|Year : 2022 | Volume
| Issue : 3 | Page : 368-373
Etiological profile of seizure in children of age group 1 month to 18 years with special reference to neuroimaging in a tertiary care hospital
Bikram Mondal1, Oendrila Sarkar2, Pankaj K Halder3, Sukanya Deb4, Debasree Guha4, Amita S Mandal5
1 Department of Pediatric Medicine, Jawaharlal Nehru Hospital and Research Centre, Bhilai 490009, Chhattisgarh, India
2 Spandan Nursing Home, Bhatenda, Kolkata 700059, West Bengal, India
3 Department of Pediatric Surgery, R. G. Kar Medical College, Kolkata 700004, West Bengal, India
4 Department of Pediatric Medicine, R. G. Kar Medical College, Kolkata 700004, India
5 Divine Child Care Unit, Kolkata 700010, West Bengal, India
|Date of Submission||12-Jul-2022|
|Date of Acceptance||08-Aug-2022|
|Date of Web Publication||29-Sep-2022|
Dr. Pankaj K Halder
Saroda Pally, Sitko Road, Baruipur, Kolkata 700144, West Bengal
Source of Support: None, Conflict of Interest: None
Background: Seizure is a common cause of childhood hospitalization. Neuroimaging studies help in identifying etiologies, including the rare ones, and planning management. Purpose: The aim of this study is to determine the etiology of seizures in pediatric patients and the utility of neuroimaging in the same. Materials and Methods: A prospective study was carried out on 100 children who were admitted with seizures (including recurrent episodes) in our tertiary care institute. The sociodemographic profile, clinical features, neuroimaging findings, and findings of other investigations were documented and analyzed, to classify the type and etiology of seizures. Results: The male–female ratio among patients was 1.94: 1. Seizures of generalized onset were most common (95%), affecting mostly the age group of 1–5 years (50.53%), followed by the 5–18 years (29.47%) and the 1 month to 1 year (20%) groups. The etiologies were simple febrile seizure (51%), seizure disorder (8%), cerebral palsy (8%), acute viral meningoencephalitis (7%), pyogenic meningitis (6%), and complex febrile seizure (5%). Neuroimaging was carried out in 30 children, in which 14 showed abnormal reports, and abnormal electroencephalogram (EEG) report was found in 6 out of 10 patients. The analysis of the distribution of the types of seizures concerning age, gender, family history of seizure, history of seizure, socioeconomic status, and developmental milestones did not reveal any statistically significant relationships (P > 0.05). Conclusion: Seizure of generalized onset was the most common type, and the most common etiology was a simple febrile seizure. Abnormal neuroimaging/EEG findings were more pronounced in patients with focal seizures.
Keywords: Etiology, febrile, focal, generalized, neuroimaging, pediatric, seizure, simple
|How to cite this article:|
Mondal B, Sarkar O, Halder PK, Deb S, Guha D, Mandal AS. Etiological profile of seizure in children of age group 1 month to 18 years with special reference to neuroimaging in a tertiary care hospital. MGM J Med Sci 2022;9:368-73
|How to cite this URL:|
Mondal B, Sarkar O, Halder PK, Deb S, Guha D, Mandal AS. Etiological profile of seizure in children of age group 1 month to 18 years with special reference to neuroimaging in a tertiary care hospital. MGM J Med Sci [serial online] 2022 [cited 2022 Nov 29];9:368-73. Available from: http://www.mgmjms.com/text.asp?2022/9/3/368/357482
| Introduction|| |
Seizure is a common neurological symptom and one of the most frequent reasons for the hospitalization of children. Seizure disorder is a general term that includes epilepsy, febrile seizures, and symptomatic seizures secondary to metabolic, infectious, or other causes. It is divided into two major categories: generalized onset seizure (GOS) and focal onset seizure (FOS). The International League Against Epilepsy (ILAE) has developed a sound system for the classification of seizure type and etiology. The etiological spectrum of acute symptomatic seizures in developing countries is distinctly different from that of developed countries. Investigation of children with seizures is based on history and examination as there is an extensive differential diagnosis including meningitis, encephalitis, cerebral malaria, toxic ingestion, electrolyte imbalance, tumors, and underlying chronic illness. Neuroimaging has emerged as an important modality for the etiological diagnosis of seizure disorder nowadays. It helps in identifying focal seizure or persistent seizure activity, focal neurologic deficit, neurocutaneous di sorders, signs of elevated intracranial pressure, ventriculoperitoneal shunt, traumatic lesions, and cysticercosis in endemic countries. Proper diagnosis of seizure disorder is always challenging in resource-poor countries. A better understanding of seizures in terms of clinical presentation and etiology is imperative for abortion of acute attack, long-term control of epilepsy, and undertaking preventive measures at the community level to decrease the burden of the disease in the community. With this background in mind, we carried out this study to assess the etiological profile of seizures in children in our region and the role of neuroimaging in such assessment.
