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Prevalence of and Risk Factors for Intracranial Abnormalities in Unprovoked Seizures
Peter S Dayan1, Kathleen Lillis2, Jonathan Bennett3
1Department of Pediatrics, Columbia University College of Physicians and Surgeons, New York, New York; psd6@columbia.edu.
Insights
In children with a first unprovoked seizure, clinically relevant intracranial abnormalities occur in 11%. Most children do not need immediate neuroimaging, but history and exam findings can identify those at higher risk.
Area of Science:
- Pediatric Neurology
- Neuroimaging
- Epilepsy Management
Background:
- Limited prospective data exist on neuroimaging benefits for children with unprovoked seizures.
- Identifying children who require prompt neuroimaging is crucial for effective management.
Purpose of the Study:
- To determine the prevalence of clinically relevant intracranial abnormalities in children experiencing their first unprovoked seizure.
- To identify risk factors associated with these abnormalities.
Main Methods:
- A prospective, 6-center study involving children aged over 28 days to 18 years with unprovoked seizures.
- Clinical data were collected by emergency department clinicians using a standardized form.
- Outcome was defined as clinically relevant intracranial abnormalities on CT or MRI that could alter management.
Main Results:
- 40 out of 354 (11.3%) patients had relevant intracranial abnormalities.
- Only 3 patients (0.8%) had emergent/urgent abnormalities requiring immediate intervention.
- A high-risk medical history and focal seizure aspects were independently associated with relevant abnormalities.
Conclusions:
- Clinically relevant intracranial abnormalities are found in 11% of children with first unprovoked seizures.
- The low incidence of emergent/urgent abnormalities suggests routine ED neuroimaging may not be necessary for most cases.
- Patient history and physical examination are key to identifying children at higher risk for abnormalities.
Background And Objectives:
Prospective data are lacking to determine which children might benefit from prompt neuroimaging after unprovoked seizures. We aimed to determine the prevalence of, and risk factors for, relevant intracranial abnormalities in children with first, unprovoked seizures.
Methods:
We conducted a 6-center prospective study in children aged >28 days to 18 years with seemingly unprovoked seizures. Emergency department (ED) clinicians documented clinical findings on a standardized form. Our main outcome was the presence of a clinically relevant intracranial abnormality on computed tomography (CT) or MRI, defined as those that might change management, either emergently, urgently, or nonurgently.
Results:
We enrolled 475 of 625 (76%) eligible patients. Of 354 patients for whom cranial MRI or CT scans were obtained in the ED or within 4 months of the ED visit, 40 (11.3%; 95% confidence interval [CI]: 8.0-14.6%) had clinically relevant intracranial abnormalities, with 3 (0.8%; 95% CI: 0.1-1.8%) having emergent/urgent abnormalities. On logistic regression analysis, a high-risk past medical history (adjusted odds ratio: 9.2; 95% CI: 2.4-35.7) and any focal aspect to the seizure (odds ratio: 2.5; 95% CI: 1.2-5.3) were independently associated with clinically relevant abnormalities.
Conclusions:
Clinically relevant intracranial abnormalities occur in 11% of children with first, unprovoked seizures. Emergent/urgent abnormalities, however, occur in <1%, suggesting that most children do not require neuroimaging in the ED. Findings on patient history and physical examination identify patients at higher risk of relevant abnormalities.
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