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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 29  |  Issue : 1  |  Page : 42-49

Seizures in children: Spectrum of findings on brain magnetic resonance imaging at the Korle Bu Teaching Hospital, Ghana


1 Department of Radiology, Korle Bu Teaching Hospital, Accra, Ghana
2 Department of Medical Imaging, School of Medical Sciences, College of Health and Allied Sciences, University of Cape Coast, Accra, Ghana
3 Department of Radiology, University of Ghana Medical School, Accra, Ghana
4 Department of Medical Imaging, University of Health and Allied Sciences, Ho, Ghana
5 Department of Imaging Technology and Sonography, University of Cape Coast, Cape Coast, Ghana
6 Korle Bu Teaching Hospital, 1 Guggisberg Avenue, Accra, Ghana

Date of Submission04-May-2022
Date of Acceptance05-Aug-2022
Date of Web Publication15-Nov-2022

Correspondence Address:
Dr. Klenam Dzefi-Tettey
Department of Radiology, Korle Bu Teaching Hospital, 1 Guggisberg Avenue, Accra
Ghana
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/wajr.wajr_11_22

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  Abstract 


Background: The current imaging modality of choice in the evaluation of patients with seizures is magnetic resonance imaging (MRI). MRI with a specific seizure protocol considerably has a positive impact on patients' management. This study determined the spectrum of brain findings in children with seizures.
Materials and Methods: The study subjects were 191 children aged 1–16 years who presented with seizures within January 2017–August 2021. Socio-demographics and MRI examinations were retrospectively studied. Brain MRI images of patients with their respective reports were analyzed by experienced radiologists. Data from these reports were collected and coded into Statistical Package for Social Sciences (SPSS) version-20.0 for analysis.
Results: One hundred and ninety-one children were included in the study comprising 99 (51.8%) males and 92 (48.2%) females. Abnormal brain images were noted in 89 (46.6%) of the study population. The most common abnormalities were cerebral atrophy 41 (21.5%), white matter T2 Fluid-attenuated inversion recovery hyperintensities 22 (11.5%), and temporal lobe atrophy 9 (4.7%). Twenty-six (29.2%) of the children presented with multiple lesions and these were more common in children <5 years of age.
Conclusion: MRI is extremely useful in the early detection and diagnosis of the causes of seizures in children in low socio-economic setting like ours. The majority of the children with brain lesions were under five years, and in a setting like ours, all efforts should be made to image them since they are sometimes denied MRI due to the relatively high cost of the procedure.

Keywords: Brain, children, epilepsy, Ghana, magnetic resonance imaging, seizure


How to cite this article:
Dzefi-Tettey K, Edzie EK, Brakohiapa EK, Kekessie KK, Piersson AD, Acheampong F, Gorleku PN, Nixon HR, Asemah AR, Kusodzi H. Seizures in children: Spectrum of findings on brain magnetic resonance imaging at the Korle Bu Teaching Hospital, Ghana. West Afr J Radiol 2022;29:42-9

How to cite this URL:
Dzefi-Tettey K, Edzie EK, Brakohiapa EK, Kekessie KK, Piersson AD, Acheampong F, Gorleku PN, Nixon HR, Asemah AR, Kusodzi H. Seizures in children: Spectrum of findings on brain magnetic resonance imaging at the Korle Bu Teaching Hospital, Ghana. West Afr J Radiol [serial online] 2022 [cited 2022 Dec 1];29:42-9. Available from: https://www.wajradiology.org/text.asp?2022/29/1/42/361181




  Introduction Top


Seizures are common disorders that have been known from time immemorial and are often encountered in medical practice. According to literature, up to 10% of the general population will have at least one seizure in their lifetime, with the highest rates occurring in early infancy and late adulthood.[1] It is one of the most prevalent neurological symptoms in newborns and young children, with a wide range of causes prompted by disease or injury, and in some cases, they are idiopathic. Neonatal seizures affect about 5% of newborns, febrile seizures affect 2%–4% of young children, and epileptic seizures affect up to 1% of children and adolescents. Other acute traumas, such as head trauma, can also cause seizures, however, their prevalence in children is difficult to measure.[2]

