The role of brain computed tomography in evaluating children with new onset of seizures in the emergency department

Background: The purpose of neuroimaging of a patient with new onset of seiz ures is to demonstrate cause and explore the prognosis. It was recently rec ommended that emergency brain computed tomography (CT) be performed only in adult seizure patients with an increased likelihood of life-threatening le sions, i.e., those with new focal deficits, persistent altered mental statu s, fever, recent trauma, persistent headaches, history of cancer, history o f anticoagulation, or suspicion of acquired immunodeficiency syndrome. The objective of this study was to determine the diagnostic utility of emergenc y brain CT in children who present to the emergency department with new ons et of seizures. Methods: A 1-year retrospective chart review of all children who presented to the emergency department of the Schneider Children's Hospital with a new onset of seizures and who underwent CT of the brain, excluding children wi th simple febrile seizures. Results: Sixty-six patients, 34 boys and 32 girls with a mean age of 4.9 ye ars, qualified for inclusion in the study. Fifty-two patients (78.8%) had n ormal CT results and 14 patients (21.2%) had abnormal CT results. Seizure c ause was considered cryptogenic in 33 patients, of whom 2 (6%) had abnormal CT results; neither patient required intervention. Seizure cause was consi dered symptomatic in 20 patients, of whom 12 (60%) had abnormal CT results (p < 0.0001). In two patients with abnormal CT scans (both acute symptomati c), the imaging findings were of immediate therapeutic significance and wer e predictable from the clinical history and the physcial examination. None of the 13 patients with complex febrile seizure cause had an abnormal CT sc an. Patients with partial convulsive seizures were more likely to have abno rmal CT scans than patients with generalized convulsive seizures, but the d ifference was not statistically significant. Conclusions: The routine practice in many pediatric emergency departments o f obtaining brain CT scans for all patients with new onset of nonfebrile se izures is unjustified, History and physical examination are sufficient to i dentify those patients for whom such studies are likely to be appropriate. Emergent CT is not indicated for patients with no known seizure risk factor s, normal neurological examinations, no acute symptomatic cause other than fever, and reliable neurological follow-up. For these patients, referral to a pediatric neurologist for further workup, including electroencephalograp hy and the more diagnostically valuable magnetic resonance imaging, would b e more appropriate.