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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 3  |  Issue : 2  |  Page : 503-516

Role of neuroimaging and electroencephalogram in first unprovoked seizures in children from Cairo


1 Department of Radiodiagnosis, of Medicine (For Boys), Al Azhar University, Cairo, Egypt
2 Department of Pediatric, Faculty of Medicine (For Boys), Al Azhar University, Cairo, Egypt
3 Department of Clinical Neurophysiology, Faculty of Medicine, Cairo University, Giza, Egypt

Date of Submission20-Feb-2019
Date of Acceptance16-Jun-2019
Date of Web Publication24-Oct-2019

Correspondence Address:
MD Mohamed S Elfeshawy
Lecturer of Radio Diagnosis, Faculty of Medicine (for boys), Al Azhar university in Cairo, Radiology Department, Al-Hussien University Hospital, 1st Al-Azhar street, Gamaliyya, Cairo, 11311
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/sjamf.sjamf_15_19

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  Abstract 


Background First unprovoked seizure (FUS) and complex febrile seizure (CFS) are common pediatric issues of great debate with respect to the role of electroencephalogram (EEG) and neuroimaging in their diagnosis.
Aim To determine the frequency of abnormal EEG and neuroimaging results in children with FUS and CFS and to detect the correlation between EEG and neuroimaging results.
Patients and methods A total of 100 children (6 months to 12 years of age), who presented with first afebrile or CFS underwent EEG and neuroimaging (computed tomography and/or MRI). This was a prospective randomized controlled trial.
Results A total of 100 cases within the age group 6 months to 12 years were recruited. FUS was seen in 63 cases and CFS in 37 cases. Overall, 69.8% cases of FUS were generalized and 30.2% were focal. The prevalence of EEG abnormality was found in 33% of the whole studied population: 44.4% in patients with FUS and 13.5% in patients with CFS. The prevalence of neuroimaging abnormality was found in 15% of the whole studied population: 20.6% in patients with FUS and 5.4% in patients with CFS. Neuroimaging abnormality was seen more commonly in those patients who had an abnormal EEG, with a statistically significant increase in cases with FUS.
Conclusion EEG and neuroimaging abnormalities were more prevalent in children with FUSs than those with CFSs. Abnormal EEG and neuroimaging were more common in children with partial seizures than those with generalized seizures. Neuroimaging was abnormal in a significant number of children having abnormal EEG, so neurologically free patients having normal EEG can be safely discharged without neuroimaging, if follow-up is assured. When EEG is abnormal in FUS, the probability of having abnormal neuroimaging increases as compared with those cases where EEG is normal. In case of generalized seizures, patients with abnormal EEG may have abnormal computed tomography/MRI scans, but there are fewer possibilities of a patient with abnormal EEG to have a normal neuroimaging. In partial seizures, abnormal EEG increases the risk of having abnormal neuroimaging than in generalized seizures, and normal EEG in partial seizures markedly decreases the risk of having an abnormal neuroimaging generalized seizures. CFSs in otherwise neurologically free children rarely indicate the presence of lesion on neuroimaging even if associated with EEG abnormalities. Neuroimaging abnormalities in neurologically free children with FUS and CFSs do not require urgent intervention.

Keywords: MRI, neurology, seizures


How to cite this article:
Elfeshawy MS, Afia AA, Alsawah AY, Mohammed MI, Abdelkader AA. Role of neuroimaging and electroencephalogram in first unprovoked seizures in children from Cairo. Sci J Al-Azhar Med Fac Girls 2019;3:503-16

How to cite this URL:
Elfeshawy MS, Afia AA, Alsawah AY, Mohammed MI, Abdelkader AA. Role of neuroimaging and electroencephalogram in first unprovoked seizures in children from Cairo. Sci J Al-Azhar Med Fac Girls [serial online] 2019 [cited 2019 Nov 20];3:503-16. Available from: http://www.sjamf.eg.net/text.asp?2019/3/2/503/269843




  Introduction Top


Seizure is a common neurological problem in the pediatric age group and occurs in 10% of children. Approximately 5% of all medical attendances to accident and emergency department are related to seizures [1].

Unprovoked seizures occur in patients older than one month and have no acute precipitant, but improvement of the diagnostic techniques increases the chance of finding the unknown causes [1].