Attaining a standard classification of seizures has been a challenge for so many years. The classification used in 1981, 1985, and 1987 by the International League Against Epilepsy (ILAE) came with its own limitations and consequences.[3] By way of solving the setbacks associated with these classifications, the ILAE released a revised version in March 2017, aimed at simplifying terminologies that patients and caregivers can easily understand.[4] According to the new classification, seizures are categorized under three onsets, namely: focal onset, generalized onset, and unknown onset. They explained that focal seizures occur when abnormal electrical activities originate from one side of the cerebral hemisphere and may later progress to the other side. For generalized seizures, both the right and left cerebral hemispheres experience abnormal electrical activities simultaneously and later spread to other brain neuronal networks evidenced by the patient clinical presentation or electroencephalography features. Finally, the ILAE suggested that in a situation where the seizures occur during sleep or in a condition that cannot be described, thus, the information given is a seizure event that cannot be described due to the incomplete information given, then it should be regarded as unclassified seizure and hence the name, unknown onset.[4]

The use of neuroimaging in the examination of patients with first-onset seizures is critical, especially in the detection of structural brain lesions that can act as epileptogenic foci and are surgically resectable.[5] Notably, computed tomography (CT) and magnetic resonance imaging (MRI) are considered the diagnostic evaluation of choice for children with their first seizure. There is widespread agreement that children who suffer their first seizure without warning should undergo brain CT or MRI to identify any processes that may be causing the seizure.[6] Although cranial CT offers a benefit in emergency conditions, experts believe that MRI has a higher yield and is generally preferable in nonemergency situations.[7] MRI is the recommended imaging modality for patients with seizures because of its superior sensitivity for lesion detection, such as heterotopias and mesial temporal sclerosis (MTS), which are both related to childhood-onset seizures.[8],[9],[10]

In sub-Saharan Africa, seizures in children are increasingly becoming an indication for neuroimaging.[11] Studies in Ghana have found that to a significant extent, seizures are associated with some conditions such as active convulsive epilepsy, eclampsia, and preeclampsia.[12],[13] The aim of this study was to determine the spectrum of findings on brain MRI of children with seizures to establish baseline data for seizures and its associated burden in Ghana.


  Materials and Methods Top


Study site and design

The study was a retrospective study conducted at the Department of Radiology of the Korle Bu Teaching Hospital (KBTH), a Tertiary Hospital in Accra, Ghana's capital. This 2000-bed hospital, established in 1923, is now Africa's third largest hospital and the country's primary referral facility.[14] Approval for this study was given by the KBTH Institutional Review Board.

Data collection

Data for the study were retrieved from the Picture Archiving and Communication System (PACS) of the radiology department between January 2017 and August 2021. Brain MRI images of children between 1 and 16 years who presented for brain MRI on account of seizure during the study were consecutively included in the study and a total of 191 images were retrieved with no exclusions made. No missing data were found. These brain images were examined by two experienced radiologists who were blinded to the previous reports of the patients.

Imaging procedure and interpretation

The MRI examination was carried out on a 1.5 Tesla Toshiba Vintage Titan MRI machine with serial number GH-0029-01-CMR-01 using the routine MRI seizure protocol. The following scanning sequences were used; Sagittal T1 3D Isotropic 3D TFE 1 mm, axial T2*GRE FFE 2 mm, axial T2 TSE 1 mm, axial DWI 3 mm Short Tau Inversion Recovery (STIR), oblique coronal fluid-attenuated inversion recovery (FLAIR) TSE 3 mm and oblique coronal T2 TSE 2 mm. These images were stored in PACS. One hundred and forty-one of the children were scanned under sedation and intravenous Gadolinium (Magnevist) contrast medium (4 mg/ml) was administered to 43% of the cases. Two radiologists with more than 15 years of experience in reporting brain MRI reviewed the retrieved images.

