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Marin JR, Lyons TW, Claudius I, Fallat ME, Aquino M, Ruttan T, Daugherty RJ. Optimizing Advanced Imaging of the Pediatric Patient in the Emergency Department: Technical Report. Pediatrics 2024; 154:e2024066855. [PMID: 38932719 DOI: 10.1542/peds.2024-066855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/28/2024] [Indexed: 06/28/2024] Open
Abstract
Advanced diagnostic imaging modalities, including ultrasonography, computed tomography, and magnetic resonance imaging, are key components in the evaluation and management of pediatric patients presenting to the emergency department. Advances in imaging technology have led to the availability of faster and more accurate tools to improve patient care. Notwithstanding these advances, it is important for physicians, physician assistants, and nurse practitioners to understand the risks and limitations associated with advanced imaging in children and to limit imaging studies that are considered low value, when possible. This technical report provides a summary of imaging strategies for specific conditions where advanced imaging is commonly considered in the emergency department. As an accompaniment to the policy statement, this document provides resources and strategies to optimize advanced imaging, including clinical decision support mechanisms, teleradiology, shared decision-making, and rationale for deferred imaging for patients who will be transferred for definitive care.
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Affiliation(s)
- Jennifer R Marin
- Departments of Pediatrics, Emergency Medicine, & Radiology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Todd W Lyons
- Division of Emergency Medicine, Harvard Medical School, Boston Children's Hospital, Boston, Massachusetts
| | - Ilene Claudius
- Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, California
| | - Mary E Fallat
- The Hiram C. Polk, Jr Department of Surgery, University of Louisville School of Medicine, Norton Children's Hospital, Louisville, Kentucky
| | - Michael Aquino
- Cleveland Clinic Imaging Institute, and Section of Pediatric Imaging, Cleveland Clinic Lerner College of Medicine of Case Western University, Cleveland Clinic Children's Hospital, Cleveland, Ohio
| | - Timothy Ruttan
- Department of Pediatrics, Dell Medical School, The University of Texas at Austin; US Acute Care Solutions, Canton, Ohio
| | - Reza J Daugherty
- Departments of Radiology and Pediatrics, University of Virginia School of Medicine, UVA Health/UVA Children's, Charlottesville, Virginia
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Marin JR, Lyons TW, Claudius I, Fallat ME, Aquino M, Ruttan T, Daugherty RJ. Optimizing Advanced Imaging of the Pediatric Patient in the Emergency Department: Technical Report. J Am Coll Radiol 2024; 21:e37-e69. [PMID: 38944445 DOI: 10.1016/j.jacr.2024.03.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/01/2024]
Abstract
Advanced diagnostic imaging modalities, including ultrasonography, computed tomography, and magnetic resonance imaging (MRI), are key components in the evaluation and management of pediatric patients presenting to the emergency department. Advances in imaging technology have led to the availability of faster and more accurate tools to improve patient care. Notwithstanding these advances, it is important for physicians, physician assistants, and nurse practitioners to understand the risks and limitations associated with advanced imaging in children and to limit imaging studies that are considered low value, when possible. This technical report provides a summary of imaging strategies for specific conditions where advanced imaging is commonly considered in the emergency department. As an accompaniment to the policy statement, this document provides resources and strategies to optimize advanced imaging, including clinical decision support mechanisms, teleradiology, shared decision-making, and rationale for deferred imaging for patients who will be transferred for definitive care.
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Affiliation(s)
- Jennifer R Marin
- Departments of Pediatrics, Emergency Medicine, & Radiology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.
| | - Todd W Lyons
- Division of Emergency Medicine, Harvard Medical School, Boston Children's Hospital, Boston, Massachusetts
| | - Ilene Claudius
- Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, California
| | - Mary E Fallat
- The Hiram C. Polk, Jr Department of Surgery, University of Louisville School of Medicine, Norton Children's Hospital, Louisville, Kentucky
| | - Michael Aquino
- Cleveland Clinic Imaging Institute, and Section of Pediatric Imaging, Cleveland Clinic Lerner College of Medicine of Case Western University, Cleveland Clinic Children's Hospital, Cleveland, Ohio
| | - Timothy Ruttan
- Department of Pediatrics, Dell Medical School, The University of Texas at Austin; US Acute Care Solutions, Canton, Ohio
| | - Reza J Daugherty
- Departments of Radiology and Pediatrics, University of Virginia School of Medicine, UVA Health/UVA Children's, Charlottesville, Virginia
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Shuster B, Switzer BE, Krishnasamy M, Garimella R, Vu T, Tierney D, Port C. Safely Shifting MRIs for Seizure Evaluation to the Outpatient Setting. Hosp Pediatr 2023; 13:1077-1086. [PMID: 37960877 DOI: 10.1542/hpeds.2023-007333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2023]
Abstract
BACKGROUND AND OBJECTIVES When a patient is admitted for seizure-like activity, in addition to obtaining a thorough history and physical exam, the evaluation may include a neurology consultation, EEG, and brain MRI. The cost of an inpatient MRI is significant and only 2% of MRIs yield clinically significant findings. At our institution, there was a 20% increase in patients undergoing inpatient MRI from 2018 to 2020. Our aim: Decrease the percentage of patient encounters receiving inpatient brain MRIs for seizure evaluation from 50% to 40% in 6 months by safely shifting MRIs to the outpatient setting. METHODS Initially, provider variability in ordering practices of MRIs was analyzed. Stakeholders were gathered and a local guideline was developed to standardize MRI utilization. A process map was created and highlighted barriers to obtaining an outpatient MRI. A new standard process was developed that streamlined and automated processes, and reduced delays and reliance on patients' families. RESULTS Since implementation of the new clinical guideline, the percentage of inpatient MRIs ordered for patient encounters presenting with seizures and seizure-like episodes decreased from a mean of 50% to 26%. Significant reductions occurred for patients with complex febrile seizures, provoked but afebrile seizures, and unprovoked seizures. The MRI guideline recommendations were followed in 93% of encounters in the final 12 months. None of the patients who underwent outpatient MRI required readmission for acute findings. CONCLUSIONS In this project, the percentage of inpatient MRIs was safely decreased with the implementation of a clinical guideline and standardized process.
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Affiliation(s)
- Brooke Shuster
- Department of Pediatrics, Inova Children's Hospital, Falls Church, Virginia
| | - Barbara E Switzer
- Department of Pediatrics, Inova Children's Hospital, Falls Church, Virginia
| | - Meenu Krishnasamy
- Department of Pediatrics, Inova Children's Hospital, Falls Church, Virginia
| | - Rijutha Garimella
- Department of Pediatrics, Inova Children's Hospital, Falls Church, Virginia
| | - Thuy Vu
- Pediatric Specialists of Virginia, Fairfax, Virginia
| | - Daniel Tierney
- Department of Pediatrics, Inova Children's Hospital, Falls Church, Virginia
| | - Courtney Port
- Department of Pediatrics, Inova Children's Hospital, Falls Church, Virginia
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Woo S, Nah S, Kim M, Kim S, Lee D, Lee J, Moon J, Han S. Factors Associated with Neuroimaging Abnormalities in Children with Afebrile Seizure: A Retrospective Multicenter Study. West J Emerg Med 2023; 24:279-286. [PMID: 36976593 PMCID: PMC10047732 DOI: 10.5811/westjem.2022.12.57505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 12/15/2022] [Indexed: 03/22/2023] Open
Abstract
Introduction: Neuroimaging is recommended for patients with seizures to identify intracranial pathology. However, emergency physicians should consider the risks and benefits of neuroimaging in pediatric patients because of their need for sedation and greater sensitivity to radiation than adults. The purpose of this study was to identify associated factors of neuroimaging abnormalities in pediatric patients experiencing their first afebrile seizure.
Methods: This was a retrospective, multicenter study that included children who presented to the emergency departments (ED) of three hospitals due to afebrile seizures between January 2018– December 2020. We excluded children with a history of seizure or acute trauma and those with incomplete medical records. A single protocol was followed in the three EDs for all pediatric patients experiencing their first afebrile seizure. We performed multivariable logistic regression analysis to identify factors associated with neuroimaging abnormalities.
Results: In total, 323 pediatric patients fulfilled the study criteria, and neuroimaging abnormalities were observed in 95 patients (29.4%). Multivariable logistic regression analysis showed that Todd’s paralysis (odds ratio [OR] 3.72, 95% confidence interval [CI] 1.03-13.36; P=0.04), absence of poor oral intake (POI) (OR 0.21, 95% CI 0.05-0.98; P=0.05), lactic acidosis (OR 1.16, 95% CI 1.04- 1.30; P=0.01), and higher level of bilirubin (OR 3.33, 95% CI 1.11-9.95; P=0.03) were significantly associated with neuroimaging abnormalities. Based on these results, we constructed a nomogram to predict the probability of brain imaging abnormalities.
Conclusion: Todd’s paralysis, absence of POI, and higher levels of lactic acid and bilirubin were associated factors of neuroimaging abnormalities in pediatric patients with afebrile seizure.
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Affiliation(s)
- Seungho Woo
- Soonchunhyang University Bucheon Hospital, Department of Emergency Medicine, Bucheon, Republic of Korea
| | - Sangun Nah
- Soonchunhyang University Bucheon Hospital, Department of Emergency Medicine, Bucheon, Republic of Korea
| | - Minsol Kim
- Soonchunhyang University Bucheon Hospital, Department of Pediatrics, Bucheon, Republic of Korea
| | - Sangil Kim
- Soonchunhyang University Seoul Hospital, Department of Emergency Medicine, Seoul, Republic of Korea
| | - Dongwook Lee
- Soonchunhyang University Cheonan Hospital, Department of Emergency Medicine, Cheonan, Republic of Korea
| | - Jaewook Lee
- Soonchunhyang University Bucheon Hospital, Department of Radiology, Bucheon, Republic of Korea
| | - Jieun Moon
- Soonchunhyang University Bucheon Hospital, Clinical Trial Center, Department of Biostatistics, Bucheon, Republic of Korea
| | - Sangsoo Han
- Soonchunhyang University Bucheon Hospital, Department of Emergency Medicine, Bucheon, Republic of Korea
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Senger KPS, Kesavadas C. Imaging in Pediatric Epilepsy. Semin Roentgenol 2023; 58:28-46. [PMID: 36732009 DOI: 10.1053/j.ro.2022.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2022] [Revised: 10/23/2022] [Accepted: 11/14/2022] [Indexed: 12/14/2022]
Affiliation(s)
| | - C Kesavadas
- Sree Chita Institute of Medical Sciences and Technology, Trivandrum, Kerala, India.
