Role of Neuroimaging and Electroencephalogram in Children ... … · 3-Clinical Neurophysiology, Faculty of Medicine- Cairo University, Egypt. Introduction Seizure is a common neurological

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Full Length Research Paper

Role of Neuroimaging and Electroencephalogram in Children with First Afebrile and Complex Febrile Seizures

Mohamed Salah Tafeek Elfeshawy1*; Ali Abdellatif Afia2; Ahmed Yousef Alsawah2; Mahmoud Ismail Mohammed2 and Ann AliAbdelkader3 1-Radiodiagnosis Department, Faculty of Medicine (For Boys), Al-Azhar University, Cairo, Egypt. 2-Pediatric Department, Faculty of Medicine (For Boys), Al-Azhar University, Cairo, Egypt. 3-Clinical Neurophysiology, Faculty of Medicine- Cairo University, Egypt.

Introduction

Seizure is a common neurological problem in the pediatric age group and occurs in 10% of children. About 5% of all medical attendances

to accident and emergency department are related to seizures (Saini and Baghel 2013). Seizures account for about 1% of all emergency

department visits, and about 2% of visits of children's hospital emergency department visits (Martindale et al., 2011). Unprovoked seizures

occur in patients older than one month and have no acute precipitant, but improvement of the diagnostic techniques increases the chance of

finding the unknown causes (Beghi, et al., 2010). Febrile seizures (FS) are the most common type of childhood seizures. It is also a

common cause of pediatric hospital admission and parental concern. The reported incidence of febrile seizures is up to 14 %. FS is further

classified as simple febrile seizures (SFS) or complex febrile seizures (CFS), with complex febrile seizures defined as seizure lasting more

than 15 minutes, repeated seizures occurring within 24 hours and focal seizure activity or focal findings present during the postictal period.

Although there are enough investigations and data concerning initial management, there is somewhat less well developed data in complex

febrile seizures (leung and Robertson, 2007). There are few studies that describe neuroimaging [Computed Tomography (CT) and

Magnetic Resonance Imaging (MRI)] and Electroencephalogram (EEG) data in children who present with new-onset seizures. The EEG is

recommended as a part of the neurodiagnostic evaluation of the child with an apparent first unprovoked seizure (Pohlmann et al., 2006).

Insufficient evidence is available to make a standard recommendation or guideline for the use of routine neuroimaging in children with first

unprovoked seizure. In contrast, guidelines for obtaining neuroimaging in adult patients presenting with seizure have been published. In a

few studies that have reviewed the yield of neuroimaging in children with unprovoked seizure, the prevalence of abnormalities ranged from

0% to 21% (Simone et al., 2006).

Although there is ample investigation and data concerning initial management, treatment approaches, and outcomes in children with

simple febrile seizures, there is somewhat less well-developed data on Complex Febrile Seizures (Rasool et al., 2012). The aim of this

work is to determine the frequency of abnormal electroencephalogram and neuroimaging in children with first unprovoked and complex

Article history Received: 25-11-2016 Revised: 04-12-2016 Accepted: 07-12-2016

Corresponding Author: M. S. T. Elfeshawy Radiodiagnosis Departments, Faculty of Medicine (For Boys), Al-Azhar University, Cairo, Egypt.

Abstract Background and Objective: First unprovoked seizure (FUS) and Complex febrile seizure (CFS) are common pediatric issues of great debate as regard role of Electroencephalogram ( EEG) and neuroimaging in their diagnosis. Aim of the work: To determine the frequency of abnormal EEG and neuroimaging in children with FUS and CFS and to detect the correlation between electroencephalogram and neuroimaging results. Patients and Methods: A total of 100 children (6 months to 12 years of age), who presented with first afebrile or CFS underwent EEG and neuroimaging (CT and/or MRI). Results: 100 cases were involved at age group (6 months- 12 years), FUS were (63 cases) and CFS was (37 cases). (69.8%) cases of FUS were generalized and (30.2%) were focal. The prevalence EEG abnormality was found in (33%) of whole studied population. (44.4%) in FUS and 13.5% in CFS patients. The prevalence neuroimaging abnormality was found in (15%) of the whole studied population where (20.6%) in FUS and (5.4%) in CFS patients. Neuroimaging abnormality was seen more commonly in those patients who had an abnormal EEG with statistically significant increase in cases with FUS. Conclusion: EEG and neuroimaging abnormalities are more prevalent FUS than CFS, and there is increased incidence in neuroimaging abnormalities in children with abnormal EEG. Key words: First unprovoked seizure (FUS), Complex febrile seizure (CFS), Neuro imaging, Electroencephalogram (EEG), American Academy of Neurology (AAN), International League against Epilepsy (ILAE).

