European Journal of Cardiovascular Medicine

Seizures are among the most frequent neurological emergencies in childhood and contribute substantially to pediatric morbidity worldwide. The lifetime incidence of epilepsy is estimated to be approximately 3%, with nearly 10% of children experiencing at least one seizure episode during early life [1]. While febrile seizures are common in younger children, afebrile seizures require more detailed evaluation, as they often indicate underlying structural or functional brain pathology [2].

Electroencephalography (EEG) and neuroimaging are considered cornerstone investigations for children presenting with unprovoked afebrile seizures. EEG provides crucial insights into epileptiform discharges, seizure type, and possible syndromic classification, whereas neuroimaging modalities such as CT and MRI can reveal abnormalities including gliosis, cortical dysplasia, hypoxic–ischemic injury, and space-occupying lesions [3]. Early identification of these abnormalities is essential for prognostication and therapeutic decision-making [4].

Despite their complementary roles, the correlation between EEG and neuroimaging findings in pediatric seizures has shown variability across studies. Several reports highlight a high yield of EEG abnormalities, while others emphasize the importance of neuroimaging in identifying clinically relevant lesions even in children with normal EEG recordings [2,5]. Furthermore, there remains limited data from India regarding the combined diagnostic value of EEG and neuroimaging in developmentally normal children presenting with afebrile seizures [1,4].

The present study was undertaken to evaluate EEG and neuroimaging findings in children aged 1–14 years presenting with afebrile seizures and to assess their correlation. Additionally, the study analyzed antiepileptic drug usage patterns in relation to seizure type and investigation results.

Study Design and Setting:
This was a prospective observational study conducted in the Department of Pediatrics, Konaseema Institute of Medical Sciences and Research Foundation (KIMS & RF), Amalapuram, Andhra Pradesh.

Study Population:
The study period was from October 2022 to January 2025 and included developmentally normal children aged 1–14 years who presented with afebrile seizures, either as outpatients or inpatients

Sample Size:
The sample size was calculated using the formula N = 4pq/d², with an expected prevalence of 37% and a 20% allowable error, yielding a requirement of 145 participants. Of 165 children initially screened, 41 were excluded due to not meeting eligibility criteria or loss to follow-up. The final study population comprised 124 children.

Inclusion Criteria:

• Children between 1 and 14 years of age.
• Developmentally normal children presenting with afebrile seizures (first or recurrent episodes).

Exclusion Criteria:

• Febrile seizures.
• Children with developmental delay, cerebral palsy, or other neurological deficits.
• Seizures following trauma.

Clinical Evaluation:
All enrolled children underwent a detailed clinical history, including family history of seizures, followed by a thorough neurological examination. Standardized proforma was used to record demographic and clinical data.

EEG Examination:
EEG was performed using a 24-channel RMS machine, with recordings lasting 15–30 minutes. Photic stimulation was used in younger children, while hyperventilation and sleep recordings were included in older children. EEG interpretations were performed by a neurologist blinded to the clinical and imaging findings.

Neuroimaging:
CT scans were performed using a Siemens 128-slice scanner, and MRI scans were obtained using a Siemens 1.5 Tesla system. Imaging included T1, T2, FLAIR, diffusion-weighted, and coronal sequences. Short sedation was administered when required in younger children. All imaging studies were interpreted by a radiologist blinded to EEG findings.

Treatment and Follow-up:
Antiepileptic drugs (AEDs) were prescribed as per the discretion of the treating pediatrician. Children were followed up to assess seizure control and drug requirement.

Statistical Analysis:
Data were compiled in Microsoft Excel and analyzed using SPSS software. Descriptive statistics were used for frequencies and percentages. Associations between EEG and neuroimaging findings were assessed using the chi-square test. A p value <0.05 was considered statistically significant.

A total of 124 developmentally normal children aged between 1–14 years with afebrile seizures were included in the present study. The mean age of the cohort was 6.77 ± 3.9 years, with the majority (49.2%) belonging to the 1–5 year age group, followed by 36.3% in the 5–10 year group and 14.5% in the 10–14 year group. Males comprised 55.6% of the study population, while females accounted for 44.4%. A positive family history of seizures was noted in 19.4% of children (Table 1).

Table 1. Demographic Profile of Study Population (N=124)

Figure 1. Age distribution

Figure 2. Sex Distribution

Figure 3. Family History of Seizures

Seizure Characteristics

Generalized seizures were more frequent than focal seizures, accounting for 64.5% and 35.5% of cases, respectively. Age-stratified analysis revealed that both focal and generalized seizures were most frequent in the 1–5 year group, whereas older children showed a relatively lower proportion of focal seizures. Gender-wise comparison indicated no significant difference between males and females with respect to seizure type. A family history of seizures was present in 15% of children with generalized seizures and 27.2% with focal seizures (Table 2).

Table 2. Clinical Characteristics of Seizures

EEG and Neuroimaging Findings

Electroencephalogram (EEG) abnormalities were detected in 84.6% of children, while 15.4% had normal EEG recordings. The most frequent abnormality observed was bilateral generalized epileptiform activity (42.7%), followed by sharp spikes (14.5%), sharp waves (13.7%), and burst spikes (12.1%). Slow wave abnormalities were less frequent (1.6%). Neuroimaging (CT or MRI) revealed abnormalities in 23.4% of the children, with gliosis being the predominant finding (27% of abnormal scans). The majority (76.6%) had normal imaging studies (Table 3).

