Pediatric first time non-febrile seizure with focal manifestations: Is emergent imaging indicated?

PURPOSE To assess the prevalence of clinically urgent intra-cranial pathology among children who had imaging for a first episode of non-febrile seizure with focal manifestations. METHODS We performed a cross sectional study of all children age 1 month to 18 years evaluated for first episode of non-febrile seizure with focal manifestations and having neuroimaging performed within 24h of presentation at a single pediatric ED between 1995 and 2012. We excluded intubated patients, those with known structural brain abnormality and trauma. A single neuro-radiologist reviewed all cranial computed tomography and/or magnetic resonance imaging performed. We defined clinically urgent intracranial pathology as any finding resulting in a change of initial patient management. We performed univariate analysis using χ(2) analysis for categorical data and Mann-Whitney U test for continuous data. RESULTS We identified 319 patients having a median age of 4.6 years [IQR 1.8-9.4] of which 45% were female. Two hundred sixty-two children had a CT scan, 15 had an MR and 42 had both. Clinically urgent intra-cranial pathology was identified on imaging of 13 patients (4.1%; 95% CI: 2.2, 7.0). Infarction, hemorrhage and thrombosis were most common (9/13). Twelve of 13 were evident on CT scan. Persistent Todd's paresis and age ≤ 18 months were predictors of clinically urgent intracranial pathology. Absence of secondary generalization and multiple seizures on presentation were not predictive. CONCLUSIONS Four percent of children imaged with first time, afebrile focal seizures have findings important to initial management. Children younger than ≤ 18 months are at increased risk.