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title: "Pediatric Seizure"
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docid: "3e2ea1fa-0651-45eb-bc1f-b072af8dd434"
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authors:
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- key: "b94c42b1-c572-4e72-ac48-bfe85989e2f3"
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value: "Andrew T. Trout, MD"
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- key: "0a00bb19-ed17-4500-8bae-c9463720a4fb"
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value: "Nadeen K. Abu Ata, MD"
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- key: "d2ed5cde-67ab-491a-963b-3c0f245d1fd8"
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value: "Karol Cardenas, MD"
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breadcrumbs:
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-
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name: "Nuclear Medicine"
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slug: "nuclear-medicine"
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treeNodeId: "2406533f-6523-4211-841e-b92d6f8cf34e"
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-
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name: "Pediatrics"
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slug: "pediatrics"
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treeNodeId: "8e60feb1-8a8a-42e6-9f90-5270fdc48da2"
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-
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name: "Central Nervous System"
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slug: "central-nervous-system"
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treeNodeId: "435fce7c-f625-479e-9355-82bab423f838"
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-
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name: "Pediatric Seizure"
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slug: "pediatric-seizure"
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treeNodeId: null
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category: "Nuclear Medicine"
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cmeTopicId: "57ed2edc-8f94-4608-8ae8-a421b16d7851"
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documentVersionId: "0d72d140-13c0-4727-843d-665ecaa6a0eb"
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imageCount: 23
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lastUpdated: "06/20/25"
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pageDescription: "Pediatric Seizure"
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pageKeywords: "Nuclear Medicine, Pediatrics, Central Nervous System, Pediatric Seizure"
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pageTitle: "Pediatric Seizure | STATdx"
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enhancedTitle: "Pediatric Seizure"
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type: "DX"
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references: true
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breadcrumbs:
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- "Nuclear Medicine"
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- "Pediatrics"
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- "Central Nervous System"
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- "Pediatric Seizure"
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---
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# KEY FACTS
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- ## Imaging
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- Nuclear imaging is not part of routine evaluation of isolated seizures
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- Plays important role in multidisciplinary/multimodality work-up of intractable epilepsy
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- Nuclear imaging may identify structurally inconspicuous epileptogenic foci
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- SPECT: Radiotracer deposition reflects regional cerebral blood flow
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- Interictal: Epileptogenic focus appears as area of decreased radiotracer deposition (hypoperfusion)
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- Ictal: Epileptogenic focus appears as area of increased radiotracer deposition (hyperperfusion)
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- SISCOM may identify epileptogenic foci that are inconspicuous on visual assessment of ictal and interictal SPECT images
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- F-18 FDG PET: Epileptogenic focus appears as area of hypometabolism (larger than epileptogenic focus)
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- Statistical parametric mapping can help detect and confirm foci of hypometabolism
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- MR is ideal modality to identify structural causes of seizure/epilepsy
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- Mesial temporal sclerosis: Decreased volume, increased T2 signal in hippocampus
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- Focal cortical dysplasia (FCD): Focal cortical thickening and increased T2 signal, blurring of gray-white junction
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- ## Clinical Issues
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- Most common cause of epilepsy
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- Young: FCD
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- Adolescent/young adult: Mesial temporal sclerosis
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- Antiepileptic drugs are 1st line of therapy
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- Surgical resection: Reserved for patients with intractable, focal epilepsy
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# TERMINOLOGY
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- ## Definitions
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- Seizure: Clinical manifestation of aberrant neuronal electrical discharge(s) in brain
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- Epilepsy: ≥ 2 unprovoked, afebrile seizures
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# IMAGING
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- ## General Features
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- Imaging of isolated/acute seizures is generally structural (CT/MR) and reserved for patients with focal or complex seizures or focal neurologic signs
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- Imaging is important component in management of epilepsy