Febrile seizures (FS) are the most common type of childhood seizures. It is also a common cause of pediatric hospital admission and parental concern. The reported incidence of FSs is up to 14%. FS is further classified as simple febrile seizures (SFS) or complex febrile seizures (CFS), with CFSs defined as seizure lasting more than 15 min, repeated seizures occurring within 24 h, and focal seizure activity or focal findings present during the postictal period. Although there are enough investigations and data concerning initial management, there is somewhat less well-developed data in CFSs [2].


  Neuroimaging Top


Insufficient evidence is available to make a standard recommendation or guideline for the use of routine neuroimaging in children with first unprovoked seizure (FUS). In contrast, guidelines for obtaining neuroimaging in adult patients presenting with seizure have been published. In a few studies that have reviewed the yield of neuroimaging in children with unprovoked seizure, the prevalence of abnormalities ranged from 0 to 21% [3].

The decision of doing neuroimaging in FUSs should be individualized, and electroencephalogram (EEG) can be helpful. For example, a focal EEG may increase suspicion of structural abnormality. Patients who have clearly defined epileptic syndromes, such as petit mal epilepsy or benign Rolandic epilepsy, do not necessarily require neuroimaging. AAN practice parameters recommend nonurgent imaging after initial seizure if there is associated significant cognitive or motor impairment, unexplained abnormalities on the neurological examination, partial-onset seizures, an EEG inconsistent with benign or primary generalized epilepsy, and in patients younger than 1 year [4].

Clinically significant neuroimaging abnormalities have been reported in 2% of children presenting with first afebrile seizure without focal features or predisposing conditions [5].

The prevalence of abnormal neuroimaging in an adult with a new-onset seizure is 34–45%. However, the role of emergent neuroimaging in children presenting with first afebrile seizure is still not well defined. Based on several studies, the prevalence of abnormal neuroimaging in pediatric patients with a new-onset afebrile seizure is from 0 to 21% [6].

If neuroimaging is obtained, MRI is the preferred method of imaging to avoid radiation exposure while providing more detailed diagnostic information [7].

Identification of lesions altered the acute medical or surgical management in up to 8% of children. Accordingly, AAN recommends considering emergent head computed tomography (CT) for all patients with a first seizure, particularly those who have risk factors for abnormal neuroimaging ([Figure 1] and [Figure 2]) [8],[9].
Figure 1 An 18-month-old boy with first unprovoked seizure: axial T2Wimages reveal bilateral butterfly abnormal signal extending from the subcortical U fibers to the periventricular deep white matte changes owing to metachromatic leukodystrophy [9].

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Figure 2 A 13-year-old boy with first unprovoked seizure. Coronal T2W images through occipital horns reveal signal void left parasagittal lesion owing to A-V malformation [9].

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Electroencephalography

The EEG, which is entirely harmless and relatively inexpensive, is the most important investigative tool in the diagnosis and management of epilepsies. However, for the EEG to provide accurate assessments, it must be properly performed by experienced technologists and carefully studied and interpreted in the context of a well-described clinical setting by experienced physicians [10].

EEG does not generally need to be obtained in the emergency department unless there is concern about nonconvulsive status epilepticus or ongoing seizures in a pharmacologically paralyzed or comatose patient. EEG can detect focal lesions not visible with neuroimaging and show epileptiform findings that allow diagnosis of particular epilepsy syndromes [11].

AAN and Child Neurology Society recommend an EEG as a standard of care for a child presenting with a first afebrile seizure. The EEG is useful to evaluate risk of seizure recurrence, to determine whether a seizure is focal or generalized, to screen for focal abnormalities and possible need for MRI, to identify epilepsy syndrome classification, to guide choice of antiepileptics, and to aid in prognosis [12].

An EEG discharge is of great diagnostic and management significance if it is associated with clinical manifestations. However, these symptoms may be minor and escape recognition without video recordings. Video-EEG recordings are particularly important in the identification of absences, which are easily elicited by hyperventilation, myoclonic jerks, or focal seizures, as well as psychogenic or other nonepileptic seizures, particularly those of the hyperventilation syndrome ([Figure 3] and [Figure 4]) [13],[14].
Figure 3 Bursts of generalized spike waves at 1–4 s in patient with a single generalized tonic-clonic convulsion, indicating a higher probability of seizure recurrence [14].

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Figure 4 Generalized slowing recorded a day after a febrile seizure in a 27-month-old girl [14].

