First Episode of Afebrile Seizure in Role of EEG and MRI in First Episode of Afebrile Seizure in Developmentally Normal Children Aged 1-12 Years Dr. Aniruddha Ghosh Prof. (Dr.) Maya Mukhopadhyay Prof. (Dr.) Swapan Mukhopadhyay Department of Pediatric Medicine & Pediatric Neurology Institute of Child Health, Kolkata Role of EEG & MRI in first episode of afebrile seizure in developmentally normal children aged 1-12 years

Background: Role of EEG & MRI in first episode of afebrile seizure in developmentally normal children aged 1-12 years

Seizures are the most common pediatric neurological disorder. 4-10 % children suffer at least one episode of seizure in the first 16 years of life. Seizures account for about 1% of all emergency department visits and about 2% of childrens’ hospital visits. Seizures are frightening and many parents who witness a first seizure fear initially that their child is dying and they live in this fear even after child improves. Ref: Martindale JL, Goldstein JN, Pallin DJ: Emergency department seizure epidemiology. Emerg Med Clin North Am 2011 Feb; 29(1):15-27. Role of EEG & MRI in first episode of afebrile seizure in developmentally normal children aged 1-12 years

There are limited studies on first episode of afebrile seizure in developing countries like India. Most studies done so far have focused on epilepsy and clinical seizure types. There are few studies that describe and correlate neuroimaging especially Magnetic Resonance Imaging (MRI) and Electroencephalogram (EEG)- both the data in children who present with new onset afebrile seizures. Role of EEG & MRI in first episode of afebrile seizure in developmentally normal children aged 1-12 years

Recommendations. • The EEG is recommended as part of the neurodiagnostic evaluation of the child with an apparent first unprovoked seizure. (Standard) • If a neuroimaging study is obtained, MRI is the preferred modality.(Guideline) • Emergent neuroimaging should be performed in a child of any age who exhibits a postictal focal deficit (Todd’s paresis) not quickly resolving, or who has not returned to baseline within several hours after the seizure.(Option) • Nonurgent imaging studies with MRI should be seriously considered in any child with a significant cognitive or motor impairment of unknown etiology, unexplained abnormalities on neurologic examination, a seizure of partial (focal) onset with or without secondary generalization, an EEG that does not represent a benign partial epilepsy of childhood or primary generalized epilepsy, or in children under 1 year of age. (Option) Role of EEG & MRI in first episode of afebrile seizure in developmentally normal children aged 1-12 years

Future research should address the use of brain MRI in this clinical setting. At present, insufficient data are available to make any recommendations regarding the emergent or semi-emergent use of MRI, which may potentially have greater sensitivity than CT for detecting brain pathology underlying seizure disorders. It will be particularly useful to segregate results by age, including pediatric and elderly patients. Role of EEG & MRI in first episode of afebrile seizure in developmentally normal children aged 1-12 years

Role of EEG & MRI in first episode of afebrile seizure in developmentally normal children aged 1-12 years

Ideally an EEG should be obtained. MRI aids in diagnosis and should be done for all patients except those with idiopathic generalised epilepsies. Role of EEG & MRI in first episode of afebrile seizure in developmentally normal children aged 1-12 years

Recommendations for future seizure studies: Galliard et al for the International League Against Epilepsy, Committee for Neuroimaging, Subcommittee for Pediatric Neuroimaging. Guidelines for imaging infants and children with afebrile seizures, 2011. Recommendations for future seizure studies: Study should have a clearly defined question. Seizure studies should aim at a specific age group Data should be collected prospectively. Clear cut inclusion & exclusion criteria. Time points are to be fixed for EEG & MRI. Uniform imaging modality is to be applied to all study population. Blinding should be applied wherever possible. Role of EEG & MRI in first episode of afebrile seizure in developmentally normal children aged 1-12 years

Objectives: Role of EEG & MRI in first episode of afebrile seizure in developmentally normal children aged 1-12 years

To study EEG & MRI findings in cases of first episode afebrile seizures and find their correlation Role of EEG & MRI in first episode of afebrile seizure in developmentally normal children aged 1-12 years

Materials & Methodology: Role of EEG & MRI in first episode of afebrile seizure in developmentally normal children aged 1-12 years

STUDY DESIGN: Hospital based prospective cross sectional study STUDY PERIOD : May 2015 to May 2016 [12 months] STUDY POPULATION : Children from 1 year to 12 years of age admitted at Our hospital [located in Kolkata, West Bengal, India] STUDY AREA: Indoors of a tertiary care referral hospital Role of EEG & MRI in first episode of afebrile seizure in developmentally normal children aged 1-12 years

[MedCalc v11.6 : Mariakarke, Belgium: Medcalc Software 2011] SAMPLE SIZE: 51 patients EEG by 21-channel RMS EEG-24 machine & MRI by 1.5 Tesla Siemens Magnetom Essenza machine with application of specific Pediatric MRI protocols were performed. Blinding was applied while reading of MRIs. STATISTICAL ANALYSIS: by Fisher’s exact test with Freeman Halton extension, p-value, Cohen’s Unweighted Kappa Coefficient . [MedCalc v11.6 : Mariakarke, Belgium: Medcalc Software 2011] INCLUSION CRITERIA EXCLUSION CRITERIA Children aged 1-12 years Age: < 1 year; >12 years; Developmentally normal Febrile convulsions, meningitis, recurrent seizures, already diagnosed neurological disorder, dyselectrolytemia, H/O head trauma, drug overdose, toxic exposure. Admitted with first episode of afebrile seizure Inability to procure consent Role of EEG & MRI in first episode of afebrile seizure in developmentally normal children aged 1-12 years

