E Emergency brain computed tomography in children

with seizures: Who is most likely to benefit?

Marjorie A. Garvey, MBBCh, William. D. Gaillard, MD, Jerome A. Rusin, MD, Daniel Ochsenschlager, MD,
Steven Weinstein, MD, J. A. Conry, MD, D. Rene Winkfield, CPNP, and L. Gilbert Vezina, MD

roimaging before being discharged from

Objective: To determine whether the recently published guidelines on neu- the ED. For all other patients, an ap-
roimaging in patients with new-onset seizures are applicable to children. pointment for neuroimaging should be
Methods: We carried out a retrospective analysis of 107 neurologically normal included in the ED disposition except
when follow-up cannot be ensured, in
children (excluding children with simple febrile seizures) who had undergone
which case scanning should be done be-
neuroimaging when they presented to the emergency department with a possi-
fore discharge.
ble first seizure.
Results: Eight of the 107 children had nonepileptic events (gastroesophageal
CT Computed tomography
reflux, syncopal event, rigor). Of the remaining 99 children, 49 had provoked
ED Emergency department
seizures (complicated febrile seizure, meningo-encephalitis, toxic or metabolic MRI Magnetic resonance imaging
abnormalities), and 50 had unprovoked seizures. A total of 19 children had
brain abnormalities identified on computed tomography (CT) scan; 7 received
further investigation or intervention as a result of CT scan findings (2 with tu- It is unclear whether these guidelines
mors, 3 with vascular anomalies, 1 with cysticercosis, and 1 with obstructive hy- hold for children. The recommendations
cited above were formulated after a re-
drocephalus). CT scan abnormalities requiring treatment or monitoring were
view of 51 articles regarding the use of
more frequently seen in children with their first unprovoked seizure (P < .01)
emergency neuroimaging in patients pre-
and in those children whose seizure onset had been focal or who had focal ab-
senting with seizures.8 Four of the 51
normalities identified on postictal neurologic examination (P < .04). studies reviewed included children, and
Conclusion: In a child, a seizure in the setting of a fever rarely indicates the only 2 dealt specifically with new-onset
presence of an unexpected CT scan lesion requiring intervention. (J Pediatr seizures. In the report by McAbee et al,9
1998;133:664-9) CT scanning was performed within 2
weeks of a new-onset seizure. In this
study CT scan abnormalities were found
in 6 (7.5%) of 81 neurologically normal
Approximately 30% of adults with a first lished guidelines regarding the use of children, 4 of whom required further in-
seizure will have brain abnormalities de- neuroimaging in patients presenting to vestigation and treatment. The second
tected by computed tomography scan.1-5 the emergency department with new- study10 reported no structural brain ab-
The American College of Emergency onset seizures.6,7 These guidelines identi- normalities in 25 children who had a CT
Physicians, American Academy of Neu- fy certain factors that point to an in- or magnetic resonance imaging scan dur-
rology, American Association of Neuro- creased risk for a CT scan abnormality ing investigation of their first seizure.
logical Surgeons, and American Society that may require intervention. These fac- In some hospitals it is standard to per-
of Neuroradiology have recently pub- tors can be found in the history (age over form a CT scan on every child in the ED
40 years, persistent headache, or seizures with a first seizure. However, the high
From the Departments of Neurology, Diagnostic Imaging with focal onset); results of physical ex- cost of emergency CT scanning, its low
and Radiology, and Emergency Medicine, Childrens Na- amination (new focal deficits, persistent- yield in children with new-onset
tional Medical Center, Washington, DC. ly altered mental status, fever); and ini- seizures, and the increased use of MRI in
Submitted for publication Dec 5, 1997; revision re- tial laboratory results (no identified the investigation of seizures prompted us
ceived June 10, 1998; accepted Sept 4, 1998.
metabolic or toxic cause for the seizure). to reevaluate the true benefit of emer-
Reprint requests: W. D. Gaillard, MD, Department
of Neurology, Childrens National Medical Center,
Based on these guidelines, clinical policy gency CT scanning in our facility. Our
111 Michigan Ave, NW, Washington, DC 20010. of the American College of Emergency aims were to investigate whether CT
Copyright 1998 by Mosby, Inc. Physicians recommends that patients imaging had contributed to the manage-
0022-3476/98/$5.00 + 0 9/21/94318 with these risk factors should have neu- ment of new-onset seizures and to identi-