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If initial EEG findings are negative and clinical suspicion for epilepsy is high, sleep-deprived EEG is beneficial. This test detects abnormalities in 21–35% of patients with initially normal EEG findings, with the highest yield in the first 3 days after the seizure [15].


  Patients and methods Top


This prospective study was carried out on 100 cases with FUS and CFS in the age group from 6 months to 12 years old attending the Emergency, Inpatient, and Outpatient Departments of AL Hussein and Sayed Galal University Hospitals during the period from July 2016 to December 2017.

Inclusion criteria

  1. FUS:
    • FUS includes one or more epileptic seizures occurring within 24 h period with recovery of consciousness between seizures (ILAE Commission Report, 1997). The occurrence of multiple seizures in a 24-h period is considered as one seizure [16].
  2. CFSs: patient with FSs having one or more of the following features:
    1. Longer duration (>15 min).
    2. Recurs within 24 h.
    3. Focal seizures or general types of seizures other than generalized tonic-clonic seizure (GTCs).
    4. No post-ictal neurological abnormalities.
    5. Family history of epilepsy.
    6. Age group from 6 months to 12 years.


Exclusion criteria

The following were the exclusion criteria:
  1. Patients with suspected central nervous system (CNS) infection.
  2. Patients with simple febrile convulsions (because there is no suspected neurological insult).
  3. Patients with acute etiology of seizures such as toxins, trauma, drugs, and metabolic or electrolyte disturbances.
  4. Patients with known chronic neurologic illnesses such as cerebral palsy (CP) or mental retardation.
  5. Patients with neurological abnormalities detected at examination.


All patients were subjected to the following:
  1. Informed consent from a parent or guardian.
  2. Thorough history taking, including developmental, neurological, and family history (of convulsion or neurologic disease), emphasizing on the following:
    1. Precipitating factor for seizure, such as fever, trauma, drug intake, metabolic abnormality, prior CNS abnormality, and endocrinal or gastrointestinal tract (GIT) disease.
    2. Complete analysis of the attack, including presence of aura, onset of the seizure (focal or generalized onset), type and duration of convulsion, conscious level during the attack, if associated with cyanosis, incontinence of urine or vocalization, frequency of the attack, and post-ictal state.
  3. Full clinical examination was done focusing on neurological examination, origin of fever (if CFS), and other causes of convulsion.
  4. Laboratory investigations: blood samples are withdrawn according to situation including sepsis workup (according to suspected site of sepsis), random blood sugar (RBS), serum Natrium (Na), serum Ca, and serum Magnesium (Mg).
  5. EEG was done once for all patients using EEG machine (Model: E-series PSG; Compumedics, Australia) with standard 10–20 electrode placement system and recording for at least 40-min duration, in first contact with the child. Young children who are uncooperative are sedated using oral chloral hydrate (30–50 mg/kg/dose; maximum 100 mg/kg/dose).
  6. CT scan of the brain was done for all patients (GE-light-speed-4-slice-spiral-CT-scanner, USA).
  7. MRI of the brain was done only for patients whose CT scan needs further characterization (Philips achieva 1.5T MRI, Netherlands).


Statistical methods

  1. Data were analyzed using IBM SPSS statistics, version 22 (IBM Corp., Armonk, New York, USA).
  2. The Shapiro–Wilk test was used to examine the normality of numerical data distribution. Non-normally distributed numerical data were presented as median (interquartile range) and between-group differences were compared using the Mann–Whitney test.
  3. Categorical data were presented as number (%) and between-group differences were compared using Fisher’s exact test. The McNemar test was used for comparison of paired categorical data.
  4. Inter-method agreement was examined using Cohen κ coefficient.
  5. The Bonferroni method was used to adjust the level of significance for the number of subgroup comparisons to control the type I error.



  Results Top


Results of our study are illustrated in [Figure 5],[Figure 6],[Figure 7],[Figure 8],[Figure 9],[Figure 10],[Figure 11],[Figure 12],[Figure 13],[Figure 14],[Figure 15],[Figure 16] and [Table 1],[Table 2],[Table 3],[Table 4],[Table 5],[Table 6],[Table 7],[Table 8],[Table 9],[Table 10],[Table 11].
Figure 5 Generalized sharp slow waves in 6-month-old girl with first seizure.

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Figure 6 Bilateral centro-temporal spikes waves in a 12-year-old boy with first Rolandic seizure.

