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Appropriateness Criteria

Reference Study Type Patients/Events Study Objective(Purpose of Study) Study Results Study Quality
1. Centers for Disease Control and Prevention. Data and Statistics. Epilepsy Prevalence in the United States.  https://www.cdc.gov/epilepsy/data/index.html. Review/Other-Dx N/A Estimates of the incidence and prevalence of seizures and epilepsy in the US. N/A 4
2. Fisher RS, van Emde Boas W, Blume W, et al. Epileptic seizures and epilepsy: definitions proposed by the International League Against Epilepsy (ILAE) and the International Bureau for Epilepsy (IBE). Epilepsia. 2005; 46(4):470-472. Review/Other-Dx N/A Review definitions for epileptic seizures and epilepsy. According to the International League Against Epilepsy (ILAE) and the International Bureau for Epilepsy (IBE), epileptic seizure is a brief occurrence of signs and/or symptoms while epilepsy is characterized by an enduring tendency to generate epileptic seizures. 4
3. Fisher RS, Cross JH, French JA, et al. Operational classification of seizure types by the International League Against Epilepsy: Position Paper of the ILAE Commission for Classification and Terminology. Epilepsia. 2017;58(4):522-530. Review/Other-Dx N/A To recognize that some seizure types can have either a focal or generalized onset, to allow classification when the onset is unobserved, to include some missing seizure types, and to adopt more transparent names. Changes include the following: (1) "partial" becomes "focal"; (2) awareness is used as a classifier of focal seizures; (3) the terms dyscognitive, simple partial, complex partial, psychic, and secondarily generalized are eliminated; (4) new focal seizure types include automatisms, behavior arrest, hyperkinetic, autonomic, cognitive, and emotional; (5) atonic, clonic, epileptic spasms, myoclonic, and tonic seizures can be of either focal or generalized onset; (6) focal to bilateral tonic-clonic seizure replaces secondarily generalized seizure; (7) new generalized seizure types are absence with eyelid myoclonia, myoclonic absence, myoclonic-atonic, myoclonic-tonic-clonic; and (8) seizures of unknown onset may have features that can still be classified. The new classification does not represent a fundamental change, but allows greater flexibility and transparency in naming seizure types. 4
4. Weitemeyer L, Kellinghaus C, Weckesser M, et al. The prognostic value of [F]FDG-PET in nonrefractory partial epilepsy. Epilepsia. 2005; 46(10):1654-1660. Observational-Dx 90 patients To determine the value of FDG-PET in non-refractory partial epilepsy. Regional asymmetry of tracer distribution was seen in 43 of the 90 patients. Forty-one patients had regional glucose hypometabolism in the temporal and two patients in an extratemporal region. No difference between patients with and without a hypometabolic focus was found regarding seizure freedom after follow-up. This held true also for the subgroup of patients with epilepsy onset within 1 year before admission. Only patients with regional glucose metabolism showed an increase in seizure frequency. Multivariate analysis showed that only anticonvulsive treatment before index admission and the possibility of localizing the epileptogenic focus by using all available clinical and EEG data were independently associated with continuing seizures after a median follow-up period of 43 months. 4
5. American College of Radiology. Manual on Contrast Media. Available at: https://www.acr.org/Clinical-Resources/Contrast-Manual. Review/Other-Dx N/A To assist radiologists in recognizing and managing risks associated with the use of contrast media. No abstract available. 4
6. Baykan B, Ertas NK, Ertas M, Aktekin B, Saygi S, Gokyigit A. Comparison of classifications of seizures: a preliminary study with 28 participants and 48 seizures. Epilepsy Behav. 2005; 6(4):607-612. Review/Other-Dx 48 seizures; 28 reviewers To compare three available seizure classifications: International classification of epileptic seizures (ICES), semiological seizure classification (SSC), and proposal of a new diagnostic scheme for seizures (PDSS). Overall diagnostic success rates were 81.4% for ICES, 80.5% for PDSS, and 87.5%, for SSC. In reliability analysis, Cronbach’s alpha was 0.94 for ICES, 0.88 for PDSS, and 0.70 for SSC. 19 reviewers chose SSC, 8 chose ICES, and one chose PDSS as their preference. 4
7. Osmond E, Billetop A, Jary S, Likeman M, Thoresen M, Luyt K. Neonatal seizures: magnetic resonance imaging adds value in the diagnosis and prediction of neurodisability. Acta Paediatr. 103(8):820-6, 2014 Aug. Observational-Dx 77 Infants To determine the aetiological associations, neurological sequelae and role of magnetic resonance imaging (MRI) in term newborn infants with seizures. An underlying aetiology was found in 95% of the 77 infants identified with seizures (3.0/1000 live births). The most common diagnosis was hypoxic-ischaemic encephalopathy (HIE) (65%), followed by neonatal stroke (12%). Nine infants died, 28 of the 68 survivors developed neurodevelopmental impairment (NDI), and 15 had recurrent seizures in the first 2 years, with both outcomes more likely in those with a diagnosis other than HIE. Abnormal MRI findings were found in 45 of the 70 infants imaged. The absence of major cerebral lesions was highly predictive of a normal neurological outcome. 2
8. Pellock JM. The classification of childhood seizures and epilepsy syndromes. Neurol Clin. 1990; 8(3):619-632. Review/Other-Dx N/A Review classification of childhood seizures and epilepsy syndromes. Classification scheme helps in evaluation and treatment of patients. 4
9. Scheuer ML, Pedley TA. The evaluation and treatment of seizures. N Engl J Med 1990; 323(21):1468-1474. Review/Other-Dx N/A To review diagnosis and treatment of seizures. Electroencephalography is recommended for evaluating patients with known or suspected seizure disorder. MRI or x-ray CT can be combined with electrophysiologic studies, but MRI is more sensitive than CT in detecting cerebral lesions related to epilepsy. 4
10. Glass HC.. Neonatal seizures: advances in mechanisms and management. [Review]. Clin Perinatol. 41(1):177-90, 2014 Mar. Review/Other-Dx N/A To review the advances in mechanisms and management Neonatal seizures. No results stated in abstract. 4
11. Engel J, Jr. Report of the ILAE classification core group. Epilepsia. 2006; 47(9):1558-1568. Review/Other-Dx N/A To examine epileptic seizure types and epilepsy syndromes and to identify research which will make possible the creation of a new classification. No results stated in abstract. 4
12. Weeke LC, Groenendaal F, Toet MC, et al. The aetiology of neonatal seizures and the diagnostic contribution of neonatal cerebral magnetic resonance imaging. Dev Med Child Neurol. 57(3):248-56, 2015 Mar. Observational-Dx 378 neonates (216 males; 162 females) To delineate aetiologies and explore the diagnostic value of cerebral magnetic resonance imaging (MRI) in addition to cranial ultrasonography (cUS) in infants presenting with neonatal seizures. An underlying aetiology was identified in 354 infants (93.7%). The most common aetiologies identified were hypoxic-ischaemic encephalopathy (46%), intracranial haemorrhage (12.2%), and perinatal arterial ischaemic stroke (10.6%). When comparing MRI with cUS in these 354 infants MRI showed new findings which did not become apparent on cUS, contributing to a diagnosis in 42 (11.9%) infants and providing additional information to cUS, contributing to a diagnosis in 141 (39.8%). cUS alone would have allowed a diagnosis in only 37.9% of infants (134/354). 3
13. Panayiotopoulos CP. Chapter 5: Neonatal Seizures and Neonatal Syndromes. The Epilepsies: Seizures, Syndromes and Management. Oxfordshire (UK): Bladon Medical Publishing; 2005. Review/Other-Dx N/A To review neonatal epileptic seizures and syndromes. Epileptic syndromes that help in diagnosis and management of seizure disorders are a major advancement. 4
14. Calciolari G, Perlman JM, Volpe JJ. Seizures in the neonatal intensive care unit of the 1980s. Types, Etiologies, Timing. Clin Pediatr (Phila). 1988; 27(3):119-123. Review/Other-Dx 150 Retrospective review to determine distribution of clinical seizure types, etiologies, and timing of neonatal seizures. Hypoxic-ischemic encephalopathy (65% of total) was most common. Seizures with hypoxic-ischemic encephalopathy occurred 90% in the first 2-days of life. 80% of all seizures in the first 2-days of life were related to hypoxic-ischemic encephalopathy. 4