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Ali N, Haider S, Mustahsan S, Shaikh M, Raheem A, Soomar SM, Waheed S. Predictors of abnormal electroencephalogram and neuroimaging in children presenting to the emergency department with new-onset afebrile seizures. BMC Pediatr 2022; 22:619. [PMID: 36303125 PMCID: PMC9609244 DOI: 10.1186/s12887-022-03668-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Revised: 09/09/2022] [Accepted: 10/07/2022] [Indexed: 11/26/2022] Open
Abstract
Background Electroencephalogram and neuroimaging in pediatric patients with new-onset afebrile seizures are performed to detect any underlying pathological severe condition that may require emergent neuro-intervention and guide prognosis. This study aims to determine the predictors of abnormal EEG and neuroimaging in children presenting to the emergency department with new-onset afebrile seizures. Methods This single-center cross-sectional study was conducted at a tertiary care hospital in Karachi, Pakistan, from July 01, 2019, to June 30, 2021. All patients aged one month to 18 years who presented with new-onset afebrile seizures were included. Demographic and clinical data were recorded, including age, gender, seizure type, duration of seizure, associated signs and symptoms, and disposition. Multivariable regression analysis was applied to determine the predictors of abnormal EEG and CT scan or MRI findings. Results Out of 201 participants, most patients were in the infantile age group (41.3%), with an equal gender distribution. The most common type of seizure was generalized onset 152 (75.6%). EEG was performed on a total of 126 patients (62.7%) and out of these patients, 67 patients (53.1%) had abnormal findings. In a multivariable analysis, the age group of 5 to 10 years and seizure duration of more than 5 min were significantly associated with higher odds of abnormal EEG findings. In contrast, only the focal onset of seizure was significantly associated with higher odds of abnormal neuroimaging findings. Conclusion The study emphasizes the need for a protocol regarding the performance of EEG and neuroimaging in children presenting to the ED with new-onset afebrile seizures that would aid emergency physicians in the direction of appropriate management, thus ensuring a better quality of patient care and outcomes. Supplementary Information The online version contains supplementary material available at 10.1186/s12887-022-03668-6.
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Affiliation(s)
- Noman Ali
- grid.7147.50000 0001 0633 6224Department of Emergency Medicine, Aga Khan University, 74800 Karachi, Pakistan
| | - Sohaib Haider
- grid.7147.50000 0001 0633 6224Department of Emergency Medicine, Aga Khan University, 74800 Karachi, Pakistan
| | - Syed Mustahsan
- grid.7147.50000 0001 0633 6224Department of Emergency Medicine, Aga Khan University, 74800 Karachi, Pakistan
| | - Murk Shaikh
- grid.7147.50000 0001 0633 6224Department of Pediatrics & Child Health, Aga Khan University, 74800 Karachi, Pakistan
| | - Ahmed Raheem
- grid.7147.50000 0001 0633 6224Department of Emergency Medicine, Aga Khan University, 74800 Karachi, Pakistan
| | - Salman Muhammad Soomar
- grid.7147.50000 0001 0633 6224Department of Emergency Medicine, Aga Khan University, 74800 Karachi, Pakistan
| | - Shahan Waheed
- grid.7147.50000 0001 0633 6224Department of Emergency Medicine, Aga Khan University, 74800 Karachi, Pakistan
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Aungaroon G. A Muddy Crystal Ball for Infantile-Onset Epilepsy Outcomes. Epilepsy Curr 2022; 22:342-344. [DOI: 10.1177/15357597221123901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
[Box: see text]
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Aksu Uzunhan T, Kaçar A, Mısırlı Özdemir E, Yapıcı Ö. First afebrile seizures: Clinical and radiological view with emergent testing. Pediatr Int 2022; 64:e15089. [PMID: 34882919 DOI: 10.1111/ped.15089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Revised: 11/04/2021] [Accepted: 12/03/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND The first afebrile seizures in children are an important and common reason for emergency department admissions. We aim to examine the presentation, laboratory/neurodiagnostic investigation, and emergency management of children with first afebrile seizures. METHODS The retrospective study included 333 patients aged 1 month to 18 years admitted with a first afebrile seizure to the pediatric emergency department of Prof. Dr. Cemil Taşcıoğlu City Hospital between January 2017 and January 2020. Age, gender, seizure duration and type, treatments for seizures, laboratory, neurophysiological, and radiological investigations, ward or intensive care unit hospitalizations, and antiepileptic drugs on discharge were recorded. RESULTS The average age of the patients was 81.6 ± 62.9 months; 187 (56.2%) were male and 146 (43.8%) were female. Two hundred and sixty-one (78.4%) patients had only one seizure. In 45 (13.5%) of the patients, the seizure recurred in the emergency department. Hypoglycemia, hyponatremia, and hypocalcemia were detected in 13 (3.9%) patients. Patients with clinically significant cranial computed tomography results were at an increased risk for seizures lasting longer than 5 min. Patients with focal seizures had more recurrences, were given more antiepileptic drugs during the emergency, had better known etiology, more intensive care unit hospitalization, and greater post-discharge antiepileptic drug prescription. CONCLUSIONS Biochemical abnormalities remain in the background in the etiology of afebrile seizures. Patients with abnormal neuroimaging on cranial tomography tended to have longer seizures. Patients with focal seizures followed a more complicated course as they had more recurrences and more hospitalization in the intensive care unit.
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Affiliation(s)
- Tuğçe Aksu Uzunhan
- Department of Pediatric Neurology, Prof. Dr. Cemil Taşcıoğlu City Hospital, University of Health Sciences, İstanbul, Turkey
| | - Alper Kaçar
- Department of Pediatrics, Prof. Dr. Cemil Taşcıoğlu City Hospital, University of Health Sciences, İstanbul, Turkey
| | - Ebru Mısırlı Özdemir
- Department of Pediatrics, Prof. Dr. Cemil Taşcıoğlu City Hospital, University of Health Sciences, İstanbul, Turkey
| | - Özge Yapıcı
- Department of Pediatric Radiology, Prof. Dr. Cemil Taşcıoğlu City Hospital, University of Health Sciences, İstanbul, Turkey
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Verma M, Kumar C, Alam A, Kumar R, Koonwar S, Gupta S, Parihar A. Role of neuroimaging in children with first unprovoked seizure: A prospective observational study. Epilepsy Behav 2021; 124:108317. [PMID: 34619542 DOI: 10.1016/j.yebeh.2021.108317] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2021] [Revised: 08/30/2021] [Accepted: 08/30/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To evaluate the incidence and type of neuroimaging abnormalities in first unprovoked seizure (FUS) in children. To investigate the association of neuroimaging abnormalities with clinical variables. METHODS A prospective observational study enrolled children aged 6 months-14 years with FUS over one year at a tertiary-care teaching hospital, Northern India and subjected them to neuroimaging. Factors associated with abnormal neuroimaging were assessed using Chi square/Fischer Exact test. RESULTS Out of 115 cases, 40 (34.8%) had abnormal neuroimaging. Frequent findings were inflammatory granuloma (70%) including Neurocysticercosis (NCC) (40%), ill-defined granuloma, calcified nodule and tuberculoma followed by white matter signal alterations. Inflammatory granuloma was significantly associated with age >2 years and focal seizures. Calcified nodule was more common in children >10 years. Other neuro-abnormalities like cerebral atrophy, gliosis, infarcts, and white matter changes were significantly prevalent with generalized seizures, perinatal asphyxia, and developmental delay. CONCLUSION High prevalence of abnormalities in FUS, especially focal seizures, due to NCC warrants neuroimaging in all children with FUS in India.
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Affiliation(s)
- Manisha Verma
- Department of Paediatrics, King George's Medical University, Lucknow, India
| | - Chandrakanta Kumar
- Department of Paediatrics, King George's Medical University, Lucknow, India
| | - Areesha Alam
- Department of Paediatrics, King George's Medical University, Lucknow, India.
| | - Rashmi Kumar
- Department of Paediatrics, King George's Medical University, Lucknow, India
| | | | - Sarika Gupta
- Department of Paediatrics, King George's Medical University, Lucknow, India
| | - Anit Parihar
- Department of Radio-diagnosis, King George's Medical University, Lucknow, India
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Hourani R, Nasreddine W, Dirani M, Hmaimess G, Sabbagh S, El Tourjuman O, Wazne J, Toufaili H, AlArab N, El Dassouki M, Beydoun A. When Should a Brain MRI Be Performed in Children with New-Onset Seizures? Results of a Large Prospective Trial. AJNR Am J Neuroradiol 2021; 42:1695-1701. [PMID: 34244128 DOI: 10.3174/ajnr.a7193] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 04/05/2021] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE There is a paucity of data regarding the incidence of structural brain lesions in children with new-onset unprovoked seizures. Our aim was to determine the frequencies and types of epileptogenic lesions detected on a dedicated epilepsy protocol MR imaging according to age group, the presence of developmental delay, and the number and types of seizures. MATERIALS AND METHODS Consecutive children between 6 months and 18 years of age with new-onset unprovoked seizures were included. The frequencies and types of epileptogenic lesions were determined and then stratified according to sex, age groups, the presence of developmental delay, and the number and types of seizures at presentation. Multivariate analysis was used to identify variables significantly associated with the presence of epileptogenic lesions. RESULTS One thousand children were included. An epileptogenic lesion was identified in 26%, with malformations of cortical development being the most common lesion (32%), followed by hypoxic-ischemic injury (20%) and vascular etiologies (16%). Univariate analysis showed a significant increase in the frequency of epileptogenic lesions with decreasing age, the presence of developmental delay, and the number and types of seizures at presentation. The presence of developmental delay and seizure type at presentation remained significant in a multivariate analysis. CONCLUSIONS We documented a relatively high rate of epileptogenic lesions in children with new-onset seizures, with the presence of developmental delay and specific seizure types being associated with a higher likelihood of detecting an epileptogenic lesion on neuroimaging. This study fulfills the requirements of the study design recommended by the Practice Committee of the American Academy of Neurology, and we hope that our results will assist the relevant societies and committees in formulating neuroimaging guidelines for children with new-onset seizures.