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febrile seizures and to detect if there is a correlation between the findings of electroencephalogram and neuroimaging.

Neuroimaging

Imaging studies are one of the modalities that are very important in the management of first unprovoked seizure, revealing abnormal

findings more common than before. Abnormal imaging findings which are mentioned as 31 %(Kalnin et al., 2008). It is important that, in

the majority of cases in epilepsy, the diagnosis can be identified at onset although there are additional information, (such as subsequent

EEGs, imaging data and new clinical symptoms, assessed during a follow-up period), which can allow to clarify the etiology of seizures

and classify patients in a specific syndrome (Berg et al., 2000). The decision of doing neuroimaging in first unprovoked seizures should be

individualized, and EEG can be helpful. For example, a focal EEG may increase suspicion of structural abnormality. Patients who have

clearly defined epileptic syndromes, such as petit mal epilepsy or benign rolandic epilepsy, do not necessarily require neuroimaging. AAN

practice parameters recommend non-urgent imaging after initial seizure if there is associated significant cognitive or motor impairment,

unexplained abnormalities on the neurological examination, partial-onset seizures, an EEG inconsistent with benign or primary generalized

epilepsy, and in patients younger than 1 year (Hirtz et al., 2000). Clinically significant neuroimaging abnormalities have been reported in

2% of children presenting with first afebrile seizure without focal features or predisposing conditions (Sharma et al., 2003).

The prevalence of abnormal neuroimaging in an adult with a new-onset seizure is 34% to 45%. However, the role of emergent

neuroimaging in children presenting with first afebrile seizure is still not well-defined. Based on several studies, the prevalence of abnormal

neuroimaging in pediatric patients with a new onset afebrile seizure is from 0% to 21 % .(Alawaneh and Bataineh, 2008). If neuroimaging

is obtained, MRI is the preferred method of imaging to avoid radiation exposure while providing more detailed diagnostic information

(Chen et al., 2005).

CT is still frequently obtained based on available resources. According to one study, CT in the emergency department for children

presenting with first seizure will change acute management in approximately 3 to 8% of patients (Harden et al., 2007). In a study conducted

on 300cases with first unprovoked seizure, they found an epileptogenic lesion in 38cases (12.6%) (King et al., 1998). Neuroimaging was

performed in 475 patients and they reported the prevalence of 8%, as clinically significant abnormal neuroimaging. Their study was reliable

because of the selected exclusion criteria (Sharma et al., 2003). Most studies addressing imaging for children presenting with new-onset

seizures deal primarily with non-febrile children, showing a rate of abnormal imaging results ranging from 0% to 21 % (Maytal et al.,

2000).

Computed tomography of the head has demonstrated structural lesions in about one-third of adults and one-half of infants younger than six

months who present to the emergency department with a first seizure (Bui et al., 2002). Identification of lesions altered the acute medical or

surgical management in up to 8 % of children. Accordingly, AAN recommends considering emergent head computed tomography for all

patients with a first seizure, particularly those who have risk factors for abnormal neuroimaging (Harden et al., 2007). Researchers

recommended brain imaging FUS; however, not in the emergency room, but imaging in the following days of seizures is necessary. Brain

MRI increased hospitalization and the patient's costs. On the other hand, imaging findings may not change the patients treatment protocol,

so, brain MRI is recommended on an outpatient basis, also emphasized brain imaging in cases of FUS for localization, characterization and

emergent intervention, if necessary(Gaillard et al., 2009).

Table (1): Risk Factors for Intracranial Pathology after a First Seizure.(Harden et al., 2007). Alcoholism Bleeding disorders or anticoagulation therapy

Focal seizure or a new focal deficit

History of or current cysticercosis (or recent travel to an endemic area)

History of stroke or malignancy

Human immunodeficiency virus infection/AIDS

Electroencephalography (EEG)

EEG does not generally need to be obtained in the emergency department unless there is concern about non convulsive status epileptics or

ongoing seizures in a pharmacologically paralyzed or comatose patient. EEG can detect focal lesions not visible with neuroimaging and

show epileptiform findings that allow diagnosis of particular epilepsy syndromes (Jagoda and Gupta, 2011). If the child is clinically stable,

it may not be necessary to perform the EEG on an emergent basis. However, EEGs are an important tool in determining prognosis for

future seizures and should be strongly considered for all children with a first seizure on a non-urgent basis (Westover et al., 2010).