15. Sheth RD. Neonatal Seizures. Available at: http://www.emedicine.com/neuro/topic240.htm. Accessed May 1 2012. Review/Other-Dx N/A To review diagnosis, treatment and follow-up of neonatal seizures. MRI is most sensitive for determining etiology for neonatal seizures. Cranial US is useful when determining whether intracranial hemorrhage (intraventricular hemorrhage) has occurred. Cranial CT is a more sensitive than US in detecting parenchymal abnormalities. 4
16. Girard N, Raybaud C. Neonates with seizures: what to consider, how to image. Magn Reson Imaging Clin N Am. 19(4):685-708; vii, 2011 Nov. Review/Other-Dx N/A To review the best imaging modality for seizures in neonates. No results stated in abstract. 4
17. Glass HC, Bonifacio SL, Sullivan J, et al. Magnetic resonance imaging and ultrasound injury in preterm infants with seizures. J Child Neurol. 2009; 24(9):1105-1111. Observational-Dx 236 infants To compare the incidence and type of brain abnormality detected by MRI and ultrasound in a large cohort of prematurely born neonates with seizures. During the hospital course, 9 infants (3.8%) had clinical suspicion of seizures. Magnetic resonance imaging was abnormal in each case. Periventricular hemorrhagic infarct was more common in infants with seizures. Infants with seizures were more likely to have white matter injury, though the difference was not significant. Head ultrasound failed to detect the extent of brain abnormality in 8 (89%) of the infants. In this large cohort, infants with clinical suspicion of seizures had a high rate of MRI abnormalities that were not as well characterized by head ultrasound. Magnetic resonance imaging may be the study of choice for evaluating preterm infants with seizures. 3
18. Krishnamoorthy KS, Soman TB, Takeoka M, Schaefer PW. Diffusion-weighted imaging in neonatal cerebral infarction: clinical utility and follow-up. J Child Neurol. 2000; 15(9):592-602. Review/Other-Dx 8 neonates; 19 lesions To describe the utility of echo-planar diffusion-weighted imaging in neonatal cerebral infarction. Diffusion-weighted imaging shows findings not evident on CT or routine MRI. 4
19. Leijser LM, de Bruine FT, Steggerda SJ, van der Grond J, Walther FJ, van Wezel-Meijler G. Brain imaging findings in very preterm infants throughout the neonatal period: part I. Incidences and evolution of lesions, comparison between ultrasound and MRI. Early Hum Dev 2009;85:101-9. Review/Other-Dx N/A To describe the incidences of brain imaging findings in a cohort of very preterm infants admitted to a tertiary neonatal referral center, assessed with modern neuro-imaging techniques. Secondary aims were to assess the evolution of lesions on cranial ultrasound (cUS) between admission and term equivalent age (TEA), to compare the findings on contemporaneous cUS and MRI performed around TEA, and to assess whether abnormalities were missed with either technique. No results stated in abstract. 4
20. Hsieh DT, Chang T, Tsuchida TN, et al. New-onset afebrile seizures in infants: role of neuroimaging. Neurology. 2010; 74(2):150-156. Observational-Dx 317 infants To investigate the presenting characteristics of new-onset afebrile seizures in infants (age 1-24 months) and the yield of neuroimaging. Half of the infants had partial features to their seizures, yet evidence for primary generalized seizures was rare. The majority had more than 1 seizure upon presentation. Seizures in this age group tended to be brief, with 44% lasting less than 1 minute. EEG abnormalities were found in half. One-third of CTs were abnormal, with 9% of all CTs requiring acute medical management. Over half of MRIs were abnormal, with cerebral dysgenesis being the most common abnormality (p < 0.05). One-third of normal CTs had a subsequent abnormal MRI-only 1 resulted in altered medical management. 3
21. Hesdorffer DC, Chan S, Tian H, et al. Are MRI-detected brain abnormalities associated with febrile seizure type? Epilepsia. 2008; 49(5):765-771. Observational-Dx 159 children To determine the frequency of MRI-detected brain abnormalities and to evaluate their association with febrile seizures (FS) type and with specific features of complex FS In 159 children with a first FS, imaging abnormalities occurred in 12.6% (N = 20). Eight of the 54 with complex FS had imaging abnormalities compared to 12 of the 105 with simple FS (n.s.). Compared to children with simple FS, children with both focal and prolonged FS (N = 14) were more likely to have imaging abnormality (OR = 4.3, 95% CI = 1.2-15.0), even after adjustment for abnormal neurological examination. Imaging abnormalities included those known to be associated with seizures (e.g., focal cortical dysplasia) and those not typically associated with seizures (e.g., subcortical focal hyperintensities > or = 5 mm). 2
22. Jung DE, Ritacco DG, Nordli DR, Koh S, Venkatesan C. Early Anatomical Injury Patterns Predict Epilepsy in Head Cooled Neonates With Hypoxic-Ischemic Encephalopathy. Pediatr Neurol. 53(2):135-40, 2015 Aug. Observational-Dx 73 infants To determine whether early anatomical injury patterns on magnetic resonance imaging-correlate with the development of postneonatal epilepsy in infants treated with selective head cooling for hypoxic-ischemic encephalopathy. Outcome was favorable for our cohort of 73 individuals with a mean follow-up of 41 (+/-7) months. The majority (66%) survived with no seizure recurrence, whereas 13 (18%) developed postneonatal epilepsy, including eight who had infantile spasms. Twelve infants (16%) died. The most common magnetic resonance imaging pattern was diffuse brain injury involving both cortical and subcortical gray matter (26/73, 35%), followed by cortical and subcortical white matter injury (18/73, 25%) and normal magnetic resonance imaging (16/73, 22%). In 13 infants (18%), the brainstem was involved in addition to cortical and subcortical gray matter; nine died and all four surviving infants developed infantile spasms. All 18 infants with cortical and subcortical white matter injury survived and none developed postneonatal epilepsy. The risk of postneonatal epilepsy was associated with injury involving subcortical regions (basal ganglia, thalamus +/- brainstem) (12/39 versus 1/34, P < 0.003). 2
23. DiMario FJ, Jr. Children presenting with complex febrile seizures do not routinely need computed tomography scanning in the emergency department. Pediatrics. 2006; 117(2):528-530. Review/Other-Dx N/A To examine imaging of children presenting with complex febrile seizures. MRI is sensitive and clinically useful for most patients who are undergoing neurologic evaluation in the absence of suspected trauma or an immediate neurosurgical problem. 4
24. Grill MF, Ng YT. &#34;Simple febrile seizures plus (SFS+)&#34;: more than one febrile seizure within 24 hours is usually okay. Epilepsy &#38; Behavior. 27(3):472-6, 2013 Jun. Observational-Dx 32 subjects To investigate whether children with recurrent febrile seizures within a 24-hour period need to be worked up differently from children with simple febrile seizures. Two children had abnormal Magnetic Resonance Imaging (MRI) findings - both benign: one is thought to represent postictal changes, and the other one is an incidental arachnoid cyst. Of the 4 abnormal electroencephalography (EEGs), one showed epileptiform discharges, while the others showed generalized ictal or postictal features. 3
25. Kimiwada T, Juhasz C, Makki M, et al. Hippocampal and thalamic diffusion abnormalities in children with temporal lobe epilepsy. Epilepsia. 2006; 47(1):167-175. Observational-Dx 14 patients; 14 controls To assess hippocampal and thalamic diffusion abnormalities in children with temporal lobe epilepsy. Fractional anisotropy (FA) and apparent diffusion coefficient (ADC) values were compared with diffusion tensor imaging (DTI) data of 14 controls (no epilepsy), as well as glucose PET findings. Decreased FA (p < 0.001) and increased ADC (p = 0.003) values were found in the hippocampi ipsilateral to the seizure focus. Significant FA decreases (p = 0.002) also were seen in the contralateral hippocampi, despite unilateral seizure onset and excellent surgical outcome in patients who underwent surgery. ADC values showed a trend for increase in the thalami ipsilateral to the epileptic focus in the seven children with secondarily generalized seizures (p = 0.09). No group differences of ADC or FA were found in the lentiform nuclei. The DTI variables did not correlate with regional glucose metabolism in any of the structures analyzed. DTI seems to be sensitive for detecting abnormalities in children with partial epilepsy, even in structures without apparent changes on conventional MRI. 3
