Excessive testing in emergent evaluation of children with first unprovoked seizure

Backround: The first episode of an afebrile seizure is a common cause of admission of children to emergency departments. Alot of tests are routinely performed for these patients. The cost of such an evaluation is high and benefits are doubtful. We conducted this study in order to evaluate the results of the tests and find out what tests are necessary for children with first unprovoked seizure. In a 7-year retrospective study files of 150 children aged between 1 month and 14 years admitted with first afebrile seizure to the pediatric ward of Rasool Akram hospital were reviewed. Reports of the brain neuroimaging studies (Ct-scan & MRI) and laboratory tests were extracted. 150 patients with a mean age of 53 ± 48 months qualified for inclusion in the study. 143 (95%) of 150 children with first afebrile seizure were imaged. Ninety percent (128/143) had normal neuroimaging. Emergent computed tomography as the initial study was performed in 90% (128/143) and MRI in 10% (15/143). Sixty patients had both MRI and CT-scans. Clinically significant neuroimaging abnormalities were reported in only 9.7% (14/143). There was a significant relation (P<0.001) between focal seizures and abnormal neuroimaging. Children under 24 months of age were also more prone to have abnormal imaging (p<0.002). Laboratory tests including complete blood count (CBC) and chemistry panel (Na, K, Ca, BUN, Cr) were performed for all. Only two patients had low serum calcium level, later diagnosed as vitamin D resistant rickets. The most important aspect of management of a child after a first afebrile seizure is careful history taking and physical examination. Laboratory tests should be requested in very limited situations. Emergent brain CT-scans are recommended for children with focal seizures, abnormal findings on physical examination, presence of any predisposing factors and those under 24 months of age.