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Figure 7 Left temporal sharp waves in 1.5-year-old boy with first focal seizure.

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Figure 8 Bilateral centro-temporal sharp (black arrow) and sharp slow (move arrow) waves in a 8-year-old boy with first generalized seizure.

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Figure 9 Generalized polyspike activity in a 4-year-old boy with complex febrile seizure.

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Figure 10 Case no. 1. computed tomography scan shows interhemispheric well-defined cystic lesion iso-attenuating to the cerebrospinal fluid (CSF) equivalent to 5 HU; such cystic lesions together with coexisting corpus callosum agenesis splay the bodies of both lateral ventricles.

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Figure 11 Case no. 2. (a) Axial T1 WI, (b) axial T2 WI, (c) axial FLAIR, and (d) diffusion WI show left basi temporal extra-axial arachnoid cyst that follows the cerebrospinal fluid (CSF) signal at all pulse sequences.

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Figure 12 Case no. 3. Selected computed tomography cuts at the level of sylvain fissure show evidence of lissencephaly and mild ventricuolmegaly with periventricular deep white matter volume loss.

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Figure 13 Case no. 4. Selected axial FLAIR (a, b), sagittal T1 WI (c), axial T1 WI (d), and selected axial T2 WIs (e, f) cuts revealed patchy areas of abnormal high T2 and FLAIR signal are seen in deep white matter periventricular regions of both cerebral hemispheres associated with reduced bilateral peri-trigonal white matter volume and irregular tenting of atria of lateral ventricles. Partial thinning out of the posterior corpus callosum (arrowed), likely representing sequelae of peri-natal hypoxic/ischemic insult (Partial prolonged type).

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Figure 14 Case no 5. Computed tomography brain shows widely separated bodies of both lateral ventricles as a result of corpus callosum agenesis.

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Figure 15 Case no 6. Axial T2 and FLAIR WI of a 3-year-old girl shows bilateral periventricular deep white matter abnormal signal, related to diffuse hypomyelination.

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Figure 16 Case no 7. Axial T2 revealed semilobar holoprosencephaly, showing monoventricle with partially developed occipital and temporal horns. Incomplete falx cerebri, incompletely formed interhemispheric fissures are seen, especially anteriorly and high dysplastic corpus callosum.

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Table 1 Patient characteristics

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Table 2 Electroencephalogram findings in the study population

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Table 3 Neuroimaging findings in the study population

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Table 4 Comparison between patients with first unprovoked and those with complex febrile seizures

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Table 5 Comparison between patients with generalized and those with focal unprovoked seizures

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Table 6 Prevalence of neuroimaging abnormalities in patients with normal or abnormal electroencephalogram

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Table 7 Prevalence of neuroimaging abnormalities in patients with complex febrile seizures and normal or abnormal electroencephalogram

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Table 8 Prevalence of neuroimaging abnormalities in patients with unprovoked seizures and normal or abnormal electroencephalogram

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Table 9 Prevalence of neuroimaging abnormalities in patients with generalized unprovoked seizures and normal or abnormal electroencephalogram

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Table 10 Prevalence of neuroimaging abnormalities in patients with focal unprovoked seizures and normal or abnormal electroencephalogram

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Table 11 Prevalence of computed tomography scan abnormalities in patients with normal or abnormal electroencephalogram in the whole study population and in various patient subgroups

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  Discussion Top


In this study, EEG abnormality was found in 33% of the whole study cases, including FUSs and CFSs. EEG abnormality was higher in a similar study done by Rasool et al. [17], who found that EEG abnormality was detected in 56.2% of all studied population. The difference can be explained by that, in our study, EEG is done on first contact with the complaining child where most cases are examined at third to seventh day of the attack, whereas in the study done by Rasool et al. [17]. EEG was done within the first 48 h of the attack.

In this study, EEG abnormality was found in 44.4% of cases with FUSs. This is consistent with the study results of Hamiwka et al. [18], where EEG was done in 127 children with FUSs and was abnormal in 41% of cases.

In this study, EEG abnormalities were significantly low (P<0.025) among the patients with CFSs (13.5%) in comparison with FUSs (44.4%). This finding agreed with Rasool et al. [17].