26. Natsume J, Bernasconi N, Miyauchi M, et al. Hippocampal volumes and diffusion-weighted image findings in children with prolonged febrile seizures. Acta Neurol Scand. 2007; 115(4 Suppl):25-28. Observational-Dx 12 patients; 13 controls To assess hippocampal volumes and diffusion-weighted image findings in children with prolonged febrile seizures (PFS) and compare them with the PFS duration and EEG. Seizure duration ranged from 40 to 95 min. In seven out of twelve patients, seizures were refractory and lasted for 60 min or longer despite intravenous infusion of diazepam. In the patients with PFS for 60 min or longer, HV were significantly larger than that of controls. In all patients, there was a positive correlation between HV and seizure duration. DWI showed hyperintensity in unilateral hippocampus in three patients with intractable seizures, ipsilateral thalamus in two, and cingulate in one. EEG showed abnormalities in temporal areas ipsilateral to the DWI abnormalities in these patients. 3
27. Hardasmalani MD, Saber M. Yield of diagnostic studies in children presenting with complex febrile seizures. Pediatr Emerg Care. 28(8):789-91, 2012 Aug. Observational-Dx 71 patients To determine the yield of diagnostic workup in children presenting with complex febrile seizures. There were 71 eligible encounters (mean age, 1.5 years); 59.2% were males. None of the 71 patients had positive blood or urine cultures; none had abnormal blood count or serum chemistries. Only 1 patient who had a very abnormal presentation in febrile status epilepticus had positive cerebrospinal fluid culture and abnormal brain computed tomography scan and magnetic resonance imaging. 3
28. Provenzale JM, Barboriak DP, VanLandingham K, MacFall J, Delong D, Lewis DV. Hippocampal MRI signal hyperintensity after febrile status epilepticus is predictive of subsequent mesial temporal sclerosis. AJR. 2008; 190(4):976-983. Observational-Dx 11 patients; 30 healthy children; 2 observers Prospective blinded study to determine whether hippocampal MRI signal hyperintensity after febrile status epilepticus is predictive of subsequent mesial temporal sclerosis. 7 children had hyperintense signal intensity ranging from 1 (minimally increased) to 4 (markedly increased). MRI findings of a markedly hyperintense hippocampus in children with febrile status epilepticus was highly associated with mesial temporal sclerosis. 2
29. Teng D, Dayan P, Tyler S, et al. Risk of intracranial pathologic conditions requiring emergency intervention after a first complex febrile seizure episode among children. Pediatrics. 2006;117(2):304-308. Observational-Dx 71 children To determine the likelihood of intracranial pathologic conditions requiring emergency neurosurgical or medical intervention among children without meningitis who presented to the pediatric emergency department after a first complex febrile seizure. Data for 71 children with first complex febrile seizures were analyzed. Fifty-one (72%) had a single complex feature (20 focal, 22 multiple, and 9 prolonged), and 20 (28%) had multiple complex features. None of the 71 patients (1-sided 95% confidence interval: 4%) had intracranial pathologic conditions that required emergency neurosurgical or medical intervention. 3
30. Lee ST, Lui TN. Early seizures after mild closed head injury. J Neurosurg. 1992;76(3):435-439. Review/Other-Dx 4,232 patients To review seizure incidence in adult patients with mild closed head injury who did not receive prophylactic anticonvulsant agents. No definite intracranial pathological findings were detected by CT in 53% of patients with early posttraumatic seizures; 6 patients had intracranial hemorrhage without intracranial parenchymal damage (3 with epidural hematoma and 3 with subarachnoid hemorrhage). The most common positive CT findings in the early post-traumatic-seizure group were intracerebral hemorrhage (24%), followed by acute subdural hematoma with intracerebral hemorrhage (17%). Intracerebral parenchymal damage could be identified on CT scans in 41 (48.8%) of 84 patients with generalized tonic-clonic seizures and 5 (31%) of 16 patients with partial seizures with motor symptoms. The intracerebral parenchymal damage was most commonly detected in the frontal lobe (21%) and the temporal lobe (19%). 7 patients with early post-traumatic seizures received emergency craniotomy to remove an intracranial hematoma (epidural in 3, subdural and intracerebral in 4) because the mass effect resulted in significant midline shift as seen on CT scans. 4
31. Sharma S, Riviello JJ, Harper MB, Baskin MN. The role of emergent neuroimaging in children with new-onset afebrile seizures. Pediatrics. 2003; 111(1):1-5. Observational-Dx 500 Retrospective review to determine the frequency of clinically significant abnormal neuroimaging in children with new-onset afebrile seizures (ASZ), and identify children at high-risk or low-risk for abnormal neuroimaging. Ninety-five percent of patients (475/500) with new-onset ASZ had neuroimaging. Clinically significant abnormal neuroimaging was noted in 8% (95% confidence interval [CI]: 6, 11; 38/475) of patients. Recursive partition analysis identified 2 criteria associated with high risk for clinically significant abnormal neuroimaging: 1) the presence of a predisposing condition, and 2) focal seizure if <33 months old. Of the high-risk patients, 26% (95% CI: 17, 35; 32/121) had clinically significant abnormal neuroimaging compared with 2% (95% CI: 0.6, 3.7; 6/354) in the low-risk group. 3
32. Whelan H, Harmelink M, Chou E, et al. Complex febrile seizures-A systematic review. Dis Mon 2017;63:5-23. Review/Other-Dx N/A To critically analyze original literature to attempt to answer questions about complex febrile seizures. No abstract available. 4
33. Garvey MA, Gaillard WD, Rusin JA, et al. Emergency brain computed tomography in children with seizures: who is most likely to benefit? J Pediatr. 1998; 133(5):664-669. Observational-Dx 99 Retrospective review to determine if emergency brain CT in patients with new-onset seizures will benefit children. 19 children had brain abnormalities on CT. CT abnormalities requiring treatment or monitoring were more frequently seen in children with their first unprovoked seizure (P<.01) and in those whose seizure onset had been focal or who had focal abnormalities identified on postictal neurologic examination (P<.04). 3
34. Shinnar S, Bello JA, Chan S, et al. MRI abnormalities following febrile status epilepticus in children: the FEBSTAT study. Neurology. 2012;79(9):871-877. Observational-Dx 96 controls; 199 FSE children To determine the acute and long-term consequences of febrile status epilepticus (FSE) in childhood. A total of 22 (11.5%) children had definitely abnormal (n = 17) or equivocal (n = 5) increased T2 signal in the hippocampus following FSE compared with none in the control group (p < 0.0001). Developmental abnormalities of the hippocampus were more common in the FSE group (n = 20, 10.5%) than in controls (n = 2, 2.1%) (p = 0.0097) with hippocampal malrotation being the most common (15 cases and 2 controls). Extrahippocampal imaging abnormalities were present in 15.7% of the FSE group and 15.6% of the controls. However, extrahippocampal imaging abnormalities of the temporal lobe were more common in the FSE group (7.9%) than in controls (1.0%) (p = 0.015). 2
35. Jan M, Neville BG, Cox TC, Scott RC. Convulsive status epilepticus in children with intractable epilepsy is frequently focal in origin. Can J Neurol Sci. 2002; 29(1):65-67. Review/Other-Dx 18 A study on children with recurrent non-febrile convulsive status epilepticus to assess the evidence for focal origin. Clinical and radiological data was also reviewed. The patient's ages ranged between 6-22 years (mean 15.3, SD 4), and 67% were males. Most children (89%) had a severe cognitive and / or behavioural disorder. Most patients (89%) had multiple seizure types and 95% of these were partial seizures. Twelve (67%) children had at least one episode of CSE with focal features identified clinically. Focal brain abnormalities were detected on 18% and 55% of CT and MRI films respectively. Overall, 53% had a focal abnormality on structural neuroimaging. Interictal EEG revealed focal or multifocal abnormalities on at least one occasion in 94% and 22% of patients respectively. Overall, 17 patients had focal features on at least one EEG. Thirteen ictal EEGs were recorded on 11 (61%) patients. Ten (91%) of these recordings revealed a focal onset. 4
