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Am Fam Physician. 2003;67(12):2596-2599

The role of neuroimaging in children presenting to the emergency department with new-onset afebrile seizures has not been established. Sharma and colleagues attempted to identify clinical variables that place children at high or low risk for abnormal findings.

The study group retrospectively reviewed the medical records of 500 consecutive visits to the emergency department of a children's hospital for new-onset afebrile seizures. The authors abstracted historical, clinical, and neuroimaging data from the records. The major outcome variable was clinically significant findings on computed tomography (CT) or magnetic resonance imaging (MRI).

The median age of qualifying patients was 46 months. Neuroimaging was obtained in 95 percent of patients; 91 percent had CT, and 4 percent had MRI as the initial study. Normal neuroimaging results were reported in 83 percent of these patients. Clinically insignificant findings were reported in 9 percent, and clinically significant abnormalities were reported in 8 percent. High-risk patients were defined as those with a predisposing condition (such as sickle cell disease), and focal seizure and age younger than 33 months. Of the 475 patients who received neuroimaging, 25 percent were in the high-risk group, according to these criteria. Among patients with clinically significant abnormal findings, six (1.7 percent) met low-risk criteria and 32 (26 percent) met high-risk criteria.

Clinically significant abnormal findings in patients with new-onset afebrile seizures are found much less frequently in children than in adults. The authors conclude that emergent neuroimaging should be considered in children with new-onset afebrile seizures with the following high-risk features: (1) conditions that predispose them to intracranial abnormalities and (2) focal seizures in children who are younger than 33 months. Even patients in the latter category may not need immediate imaging, especially if MRI is not available. In all other children, neuroimaging can be deferred safely to the outpatient setting.

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