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- Structural imaging (CT/MR) often performed at diagnosis to exclude structural cause
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- Multimodality imaging (including nuclear) plays substantial role in work-up of intractable epilepsy
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- Work-up of intractable epilepsy is multidisciplinary/multimodality process
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- Clinical assessment: History, seizure semiology
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- Electroencephalography (EEG): Scalp and intracranial
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- MR: Structural, ± functional
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- Perfusion (SPECT) imaging
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- Metabolic (F-18 FDG PET) imaging
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- Magnetoencephalography
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- ## Nuclear Medicine Findings
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- Nuclear imaging not part of routine evaluation of isolated seizures
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- May identify structurally inconspicuous epileptogenic foci
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- **SPECT perfusion**
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- Radiotracer deposition reflects regional cerebral blood flow
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- Tc-99m hexamethylpropyleneamine oxime (HMPAO) and Tc-99m ethyl cysteinate dimer (ECD) most commonly used tracers
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- Lipophilic, small molecules diffuse across blood-brain barrier
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- ECD clears more rapidly from blood pool, has more linear extraction at high blood flow rates; less nonspecific scalp and soft tissue uptake than HMPAO
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- High 1st-pass extraction, peak accumulation in ~ 2 min, no substantial redistribution
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- Can image for at least 2 hours after injection without substantial loss of fidelity
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- Interictal SPECT
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- Epileptogenic focus appears as area of decreased radiotracer deposition (hypoperfusion)
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- Ictal SPECT
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- Epileptogenic focus appears as area of increased radiotracer deposition (hyperperfusion)
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- Correspondence to epileptogenic focus depends on interval between seizure onset and injection; longer intervals allow more propagation to surrounding tissue
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- Beware of pseudonormalization where hyperperfusion during ictus makes baseline hypoperfused focus appear symmetric to normal side
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- Higher sensitivity than interictal SPECT for epileptogenic focus
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- Subtraction ictal SPECT coregistered to MR (SISCOM)
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- Means to compare ictal and interictal SPECT imaging and localize abnormalities to MR
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- Foci of ictal hyperperfusion that correspond with interictal hypoperfusion appear as foci of activity on SISCOM
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- May identify epileptogenic foci that are inconspicuous on visual assessment of ictal and interictal SPECT images
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- **F-18 FDG PET**
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- Interictal exam due to prolonged (~ 30 min) uptake of F-18 FDG
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- If seizure occurs during uptake phase, may see hypermetabolism at epileptogenic focus and in surrounding brain
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- Indirect marker of neuronal activity
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- Epileptogenic focus appears as area of hypometabolism
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- Area of hypometabolism is generally larger than epileptogenic focus
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- Highest accuracy in temporal lobe epilepsy (TLE), less likely to identify epileptogenic focus in extratemporal epilepsy
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- Contributes most in cases of structurally inconspicuous TLE or cases of suspected cortical dysplasia in children with apparent negative MR
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- Higher sensitivity than interictal SPECT, especially in TLE (84% vs. 66% in one metaanalysis)
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- Postprocessing with statistical parametric mapping (SPM) can help detect and confirm foci of hypometabolism
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- SPM compares, on pixel by pixel basis, F-18 FDG uptake in patient to normal database to identify foci of abnormally decreased uptake
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- In addition to identifying epileptogenic focus, it may provide prognostic information
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- For example, in patients with unilateral temporal lobe epilepsy, presence of bitemporal glucose hypometabolism is associated with poor memory performance
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- With both SPECT and PET imaging, may see corresponding downstream abnormality in cerebellar hemisphere opposite involved cerebral hemisphere
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- Decreased radiotracer uptake on interictal SPECT and F-18 FDG PET
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- Increased radiotracer uptake on ictal SPECT
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- Hypometabolism of ipsilateral thalamus can be seen in cases of focal epilepsy (mostly in frontal and temporal cortex, medial temporal lobe epilepsy)
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- **Other tracers**
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- C-11 flumazenil: Binds CNS gamma-aminobutyric acid (GABA) receptors; GABA receptors are decreased in epileptogenic foci
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- C-11 has short half-life (20 minutes), requiring onsite cyclotron (limiting its use)
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- ## MR Findings