36. Arango JI, Deibert CP, Brown D, Bell M, Dvorchik I, Adelson PD. Posttraumatic seizures in children with severe traumatic brain injury. Childs Nerv Syst. 28(11):1925-9, 2012 Nov. Observational-Dx 130 cases To share the experience contributing to build evidence for better care. The incidence of early posttraumatic seizures (EPTS) observed in our population (19 %) exceeds those previously reported. Such findings likely reflect the importance of close monitoring including electroencephalographic (EEG). An association between the presence of EPTS and the development of late posttraumatic seizures (LPTS) was evidenced (p=0.001; 95 % CI 2.2, 16.5), while this association should not be assumed as a measure of causality, it should be considered for the management of patients presenting EPTS. Non-accidental trauma and young age were identified as independent predictors for the development of seizures. 3
37. Young AC, Costanzi JB, Mohr PD, Forbes WS. Is routine computerised axial tomography in epilepsy worth while? Lancet. 1982; 2(8313):1446-1447. Observational-Dx 220 To determine the value of routine CT of the brain in patients with epilepsy or isolated seizures. CT was normal in 94% of patients without focal features. Only a quarter of the abnormalities on CT were potentially treatable by surgery, and only 10% of all the patients had their management changed as a result of CT. 4
38. Ibrahim K, Appleton R. Seizures as the presenting symptom of brain tumours in children. Seizure. 2004; 13(2):108-112. Observational-Dx 81 To retrospectively review frequency of brain tumors presenting with seizures. In 10 (12%) of 81 children with brain tumor, seizures were the presenting clinical symptom. 4
39. Park JT, Chugani HT. Post-traumatic epilepsy in children-experience from a tertiary referral center. Pediatr Neurol. 52(2):174-81, 2015 Feb. Observational-Dx 321 children To review and analyze clinical variables in children following traumatic brain injury to understand the epidemiologic and clinical characteristics of post-traumatic epilepsy in our urban population. Patients who had severe traumatic brain injury and post-traumatic epilepsy had an abnormal acute head computed tomography. These patients had increased number of different seizure types, increased risk of intractability of epilepsy, and were on multiple antiepileptic drugs. Hypomotor seizure was the most common seizure type in these patients. There was a high prevalence of patients who suffered nonaccidental trauma, all of whom had severe traumatic brain injury. 3
40. Maytal J, Krauss JM, Novak G, Nagelberg J, Patel M. The role of brain computed tomography in evaluating children with new onset of seizures in the emergency department. Epilepsia. 2000; 41(8):950-954. Observational-Dx 66 Retrospective chart review to determine the diagnostic utility of emergency brain CT in children who present to the emergency department with new onset of seizures. Sixty-six patients, 34 boys and 32 girls with a mean age of 4.9 years, qualified for inclusion in the study. Fifty-two patients (78.8%) had normal CT results and 14 patients (21.2%) had abnormal CT results. Seizure cause was considered cryptogenic in 33 patients, of whom 2 (6%) had abnormal CT results; neither patient required intervention. Seizure cause was considered symptomatic in 20 patients, of whom 12 (60%) had abnormal CT results (p < 0.0001). In two patients with abnormal CT scans (both acute symptomatic), the imaging findings were of immediate therapeutic significance and were predictable from the clinical history and the physical examination. None of the 13 patients with complex febrile seizure cause had an abnormal CT scan. Patients with partial convulsive seizures were more likely to have abnormal CT scans than patients with generalized convulsive seizures, but the difference was not statistically significant. 4
41. Goldstein JL, Leonhardt D, Kmytyuk N, Kim F, Wang D, Wainwright MS. Abnormal neuroimaging is associated with early in-hospital seizures in pediatric abusive head trauma. Neurocrit Care. 15(1):63-9, 2011 Aug. Observational-Dx 54 cases To determine frequency and risks for in-hospital seizures after Abusive head trauma (AHT). A total of 54 cases of AHT were identified during the study period. During the first week following hospital admission, 33% of patients were observed to have clinical seizures. The occurrence of clinical seizures after admission was associated with findings on initial Computed tomography (CT) including midline shift, cerebral edema, and loss of gray white differentiation. Magnetic resonance imaging (MRI) findings associated with clinical seizures after admission included midline shift, cerebral edema, infarction, and restricted diffusion. The presenting complaint of seizures or acute mental status changes well as a variety of abnormal imaging findings including gray white blurring, infarction, and edema were associated with shortterm outcomes. 2
42. Hart YM, Sander JW, Johnson AL, Shorvon SD. National General Practice Study of Epilepsy: recurrence after a first seizure. Lancet. 1990; 336(8726):1271-1274. Observational-Dx 564 To assess 2 to 4 year follow-up of patients with definite seizures. 67% (95% CI: 63%-71%) had a recurrence within 12 months of the first seizure, and 78% (74%-81%) had a recurrence within 36 months. Seizures associated with a neurological deficit (present at birth) had a high rate of recurrence (100% by 12 months), while seizures that occurred within 3 months of an acute insult to the brain, had a lower risk of recurrence (40% [29%-51%] by 12 months. 3
43. Hirtz DG. Generalized tonic-clonic and febrile seizures. Pediatr Clin North Am. 1989; 36(2):365-382. Review/Other-Dx N/A To review generalized and febrile seizures. Children with febrile seizures have a good prognosis, and only a small minority of children go on to become epileptic. Most outgrow the tendency to have seizures, and the seizures do not appear to cause lasting intellectual or neurologic damage. Relatively few children need be exposed to daily anticonvulsant therapy, and these would be primarily children whose clinical picture is quite atypical. 4
44. Wootton-Gorges SL, Soares BP, Alazraki AL, et al. ACR Appropriateness Criteria® Suspected Physical Abuse-Child. J Am Coll Radiol 2017;14:S338-S49. Review/Other-Dx N/A Evidence-based guidelines to assist referring physicians and other providers in making the most appropriate imaging or treatment decision for suspected physical abuse-child. No results stated in the abstract 4
45. Greiner MV, Greiner HM, Care MM, Owens D, Shapiro R, Holland K. Adding Insult to Injury: Nonconvulsive Seizures in Abusive Head Trauma. Journal of Child Neurology. 30(13):1778-84, 2015 Nov. Review/Other-Dx 199 subjects To determine the prevalence of nonconvulsive seizures and nonconvulsive status epilepticus in patients with abusive head trauma who underwent electroencephalography (EEG) monitoring and to describe predictive factors for this population. Of these, 20 (27.4%) had nonconvulsive seizures and 3 (4.1%) had nonconvulsive status epilepticus. The presence of subarachnoid hemorrhage and cortical T2 / fluid-attenuated inversion recovery signal abnormalities were both significantly associated with the presence of nonconvulsive seizures / nonconvulsive status epilepticus. 4
46. Reinus WR, Wippold FJ, 2nd, Erickson KK. Seizure patient selection for emergency computed tomography. Ann Emerg Med. 1993; 22(8):1298-1303. Observational-Dx 115 patients: 60-known seizure disorder; 38-new onset seizure; 17-possible seizure To retrospectively evaluate the medical records of patients with seizures to determine the need for emergency CT. Results of neurologic examination and CT were compared in 105 patients. Abnormal neurologic examination predicted 19/20 positive CT scans (95%) and demonstrated a strong association with CT results (P<.00004). Only a history of malignancy correlated to CT findings (P<.008). According to the results, the greatest benefit from emergency CT will be from patients with either a history of malignancy or an abnormal neurologic examination. 3
47. Itomi K, Okumura A, Negoro T, et al. Prognostic value of positron emission tomography in cryptogenic West syndrome. Dev Med Child Neurol. 2002; 44(2):107-111. Review/Other-Dx 17 To examine the prognostic value of PET in cryptogenic West syndrome. Cortical hypometabolism was detected in 11 infants on the first PET and in 5 infants on the second. Rate of developmental delay at the last follow-up was significantly higher in infants with hypometabolism on the second PET than in those without PET abnormalities (p<0.05). Rate of seizure occurrence after initial treatment was higher in infants with cortical hypometabolism on the second PET, but the difference was not statistically significant. 4
48. Otsubo H, Chuang SH, Hwang PA, Gilday D, Hoffman HJ. Neuroimaging for investigation of seizures in children. Pediatr Neurosurg. 1992; 18(2):105-116. Review/Other-Dx N/A Review value of different imaging modalities in children with seizures. A number of imaging modalities (CT, MRI, and Xenon CT, SPECT and PET) are being used for studying the abnormality in order to help plan surgery. 4
