Practice parameter: evaluating a first nonfebrile seizure in children: report of the quality standards subcommittee of the American Academy of Neurology, The Child Neurology Society, and The American Epilepsy Society

Sleep Induction in Pediatric EEG Recordings: Chloral Hydrate Versus Melatonin and Hydoxyzine

PURPOSE

Electroencephalography (EEG) recording in pediatric patients is difficult because of patient compliance, and children who are unsuitable for behavioral training usually require sedation for EEG recordings. The aim of this study was to examine the effects of agents commonly used in daily practice for sleep induction on sleep transition, sleep architecture, and frequency of movement artifacts on EEG recordings.

METHODS

A retrospective analysis was made of the demographic data and sleep EEG recordings of patients who underwent sleep EEG because of suspected seizure between 2021 and 2022. The study included patients aged 4 to 18 years, and patients with a new or previous diagnosis of epilepsy were excluded from the study.

RESULTS

Evaluation was made of 88 patients, comprising 35 (39.8%) girls and 53 (60.2%) boys with a mean age of 10.6 ± 4.3 years. In the analysis of the patients who did not sleep at all during the EEG recording, the drugs administered to the patients for sedation were observed to be hydroxyzine in 4 (14.8%) patients, chloral hydrate in 1 (2.8%) patient, and melatonin in 5 (20%) patients. Sleep duration was seen to be longer and the rates of motion artifacts and awakening during filming were lower in the patients treated with chloral hydrate.

CONCLUSIONS

The results of this study showed that chloral hydrate was the most effective drug for inducing sleep. There is a need for further similar prospective studies to be performed on patients diagnosed with epilepsy and those aged <4 years. Possible complications should be considered before using each agent for sleep induction.

First Seizures, Acute Repetitive Seizures, and Status Epilepticus

OBJECTIVE

This article provides current evidence on how and when to treat unprovoked first seizures in children and adults, guides intervention with appropriate doses and types of modern and effective therapies for acute repetitive (cluster) seizures, and reviews evidence for the diagnosis and management of established, refractory and super-refractory status epilepticus.

LATEST DEVELOPMENTS

Artificial intelligence shows promise as a clinical assistant in decision making after a first seizure. For nonanoxic convulsive refractory status epilepticus third-phase treatment, equipoise exists regarding whether it is better to add a second IV nonsedating antiseizure medication given via loading dose (eg, brivaracetam, lacosamide, levetiracetam, fosphenytoin or valproic acid) or to start an anesthetizing continuous IV infusion antiseizure medication such as ketamine, midazolam, propofol or pentobarbital.

ESSENTIAL POINTS

After a first seizure, the risk of a second seizure is about 36% at 2 years and 46% after 5 years. The risk is doubled in the presence of EEG epileptiform discharges, a brain imaging abnormality, a nocturnal first seizure, or prior brain trauma. For acute repetitive seizures, providers should give a proper dose of benzodiazepines based on the patient's weight and needs. First-phase treatment for convulsive established status epilepticus is the immediate administration of full doses of benzodiazepines. Second-phase treatment for convulsive established status epilepticus is a full loading dose of IV fosphenytoin, levetiracetam, valproic acid, or if necessary, phenobarbital.

Implementing Guidelines and Measures in Epilepsy Care

ABSTRACT

People with epilepsy must receive up-to-date, high-quality care that aligns with current understanding of basic disease mechanisms, improved diagnostic testing, and evolving medical and surgical treatments. Varying progress has been made in identifying, measuring, and mitigating epilepsy care gaps. Epilepsy guidelines and quality measures should be developed using rigorous processes informed by systematic reviews of best evidence in conjunction with prioritization of need. Epilepsy measures help operationalize guidelines and practice parameters. Most epilepsy quality indicators are process-based metrics defined by delivering care to the patient. Systematic and reliable tracking and documentation of seizure frequency using consistent language is required as a patient-reported outcome within individuals over time and across populations. Emerging literature has demonstrated gaps in epilepsy care, perhaps highlighting limitations in the dissemination and implementation of guidelines and quality measures in clinical practice. Quality improvement methods applied to clinical data registries and learning health systems may afford new opportunities to iteratively, collaboratively, and feasibly disseminate guidelines and quality measures, measure epilepsy care quality, allow for the testing of interventions to mitigate identified care gaps, and, ultimately, improve care for patients with epilepsy.

Decreasing Unnecessary Resource Utilization for New-onset, Unprovoked, Afebrile Seizure in the Emergency Department

Introduction

Pediatric seizures account for approximately 1% of emergency department (ED) presentations. Laboratory evaluation and emergent electroencephalogram (EEG) are not indicated in patients with a new-onset, unprovoked, afebrile seizure with a normal physical examination. This study aimed to reduce unnecessary ED resource utilization.

Methods

Through plan-do-study-act cycles from March 2021 to July 2023, a multidisciplinary team implemented change concepts, including creating a clinical pathway and supporting order sets, scheduling outpatient EEGs from the ED, and automating messages to the neurology team to ensure patient follow-up. The primary outcome measure was the percentage of qualified patients who received an EEG in the ED. Secondary outcome measures were the percentage of patients who had ED complete blood counts or neurology consults, the room-to-discharge time in minutes, and healthcare cost per patient. The balancing measure was the 30-day ED bounce-back rate.

Results

Thirty-four and 99 patients met the inclusion criteria for the baseline and implementation phases, respectively. ED EEGs decreased from 59% to 1%. Complete blood counts and neurology consults decreased from 50% to 16% and 90% to 31%, respectively. Room-to-disposition time decreased from 308 to 203.5 minutes. Preliminary healthcare cost per patient decreased by $630. The 30-day bounce-back rate increased from 0% to 8%.

Conclusions

Implementing a new-onset seizure pathway decreased ED resource utilization, shortened room-to-discharge time, and lowered healthcare costs.

Intravenous lacosamide for acute repetitive seizures and convulsive status epilepticus in critically ill children

OBJECTIVE

Acute repetitive seizures and convulsive status epilepticus are common neurological emergencies in critically ill children. The aim of the study was to evaluate the effectiveness and safety of intravenous lacosamide in critically ill children with acute repetitive seizures and convulsive status epilepticus.

METHODS

This retrospective study included children who received intravenous lacosamide for acute repetitive seizures or convulsive status epilepticus from October 2017 to September 2022 and were admitted to the pediatric intensive care unit at a tertiary medical center. Children who were newly started on intravenous lacosamide were included and divided into two groups: (a) previously healthy, and (b) history of epilepsy and receiving antiseizure medications. Efficacy was defined as the cessation of seizures within 72 h of administering lacosamide. Adverse effects were defined using predefined criteria, and most were evaluated during the first 7 days.

RESULTS

Sixty-seven children were enrolled, including 25 (37.3%) girls and 42 (62.7%) boys with a mean age of 7.20 ± 5.66 years. Among them, 30 (44.8%) had acute repetitive seizures, and 37 (55.2%) had convulsive status epilepticus. The seizure types were focal onset (n = 34, 50.7%), generalized onset (n = 27, 40.3%), and mixed type (n = 6, 9.0%). In the previously healthy group, 9 patients had acute repetitive seizures and 23 had convulsive status epilepticus, and the rates of seizure cessation when lacosamide was used as the first to fourth choice of antiseizure medication were 100.0%, 85.7%, 40.0%, and 50.0%, respectively, compared to 73.7%, 54.5%, 100.0%, and 0.0% in the patients with epilepsy (21 had acute repetitive seizures and 14 had convulsive status epilepticus). Sixteen (23.9%) patients developed bradycardia and 1 (1.5%) patient developed a rash.

SIGNIFICANCE

The early use of intravenous lacosamide was effective with acceptable side effects in treating acute repetitive seizures and convulsive status epilepticus in critically ill children, including young infants and children less than 4 years old and those with different etiologies.