The EEG, which is entirely harmless and relatively inexpensive, is the most important investigative tool in the diagnosis and management

of epilepsies. However, for the EEG to provide accurate assessments, it must be properly performed by experienced technologists and

carefully studied and interpreted in the context of a well-described clinical setting by experienced physicians(Panayiotopoulos, 2010). More

than 40% of patients with epileptic disorders may have one normal inter-ictal EEG, although this percentage falls dramatically to 8% with a

series of EEGs and appropriate activating procedures, particularly sleep deprivation (Binnie and Prior, 1994). AAN and Child Neurology



Society recommend an EEG as a standard of care for a child presenting with a first afebrile seizure. The EEG is useful to evaluate risk of

seizure recurrence, to determine whether a seizure is focal or generalized, to screen for focal abnormalities and possible need for MRI, to

identify epilepsy syndrome classification, to guide choice of antiepileptic’s, and to aid in prognosis (Wiebe et al., 2008).

EEG should be performed in all patients with suspected seizures of unknown etiology (e.g., unprovoked seizures). Epileptiform

abnormalities are detected in 59 % of children with new-onset seizures (Krumholz et al., 2007). EEGs performed for new-onset seizures

show epileptiform discharge in approximately 18% to 56% of children and 12% to 50% of adults. An EEG after sleep deprivation improves

detection of epileptiform abnormalities, showing discharge (Figure 3, 4) in 13% to 35% of patients whose standard EEG was normal. Some

studies have also shown a higher yield with EEG performed within 24 hours after the seizure (Wirrell and Elaine, 2010).

Fig(1): An18-month-old boy with FUS: Axial T2W images reveal bilateral butterfly abnormal signal extending from the sub cortical U

fibers to the peri ventricular deep white matte changes due to metachromatic leukodystrophy(Mohammadi, et al., 2013).

Fig (2): A 13 year-old-boy with FUS; Coronal T2W images through occipital horns reveal signal void left parasagittal lesion due to A-

Vmalformation (Mohammadi, et al., 2013). EEG-detected abnormalities may also be associated with a significantly higher risk of seizure recurrence, which may have implications for

treatment. Ideally, EEG should be obtained 24 to 48 hours after the seizure, should be performed using hyperventilation/ photic stimulation,

and should capture asleep and awake states because these measures increase the likelihood of detecting abnormalities (Berg, 2008). An

EEG discharge is of great diagnostic and management significance if it is associated with clinical manifestations. However, these

symptoms may be minor and escape recognition without video recordings. Video-EEG recordings are particularly important in the

identification of absences, which are easily elicited by hyperventilation, myoclonic jerks or focal seizures, as well as psychogenic or other

non-epileptic seizures, particularly those of the hyperventilation syndrome (Ferrieet al., 1998). If initial EEG findings are negative and

clinical suspicion for epilepsy is high, sleep-deprived EEG is beneficial. This test detects abnormalities in 21 to 35 percent of patients with

initially normal EEG findings, with the highest yield in the first three days after the seizure (Gandelman and Theitler, 2011). A routine EEG

recording is an evidence-based standard recommendation of the diagnostic evaluation of a child after a first afebrile seizure (Hirtz et al.,

2000).

Children after the neonatal period and adolescents who are otherwise normal when they present with their first generalized seizure

constitute a different situation. If the history is benign and the examination is normal, an EEG is the only test that is indicated, Even the

EEG is helpful only ina minority of instances. A normal EEG would not exclude the diagnosis of a seizure if the history was sufficiently

clear. An abnormal interracial EEG helps if the diagnosis made by history was uncertain. Many children who have had a seizure have a

normal EEG in the interracial period or they show nonspecific abnormalities such as diffuse slowing. EEG does not always assist in the



diagnosis of a seizure disorder; it also not entirely reliable in predicting whether there will be further episodes. However, the initial EEG

may define a focus of abnormal brain activity or occasionally show specific pattern that has some predictive value and helps to plan the

treatment (Berg et al., 2000).

Fig (3): Bursts of generalized spike-waves at 1- to 4-seconds in patient with a single generalized tonic-clonic convulsion indicates a higher

probability of seizure recurrence (Mclachln, 1993).