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- Mesial temporal sclerosis: Decreased volume and increased T2 signal in mesial temporal structures, including hippocampal formation
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- Resultant asymmetry in size of temporal horn of lateral ventricle
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- Focal cortical dysplasia (FCD): Cortical thickening and increased T2 signal, extension of T2 signal to ventricle, blurring of gray-white junction
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# DIFFERENTIAL DIAGNOSIS
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- ## CNS Tumor
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- May or may not be cause of seizures
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- May appear as focus of hypo- or hyperperfusion on SPECT
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- May appear as focus of hypometabolism on F-18 FDG PET if low grade
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- ## Congenital Anomalies
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- [Structural abnormalities: Heterotopic gray matter, abnormal sulcation, schizencephaly](/document/heterotopic-gray-matter/c88b27b7-d352-4231-b296-bd9d93b8c68b)
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- May appear as focus of hypometabolism on FDG PET, even if not epileptogenic
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- ## Tuberous Sclerosis
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- Can be difficult to identify epileptogenic focus as majority of tubers are hypoperfused and hypometabolic
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- Epileptogenic tubers generally show perfusion/metabolic abnormalities larger than area of structural abnormality
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- ## Rasmussen Encephalitis
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- Progressive inflammatory process involving unilateral cerebral hemisphere, generally with progressive cerebral atrophy
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- Appears as large areas (lobar or hemispheric) of perfusion or metabolic abnormality
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# PATHOLOGY
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- ## Gross Pathologic & Surgical Features
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- Mesial temporal sclerosis: Hard, shrunken hippocampus
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- FCD: Firm, rubbery cortical focus
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- ## Microscopic Features
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- Mesial temporal sclerosis
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- Variable distribution of pyramidal neuronal loss
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- Gliosis
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- FCD: Abnormalities in neuronal migration resulting in cortical dyslamination
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- Type I: Abnormal cortical layering
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- Ia: Abnormal radial migration of neurons with abundant microcolumns (> 8 neurons vertically arranged), most conspicuous in layer 3
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- May see immature small neurons or hypertrophic pyramidal neurons outside of layer 5
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- Ib: Abnormal tangential cortical layering
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- May see no layering at all or abnormal layering of layers 2 &/or 4
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- May see immature small neurons, hypertrophic pyramidal neurons outside of layer 5, or normal neurons with disordered dendrites
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- Ic: Abnormal radial and tangential lamination
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- Type II: Abnormal cortical layering **and**cytologic abnormalities
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- IIa: No identifiable cortical layering except layer 1
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- Dysmorphic neurons (enlarged cell body and nucleus, neurofilament accumulation in cytoplasm)
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- IIb: No identifiable cortical layering except layer 1
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- Dysmorphic neurons **and** balloon cells (large cell body, multiple nuclei, eosinophilic cytoplasm)
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- Type III: Abnormal cortical layering associated with primary brain lesion (adjacent or in same lobe)
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- IIIa: FCD associated with hippocampal sclerosis
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- IIIb: FCD associated with tumors
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- IIIc: FCD associated with vascular malformation
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- IIId: FCD associated with any other lesion acquired in early life
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# CLINICAL ISSUES
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- ## Demographics
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- ### Epidemiology
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- Seizure
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- Most common causes of acute seizures: Fever, infection, head injury
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- Febrile seizures
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- Usually occur between 6 months and 5 years of age
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- Occur in 3-8% of children < 5 years
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- 60% risk of recurrence
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- Epilepsy
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- Highest incidence in 1st year of life (~ 90-200 per 100,000)
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- Prevalence higher in rural areas
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- Risk factors
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- Family history
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- Prior febrile seizure: 2-7% develop epilepsy
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- Most common causes
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- Young: FCD
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- Adolescent/young adult: Mesial temporal sclerosis
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- Intractable epilepsy occurs in 20-30%
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- ## Natural History & Prognosis
