Infantile spasms: A proposal for a staged evaluation

The purpose of this study was to determine whether a staged, algorithmic ev aluation of infantile spasms could be developed to minimize patient discomf ort, treatment delay, and overall costs. A retrospective chart review of pa tients diagnosed with infantile spasms at the authors' institution during a 10-year period was performed, with 29 patients identified; 28 charts were reviewed. By history and physical examination, 21 were classified as sympto matic and seven as cryptogenic, Of the 21 symptomatic patients, 13 had a kn own etiology at presentation; with further testing the specific etiology wa s determined in two more. Two in the cryptogenic group were reclassified on the basis of neuroimaging findings. Evaluations included neuroimaging (27, 15 abnormal), cerebrospinal fluid studies (nine, all normal), comprehensiv e metabolic studies (17, all normal), chromosomal analysis (11, two abnorma l), and ophthalmologic evaluation (27, six abnormal). The average cost of t he studies per patient was $5,076 at the authors' institution. Etiologic yi eld was increased by 20% with neuroimaging, The other investigations either confirmed a known etiology or were noncontributory, On the basis of these findings, the authors propose an algorithm for a more focused evaluation of infantile spasms. Using the algorithm, the authors suggest directly procee ding to therapy in patients with specific etiologies determined by history and examination, Further evaluation should start with neuroimaging. Subsequ ent evaluations should be on the basis of those results. The authors estima te a potential 60-90% reduction in total costs if this algorithm is applied . (C) 1998 by Elsevier Science Inc. All rights reserved.