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Affiliation(s)
- R Hourani
- Department of Radiology (R.H., N.A.), American University of Beirut Medical Center, Beirut, Lebanon
| | - W Nasreddine
- Department of Neurology (W.N., M.D., A.B.), American University of Beirut Medical Center, Beirut, Lebanon
| | - M Dirani
- Department of Neurology (W.N., M.D., A.B.), American University of Beirut Medical Center, Beirut, Lebanon
| | - G Hmaimess
- Department of Pediatrics (G.H.), St George Hospital Medical University Center, University of Balamand, Beirut, Lebanon
| | - S Sabbagh
- Department of Pediatrics (S.S.), Hotel Dieu de France Hospital, Beirut, Lebanon
| | - O El Tourjuman
- Department of Neurology (O.E.T., J.W., M.E.D.), Rafic Hariri University Hospital, Beirut, Lebanon
| | - J Wazne
- Department of Neurology (O.E.T., J.W., M.E.D.), Rafic Hariri University Hospital, Beirut, Lebanon
| | - H Toufaili
- Labib Medical Center (H.T.), Beirut, Lebanon
| | - N AlArab
- Department of Radiology (R.H., N.A.), American University of Beirut Medical Center, Beirut, Lebanon
| | - M El Dassouki
- Department of Neurology (O.E.T., J.W., M.E.D.), Rafic Hariri University Hospital, Beirut, Lebanon
| | - A Beydoun
- Department of Neurology (W.N., M.D., A.B.), American University of Beirut Medical Center, Beirut, Lebanon
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Trofimova A, Milla SS, Ryan ME, Pruthi S, Blount JP, Desai NK, Glenn OA, Islam MP, Kadom N, Mirsky DM, Myseros JS, Partap S, Radhakrishnan R, Rose E, Soares BP, Trout AT, Udayasankar UK, Whitehead MT, Karmazyn B. ACR Appropriateness Criteria® Seizures-Child. J Am Coll Radiol 2021; 18:S199-S211. [PMID: 33958113 DOI: 10.1016/j.jacr.2021.02.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Accepted: 02/17/2021] [Indexed: 12/11/2022]
Abstract
In children, seizures represent an extremely heterogeneous group of medical conditions ranging from benign cases, such as a simple febrile seizure, to life-threatening situations, such as status epilepticus. Underlying causes of seizures also represent a wide range of pathologies from idiopathic cases, usually genetic, to a variety of acute and chronic intracranial or systemic abnormalities. This document discusses appropriate utilization of neuroimaging tests in a child with seizures. The clinical scenarios in this document take into consideration different circumstances at the time of a child's presentation including the patient's age, precipitating event (if any), and clinical and electroencephalogram findings and include neonatal seizures, simple and complex febrile seizures, post-traumatic seizures, focal seizures, primary generalized seizures in a neurologically normal child, and generalized seizures in neurologically abnormal child. This practical approach aims to guide clinicians in clinical decision-making and to help identify efficient and appropriate imaging workup. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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Affiliation(s)
| | - Sarah S Milla
- Emory University and Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Maura E Ryan
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Sumit Pruthi
- Panel Chair, Vanderbilt Children's Hospital, Nashville, Tennessee
| | | | | | - Orit A Glenn
- University of California San Francisco, San Francisco, California
| | - Monica P Islam
- Nationwide Children's Hospital, Columbus, Ohio, American Academy of Neurology, Acting Director, Nationwide Children's Hospital Epilepsy Program, Director, Nationwide Children's Hospital Evoked Potential and Neurophysiologic Intraoperative Monitoring Program; Director, Nationwide Children's Hospital Tuberous Sclerosis Complex Clinic
| | - Nadja Kadom
- Emory University and Children's of Atlanta (Egleston), Atlanta, Georgia
| | | | - John S Myseros
- Children's National Hospital, Children's National Health System, Washington, District of Columbia, Neurosurgery expert, Vice Chief, Neurosurgery, Children's National Hospital
| | - Sonia Partap
- Stanford University, Stanford, California, American Academy of Pediatrics
| | | | - Emily Rose
- Keck School of Medicine of USC, Los Angeles, California, American College of Emergency Physicians
| | - Bruno P Soares
- University of Vermont Medical Center, Burlington, Vermont, Division Director, Neuroradiology, Vice Chair of Imaging Research, University of Vermont Medical Center
| | - Andrew T Trout
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, Officer, Joint Review Committee on Educational Programs in Nuclear Medicine Technology
| | | | | | - Boaz Karmazyn
- Specialty Chair, Riley Hospital for Children Indiana University, Indianapolis, Indiana
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Nezami A, Tarhani F, Shoshtari NK. Organic Lesions in the Brain MRI of Children with Febrile Seizure. Curr Med Imaging 2021; 17:148-154. [PMID: 32101131 DOI: 10.2174/1573405616666200226103615] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2019] [Revised: 01/28/2020] [Accepted: 02/10/2020] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Seizure is the most common neurological disorders in children, where 4-10% of the cases experience at least one seizure before the age of 16. The most frequent causes of seizures in children are fever, epilepsy, infection and brain damage. The aim of this study was to investigate the frequency of organic lesions in MRI of children with seizures unrelated to fever. MATERIALS AND METHODS This cross-sectional study included children presented with fever-unrelated seizures. The MRI was examined by a radiologist to identify abnormal findings in each patient. A researcher-made questionnaire including general information, history of head trauma, obstructed labor and the history of seizure was completed for the patients. RESULTS Of 287 children with fever-related seizure, 127 (45.7%) were male and 151 (54.3%) were female. History of seizure, history of obstructed labor, abnormal MRI, complete delay, use of antiepileptic drug and history of trauma were 22(9.9%), 1 (0.4%), 11(4%), 5(1.8%), 259(93.2%) and 12 (4.3%), respectively. Of 11 patients with abnormal MRI, 4 had MTS lesions, 2 had tumor lesions, 2 had scarring trauma, 1 had an epidural abscess and 1 had meningitis. The frequency of organic lesions had no significant differences based on gender, use of antiepileptic drug and traumatic history, but it had a significant relation with obstructed labor andthehistory of seizure. CONCLUSION The results showed that organic brain lesions in children with fever-unrelated seizure had a significant relationship with the history of seizure and obstructed maternal labor.
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Affiliation(s)
- Alireza Nezami
- Department of Cardiology, School of Medicine, Lorestan University of Medical Sciences, Khorramabad, Iran
| | - Fariba Tarhani
- Department of Cardiology, School of Medicine, Lorestan University of Medical Sciences, Khorramabad, Iran
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Assadsangabi R, Ozturk A, Kantamneni T, Azizi N, Asaikar SM, Hacein-Bey L. Neuroimaging of Childhood Epilepsy: Focal versus Generalized Epilepsy. JOURNAL OF PEDIATRIC EPILEPSY 2021. [DOI: 10.1055/s-0040-1722301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
AbstractNeuroimaging plays an increasingly crucial role in delineating the pathophysiology, and guiding the evaluation, management and monitoring of epilepsy. Imaging contributes to adequately categorizing seizure/epilepsy types in complex clinical situations by demonstrating anatomical and functional changes associated with seizure activity. This article reviews the current status of multimodality neuroimaging in the pediatric population, including focal lesions which may result in focal epileptic findings, focal structural abnormalities that may manifest as generalized epileptiform discharges, and generalized epilepsy without evidence of detectable focal abnormalities.
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Affiliation(s)
- Reza Assadsangabi
- Department of Neuroradiology, Radiology, University of California Davis School of Medicine, Sacramento, California, United States
| | - Arzu Ozturk
- Department of Neuroradiology, Radiology, University of California Davis School of Medicine, Sacramento, California, United States
| | - Trishna Kantamneni
- Department of Neurology, University of California Davis School of Medicine, Sacramento, California, United States
| | - Nazarin Azizi
- Department of Neuroradiology, Radiology, University of California Davis School of Medicine, Sacramento, California, United States
| | - Shailesh M. Asaikar
- Child & Adolescent Neurology Consultants, Sacramento, California, United States
| | - Lotfi Hacein-Bey
- Department of Neuroradiology, Radiology, University of California Davis School of Medicine, Sacramento, California, United States
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Brugman J, Solomons RS, Lombard C, Redfern A, Du Plessis AM. Risk-Stratification of Children Presenting to Ambulatory Paediatrics with First-Onset Seizures: Should We Order an Urgent CT Brain? J Trop Pediatr 2020; 66:299-314. [PMID: 31625577 DOI: 10.1093/tropej/fmz071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
INTRODUCTION A computed tomography (CT) brain scan is an often-utilised emergency department imaging modality to detect emergent intra-cranial pathology in a child with a first seizure. Identifying children at low risk of having a clinically significant intra-cranial abnormality could prevent unnecessary radiation exposure and contrast/sedation-related risks. OBJECTIVES To identify clinical variables which could predict clinically significant CT brain abnormalities and use recursive partitioning analysis to define a low-risk group of children in whom emergent CT brain can be deferred. METHODS Retrospective cross-sectional review of 468 children who underwent emergent CT brain after presenting to a low- and middle-income paediatric emergency department following first seizure. RESULTS In total 133/468 (28.4%) of CT brain scans had clinically significant abnormalities. Failure to return to neurological baseline and focal neurological deficit persisting >36 h had statistical significance in a multiple regression analysis. Recursive partitioning analysis, applied to a subgroup without suspected tuberculous meningitis (n = 414), classified 153 children aged between 6 months and 5 years, who had a normal neurological baseline, had returned to baseline post-seizure, and were not in status epilepticus, as non-clinically significant scans and 98% were correctly classified. CONCLUSION Our study re-inforces the American Academy of Neurology recommendation that children with persistent post-ictal abnormal neurological status and/or post-ictal focal deficit be prioritised for emergent CT brain. Having excluded children with suspected tuberculous meningitis, the remaining subgroup aged 6 months to 5 years presenting with a non-status first seizure, normal neurological baseline and return to baseline post-seizure, are at very low risk of having a clinically significant CT brain abnormality.