PLAIN LANGUAGE SUMMARY

Acute repetitive seizures and convulsive status epilepticus are common neurological emergencies in pediatric intensive care units (PICUs), traditional intravenous antiseizure medications (ASMs) include phenytoin, valproic acid, levetiracetam, and phenobarbital. In this study, we categorized patients based on their epilepsy history and different etiologies. We observed that early use of lacosamide, even in young infants, demonstrated good efficacy and safety.

Recommendations for Choosing Wisely in Pediatric Emergency Medicine: Five Opportunities to Improve Value

Unnecessary diagnostic tests and treatments in children cared for in emergency departments (EDs) do not benefit patients, increase costs, and may result in harm. To address this low-value care, a taskforce of pediatric emergency medicine (PEM) physicians was formed to create the first PEM Choosing Wisely recommendations. Using a systematic, iterative process, the taskforce collected suggested items from an interprofessional group of 33 ED clinicians from 6 academic pediatric EDs. An initial review of 219 suggested items yielded 72 unique items. Taskforce members independently scored each item for its extent of overuse, strength of evidence, and potential for harm. The 25 highest-rated items were sent in an electronic survey to all 89 members of the American Academy of Pediatrics PEM Committee on Quality Transformation (AAP COQT) to select their top ten recommendations. The AAP COQT survey had a 63% response rate. The five most selected items were circulated to over 100 stakeholder and specialty groups (within the AAP, CW Canada, and CW USA organizations) for review, iterative feedback, and approval. The final 5 items were simultaneously published by Choosing Wisely United States and Choosing Wisely Canada on December 1, 2022. All recommendations focused on decreasing diagnostic testing related to respiratory conditions, medical clearance for psychiatric conditions, seizures, constipation, and viral respiratory tract infections. A multinational PEM taskforce developed the first Choosing Wisely recommendation list for pediatric patients in the ED setting. Future activities will include dissemination efforts and interventions to improve the quality and value of care specific to recommendations.

Efficient diagnosis leads to better care: streamlining epilepsy diagnosis pathways

Added Value of Advanced Workup After the First Seizure: A 7-Year Cohort Study De Stefano P, Ménétré E, Stancu P, Mégevand P, Vargas MI, Kleinschmidt A, Vulliémoz S, Wiest R, Beniczky S, Picard F, Seeck M. Epilepsia. 2023;64(12):3246-3256. doi:10.1111/epi.17771 Objective: This study was undertaken to establish whether advanced workup including long-term electroencephalography (LT-EEG) and brain magnetic resonance imaging (MRI) provides an additional yield for the diagnosis of new-onset epilepsy (NOE) in patients presenting with a first seizure event (FSE). Methods: In this population-based study, all adult (≥ 16 years) patients presenting with FSE in the emergency department (ED) between March 1, 2010 and March 1, 2017 were assessed. Patients with obvious nonepileptic or acute symptomatic seizures were excluded. Routine EEG, LT-EEG, brain computed tomography (CT), and brain MRI were performed as part of the initial workup. These examinations’ sensitivity and specificity were calculated on the basis of the final diagnosis after 2 years, along with the added value of advanced workup (MRI and LT-EEG) over routine workup (routine EEG and CT). Results: Of the 1010 patients presenting with FSE in the ED, a definite diagnosis of NOE was obtained for 501 patients (49.6%). The sensitivity of LT-EEG was higher than that of routine EEG (54.39% vs 25.5%, P < .001). Similarly, the sensitivity of MRI was higher than that of CT (67.98% vs 54.72%, P = .009). Brain MRI showed epileptogenic lesions in an additional 32% compared to brain CT. If only MRI and LT-EEG were considered, 5 would have been incorrectly diagnosed as nonepileptic (5/100, 5%) compared to patients with routine EEG and MRI (25/100, 25%, P = .0001). In patients with all 4 examinations, advanced workup provided an overall additional yield of 50% compared to routine workup. Significance: Our results demonstrate the remarkable added value of the advanced workup launched already in the ED for the diagnosis of NOE versus nonepileptic causes of seizure mimickers. Our findings suggest the benefit of first-seizure tracks or even units with overnight EEG, similar to stroke units, activated upon admission in the ED.

Effects of the coronavirus disease outbreak on the development of neurological disorders in children: A comparison of the incidence of febrile seizure and epilepsy using an interrupted time-series approach

BACKGROUND

With the outbreak of COVID-19, school closures and quarantines following social distancing have brought significant changes to children's lifestyles. Therefore, we aimed to compare the population-adjusted incidence of febrile seizures(FS) and epilepsy before and after the COVID-19 outbreak in Korea and to assess the effects of the COVID-19 outbreak on the incidence by region and age group.

METHODS

A retrospective cohort study was conducted using nationwide claims data and covid data from January 2019 to December 2020. The incidence of diseases and difference in incidence before (Jan 20 to Dec 30, 2019) and after (Jan 20 to Dec 30, 2020) the COVID-19 outbreak was measured using rate ratio. An Interrupted time series analysis was used to identify the effect of COVID-19 on trends of FS and epilepsy. Subgroup analysis by age, sex, insurance, and risk of coronavirus by area were conducted.

RESULTS

Following the onset of the pandemic, the number of newly diagnosed FS cases decreased sharply by 69 % (24,182 to 7238), whereas the incidence of epilepsy, increased to 1.02 times (30,286-29,312), when adjusted in proportion to the population. Notably, a greater decrease in the incidence of FS were found in the regions with high-risk of coronavirus. A result of segmented regression analysis proved the decrease was significant and made immediately after the pandemic started(p < 0.001). In contrast to the incidence of FS, that of epilepsy did not exhibit a significant month-to-month change during the baseline period, immediately after the pandemic started, and during the pandemic.

CONCLUSIONS

The COVID-19 outbreak and resulting social distancing measures reduced the incidence of febrile seizure immediately rather than gradually. Unlike in the case of acute febrile seizure, the COVID-19 pandemic had no effect on the incidence of chronic epilepsy.

Nonfebrile Seizures in Pediatrics: Key Points to Remember

Seizures are the most common neurological disorder in pediatrics, and their initial approach aims at clinical stabilization. A thorough patient evaluation may provide important clues for the etiological diagnosis. A 12-month-old female child was observed in the emergency department after experiencing her first apyretic seizure. She had a history of congenital alopecia and, on physical examination, presented subtotal alopecia and milia. Initial investigation revealed hypocalcemia; therefore, intravenous calcium correction was started with a partial response. The analytical study was extended, revealing hypophosphatemia, elevated parathormone, and 1,25(OH)2 vitamin D with normal 25(OH) vitamin D. The genetic analysis confirmed hereditary vitamin D-resistant rickets (HVDRR). The integration of the findings was crucial to diagnostic reasoning and to guide further investigation. HVDRR is a rare disorder, with more severe clinical presentations associated with alopecia. Early diagnosis and treatment are fundamental to minimize the impact on growth and the development of other comorbidities.

Safely Shifting MRIs for Seizure Evaluation to the Outpatient Setting

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.

Diagnostic Yield of Five Minutes Compared to Three Minutes Hyperventilation During Electroencephalography in Children

Purpose: To investigate whether hyperventilation (HV) for 5 minutes increases the diagnostic yield of electroencephalography (EEG) compared to 3 minutes HV and to determine whether performing HV for 5 minutes is feasible and safe in children. Methods: Data were evaluated from 579 children aged less than 18 years, referred to EEG for epilepsy evaluation. Occurrence of seizures, HV induced interictal epileptiform discharges precipitation and potentiation and adverse events if any were noted during the first 3 minutes and last 2 minutes of HV separately. Results: 398 children (68.7%) completed 5 minutes HV. Seizures were precipitated during the first 3 minutes of HV in 2 children, and during the last 2 minutes in one more child. Inter-ictal EEG abnormalities were precipitated in the first 3 minutes of HV in 31 children, and during the last 2 min in 4 more children. All 398 children completed HV during the last 2 minutes successfully and no adverse events occurred during the last 2 minutes of HV. Conclusion: 33.33% of seizures and 11.5% of inter-ictal EEG abnormalities triggered by HV occurred during the last 2 min of HV. This finding supports the utility of prolonged hyperventilation for 5 minutes. Prolonged HV for 5 minutes increases the diagnostic yield of EEG in paediatric population and it is safe and feasible.