| Materials and methods|| |
A prospective, cross-sectional study was conducted in the inpatient facility of the department of pediatrics, in a tertiary care hospital from July 2020 to June 2021. The sample size for our observational study was calculated with the help of the Cochrane formula. As the prevalence/incidence of seizures in the community is quite low in percentage, we considered the proportion of febrile seizures for sample size calculation, which is the most common cause of seizures overall. As mentioned before, this proportion is around 50%. So, P = 0.50; z-value for 5% confidence level is 1.96, while e (allowable error) is 10%. Thus, the minimum sample size
(N) = (〖1.96〗^2*p*(1−p))/e^2 = (3.8416*0.50*0.50)/(0.10)2=100.
This study included patients of either sex, aged between 1 and 18 years, who were admitted to the pediatric ward and pediatric intensive care unit (PICU), with the chief complaint of seizures (including recurrent episodes). We excluded the patients who were found to (i) have a condition that mimics seizures as reassessed by history and clinical examination, (ii) have an unreliable history, and (iii) be willing to participate in this study.
The inclusion criteria include the age group from 1 month to 18 years of age and admitted to the pediatric ward and PICU with chief complaints of seizures (including recurrent episodes).
The criteria were as follows:
- (a) Parents/patients not willing to take part in the study;
- (b) Patients in which reliable information was not available;
- (c) Patients who were found with a condition that mimics seizures as re-assessed by history and clinical examination.
Approval from the Institutional Ethics Committee was taken before the initiation of this study (approval no. JLNHRC/IEC/2020/59). Patients with “seizure,” as defined by the transient occurrence of signs and symptoms resulting from abnormal, excessive, or synchronous activity in the brain, were evaluated. After screening, the cases that fulfilled predefined inclusion and exclusion criteria were enrolled in the study. Parents of these prospective cases were counseled regarding the objectives and methodology of the study. Written informed consent from parents of every study subject was taken.
Baseline data details, according to a pretested proforma, were recorded along with investigation reports and numbered consecutively. The proforma included the type and etiology of seizures, according to the ILAE 2017 guidelines, socioeconomic profile according to the modified Kuppuswamy scale, clinical features, and assessment of sensorium according to the Glasgow Coma Scale, neuroimaging findings, and findings of other investigations.
Background variables of each patient include age, gender, type of seizure, socio-economic profile, clinical features, the status of the sensorium, neuroimaging findings, and cerebrospinal fluid (CSF) analysis. Other investigations [hemogram, serum electrolytes, blood sugar, fundus examination, and electroencephalography (EEG)] were taken into consideration for statistical analysis.
For statistical analysis, data were entered into a Microsoft Excel (2019 MSO Version 2201 Build 16.0.14827.20198 64-bit, Microsoft Corporation, Redmond, WA, USA) and then analyzed on software SPSS (version 26.0; SPSS Inc., Chicago, IL, USA). Numerical data were presented as mean ± SD, and categorical variables were expressed as frequencies and percentages. Non-parametric/unpaired proportions data were compared by the χ2 test. The P-value of 0.05 or less was considered statistically significant.
| Results|| |
The GOS was 19 times more common than FOS. GOS affected mostly (50.53%) children in the age group of 1–5 years, followed by 5–18 years (29.47%) and 1 month to 1 year (20%) [Table 1]. However, no significant difference between the type of seizure and age group was obtained (P = 0.05). The most common cause of seizure was a simple febrile seizure (SFS) (51%) and had an overall 1.94:1 male predominance. Apart from SFS, other leading etiologies were seizure disorder (8%), cerebral palsy (8%), acute viral meningoencephalitis (7%), pyogenic meningitis (6%), complex febrile seizure (5%), and so on [Table 2].
|Table 1: Distribution of patients according to the age group and etiology of the seizure (n = 100)|
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|Table 2: Distribution of patients according to etiology and type of seizure (n = 100)|
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The family history of seizures was present only in the GOS group. Similarly, delayed milestones were found only in 8.42% of the patients in the GOS group. However, a history of seizures was positive in both GOS (13.68%) and FOS groups (20%). Regarding socio-economic status, 68%, 5%, and 27% of patients were from the lower, middle, and upper classes, respectively. The statistical analysis by Fisher’s exact test for the gender, age at presentation, family history of seizure, delayed milestones, history of seizure, and socio-economic status showed the P-values of 0.55, 0.05, 0.65, 0.65, 0.53, and 0.65, respectively.