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Affiliation(s)
- Jaanri Brugman
- Division of Radiodiagnosis, Department of Medical Imaging and Clinical Oncology, Faculty of Medicine and Health Sciences, Stellenbosch University and Tygerberg Hospital, Francie van Zijl Drive, Tygerberg, Cape Town, South Africa
| | - Regan Shane Solomons
- Department of Pediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Carl Lombard
- Biostatistics Unit, South African Medical Research Council, Cape Town, South Africa
| | - Andrew Redfern
- Department of Pediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Anne-Marie Du Plessis
- Division of Radiodiagnosis, Department of Medical Imaging and Clinical Oncology, Faculty of Medicine and Health Sciences, Stellenbosch University and Tygerberg Hospital, Francie van Zijl Drive, Tygerberg, Cape Town, South Africa
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Shaikh Z, Torres A, Takeoka M. Neuroimaging in Pediatric Epilepsy. Brain Sci 2019; 9:E190. [PMID: 31394851 PMCID: PMC6721420 DOI: 10.3390/brainsci9080190] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2019] [Revised: 07/18/2019] [Accepted: 08/06/2019] [Indexed: 12/27/2022] Open
Abstract
Pediatric epilepsy presents with various diagnostic challenges. Recent advances in neuroimaging play an important role in the diagnosis, management and in guiding the treatment of pediatric epilepsy. Structural neuroimaging techniques such as CT and MRI can identify underlying structural abnormalities associated with epileptic focus. Functional neuroimaging provides further information and may show abnormalities even in cases where MRI was normal, thus further helping in the localization of the epileptogenic foci and guiding the possible surgical management of intractable/refractory epilepsy when indicated. A multi-modal imaging approach helps in the diagnosis of refractory epilepsy. In this review, we will discuss various imaging techniques, as well as aspects of structural and functional neuroimaging and their application in the management of pediatric epilepsy.
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Affiliation(s)
- Zakir Shaikh
- Department of Pediatrics, Division of Pediatric Neurology, Boston Medical Center, Boston University School of Medicine, Boston, MA 02118, USA
| | - Alcy Torres
- Department of Pediatrics, Division of Pediatric Neurology, Boston Medical Center, Boston University School of Medicine, Boston, MA 02118, USA.
| | - Masanori Takeoka
- Department of Pediatric Neurology, Children's Hospital Boston, Harvard Medical School, Boston, MA 02115, USA
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16
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Clinico-etiological Profile and Developmental Status of Infants Aged 1-24 months with Epilepsy. Indian J Pediatr 2019; 86:681-685. [PMID: 30976964 DOI: 10.1007/s12098-019-02943-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Accepted: 03/25/2019] [Indexed: 10/27/2022]
Abstract
OBJECTIVE To study the clinico-etiological profile of epilepsy in children aged 1-24 mo attending a tertiary-care public hospital. METHODS All infants aged 1-24 mo with epilepsy (as per International League Against Epilepsy, 2014) presenting between April 2016 and March 2017 were enrolled. Detailed history and examination were done in all children, and developmental assessment was done using Developmental Assessment Scale for Indian Infants (DASII). Electroencephalography and neuroimaging (CT/MRI) were done for all subjects. RESULTS Sixty children (39 males) were consecutively enrolled after informed written consent. The mean (SD) age at seizure onset was 4.3 (4.14) mo. Perinatal asphyxia (45%) and malformations of cortical development (18.3%) were the commonest etiologies. Neurological examination was abnormal in 68.3%, and a neuroimaging abnormality was present in 76% of children. Fifteen patients (25%) had West syndrome, which was symptomatic in the majority (73.3%). Developmental delay (DQ < 70) was the commonest co-morbidity (81.7%); 28.3% had profound delay. Odds of having developmental delay were 13-times higher in those with an abnormal neurological examination [OR 13.5 (2.82-64.67), P = 0.001], and nearly 9-times higher with abnormal neuroimaging [OR 8.9 (2.11-37.9), P = 0.003]. CONCLUSIONS Epilepsy in children <2 y is symptomatic in the majority, with sequelae of birth asphyxia as the commonest etiology. High prevalence of co-morbid developmental delay underscores the need for routine evaluation and early intervention in all high-risk infants.
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Drapkin Z, Franchek-Roa K, Srinivas GL, Buchi KF, Miescier MJ. Is my baby normal? A review of seemingly worrisome but normal newborn signs, symptoms and behaviors. Am J Emerg Med 2019; 37:1153-1159. [PMID: 30952605 DOI: 10.1016/j.ajem.2019.03.028] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Revised: 03/18/2019] [Accepted: 03/20/2019] [Indexed: 12/20/2022] Open
Abstract
Infant patients are a unique challenge to emergency department (ED) physicians as the spectrum of normal infant signs, symptoms and behaviors are often difficult to differentiate from abnormal and potentially life-threatening conditions. In this article, we address some common chief complaints of neonates and young infants presenting to the ED, and contrast reassuring neonatal and young infant signs and symptoms against those that need further workup and intervention.
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Affiliation(s)
- Zachary Drapkin
- Department of Pediatrics, Division of Pediatric Emergency Medicine, University of Utah, Salt Lake City, UT, USA; Department of Surgery, Division of Emergency Medicine, University of Utah, Salt Lake City, UT, USA.
| | | | - Ganga L Srinivas
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Karen F Buchi
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Michael J Miescier
- Department of Pediatrics, Division of Pediatric Emergency Medicine, University of Utah, Salt Lake City, UT, USA
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18
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Challenges in managing epilepsy associated with focal cortical dysplasia in children. Epilepsy Res 2018; 145:1-17. [DOI: 10.1016/j.eplepsyres.2018.05.006] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2017] [Revised: 04/30/2018] [Accepted: 05/12/2018] [Indexed: 12/15/2022]
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Coryell J, Gaillard WD, Shellhaas RA, Grinspan ZM, Wirrell EC, Knupp KG, Wusthoff CJ, Keator C, Sullivan JE, Loddenkemper T, Patel A, Chu CJ, Massey S, Novotny EJ, Saneto RP, Berg AT. Neuroimaging of Early Life Epilepsy. Pediatrics 2018; 142:peds.2018-0672. [PMID: 30089657 PMCID: PMC6510984 DOI: 10.1542/peds.2018-0672] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/13/2018] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES We assessed the adherence to neuroimaging guidelines and the diagnostically relevant yield of neuroimaging in newly presenting early life epilepsy (ELE). METHODS There were 775 children with a new diagnosis of epilepsy (<3 years old at onset) who were recruited through the ELE study at 17 US pediatric epilepsy centers (2012-2015) and managed prospectively for 1 year. The data were analyzed to assess the proportion of children who underwent neuroimaging, the type of neuroimaging, and abnormalities. RESULTS Of 725 children (93.5%) with neuroimaging, 714 had an MRI (87% with seizure protocols) and 11 had computed tomography or ultrasound only. Etiologically relevant abnormalities were present in 290 individuals (40%) and included: an acquired injury in 97 (13.4%), malformations of cortical development in 56 (7.7%), and other diffuse disorders of brain development in 51 (7.0%). Neuroimaging was abnormal in 160 of 262 (61%) children with abnormal development at diagnosis versus 113 of 463 (24%) children with typical development. Neuroimaging abnormalities were most common in association with focal seizure semiology (40%), spasms (47%), or unclear semiology (42%). In children without spasms or focal semiology with typical development, 29 of 185 (16%) had imaging abnormalities. Pathogenic genetic variants were identified in 53 of 121 (44%) children with abnormal neuroimaging in whom genetic testing was performed. CONCLUSIONS Structural abnormalities occur commonly in ELE, and adherence to neuroimaging guidelines is high at US pediatric epilepsy centers. These data support the universal adoption of imaging guidelines because the yield is substantially high, even in the lowest risk group.
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Affiliation(s)
- Jason Coryell
- Departments of Pediatrics, Oregon Health and Sciences University, Portland, Oregon,Departments of Neurology, Oregon Health and Sciences University, Portland, Oregon
| | - William D. Gaillard
- Department of Neurology, Children’s National Health System and School of Medicine, The George Washington University, Washington, District of Columbia
| | | | - Zachary M. Grinspan
- Health Information Technology Evaluation Collaborative, Weill Cornell Medicine and New York–Presbyterian Hospital, New York, New York
| | | | - Kelly G. Knupp
- Department of Pediatrics and Neurology, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | | | - Cynthia Keator
- Jane and John Justin Neurosciences Center, Cook Children’s Health Care System, Fort Worth, Texas
| | - Joseph E. Sullivan
- Department of Neurology, University of California, San Francisco, San Francisco, California
| | - Tobias Loddenkemper
- Division of Epilepsy and Clinical Neurophysiology, Boston Children’s Hospital and Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Anup Patel
- Department of Pediatrics, The Ohio State University and Nationwide Children’s Hospital, Columbus, Ohio
| | - Catherine J. Chu
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts
| | - Shavonne Massey
- Departments of Neurology, Perelman School of Medicine, University of Pennsylvania and Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania,Departments of Pediatrics, Perelman School of Medicine, University of Pennsylvania and Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Edward J. Novotny
- Departments of Division of Pediatric Neurology, Neurology, Seattle Children’s Research Institute, Seattle Children’s Hospital and University of Washington, Seattle, Washington,Departments of Pediatrics, Seattle Children’s Research Institute, Seattle Children’s Hospital and University of Washington, Seattle, Washington,Center for Integrative Brain Research, Seattle Children’s Research Institute, Seattle Children’s Hospital and University of Washington, Seattle, Washington
| | - Russel P. Saneto
- Departments of Division of Pediatric Neurology, Neurology, Seattle Children’s Research Institute, Seattle Children’s Hospital and University of Washington, Seattle, Washington
| | - Anne T. Berg
- Epilepsy Center, Ann and Robert H. Lurie Children’s Hospital of Chicago and Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
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Abstract
Advances in medical imaging are invaluable in the care of pediatric patients in the emergent setting. The diagnostic accuracy offered by studies using ionizing radiation, such as plain radiography, computed tomography, and fluoroscopy, are not without inherent risks. This article reviews the evidence supporting the risk of ionizing radiation from medical imaging as well as discusses clinical scenarios in which clinicians play an important role in supporting the judicious use of imaging studies.