49. Dayan PS, Lillis K, Bennett J, et al. Prevalence of and Risk Factors for Intracranial Abnormalities in Unprovoked Seizures. Pediatrics. 136(2):e351-60, 2015 Aug. Observational-Dx 444 children To determine the prevalence of, and risk factors for, relevant intracranial abnormalities in children with first, unprovoked seizures. We enrolled 475 of 625 (76%) eligible patients. Of 354 patients for whom cranial magnetic resonance imaging (MRI) or computed tomography (CT) scans were obtained in the Emergency department (ED) or within 4 months of the ED visit, 40 (11.3%; 95% confidence interval [CI]: 8.0–14.6%) had clinically relevant intracranial abnormalities, with 3 (0.8%; 95% CI: 0.1–1.8%) having emergent/urgent abnormalities. On logistic regression analysis, a high-risk past medical history (adjusted odds ratio: 9.2; 95% CI: 2.4–35.7) and any focal aspect to the seizure (odds ratio: 2.5; 95% CI: 1.2–5.3) were independently associated with clinically relevant abnormalities. 2
50. Lefkopoulos A, Haritanti A, Papadopoulou E, Karanikolas D, Fotiadis N, Dimitriadis AS. Magnetic resonance imaging in 120 patients with intractable partial seizures: a preoperative assessment. Neuroradiology. 2005; 47(5):352-361. Review/Other-Dx 120 To describe MRI findings in patients with intractable partial seizures and compare different MR sequences. Coronal, thin images are most useful in the assessment of the hippocampus. Fluid-attenuated inversion recovery (FLAIR) and inversion recovery (IR) are useful in the detection of lesions abutting cerebrospinal fluid spaces and developmental disorders, respectively, while T1 SE sequences before and after the intravenous administration of gadolinium offer great facility in identifying space-occupying lesions and infections. MRI is the most important diagnostic tool for the assessment of epileptogenic foci. 4
51. Wu WC, Huang CC, Chung HW, et al. Hippocampal alterations in children with temporal lobe epilepsy with or without a history of febrile convulsions: evaluations with MR volumetry and proton MR spectroscopy. AJNR Am J Neuroradiol. 2005; 26(5):1270-1275. Observational-Dx 55 To assess the hippocampal alterations in epileptic children with or without a history of febrile convulsions by using MR spectroscopy and volumetry. Children with temporal lobe epilepsy and early history of febrile convulsion tend to have lower hippocampal volumes and NAA/(Cr + Cho) ratios than do temporal lobe epilepsy children without history of febrile convulsion. MR volumetry and spectroscopy are equally capable of showing the trends of hippocampal alternations in children with temporal lobe epilepsy with or without febrile history. 3
52. Avery RA, Zubal IG, Stokking R, et al. Decreased cerebral blood flow during seizures with ictal SPECT injections. Epilepsy Res. 2000;40(1):53-61. Observational-Dx 21 patients had ictal and interictal HMPAO SPECT scans To determine whether ictal SPECT injections demonstrate a similar change in regional cerebral blood flow around 100 s from seizure onset. By examining ictal SPECT injections made 90 s after seizure onset, evidence was found that reduced regional cerebral blood flow may exist during ictus. Change in regional cerebral blood flow around 90 s is also observed in postictal injections, suggesting a common metabolic mechanism may be responsible. 3
53. Aprahamian N, Harper MB, Prabhu SP, et al. Pediatric first time non-febrile seizure with focal manifestations: is emergent imaging indicated?. Seizure. 23(9):740-5, 2014 Oct. Review/Other-Dx 319 patients To assess the prevalence of clinically urgent intra-cranial pathology among children who had imaging for a first episode of non-febrile seizure with focal manifestations. We identified 319 patients having a median age of 4.6 years [interquantile range (IQR) 1.8–9.4] of which 45% were female. Two hundred sixty-two children had a computed tomography (CT) scan, 15 had an magnetic resonance (MR) and 42 had both. Clinically urgent intra-cranial pathology was identified on imaging of 13 patients (4.1%; 95% CI: 2.2, 7.0). Infarction, hemorrhage and thrombosis were most common (9/13). Twelve of 13 were evident on CT scan. Persistent Todd’s paresis and age 18 months were predictors of clinically urgent intracranial pathology. Absence of secondary generalization and multiple seizures on presentation were not predictive. 4
54. Avery RA, Spencer SS, Spanaki MV, Corsi M, Seibyl JP, Zubal IG. Effect of injection time on postictal SPET perfusion changes in medically refractory epilepsy. Eur J Nucl Med. 1999; 26(8):830-836. Observational-Dx 27 patients receiving postictal and interictal SPET scans To examine effect of injection time on postictal SPET perfusion changes in medically refractory epilepsy. Most patients (8/12, 67%) receiving postictal injections within 100 s after seizure onset demonstrated hyperperfusion, while all patients (15/15, 100%) receiving postictal injections >100 after seizure onset showed hypoperfusion. Explanation of this phenomenon is unknown but findings appear to parallel known changes in cerebral lactate levels. 3
55. Weil S, Noachtar S, Arnold S, Yousry TA, Winkler PA, Tatsch K. Ictal ECD-SPECT differentiates between temporal and extratemporal epilepsy: confirmation by excellent postoperative seizure control. Nucl Med Commun. 2001; 22(2):233-237. Observational-Dx 30 To determine whether SPECT can separate temporal (TE) lobe from extra temporal lobe epilepsy (ETE). Ictal SPECT showed isolated temporal hyperperfusion in 90% of TE patients and normal perfusion in two patients. Sensitivity of ictal ECD-SPECT for correct localization of the seizure onset zone was 80% in all patients, 86% in TE patients and 66% in ETE patients. Ictal ECD-SPECT can be used to distinguish between TE and ETE. 3
56. Calcagni ML, Giordano A, Bruno I, et al. Ictal brain SPET during seizures pharmacologically provoked with pentylenetetrazol: a new diagnostic procedure in drug-resistant epileptic patients. Eur J Nucl Med Mol Imaging. 2002; 29(10):1298-1306. Observational-Dx 33 To prove feasibility of pharmacologic induced seizures in ictal SPET. In 27 of 33 patients (82%), interictal-ictal SPET showed the hypo-hyperperfusion SPET pattern. Video-EEG showed a single epileptogenic zone in 21/33 patients (64%), and MRI showed anatomical lesions in 19/33 patients (57%). Ictal brain SPET provides ictal images because (99m)-Tc-ECD is injected immediately upon seizure onset. 2
57. Mohan KK, Chugani DC, Chugani HT. Positron emission tomography in pediatric neurology. Semin Pediatr Neurol. 1999; 6(2):111-119. Review/Other-Dx N/A To review utility of PET in pediatric neurology. In patients with intractable partial seizures, PET helps to localize focus for resection. 4
58. Olszewska DA, Costello DJ. Assessment of the usefulness of magnetic resonance brain imaging in patients presenting with acute seizures. Ir J Med Sci. 183(4):621-4, 2014 Dec. Observational-Dx 91 studies To prospectively determine the usefulness of early Magnetic Resonance Imaging (MRI) brain in a cohort of patients presenting with acute seizures. Of the 91 studies, 51 were normal (56 %). The remaining 40 studies were abnormal as follows: microvascular disease (usually moderate/severe) (n = 19), posttraumatic gliosis (n = 7), remote symptomatic lesion (n = 6), primary brain tumour (n = 5), venous sinus thrombosis (n = 3), developmental lesion (n = 3), postsurgical gliosis (n = 3) and single cases of demyelination, unilateral hippocampal sclerosis, lobar haemorrhage and metastatic malignant melanoma. Abnormalities in diffusion- weighted sequences that were attributable to prolonged ictal activity were seen in nine patients, all of who had significant ongoing clinical deficits, most commonly delirium. Of the 40 patients with abnormal MRI studies, seven patients had unremarkable computed tomography (CT) brain. MR brain imaging revealed the underlying cause for acute seizures in 44 % of patients. CT brain imaging failed to detect the cause of the acute seizures in 19 % of patients in whom subsequent MRI established the cause. 2
59. Juhasz C, Chugani DC, Padhye UN, et al. Evaluation with alpha-[11C]methyl-L-tryptophan positron emission tomography for reoperation after failed epilepsy surgery. Epilepsia. 2004; 45(2):124-130. Observational-Dx 33 To determine role of PET using alpha-[11C] methyl-L-tryptophan (AMT) in detecting nonresected epileptic foci in patients with previously failed neocortical resection. AMT-PET can identify nonresected epileptic cortex and assist in planning reoperation. 3
