1. 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

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

3. 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

4. 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

5. 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

6. 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

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

8. 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

9. 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

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

11. 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

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

13. 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

14. [MedCalc v11.6 : Mariakarke, Belgium: Medcalc Software 2011]
SAMPLE SIZE: 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

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

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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

25. 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

26. Reference ranges: > 0.7 : Very good agreement.
Cohen’s Unweighted Kappa Co-efficient :
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.
: Equivocal agreement
<0.3: Very poor agreement.
Here, the value is (<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

27. 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

28. 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

29. 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

30. 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

31. Thank you for your attention