageal pH monitoring and GI fiberscopy, respecting the QOL of the patient and family. Laparoscopic fundoplication has become the first choice in surgical treatment of GER because of its good results. However, an anti-reflux procedure is not effective in patients with intractable aspiration. A laryngotracheal separation procedure should be applied for these cases.