664
THE JOURNAL OF PEDIATRICS
VOLUME 133, NUMBER 5
fy risk factors associated with CT scan
abnormalities that required intervention.
We therefore wished to ascertain
whether the recently published guide-
lines were applicable to previously neu-
rologically normal children with a first
seizure.
PATIENTS AND
METHODS
We identified, retrospectively, all chil-
dren without a history of neurologic ill-
ness who presented to the ED of Chil-
drens National Medical Center and had
a CT scan because of a first seizure be-
tween July 1993 and June 1994. Two
methods were used:
1. From the diagnostic related groups,
we identified all children with a
first time seizure who had a CT
scan as part of the investigation in
the ED.
2. From the Neuroimaging Depart-
ment log book, we reviewed the
charts of all children who had re-
ceived a CT scan because of a
seizure and identified those with
new-onset seizures.
We used both these methods in order to
include any children with structural brain
lesions (tumors, arteriovenous malforma-
tions) who had presented with a seizure
to the ED but whose diagnostic related
group reflected the underlying diagnosis
rather than the initial symptom.
Excluded from the study were all pa-
tients with a previously identified under-
lying neurologic disorder (eg, cerebral
palsy, ventriculoperitoneal shunt) or sys-
temic disorder such as hepatic or renal
failure or systemic lupus erythematosus.
Also excluded were patients with a pre-
viously diagnosed neurocutaneous syn-
drome, brain tumor, or other underlying
malignancy. Because children with sim-
ple febrile convulsions do not routinely
receive CT scans in our ED, we also ex-
cluded children between the ages of 6
months and 5 years who in the setting of
a febrile illness had a brief (<20 minutes),
generalized seizure and normal findings
on postictal neurologic examination.
From the ED records, inpatient charts,
and outpatient records, the following in-
formation was recorded: age at the time of
the episode, antecedent factors from the
medical history, prodromic symptoms,
events immediately before the episode,
description and duration of the episode,
evidence of abnormal neurologic signs in
the postictal period, and results of investi-
gations done in the ED (laboratory tests
and CT scans). Any further investigations
the child received as a result of the CT
scans, such as MRI scans and an-
giograms, were documented. If the child
had undergone surgery, this was also
noted, as well as any pathology reports.
All children had CT scans before inpa-
tient admission or discharge from the ED.
Every scan was performed on a General
Electric 9800 scanner with axial 5-mm im-
ages through the posterior fossa and 10-
mm images above this. Contrast was ad-
ministered only for better definition of an
abnormal noncontrast CT scan or when a
diagnosis of encephalitis was suspected.
All CT scans were read by 1 of 2 pediatric
neuroradiologists (J.A.R or L.G.V.).
With the information obtained from the
history, examination, and results of the
laboratory investigations performed in the
ED, the children were assigned a seizure
diagnosis. Children were then divided into
groups according to whether they had a
provoked seizure (complicated febrile
seizure or seizure associated with cerebral
palsy, encephalopathy, anoxia, trauma, or
administration of a vaccine) or an unpro-
voked seizure. Children had unprovoked
seizures if the history or laboratory inves-
tigations did not reveal acute factors that
may have contributed to the seizure.
Information obtained by CT scanning
was considered to have contributed to the
management of the seizure if the child re-
ceived either further investigation or treat-
ment because of the CT scan abnormality.
Odds ratio (with 95% CIs) and Fishers
exact tests were performed when appro-
priate. All reported P values are 2-tailed.
RESULTS
A total of 107 children with a first
seizure had a CT scan while being as-
sessed in the ED. The diagnostic related
group identified 74 children, and the CT
log book revealed an additional 33. Sev-
GARVEY ET AL
enteen children had contrast-enhanced
CT scans in addition to the noncontrast
scan. Five of these children received con-
trast for better definition of an abnormal-
ity on the noncontrast scan; the remain-
ing 12 received contrast because of
suspected encephalitis. Electrolytes were
measured in all children, though calcium
and magnesium levels were measured in
only 80 (75%). Lumbar punctures were
performed in 69 (64%) of the children.
Seizure Diagnosis
The episodes in 8 children were not
considered to be seizures (gastro-
esophageal reflux in 6, rigor in 1, and syn-
cope in 1), and these were excluded from
further analysis. An acute precipitating
factor was identified in 49 children (pro-
voked seizure). Fifty children had no fea-
tures, determined by either history or lab-
oratory tests, that could have provoked
their seizure (unprovoked seizure).
Provoked Seizures
TOXIC-METABOLIC FACTORS. One 5-
month-old child had a positive cocaine
screen. Ten children had electrolyte ab-
normalities, which may have precipitated
the seizures. Five children had hypocal-
cemia with calcium levels ranging be-
tween 1.05 and 1.6 mmol/L (4.2 to 6.5
mg/dL). One child had transient hy-
poparathyroidism, and another had rick-
ets, but no cause could be established in
the remaining 3 patients. Five children
had hyponatremia with sodium levels be-
tween 111 and 122 mmol/L. Viral gas-
troenteritis and diluted formula feeds
were responsible for the hyponatremia in
2 children, but no cause could be identi-
fied in the remaining children. The mean
age of the 10 children with electrolyte ab-
normalities was 14 months (standard de-
viation, 21 months; range, 1 month to
5.6 years), with a median age of 6 months.
Two children in this group were lethargic,
and 2 were excessively irritable (includ-
ing the child with a positive cocaine
screen), but the other children had nor-
mal findings on neurologic examination.
SEIZURES ASSOCIATED WITH FEVER.
Of the 34 children who had a fever in as-
sociation with the seizure, 12 had a sus-
665
 GARVEY ET AL THE JOURNAL OF PEDIATRICS
NOVEMBER 1998

