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F e b r u a r y 2 0 0 6 • w w w. c l i n i c a l n e u r o l o g y n e w s .

c o m Pediatric Neurology 17

MRI Aids Diagnosis of New-Onset Afebrile Seizures

BY DIANA MAHONEY seizure type and epilepsy syndrome (Neu- to the emergency department, 82% of the children. Electroencephalography showed
Ne w England Bureau rology 2000;55:616-23). infants had experienced two or more abnormal results in 62% of patients, in-
There was insufficient evidence for the seizures. All of the patients were evaluat- cluding focal abnormalities, hypsarrhyth-
L O S A N G E L E S — Magnetic resonance routine use of other studies, such as lum- ed by a child neurologist on the basis of mia, and generalized spikes.
imaging is useful for identifying the etiol- bar puncture and neuroimaging, so these the patient history: laboratory values, in- By comparison, neuroimaging results
ogy of new-onset afebrile seizures in in- were deemed warranted only under spe- cluding complete blood count, elec- were particularly revealing, Dr. Benko
fancy and, when available, should be in- cific circumstances and at a neurologist’s trolytes, urinalysis, and toxicology screen; said. With CT, congenital malformations
cluded as a part of the standard diagnostic discretion, according to the parameters. 24-hour observation; electroencephalog- were identified in 12% of the patients im-
evaluation in this population, according to More studies with large, well character- raphy; and CT, MRI, and/or lumbar punc- aged, evidence of trauma was seen in 5%,
Dr. William S. Benko. ized samples were needed, according to the ture at the clinician’s discretion. and atrophy was evident in 3%.
Of 103 MRIs performed in 144 infants Among the patients scanned by MRI,
presenting to the emergency department dysplasia was seen in 14%. These abnor-
of Children’s National Medical Center in malities included focal diffuse involvement,
Washington between January 2001 and dysgenesis, heterotopias, Aicardi syn-
January 2005 with new-onset afebrile drome, and Dandy Walker malformation.
seizures (NOAS), 40% detected diagnostic MRI also detected vascular events in 8%
abnormalities related to the seizures, Dr. of patients. These included new and old

Benko said in a presentation at the annual cerebrovascular accidents, hemorrhage,
meeting of the Child Neurology Society. subdural hematoma, and Sturge-Weber
By comparison, in 136 of the 144 infants syndrome.
who underwent CT, abnormalities were de- The abnormalities noted on MRI but
tected in 42% of the scans; however, 15% missed on CT included dysplasia, mesial

of these were deemed incidental findings. temporal sclerosis, cerebrovascular acci-
Fifteen of the infants with normal CT dents, and tuberous sclerosis, he said. “The
scans had abnormal MRIs. “In the major- yield of CT-negative, MRI-positive find-

ity of these CT-negative, MRI-positive pa- ings was highest in patients with focal
tients, the CT scans did not identify focal neurologic exam, neurodevelopmental de-
abnormalities,” said Dr. Benko of the Na- This MRI sagittal image shows a single A proton density axial image shows lay, focal EEG, focal seizure, [and MRI ev-
tional Institute of Neurological Disorders subependymal lesion not seen on CT. tubers of tuberous sclerosis complex. idence of right mesial temporal sclerosis].”
and Stroke in Bethesda, Md. The decision to perform MRI was made
According to practice parameters pub- parameter, before neuroimaging could be “In this afebrile population, we found by the treating neurologist, raising the pos-
lished in 2000 by the Quality Standards considered for routine evaluation of NOAS. that CBC, urinalysis, and toxicology screens sibility of a selection bias, Dr. Benko said.
Subcommittee of the American Academy Toward that end, Dr. Benko and col- were not at all useful or contributory,” Dr. In addition, the findings are limited by
of Neurology, the Child Neurology Soci- leagues investigated a prospective cohort Benko said. Of 59 infants who were given the fact that not all the patients who un-
ety, and the American Epilepsy Society, the of 1,189 patients presenting to the hospi- lumbar punctures, 90% had normal results derwent CT scans also underwent MRIs,
evaluation of a first nonfebrile seizure in tal’s emergency department identified and 5 had evidence of pleocytosis. concluded Dr. Benko, who conducted the
a child should include EEG as a routine with possible NOAS. Treatable electrolyte abnormalities, in- investigation during his pediatric neurol-
part of the diagnostic evaluation to predict Out of the entire cohort, 144 patients cluding hypocalcemia, hyponatremia, and ogy fellowship at Children’s National Med-
the risk of recurrence and to classify the were infants. By the time of presentation hypoglycemia were detected in five of the ical Center. ■

