Practice parameter: Evaluating a first nonfebrile seizure in children

Abstract

Article abstract-Objective: The Quality Standards Subcommittee of the American Academy of Neurology develops practice parameters as strategies for patient management based on analysis of evidence. For this practice parameter, the authors reviewed available evidence on evaluation of the first nonfebrile seizure in children in order to make practice recommendations based on this available evidence. Methods: Multiple searches revealed relevant literature and each article was reviewed, abstracted, and classified. Recommendations were based on a three-tiered scheme of classification of the evidence. Results: Routine EEG as part of the diagnostic evaluation was recommended; other studies such as laboratory evaluations and neuroimaging studies were recommended as based on specific clinical circumstances. Conclusions: Further studies are needed using large, well-characterized samples and standardized data collection instruments. Collection of data regarding appropriate timing of evaluations would be important.

Brief Resolved Unexplained Events (Formerly Apparent Life-Threatening Events) and Evaluation of Lower-Risk Infants

“…30 Although EEG is recommended by the American Academy of Neurology after a firsttime nonfebrile seizure, the yield and sensitivity of an EEG after a first-time ALTE in a lower-risk child are low. 86 Thus, the evidence available suggests no utility for routine EEG to evaluate for epilepsy in a lower-risk BRUE. However, our recommendations for BRUEs are based on no prospective studies and on only a single retrospective study.…”

Prevalence of and Risk Factors for Intracranial Abnormalities in Unprovoked Seizures

“…[1][2][3] Approximately 8% to 31% of children with first, unprovoked seizures have abnormalities upon neuroimaging and ,1% to 8% have abnormalities warranting intervention. [4][5][6][7][8][9][10][11][12] The wide range of estimates results from the varying populations studied, differing outcome definitions, and the varied use of MRI. [4][5][6][7][8][9][10][11][12] The majority of patients undergo acute neuroimaging, most frequently computed tomography (CT).…”

“…[5][6][7][8][9][10][11][16][17][18] Most previous studies, however, have been retrospective, have not included standardized evaluations of patients, or the clinical findings were not elicited by acute care providers. [4][5][6][7][8][9][10][11][12][16][17][18][19][20][21] Existing guidelines provide only weak recommendations regarding which children might benefit from prompt neuroimaging. [9][10][11] Our primary aim was to determine the prevalence of, and risk factors for, clinically relevant intracranial abnormalities on neuroimaging in a well-described group of children who presented to medical care for the first time after having sustained unprovoked seizures.…”

“…[4][5][6][7][8][9][10][11][12][16][17][18][19][20][21] Existing guidelines provide only weak recommendations regarding which children might benefit from prompt neuroimaging. [9][10][11] Our primary aim was to determine the prevalence of, and risk factors for, clinically relevant intracranial abnormalities on neuroimaging in a well-described group of children who presented to medical care for the first time after having sustained unprovoked seizures. Our secondary aim was to derive a prediction model to identify children in this population at low risk of clinically relevant intracranial abnormalities.…”

“…We chose the clinical findings on the basis of an extensive review of the literature and through detailed discussions with faculty physicians who were expert in pediatric and adult neurology. [5][6][7][8][9][10][11] To assess interrater reliability of clinical findings, a second clinician performed an independent evaluation within 30 minutes of the first assessor on a convenience sample (47%) of those enrolled (details published previously). 22 Clinician assessors were asked to complete the data form before they had knowledge of cranial CT or MRI results, if obtained.…”