Table. CT abnormalities in 19 children with new-onset seizures

Case no. Age Seizure onset Duration (min) CT scan Category Diagnosis
9 2 y 6 mo CPS 1-5 Asymmetric TH P Complicated FC
13 10 mo FL 1-5 Asymmetric TH, P Hypomelanosis of Ito
prominent Rt frontal sulci
14 3 y 2 mo CPS 5-20 Rt frontal superficial Hge U Cavernous angioma
15 14 y CPS 1-5 Lt frontal lobe lesion U AVM
18 1 y 2 mo FR 5-20 Mild central atrophy P Complicated FC
19 7 mo G 1-5 Cerebral angioma P Toxic-metabolic
20 14 y CPS 1-5 Rt frontal encephalomalacia U Encephalomalacia
29 9 mo G >20 Leptomeningeal enhancement P Partially treated
meningitis
31 13 y CPS 1-5 Cysticercosis U Cysticercosis
38 2y 10 mo G 1-5 PVL U Unprovoked
67 1 y 4 mo CPS >20 Rt parietal Hge U AVM

68 2 y 4 mo G >20 Obstructive hydrocephalus U Hydrocephalus

80 5 mo G <1 Lt parietal tumor U PNET

84 2 y 10 mo FR 5-20 PVL U Unprovoked

85 1 y 8 mo G 5-20 Mild hydrocephalus P Encephalitis
87 12 y 6 mo FR 1-5 Lt central gyrus tumor U Low-grade glioma
88 1 y 2 mo G >20 CB venous angioma P Complicated FC
90 1 mo FR 5-20 Meningoencephalitis P Enteroviral encephalitis
104 7 mo G 1-5 PVL P Toxic-metabolic

CPS, Complex partial seizure; TH, temporal horn of the lateral ventricle; P, provoked; FC, febrile convulsion; FL, Left focal seizure; Rt, right; Exam, neurologic
examination; Hge, hemorrhage; U, unprovoked; Lt, left; AVM, arteriovenous malformation; FR, right focal seizure; G, generalized seizure; Lab, laboratory results;
Dec, decreased; Tx, treatment; CSF, cerebrospinal fluid; WC, white cell; Prot, CSF protein (g/L [mg/dL]); Gluc, CSF glucose (mmol/L [mg/dL]); PVL, periventric-
ular leukomalacia; PNET, primitive neuroectodermal tumor; Path, pathology report; CB, cerebellar; Inc, increased.