60. Kalnin AJ, Fastenau PS, deGrauw TJ, et al. Magnetic resonance imaging findings in children with a first recognized seizure. Pediatr Neurol. 2008; 39(6):404-414. Review/Other-Dx 281 children A large prospective study to characterize structural abnormalities associated with onset of seizures in children, using magnetic resonance imaging and a standardized classification system. At least one magnetic resonance imaging abnormality was identified in 87 of 281 (31%) children with a first recognized seizure. Two or more abnormalities were identified in 34 (12%). The commonest abnormalities were ventricular enlargement (51%), leukomalacia/gliosis (23%), gray-matter lesions such as heterotopias and cortical dysplasia (12%), volume loss (12%), other white-matter lesions (9%), and encephalomalacia (6%). Abnormalities defined as significant, or potentially related to seizures, occurred in 40 (14%). Temporal lobe and hippocampal abnormalities were detected at a higher frequency than in previous studies (13/87). Magnetic resonance imaging and a standardized, reliable, valid scoring system demonstrated a higher rate of abnormal findings than previously reported, including findings formerly considered incidental. Practice parameters may need revision, to expand the definition of significant abnormalities and support wider use of magnetic resonance imaging in children with newly diagnosed seizures. 4
61. Singh RK, Stephens S, Berl MM, et al. Prospective study of new-onset seizures presenting as status epilepticus in childhood. Neurology. 74(8):636-42, 2010 Feb 23. Review/Other-Dx 1,382 patients To characterize children with new-onset seizures presenting as status epilepticus at a tertiary care children's hospital. A total of 144 patients presented in status epilepticus. The average age was 3.4 years. The majority of seizures (72%) lasted between 21 and 60 minutes. The majority of patients had no significant past medical history; one-fourth had a family history of epilepsy. Five (4%) patients with EEGs had electrographic seizures during the study, captured only with prolonged monitoring. The most common etiology was febrile convulsion, followed by cryptogenic. The most common acute symptomatic cause was CNS infection; the most common remote symptomatic cause was cerebral dysgenesis. Combined CT and MRI provided a diagnosis in 30%. CT was helpful in identifying acute vascular lesions and acute edema, whereas MRI was superior in identifying subtle abnormalities and remote symptomatic etiologies such as dysplasia and mesial temporal sclerosis. 4
62. Yang PJ, Berger PE, Cohen ME, Duffner PK. Computed tomography and childhood seizure disorders. Neurology. 1979;29(8):1084-1088. Review/Other-Dx N/A To review the computed tomography (CT) images in childhood seizure disorders. No results stated in abstract. 4
63. Lyons TW, Johnson KB, Michelson KA, et al. Yield of emergent neuroimaging in children with new-onset seizure and status epilepticus. Seizure. 35:4-10, 2016 Feb. Observational-Dx 177 children To determine the yield of emergent neuroimaging among children with new-onset seizures presenting with status epilepticus. We included 177 children presenting with new-onset seizure with status epilepticus, of whom 170 (96%) had neuroimaging performed. Abnormal findings were identified on neuroimaging in 64/177 (36%, 95% confidence interval 29–43%) children with 15 (8.5%, 95% confidence interval 5.2–14%) children having urgent or emergent pathology. Four (27%) of the 15 children with urgent or emergent findings had a normal non-contrast computed tomography scan and a subsequently abnormal magnetic resonance image. Longer seizure duration and older age were associated with urgent or emergent intracranial pathology. 2
64. Lascano AM, Perneger T, Vulliemoz S, et al. Yield of MRI, high-density electric source imaging (HD-ESI), SPECT and PET in epilepsy surgery candidates. Clinical Neurophysiology. 127(1):150-155, 2016 Jan. Observational-Tx 190 patients To determine which procedure or combination of procedures is the most predictive of seizure-free outcome in patients undergoing epilepsy surgery. Of 190 patients, 148 (77.9%) were seizure-free at follow-up. Resection of the epileptogenic focus was associated with favorable postsurgical outcome (p < 0.05). Among 58 patients who underwent all tests, only magnetic resonance imaging [MRI] and High density electric source imaging (HD-ESI) were favorable outcome predictors (MRI: OR 10.9, p = 0.004; HD-ESI: OR 13.1, p = 0.004). Patients with concordant structural MRI and HD-ESI results had 92.3% (24/26) probability of favorable outcome. When both results were negative, probability was 0% (0/5); and when they disagreed, it was 63.0% (17/27). 2
65. Thivard L, Bouilleret V, Chassoux F, et al. Diffusion tensor imaging can localize the epileptogenic zone in nonlesional extra-temporal refractory epilepsies when [(18)F]FDG-PET is not contributive. Epilepsy Res. 97(1-2):170-82, 2011 Nov. Observational-Dx 20 patients; 40 controls To examine the localizing value of these noninvasive techniques in pre-surgical evaluation of refractory nonlesional epilepsy including both temporal lobe epilepsy (TLE) and extra-TLE. The best sensitivity was provided by Visual analysis (vPET) unblinded (75%) and the best specificity (60%) by diffusion tensor imaging (DTI). The sensitivity of vPET blinded (55%) was lower and those of [statistical parametric mapping (SPM) SPM analysis] (sPET) (40%) and voxel-based-morphometry (VBM) (35%) were still lower. In TLE, vPET analyzed either blinded or unblinded, performed the best and additional use of the other tools improved slightly the sensitivity. For extra-TLE, combining vPET and DTI results increased the number of pertinent abnormalities detected especially for circumscribed changes in frontal lobe epilepsy (FLE). 2
66. de Ribaupierre S, Fohlen M, Bulteau C, et al. Presurgical language mapping in children with epilepsy: clinical usefulness of functional magnetic resonance imaging for the planning of cortical stimulation. Epilepsia. 53(1):67-78, 2012 Jan. Review/Other-Dx 8 children To describe the concordance/complementarity of language functional magnetic resonance imaging (fMRI) and depth electrode stimulations to optimize language mapping in a small series of epilepsy children. fMRI during sentence generation robustly showed activation in the whole perisylvian regions with little reorganization (left hemisphere dominant in 7). Of the 184 electrode contacts tested for language, only 8 were positive (language disruption) in three of the seven patients with periictal language impairment and left language dominance. All of the positive contacts colocalized with an fMRI activated cluster, that is, fMRI did not miss any region critical to language (sensitivity = 100%). However, 54 of the 176 negative contacts were within activated clusters (low specificity). 4
67. Allen L, Jones CT. Emergency department use of computed tomography in children with epilepsy and breakthrough seizure activity. J Child Neurol. 22(9):1099-101, 2007 Sep. Review/Other-Dx 124 children To determine whether the National Cancer Institute statement made an impact on the number of head CT scans ordered. There was a significant increase (P = .016) in the number of CT scans performed from the years 2000-2001 to the years 2003-2004. Of the 21 children who had CT scans, 15 (71%) children did not meet American Academy of Neurology guidelines for an emergent CT scan. None of the children had an acute finding on CT, and all were discharged from the emergency department. 4
68. Leach JL, Miles L, Henkel DM, et al. Magnetic resonance imaging abnormalities in the resection region correlate with histopathological type, gliosis extent, and postoperative outcome in pediatric cortical dysplasia. J Neurosurg Pediatrics. 14(1):68-80, 2014 Jul. Observational-Dx 23 male; 20 female pediatric patients To correlate histopathological features, magnetic resonance imaging (MRI) findings, and postsurgical outcomes in children with cortical dysplasia (CD) by performing a novel resection site–specific evaluation. There were 89 resection regions (50 International League Against Epilepsy (ILAE) Type I, 29 Type IIa, and 10 Type IIb). Eleven (25.6%) of 43 children had more than one type of cortical dysplasia (CD). The authors observed MRI abnormalities in 63% of patients, characteristic enough to direct resection (lesional) in 42%. Most MRI features, MRI score = 3, and lesional abnormalities were more common in patients with Type II CD. Increased cortical signal was more common in those with Type IIb (70%) rather than Type IIa (17.2%) CD (p = 0.004). A good outcome was demonstrated in 39% of children with Type I CD and 72% of those with Type II CD (61% in Type IIa and 100% in Type IIb) (p = 0.03). A lesional MRI abnormality and an MRI score greater than 3 correlated with good outcome in 78% and 90% of patients, respectively (p < 0.03). Diffuse cortical gliosis was more prevalent in Type II CD and in resection regions exhibiting MRI abnormalities. Complete surgical exclusion of the MRI abnormality was associated with a better postoperative outcome. 2