Factors Associated with Neuroimaging Abnormalities in Children with Afebrile Seizure: A Retrospective Multicenter Study

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.

Characteristics and clinical value of early electroencephalography (EEG) after a first unprovoked seizure in children

OBJECTIVE

This study aimed to examine the timing and features of electroencephalography (EEG) as a predictor of seizure recurrence in children with a first unprovoked seizure.

METHODS

We retrospectively evaluated the medical records and EEG recordings of pediatric patients who presented within 24 h of a first unprovoked seizure between January 2018-December 2019 and had at least 1 year of pediatric neurology clinical follow-up.

RESULTS

The study included 108 patients (53.7% males) with a mean age of 98.75±57.75 months. Sixty-eight patients (63%) had an abnormal initial EEG, of which 55 (80.9%) were focal. The semiology of the first unprovoked seizure was focal in 50% of the patients and correlated with initial EEG findings (p<0.001). Forty-three patients had seizure recurrence during the follow-up period of mean 26.86±7.39 months. Recurrence was observed in the first 6 months in 30 patients and occurred twice in 4 patients. An abnormal EEG after the first unprovoked seizure was found to be an independent risk factor for recurrence, with a 2.42-fold higher recurrence risk in patients with focal EEG abnormalities compared to those with a normal EEG (p = 0.044). Analysis of 7 different timing patterns up to 96 h after the first unprovoked seizure showed that EEG timing was not associated with abnormality detection.

DISCUSSION

Our study showed that EEG abnormalities, especially focal abnormalities, after a first unprovoked seizure are a predictor of seizure recurrence. But the rate of detection of EEG abnormalities was not related to the timing of EEG recording, relative to seizure occurrence.

Computer-assisted analysis of routine electroencephalogram to identify hidden biomarkers of epilepsy: protocol for a systematic review

INTRODUCTION

The diagnosis of epilepsy frequently relies on the visual interpretation of the electroencephalogram (EEG) by a neurologist. The hallmark of epilepsy on EEG is the interictal epileptiform discharge (IED). This marker lacks sensitivity: it is only captured in a small percentage of 30 min routine EEGs in patients with epilepsy. In the past three decades, there has been growing interest in the use of computational methods to analyse the EEG without relying on the detection of IEDs, but none have made it to the clinical practice. We aim to review the diagnostic accuracy of quantitative methods applied to ambulatory EEG analysis to guide the diagnosis and management of epilepsy.

METHODS AND ANALYSIS

The protocol complies with the recommendations for systematic reviews of diagnostic test accuracy by Cochrane. We will search MEDLINE, EMBASE, EBM reviews, IEEE Explore along with grey literature for articles, conference papers and conference abstracts published after 1961. We will include observational studies that present a computational method to analyse the EEG for the diagnosis of epilepsy in adults or children without relying on the identification of IEDs or seizures. The reference standard is the diagnosis of epilepsy by a physician. We will report the estimated pooled sensitivity and specificity, and receiver operating characteristic area under the curve (ROC AUC) for each marker. If possible, we will perform a meta-analysis of the sensitivity and specificity and ROC AUC for each individual marker. We will assess the risk of bias using an adapted QUADAS-2 tool. We will also describe the algorithms used for signal processing, feature extraction and predictive modelling, and comment on the reproducibility of the different studies.

ETHICS AND DISSEMINATION

Ethical approval was not required. Findings will be disseminated through peer-reviewed publication and presented at conferences related to this field.

PROSPERO REGISTRATION NUMBER

CRD42022292261.

Role of Electroencephalogram (EEG) and Magnetic Resonance Imaging (MRI) Findings in Early Recognition and Diagnosis of Neuronal Ceroid Lipofuscinosis Type 2 Disease

Neuronal ceroid lipofuscinosis type 2 (CLN2) disease is a very rare neurodegenerative lysosomal storage disorder. Progression is rapid and irreversible, making early diagnosis crucial for timely treatment. A group of pediatric neurologists and neuroradiologists with expertise in CLN2 convened to discuss early electroencephalogram (EEG) and magnetic resonance imaging (MRI) findings in CLN2 diagnosis. Of 18 CLN2 cases, 16 (88.9%) had background slowing and 16 (88.9%) had epileptiform discharges on initial EEG. Seven of 17 (41.2%) patients who received intermittent low-frequency photic stimulation had a photoparoxysmal response. Initial MRIs showed subtle cerebellar (n = 14, 77.8%) or cerebral (n = 9, 50.0%) atrophy, white matter abnormalities (n = 11, 61.1%), and basal ganglia T2 hypointensity (n = 6, 33.3%), which became more apparent on follow-up MRI. The recognition of even subtle cerebellar atrophy and white matter signal changes in children aged 2-5 years who present with language delay, new-onset seizures, and an EEG with epileptiform discharges and background slowing should prompt investigation for CLN2. Because these early signs are not unique to CLN2, genetic testing is essential early in the diagnostic journey.

Risk of Epilepsy in Children Presenting to Emergency Departments with Their First Afebrile Seizure: A Retrospective Multicenter Study

Seizure is one of the most common neurologic disorders in pediatric emergency department visits. Early detection of epilepsy development in children with afebrile seizures is important. We identified predictors of epilepsy development in children with their first afebrile seizure. In this retrospective multicenter study, we enrolled pediatric patients aged 1 month to 18 years who presented with afebrile seizures at the emergency department from January 2017 to December 2020. Multivariable logistic regression analysis was performed to identify factors associated with epilepsy development. A total of 417 pediatric patients were enrolled, 161 (38.6%) of whom developed epilepsy. From the multivariable logistic regression analysis, older age at onset (2−5 years, odds ratio [OR] 2.611, p = 0.010; 11−15 years, OR 3.138, p = 0.003; 16−18 years, OR 4.292, p = 0.002), longer seizure duration of more than 10 min (OR 4.869, p = 0.006), two or more seizures (OR 2.378, p = 0.004), lethargy (OR 2.341, p = 0.021), and a lactate level > 2.27 mg/dL (OR 4.205, p < 0.001) were significant predictors for the development of epilepsy in children experiencing their first afebrile seizure.

A Prospective Hospital-Based Study on the Clinico-Etiological Profile of the First Episode of a Seizure in Children

Background  This study aims to examine the clinico-etiological profile of children with the first episode of a seizure and categorize seizure types based on age groups in a tertiary care hospital. Methodology  This was a prospective observational study conducted at a tertiary care medical institute in India over two years. Children (one month to 12 years of age) with the first episode of a seizure were included in the study population. The data collected included demographic profile, history, examination, biochemical profile, electroencephalogram (EEG), and neuroimaging. Children were categorized as generalized-onset, focal-onset, and unknown-onset seizures based on the International League Against Epilepsy 2017 seizure classification. Children were also classified according to specific etiologies such as structural, metabolic, or other specific causes. All the children were followed up at the hospital's outpatient clinic or through a telephonic interview. Results  A total of 220 children were examined in this study. Among them, 64% were male and 36% were female, with a male-to-female ratio of 1.75:1. Among the 220 children, 21.8% had a family history of seizure. The most common type of seizures were generalized-onset seizures (n = 110, 50%), followed by focal-onset seizures (n = 96, 43.6%). Overall, 9% of children presented with status epilepticus as their first-episode seizure. An abnormal EEG was recorded for 122 (76%) children. While 60% of children had abnormal neuroimaging findings, the remaining had normal neuroimaging. Febrile seizures (n = 92, 41.9%) were the most common cause of the first episode of a seizure. Most of the febrile seizures occurred between the age of one and four (n = 60, 65.2%). Epilepsy syndromes were the second most common etiology, followed by central nervous system (CNS) infections, structural brain abnormalities, metabolic disorders, vascular lesions, toxins, and immune-mediated causes, in that order. In 14 (6.36%) children, the etiology was unknown at the time of the study. Conclusions First-episode seizures in children cause physical, mental, and financial stress on the parents. The collection of detailed history, examinations, and appropriate investigations can help identify the etiology of seizures. It was possible to determine the etiology of the first episode of a seizure in the majority of the patients. Generalized-onset seizures were the most common. Febrile seizures, epilepsy syndrome, CNS infections, vascular lesions, and metabolic disorders were the main etiological factors, in that order.