pected meningoencephalitic process as
indicated by history or examination (eg,
altered mental status). Of the remaining
22 children, 5 had convulsions associated
with a fever but did not meet the age cri-
teria for simple febrile convulsion (6
months to 5 years), and 17 children had
a complicated febrile convulsion.
A diagnosis of meningoencephalitis
was confirmed in 7 patients, though an
infective or toxic agent was positively
identified in only 3 (enterovirus, cat-
scratch disease, and shigella enteritis). In
addition to the nonfocal neurologic signs
that had suggested the encephalitic
process, one child had asymmetric deep
tendon reflex, and another child had ab-
normal skin pigmentation. A diagnosis of
hypomelanosis of Ito was confirmed in
this latter child by later MRI studies.
MISCELLANEOUS FACTORS. The re-
maining 4 children had events that might
have played a causal role in seizure gene-
sis. One 1.5-year-old child had a seizure
3 days after receiving a diptheria-pertus-
sis-tetanus vaccination, 2 children (1 year
and 2 years old) had prolonged seizures
after breath-holding spells, and a 6-year-
old child had a generalized seizure within
1 hour of minor head trauma not associ-
ated with loss of consciousness.
Nine (18%) of the 49 children with
provoked seizures had CT scan abnor-
malities, though none required interven-
tion for the abnormalities detected.
Unprovoked Seizures
Fifty children had no features identified,
either by history or laboratory tests, which
could have provoked their seizures. Ages
ranged from 2 weeks to 16 years, with a
mean of 5 years 1 month ( 5 years) and a
median age of 3 years. Three children had
prior events that were not recognized as
seizures in the days or weeks before their
ED visit. Seven children had focal abnor-
mal findings on neurologic examination
(focal weakness, unilateral Babinski sign,
or asymmetric deep tendon reflex) after
the seizure (Todds paresis in 6 and a per-
sistent abnormality in 1). Two children
had factors in the history that pointed to a
possible underlying cerebral lesion. The
first was a 12-year-old girl who had re-
cently moved with her family to the Unit-
ed States from a country where cysticer-
cosis is endemic, and the second was a
14-year-old girl who had received treat-
ment for a brain abscess 2 years earlier.
CT scan abnormalities were identified in
10 children, 7 of whom required further
investigation or treatment (Table).
Seizure Type
A history of a generalized convulsion
was identified in 62 patients. The re-
maining 37 children had a focal onset to
their seizures; 8 of these children had a