Fig (4): Generalized slowing recorded a day after a febrile seizure in a 27-month-old girl (Jeonget el., 2013).

Lumbar Puncture in Unprovoked Seizures Lumbar puncture is frequently performed in children in the presence of fever and seizures to rule out intracranial infection. The American

Academy of Neurology Practice Parameter (February 2000) concluded that, there was no evidence regarding the yield of routine lumbar

puncture after the first non-febrile seizure. However, they still recommended lumbar puncture in the very young child (less than 6 months

age)” or in any child who appeared to have encephalopathy or exhibited meningioma’s (Hirtz et al., 2000). A lumber puncture is indicated

whenever meningeal signs are present or in very young children, in whom meningeal signs may not be significant. Lumbar puncture is also

recommended if a child who had a first unprovoked seizure remains with diminution of level of consciousness for a long period which

cannot be attributed to postictal state. In the majority of circumstances, the caretaker physician may prefer to perform a cranial

neuroimaging examination, especially if the child has to have a lumbar puncture examination. In these cases, by performing cranial

neuroimaging, the probability of increased intracranial pressure is investigated (Ghofrani, 2013). There is no evidence regarding the yield of

routine lumbar puncture following a first no febrile seizure. The one study available is limited in size and age range. In the very young child

(less than 6 months age), in the child of any age with persistent (cause unknown) alteration of mental status or failure to return to baseline,

or in any child with meningeal signs, lumbar puncture should be performed (American Academy of Neurology, 1993).

Patients and methods

This prospective study has been carried on 100 cases with FUS and CFS at age group from 6 months to 12 years old attending the

emergency, inpatient, and outpatient departments of AL- Hussien and SayedGalal university hospitals over period of 10 months

Inclusion Criteria

First unprovoked seizure include:

First unprovoked seizure includes one or more epileptic seizures occurring within 24 hour period with recovery of consciousness

between seizures (ILAE Commission Report, 1997). The occurrence of multiple seizures in a 24-hours period is considered as one

seizure (Fisher et al., 2005).

Complex febrile seizures include: patient with febrile seizures having one or more of the following features:

1- Longer duration (>15 min).

2- Recurs within 24 hours.

3- Focal seizures or general types of seizures other than ( GTCs)

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4- No postictal neurological abnormalities.

5- Family history of epilepsy.

6- Age older than 5 years (Millar, 2006);(Amir et al., 2012).

Exclusion Criteria:

Patients with suspected CNS infection.

Patients with simple febrile convulsions.

Patients with acute etiology of seizures as, toxins, trauma, drugs, metabolic or electrolyte disturbances.

Patients with known chronic neurologic illnesses as CP or MR.

Patients with neurological abnormalities detected at examination.

All patients were subjected to:

Informed consent from a parent or guardian.

Thorough history taking including: developmental, neurological, and family history (of convulsion or neurologic disease),

emphasizing on:

Precipitating factor for seizure: As fever, trauma, drug intake, metabolic abnormality, prior CNS abnormality, endocrinal or GIT

disease.

Complete analysis of the attack including: Presence of aura, onset of the seizure (focal or generalized onset), type and duration of

convulsion, conscious level during the attack, if associated with cyanosis, incontinence of urine or vocalization, frequency of the

attack and postictal state.

Full clinical examination was done focusing on neurological examination, origin of fever (If CFS) and other causes of convulsion.

Laboratory investigations: Blood samples are withdrawn according to situation including: sepsis work up (according to suspected

site of sepsis), RBS, serum Na, Ca, and Mg.

EEG was done once for all patients using EEG machine (Model: E-series PSG, compumedics, Australia) with standard 10-20

electrode placement system and recording for at least 40 minutes duration, in first contact with child young children which are

uncooperative are sedated using oral chloral hydrate (30-50 mg/kg/dose. Max100mg/kg/dose).

Lumbar puncture was done when CNS infection is suspected (which are excluded from study).

CT scan of the brain was done for all patients.(GE-light-speed-4-slice-spiral-ct-scanner)

MRI brain was done only for patients whose CT scan needs further characterization.(philipsachieva 1.5TMRI)

Scheme of Work

Statistical Methods Data were analyzed using IBM© SPSS© Statistics version 22 (IBM© Corp., Armonk, NY, USA).

The Shapiro-Wilk test was used to examine the normality of numerical data distribution. Non-normally distributed numerical data were

presented as median (Interquartile range) and between-group differences were compared using the Mann-Whitney test.