Thus none of these variables was predictive of seizure activity in this study (P > 0.05). Clinical examination revealed altered sensorium, signs of meningeal irritation, cranial nerve abnormalities, and abnormalities of the motor system in 15%, 14%, 2%, and 17% of the cases, respectively [Table 3].
|Table 3: Distribution of patients according to neurological signs and type of seizure (n = 100)|
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The neuroimaging was abnormal in 47% of the cases out of 30 patients who underwent the same (26 patients in the GOS group and 4 patients in the FOS group). The different abnormal neuroimaging findings in seizure patients are depicted in [Table 4]. EEG was done in 10 cases with GOS, of whom 60% showed abnormal findings [Figure 1]. The normal higher function was seen in 85% of the cases. About 94% of the patients were successfully managed and were discharged subsequently, five patients took leave against medical advice, and one was referred to another medical college.
|Table 4: Different abnormal neuroimaging findings in seizure patients (n = 30)|
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|Figure 1: Distribution of patients according to the type of seizure and EEG findings (n=10)|
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| Discussion|| |
It has been estimated that at least 4–10% of the children will have one episode of seizure in the first 14 years of life. Seizure disorder leads to more than 7 million disability-adjusted life years. The incidence of seizures in our series was more in males (66%) than in females (34%). Kumar et al. found a male–female ratio of 1.2:1, whereas Chaudhary et al. showed a male–female ratio of 1.6:1. Similarly, Adhikari et al. reported greater prevalence in males (a male–female ratio of 1.58:1), though no definite causal relationship for this male preponderance is explained in the literature.
The incidence of seizures is highest in the first 3 years of life, with decreasing frequency in subsequent years. In the studies by Kumar et al. and Adhikari et al., the largest (30%) proportion of children was in the age group of 1–2 years. Chen et al. found that 94% of the children with first attacks of seizure disorder were younger than 6 years. Similarly, Poudel et al. observed that 43% of seizure patients were between the age group of 2–4 years. In our study, most of the children with SFS were younger than 5 years of age (19% were below 1 year and 49% were between the age group of 1–5 years). However, children of more than 5 years of age with seizure disorder usually have other etiologies such as meningitis, neurocysticercosis, hypertensive encephalopathy, stroke, cerebral malaria, and brain tumor. For neonatal seizures, a different spectrum of etiologies (septicemia, hypoglycemia, hypoxic-ischemic encephalopathy, and metabolic disorders) has been reported in the literature; we did not include neonatal seizures in our study.
The seizures are categorized into two major categories: generalized onset and focal onset. GOS is again categorized into absences and convulsions. FOS is further classified as focal motor, dyscognitive, focal sensory, and secondarily generalized seizures (formerly known as complex partial seizures). We observed GOS and FOS in 95% and 5% of our patients, respectively. The GOS is the most common type as reported in the studies by Saravanan et al., Kumar et al., and Chaudhary et al. They found GOS in 59%, 91.4%, and 82.1% of the patients and FOS in 41%, 8.6%, and 17.9% of patients in their series, respectively.,
The ILAE has classified seizures into three large etiological classes: hereditary, structural/metabolic, and unknown. The revised classification of epilepsy in ILAE involves multiple rare syndromes that rely on the availability of EEG as well as neuroimaging facilities, which are difficult to avail in resource-poor situations. In our study, the leading four causes of seizure were SFS (51%), seizure disorder (8%), cerebral palsy (8%), and acute viral meningoencephalitis (7%). As compared to our study, Kumar et al. found SFS (46.7%), seizure disorder (19.2%), cerebral palsy (15%), and viral encephalitis (5.8%) in their study. Another study by Saravanan et al. reported the relative incidence of etiologies as follows: SFS (36.5%), seizure disorder (33.2%), encephalitis (18%), and camphor poisoning (13%), as the leading causes of seizures. We also encountered a few rare causes of seizures such as neurocysticercosis (2%), hypernatremia (2%), gamma-benzene hexachloride poisoning (2%), hepatic encephalopathy (2%), cerebral malaria (2%), tubercular meningitis (2%), hypertensive encephalopathy (1%), stroke (1%), and brain tumor (1%).
Several studies have shown that the routine assessment of serum electrolytes, calcium, phosphorus, magnesium, complete blood count, blood urea nitrogen and creatinine, and glucose is not mandatory in seizure patients with otherwise normal physical findings, who have no risk factors for epilepsy, or whose consciousness level has returned to baseline. However, blood glucose should be determined in children with prolonged postictal obtundation or with poor oral intake (prolonged fasting). Seizures due to situations of electrolyte imbalance or hypoglycemia were rare in our study, and thus extensive blood biochemical workup was undertaken, only as indicated.
