Neuroimaging for Pediatric Non-First-Time Seizures in the Emergency Department.

Background and
Objectives: Neuroimaging is often part of the workup for a pediatric patient presenting with a seizure to an emergency department (ED). We aim to evaluate when neuroimaging in the ED for children with a non-first-time seizure, or nonindex seizure (NIS), is associated with an acute change in management (ACM).
Methods: This is a retrospective cohort study of all pediatric patients presenting to an ED from 2008 to 2018 with a NIS, excluding repeat febrile seizures, who underwent neuroimaging. Clinical characteristics were extracted from the electronic medical record. The primary outcome was new abnormal neuroimaging resulting in an ACM, defined as admission to the hospital, neurosurgical intervention, or new nonseizure medication administration.
Results: We identified 492 encounters. Neuroimaging revealed new findings in 21% of encounters and led to ACMs in 5% of encounters. ACMs included admissions, neurosurgical interventions, and nonseizure medication changes. Factors associated with ACM included new seizure type (odds ratio [OR] 3.3, 95% confidence interval [CI] 1.3-8.0), new focal examination finding (OR 3.0, 95% CI 1.3-7.1), altered mental status (OR 2.9, 95% CI 1.2-7.0), and a history of only provoked seizures (OR 2.8, 95% CI 1.0-7.5). Patients with 2 risk factors had an OR of 6.9 (95% CI 1.8-26.5) for an ACM, and those with 3-4 risk factors had an OR of 45.8 (95% CI 9.8-213.2). The negative predictive value for ACM in a patient with no risk factors was 98.6% (95% CI 95.9-99.5). Discussion: Patients with a NIS who have abnormal neuroimaging associated with an ACM present with unique risk factors. Prospectively validating these factors may allow for a prediction tool for NIS in EDs where reduced exposure to ionizing radiation, sedation, and resource utilization are critically important.