Pediatric Brain-Death Guidelines Often Ignored, Update Needed

BY ROBERT FINN from two exams to be conducted at sepa- Neurosurgeons and pediatric intensivists
San Francisco Bureau rate times; the physician conducting each
exam should evaluate the patient on the 14
were each involved in about 29% of the ex-
ams, with internists, neurologists, and/or
Elements for Brain
S A N F R A N C I S C O — Pediatric brain-
death guidelines were followed to the let-
clinical elements. The review’s findings
showed that on the first exam, charts from
other physicians involved in the remainder.
Measurement of cerebral blood flow
Death Declaration
ter in only 1 case of 142 that resulted in or-
gan donation during a 5-year period in
Southern California, Dr. Mudit Mathur
only 8 of the 142 cases included docu-
mentation of more than 10 elements. On
the second exam, charts from only three
was used to confirm brain death in 73% of
106 cases. Brain death was confirmed by
electroencephalogram in 22% of cases. Pa-
I n his study, Dr. Mathur and his col-
leagues examined charts of pedi-
atric organ donors for documenta-
reported at the annual congress of the So- cases included notes on more than 10 el- tients had both exams in only six cases. tion of the following 14 elements
ciety of Critical Care Medicine. ements. In only one case were all 14 ele- “It’s not surprising why we have a pref- that should be considered before de-
“There is an urgent need for the update ments recorded at both exams. erence for relying on cerebral blood flow,” claring a child to be brain dead, ac-
and revision of these criteria. ... What we Also, among the cases studied, the cor- Dr. Mathur said. “It’s a lot easier to explain cording to 1987 guidelines (Arch.
need are clear, consistent, uniform, and re- rect age-specific interval was followed only this [scan] to a parent than anything else Neurol. 1987;44:587-8):
liable guidelines in terms of brain-death di- 12% of the time. that we do.” 씰 Documented etiology of coma
agnosis, declaration, documentation, and Dr. Mathur and his colleagues reviewed “I must say I find this utterly shocking,” 씰 Coexistence of coma and apnea
reporting,” said Dr. Mathur, a pediatric the charts of all children referred to One- said a member of the audience, who iden- 씰 Flaccid tone, no movements
critical care specialist at Loma Linda Legacy, Southern California’s organ pro- tified himself as a physician from 씰 Absence of pupillary reflex
(Calif.) University Children’s Hospital. curement organization, from January 2000 Southampton in the United Kingdom. 씰 Absence of corneal reflex
The guidelines, issued in 1987 by the to December 2004. OneLegacy serves sev- “We’ve had a [brain-death] checklist for 씰 Absence of gag reflex
American Academy of Pediatrics Task en Southern California counties that to- years.” He said that he was particularly 씰 Absence of cough reflex
Force on Brain Death in Children, call for gether have a population of 18 million surprised in light of the American repu- 씰 Absence of eye movement with
the evaluation of 14 clinical elements in de- people, 220 hospitals, and 14 transplant tation for litigiousness. doll’s eye maneuver
termining that a child is brain dead (Arch. centers. Of 277 patients referred during “I agree that these are shocking data,” 씰 Absence of respiratory effort
Neurol. 1987;44:587-8). (See sidebar.) the 5-year period, 142 had organ donation. Dr. Mathur replied. “However, California 씰 Absence of hypothermia
A review showed that the charts of the A majority of those children (80%) were law requires in a situation of organ dona- 씰 Absence of hypotension
142 children declared to be brain dead con- 1 year of age or older. tion that two physicians document that 씰 Irreversibility of changes
tained documentation of a median of 6 of About a third of the patients were seen the patient is brain dead. [The law does 씰 No history of drug or metabolic
the 14 elements considered crucial to es- in children’s hospitals, another third in not] lay out any medical testing or any intoxication
tablishing brain death. Involvement of a pe- community hospitals, and the rest in coun- guidelines or documentation. So if two 씰 Absence of respiratory effort on
diatric intensivist in the diagnosis did not re- ty hospitals, university-affiliated hospitals, physicians licensed in the state of Califor- apnea test.
sult in more elements being recorded. and combined adult and children’s hospi- nia can say a patient is brain dead, that’s
The AAP guidelines call for the diagno- tals. Two-thirds of the patients received sufficient. They don’t have to specify how Source: Dr. Mathur
sis of brain death to be based on findings their care in a pediatric ICU. they determined it.” ■