Investigations in children with seizures visiting a pediatric emergency department: A monocenter study

AIM

Neurological disorders, in particular seizure, are one of the reasons for admission in pediatric emergency departments (PED). We aimed to evaluate the frequency and the relevance of each investigation for seizure management in the PED.

METHODS

We conducted a one-year retrospective study. Based on predefined criteria, we evaluate the appropriateness of the investigations. Logical regression was used to study the risk factors for acute symptomatic seizure (ASS).

RESULTS

We identified 691 visits to the PED for an epileptic event over an annual volume of 80,320 visits. Seizures occurring in Children with epilepsy were the most frequent epileptic events seen in the PED (42%). Looking at the investigation performed in the PED, a blood electrolytes analysis was performed in 26%, neuroimaging in 9%, electroencephalography recording in 9% and LP in 5% of patients. ASSs represented 2.1% of the seizures and 0.6% of PED neurological visits. In the multivariate analysis, an initial abnormal neurological examination (OR, 20.92 [4.87; 89.81, p<0.0001) was the only risk factor that remained significantly associated with ASS. A seizure occurring in an epilepsy patient was significantly associated with an unprovoked seizure (OR, 0.12 [0.02; 0.57], p<0.008).

INTERPRETATION

All ASSs were associated with a positive or abnormal examination. Moreover, there is a significant proportion of investigations requested in cases of an epileptic event that did not lead to a diagnosis or modification of the management. Based on our methods, there seems to be an overuse of investigations for seizure in children with epilepsy.

Staring Spells: How to Distinguish Epileptic Seizures from Nonepileptic Staring

OBJECTIVE

To determine the nature of staring spells and factors distinguishing epileptic from nonepileptic staring spells, we studied the clinical and demographic features of children with staring spells referred to a regional new-onset seizure clinic.

STUDY DESIGN

Our retrospective chart review encompassed 2818 consecutive patients evaluated in the new-onset seizure clinic between September 22, 2015, and March 19, 2018. We identified 121 patients with newly presenting staring spells.

RESULTS

Sixty-two of 121 (51%) children were diagnosed with nonepileptic staring spells and 59 (49%) with epileptic seizures (24 with absence epilepsy, 35 with focal epilepsy). Patients with nonepileptic staring spells were younger (4.8 vs 7.1 years, P = .001) and more likely to have developmental delay (P = .005) than the seizure group. There was an 8.9-month delay on average from the onset of staring spells to the new-onset seizure clinic visit. The emergency department was a referral source for 80% (28/35) of focal seizures. In children with focal seizures, the staring spells typically lasted >1minute (29/35, 83%), whereas only 19 of 62 (31%) of children with nonepileptic staring spells had events lasting this long (P = .04). All children had a routine electroencephalography (EEG) on the day of new-onset seizure clinic visit. EEG was diagnostic in 100% (24/24) of absence seizures and 51% (18/35) of focal seizures.

CONCLUSIONS

In children presenting with staring spells, the differential diagnosis of epileptic staring spells vs nonepileptic staring spells can be made by history and routine EEG. Staring was as likely to be epileptic as nonepileptic spells. Younger children with developmental delay were more likely to have nonepileptic events. Our simple approach based on event duration, postictal symptoms, and EEG allowed identification of epileptic staring on first visit to new-onset seizure clinic but requires validation in future prospective studies including long-term video EEG monitoring and follow-up.

Evaluation of First Seizure and Newly Diagnosed Epilepsy

PURPOSE OF REVIEW

This article focuses on the evaluation of children and adults who present with new-onset seizures, with an emphasis on differential diagnosis, classification, evaluation, and management.

RECENT FINDINGS

New-onset seizures are a common presentation in neurologic practice, affecting approximately 8% to 10% of the population. Accurate diagnosis relies on a careful history to exclude nonepileptic paroxysmal events. A new classification system was accepted in 2017 by the International League Against Epilepsy, which evaluates seizure type(s), epilepsy type, epilepsy syndrome, etiology, and comorbidities. Accurate classification informs the choice of investigations, treatment, and prognosis. Guidelines for neuroimaging and laboratory and genetic testing are summarized.

SUMMARY

Accurate diagnosis and classification of first seizures and new-onset epilepsy are key to choosing optimal therapy to maximize seizure control and minimize comorbidities.

A tale of two cohorts: Differing outcomes in infantile-onset focal epilepsy

OBJECTIVE

Infants with focal-onset epilepsy are an understudied population, requiring additional evaluation for clinical assessment and prognostication. Our goal was to characterize the etiology and natural history of infantile-onset focal epilepsy.

METHODS

We retrospectively identified all infants (0-24 months) with onset of focal epilepsy while resident in Olmsted County, Minnesota, between 1980 and 2018, using the Rochester Epidemiology Project Database. We assessed the impact of etiology on both seizure and neurodevelopmental outcome, and mortality.

RESULTS

Of 686 children with epilepsy onset <18 years, 125 (18.2%) presented with focal-onset seizures in infancy. Median follow-up for this group was 10.9 years (interquartile range [IQR] 6.2, 19.3). Etiology was identified in 65.6% (structural N = 62, genetic N = 13, both structural and genetic N = 3, metabolic N = 4). Of 107 patients followed >2 years, 38 (35.5%) developed drug-resistant epilepsy (DRE). DRE was more likely with younger age at onset, known etiology, and presence of epileptic spasms. Sixty-eight (63.0% of those with follow-up) were developmentally delayed at last follow-up, and known etiology, DRE, and presence of epileptic spasms were significantly associated with delay (p < .001 for all). Fifteen patients (12.0%) died at a median age of 7.1 years (IQR 1.7, 21.7), but only one death was seizure related (suspected sudden unexpected death in epilepsy [SUDEP]). Of 20 infants with normal development at onset and no known etiology with >2 years follow-up, none developed DRE, all were seizure-free at last follow-up (95% off antiseizure medications [ASMs]), and all remained developmentally normal.

SIGNIFICANCE

Infantile-onset focal epilepsy accounts for 18% of all epilepsy in childhood, is frequently due to known etiologies, and has a high rate of DRE. However, developmentally normal infants without a known cause appear to have a very favorable course.

Neuroimaging for Pediatric Non-First-Time Seizures in the Emergency Department

Background

& Objectives: Neuroimaging is often part of the workup for a pediatric patient presenting with a seizure to an emergency department (ED). We aim to evaluate when neuroimaging in the emergency department for children with a non-first-time seizure, or non-index seizure (NIS), is associated with an acute change in management (ACM).

Methods:

Retrospective cohort study of all pediatric patients presenting to an ED from 2008-2018 with a NIS, excluding repeat febrile seizures, who underwent neuroimaging. Clinical characteristics were extracted from the electronic medical record. The primary outcome was new abnormal neuroimaging resulting in an ACM, defined as admission to the hospital, neurosurgical intervention, or new non-seizure medication administration.

