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Neuroimaging for Pediatric Non-First-Time Seizures in the Emergency Department
Emma Mazzio1, Rakesh D Mistry1, Scott Rosenthal1
1Section of Neurology (EM, SR, ES, JJ, JM, RM, MS), Department of Pediatrics, University of Colorado Anschutz Medical Campus, Children's Hospital Colorado, Aurora; Section of Emergency Medicine Department of Pediatrics (RDM, JL), University of Colorado Anschutz Medical Campus, Children's Hospital Colorado, Aurora; and Division of Neurology (CAP), Department of Pediatrics, Children's Hospital of Philadelphia, PA.
Insights
Neuroimaging in pediatric emergency departments for nonindex seizures (NIS) rarely changes management. Identifying specific risk factors can help predict when neuroimaging is necessary for acute management changes in children with recurrent seizures.
Area of Science:
- Pediatric Emergency Medicine
- Pediatric Neurology
- Medical Imaging
Background:
- Neuroimaging is a common diagnostic tool for pediatric patients presenting with seizures in the emergency department (ED).
- The utility of neuroimaging for children with a non-first-time seizure (NIS), or recurrent seizure, requires further evaluation to determine its impact on acute management changes (ACM).
Purpose of the Study:
- To assess the association between neuroimaging in the ED and an acute change in management for pediatric patients with a nonindex seizure (NIS).
- To identify clinical factors associated with acute management changes in children with NIS undergoing neuroimaging.
Main Methods:
- Retrospective cohort study of pediatric patients presenting to the ED between 2008 and 2018 with a NIS (excluding repeat febrile seizures) who underwent neuroimaging.
- Data on clinical characteristics were extracted from electronic medical records.
- The primary outcome was a new abnormal neuroimaging finding leading to an ACM, defined as hospital admission, neurosurgical intervention, or new nonseizure medication administration.
Main Results:
- Of 492 encounters, 21% had new neuroimaging findings, and 5% resulted in an ACM.
- Factors associated with ACM included new seizure type, new focal examination findings, altered mental status, and a history of only provoked seizures.
- The odds of ACM increased significantly with the number of risk factors present, with a negative predictive value of 98.6% for ACM in patients with no identified risk factors.
Conclusions:
- Abnormal neuroimaging associated with ACM in pediatric NIS patients is linked to specific, identifiable risk factors.
- Prospective validation of these risk factors could lead to a predictive tool for guiding neuroimaging decisions in the ED, potentially reducing radiation exposure, sedation, and resource use.
Background And Objectives:
Neuroimaging is often part of the workup for a pediatric patient presenting with a seizure to an emergency department (ED). We aim to evaluate when neuroimaging in the ED for children with a non-first-time seizure, or nonindex seizure (NIS), is associated with an acute change in management (ACM).
Methods:
This is a retrospective cohort study of all pediatric patients presenting to an ED from 2008 to 2018 with a NIS, excluding repeat febrile seizures, who underwent neuroimaging. Clinical characteristics were extracted from the electronic medical record. The primary outcome was new abnormal neuroimaging resulting in an ACM, defined as admission to the hospital, neurosurgical intervention, or new nonseizure medication administration.
Results:
We identified 492 encounters. Neuroimaging revealed new findings in 21% of encounters and led to ACMs in 5% of encounters. ACMs included admissions, neurosurgical interventions, and nonseizure medication changes. Factors associated with ACM included new seizure type (odds ratio [OR] 3.3, 95% confidence interval [CI] 1.3-8.0), new focal examination finding (OR 3.0, 95% CI 1.3-7.1), altered mental status (OR 2.9, 95% CI 1.2-7.0), and a history of only provoked seizures (OR 2.8, 95% CI 1.0-7.5). Patients with 2 risk factors had an OR of 6.9 (95% CI 1.8-26.5) for an ACM, and those with 3-4 risk factors had an OR of 45.8 (95% CI 9.8-213.2). The negative predictive value for ACM in a patient with no risk factors was 98.6% (95% CI 95.9-99.5).
Discussion:
Patients with a NIS who have abnormal neuroimaging associated with an ACM present with unique risk factors. Prospectively validating these factors may allow for a prediction tool for NIS in EDs where reduced exposure to ionizing radiation, sedation, and resource utilization are critically important.
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