Categorical data were presented as number (%) and between-group differences were compared using Fisher’s exact test. The McNemar

test was used for comparison of paired categorical data.

Inter-method agreement was examined using Cohen kappa coefficient (κ).

http://www.compumedics.com.au/index.php/sleep-diagnostics/laboratory-based/high-definition/profusion-sleep-4



The Bonferroni method was used to adjust the level of significance for the number of subgroup comparisons in order to keep the type I

error.

Results: Table (2): Patients’ Characteristics:

Table (3): EEG Findings in The study Population:



Fig (5): Generalized sharp slow wavesin 6 months old girl with first seizure.

Fig (6): Bilateral centro-temporal spikes waves in 12 years old boy with first rolandic seizure.

Fig (7): left temporal sharp waves in 1.5 years old boy with first focal seizure.

Fig (8): Bilateral centro-temporal sharp (black arrow) and sharp slow (move arrow) waves in 8 years old boy with first generalized

seizure.



Fig (9): Generalized Polyspike activity in 4 years old boy with complex febrile seizure.

Table (3): Neuroimaging findings in the study Population.

Fig (10): case No 1: CT scan shows inter hemispheric arachnoid cyst



Fig (11): case No 2: Axial T1 WI shows left basi temporal extra axial arachnoid cyst

Fig (12): case No 3: Selected CT cuts at the level of Sylvain fissure shows evidence of lissencephaly, mild ventricuolmegaly with peri

ventricular deep white matter volume loss and leukomalacia

Fig (13): case No 4: Selected axial T2 and FLAIR WI cuts revealed bilateral perirolandiccortices andperi ventricular deep white

leukomalacia , Picture of Hypoxic Ischemic Insult.



Fig (14): Case No 5: CT brain shows widely separated bodies of both lateral ventricles as a result of corpus callosum agenesis

Fig (15): Case No 6: Axial T1 and T2 WI of 3 years old girl shows bilateral periventricular deep white matter abnormal signal, related to

diffuse hypomyelination

Fig (16): Axial T2 revealed semilobarholoprosencephaly shows mono ventricle with partially developed occipital and temporal horns. In

complete falxcerebri, incompletely formed inter hemispheric fissure, especially anteriorly and high dysplastic corpus callosusm



Table (4): Comparison between Patients with First unprovoked or Complex Febrile Seizures

Table (5): Comparison between Patients with Generalized and Focal Unprovoked Seizures



Table (6): Prevalence of Neuroimaging Abnormalities in Patients with Normal or Abnormal EEG

Table (7): Prevalence of Neuroimaging Abnormalities in Patients with Complex Febrile Seizures and Normal or Abnormal EEG

Table (8): Prevalence of Neuroimaging Abnormalities in Patients with Unprovoked Seizures and Normal or Abnormal EEG

Table (9): Prevalence of Neuroimaging Abnormalities in Patients with Generalized Unprovoked Seizures and Normal or Abnormal EEG



Table (10): Prevalence of Neuroimaging Abnormalities in patients with Focal Unprovoked Seizures and Normal or Abnormal EEG

Table (11): Prevalence of CT Scan Abnormalities in Patients with Normal or Abnormal EEG in The whole Study Population and in

Various Patient Subgroups

Discussion:

Seizure-related symptoms account for about 10% of all visits to emergency departments, with higher proportions among infants and young

children (Pallin, et al., 2008). In this work we intended to estimate the prevalence of abnormal electroencephalogram and neuroimaging

(CT/MRI) and, specifically, correlate between the electroencephalogram and neuroimaging findings among patients with first unprovoked

seizures and complex febrile seizures. The mean age of study children was 3.8 years with Interquartile range was from 1 to 8 years. Fifty

six cases were males and forty four were females . Forty four (69.8%) cases with first unprovoked seizures were generalized while 19 cases

(30.2%) were focal seizures.Of generalized unprovoked seizures GTCs were the most common type of seizures (45.5%) followed by clonic

seizures (29.5%), tonic seizures (18.2%), and lastly atonic seizures were (6.8%). Complex focal seizures represented (68.4%) of focal

unprovoked seizures while simple focal seizures (31.6%). Family history of seizures was present in (24%) of all cases and the mean

duration of seizures was 5 minutes with range of (0.3 – 20) minutes and there is statistically significant prolonged duration of seizures in

patients with complex febrile seizures (P < 0.025) in comparison with unprovoked seizures.In our study, EEG abnormality was found in

(33%) of the whole study cases including first unprovoked seizures and complex febrile seizures , EEG abnormality was higher in a similar

study done by Rasool et al. (2012), who found that EEG abnormality was detected in 56.2% of all study population. The difference can be

explained by that, in our study EEG is done on first contact with complaining child where most cases are examined at third to seventh day

of the attack, while in the study done by Rasool et al. EEG was done within the first 48 hours of the attack.