Results & Analysis: Role of EEG & MRI in first episode of afebrile seizure in developmentally normal children aged 1-12 years

Types of seizures Seizure type N % Partial/Focal 13 25.5 Generalised 5.9% 25.5% 68.6% Seizure type N % Partial/Focal 13 25.5 Generalised 35 68.6 Undetermined 3 5.9 Total 51 100 Role of EEG & MRI in first episode of afebrile seizure in developmentally normal children aged 1-12 years

Partial/Focal seizure More elaborately... Type of seizure N Percentage Generalised seizure Tonic clonic 33 94.3 % Absence 2 5.7 % Total 35 68.6 % Partial/Focal seizure Simple 15.4 % Complex 9 69.2 % Secondary generalised 13 25.5 % Undetermined 3 5.9 % 51 100 % Role of EEG & MRI in first episode of afebrile seizure in developmentally normal children aged 1-12 years

Gender distribution Type of Seizure Male (n=30) Female (n=21) n % 20 Generalised 20 66.7 15 71.4 Partial/Focal 8 26.7 5 23.8 Undetermined 2 6.6 1 4.8 Total 30 58.8 21 41.2 20 15 8 5 2 1 No statistically significant difference Role of EEG & MRI in first episode of afebrile seizure in developmentally normal children aged 1-12 years

Age distribution 1-6 Years > 6 Years Type of Seizure n % Generalised 26 78.8 9 50.0 Partial/Focal 5 15.2 8 44.4 Undetermined 2 6.0 1 5.6 Total 33 64.7 18 35.3 26 9 8 5 2 1 No statistically significant difference Role of EEG & MRI in first episode of afebrile seizure in developmentally normal children aged 1-12 years

EEG abnormalities in different types of seizures 54.3% 23.1% 45.7% 76.9% 66.7% 33.3% Role of EEG & MRI in first episode of afebrile seizure in developmentally normal children aged 1-12 years

Types of EEG tracings 15.4% 5.7% 23.1% 20% 23.1% 11.4% 33.3% 7.7% Role of EEG & MRI in first episode of afebrile seizure in developmentally normal children aged 1-12 years

2.9% 7.7% 2.9% 2.9% Role of EEG & MRI in first episode of afebrile seizure in developmentally normal children aged 1-12 years

MRI abnormalities in different types of seizures 60% 30.8% 40% 69.2% 66.7% 33.3% Role of EEG & MRI in first episode of afebrile seizure in developmentally normal children aged 1-12 years

Types of MRI abnormalities 11.1% 7.1% 22.2% 7.1% 11.1% 50% 7.1% 55.6% 28.7% Role of EEG & MRI in first episode of afebrile seizure in developmentally normal children aged 1-12 years

Correlation between EEG & MRI Normal MRI Abnormal MRI Normal EEG 11 (21.57%) 13 (25.49%) Abnormal EEG 16 (31.37%) Role of EEG & MRI in first episode of afebrile seizure in developmentally normal children aged 1-12 years

Reference ranges: > 0.7 : Very good agreement. Cohen’s Unweighted Kappa Co-efficient : 0.133. This Coefficient measures inter-rater agreement for qualitative (cattegorical) items. It is a more robust measure than simple percentage agreement calculation, since kappa takes into account the agreement occurring by chance. Reference ranges: > 0.7 : Very good agreement. 0.5-0.7: Equivocal agreement <0.3: Very poor agreement. Here, the value is 0.133 (<0.3). So it is statistically proven that EEG & MRI are in very poor agreement in case of first episode of afebrile seizures in developmentally normal children aged 1-12 years. This indicates : One test cannot be a substitute of the other. Role of EEG & MRI in first episode of afebrile seizure in developmentally normal children aged 1-12 years

Limitations: Sample size is moderate with comparison to internationally accepted studies. Due to economical constraint some patients were missed. Role of EEG & MRI in first episode of afebrile seizure in developmentally normal children aged 1-12 years

This study characterized structural abnormalities associated with onset of seizures in children using MRI and a standardized classification system in a large prospective cohort. A total of 281 children aged 6 to 14 years completed an MRI within six months of their first recognized seizure. Use of MRI and a standardized reliable and valid scoring system demonstrated a higher rate of abnormal findings than previous investigations, including findings that might have been considered incidental in the past. Practice parameters may need to be revised to expand the definition of significant abnormalities and to support wider use of MRI in children with newly diagnosed seizures. Role of EEG & MRI in first episode of afebrile seizure in developmentally normal children aged 1-12 years

Results: The prevalence of significant MRI abnormalities was 21. 9% Results: The prevalence of significant MRI abnormalities was 21.9%. The most common abnormalities included white-matter lesions (27.6%), volume loss (19.6%), gray-matter lesions (19.6%), and ventricular enlargement (12%). Conclusions: The use of MRI and a reliable standardized scoring system at diagnosis of epilepsy in children identified a high rate of significant abnormalities findings. This may have important implications for practice guidelines in this population. Role of EEG & MRI in first episode of afebrile seizure in developmentally normal children aged 1-12 years

Conclusion: The study findings indicate that EEG & MRI both should be obtained in all the cases of first episode of afebrile seizure in developmentally normal children aged 1-12 years. Role of EEG & MRI in first episode of afebrile seizure in developmentally normal children aged 1-12 years

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