There is broad acceptance for the use of guideline-endorsed neuroimaging studies as the standard of care in evaluating early-life epilepsy across U.S pediatric centers, an observational study shows.
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Furthermore, the study authors reported, the use of neuroimaging is supported by their data, which showed that a brain MRI obtained up to 1 year after an early-life epilepsy (ELE) diagnosis provides a high diagnostic yield, regardless of clinical factors – including seizure type or development.
“Neuroimaging, and MRI in particular, frequently identifies an etiology for ELE, enhancing the ability of neurologists to provide a precise diagnosis, offer anticipatory guidance, and consider the full array of available therapies,” wrote Jason Coryell, MD, a child neurologist, and his colleagues Aug. 8 in Pediatrics.
Early childhood epilepsy occurs in 1-2 out of every 1,000 children under age 3, Dr. Coryell and his colleagues said. Consensus guidelines recommend MRI for the evaluation of ELE, but no data evaluate whether it is being used in clinical practice, said Dr. Coryell of the Oregon Health & Science University, Portland, and his colleagues. The research team, therefore, set out to identify the yield and findings of neuroimaging in incident cases of epilepsy in 775 children with newly diagnosed ELE (diagnosed before age 3 years) seen at 17 U.S. pediatric epilepsy centers between 2012 and 2015.
They found that the use of neuroimaging was high, with 725 children (93.5%) having had a neuroimaging study. Of those, 714 had an MRI as recommended in current guidelines (87% with seizure protocols), and 11 had computed tomography or ultrasound only.
According to Dr. Coryell and his colleagues, the high use of MRI in the cohort likely could be attributed to three factors: neuroimaging is recommended in guidelines, the improved accessibility of imaging, and increased physician familiarity with the role of MRI in epilepsy.
These included an acquired injury in 97 (13.4%), malformations of cortical development in 56 (7.7%), and other diffuse disorders of brain development in 51 (7.0%).
Neuroimaging was abnormal in 61% (160 of 262) of children with abnormal development at diagnosis, compared with 24% (113 of 463) with typical development.
Structural abnormalities also were high and most common in children with focal seizure semiology (40%), spasms (47%), or unclear semiology (42%).
In children without spasms or focal semiology with typical development, 16% (29 of 185 children) had imaging abnormalities. Pathogenic genetic variants were identified in 44% (53 of 121) of children with abnormal neuroimaging in whom genetic testing was performed.
The research team concluded that their data supported the universal adoption of imaging guidelines for ELE, because the yield was substantially high – even in the lowest-risk group.
“In our cohort 1 in 6 children presenting with typical development and without either focal seizures or spasms still had abnormal neuroimaging,” Dr. Coryell and his coauthors wrote. “This supports the continued adherence to guidelines.”
They advised that next steps include standardization of ELE MRI protocol. “Although there has been widespread adoption of epilepsy protocols, these have been geared toward identification of hippocampal abnormalities in older children and adults rather than toward the young, myelinating brain,” the researchers added.
The team noted several limitations. One limitation cited is the study’s identification of patients by using tertiary centers that might provide care for children who are more severely affected than those in the general population.
The Pediatric Epilepsy Research Foundation in Dallas funded the research. Dr. Coryell and his colleagues said they have no financial disclosures. Several of the researchers declared potential conflicts of interest relating to consulting fees.
SOURCE: Coryell J et al. Pediatrics. 2018 Aug 8. doi: 10.1542/peds.2018.0672.