666
THE JOURNAL OF PEDIATRICS
VOLUME 133, NUMBER 5
Comments
Apnea at 2 wk
Febrile for 2 d; multiple episodes;
Exam: abnormal skin pigmentation
MRI: Rt frontal Hge; surgical resection
MRI: AVM; surgical resection
Exam: lethargy; Lab: Dec Na+ (119)
Brain abscess Tx at 12 y of age
Exam: intubated; Lab: CSF, WC 56;
Prot: 0.56 [56]; Gluc: 1.65 [30]
Treated with praziquantel
Febrile seizure at 1 y 10 mo
Exam: Lt hemiparesis;
MRI: Rt parietal Hge; surgical resection
Hydrocephalus; no surgical intervention
Exam: Rt Babinski; MRI: tumor;
surgical resection; Path: PNET
Exam: fever, irritable, Varicella
MRI: tumor; surgical resection
Multiple episodes
Exam: irritable, Inc tone; lethargic
Exam: fever, Inc tone, irritable;
Lab: Dec Na+ (116)
complex partial seizure. Eleven (30%) of
the 37 with focal seizures had CT scan
abnormalities, and 5 (13.5%) of these re-
ceived treatment for the cerebral lesion
detected by the CT scan. Eight (13%) of
the 62 children with generalized seizures
had CT scan abnormalities. Only 2 (3%)
received treatment or further investiga-
tion based on the result of the CT scan.
Neurologic Examination
Twenty children had abnormalities
identified on the postictal neurologic ex-
amination. An additional 3 children were
sedated after intubation on arrival to the
ED, making it difficult to assess their neu-
rologic status. Five (25%) of these 20 chil-
dren had abnormal findings on CT scans.
Ten children had focal neurologic abnor-
malities, and of these, 2 had lesions detect-
ed by CT scan; both required urgent or
timely surgical treatment. CT scan abnor-
malities were found in 3 of the 13 children
who either had nonfocal neurologic ab-
normalities (confusion, lethargy, or exces-
sive irritability) or who had been sedated;
none of these required additional treat-
ment based on the CT scan finding.
Magnetic Resonance Imaging
Thirty-three children had MRI scan-
ning within 6 months of the initial presen-
tation to the ED with their first seizure.
MRI findings were identical to the CT
scan findings in 18 children, and in 4 chil-
dren the MRI scan provided better defin-
ition of a lesion before surgery. Eleven
children had MRI scan findings that
were different from the CT scan results,
mostly mild increases in ventricular size
(3) or evidence of atrophy (4); none of
these undetected cerebral lesions re-
quired medical or surgical intervention.
Analysis
Children with unprovoked seizures
had a significantly higher number of im-
portant CT scan abnormalities compared
with those with provoked seizures, re-
gardless of the cause (Fishers exact test,
P = .01). CT scan abnormalities requir-
ing intervention were also more fre-
quently seen in children who had either
a focal onset of their seizure or focal find-
ings on neurologic examination (Fishers
exact test, P = .04; odds ratio = 6.41, 95%
CI = 1.03, 39.7).
DISCUSSION
A total of 19 (19.4%) of 99 children
who presented to the ED with a first
seizure had a CT scan abnormality,
though only 7 (7%) required further in-
tervention or referral based on the CT
findings. Thus 93% of the CT scans
added little helpful information. CT scan
abnormalities of therapeutic importance
were most prevalent in children with un-
provoked seizures and in those with ei-
ther a focal seizure or focal findings on
postictal neurologic examination. This is
in keeping with the findings in adults.8
Unlike studies in adults, in this study
CT scan lesions were not common in chil-
dren who had seizures in the setting of a
febrile illness. Just under half of the chil-
dren in this study had seizures provoked
GARVEY ET AL
by febrile illnesses or metabolic abnor-
malities. Management of these cases
should be directed at the febrile illness or
the underlying cause of the seizure, but
CT scans are unlikely to provide addi-
tional useful information. As in adults,
however, a CT scan should be performed
in any child who has persistent altered
mental status or other signs of increased
intracranial pressure.7 Neuroimaging is
not necessary to diagnose an intracranial
infective process (meningitis, encephali-
tis); and when this is suspected, antibi-
otics (in the case of bacterial meningitis),
anti-epileptic medication for seizures, and
supportive treatment for increased in-
tracranial pressure should not be delayed
while awaiting either the results of the
CT scan or lumbar puncture.
Although we did not include children
with simple febrile convulsions in this
study, some children were assigned a di-
agnosis of complicated febrile convulsion
after the clinical and laboratory assess-
ments in the ED. Such a diagnosis can-
not be made without a careful search for
disorders that may cause focal, pro-
longed, or multiple seizures in the setting
of a fever.11-13 In keeping with the study
of al-Qudah,14 our results suggest that
these children are unlikely to have unex-
pected intracranial lesions that require
intervention. However, further study is
warranted to determine the true inci-
dence of intracranial pathology in this
group of patients.
Three children in this study had fac-
tors in the history or on examination that
suggested a specific, previously undiag-
nosed structural or infective cerebral
process. All 3 had abnormal findings on
CT scan: 2 had a structural cerebral dis-
order, which did not require interven-
tion; and the third child, who had cys-
ticercosis, was treated as an outpatient.
Two of these children received MRI
scans as outpatients; one scan showed
the previously seen cysticercosis lesion in
more detail, and the other defined an
area of heterotopia. As in these children,
when the history or examination of a
child with a new-onset seizure points to
an underlying disorder associated with
intracranial pathology, a neuroimaging
study should be performed. In some of
these cases, however, it may be possible
667
 GARVEY ET AL
to perform outpatient neuroimaging,
avoiding an emergency CT scan.
Thirty-three patients in this study had
subsequent MRI scans. Eleven had le-
sions not previously seen on the CT scan.
None required urgent intervention,
though the MRI in one child established
a diagnosis of a neurocutaneous disorder
(hypomelanosis of Ito). Further study is
necessary to determine the comparative
usefulness of MRI or CT scans and their
respective roles in the investigation of