Statistical analysis

The Statistical Package for Social Sciences (SPSS Inc., Chicago, IL, USA) version 20.0 was used to analyze the data, and Microsoft Excel 2010 was used to create tables and charts (Microsoft Corp., Redmond, WA, USA). For count data, descriptive analyses were reported as proportions, and for continuous data, mean with standard deviation (SD). The ages of the children were classified as follows: <5 years (young children), 5–10 years (middle-aged children), and 11–16 years (older children). Socio-demographics and brain imaging findings were compared using the Chi-squared test for independence. The Fisher's exact test was employed when one or more expected cell counts were fewer than five. An interrater reliability using Kappa statistic was performed to determine the consistency between the two radiologists. P < 0.05 was chosen as the statistically significant level.


  Results Top


One hundred and ninety-one children were enrolled in this study. There were 99 (51.8%) boys and 92 (48.2%) girls, aged 1–16-year-old (mean ± SD: 7.38 ± 5.332 years) of whom 102 (53.4%) had no abnormality detected on MRI. Abnormal findings were 45 (45.5%) and 44 (47.8%) in males and females, respectively. Fifty-one (57.3%) of these abnormalities were single lesion, whereas 26 (29.2%) were two or more lesions. Majority of the patients were below the age of 5 years. In terms of gender, there were no statistically significant differences between children with abnormal brain MRI and those with normal brain MRI (P = 0.743). However, a statistically significant difference was found in the different age groups of children with and without abnormalities [Table 1]. A chart of the children with seizures distributed by their age groupings and gender showed that the number of males in each age class was slightly more than the number of females [Figure 1].
Figure 1: Children with seizures distributed by age and gender

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Table 1: Demographics and number of lesions in patients with or without abnormalities

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Imaging findings

The interrater reliability for the two radiologists was found to be Kappa = 0.91 (P < 0.001), confidence interval (0.621, 0.976), implying an almost perfect agreement in the images reviewed. The most common brain abnormalities were cerebral atrophy 41 (21.5%), white matter T2 (FLAIR) hyperintensities 22 (11.5%), and temporal lobe atrophy 9 (4.7%). With the exception of the cerebral atrophy (χ2 = 23.685), (P < 0.001), none of the abnormalities found had a statistically significant association among the different age groups. The spectrum of abnormal findings is shown in [Table 2]. Children <5-year-old accounted for the predominant proportion of children with multiple lesions whereas an equal proportion of multiple lesions was seen in those between 5–10 years and 11–16 years [Figure 2].
Figure 2: Distribution of age groups with multiple lesions

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Table 2: Abnormal brain magnetic resonance imaging findings in children with seizures

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Images of some selected brain abnormalities showing agenesis of the corpus callosum, lissencephaly, T2/FLAIR hyperintensities, syntelencephaly, diffuse brain atrophy, subependymal astrocytomas, and hydrocephalus in these children are shown in [Figure 3],[Figure 4],[Figure 5],[Figure 6],[Figure 7],[Figure 8],[Figure 9], respectively.
Figure 3: Axial T2W MR Image of the brain of a 1-year-old male showing agenesis of the corpus callosum

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Figure 4: Axial T2W and T1W images of the brain of a 1-year-old female showing Lissencephaly (pachygyria agyria spectrum) and dilatation of the posterior horn of the right lateral ventricle

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Figure 5: Axial and coronal FLAIR brain MRI of a 13-month-old–female showing confluent periventricular T2/FLAIR hyperintensities in the cerebral hemispheres bilaterally suggesting hypoxic-ischemic injury or a leukodystrophy. FLAIR – Fluid-attenuated inversion recovery, MRI – Magnetic resonance imaging

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Figure 6: Axial T1W nonenhanced brain MRI of a 14-month-old–female presenting with seizures showing syntelencephaly. Also noted was a minimal acute right subdural hematoma. MRI – Magnetic resonance imaging