Table 3. EEG and Neuroimaging Findings

Antiepileptic Drug Usage and Correlations

Most children (83.1%) were managed with a single antiepileptic drug (AED), 15.3% required two drugs, and only 1.6% needed three drugs. Generalized seizures were predominantly controlled with monotherapy (90%), whereas a higher proportion of children with focal seizures required dual therapy (27.2%). Valproate was the most frequently prescribed AED (70%), followed by phenobarbitone and carbamazepine (14.5% each), phenytoin (9.6%), levetiracetam (5.6%), and clobazam (3.2%).

Correlation analysis demonstrated that 47.4% of children with normal EEG findings had abnormal neuroimaging, whereas only 19% of those with abnormal EEG showed concurrent imaging abnormalities. This association was statistically significant (p = 0.007) (Table 4)

Table 4. Antiepileptic Drug (AED) Usage and Correlations

In this prospective observational study of 124 developmentally normal children with afebrile seizures, generalized seizures (64.5%) were more common than focal seizures (35.5%). This observation is consistent with published guidelines, which emphasize that generalized tonic–clonic seizures are frequently encountered as first afebrile seizures in children [6]. Nevertheless, other international studies have highlighted that focal seizures can predominate in certain cohorts, reflecting etiological and demographic variations [8].

EEG abnormalities were detected in 84.6% of our cases, which is in line with previous work reporting abnormal EEG yields ranging between 70–85% [6,7]. Bilateral generalized epileptiform discharges were the most frequent abnormality in our series, whereas focal sharp waves and burst spikes were also common, underscoring the heterogeneous electrical manifestations of pediatric seizures. Similar findings have been reported by Fox et al. [7], who demonstrated that EEG can be predictive of structural abnormalities in pediatric populations requiring intensive care support.

Neuroimaging abnormalities were noted in 23.4% of children, most frequently gliosis. This proportion falls within the reported 10–38% range in earlier studies [9,10]. Abnormal imaging was more often associated with focal seizures than generalized seizures, which corroborates the view that neuroimaging is particularly valuable in children with focal semiology or focal EEG features [9]. Importantly, nearly half (47.4%) of the children with normal EEGs had abnormal neuroimaging, a finding consistent with Mesraoua et al. [10], who emphasized that imaging can reveal clinically relevant abnormalities even in cases without electrographic changes.

With regard to AED usage, most children (83.1%) achieved control with monotherapy, and valproate was the most frequently prescribed agent. This finding is in line with recommendations from international practice parameters that support valproate as a first-line therapy for generalized seizures in children [6]. Polytherapy was more often required in focal seizure cases, reflecting greater therapeutic complexity, which has also been highlighted in recent observational cohorts of pediatric focal epilepsy [8].

Our correlation analysis demonstrated a statistically significant relationship between EEG and neuroimaging (p = 0.007). Notably, abnormal imaging was present in nearly half of the children with normal EEGs, reinforcing the importance of combined use of both modalities. Recent studies echo this conclusion, emphasizing that reliance on EEG alone risks underdiagnosis of structural pathology [9,11]. Alyoubi et al. [11] similarly reported a wide spectrum of MRI and electrographic abnormalities in pediatric seizure cohorts, underscoring the complementary role of both investigations. Moreover, a recent Indian study by Ramanathan and Siva [12] also found a strong correlation between EEG and neuroimaging in children with unprovoked seizures, further validating our findings.

Strengths and Limitations

The strengths of this study include a well-characterized pediatric cohort and blinded interpretation of EEG and imaging results. However, limitations include single-center design, modest sample size, and resource constraints that limited universal MRI availability, potentially underestimating subtle cortical abnormalities.

Clinical Implications

Our findings suggest that EEG, while highly sensitive, may miss important structural lesions. Neuroimaging adds crucial diagnostic value, especially in focal seizures and in patients with normal EEG. The complementary use of both modalities is essential for accurate diagnosis, rational therapy selection, and improved seizure outcomes in children.

Strengths and Limitations

The strengths of our study include a well-defined pediatric cohort, blinded interpretation of EEG and imaging, and comprehensive assessment of drug usage patterns. Limitations include single-center design, modest sample size, and lack of long-term follow-up to assess seizure recurrence or neurodevelopmental outcomes. Additionally, MRI could not be performed in all cases due to resource constraints, which may have underestimated subtle cortical abnormalities.

Clinical Implications

Our findings reinforce that EEG is a sensitive tool for seizure characterization, but neuroimaging provides essential structural insights, particularly in focal seizures and in children with normal EEG. Most children respond well to monotherapy, emphasizing the importance of early diagnosis and rational drug selection.

This study highlights the complementary roles of EEG and neuroimaging in evaluating developmentally normal children with afebrile seizures. EEG abnormalities were highly prevalent (84.6%), with bilateral generalized epileptiform activity being the most frequent pattern. Neuroimaging revealed abnormalities in 23.4% of cases, predominantly gliosis, and was especially valuable in children with focal seizures and in those with normal EEG findings. A significant correlation was demonstrated between EEG and neuroimaging, emphasizing the importance of combined assessment. Most children achieved good seizure control with monotherapy, particularly valproate. These findings underscore the need for integrated diagnostic approaches to optimize management and outcomes.

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