69. Kim YH, Kang HC, Kim DS, et al. Neuroimaging in identifying focal cortical dysplasia and prognostic factors in pediatric and adolescent epilepsy surgery. Epilepsia. 52(4):722-7, 2011 Apr. Observational-Dx 48 cases To determine the sensibility of each imaging tool in identifying focal cortical dysplasia (FCD) in children and adolescents with epilepsy and to define the prognostic factors of pediatric and adolescent epilepsy surgery. Brain magnetic resonance imaging (MRI) was able to localize FCD in 30 patients and fluorodeoxyglucose positron emission tomography (FDG-PET) and/or subtraction ictal single photon emission computed tomography (SPECT) coregistered with MRI provided additional information that helped to define the lesion in 13 patients. When comparing the pathologic results between a mild malformation of cortical development (MCD) and FCD type I and II, we noted a strong tendency for patients with FCD to have MRI abnormalities (p = 0.005). In addition, severe pathologic features (Palmini’s classification, FCD type II) (p = 0.025) showed significant correlation with a better surgical outcome. To define the primary epileptogenic area, various interictal epileptiform discharges and the results of multimodal neuroimaging studies were helpful, and younger age at the time of operation could aid in more favorable surgical outcomes (p = 0.048). Our study showed a significant relationship between pathologic grade and the detectability of FCD by brain MRI. In addition, early surgery can be justified by showing that advanced neuroimaging studies in children with FCD and even with extensive epileptiform discharges have a higher rate of success. 2
70. Menon RN, Radhakrishnan A, Parameswaran R, et al. Does F-18 FDG-PET substantially alter the surgical decision-making in drug-resistant partial epilepsy?. Epilepsy Behav. 51:133-9, 2015 Oct. Observational-Dx 117 patients To critically analyze the utility of F-18 fluoro-deoxy-glucose positron emission tomography (FDG-PET) in the presurgical evaluation and surgical selection of patients with drug-resistant partial epilepsy (DRE) based on the results obtained through its use in our comprehensive epilepsy program. Of the 117 patients (age: 5–42 years) who underwent F-18 FDG-PET, 64 had normal MRI, and 53 had lesions. Electroclinical data favored temporal ictal onset in 48 (41%), extratemporal in 60 (51.3%), and uncertain lobar localization in 9 (7.7%). The topography of PET hypometabolism was localizing in 53 (45.3%), lateralizing in 12 (10.3%), and 52 (44.4%) had either normal or discordant results. In the nonlesional group, focal hypometabolism was concordant to the area of ictal onset in 27 (41.5%) versus 38 (58.5%) in the lesional group (p = 0.002). Greater concordance was noted in temporal lobe epilepsy (TLE) (78.0%) as compared to extratemporal epilepsy (ETPE) (28.6%) (p b 0.001). Positron emission tomography was more concordant in patients with mesial temporal sclerosis than in those with other lesions (82.8% versus 50%) (p = 0.033). Positron emission tomography helped in surgical decision-making in 68.8% of TLE and 23.3% of ETPE cases. Overall, 37 patients (31.6%) were directly selected for resective surgery based on PET results. 3
71. Perissinotti A, Setoain X, Aparicio J, et al. Clinical Role of Subtraction Ictal SPECT Coregistered to MR Imaging and (18)F-FDG PET in Pediatric Epilepsy. J Nucl Med. 55(7):1099-105, 2014 Jul. Observational-Dx 54 children To evaluate the usefulness of radionuclide imaging techniques for presurgical evaluation of epileptic pediatric patients, we compared the results of video electroencephalography (EEG), brain magnetic resonance (MR) imaging, interictal single photon emission computed tomography (SPECT), ictal SPECT, subtraction ictal SPECT coregistered to MR imaging (SISCOM), and interictal positron emission tomography (PET) with 18 fludeoxyglucose (18F-FDG). SISCOM and 18F-FDG PET concordance with the presumed location of the epileptogenic zone (PEZ) was significantly higher than MR imaging (P , 0.05). MR imaging showed localizing results in 21 of 54 cases (39%), SISCOM in 36 of 54 cases (67%), and 18F-FDG PET in 31 of 54 cases (57%). If we consider SISCOM and 18F-FDG PET results together, nuclear medicine imaging techniques showed coinciding video-EEG results in 76% of patients (41/54). In those cases in which MR imaging failed to identify any epileptogenic lesion (61% [33/54]), SISCOM or 18F-FDG PET findings matched PEZ in 67% (22/33) of cases. 3
72. Widjaja E, Shammas A, Vali R, et al. FDG-PET and magnetoencephalography in presurgical workup of children with localization-related nonlesional epilepsy. Epilepsia. 54(4):691-9, 2013 Apr. Observational-Dx 65 patients To evaluate sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of Fluoro-2-deoxy-D-glucose positron emission tomography (FDG-PET), magnetoencephalography (MEG), FDGPET + MEG, and FDG-PET/MEG in children with nonlesional localization-related epilepsy. Sixteen (72.7%) of 22 had Engel I seizure outcome. MEG was concordant with surgical resection in 18 patients, 14 had Engel I, and four had Engel II–IV outcomes. MEG was nonlocalizing or nonconcordant in four patients; two patients had Engel I and two had Engel II–IV outcomes. FDG-PET was concordant with surgical resection in 14 patients; 9 had Engel I outcome, and 5 had Engel II–IV outcome. FDG-PET was nonlocalizing or nonconcordant in seven patients with Engel I, and one with Engel III outcome. The sensitivity, specificity, PPV, and NPV of MEG were 85.0%, 99.1%, 94.4%, and 97.3%, respectively. The sensitivity, specificity, PPV, and NPV of FDG-PET were 65.0%, 94.4%, 68.4%, and 93.6%, respectively. There was no significant difference between MEG and FDG-PET for concordance with surgical resection (v2 = 2.794, p = 0.095). FDG-PET + MEG, defined as two tests concordant with surgical resection, had reduced sensitivity and NPV, but increased specificity and PPV (55.0%, 92.3%, 100%, and 100%, respectively) relative to individual tests. FDG-PET/MEG, defined as one or both test(s) concordant with surgical resection, had increased sensitivity and NPV but reduced specificity (95.0%, 99.0%, and 93.5%, respectively) relative to individual tests. The two tests FDG-PET and MEG were complementary in the assessment of children with localization- related epilepsy, particularly when one test was nonlocalizing or nonconcordant. 2
73. LoPinto-Khoury C, Sperling MR, Skidmore C, et al. Surgical outcome in PET-positive, MRI-negative patients with temporal lobe epilepsy. Epilepsia. 53(2):342-8, 2012 Feb. Observational-Dx 193 patients To determine whether invasive monitoring altered surgical outcomes in this group of patients. There were 46 positron emission computed tomography/+ magnetic resonance imaging (PET+/MRI) patients (of whom 36 had 2-year surgical outcome available) and 147 mesial temporal sclerosis (MTS) patients. There was no difference between the two groups with regard to history of febrile convulsions, generalized tonic–clonic seizures, interictal spikes, depression, or family history. Mean age at first seizure was higher in PET+/MRI) patients (19 ± 13 vs.14 ± 13 years, Mann-Whitney test, p = 0.008) and disease duration was shorter (14 ± 10 vs. 22 ± 13 years, student’s t-test, p = 0.0006). Class I surgical outcomes did not differ significantly between the PET+/MRI) patients and the MTS group (2 and 5 year outcomes were 76% and 75% for the PET+/MRI) group, and 71% and 78% for the MTS group); neither did outcomes of the PET+/MRI) patients who were implanted prior to resection versus those who went directly to surgery (implanted patients had 71% and 67% class I outcomes at 2 and 5 years, whereas. nonimplanted patients had 77% and 78% class I outcomes, p = 0.66 and 0.28). Kaplan-Meier survival statistics for both comparisons were nonsignificant at 5 years. Dentate gyrus and hilar cell counts obtained from pathology for a sample of patients also did not differ between groups.PET-positive, MRI-negative temporal lobe epilepsy (TLE) patients in our study had excellent surgical outcomes after anterior temporal lobectomy (ATL), very similar to those in patients with MTS, regardless of whether or not they undergo intracranial monitoring. These patients should be considered prime candidates for ATL, and intracranial monitoring is probably unnecessary in the absence of discordant data. 2
