What diagnostic studies should be ordered for a 5-year-old boy presenting to the Emergency Department (ED) with new-onset seizures, a history of a previous seizure 3 weeks ago, and no current fever, who has not undergone a neurological workup by a neurologist?

From the Guidelines

For a 5-year-old boy presenting to the ED with new-onset seizures and a history of a previous seizure 3 weeks ago without current fever, I recommend ordering several diagnostic studies, prioritizing brain imaging with MRI over CT to evaluate for structural abnormalities, as supported by the most recent evidence 1.

Diagnostic Approach

The diagnostic approach should include:

• A complete blood count (CBC), comprehensive metabolic panel (CMP), serum glucose, calcium, magnesium, and sodium levels to identify metabolic abnormalities that could trigger seizures.
• An electroencephalogram (EEG) is essential to detect abnormal electrical activity in the brain.
• Brain imaging with MRI is preferred over CT to evaluate for structural abnormalities, though CT may be performed first in the emergency setting if there are concerns about increased intracranial pressure, as suggested by 1 and 1.
• A lumbar puncture should be considered if there's any suspicion of infection, especially if the child had a recent fever or shows signs of meningitis.
• Toxicology screening may be appropriate depending on the history and circumstances.

Imaging Priorities

According to the American College of Radiology 1, MRI is the preferred imaging modality for evaluating structural abnormalities in children with new-onset seizures, due to its higher sensitivity and ability to detect lesions that may not be visible on CT scans.

Recent Guidelines

The most recent guidelines from the American College of Radiology 1 and the Pediatrics journal 1 support the use of MRI as the primary imaging modality for children with new-onset seizures, and emphasize the importance of adjusting CT parameters for pediatric patients to minimize radiation exposure.

Referral to Specialist

The child should be referred to a pediatric neurologist for follow-up care as soon as possible, as the history of two unprovoked seizures strongly suggests epilepsy requiring specialized management.

From the Research

Diagnostic Studies for New-Onset Seizures in Children

The following diagnostic studies should be considered for a 5-year-old boy presenting to the Emergency Department (ED) with new-onset seizures:

• Electroencephalography (EEG) to evaluate the electrical activity of the brain 2, 3, 4
• Magnetic Resonance Imaging (MRI) with a dedicated seizure protocol to identify potentially epileptogenic lesions 2, 3, 4
• Referral to a pediatric neurologist for further workup and evaluation 5

Indications for Neuroimaging

Neuroimaging, such as Computed Tomography (CT) or MRI, may be indicated in certain situations:

• Abnormal neurological examination 5
• Acute symptomatic cause, such as trauma or infection 5, 6
• Focal seizures or partial convulsive seizures 5, 2
• Abnormal EEG results 2, 4

Limitations of CT Scans

CT scans may not be necessary for all patients with new-onset seizures:

• Routine practice of obtaining brain CT scans for all patients with new onset of nonfebrile seizures is unjustified 5
• CT scans may miss epileptogenic lesions that can be detected by MRI with a dedicated seizure protocol 4