Results:

We identified 492 encounters. Neuroimaging revealed new findings in 21% of encounters and led to ACMs in 5% of encounters. ACMs included admissions, neurosurgical interventions, and non-seizure medication changes. Factors associated with ACM included new seizure type (OR 3.3, 95% CI 1.3-8.0), new focal exam finding (OR 3.0, 95% CI 1.3-7.1), altered mental status (OR 2.9, 95% CI 1.2-7.0), and a history of only provoked seizures (OR 2.8, 95% CI 1.0-7.5). Patients with 2 risk factors had an OR 6.9 (95% CI 1.8 – 26.5) for an ACM, those with 3-4 risk factors had an OR of 45.8 (95% CI 9.8-213.2). The negative predictive value for ACM in a patient with no risk factors was 98.6% (95% CI 95.9 - 99.5).

Discussion:

Patients with a NIS who have abnormal neuroimaging associated with an ACM present with unique risk factors. Prospectively validating these factors may allow for a prediction tool for NIS in EDs where reduced exposure to ionizing radiation, sedation, and resource utilization is critically important.

Racial and ethnic differences in low-value pediatric emergency care

BACKGROUND

Disparities in health care quality frequently focus on underuse. We evaluated racial/ethnic differences in low-value services delivered in the pediatric emergency department (ED).

METHODS

We performed a retrospective cross-sectional study of low-value services in children discharged from 39 pediatric EDs from January 2018 to December 2019 using the Pediatric Hospital Information System. Our primary outcome was receipt of one of 12 low-value services across nine conditions, including chest radiography in asthma and bronchiolitis; beta-agonist and corticosteroids in bronchiolitis; laboratory testing and neuroimaging in febrile seizure; neuroimaging in afebrile seizure; head injury and headache; and any imaging in sinusitis, constipation, and facial trauma. We analyzed the association of race/ethnicity on receipt of low-value services using generalized linear mixed models adjusted for age, sex, weekend, hour of presentation, payment, year, household income, and distance from hospital.

RESULTS

We included 4,676,802 patients. Compared with non-Hispanic White (NHW) patients, non-Hispanic Black (NHB) and Hispanic patients had lower adjusted odds (aOR [95% confidence interval]) of receiving imaging for asthma (0.60 [0.56 to 0.63] NHB; 0.84 [0.79 to 0.89] Hispanic), bronchiolitis (0.84 [0.79 to 0.89] NHB; 0.93 [0.88 to 0.99] Hispanic), head injury (0.84 [0.80 to 0.88] NHB; 0.80 [0.76 to 0.84] Hispanic), headache (0.67 [0.63 to 0.72] NHB; 0.83 [0.78 to 0.88] Hispanic), and constipation (0.71 [0.67 to 0.74] NHB; 0.76 [0.72 to 0.80] Hispanic). NHB patients had lower odds (95% CI) of receiving imaging for afebrile seizures (0.89 [0.8 to 1.0]) and facial trauma (0.69 [0.60 to 0.80]). Hispanic patients had lower odds (95% CI) of imaging (0.57 [0.36 to 0.90]) and blood testing (0.82 [0.69 to 0.98]) for febrile seizures. NHB patients had higher odds (95% CI) of receiving steroids (1.11 [1.00 to 1.21]) and beta-agonists (1.38 [1.24 to 1.54]) for bronchiolitis compared with NHW patients.

CONCLUSIONS

NHW patients more frequently receive low-value imaging while NHB patients more frequently receive low-value medications for bronchiolitis. Our study demonstrates the differences in care across race and ethnicity extend to many services, including those of low value. These findings highlight the importance of greater understanding of the complex interaction of race and ethnicity with clinical practice.

Operational diagnosis of epilepsy in children at undetermined risk: A meta-analysis of prognostic factors for seizure recurrence

PURPOSE

According to the operational epilepsy definition adopted by the International League Against Epilepsy (ILAE) in 2014, in patients with one unprovoked seizure, clinicians must stratify the recurrence risk to determine if the criteria for diagnosis of epilepsy have been met and if antiseizure medications (ASM) are required. A remote symptomatic etiology was considered to be one of the best predictors for seizure recurrence, also according to the available prediction tools, but in children with a previously negative history and a normal neurological examination, estimating the probability of seizure relapse remains less obvious. This meta-analysis aimed to fill this gap of knowledge.

METHODS

The PubMed, Embase, and Scopus databases were searched from January 2000 to December 2020. We selected studies reporting children (1 month-18 years old) presenting a first unprovoked seizure. The absence of a known remote neurological pathology had to be clearly stated in the paper or the idiopathic/cryptogenic group data were used; the finding of epileptogenic structural brain MRI abnormalities during the diagnostic workup at the moment of the first unprovoked seizure was not an exclusion criterion. Factors analyzed, as possible predictors of recurrence, included: age at onset, sex, family history of epilepsy, type of seizure (focal or generalized), epileptiform abnormalities on EEG, and epileptogenic structural brain MRI abnormalities.

RESULTS

Four studies met the inclusion criteria and the sample size consisted of 741 children. The estimated recurrence rate within 3 years was 50% (95%CI:33.9%-66.0%). Among the predictors of recurrence, focal seizure (OR = 1.52; 95%CI = 1.05-2.19), epileptiform abnormalities on EEG (OR = 1.97; 95%CI = 1.31-2.96), and positive family history for epilepsy (OR = 2.37; 95%CI = 1.56-3.59) were associated with a statistically significant increased risk.

CONCLUSION

The analysis of data available until now cannot adequately assess the risk of recurrence after a first unprovoked seizure in neurotypical children. Prospective and multicenter cohort studies are expected.

First afebrile seizures: Clinical and radiological view with emergent testing

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.

The role of fundoscopy in pediatric seizures

Fundoscopy can guide clinicians in the decision to perform neuroimaging. Our aim was to evaluate the rate of abnormal neuroimaging following fundoscopy in children presenting with seizures to the pediatric emergency department (PED). This was a retrospective single-center study. Patients with a discharge diagnosis of seizures were evaluated. Outcome measures were the rate of abnormal brain imaging following a finding of papilledema, and the rate of repeat fundoscopies due to an inconclusive initial examination. A total of 646 patients with seizures underwent fundoscopy. Out of 3 patients who were diagnosed initially with papilledema, only one patient had an abnormal brain CT. He was diagnosed with papilledema previously, and neuroimaging was previously recommended. A total of 7.6% (49/646) of patients underwent a second fundoscopic evaluation. In view of the limited yield and accuracy of fundoscopy in the PED, its role in the clinical decision making in children with seizures is questionable. What is Known: • Seizures are not described as an isolated presenting symptom of increased ICP. • Fundoscopy in children requires skill, time, cooperation. What is New: • Papilledema was found in only one patient who presented with seizures. • Fundoscopy in the PED has limited yield and accuracy in children with seizures.

Recurrence rate of the first nonfebrile seizure in children with autism spectrum disorder

OBJECTIVE

Epilepsy prevalence is higher in children with Autism Spectrum Disorder (ASD) and is a contributor to morbidity and mortality. Little is known about the recurrence rate after the first nonfebrile seizure in this population, specifically in regard to seizure type and electroencephalogram (EEG) findings.

METHODS

We reviewed pediatric medical records at our institution between 2006 and 2016 for subjects with ASD who had a first seizure. We then looked for risk of a recurrent non-provoked seizure within the next two years.

RESULTS

Overall, the recurrence rate in this study was 70.9%. This is much higher than the general population. The recurrence rate was higher in patients who had a generalized convulsion compared to those who had a behavioral arrest. When the first seizure was a generalized convulsion, there was an 84% chance of developing a second convulsion, whereas the recurrence rate was 59% for behavioral arrest type seizures (p = 0.002). The odds of having recurrence when the first seizure is a generalized convulsion was 5.36 higher than when it was a behavioral arrest (95% CI 2.14-13.42, p < 0.001). An abnormal EEG was a strong predictor of seizure recurrence in both seizure types. However, even with a normal EEG, generalized convulsions were more likely to recur within 2 years compared to behavioral arrest (OR 6.3, 95% CI 2.1-19).