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Affiliation(s)
- Amy L Puchalski
- Department of Emergency Medicine, Division of Pediatric Emergency Medicine, Carolinas Medical Center, Levine Children's Hospital, 1000 Blythe Boulevard, Charlotte, NC 28203, USA.
| | - Christyn Magill
- Department of Emergency Medicine, Division of Pediatric Emergency Medicine, Carolinas Medical Center, Levine Children's Hospital, 1000 Blythe Boulevard, Charlotte, NC 28203, USA
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21
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Dirik MA, Sanlidag B. Magnetic resonance imaging findings in newly diagnosed epileptic children. Pak J Med Sci 2018; 34:424-428. [PMID: 29805420 PMCID: PMC5954391 DOI: 10.12669/pjms.342.14807] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Objectives Epilepsy is one of the most common chronic neurologic disorders in childhood and it affects 0.5-1% of children. The purpose of the study was to determine the prevalence and types of structural abnormalities in the epileptic children. Methods The study was performed in Near East University and Dr. Suat Gunsel University in North Cyprus. It was conducted at pediatric neurology outpatient clinic of the hospital. The records of 1 to 18 years old epileptic children in whom Magnetic Resonance Imaging (MRI) performed within 6 months after diagnosis were enrolled to the study between the dates of October 2011 and June 2017. Results Among 220 children; 131 (59.55%) had no abnormality and 89 (45.45%) had at least one abnormality in the MRI. Most commonly documented lesions were generally encephalomalacia, hydrocephaly and brain atrophy with a percent of 5.90 (13 cases), 5.45 (12 cases) and 4.55 (10 cases) respectively. Sixty nine (31.06%) of the patients had one abnormality whereas 20 (9.09%) had two or more lesion. Conclusion Abnormality in MRI examination in newly diagnosed epileptic children was high. These high rates may be due to enrollment of children with new emerging epilepsy on a chronical neurologic disorder. Additionally 20 (9.09%) of patients had a concomitant lesion. Secondary lesions were detected in cases with corpus callosum abnormality, atrophy, encephalomalacia and hydrocephaly. Primarily formed lesions are unknown; further studies are needed to confirm these findings.
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Affiliation(s)
- Mehmet Alp Dirik
- Mehmet Alp Dirik, MD. Radiologist, Department of Radioloy, Dr. Suat Gunsel University, Faculty of Medicine, Kyrenia, North Cyprus
| | - Burcin Sanlidag
- Burcin Sanlidag, MD. Pediatrician, Department of Pediatrics Division of Pediatric Neurology, Near East University, Faculty of Medicine, Nicosia, North Cyprus
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22
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Two Studies, One Message: High Yield of Genetic Testing in Infants and Young Children With Severe Epilepsies. Epilepsy Curr 2018; 18:24-26. [PMID: 29844755 DOI: 10.5698/1535-7597.18.1.24] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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23
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Sansevere AJ, Avalone J, Strauss LD, Patel AA, Pinto A, Ramachandran M, Fernandez IS, Bergin AM, Kimia A, Pearl PL, Loddenkemper T. Diagnostic and Therapeutic Management of a First Unprovoked Seizure in Children and Adolescents With a Focus on the Revised Diagnostic Criteria for Epilepsy. J Child Neurol 2017; 32:774-788. [PMID: 28503985 DOI: 10.1177/0883073817706028] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
By definition, unprovoked seizures are not precipitated by an identifiable factor, such as fever or trauma. A thorough history and physical examination are essential to caring for pediatric patients with a potential first unprovoked seizure. Differential diagnosis, EEG, neuroimaging, laboratory tests, and initiation of treatment will be reviewed. Treatment is typically initiated after 2 unprovoked seizures, or after 1 seizure in select patients with distinct epilepsy syndromes. Recent expansion of the definition of epilepsy by the ILAE allows for the diagnosis of epilepsy to be made after the first seizure if the clinical presentation and supporting diagnostic studies suggest a greater than 60% chance of a second seizure. This review summarizes the current literature on the diagnostic and therapeutic management of first unprovoked seizure in children and adolescents while taking into consideration the revised diagnostic criteria of epilepsy.
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Affiliation(s)
- Arnold J Sansevere
- 1 Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Jennifer Avalone
- 1 Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Lauren Doyle Strauss
- 2 Department of Neurology, Wake Forest Baptist Health, Wake Forest Medical School, Winston Salem, NC, USA
| | - Archana A Patel
- 1 Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Anna Pinto
- 1 Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | | | | | - Ann M Bergin
- 1 Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Amir Kimia
- 4 Department of Emergency Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Phillip L Pearl
- 1 Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Tobias Loddenkemper
- 1 Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
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Zhang L, Huang Z, Tang J, Li Y. Risk factors following first spontaneous epileptic seizure in children below 3 years of age. Int J Neurosci 2016; 127:745-751. [PMID: 27680779 DOI: 10.1080/00207454.2016.1243105] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
AIM OF THE STUDY To assess the recurrence rate after the first spontaneous epileptic seizure in pediatric patients, and determine the related risk factors. MATERIALS AND METHODS Data from 190 infants (aged between one month and three years) admitted after first spontaneous epileptic seizure to Soochow University Affiliated Children's Hospital between April 2009 and April 2011 were retrospectively analyzed; patients were followed up until April 2014. The recurrence rate and risk factors of recurrence were analyzed based on central nervous system imaging data (computed tomography or magnetic resonance imaging), electroencephalogram (EEG) and developmental quotient assessment. RESULTS Of the 190 infants, 11 cases (5.79%) were lost to follow-up. The cumulative recurrence rate of spontaneous epileptic seizure after five years was 52%. A total of 82% recurrence cases occurred within the first year. Age > 24 months (odds ratio (OR) = 0.498༌95% confidence interval (CI): 0.285-0.869) was an independent protective factor, while symptomatic seizure (OR = 1.624, 95% CI: 1.020-2.587), seizure during sleep (OR = 2.779, 95% CI: 1.757-4.397) and epileptic discharge in EEG (OR=3.269, 95% CI: 2.049-5.217) were independent risk factors. CONCLUSION Recurrence rate is high in infants after the first spontaneous epileptic seizure, and recurrence is more likely to occur within one year.
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Affiliation(s)
- Liya Zhang
- a Department of Neurology , Soochow University Affiliated Children's Hospital , Suzhou , China
| | - Zhijian Huang
- b Department of Burn and Plastic Surgery , Soochow University Affiliated Children's Hospital , Suzhou , China
| | - Jihong Tang
- a Department of Neurology , Soochow University Affiliated Children's Hospital , Suzhou , China
| | - Yan Li
- a Department of Neurology , Soochow University Affiliated Children's Hospital , Suzhou , China
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Rincon SP, Blitstein MBK, Caruso PA, González RG, Thibert RL, Ratai EM. The Use of Magnetic Resonance Spectroscopy in the Evaluation of Pediatric Patients With Seizures. Pediatr Neurol 2016; 58:57-66. [PMID: 26948493 DOI: 10.1016/j.pediatrneurol.2016.01.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Revised: 01/09/2016] [Accepted: 01/11/2016] [Indexed: 11/28/2022]
Abstract
BACKGROUND The objective was to determine if it is useful to routinely add magnetic resonance spectroscopy (MRS) to magnetic resonance imaging (MRI) in the evaluation of seizure in the pediatric patient. Specifically, how often does MRS contribute information to conventional MRI? METHODS A retrospective search, over a period of 3 years, of patients <18 years of age who underwent both MRI and MRS as part of the evaluation of seizures yielded a total of 233 cases in 216 patients. The medical records were reviewed to determine how many patients carried a diagnosis relevant to seizures. The MRIs and MRSs were reviewed by two neuroradiologists and an MR physicist/spectroscopist who determined by consensus in how many cases MRS contributed information regarding management, diagnosis, or prognosis, in addition to the findings on MRI alone. RESULTS In 100 of 233 cases (43%), MRS contributed information additional to MRI. In 40 cases, MRS contributed information relevant to patient management by prompting an evaluation for an underlying inborn error of metabolism. MRS contributed information relevant to diagnosis in 24 of 100 cases (e.g., neoplasm versus dysplasia). MRS contributed information relevant to prognosis in 36 cases (e.g., hypoxic-ischemic injury). MRS added more information in cases where the patients had a diagnosis relevant to seizure before imaging. Interestingly, in 25 cases where the MRI was normal, MRS was found to be abnormal, which prompted evaluation for an inborn error of metabolism. CONCLUSIONS These results suggest that MRS is a useful evaluation tool in addition to MRI for children undergoing imaging for the evaluation of seizures.
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Affiliation(s)
- Sandra P Rincon
- Division of Neuroradiology, Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts
| | - Marisa B K Blitstein
- Division of Neuroradiology, Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts
| | - Paul A Caruso
- Division of Neuroradiology, Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts
| | - R Gilberto González
- Division of Neuroradiology, Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts
| | - Ronald L Thibert
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts
| | - Eva-Maria Ratai
- Division of Neuroradiology, Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts.
