Is Neuroimaging Necessary After a First Complex Febrile Seizure? AAP Grand Rounds 2012;28;16 DOI: 10.1542/gr.

28-2-16

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EMERGENCY MEDICINE

Is Neuroimaging Necessary After a First Complex Febrile Seizure?

Source: Kimia AA, Ben-Joseph E, Prabhu S, et al. Yield of emergent neuroimaging among children presenting with a first complex febrile seizure. Pediatr Emerg Care. 2012;28(4):316-321; doi:10.1097/PEC.0b013e31824d8b0b o estimate the risk of PICO intracranial pathology Question: Among children treated in the among children presentemergency department for a first complex ing with their first complex fefebrile seizure, what is the risk of intracranial brile seizure (CFS), investigators pathology requiring immediate intervention? Question type: Diagnosis from Childrens Hospital Boston Study design: Retrospective cohort reviewed data on emergency department (ED) visits between 1995 and 2008 for patients aged 6 to 60 months presenting with their first CFS. A CFS was defined as a seizure which lasted >15 minutes, had focal features, or recurred within 24 hours, or a cluster of seizures. Patients with a history of an underlying seizure disorder, previous underlying illness associated with seizures or immunodeficiency, recent trauma or neurosurgical intervention, or a ventriculoperitoneal shunt were excluded. CFS patients were identified through computerized screening of electronic and written physician notes, with records subsequently manually reviewed for inclusion. Data extracted from the charts of identified CFS patients included seizure features, physical examination findings, laboratory and imaging studies, diagnosis, and disposition. The primary outcome of interest was the incidence of intracranial pathology requiring emergent neurosurgical or medical intervention Among 650,993 ED visits occurring during the study period, 526 children with a first CFS were identified. Among CFS cases, the median patient age was 17 months, 83% had never experienced a febrile seizure, and 52% were admitted to the hospital after ED evaluation. Most had 1 (73%) or 2 (25%) features of a CFS. A diagnosis of bacterial meningitis was rare (3/526, 0.5%). Neuroimaging was performed in 282 (54%) patients (268 had head computed tomography). Of those imaged, significant findings were detected in 4 children (2 with intracranial hemorrhage, 1 with acute disseminated encephalomyelitis, and 1 with abnormalities in the cerebellum), yielding a risk of intracranial pathology of 0.8% (95% CI, 0.2%-2.1%). Three of the 4 children had other findings (eg, bruises) which may have aided the clinician in determining the need for imaging. Of the 227 patients who met the CFS definition simply because they had more than 1 seizure in 24 hours, none had clinically significant intracranial pathology. The authors conclude that very few children with a first CFS have clinically significant intracranial pathology in the absence of other signs and symptoms, and note that patients who have more than 1 seizure in 24 hours that lasts 15 minutes and has no focal features are at particularly low risk.

Commentary by

Michelle Stevenson, MD, MS, FAAP, Pediatric Emergency Medicine, University of Louisville, Louisville, KY
Dr Stevenson has disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.

The authors of this study address an important clinical question for which there is a paucity of evidence. Although the guidelines published by the American Academy of Pediatrics concerning the management of a first simple febrile seizure recommend against routine neuroimaging,1 there are no recommendations to guide management of CFSs. This study has a number of limitations. Most notably, only half of the identified children with CFS included in the study underwent neuroimaging. None of the children in whom neuroimaging was not performed returned to Childrens Hospital Boston with a diagnosis of intracranial hemorrhage or mass, but these children could have subsequently been treated at other hospitals. If the risk of clinically significant intracranial pathology is calculated only among the subset of CFS patients who received emergent neuroimaging, it rises to 1.5% with an upper boundary of the 95% CI of 4%, which may be above the threshold to test for some providers. Regardless, this study should make clinicians think twice about ordering emergent neuroimaging for children with new-onset CFS when there are no other concerning signs and symptoms on physical examination, especially for children who experience a second febrile seizure within 24 hours that is neither prolonged nor focal.
References
1. American Academy of Pediatrics. Subcommittee on Febrile Seizures. Pediatrics. 2011;127(2):389-394; doi:10.1542/peds.2010-3318

Key words: complex febrile seizure, child, neuroimaging

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Is Neuroimaging Necessary After a First Complex Febrile Seizure? AAP Grand Rounds 2012;28;16 DOI: 10.1542/gr.28-2-16

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including high resolution figures, can be found at: http://aapgrandrounds.aappublications.org/content/28/2/16 This article cites 2 articles, 1 of which you can access for free at: http://aapgrandrounds.aappublications.org/content/28/2/16#BIBL This article, along with others on similar topics, appears in the following collection(s): Emergency Medicine http://aapgrandrounds.aappublications.org/cgi/collection/emergency_m edicine_sub Information about reproducing this article in parts (figures, tables) or in its entirety can be found online at: /site/misc/Permissions.xhtml Information about ordering reprints can be found online: /site/misc/reprints.xhtml

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