SIGNIFICANCE

The recurrence rate for nonfebrile seizures in children with ASD is much higher than the general population, especially for generalized convulsions. An abnormal EEG has a strong predictive value for seizure recurrence. However, even when the EEG is normal, the recurrence rate for generalized convulsions is quite high. This is an important finding as epilepsy contributes to morbidity and mortality in this group and may impact clinical decisions about when to start anti-seizure medications.

Predictors of seizure recurrence in emergency department pediatric patients with first-onset afebrile seizure: A retrospective observational study

INTRODUCTION

The primary goals of emergency department (ED) clinicians when dealing with a pediatric patient experiencing a seizure are to control the seizure and prevent seizure-related complications. After stabilizing the patient, the clinician should determine whether the patient is likely to have recurrent seizures that may need treatment such as antiepileptic drugs (AEDs). The early identification of pediatric seizure patients at high risk for recurrence can be of great help in consulting with their parents. This study aimed to identify predictors of seizure recurrence in pediatric patients who visited the ED for first-onset afebrile seizure.

METHODS

This retrospective study was conducted with pediatric patients aged 1 month to 18 years who visited our ED for afebrile seizure from January 2016 to March 2020. Children with a known seizure disorder, known underlying genetic or metabolic disorder, or acute trauma history, and those lost to follow-up were excluded. Multivariable logistic regression analysis was performed to identify factors associated with seizure recurrence.

RESULTS

A total of 253 pediatric patients were included in the study. Seizure recurrence was observed in 117 patients (46.3%). From the multivariable logistic regression analysis, older age at onset (11-15 years, odds ratio [OR] 5.781, p = 0.001; 16-18 years, OR 6.223, p = 0.002), a longer seizure duration (1-5 min, OR 3.043, p = 0.002; 6-10 min, OR 5.629, p = 0.002; >10 min, OR 8.882, p = 0.002), blood pH under 7.2 (OR 8.308, p = 0.015), and a glucose level over 144 mg/dL (OR 6.408, p = 0.030) were significantly associated with seizure recurrence. The area under the receiver operating characteristic curve for the multivariable logistic regression analysis was 0.774.

CONCLUSION

Age at onset ≥11 years, a longer seizure duration, acidosis, and hyperglycemia were predictors of seizure recurrence in children who had experienced first-onset afebrile seizure.

When Should a Brain MRI Be Performed in Children with New-Onset Seizures? Results of a Large Prospective Trial

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.

Application of a deep learning image reconstruction (DLIR) algorithm in head CT imaging for children to improve image quality and lesion detection

BACKGROUND

To evaluate the performance of a Deep Learning Image Reconstruction (DLIR) algorithm in pediatric head CT for improving image quality and lesion detection with 0.625 mm thin-slice images.

METHODS

Low-dose axial head CT scans of 50 children with 120 kV, 0.8 s rotation and age-dependent 150-220 mA tube current were selected. Images were reconstructed at 5 mm and 0.625 mm slice thickness using Filtered back projection (FBP), Adaptive statistical iterative reconstruction-v at 50% strength (50%ASIR-V) (as reference standard), 100%ASIR-V and DLIR-high (DL-H). The CT attenuation and standard deviation values of the gray and white matters in the basal ganglia were measured. The clarity of sulci/cisterns, boundary between white and gray matters, and overall image quality was subjectively evaluated. The number of lesions in each reconstruction group was counted.

RESULTS

The 5 mm FBP, 50%ASIR-V, 100%ASIR-V and DL-H images had a subjective score of 2.25 ± 0.44, 3.05 ± 0.23, 2.87 ± 0.39 and 3.64 ± 0.49 in a 5-point scale, respectively with DL-H having the lowest image noise of white matter at 2.00 ± 0.34 HU; For the 0.625 mm images, only DL-H images met the diagnostic requirement. The 0.625 mm DL-H images had similar image noise (3.11 ± 0.58 HU) of the white matter and overall image quality score (3.04 ± 0.33) as the 5 mm 50% ASIR-V images (3.16 ± 0.60 HU and 3.05 ± 0.23). Sixty-five lesions were recognized in 5 mm 50%ASIR-V images and 69 were detected in 0.625 mm DL-H images.

CONCLUSION

DL-H improves the head CT image quality for children compared with ASIR-V images. The 0.625 mm DL-H images improve lesion detection and produce similar image noise as the 5 mm 50%ASIR-V images, indicating a potential 85% dose reduction if current image quality and slice thickness are desired.

Evidence-Based Protocols in Child Neurology

Medical care has become more complex as the scientific method has expanded medical knowledge. Medicine is also now practiced across different medical systems of varying complexity, and creating standard treatment guidelines is one way of establishing uniform treatment across these systems. The creation of guidelines ensures the delivery of quality medical care and improved patient outcomes. Evidence-based medicine is the application of scientific research to produce these treatment guidelines. This article shall focus on the current treatment guidelines used for inpatient pediatric neurology.

Electroencephalogram versus Magnetic Resonance Imaging Brain as the Initial Investigation of Choice in Neurologically Normal Children with First Afebrile Seizure in India

BACKGROUND AND PURPOSE

To compare the rates of clinically relevant information provided by electroencephalogram (EEG) and magnetic resonance imaging (MRI) brain in first afebrile seizure (FAS) in children.

METHODS

In this prospective randomized controlled trial, neurologically normal children between the age of 2 and 14 years, presenting with first episode of unprovoked, afebrile generalized or partial seizures, were included. Enrolled patients were randomized into two groups. After stabilization, initial workup and management, group I-patients underwent an EEG followed by MRI, whereas group II-patients underwent an initial MRI brain followed by an EEG. The patients were followed up after results of both the investigations and then every 3 months for seizure recurrence. The primary outcome was the proportion of investigations, providing clinically relevant information. The secondary outcomes were to determine the etiological diagnosis of FAS and record adverse events associated with EEG and MRI.

RESULTS

Out of 170 enrolled patients, 52 patients (61.2%) in initial EEG group and 53 patients (70.6%) in initial MRI group had abnormal results on first investigation. An etiological diagnosis could not be made in any patient in initial EEG group. Neuroimaging revealed an etiological diagnosis in 53 patients (70.6%) in initial MRI group. Inflammatory granuloma was found to be the most common cause of FAS, followed by idiopathic epilepsy.

CONCLUSIONS

The results of our study done in neurologically normal children with FAS showed a high diagnostic yield with an initial MRI. We recommend MRI brain to be considered as the initial investigation for evaluation of FAS in children.

Management of Infants with Brief Resolved Unexplained Events (BRUE) and Apparent Life-Threatening Events (ALTE): A RAND/UCLA Appropriateness Approach

Unexpected events of breath, tone, and skin color change in infants are a cause of considerable distress to the caregiver and there is still debate on their appropriate management. The aim of this study is to survey the trend in prevention, decision-making, and management of brief resolved unexplained events (BRUE)/apparent life-threatening events (ALTE) and to develop a shared protocol among hospitals and primary care pediatricians regarding hospital admission criteria, work-up and post-discharge monitoring of patients with BRUE/ALTE. For the study purpose, a panel of 54 experts was selected to achieve consensus using the RAND/UCLA appropriateness method. Twelve scenarios were developed: one addressed to primary prevention of ALTE and BRUE, and 11 focused on hospital management of BRUE and ALTE. For each scenario, participants were asked to rank each option from '1' (extremely inappropriate) to '9' (extremely appropriate). Results derived from panel meeting and discussion showed several points of agreement but also disagreement with different opinion emerged and the need of focused education on some areas. However, by combining previous recommendations with expert opinion, the application of the RAND/UCLA appropriateness permitted us to drive pediatricians to reasoned and informed decisions in term of evaluation, treatment and follow-up of infants with BRUE/ALTE, reducing inappropriate exams and hospitalisation and highlighting priorities for educational interventions.