74. Fernandez S, Donaire A, Seres E, et al. PET/MRI and PET/MRI/SISCOM coregistration in the presurgical evaluation of refractory focal epilepsy. Epilepsy Research. 111:1-9, 2015 Mar. Observational-Dx 35 patients To investigate the usefulness of coregistration of positron emission tomography (PET) and magnetic resonance imaging (MRI) findings (PET/MRI) and of coregistration of PET/MRI with subtraction ictal single-photon emission computed tomography (SPECT) coregistered to MRI (SISCOM) (PET/MRI/SISCOM) in localizing the potential epileptogenic zone in patients with drug-resistant epilepsy. Structural MRI showed no lesions in 15 patients. In these patients, PET/MRI coregistration showed a hypometabolic area in 12 (80%) patients that was concordant with seizure onset zone on EEG in 9. In 7 patients without MRI lesions, PET/MRI detected a hypometabolism that was undetected on PET alone. SISCOM, obtained in 25 patients, showed an area of hyperperfusion concordant with the seizure onset zone on EEG in 7 (58%) of the 12 of these patients who had normal MRI findings. SISCOM hyperperfusion was less extensive than PET hypometabolism. A total of 19 patients underwent surgery; 11 of these underwent invasive-EEG monitoring and the seizure onset zone was concordant with PET/MRI in all cases. PET/MRI/SISCOM coregistration, performed in 4 of these patients, was concordant in 3 (75%). After epilepsy surgery, 13 (68%) patients are seizure-free after a mean follow-up of 4.5 years. 3
75. Shin HW, Jewells V, Sheikh A, et al. Initial experience in hybrid PET-MRI for evaluation of refractory focal onset epilepsy. Seizure. 31:1-4, 2015 Sep. Observational-Dx 29 patients To evaluate the utility/improved accuracy of hybrid PET/MR compared to current practice separate 3T MRI and PET-CT imaging for localization of seizure foci. The median interval between hybrid PET/MR and prior imaging studies was 5 months (range 1-77 months). In 24 patients, there was no change in the read between the clinical exams and hybrid PET/MR while new anatomical or functional lesions were identified by hybrid PET/MR in 5 patients without significant clinical change. Four new anatomical MR lesions were seen with concordant PET findings. The remaining patient revealed a new abnormal PET lesion without an MR abnormality. All new PET/MR lesions were clinically significant with concordant EEG and/or SPECT results as potential epileptic foci. 3
76. Kudr M, Krsek P, Maton B, et al. Ictal SPECT is useful in localizing the epileptogenic zone in infants with cortical dysplasia. Epileptic Disord. 18(4):384-390, 2016 Dec 01. Observational-Dx 13 infants To assess the localizing value of ictal single-photon emission computed tomography (SPECT) in very young epilepsy surgery candidates when cerebral haemodynamic responses are known to be immature. All five patients with complete resection of the ictal SPECT hyperperfusion zone were seizure-free compared to only one of eight patients with incomplete or no excision of hyperperfusion zones (p=0.00843). Similar results were noted for the magnetic resonance imaging/ intracranial electroencephalography (MRI/iEEG)-defined epileptogenic region; five of six patients with complete removal were seizure-free, whereas only one of seven incompletely resected patients was seizure-free (p=0.02914). All four patients who underwent complete resection of both regions were seizure-free compared to none of the six with incomplete resection (p=0.01179). 2
77. Desai A, Bekelis K, Thadani VM, et al. Interictal PET and ictal subtraction SPECT: sensitivity in the detection of seizure foci in patients with medically intractable epilepsy. Epilepsia. 54(2):341-50, 2013 Feb. Observational-Dx 53 patients To determine the relative utility of interictal PET and ictal subtraction SPECT in the localization of seizure foci, the authors compared interictal PET and ictal subtraction SPECT to subdural and depth electrode recordings in patients with medically intractable epilepsy. 53 patients underwent ICEEG monitoring with preoperative interictal PET and ictal subtraction SPECT scans. The average patient age was 32.7 years (median 32 years, range 1-60 years). 27 patients had findings of reduced metabolism on interictal PET scan, whereas all 53 patients studied demonstrated a region of relative hyperperfusion on ictal subtraction SPECT suggestive of an epileptogenic zone. ICEEG monitoring identified a single seizure focus in 45 patients, with 39 eventually undergoing resective surgery. Of the 45 patients in whom a seizure focus was localized, PET scan identified the same region in 25 cases (56% sensitivity) and SPECT in 39 cases (87% sensitivity). ICEEG was concordant with at least one study in 41 cases (91%) and both studies in 23 cases (51%). In 16 (80%) of 20 cases where PET did not correlate with ICEEG, the SPECT study was concordant. Conversely, PET and ICEEG were concordant in 2 (33%) of the 6 cases where the SPECT did not demonstrate the seizure focus outlined by ICEEG. 33 patients had surgical resection and >2 years of follow-up, and 21 of these (64%) had Engel class 1 outcome. No significant effect of imaging concordance on seizure outcome was seen. 3
78. Krsek P, Kudr M, Jahodova A, et al. Localizing value of ictal SPECT is comparable to MRI and EEG in children with focal cortical dysplasia. Epilepsia. 54(2):351-8, 2013 Feb. Observational-Dx 106 subjects To assess the predictive value of ictal singlephoton emission computed tomography (SPECT) for outcome after excisional epilepsy surgery in a large population of children with focal cortical dysplasia (FCD). The extent of hyperperfusion was focal or lobar in 58%, whereas multilobar activations occurred in only 32%; hemispheric or bilateral findings were rare. Favorable postsurgical seizure outcome was achieved in 67% patients with nonlocalized SPECT findings, 45% with nonresected ictal hyperperfusion, 36% with partially resected ictal hyperperfusion, and 86% when the zone of ictal hyperperfusion was completely resected (p = 0.000198). The favorable postsurgical outcome after complete removal of the SPECT hyperperfusion zone surpassed the 75% rate of seizure freedom in patients with removal of magnetic resonance imaging (MRI)/ electroencephalography (EEG)-defined epileptogenic region. A similar predictive value of ictal SPECT for seizure outcome was found in nonoperated patients and subjects who were undergoing reoperation. Subcortical activation conferred no predictive value. Ictal SPECT helps to define the epileptogenic zone in a high proportion of children with FCD undergoing surgical evaluation. Complete removal of both SPECT and MRI/EEG-defined regions is a strong predictor of surgical success and has important implications for surgical planning. 2
79. Chandra PS, Vaghania G, Bal CS, et al. Role of concordance between ictal-subtracted SPECT and PET in predicting long-term outcomes after epilepsy surgery. Epilepsy Res. 108(10):1782-9, 2014 Dec. Observational-Dx 123 patients To analyze the role of inter-concordance between fluorodeoxyglucose positron emission tomography (FDG-PET) and ictally subtracted single photon emission tomography (iSPECT) in predicting long-term outcomes after epilepsy surgery. One hundred twenty-three patients (74 males) were included in the study (mean age at time of surgery: 18.9 ± 10.41 years). The mean age of onset of seizures was 9.87 ± 8.37 years. The most common semiology was complex partial (45%). When both FDG-PET and iSPECT were concordant with each other, this translated into a (class I Engel at 5 years) outcome of 62% for extra-temporal epilepsies (provided they were also concordant with the lesion, as defined by magnetic resonance imaging (MRI) and video electroencephalography (vEEG)). This percentage was significant (p < 0.01) compared with all other situations (both FDG-PET/iSPECT not concordant to MRI/vEEG, only PET or iSPECT concordant with MRI/vEEG). This correlation was not found for the temporal epilepsies, where the MRI and vEEG were the most important prognostic parameters. In both temporal and extratemporal epilepsies the concordance of the iSPECT/FDG-PET with the MRI/vEEG correlated with a better 5-year outcome (temporal: 70% vs 25%; extra-temporal: 62% vs 33%; p < 0.05). 2
80. American College of Radiology. ACR Appropriateness Criteria® Radiation Dose Assessment Introduction. Available at: https://www.acr.org/-/media/ACR/Files/Appropriateness-Criteria/RadiationDoseAssessmentIntro.pdf. Review/Other-Dx N/A To provide evidence-based guidelines on exposure of patients to ionizing radiation. No abstract available. 4
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