new-onset seizures.
It is important to note that all the med-
ical records of each child were reviewed
for this study. These included the initial
ED assessment and any subsequent eval-
uations by the child neurology fellow.
Ordinarily, there is a delay of some hours
in obtaining the CT scan; for that reason,
the admitting physician will usually ob-
tain the history and perform the exami-
nation before the scan is done. However,
it was not possible to accurately deter-
mine the sequence of events for the pa-
tients in this study. Therefore it is possi-
ble that in a number children, the CT
scan results were known before the neu-
rologic examination. This may have bi-
ased the examiner toward finding postic-
tal localizing neurologic signs in children
with a focal cerebral lesion. Obtaining a
history of a focal seizure is less likely to
have been influenced by the foreknowl-
edge of a focal lesion on the CT scan, but
it is possible that caregivers were better
able to recall details of the seizure
episode with each successive description.
Despite these potential biases, our find-
ings are similar to previous reports of
new-onset seizures in adults and chil-
dren. Future studies that ensure stan-
dardized examinations and control the
information available at the time of histo-
ry-taking and examination will help clar-
ify these problems.
Three other studies have reported data
on the usefulness of CT scans in new-
onset seizures in children. It is difficult
to compare this study with 2 of these be-
cause their study populations included
children with simple febrile convul-
sions10 or with conditions carrying a
high risk of intracerebral lesions.15 How-
ever, the study population in this study
and that of McAbee et al9 are compara-
668
ble. Our study reports a percentage of
children who required urgent treatment
because of CT scan abnormalities similar
to that reported in the study by McAbee
et al, yet the total number of children
with CT scan abnormalities is higher
(19% in this study compared with 7.5%).
The policy of our neurology department
is that all children with a first time
seizure have a CT scan and (regardless
of the CT scan results) be admitted to the
hospital. Because of the retrospective de-
sign of our study, it is possible that some
neurologically normal patients with
brief, generalized afebrile seizures with-
out further sequelae did not have a CT
scan. In addition, a number of children
with uncomplicated seizures may have
presented to an outpatient clinic, thus
bypassing the ED during the study peri-
od. These children are most likely to
have normal scan findings, which might
explain the higher proportion of abnor-
mal CT scan findings in this study com-
pared with earlier reports.
As shown in prior studies,5,16 our re-
sults show that unexpected therapeuti-
cally important abnormal CT scan re-
sults are most frequently found in
patients with either focal seizures or
focal postictal neurologic deficits. How-
ever, it is important that physicians be
aware of the subtle and at times bizarre
presentation of partial seizures in chil-
dren.16,17 Some children in this study
with complex partial seizures were undi-
agnosed for up to 2 weeks because of the
unusual nature of the paroxysm; in oth-
ers, a brief change in behavior lasting a
few seconds preceded a generalized
seizure. The localizing signs identified in
the patients in this study were also sub-
tle: new weakness and clumsiness of one
arm, dragging of one leg, positive Babin-
ski sign. Moreover, the majority of focal
postictal neurologic signs were no longer
detectable the day after the seizure. Thus
restricting emergency CT scans to those
patients with evidence of focal seizures
in the history or on examination is only
feasible when history-taking and exami-
nation are performed within 24 hours of
the seizure. Moreover, physicians should
have a high index of suspicion for symp-
toms that suggest a focal onset to a
seizure and should perform a careful
THE JOURNAL OF PEDIATRICS
NOVEMBER 1998
neurologic examination, assigning im-
portance to even minor asymmetries.
This study demonstrates that the re-
cently published recommendations6,7 are
useful guidelines for children with some
modifications. Emergency CT scanning
is a useful investigative tool in a previ-
ously well child who presents with a first
time unprovoked seizure, particularly
when the seizure had a focal onset or the
postictal examination reveals focal ab-
normalities. Children who have their
first seizure in the setting of a fever are
unlikely to have unexpected cerebral le-
sions that require therapeutic interven-
tion. In the majority of cases, the deci-
sion to perform a CT scan can safely be
based on a detailed history and results of
careful neurologic examination. If the
history is difficult to obtain, the results of
the neurologic examination are subopti-
mal, or follow-up cannot be ensured, it
may be advisable to perform a CT scan
before discharging the child from the ED.
REFERENCES
1. Ramirez-Lassepas M, Cipolle RJ, Moril-
lo LR, Gumnit RJ. Value of computed
tomographic scan in the evaluation of
adult patients after their first seizure.
Ann Neurol 1984;15:536-43.
2. Hopkins A, Garman A, Clarke C. The
first seizure in adult life. Value of clinical
features, electroencephalography and
computerized tomographic scanning in
prediction of seizure recurrence. Lancet
1988;1:721-6.
3. Sempere AP, Villaverde FJ, Martinez-
Menedez B, Cabeza C, Pena P, Tejerina
JA. First seizure in adults: a prospective
study from the emergency department.
Acta Neurol Scand 1992;86:134-8.
4. Reinus WR, Wippold FJ, Erickson KK.
Seizure patient selection for emergency
computed tomography. Ann Emerg Med
1993;22:1298-303.
5. Schoenenberger RA, Heim SM. Indica-
tion for computed tomography of the
brain in patients with their first uncom-
plicated generalized seizure. Br Med J
1994;309:986-9.
6. Practice parameter: neuroimaging in the
emergency patient presenting with
seizure (summary statement). American
College of Emergency Physicians, Amer-
ican Academy of Neurology, American
Association of Neurological Surgeons,
American Society of Neuroradiology.
Ann Emerg Med 1996;28:114-8.
7. American College of Emergency Physi-
THE JOURNAL OF PEDIATRICS GARVEY ET AL
VOLUME 133, NUMBER 5