EEG shows the highest yield of findings in the first three days after the seizure (Gandelman and Theitler, 2011). If performed within 24-48

hours of a first seizure, EEG shows substantial abnormalities in about 70% of cases (Pohlmann et al., 2006). If the first EEG can be done

within 24 hours of the event the prevalence of EEG abnormalities is increased compared with later studies (King et al., 1998). EEG should

be obtained 24 to 48 hours after the seizure, should be performed using hyperventilation/ photic stimulation, and should capture asleep and

awake states because these measures increase the likelihood of detecting abnormalities (Berg, 2008). In our study, EEG abnormality was

found in (44.4%) of cases with first unprovoked seizures. This is consistent with Hamiwka et al. (2007) study results, where EEG was done

in 127 children with first unprovoked seizures and was abnormal in 41% of cases. Our results also agreed with Shinnar et al. (1994) study

results,, who found EEG abnormality to be present in 42% of patients with first unprovoked seizures. Krumholz et al. (2007), stated that,

epileptiform abnormalities are detected in 29 percent of adults and 59 percent of children with new-onset seizures. Wirrell and Elaine

(2010), stated that, EEGs performed for new-onset seizures show epileptiform discharge in approximately 18% to 56% of children. In our

study, EEG abnormalities were significantly low (P < 0.025) among the patients with complex febrile seizures (13.5%) in comparison with

first unprovoked seizures (44.4%) . This finding agreed with Rasool et al. (2012). In our study, the prevalence of EEG abnormalities in

children with complex febrile seizures was 13.5%. These findings are consistent with findings detected by Rasool et al. (2012), study

results where the EEG abnormalities of children with complex febrile seizures were 15.6% and disagree with Maytal et al. (2000), study

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results who reported that the incidence of paroxysmal abnormalities on EEG in neurologically normal children within a week of complex

febrile seizures was 0%. Our results also disagreed with Joshi et al. (2005), study results who found that 39.43% of children with complex

febrile seizures had EEG abnormalities. Our results also disagreed with Jeong et al. (2013), study results who detected EEG abnormalities

in 43% of children with complex febrile seizures. The difference can be explained by early postictal EEG registration (within 24-48 hours).

Also there disagreement between our results and another study carried by Yucel et al. (2004), who detected abnormal EEGs in 22.5% (16

of 71) of cases with complex febrile seizure. The predictive factors of abnormal EEGs were; age >3 years, EEGs performed within 7 days

and an abnormal neurological exam, whilst a family history of FS was associated with normal EEG (Joshi et al, 2005). In our study,

sharp waves alone or the combination sharp-slow waves were the most common EEG findings in the whole study cases and there is a

statistically significant increase (P < 0.025) in the incidence of Sharp-slow waves in patients with unprovoked seizures in comparison with

complex febrile seizures . In our study, the incidence of paroxysmal abnormalities on EEG especially sharp waves and sharp-slow waves

were more common in partial unprovoked seizures than generalized unprovoked seizures and there is statistically significant increase in

incidence of all abnormal EEG findings in partial seizures (P < 0.025). In our study, overall 34.1% of cases with generalized first

unprovoked seizures and 68.4% focal first unprovoked seizures had abnormal EEG findings. These findings were consistent with similar

observations made by Shinnar et al. (1994), who found that EEG abnormalities are detected in 35% of cases with generalized seizures.

As regard generalized seizures, our study results were consistent with similar observations made by Shinnar et al. (1994), who found that

EEG abnormalities are detected in 35% of cases with generalized seizures and 56% of cases with focal seizures and disagreed with Rasool

et al. (2012) study results, who found that EEG abnormalities were detected in 70% of patients with generalized seizures which can be

explained larger sample size in their study (276 patients) and early EEG doing in the first 2 days after the attack. Seventy one percent of

patients with first focal unprovoked seizures had abnormal EEG findings in the study done by Rasool et al. (2012).Similar findings (73% of

patients with partial seizures) were found by Baheti et al. (2003) study results, both are consistent with our results. In our study, CT brain

were done for all cases, while MRI brain were done for cases who’s their CT brain need further characterization (28/100). In our study, the

prevalence of neuroimaging abnormalities in children with first unprovoked seizures was 20.6% . This was in agreement with Shinnar et al.