Neuroimaging of Childhood Epilepsy: Focal versus Generalized Epilepsy

Neuroimaging 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.

Evaluation of an educational video providing key messages for doctors to counsel families following a first afebrile seizure

AIM

The aim was to evaluate an educational video in educating doctors on the key messages and follow-up pathways following a first afebrile seizure presentation. A multidisciplinary expert team developed the video (http://www.pennsw.org.au/families/resources/first-seizure-pack-and-video) based on available evidence and best-practice. It contains a role-play between the parent/child and physician. It addresses: key messages to impart following a first seizure, seizure first aid, safety messages including necessary precautions post-discharge, contents of the First Seizure Pack for families, follow-up pathway and issues for discussion with the paediatrician at a later appointment.

METHODS

Paediatric/Emergency department (ED) trainees across three Australian sites were recruited during terms 1 and 2, 2019. A repeated measures design was used. Multilevel modelling analyses were performed. The primary outcome was clinician knowledge. Secondary outcomes were confidence in answering questions and counselling families. Qualitative data on the utility, strengths and weaknesses of the video were evaluated.

RESULTS

A total of 127 participants consented, one withdrew prior to commencing. A total of 126 baseline surveys, 115 follow-up surveys and 45 1-month follow-up surveys were returned. Viewing the video significantly improved knowledge of key messages at immediate follow-up (P < 0.001) and 1-month follow-up (P = 0.048). Likewise, confidence was significantly improved; 96.5% of responders found the video useful, 90.3% were likely to use the resource in the future and 82% would change their approach to counselling. Most liked aspects of the resource were clarity/conciseness of the information (n = 70) and comprehensiveness (n = 38).

CONCLUSION

This education video significantly improved clinician knowledge and confidence in counselling families following first seizure.

Length of stay linked to neurodiagnostic workup for seizures presenting to the pediatric emergency department

INTRODUCTION

Patients presenting to the pediatric emergency department (ED) often undergo unnecessary testing that leads to prolonged ED visits. Lower ED length of stay has been linked to improved patient experience and may reduce ED overcrowding, a costly burden on a health system.

METHODS

This is a retrospective cohort study involving patient records over the period of 6 months at an urban tertiary children's hospital who presented with seizures. Febrile seizures, seizures associated with trauma, and charts of patients who did not present initially through our ED were excluded.

RESULTS

328 charts were obtained through this search criteria. Head imaging was performed in 52 (16%) patients and consisted of 81% CT (n = 42) and 19% (n = 10) magnetic resonance imaging (MRI). Obtaining an MRI was associated with a 3.5 h longer ED visit (p = 0.07); obtaining a CT was associated with a 1.5 h longer ED visit (p = 0.005). An Electroencephalogram (EEG) was obtained for 67 (20%) visits and was associated with a 3.0 h longer ED length of stay (p < 0.001). Ten % of the CT scans showed new or progressive findings and 40% of the MRIs done provided useful information for management. Thirty-seven % of EEGs performed in new onset seizure patients revealed epileptiform findings and 5% of EEGs in established seizure patients provided meaningful findings important to management.

CONCLUSION

Obtaining neurodiagnostic studies significantly prolongs duration of stay in the ED. Electroencephalograms appear to have the greatest yield in new onset seizure patients and can help make a diagnosis of an epilepsy syndrome in children.

Measuring the effects of pre-test probability on out-patient first EEG investigation in children - A guide to evidence-based EEG triage in a pandemic

INTRODUCTION

The yield of epileptiform EEG abnormalities is lower in unselected Paediatric populations than in prospective studies of incident seizures or prevalent epilepsy studies. At a time of limited capacity, it is important to match available EEG resources to children who are most likely to benefit. In this study we evaluated a prospective triage tool for estimating the likelihood of epileptiform abnormality in children's first out-patient EEG.

METHODS

We prospectively triaged 1865 out-patient referrals to the largest Paediatric EEG laboratory in Ireland. Based on a structured algorithm, we dichotomized first EEG referrals into priority and non-priority groups and assigned one of 5 sub-levels based on anticipated EEG yield. EEGs were reported by a single Consultant in Clinical Neurophysiology.

RESULTS

Triage designated 757 (41 %) EEG referrals as non-priority. Priority exceeded non-priority referrals for all age groups except children between 18 months and 3.5 years. EEGs showed a two-fold higher incidence of interictal epileptiform abnormalities for priority referrals (36 % vs 18 %, p < 0.001). Rates of interictal epileptiform abnormality correlated with the 5 sub-levels of triage (p < 0.01). Epileptiform yield was highest (39 %) for children over 5 years vs 17 % for those under 5 years (p < 0.00001); these rates increased to 49 % and 20 % respectively for priority referrals.

CONCLUSION

Structured pre-test triage of EEG referrals can identify children who have the greatest likelihood of epileptiform abnormality. In a mixed population of Paediatric referrals, the epileptiform yield of first time EEG is 49 % for children over 5 years who are referred with an appropriate EEG indication. This is subject to much variability with epileptiform yields as low as 13 % in younger children with non-priority referrals. The use of a structured triage algorithm can help to optimise utility of EEG in situations of limited laboratory capacity.

Status Epilepticus-Work-Up and Management in Children

Status epilepticus (SE) is one of the most common neurological emergencies in children and has a mortality of 2 to 4%. Admissions for SE are very resource-consuming, especially in refractory and super-refractory SE. An increasing understanding of the pathophysiology of SE leaves room for improving SE treatment protocols, including medication choice and timing. Selecting the most efficacious medications and giving them in a timely manner may improve outcomes. Benzodiazepines are commonly used as first line and they can be used in the prehospital setting, where most SE episodes begin. The diagnostic work-up should start simultaneously to initial treatment, or as soon as possible, to detect potentially treatable causes of SE. Although most etiologies are recognized after the first evaluation, the detection of more unusual causes may become challenging in selected cases. SE is a life-threatening medical emergency in which prompt and efficacious treatment may improve outcomes. We provide a summary of existing evidence to guide clinical decisions regarding the work-up and treatment of SE in pediatric patients.

Acute Seizures-Work-Up and Management in Children

Seizures are common in the pediatric population; however, most children do not go on to develop epilepsy later in life. Selecting appropriate diagnostic modalities to determine an accurate diagnosis and appropriate treatment as well as with counseling families regarding the etiology and prognosis of seizures, is essential. This article will review updated definitions of seizures, including provoked versus unprovoked, as well as the International League Against Epilepsy operational definition of epilepsy. A variety of specific acute symptomatic seizures requiring special consideration are discussed, along with neonatal seizures and seizure mimics, which are common in pediatric populations.

Evaluation of pediatric patients in new-onset seizure clinic (NOSc)

AIM

We evaluated the clinical and demographic features of children presenting with unprovoked seizures at a regional new-onset seizure clinic (NOSc).

METHODS

We retrospectively reviewed charts of 492 consecutive patients evaluated in the NOSc at the Childrne's Healthcare of Atlanta RESULTS: Nonepileptic events (NEE) were diagnosed in 102 (24%) and epileptic seizures in the remaining 326 (76%). Patients with NEE were younger than patients with epileptic seizure (5.0 vs. 7.4 years). Except for headache which occurred more frequently in NEE (14% vs. 6%), frequencies of comorbidities were similar in groups with NEE and epileptic seizure. Electroencephalogram (EEG) was performed in 98%, and finding was abnormal in 51%. Brain magnetic resonance imaging (MRI) was performed in 55%, and finding was abnormal in 15%. An electroclinical epilepsy syndrome was diagnosed in 42%. Antiseizure medication was started in 25% with first seizure and in 77% with recurrent seizures.