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26
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Sanmaneechai O, Danchaivijitr N, Likasitwattanakul S. Predictors of Abnormal Neuroimaging of the Brain in Children With Epilepsy Aged 1 Month to 2 Years: Useful Clues in a Resource-Limited Setting. J Child Neurol 2015; 30:1532-6. [PMID: 25792429 DOI: 10.1177/0883073815574199] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2014] [Accepted: 01/12/2015] [Indexed: 11/15/2022]
Abstract
Neuroimaging should be performed on infants with seizure. However, there are economic limitations in performing neuroimaging in a resource-limited setting. The younger the age, the higher the risk of having abnormal neuroimaging. The aim was to determine frequency and predictors of abnormal neuroimaging in children with epilepsy aged 1 month to 2 years. History, physical examination, electroencephalogram (EEG), and neuroimaging were reviewed. Thirty-seven of 49 (76%) had neuroimaging studies; 19 computed tomography (CT), 14 magnetic resonance imaging (MRI), and 4 had both. Abnormal neuroimaging was found in 19 (51%). Predictors of abnormal neuroimages are developmental delay, abnormal head circumference, and abnormal neurologic examination. Eight children (21%) had lesions on neuroimaging studies that altered or influenced management. Of 8 patients with normal examination and EEG, 1 had a brain tumor and another had arteriovenous malformation. Neuroimaging should be considered as an essential aid in the evaluation of infants with epilepsy, even in a resource-limited setting.
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Affiliation(s)
- Oranee Sanmaneechai
- Department of Pediatrics, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Nasuda Danchaivijitr
- Department of Radiology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
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27
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Parker MW, Shah SS, Hall M, Fieldston ES, Coley BD, Morse RB. Computed Tomography and Shifts to Alternate Imaging Modalities in Hospitalized Children. Pediatrics 2015; 136:e573-81. [PMID: 26304828 DOI: 10.1542/peds.2015-0995] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Many studies have demonstrated a rise in computed tomography (CT) utilization in abstract children's hospitals. However, CT utilization may be declining, perhaps due to awareness of potential hazards of pediatric ionizing radiation, such as increased risk of malignancy. Th e objective is to assess the trend in CT utilization in hospitalized children at freestanding children's hospitals from 2004 to 2012 and we hypothesize decreases are associated with shifts to alternate imaging modalities. METHODS Multicenter cross-sectional study of children admitted to 33 pediatric tertiary-care hospitals participating in the Pediatric Health Information System between January 1, 2004, and December 31, 2012. The rates of CT, ultrasound, and MRI for the top 10 All-Patient Refined Diagnosis Related Groups (APR-DRGs) for which CT was performed in 2004 were determined by billing data. Rates of each imaging modality for those top 10 APR-DRGs were followed through the study period. Odds ratios of imaging were adjusted for demographics and illness severity. RESULTS For all included APR-DRGs except ventricular shunt procedures and nonbacterial gastroenteritis, the number of children imaged with any modality increased. CT utilization decreased for all APR-DRGs (P values , .001). For each of the APR-DRGs except seizure and infections of upper respiratory tract, the decrease in CT was associated with a significant rise in an alternative imaging modality (P values # .005). CONCLUSIONS For the 10 most common APR-DRGs for which children received CT in 2004,a decrease in CT utilization was found in 2012. Alternative imaging modalities for 8 of the diagnoses were used.
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Affiliation(s)
| | | | - Matthew Hall
- Children’s Hospital Association, Overland Park, Kansas
| | - Evan S. Fieldston
- Division of General Pediatrics, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania; and
| | - Brian D. Coley
- Department of Radiology and Medical Imaging, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Rustin B. Morse
- Department of Pediatrics, Children’s Medical Center, Dallas, Texas
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Wilmshurst JM, Gaillard WD, Vinayan KP, Tsuchida TN, Plouin P, Van Bogaert P, Carrizosa J, Elia M, Craiu D, Jovic NJ, Nordli D, Hirtz D, Wong V, Glauser T, Mizrahi EM, Cross JH. Summary of recommendations for the management of infantile seizures: Task Force Report for the ILAE Commission of Pediatrics. Epilepsia 2015; 56:1185-97. [PMID: 26122601 DOI: 10.1111/epi.13057] [Citation(s) in RCA: 241] [Impact Index Per Article: 26.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/11/2015] [Indexed: 11/29/2022]
Abstract
Evidence-based guidelines, or recommendations, for the management of infants with seizures are lacking. A Task Force of the Commission of Pediatrics developed a consensus document addressing diagnostic markers, management interventions, and outcome measures for infants with seizures. Levels of evidence to support recommendations and statements were assessed using the American Academy of Neurology Guidelines and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system. The report contains recommendations for different levels of care, noting which would be regarded as standard care, compared to optimal care, or "state of the art" interventions. The incidence of epilepsy in the infantile period is the highest of all age groups (strong evidence), with epileptic spasms the largest single subgroup and, in the first 2 years of life, febrile seizures are the most commonly occurring seizures. Acute intervention at the time of a febrile seizure does not alter the risk for subsequent epilepsy (class 1 evidence). The use of antipyretic agents does not alter the recurrence rate (class 1 evidence), and there is no evidence to support initiation of regular antiepileptic drugs for simple febrile seizures (class 1 evidence). Infants with abnormal movements whose routine electroencephalography (EEG) study is not diagnostic, would benefit from video-EEG analysis, or home video to capture events (expert opinion, level U recommendation). Neuroimaging is recommended at all levels of care for infants presenting with epilepsy, with magnetic resonance imaging (MRI) recommended as the standard investigation at tertiary level (level A recommendation). Genetic screening should not be undertaken at primary or secondary level care (expert opinion). Standard care should permit genetic counseling by trained personal at all levels of care (expert opinion). Genetic evaluation for Dravet syndrome, and other infantile-onset epileptic encephalopathies, should be available in tertiary care (weak evidence, level C recommendation). Patients should be referred from primary or secondary to tertiary level care after failure of one antiepileptic drug (standard care) and optimal care equates to referral of all infants after presentation with a seizure (expert opinion, level U evidence). Infants with recurrent seizures warrant urgent assessment for initiation of antiepileptic drugs (expert opinion, level U recommendation). Infantile encephalopathies should have rapid introduction and increment of antiepileptic drug dosage (expert opinion, level U recommendation). There is no high level evidence to support any particular current agents for use in infants with seizures. For focal seizures, levetiracetam is effective (strong evidence); for generalized seizures, weak evidence supports levetiracetam, valproate, lamotrigine, topiramate, and clobazam; for Dravet syndrome, strong evidence supports that stiripentol is effective (in combination with valproate and clobazam), whereas weak evidence supports that topiramate, zonisamide, valproate, bromide, and the ketogenic diet are possibly effective; and for Ohtahara syndrome, there is weak evidence that most antiepileptic drugs are poorly effective. For epileptic spasms, clinical suspicion remains central to the diagnosis and is supported by EEG, which ideally is prolonged (level C recommendation). Adrenocorticotropic hormone (ACTH) is preferred for short-term control of epileptic spasms (level B recommendation), oral steroids are probably effective in short-term control of spasms (level C recommendation), and a shorter interval from the onset of spasms to treatment initiation may improve long-term neurodevelopmental outcome (level C recommendation). The ketogenic diet is the treatment of choice for epilepsy related to glucose transporter 1 deficiency syndrome and pyruvate dehydrogenase deficiency (expert opinion, level U recommendation). The identification of patients as potential candidates for epilepsy surgery should be part of standard practice at primary and secondary level care. Tertiary care facilities with experience in epilepsy surgery should undertake the screening for epilepsy surgical candidates (level U recommendation). There is insufficient evidence to conclude if there is benefit from vagus nerve stimulation (level U recommendation). The key recommendations are summarized into an executive summary. The full report is available as Supporting Information. This report provides a comprehensive foundation of an approach to infants with seizures, while identifying where there are inadequate data to support recommended practice, and where further data collection is needed to address these deficits.
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Affiliation(s)
- Jo M Wilmshurst
- Paediatric Neurology, Department of Paediatrics and Child Health, Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa
| | - William D Gaillard
- Pediatrics and Neurology, Division Epilepsy and Neurophysiology, Comprehensive Pediatric Epilepsy Program, George Washington University, Washington, District of Columbia, U.S.A
| | | | - Tammy N Tsuchida
- Department of Neurology, Children's National Medical Center, Washington, District of Columbia, U.S.A
| | - Perrine Plouin
- Clinical Neurophysiology Department, INSERM U663, Hospital for Sick Children, Paris, France
| | - Patrick Van Bogaert
- Paediatric Neurology, Department of Pediatrics, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Jaime Carrizosa
- Pediatric Department Child Neurology Service, University of Antioquia, Medellín, Colombia
| | - Maurizio Elia
- Unit of Neurology and Clinical Neurophysiopathology, IRCCS Italy Oasi Institute for Research on Mental Retardation and Brain Aging, Troina, EN, Italy
| | - Dana Craiu
- Department of Neurology, Pediatric Neurology, Psychiatry, Neurosurgery, "Carol Davila" University of Medicine Bucharest, Bucharest, Romania.,"Alexandru Obregia" Clinical Hospital, Bucharest, Romania
| | - Nebojsa J Jovic
- Neurology, Clinic of Neurology and Psychiatry for Children and Youth, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Doug Nordli
- Epilepsy Center, Children's Memorial Hospital, Chicago, Illinois, U.S.A
| | - Deborah Hirtz
- Office of Clinical Research, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Rockville, Maryland, U.S.A
| | - Virginia Wong
- Department of Paediatrics and Adolescent Medicine, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong, Hong Kong.,Division of Paediatric Neurology/Developmental Behavioural Paediatrics/NeuroHabilitation, Duchess of Kent Children Hospital, Queen Mary Hospital, Hong Kong, Hong Kong
| | - Tracy Glauser
- Comprehensive Epilepsy Center, Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, U.S.A
| | - Eli M Mizrahi
- Peter Kellaway Section of Neurophysiology, Department of Neurology, Baylor College of Medicine, Houston, Texas, U.S.A.,Section of Pediatric Neurology, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, U.S.A
| | - J Helen Cross
- Childhood Epilepsy, Paediatric Neurology, UCL-Institute of Child Health, Great Ormond Street Hospital for Children NHS Trust, NHS Foundation Trust, London, United Kingdom
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Richard H, Stogner-Underwood K, Fuller C. Congenital oligodendroglioma: clinicopathologic and molecular assessment with review of the literature. Case Rep Pathol 2015; 2015:370234. [PMID: 25755903 PMCID: PMC4338398 DOI: 10.1155/2015/370234] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2014] [Accepted: 01/29/2015] [Indexed: 02/06/2023] Open
Abstract
Oligodendroglioma is an infiltrating glial neoplasm frequently seen in adults. Pediatric oligodendrogliomas are rare, with very few cases presenting in infancy and only rare congenital examples. In contrast to adult oligodendrogliomas, pediatric cases typically lack 1p/19q codeletion. Herein we report a case of WHO grade II oligodendroglioma diagnosed in a 7-month-old male infant. The patient initially presented at 3 months of age with symptoms suspicious for seizure. Initial workup including electroencephalography (EEG), electrocardiogram (EKG), and computed tomography (CT) of the head was negative. His symptoms persisted, and subsequent magnetic resonance imaging (MRI) performed at age of 7 months revealed a 2 cm contrast-enhancing left temporal lobe mass. The mass was excised and the microscopic appearance was that of a classic low grade oligodendroglioma composed of cells with uniformly round nuclei, perinuclear halos, delicate branching capillaries, and an absence of high grade features. Mutant specific (R132H) isocitrate dehydrogenase-1 (IDH1) immunohistochemistry was negative, and the tumor lacked detectable 1p or 19q deletions by fluorescent in situ hybridization (FISH). The onset of neurological symptoms in early infancy followed by the positive MRI findings suggests that this case represents a rare example of congenital oligodendroglioma.