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Figure 7: Coronal T1 3D FLAIR FAST FE MRI image of the brain in a 3-year-old boy showing diffuse brain atrophy. FLAIR – Fluid-attenuated inversion recovery, MRI – Magnetic resonance imaging

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Figure 8: MRI, T1 coronal T1W FatSat postgadolinium enhanced images showing right and left Sub Ependymal Giant Cell Astrocytomas in a 4-year-old boy with Tuberous sclerosis. MRI – Magnetic resonance imaging

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Figure 9: Mid sagittal T1W and T1W postgadolinium enhanced MR images of the brain of an 8-year-old boy showing a midline, posterior fossa tumour in the fourth ventricle suggesting medulloblastoma or an ependymoma. The tumor enhanced heterogeneously and there is resultant obstructive hydrocephalus

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  Discussion Top


Seizure findings in children vary greatly depending on the imaging modality and protocol used, as well as the patient population investigated. According to a report by the committee for neuroimaging, 15%–16% of imaging studies have been able to gain useful information on the etiology and focus of seizures in children, and 2%–4% have been able to obtain information that could potentially change urgent medical therapy.[15] The incidence of abnormal neuroimaging in children with new-onset seizures has been discovered through some studies. In these studies, the prevalence of abnormal neuroimaging ranged from 0% to 38.6%.[16],[17],[18],[19],[20],[21],[22],[23],[24],[25],[26],[27],[28],[29]

Majority of studies have found that seizures are more common in younger children, with a decreasing frequency in the older age group, and are more common in males.[30],[31],[32],[33] The majority of the children in our study with seizures were under the age of five. In all age categories, males had a slightly higher prevalence than females. In contrary to this study, a study conducted in Nepal reported that males were found to have a higher prevalence in children under 10 years, and females were shown to have a higher prevalence in the 11–15-year-old range.[34]

Because the populations are so dissimilar, it is difficult to compare our findings to most seizure-related studies. Our study included all brain MRI done for seizures from January 2017 to August 2021, which should have given a larger sample size but due to the high cost of MRI investigations, which is usually borne by the patients, some practitioners perform a cost-benefit analysis before requesting an MRI for their patients, accounting for our sample size of 191. To corroborate this assertion, a total of 288 children aged 0–18 years were obtained as the final sample size over a 6-year study period in a recent study conducted in Kenya on brain MRI findings in children presenting with seizure.[35]

In this study, 89 (46.6%) of the children had an abnormal brain MRI finding and the proportion of abnormal finding was highest in the underfive age group. This pattern has also been reported by Obajimi et al.[36] Meanwhile, many physicians in developing countries believe that the threshold for investigating seizures in children under the age of five should be raised, because a considerable majority of seizures in this age group are clinically related to and managed as febrile convulsions.[30],[31],[32] The greater detection of structural abnormalities in children under the age of five in this study suggests a shift in practice and a lower threshold for neuroimaging in younger children. In other studies, abnormal MRI findings vary between 28.5% and 55.86%.[37],[38],[39] In general, abnormal MRI findings in children with seizure disorder appear to be more common in developing countries than in developed countries, with rates ranging from 12% to 20%.[40] This disparity is likely due to the increased risk of endemic diseases such as malaria or neurocysticercosis, birth-related injuries, all of which are common in developing countries[41],[42] and have a positive correlation with brain abnormalities.

In our study, brain atrophy was the most common abnormality, accounting for 41 (21.5%), which is consistent with the findings of Amirsalari et al. and Ali et al., who found brain atrophy to be the most common abnormality in 10% and 12.91% of their study populations, respectively.[37],[38] In other studies, brain atrophy was shown to be the third most prevalent abnormality, accounting for 4.55%.[43] Although the process of brain volume loss is less reported in children, there is a growing body of data that it can also be observed in children. Our results showed that the predominant population involved were children under-5 years with the least being 5–10-year-old group as opposed to a study in northern Tanzania. The demographic characteristics of their study showed that the predominant population with brain atrophy were children above 10 years of age, while the under-5 years constituted a relatively lower population.[44]

