What is the role of neuroimaging in the diagnosis of pediatric first seizure?

Updated: Aug 16, 2018
  • Author: Shelley R Waite, MD; Chief Editor: Amy Kao, MD  more...
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The role of neuroimaging in a child with new-onset afebrile seizures is controversial. Emergent neuroimaging should be performed when there is a high clinical suspicion for a condition requiring immediate intervention, such as recent head trauma, recurrent seizures, focal or new neurologic deficits, and papilledema. Neuroimaging should also be considered if the patient has not returned to baseline. In marked distinction to the adult population seen in the emergency department, afebrile seizures in children are not commonly associated with abnormal neuroimaging.

Clinically significant neuroimaging abnormalities have been reported in 2% of children presenting with first afebrile seizure without focal features or predisposing conditions. [9] The decision of whether or not to obtain neuroimaging in these cases should be made on an individual basis, and an electroencephalogram (EEG) can be helpful. For example, a focal EEG may increase suspicion for a structural abnormality. Patients who have clearly defined epileptic syndromes, such as absence epilepsy or benign rolandic epilepsy, do not necessarily require neuroimaging. American Academy of Neurology (AAN) practice parameters recommend nonurgent imaging after initial seizure in situations in which there is a significant cognitive or motor impairment, unexplained abnormalities on the neurological examination, partial-onset seizures, an EEG inconsistent with a benign or primary generalized epilepsy, and in patients younger than 1 year. [5]

If neuroimaging is obtained, MRI is the preferred method of imaging to avoid radiation exposure while providing more detailed diagnostic information. [7] However, CT is still frequently obtained based on available resources.

According to one study, CT in the emergency department for children presenting with first seizure will change acute management in approximately 3 to 8% of patients. [10]

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