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Affiliation(s)
- Hope Richard
- 1Department of Pathology, Virginia Commonwealth University Health System, 1101 E. Marshall Street, P.O. Box 980662, Richmond, VA 23298, USA
- *Hope Richard:
| | - Kimberly Stogner-Underwood
- 1Department of Pathology, Virginia Commonwealth University Health System, 1101 E. Marshall Street, P.O. Box 980662, Richmond, VA 23298, USA
- 2Department of Pathology, Wake Forest Baptist Medical Center, Medical Center Boulevard, Winston-Salem, NC 27157, USA
| | - Christine Fuller
- 1Department of Pathology, Virginia Commonwealth University Health System, 1101 E. Marshall Street, P.O. Box 980662, Richmond, VA 23298, USA
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30
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Aprahamian N, Harper M, Prabhu S, Monuteaux M, Sadiq Z, Torres A, Kimia A. Pediatric first time non-febrile seizure with focal manifestations: Is emergent imaging indicated? Seizure 2014; 23:740-5. [DOI: 10.1016/j.seizure.2014.06.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2014] [Revised: 05/31/2014] [Accepted: 06/03/2014] [Indexed: 11/25/2022] Open
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31
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Dunoski B, Slovis TL. Update in pediatric imaging. Adv Pediatr 2014; 61:75-125. [PMID: 25037125 DOI: 10.1016/j.yapd.2014.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Brian Dunoski
- Children's Hospital of Michigan, 3901 Beaubien Drive, Detroit, MI 48301, USA; Children's Mercy Hospital, 2401 Gillham Road, Kansas City, MO 64108, USA
| | - Thomas L Slovis
- Children's Hospital of Michigan, 3901 Beaubien Drive, Detroit, MI 48301, USA.
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32
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Abstract
Seizures are a commonly encountered condition within the emergency department and, because of this, can engender complacency on the part of the physicians and staff. Unfortunately, there is significant associated morbidity and mortality with seizures, and they should never be regarded as routine. This point is particularly important with respect to seizures in pediatric patients. The aim of this review is to provide a current view of the various issues that make pediatric seizures unique and to help elucidate emergent evaluation and management strategies.
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MESH Headings
- Anticonvulsants/therapeutic use
- Child
- Child, Preschool
- Diagnosis, Differential
- Humans
- Infant
- Infant, Newborn
- Infant, Newborn, Diseases/diagnosis
- Infant, Newborn, Diseases/etiology
- Infant, Newborn, Diseases/therapy
- Seizures/diagnosis
- Seizures/etiology
- Seizures/therapy
- Seizures, Febrile/diagnosis
- Seizures, Febrile/therapy
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Affiliation(s)
- Maneesha Agarwal
- Department of Emergency Medicine, Carolinas Medical Center, 3rd Floor Medical Education Building, 1000 Blythe Boulevard, Charlotte, NC 28203, USA
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33
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Williams SE, Edwards KM, Baxter RP, LaRussa PS, Halsey NA, Dekker CL, Vellozzi C, Marchant CD, Donofrio PD, Reimschisel TE, Berger M, Gidudu JF, Klein NP. Comprehensive assessment of serious adverse events following immunization by health care providers. J Pediatr 2013; 162:1276-81, 1281.e1. [PMID: 23452584 PMCID: PMC7125713 DOI: 10.1016/j.jpeds.2013.01.028] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2012] [Revised: 12/04/2012] [Accepted: 01/10/2013] [Indexed: 11/25/2022]
Affiliation(s)
- S. Elizabeth Williams
- Vanderbilt Vaccine Research Program, Vanderbilt University Medical Center, Nashville, TN,Reprint requests: S. Elizabeth Williams, MD, Vanderbilt Vaccine Research Program, Vanderbilt University Medical Center, 1161 21st Ave S, CCC 5326 MCN, Nashville, TN 37232-2573
| | - Kathryn M. Edwards
- Vanderbilt Vaccine Research Program, Vanderbilt University Medical Center, Nashville, TN
| | | | - Philip S. LaRussa
- Division of Pediatric Infectious Diseases, Columbia University, New York City, NY
| | - Neal A. Halsey
- Department of International Health, Disease Prevention and Control Program, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD
| | - Cornelia L. Dekker
- Division of Pediatric Infectious Diseases, Stanford University School of Medicine, Stanford, CA
| | - Claudia Vellozzi
- Immunization Safety Office, Division of Healthcare Quality and Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Office of Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA
| | | | - Peter D. Donofrio
- Vanderbilt Vaccine Research Program, Vanderbilt University Medical Center, Nashville, TN
| | - Tyler E. Reimschisel
- Vanderbilt Vaccine Research Program, Vanderbilt University Medical Center, Nashville, TN
| | - Melvin Berger
- Immunology Research and Development, CSL Behring LLC, King of Prussia, PA
| | - Jane F. Gidudu
- Immunization Safety Office, Division of Healthcare Quality and Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Office of Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA
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34
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Woermann FG, Vézina G. Structural imaging in children with chronic focal epilepsy: diagnostic algorithms and exploration strategies. HANDBOOK OF CLINICAL NEUROLOGY 2013; 111:747-57. [PMID: 23622222 DOI: 10.1016/b978-0-444-52891-9.00077-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/07/2023]
Abstract
Malformations of cortical development, especially focal cortical dysplasia in infants and children, and hippocampal sclerosis in adolescents with epilepsy are frequent lesions, but they are overlooked on standard MRI. In infants, errors in the interpretation of MRI in epilepsy can be attributed to MRI signal changes due to ongoing myelination. Poor technique, perceptual misses, incomplete knowledge and poor judgment are, however, other likely sources of errors when reading MRIs. This review covers MRI search strategies, i.e., how to conduct MRI examinations in epilepsy and what to expect in the structural MRI of an infant or child with focal epilepsy. Exploiting increased sensitivity, false positive results can be avoided in the light of a clinical hypothesis, possibly isolating a localized brain area by seizure semiology, EEG, and sometimes PET prior to MR reading.
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35
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Noh BH, Berg AT, Nordli DR. Concordance of MRI lesions and EEG focal slowing in children with nonsyndromic epilepsy. Epilepsia 2013; 54:455-60. [DOI: 10.1111/epi.12095] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/13/2012] [Indexed: 11/30/2022]
Affiliation(s)
- Byoungho H. Noh
- Department of Pediatrics; Kangwon National University Hospital; Kangwon National University; Chuncheon; Gangwon; Korea
| | - Anne T. Berg
- Epilepsy Center; Anne & Robert H. Lurie Children's Hospital of Chicago; Northwestern University; Chicago; Illinois; U.S.A
| | - Douglas R. Nordli
- Epilepsy Center; Anne & Robert H. Lurie Children's Hospital of Chicago; Northwestern University; Chicago; Illinois; U.S.A
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36
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Eltze CM, Chong WK, Cox T, Whitney A, Cortina-Borja M, Chin RFM, Scott RC, Cross JH. A population-based study of newly diagnosed epilepsy in infants. Epilepsia 2012; 54:437-45. [DOI: 10.1111/epi.12046] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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37
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Bautovich T, Numa A. Role of head computed tomography in the evaluation of children admitted to the paediatric intensive care unit with new-onset seizure. Emerg Med Australas 2012; 24:313-20. [PMID: 22672172 DOI: 10.1111/j.1742-6723.2012.01561.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The role of neuroimaging in children presenting with new-onset seizure is poorly defined. This study evaluates the incidence of abnormal CT findings in children admitted to the paediatric intensive care unit (PICU) with new-onset seizure and examines potential clinical variables associated with abnormal head CT findings. METHODS A retrospective analysis of 89 previously asymptomatic children admitted to Sydney Children's Hospital (Sydney, Australia) PICU between November 2005 and September 2009 with new-onset seizure was undertaken. Demographic data, clinical details and head CT findings were abstracted from medical records. The clinical significance and the impact of CT findings on acute management decisions was analysed. Clinical variables associated with abnormal clinically significant CT results were examined. RESULTS A total of 71/89 patients underwent head CT. Of the children who underwent head CT (n= 71), clinically significant CT results were found in 19.7% of patients and head CT findings resulted in a change in acute management in 7% of patients. Children without fever were more than twice as likely to have a positive CT scan (P= 0.049); however, a substantial proportion (6/45) of febrile children also had abnormal scans. Focal seizures were not predictive of abnormal CT results. There was a significant relationship between abnormal CT and multiple seizures (P < 0.02), and age less than 24 months (P < 0.049). CONCLUSION In this highly selected group head CT findings are frequently abnormal and might change acute management. Children admitted to the PICU with first presentation of seizure who have multiple seizures and/or are aged <2 years should have immediate CT or MRI scanning.