(2001), study results who found that 21% of cases with first unprovoked seizures had neuroimaging abnormalities and also agreed with

Garvey et al. (1998), where 19% patients were found to have abnormal neuroimaging and disagreed with the frequency of total

neuroimaging abnormalities in cases with first unprovoked seizures in the study done by Mohammadi et al. (2013), who reported abnormal

neuroimaging in 27.1% of cases. But this difference can be by the use of MRI in vast majority of patients (82/96) in their study compared

with (24/63) cases in our study. On the other side Khodapanahandeh and Hadizadeh (2006), were reported that neuroimaging abnormalities

were found in 10% of patients and Sharma et al. (2003), reported neuroimaging abnormalities were reported in 8% of patients. Both results

are less than that of our study. In our study, the prevalence of brain CT scan abnormalities in children with first unprovoked seizures was

20.6% as presented in, these finding agreed with than in the study done by Maytal et al. (2000), who detected that 21.2% had abnormal CT

results and disagreed with Vieira et al. (2006), study results who found abnormalities in 29.44%of cases which can be explained by larger

sample size (387) in their study and disagreed with Mathur et al. (2007), study results who detected CT brain abnormalities in 32% of all

children with a first unprovoked seizure. Rasool et al. (2012), Found that, CT brain abnormalities was detected in 12.3% of cases this can

be explained by that the nature of some of brain lesions detected in their study need MRI to be detected overtly, so that the percent of

patients with MRI lesions were 20% in their study. In our study the prevalence of neuroimaging (CT/MRI) abnormalities in complex febrile

seizures were (2/33) 5.4%which agreed with Rasool et al. (2012), who found that, neuroimaging abnormalities was detected in 1.6 % of

cases and disagreed with Hesdorffer et al. (2008), found that 14.8 % of children with complex febrile convulsions had neuroimaging

abnormalities. This difference can be explained by that, MRI is the neuroimaging modality used for all patients in their study.

In our study the prevalence of abnormal CT scan in children with complex febrile seizures was 2.7% (1 patient) This agreed with Rasool et

al. (2012), study results who reported that, CT brain findings in children with complex febrile seizures were found in 1.6% of cases and also

agreed with McAbee et al. (1989), who reported that (5%) of patient with complex febrile seizures had an abnormal CT scan. Our results

were disagreed with that of Maytal et al. (2000), who detected that 0% of children with complex febrile seizures had abnormal CT brain

and with Teng et al. (2006),study results who stated that cranial CT detected abnormalities(13.8%) children with complex febrile seizures.

In our study, the prevalence of abnormal CT scan in children with generalized first seizures was (7/44)15.9% while that of focal seizures

was (6/19) 31.6%. These findings were consistent with that of Maytal et al. (2000), who reported that in generalized seizures, 82.5% cases

had normal CT scan and 17.5% had abnormal CT whereas in partial seizures, 70.8% had normal imaging and abnormal CT was seen in

29.2%. So showing overall abnormal CT scan in 21.2% of the patients which is also agreed with our study. Alawaneh H and Bataineh

(2008), also found that the frequency of CT abnormality in patients with partial seizures were (7/22) (31.8%) patients which agreed with

our results. As regard to generalized seizures, they found that (4/78) (5%) had abnormal neuroimaging results which disagreed with our

results. Khodapanahandeh and Hadizadeh (2006), were reported also similar prevalence of CT brain abnormality in patients with partial

seizures as our study results which was 30%, while in those with generalized seizures had abnormal neuroimaging results in 4% which

disagreed with our study. In the study done by Rasool et al. (2012), abnormal neuroimaging was detected in 15.5% of patients with focal

seizures and 10% of patients with generalized seizures which disagreed with our results. In the current study brain atrophic changes were

the most common neuroimaging abnormality. Other lesions include; lissencephaly, ventriculomegaly, encephalomalacia, arachnoid cyst,

corpus callosum dysgenesis, delayed maturation and encephalomalacia& atrophic changes of total population

