The value of head computed tomography (CT) in children presenting with focal seizures to a paediatric ambulatory unit in a resource constrained setting

[摘要] ENGLISH ABSTRACT : BACKGROUNDChildren presenting to the ED with new onset focal seizures are often evaluated using urgent head computed tomography (CT). Although MRI is the preferred neuroimaging modality in children as it avoids the radiation risk of CT, with added superior resolution, MRI is not routinely available in the emergency setting1 2 3. The recommendations for neuroimaging, and specifically CT, in children presenting with new-onset focal seizures is poorly defined and the diagnostic yields tend to vary according to study settings and population. OBJECTIVEThis study evaluated the utility, diagnostic yield and therapeutic interventions of head CT scans in children admitted with first onset focal seizures to the Paediatric Ambulatory & Emergency Unit at Tygerberg Children's Hospital (TCH); and examined potential historical and clinical variables associated with abnormal head CT findings. METHODS A retrospective cohort analysis of 168 previously well children with new-onset focal seizures, admitted to TCH between January 2013 and December 2014, was undertaken. Demographic data, clinical details and head CT findings were abstracted from the radiological and medical hospital records. Data was analysed using Stata. Descriptive statistics was used to analyse demographic data and outcome. Univariate Comparisons and multiple biniary logistic regression analysis were done to determine adjusted associations between historical and/or clinical findings and CT scan results. RESULTSClinical significant CT scan abnormalities were identified in 32% (n=54/168) of children and head CT findings were of therapeutic significance in 81% (n=44/54) of children. The majority of CT abnormalities were related to infectious granulomas (n=21/54); followed by TB meningitis (n=12/54) and cerebral venous thrombosis (n=4/54). An abnormal neurological clinical examination as indicator for abnormal CT scan was statistically significant (p < 0.001). Three quarters of patients (n=26/35) with an abnormal neurological examination, had an abnormal CT scan result. Age, HIV-status, malnutrition, duration of seizures, exposure to a household TB contact and travel history was not shown to be statistically predictive of abnormal CT results, but the sample size was too small for multivariate logistic regression analysis to determine adjusted associations. CONCLUSIONWe recommend strongly the use of urgent CT imaging in all children with neurological abnormalities. Our findings further suggest that imaging is valuable for therapeutic decisions in children suspected of neuro-infections (other than neurocycticercosis), vascular abnormalities, and space occupying lesions based on history and physical examination. Suspected structural abnormalities in infants younger than 2 years of age are best evaluated with a MRI in the non-urgent setting.Our findings further suggest that in a TB endemic setting, an initial CXR and tuberculin test may identify children requiring a TB work-up to diagnose tuberculous neuro-infection without the need for a CT scan.

[发布机构] Stellenbosch University