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Note: controversies are not meant to have a “right” answer – they are to see how most people are practicing. Would love your comments also regarding your thought processes and the evidence behind your decisions. We can learn from each other!
You are seeing a child who has had a self-resolving 5 minute generalized tonic-clonic seizure for the first time. The patient is afebrile, previously healthy, and has a normal non-focal neurologic exam. There is no evidence on your evaluation of another cause for the seizure, such as meningitis or a toxicological cause. There is no associated headache or vomiting. Family history if non-contributory. MRI is unavailable from the ED.
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July 16, 2021 at 11:22 am
Selective: persistent (>1h) AMS or focal deficit (especially <3yo), recurrent seizure in ED, trauma or suspect NAT, e/o neurocutaneous syndrome based on exam or other high-risk comorbidity (SCD, malignancy).
July 19, 2021 at 5:52 pm
A retrospective study of 155 patients age 1 month to 18 years seen in the PED for first afebrile seizure found that 46.5% underwent head CT, but only 3 had clinically significant findings, and these findings did not require acute management (PMID 29987971). In contrast, a prospective study done in a resource-poor population in Nepal of 447 patients age 1 month to 20 years with afebrile seizure found that 71.8% underwent head CT, and 32% of the 447 patients had abnormal findings on CT (most common: atrophy and neurocysticercosis). The American Academy of Neurology guidelines summarize the evidence as follows: up to 1/3 have abnormalities on neuroimaging, but only ~2% have findings that contribute to acute clinical management. They recommend neuroimaging if there is a postictal focal deficit not quickly resolving or the child has not returned to baseline within several hours after the seizure (https://n.neurology.org/content/55/5/616). Australian guidelines suggest considering imaging for children < 6 months, among other indications (https://www.rch.org.au/clinicalguide/guideline_index/Afebrile_seizures/). British guidelines suggest imaging in children with 2 or more afebrile seizures and no clinical or EEG features of an idiopathic epilepsy syndrome (https://bcmj.org/articles/approach-child-first-afebrile-seizure).