Rasool et al. (2012), also found that brain atrophic changes were the most common neuroimaging abnormality in their study, and other

http://www.ncbi.nlm.nih.gov/pubmed/?term=Joshi%20C%5BAuthor%5D&cauthor=true&cauthor_uid=16099180



findings were, focal hypodense lesion, white matter hypodensity and lissencephaly. While in a study of neuroimaging findings in children

with first unprovoked seizures done by Mohammadi et al. (2013),The most common imaging findings were gliosis followed by

dysmyelination, hemorrhage, brain atrophy, dysgenesis, infarction and encephalomalacia. In our study, a correlation between EEG and

neuroimaging in the whole study cases was made. Neuroimaging abnormality was seen in 15/100 (15%) of patients and EEG abnormality

was seen in 33/100 (33%) of patients. A total of 64/100 (64%) of the patients with normal EEG had normal neuroimaging, while 3/67

(4.5%) of the patients with normal EEG had abnormal CT scans. Out of the patients who had abnormal EEG 33/100 (33%), neuroimaging

abnormality was seen in 12/33 (36.4%) and CT was normal in 21/33 (63.6%) of the patients, which was statistically significant with P

value <0.008. A correlation also was made between EEG and neuroimaging in patients with CFS, where 0% of patients with abnormal

EEG had abnormal neuroimaging and 6.3% of patients with normal EEG had abnormal neuroimaging, which was statistically in significant

A correlation also was made between EEG and neuroimaging in patients with unprovoked seizures, where 42.9% of patients with abnormal

EEG had abnormal neuroimaging and 57.1% abnormal EEG had normal neuroimaging. Also 2.9% of patients with normal EEG had

abnormal neuroimaging, while 97.1% patients with normal EEG normal neuroimaging, which was statistically significant with (P value

<0.008). A correlation also was made between EEG and neuroimaging in patients with generalized unprovoked seizures, where 40% of

patients with abnormal EEG had abnormal neuroimaging and 60% of patients with abnormal EEG had normal neuroimaging. On the other

side 3.4% of patients with normal EEG had abnormal neuroimaging and 96.6% of patients with normal EEG had normal neuroimaging,

there was some correlation but not statistically significant (Trend). A correlation also was made between EEG and neuroimaging in patients

with focal unprovoked seizures (Table 10), where 46.2 % of patients with abnormal EEG had abnormal neuroimaging and 53.8% of

patients with abnormal EEG had normal neuroimaging. On the other side 0% of patients with normal EEG had abnormal neuroimaging and

100% of patients with normal EEG had normal neuroimaging, there was some correlation but not statistically significant (Trend).

A correlation also was made between EEG and CT in the whole study cases and patients with complex febrile seizures, total unprovoked

seizures, generalized and focal unprovoked seizures, there was statistically significant correlation in the whole study cases and total

unprovoked seizures group (P<0.01). Negative correlation in complex febrile seizure group other and unprovoked seizure subgroups can be

explained by smaller sample sizes. Strong agreement was detected between MRI and CT brain in the whole study population, first

unprovoked group and focal & generalized first unprovoked subgroups

Conclusion

EEG abnormalities were more prevalent in children with first unprovoked seizures than those with complex febrile seizures. Abnormal

neuroimaging were also more common in children with first unprovoked seizures than those with complex febrile seizures. Abnormal EEG

and neuroimaging were more common in children with partial seizures than those with generalized seizures. Neuroimaging was abnormal

in significant number of children having abnormal EEG, so neurologically free patients having normal EEG can be safely discharged

without neuroimaging, if follow-up is assured. When EEG is abnormal in first unprovoked seizure, the probability of having abnormal

neuroimaging increases as compared to those cases where EEG is normal. In case of generalized seizures, patients with abnormal EEG may

have abnormal CT/MRI scans. But there are fewer possibilities of a patient with abnormal EEG to have a normal neuroimaging . In partial

seizures abnormal EEG increases the risk of having abnormal neuroimaging than in generalized seizures and normal EEG in partial

seizures markedly decreases the risk of having an abnormal neuroimaging generalized seizures. Complex febrile seizures in otherwise

neurologically free children rarely indicate the presence of lesion on neuroimaging even if associated with EEG abnormalities

Neuroimaging abnormalities in neurologically free children with first unprovoked seizure and Complex febrile seizures don’t require urgent

intervention.

Recommendations EEG is recommended for all children with first unprovoked seizures.

Children with abnormal EEG findings are highly recommended to perform brain CT for possibility of associated structural brain

abnormality especially if seizures are focal.

Otherwise neurologically free children with complex febrile seizures need no neuroimaging scan.

Further studies with larger sample size are recommended.

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