INTERPRETATION

For children with newly-presenting seizures, a regional NOSc provided efficient, timely diagnosis and appropriate evaluations and treatment. Timely recognition of NEE resulted in fewer unnecessary evaluations and treatment for a quarter of referred patients whereas identification of the specific types of seizures and epilepsy allowed appropriate use, including deferral, of neuroimaging and guided treatment selection.

Indications for epilepsy monitoring in pediatric and adolescent health care

Seizures present in childhood with infinite diversity. History alone may suffice for diagnosis in some cases; more often additional evidence is needed to clarify events of concern. Electroencephalography (EEG) is a primary methodology used for seizure identification and management. Pediatric and adolescent health care providers are increasingly asked to make decisions about when and how to refer patients for eventual monitoring and must then be able to confidently interpret any resulting report(s). Comprehensive literature review was undertaken to provide a succinct and up-to-date overview aimed at general and subspecialty non-neurologist pediatric and adolescent health care providers to not only convey a solid general understanding of EEG and what it entails for patients and their families, but also foster a deeper understanding of the indications for monitoring-and how to interpret documented findings. In plain language this resultant guide reviews EEG basics, provides a crash course in the various types of EEG available, discusses broad indications for epilepsy monitoring, guides counseling and management for patients and their families both before and after EEG, and ultimately aids in the interpretation of both findings and prognosis. This review should allow both primary and subspecialty non-neurologic pediatric and adolescent health care providers to better identify when and how to best utilize EEG as part of a larger comprehensive clinical approach, distinguishing and managing both epileptic and nonepileptic disorders of concern while fostering communication across providers to facilitate and coordinate better holistic long-term care of pediatric and adolescent patients.

Sounds unrealistic: an adolescent girl with anorexia nervosa consumes 19 L of fluid in a few hours: what happens to the physiology?

BACKGROUND

Adolescents with eating disorders (EDs) may present not only with abnormal eating behaviors but also with abnormal drinking behaviors varying widely. These behaviors include water loading to cheat on weight measurements, to feel full and suppress appetite and/or to induce vomiting; as well as restricting fluid intake in addition to food.

METHOD

We present a 16-year-old female adolescent with anorexia nervosa restrictive type and major depressive disorder who was hospitalized due to acute food refusal and developed generalized seizures due to dilutional hyponatremia in consequence of consuming excessive amount of water. Psychiatric diagnoses were made according to 'The Diagnostic and Statistical Manual of Mental Disorders' (5th ed.; DSM-5) criteria.

RESULTS

After starting nutritional rehabilitation with a low calorie meal plan to avoid refeeding syndrome, a weight gain of 2 kg was noted in the second day of hospitalization. At the bedside visit, she was observed in a disoriented manner and consecutively in seconds, lost consciousness with a generalized tonic-clonic seizure lasting 2 min. Her serum sodium level was measured as 116 mEq/L, which was normal at the time of admission. It was later learned that she secretly ingested 19 L of water in a short amount of time. She regained consciousness and no further seizures were observed after intravenous sodium deficit correction and fluid restriction therapy. Her serum sodium level was normalized (137 mEq/L) within 12 h.

CONCLUSION

A thorough clinical assessment of hydration and drinking behaviors as well as eating behaviors is essential for patients with EDs to avoid serious medical complications with high mortality and morbidity during follow-up. It is interesting that this amount of fluid consumption in such a short period of time did not present to the clinic with vomiting, gastric dilatation or bowel irrigation symptoms in a case with acute food refusal and restriction for a year, instead absorbed very quickly causing acute and severe symptomatic hyponatremia with generalized seizures.

Recurrence of First Afebrile Unprovoked Seizure and Parental Consanguinity: A Hospital-Based Study

PURPOSE

The aim of the current study was to determine the incidence, clinical characteristics, and risk factors associated with the recurrence of first unprovoked seizure in children.

METHODS

A retrospective, observational study was conducted at King Abdullah University Hospital in Jordan. Children aged from 1 month to 16 years old who attended the hospital between January 2013 to December 2017 were evaluated on the basis of medical records, from the first visit and for a 1-year follow-up period.

RESULTS

During the study period, a total of 290 cases with first unprovoked seizure were included. The incidence of first unprovoked seizure was 441 cases per 100 000 patient visits to the pediatric clinic. More than half of the cases developed a second attack (55.3%). Children with parental consanguinity were almost 3 times more likely to develop a second attack of seizure compared to those without parental consanguinity (odds ratio [OR] = 2.785, 95% confidence interval [CI] = 1.216-6.378, P = .015) and patients who had a history of focal type of seizure were almost twice as likely to develop seizure recurrence (OR = 1.798, 95% CI = 1.013-3.193, P = .045).

CONCLUSIONS

The current results showed a high incidence of first unprovoked seizure among children in Jordan. Parental consanguinity and focal seizure were associated with the increased risk of recurrent attack. This finding highlights the need for public education regarding the outcomes of parental consanguinity to improve the patient's quality of life.

Abdominal Epilepsy: A Rare Cause of Unexplained Abdominal Pain

Abdominal epilepsy (AE) is a very rare diagnosis; it is considered to be a category of temporal lobe epilepsies and is more commonly a diagnosis of exclusion. Demographic presentation of AE is usually in the pediatric age group. However, there is recorded documentation of its occurrence even in adults. AE can present with unexplained, relentless, and recurrent gastrointestinal symptoms such as paroxysmal pain, nausea, bloating, and diarrhoea that improve with antiepileptic therapy. It is commonly linked with electroencephalography (EEG) changes in the temporal lobes along with symptoms that reflect the involvement of the central nervous system (CNS) such as altered consciousness, confusion, and lethargy. Due to the vague nature of these symptoms, there is a high chance of misdiagnosing a patient. We present the case of a 20-year-old man with AE who was misdiagnosed with psychogenic abdominal pain after undergoing multiple investigations with various hospital departments.

Intoxication From Accidental Marijuana Ingestion in Pediatric Patients: What May Lie Ahead

Marijuana is the most commonly used illicit drug. In young children, there are relatively few reports in the literature of acute marijuana intoxication. Here, we describe the case of a previously healthy 2-year-old girl who presented with clinical seizures. A urine toxicology screen showed elevated levels of tetrahydrocannabinol. The source of the drug was not identified. After a short stay in the hospital, the patient fully recovered with only supportive measures. In this report, we also summarize all domestic and international cases of marijuana intoxication in children younger than 6 years, in conjunction with the number of exposures in children of similar age identified by the US National Poison Data System. This report highlights what is becoming a more common problem. As cannabis continues to be decriminalized across the United States with its increasingly diverse modes of delivery, the potential for accidental exposure in infants and young children also rises. Clinicians should now routinely consider marijuana intoxication in children who present with acute neurological abnormalities.

Risk-Stratification of Children Presenting to Ambulatory Paediatrics with First-Onset Seizures: Should We Order an Urgent CT Brain?

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.

A reappraisal of the value of video-EEG recording in the emergency department

Introduction: Some neurologic conditions that can quickly and with low costs be recognized, classified and treated thanks to the availability of an EEG recording in an emergency setting. However, although considered a cheap, not invasive, highly accurate diagnostic investigation, still today, an EEG recording in emergency, in real time during the event paroxysmal ictal phase, is not yet been become a routine.Areas covered: This review will cover the role and utility of EEG recording in the emergency setting, both in emergency department and intensive care unit, in adult and pediatric age, in people admitted for status epilepticus (convulsive or non-convulsive), paroxysmal non-epileptic events, or other conditions/diseases presenting with mental status changes.Expert opinion: The prompt recognition of some specific EEG-patterns can permit an immediate and appropriate therapeutic choice with the resolution of dramatic clinical pictures, which, if not recognized, sometimes could result in severe prognostic events with high mortality or neuropsychiatric disability. It is important in the next future, to improve the availability of these EEG digital continuous monitoring, which should be widely used in emergency settings, developing moreover tools and techniques permitting also review, analysis and EEG-reporting by experts who can work away from the hospital.