Similarly, routine lumbar puncture for CSF study is not indicated in a patient who is alert and oriented after a first febrile seizure. However, it should be considered for all infants younger than 6 months of age, who present with fever and seizure, or if the child is ill-appearing, or at any age if there are clinical signs or symptoms of meningeal irritation/a prolonged postictal period, or a child of 6–12 months of age who has unreliable, or unknown, Hemophilus influenzae type B and Streptococcus pneumoniae immunization status.
We performed the CSF analysis in 29 cases, of whom 52% had abnormal reports. Saravanan et al. observed abnormality in the CSF study in 41% of their patients with seizures.
Neuroimaging examination of the brain can help emergency physicians to identify the rarer causes of seizures, more so in cases of FOS (80%), but also GOS (10.52%). In our study, out of five patients with FOS, neuroimaging was performed on four (80%) patients and all (100%) had shown abnormal reports. While in the GOS (n = 26), only 10 (38.46%) had abnormal neuroimaging findings. In our study, the overall neuroimaging abnormality was 46.67% (14 out of 30 patients). In addition, the common neuroimaging abnormalities were cortical atrophy (13.14%), followed by cerebral edema (10%), basal exudate (6.67%), infarction (6.67%), cyst (6.67%), and medulloblastoma (3.34%). Most of the children who showed abnormal neuroimaging findings could be predicted from their clinical histories and examinations. In the present study, 15% of the cases had altered sensorium, 14% had signs of meningeal irritation, and 2% had cranial nerve abnormalities, and abnormalities of the motor system were present in 17% of the cases. Kumar et al. reported abnormal neuroimaging findings in 51.2% of the cases in their study. Chaudhary et al. and Shivaprakash et al. identified neuroimaging abnormalities in 42.9% and 20.34% of their cases, respectively. Magnetic resonance imaging of the brain is not necessary for patients with SFS, as an abnormal finding is very unusual. In our study, 70% of the cases had no suggestive history or clinical findings and thus were not subjected to neuroimaging study. Adamsbaum et al. suggested that emergency neuroimaging should not be arranged routinely for a child who presents with the first attack of seizure with no known history of head injury, normal physical and neurological examination, or no acute symptomatic cause other than fever. Likewise, EEG is not an obligatory investigation for a child with the first SFS who is otherwise neurologically healthy. Saravanan and Kumar et al. reported abnormal EEG findings in 51.9% and 70% of the patients, respectively. We found abnormal EEG findings in 6 (60%) out of the 10 patients with GOS.
During the management of the seizure patient, it is helpful to be aware of the regional microbiology of central nervous system infections, the reach of disease-specific immunization programs, and the status of healthcare facilities including transportation and preparedness for emergency management. While fever is not an independent predictor of mortality, however, meningitis and meningoencephalitis do cause a significant increment in both mortality and morbidity, particularly in a patient with a seizure disorder. We successfully managed 94% of our patients, whereas five patients took leave against medical advice, and one was referred to a higher center.
This study highlights the current scenario of the pattern of pediatric-onset seizures in a tertiary care center. Seizures beginning in early life require special attention to their etiology as most of them are secondary to some underlying etiology. Primary care physicians play a pivotal role in identifying seizures and should encourage these patients to undergo neuroimaging to arrive at an appropriate etiological diagnosis.
| Conclusion|| |
In conclusion, we reiterate that GOS is the most common type of seizure in the pediatric population. The SFS is more common than seizure disorder/cerebral palsy/acute viral meningoencephalitis, especially in children younger than 5 years of age, whereas seizure disorder is common in the >5-year age group. As far as our small series is concerned, neuroimaging, CSF study, and an EEG should be reserved for the patients with altered sensorium/signs of meningeal irritation/abnormal higher function, and a suspected seizure disorder. However, specific approaches based on institutional practice and physicians’ experience always have a better impact on the medical management of seizures. Lastly, educating family and children about the disease and how to deal with active convulsions are important for organizing a successful therapeutic approach.
Neonatal seizures have not been included in this study. The limited (n = 100) number of cases was due to the restricted study period (1 year), which was probably insufficient to draw a very robust opinion. A larger study population with a control group could yield a more decisive result.
Ethical consideration and patient consent
The Institutional Ethics Committee of the Jawaharlal Nehru Hospital and Research Centre, Bhilai, Chhattisgarh, India has approved to undertake the proposed clinical study on “Etiological profile of seizure in children of age group 1 month to 18 years with special reference to neuroimaging in a tertiary care hospital” vide their letter no. JLNHRC/IEC/2020/59 dated 19.11.2020. Written informed consent from parents of every study subject was taken.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4]