Our results disagreed with the study results of Joshi et al. [19], who found that 39.43% of children with CFSs had EEG abnormalities. Our results also disagreed with the study results of Jeong et al. [16], who detected EEG abnormalities in 43% of children with CFSs. The difference can be explained by early postictal EEG registration (within 24–48 h). Moreover, there is disagreement between our results and another study carried out by Yucel et al. [20], who detected abnormal EEGs in 22.5% (16 of 71) of cases with CFS.

In this study, CT brain were done for all cases, whereas MRI brain were done for cases whose CT of the brain needs further characterization (28/100).

In this study, the prevalence of neuroimaging abnormalities in children with FUSs was 20.6%. This was in agreement with the study results of Shinnar et al. [21], who found that 21% of cases with FUSs had neuroimaging abnormalities.

In the study done by Mohammadi et al. [22], abnormal neuroimaging result was reported in 27.1% of cases. However, this difference could be owing to the use of MRI in most patients (82/96) in their study compared with 24/63 cases in our study.

In this study, the prevalence of brain CT scan abnormalities in children with FUSs was 20.6%, as presented in [Table 4]. These finding agreed with the study done by Maytal et al. [9], who detected that 21.2% had abnormal CT results, and disagreed with the study results of Vieira et al. [23], who found abnormalities in 29.44% of cases, which can be explained by larger sample size (387) in their study, and disagreed with the study results of Mathur et al. [24], who detected CT brain abnormalities in 32% of all children with a FUS.

In this study, the prevalence of neuroimaging (CT/MRI) abnormalities in CFSs was 5.4% (2/33), which agreed with Rasool et al. [17] who found that neuroimaging abnormalities was detected in 1.6% of cases, and disagreed with Hesdorffer et al. [25], who found that 14.8% of children with complex febrile convulsions had neuroimaging abnormalities. This difference can be explained by that, MRI is the neuroimaging modality used for all patients in their study.

In this study, the prevalence of abnormal CT scan in children with generalized first seizures was 15.9% (7/44) whereas that of focal seizures was 31.6% (6/19). These findings were consistent with that of Maytal et al. [9], who reported that in generalized seizures, 82.5% cases had normal CT scan result and 17.5% had abnormal CT scan result, whereas in partial seizures, 70.8% had normal imaging, and abnormal CT scan result was seen in 29.2%, showing overall abnormal CT scan result in 21.2% of the patients, which also agrees with our study.

In this study, brain atrophic changes were the most common neuroimaging abnormality. Other lesions include lissencephaly, ventriculomegaly, encephalomalacia, arachnoid cyst, corpus callosum dysgenesis, delayed maturation and encephalomalacia, and atrophic changes of the total population.

Rasool et al. [17] also found that brain atrophic changes were the most common neuroimaging abnormality in their study, and other findings were focal hypodense lesion, white matter hypodensity, and lissencephaly. However, in a study of neuroimaging findings in children with FUSs done by Mohammadi et al. [22], the most common imaging findings were gliosis followed by dysmyelination, hemorrhage, brain atrophy, dysgenesis, infarction, and encephalomalacia.


  Conclusion Top


  1. EEG and neuroimaging abnormalities were more prevalent in children with FUSs than those with CFSs.
  2. Abnormal EEG and neuroimaging were more common in children with partial seizures than those with generalized seizures.
  3. Neuroimaging was abnormal in a significant number of children having abnormal EEG, so neurologically free patients having normal EEG can be safely discharged without neuroimaging, if follow-up is assured.
  4. When EEG is abnormal in FUS, the probability of having abnormal neuroimaging result increases as compared with those cases where EEG result is normal.
  5. In case of generalized seizures, patients with abnormal EEG result may have abnormal CT/MRI scan results, but there are fewer possibilities of a patient with abnormal EEG result to have a normal neuroimaging result.
  6. In partial seizures, abnormal EEG result increases the risk of having abnormal neuroimaging result than in generalized seizures, and normal EEG result in partial seizures markedly decreases the risk of having an abnormal neuroimaging result in generalized seizures.
  7. CFSs in otherwise neurologically free children rarely indicate the presence of lesion on neuroimaging even if associated with EEG abnormalities.
  8. Neuroimaging abnormalities in neurologically free children with FUS and CFSs do not require urgent intervention.


Acknowledgements

This study was supported by Radiology and Pediatric Departments, Al Hussein University Hospital, Faculty of Medicine (for Boys), Al Hussein University Hospital.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14], [Figure 15], [Figure 16]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9], [Table 10], [Table 11]



 

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