MTS can be reliably detected by MRI and is the most common cause of intractable temporal lobe epilepsy (TLE).[45],[46] MTS was the most common temporal lobe lesion seen on brain MRI in children with new-onset and intractable TLE, according to Harvey et al. and Grattan-Smith et al., with rates of 21% and 57%, respectively.[47],[48] In a study of children under the age of 18 years who had surgery for TLE, MTS was the most prevalent finding.[49]

According to research, MTS is uncommon in early childhood.[50] The prevalence of MTS was 1.6% in our study (3 out of 191 children). In other studies, MTS was found in 3.1% (12 out of 390 children) of all brain MRI studies and none in a study done in Nigeria.[51],[52] Other studies have also suggested that MTS is more prevalent in children than previously thought. In a study by Kalnin et al., they found that MTS constituted 15% (53 out of 349) of all abnormalities observed in children.[53]

A possible reason accounting for the low frequency of MTS in this study could be attributed to the fact that our study used a routine MRI seizure protocol whereas the study by Kalnin et al. used a high-resolution MRI together with a standardized scoring system for rating the MRI examination. MTS is likely difficult to be detected from routine brain MRI. McBride et al. compared the results of routine MRI outside of an epilepsy facility to the results of specific temporal lobe seizure protocols used at major epilepsy centers. They found that although routine MRI detected low-grade tumors and vascular malformations, it could not detect hippocampal sclerosis.[54] This is because the hippocampal structures are generally flat and reside mostly in the axial plane (where most routine sequences are done), therefore, subtle lesions of the hippocampus could be missed.[55]

The number of children with multiple lesions was 26 (29.2%) and was commonly observed in children under 5 years of age. In a study by Dirik and Sanlidag and Kalnin et al., multiple lesions in children following their first seizure were observed in 9.09% and 12% of the children, respectively.[43],[53] A 4-year-old boy with tuberous sclerosis and a history of seizure in our study had the typical brain features; subependymal giant cell astrocytomas, subependymal nodules, and cortical tubers on brain MRI.

Although conventional MR sequences are routinely used for detecting intracranial lesions in seizure disorder, they are not able to reveal the subtle microstructural characteristics. Newer MRI techniques are used to investigate imaging correlates of neurobehavioral phenotype, epilepsy, and microstructural brain tissue properties.[56] Diffusion-tensor imaging (DTI) and fiber tractography are two emerging techniques that show the white matter fibers' direction and integrity.[57] DTI is a new MRI technique in neuroimaging that uses anisotropic diffusion to visualize the white matter axonal pathway's integrity.[58] DTI has been used in a lot of investigations to look into the anatomical changes in white and gray matter structures.

In a study conducted in Kenya, abnormal MRI findings were found in 33% of children with seizures who underwent MRI. Encephalomalacia due to persistent infarcts, cerebral atrophy, neuronal migratory disorders, periventricular leukomalacia, and hippocampal sclerosis were the most prevalent imaging findings.[35] A study of childhood seizures presented at a tertiary hospital in South Africa reported 34% of abnormalities in children, with the most common abnormalities being perinatal hypoxic insult, neuronal migration disorders, and neurocutaneous disorders.[11] Brain atrophy and prenatal insults were the most common positive findings in a study in Tanzania, which indicated abnormalities in 29% of the children.[59] These investigations uncover an etiological profile that includes prenatal insults as one of the most common findings: identifying a preventable cause of seizures that necessitates purposeful interventions in maternal and newborn health.

A major limitation was the small sample size which was retrieved from PACS during this retrospective study.


  Conclusion Top


The study emphasizes the increased likelihood of abnormal brain anomalies in children under 5-year-old presenting with seizures and adds to the growing body of evidence supporting the use of MRI in children with seizures in our setting. The authors recommend that MRI be used more frequently and that specific protocols be developed to aid in the diagnosis of causes of seizures in children and this will improve management and thus prevent further damage to the developing brains in some children.

Acknowledgment

We are grateful to the entire staff of the Radiology department of the Korle Bu Teaching Hospital.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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