What is the most appropriate next step for a young boy who had a seizure after hitting his head, is conscious, oriented, and has no neurological deficit?

Management of Post-Traumatic Seizure in a Pediatric Patient

Urgent non-contrast CT head is the most appropriate next step for this young boy who experienced a post-traumatic seizure, even though he has returned to baseline neurological status. 1, 2

Rationale for Urgent CT Imaging

The American College of Radiology explicitly states that CT head without contrast or MRI head without contrast is usually appropriate for the initial imaging of children with post-traumatic seizures, with these procedures being equivalent alternatives 1. However, in the acute emergency setting, CT is the practical choice because:

• CT can identify 100% of acutely treatable lesions in patients with post-traumatic seizures, with 7% requiring urgent surgical intervention 2
• CT rapidly detects intracranial hemorrhage, mass effect, or other structural pathology that may require immediate neurosurgical intervention 1, 2
• The presence of seizure after head trauma is an independent predictor for intracranial pathology, regardless of current neurological status 1, 2

Why Not Discharge or Observation Alone?

While the child appears neurologically normal now, this clinical presentation does not exclude significant intracranial injury:

• Post-traumatic seizures indicate increased risk for underlying structural brain injury that may not be apparent on clinical examination alone 1, 2
• Seizures occur in 2.4% of mild traumatic brain injury cases but can indicate more severe injury requiring intervention 1
• The American Academy of Pediatrics recommends emergent neuroimaging when there is concern for intracranial pathology, and post-traumatic seizure qualifies as such concern 1

Clinical Decision Algorithm

Perform urgent non-contrast CT head first to rule out:

• Intracranial hemorrhage (subdural, epidural, subarachnoid, intraparenchymal) 1, 2
• Skull fractures with underlying brain injury 1
• Cerebral edema or mass effect 3
• Other acute structural lesions requiring neurosurgical intervention 2

After CT results:

• If CT shows acute pathology requiring intervention → immediate neurosurgical consultation 2
• If CT is normal → admission for observation may still be warranted given the post-traumatic seizure, with decision based on seizure characteristics and clinical context 1
• MRI may be obtained later (non-emergently) if CT is negative but clinical suspicion remains, as MRI is more sensitive for microhemorrhages and diffuse axonal injury 1

Important Caveats

Do not be falsely reassured by normal neurological examination. Research shows that:

• 22% of patients with normal neurologic examinations still have abnormal imaging findings 4
• Young age and presence of subdural hematoma are independent predictors for post-traumatic seizures, meaning the seizure itself suggests higher-risk injury 1, 2

The brief duration (one minute) and complete resolution of the seizure does not eliminate the need for imaging in the post-traumatic context, as this differs fundamentally from non-traumatic first seizures where imaging may be deferred in low-risk patients 1, 4