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Affiliation(s)
- Tanya Bautovich
- Paediatric Intensive Care Unit, Sydney Children's Hospital, High Street, Randwick, Sydney, NSW 2031, Australia.
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38
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Lateef TM, Kriss R, Carpenter K, Nelson KB. Neurologic complaints in young children in the ED: when is cranial computed tomography helpful? Am J Emerg Med 2012; 30:1507-14. [PMID: 22386353 DOI: 10.1016/j.ajem.2011.12.018] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2011] [Revised: 12/12/2011] [Accepted: 12/13/2011] [Indexed: 11/16/2022] Open
Abstract
MAIN OBJECTIVE The objective of this study is to describe the use of emergent head computed tomography (CT) in young children and ask in which circumstances scans contributed to immediate management. METHODS We reviewed electronic records of children, aged 1 month through 6 years, who received a head CT at a large suburban emergency department between February 2008 and February 2009. Age, sex, chief complaint, history, physical examination, indication for and results of head CT, red flags in history or physical examination, final disposition, and number of head CT scans performed to date were recorded. Abnormalities on CT scans were classified as significant or incidental, and subsequent interventions were documented. RESULTS Emergent head CTs were performed on 394 children. The most common indications were trauma, 65%; seizure, 11%; and headache, 6%. Computed tomographic abnormalities were found in 40% (154 children): 32 significant findings,104 incidental findings, and 22 preexisting abnormalities. Four children with significant findings required immediate intervention. They all had red flags in both history and physical examination, and 3 of 4 children had known preexisting pathology; 1 child had nonaccidental trauma. Only 1 child had a significantly abnormal CT with no identifiable red flags; this child was admitted for observation and was discharged within 24 hours. Approximately a third of children had no readily identifiable red flag for the CT scans that they received. Of note, 20% of the young children had received more than 1 head CT scan to date, and 6% had between 6 and 20 scans. CONCLUSIONS Every child in this sample who required emergency intervention had red flags on history and physical examination. The 35% of CT scans performed in young children without red flags did not contribute usefully to their acute management.
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Menoch MJA, Hirsh DA, Khan NS, Simon HK, Sturm JJ. Trends in computed tomography utilization in the pediatric emergency department. Pediatrics 2012; 129:e690-7. [PMID: 22331345 DOI: 10.1542/peds.2011-2548] [Citation(s) in RCA: 97] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE The purpose of this study was to determine the overall trend of computed tomography (CT) utilization in the pediatric emergency department (PED) from 2003 to 2010 and to determine trends categorized by common chief complaints. METHODS Electronic chart records at 2 tertiary care PEDs within a large pediatric health care system were reviewed from January 2003 through December 2010. The annual CT utilization rate, by anatomic location, was determined. Annual CT utilization rates were compared with alternative imaging trends for visits with chief complaints of head injury, seizure, and abdominal pain. Analysis was performed with linear regression. RESULTS There was no change in overall CT utilization from 2003 to 2010 (β 0.25, 95% confidence interval [CI] [-1.61 to 2.73]) or within anatomic subgroups. Head CT utilization for the chief complaints of seizure (β -0.97, 95% CI [-1.44 to -0.90]) and head injury (β -0.93, 95% CI [-1.71 to -0.73]) showed significant declines. Although there was no change in the abdominal CT utilization rate for abdominal pain, abdominal ultrasound utilization for abdominal pain significantly increased (β 0.89, 95% CI [0.25-0.79]). CONCLUSIONS Our data showed no overall increase in CT utilization through 2010. In areas where alternative non-radiation-based modalities were options, there were decreased CT trends and increased use of potential alternative non-radiation-based modalities. This is the first large PED cohort study to show a decrease in CT utilization in recent years in a regional pediatric referral center and may correlate with increased awareness of radiation risk in children.
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Affiliation(s)
- Margaret J A Menoch
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia, USA.
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40
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FALLAH R, NAFISI MOGHADAM R, FALLAH TAFTI M, SALMANI NODOUSHAN M. Results of noncontrast brain computed tomography scans of 1-18 year old epileptic children. IRANIAN JOURNAL OF CHILD NEUROLOGY 2012; 6:33-8. [PMID: 24665270 PMCID: PMC3943031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/19/2012] [Revised: 06/23/2012] [Accepted: 07/15/2012] [Indexed: 10/31/2022]
Abstract
OBJECTIVE The advent of computed tomography (CT) scan revolutionized the diagnostic evaluation of neurologic patients. The aim of this study was to evaluate brain CT results of epileptic children. MATERIALS & METHODS In a descriptive cross-sectional study, noncontrast brain CT scan of 150 consecutive 1-18 year old epileptic children whom were referred to pediatric neurology clinic of Shahid Sadoughi University of Medical Sciences, from May 2008 to October 2010 in Yazd-Iran, evaluated. RESULTS Sixty two girls and 88 boys with mean age of 6.6 ± 4.3 years were evaluated. In 38 (25.3 %) children, seizure onset age was under one year and 38 others had abnormal mental / developmental status. Fifty three children (35.3 %) and 97 (64.7%) had partial and generalized seizures, respectively. Partial seizures were more prevalent in children with seizure onset in < 1 year [41.5% (22/53) vs. 16.5% (16/97)] Result of CT was normal in 74 % (n=111). Among the patients with abnormal results, 18(46%) had brain atrophy, 10 (25.6%) structural CNS dysgenesia, six (15.4%) intracranial calcification, three (7.8%) hydrocephaly and two had (5.2%) brain tumor. Abnormal brain CT was more prevalent in patients with seizure onset in less than one year of age [60.5% (23 of 38) vs. 14.3% (16 of 112), p = 0.003], partial epilepsy [51% (27 of 53) vs. 12% (12/97)], and abnormal developmental status [ 81.5% (31 of 38) vs.7% (8 of 112]. Mean age of seizure onset in epileptic children with abnormal brain CT scan was less (M ± SD:1/17 ± 0.6 years versus 4.02±1.9 years). CONCLUSION Brain CT scan might be considered in evaluation of epileptic children with partial seizures, seizure onset in less than one year of age or neurodevelopmental delay.
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Affiliation(s)
- Razieh FALLAH
- Associate Professor of Pediatric Neurology, Department of Pediatrics, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
| | - Reza NAFISI MOGHADAM
- Assistant Professor of Radiology, Department of Radiology, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
| | - Mohammad FALLAH TAFTI
- Assistant Professor of Radiology, Department of Radiology, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
| | - Mahdi SALMANI NODOUSHAN
- Medical Student, Ali Ben Abitalib Medical College, Islamic Azad University of Yazd, Yazd, Iran
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41
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Abstract
Identification of the structural lesions that underlie pediatric epilepsy can be challenging. Careful evaluation of the gray-white matter interface is crucial, and necessitates multiplanar thin images of high resolution that can differentiate focal lesions from partial volume averaging artifacts created by the innate gyral configuration. Careful evaluation of the hippocampus and of the myelination patterns can further increase the diagnostic yield of the study. Magnetization transfer imaging can call attention to a lesion that is either very subtle or not evident on conventional sequences. Detection of cortical anomalies is best performed early in infancy, preferably before 6 months of age. If the initial magnetic resonance imaging (MRI) scan is performed between 9 and 18 months of age and is negative, a repeat scan after 2 years of age may be necessary.
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Affiliation(s)
- Louis-Gilbert Vézina
- Department of Diagnostic Imaging and Radiology, Children's National Medical Center, Washington, District of Columbia 20010, USA.
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42
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Packer RJ, Villongco J, Batshaw M, Holbrook P, Gaillard WD, Pearl PL, Weinstein S, Zechman E. Center for Neuroscience and Behavioral Medicine: an innovative administrative structure and possible paradigm for the future. Pediatr Neurol 2011; 44:1-9. [PMID: 21147380 DOI: 10.1016/j.pediatrneurol.2010.07.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2010] [Accepted: 07/26/2010] [Indexed: 11/25/2022]
Abstract
Child neurology has evolved from a primarily diagnostic to a therapeutic subspecialty. Despite well-documented manpower shortages, child neurology programs at major children's hospitals have expanded, and the optimal administrative structure for child neurology programs has not been clearly defined. The Division of Child Neurology at Children's National Medical Center in Washington, DC, is a part of the Center for Neuroscience and Behavioral Medicine. This center includes multiple medical, behavioral health, and surgical subspecialties, and fosters the development of child neurology. During the 10 years of its existence, the number of board-certified or eligible child neurologists within the center has tripled to over 30. Because of its success, the Division of Child Neurology was split into three free-standing divisions and two institutes. This unique structure has fostered the development of numerous multidisciplinary programs, and is fiscally sustainable. The strengths, limitations, and challenges of this structure in terms of child neurology are reviewed. This administrative structure has been successful and may act as a model for other programs.
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Affiliation(s)
- Roger J Packer
- Center for Neuroscience and Behavioral Medicine, Children's National Medical Center, Washington, DC 20010, USA.
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43
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Capampangan DJ, Hoerth MT, Drazkowski JF, Lipinski CA. Olfactory and Gustatory Hallucinations Presenting as Partial Status Epilepticus Because of Glioblastoma Multiforme. Ann Emerg Med 2010; 56:374-7. [DOI: 10.1016/j.annemergmed.2010.02.020] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2010] [Revised: 02/08/2010] [Accepted: 02/16/2010] [Indexed: 10/19/2022]
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Provenzale JM. Imaging findings of structural causes of epilepsy in children: a guide for the radiologist in the emergency room. Emerg Radiol 2010; 17:479-86. [PMID: 20596745 DOI: 10.1007/s10140-010-0884-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2010] [Accepted: 06/14/2010] [Indexed: 11/26/2022]
Abstract
Evaluation of the child with epilepsy is a relatively common indication for imaging in the emergency room setting. This room outlines some of the more important imaging features of causes of epilepsy in children.
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Affiliation(s)
- James M Provenzale
- Department of Radiology, Duke University Medical Center, Durham, NC 27710, USA.
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