cians. Clinical policy for the initial ap-
proach to patients presenting with a chief
complaint of seizure who are not in sta-
tus epilepticus. Ann Emerg Med 1997;
29:706-24.
8. Greenberg MK, Barsan WG, Starkman
S. Neuroimaging in the emergency pa-
tient presenting with a seizure. Neurolo-
gy 1996;47:26-32.
9. McAbee GN, Barasch ES, Kurfist LA.
Results of computed tomography in neu-
rologically normal children after initial
onset of seizures. Pediatr Neurol 1989;
5:102-6.
10. Landfish N, Gieron-Korthals M, Weibley
RE, Panzarino V. New onset childhood
seizures. Emergency department experi-
ence. J Fla Med Assoc 1992;79:697-700.
11. Al-Eissa YA. Lumbar puncture in the
clinical evaluation of children with
seizures associated with fever. Pediatr
Emerg Care 1995;11:347-50.
12. Berger C, Braegger CP, Albisetti M,
Landau K, Nadal D. Cerebral tuberculo-
sis presenting as complex febrile convul-
sions. Neuropediatrics 1996;27:161-3.
13. Cameron PD, Wallace SJ, Munro J.
Herpes simplex virus encephalitis: prob-
lems in diagnosis. Dev Med Child Neu-
rol 1992;34:134-40.
14. al-Qudah AA. Value of brain CT scan in
children with febrile convulsions. J Neu-
rol Sci 1995;128:107-10.
15. Warden CR, Brownstein DR, Del Becca-
ro MA. Predictors of abnormal findings of
computed tomography of the head in pe-
diatric patients presenting with seizures.
Ann Emerg Med 1997;29:518-23.
16. Koprowski C, Clancy R. Clinical predic-
tors of computed tomography in epileptic
children. J Child Neurol 1986;1:145-8.
17. Daras M, Tuchman AJ, Strobos RJ.
Computed tomography in adult-onset
epileptic seizures in a city hospital popu-
lation. Epilepsia 1987;28:519-22.

BOUND VOLUMES AVAILABLE TO SUBSCRIBERS

Bound volumes of the 1998 issues of The Journal of Pediatrics are available to subscribers (only)
from the Publisher, at a cost of $91.00 for domestic, $114.49 for Canadian, and $107.00 for in-
ternational subscribers, for Vol. 132 (January-June) and Vol. 133 (July-December), shipping
charges included. Each bound volume contains subject and author indexes, and all advertising
is removed. Copies are shipped within 60 days after publication of the last issue in the volume.
The binding is durable buckram, with the Journal name, volume number, and year stamped in
gold on the spine. Payment must accompany all orders. Contact Mosby, Inc., Subscription Ser-
vices, 11830 Westline Industrial Dr., St. Louis, MO 63146-3318, USA/800-453-4351, or 314-
453-4351.
Subscriptions must be in force to qualify. Bound volumes are not available in place of a
regular Journal subscription.

669
All in-text references underlined in blue are linked to publications on ResearchGate, letting you access and read them immediately.