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- Epilepsy subtypes: Current terminology
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- Genetic abnormality without discrete structural abnormality
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- Structural or metabolic
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- Discrete structural epileptogenic lesion
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- Many of these are genetic in etiology
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- Metabolic condition leading to propensity for seizures
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- Unknown cause
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- FCD: Malformation of cortical development
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- Secondary to insult (genetic, infectious, ischemic) during development
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- Mesial temporal sclerosis
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- Often secondary to insult (infection, trauma, febrile seizures) early in life
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- ## Treatment
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- Antiepileptic drugs
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- 1st line of therapy
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- Managing clinician will often try multiple agents and combinations of agents to achieve seizure reduction (or freedom) with minimum of side effects
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- Ketogenic diet
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- Vagal nerve stimulator
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- Used in patients with drug-resistant epilepsy who are not candidates for resection
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- Deep brain stimulator
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- Used in patients with drug-resistant epilepsy who are not candidates for resection
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- Surgical resection: Reserved for patients with drug-resistant, focal epilepsy
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- Outcomes better if resection includes sites identified on SISCOM
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- Outcome of surgery for FCD is better if lesion visible by MR
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d21db106-d94e-4b66-b849-bb707a0aabd1
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## References
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# Selected References
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1. [Ponisio MR et al: FDG-PET/MRI in the presurgical evaluation of pediatric epilepsy. Pediatr Radiol. 54(10):1589-602, 2024](http://www.ncbi.nlm.nih.gov/pubmed/?term=39123082%5Bpmid%5D)
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1. [Guo J et al: Seizure outcome after surgery for refractory epilepsy diagnosed by (18)F-fluorodeoxyglucose positron emission tomography ((18)F-FDG PET/MRI): a systematic review and meta-analysis. World Neurosurg. 173:34-43, 2023](http://www.ncbi.nlm.nih.gov/pubmed/?term=36746239%5Bpmid%5D)
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1. [Juhász C et al: Utility of MRI, PET, and ictal SPECT in presurgical evaluation of non-lesional pediatric epilepsy. Seizure. 77:15-28, 2020](http://www.ncbi.nlm.nih.gov/pubmed/?term=31122814%5Bpmid%5D)
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1. [Wong-Kisiel LC et al: Challenges in managing epilepsy associated with focal cortical dysplasia in children. Epilepsy Res. 145:1-17, 2018](http://www.ncbi.nlm.nih.gov/pubmed/?term=29803953%5Bpmid%5D)
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1. [Manford M: Recent advances in epilepsy. J Neurol. 264(8):1811-24, 2017](http://www.ncbi.nlm.nih.gov/pubmed/?term=28120042%5Bpmid%5D)
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1. [Mountz JM et al: Pediatric epilepsy: neurology, functional imaging, and neurosurgery. Semin Nucl Med. 47(2):170-87, 2017](http://www.ncbi.nlm.nih.gov/pubmed/?term=28237005%5Bpmid%5D)
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1. [Duncan JS et al: Brain imaging in the assessment for epilepsy surgery. Lancet Neurol. 15(4):420-33, 2016](http://www.ncbi.nlm.nih.gov/pubmed/?term=26925532%5Bpmid%5D)
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1. [Miyata H et al: Surgical pathology of epilepsy-associated non-neoplastic cerebral lesions: a brief introduction with special reference to hippocampal sclerosis and focal cortical dysplasia. Neuropathology. 33(4):442-58, 2013](http://www.ncbi.nlm.nih.gov/pubmed/?term=23530853%5Bpmid%5D)
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1. [Sidhu R et al: Pediatric seizures. Pediatr Rev. 34(8):333-41; 342, 2013](http://www.ncbi.nlm.nih.gov/pubmed/?term=23908360%5Bpmid%5D)
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1. [Kim S et al: SPECT Imaging of epilepsy: an overview and comparison with F-18 FDG PET. Int J Mol Imaging. 2011:813028, 2011](http://www.ncbi.nlm.nih.gov/pubmed/?term=21785722%5Bpmid%5D)
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1. [O'Brien TJ et al: Subtraction peri-ictal SPECT is predictive of extratemporal epilepsy surgery outcome. Neurology. 55(11):1668-77, 2000](http://www.ncbi.nlm.nih.gov/pubmed/?term=11113221%5Bpmid%5D)
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1. [Won HJ et al: Comparison of MR imaging with PET and ictal SPECT in 118 patients with intractable epilepsy. AJNR Am J Neuroradiol. 20(4):593-9, 1999](http://www.ncbi.nlm.nih.gov/pubmed/?term=10319968%5Bpmid%5D)
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1. [Devous MD Sr et al: SPECT brain imaging in epilepsy: a meta-analysis. J Nucl Med. 39(2):285-93, 1998](http://www.ncbi.nlm.nih.gov/pubmed/?term=9476937%5Bpmid%5D)
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## Images
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### Selected Images
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*Coronal interictal F-18 FDG PET in a 15-year-old with focal left temporal seizures on EEG and findings of left hippocampal sclerosis on MR shows diffuse hypometabolism of the left temporal lobe <img src='img/arrows/WS.png'/>, indicative of a seizure focus. Interpretation of functional brain imaging is aided by the fact that perfusion (SPECT) and metabolism (F-18 FDG) should be symmetric between the cerebral hemispheres and between the cerebellar hemispheres.*
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*Coronal interictal F-18 FDG PET in a 15-year-old with focal left temporal seizures on EEG and findings of left hippocampal sclerosis on MR shows diffuse hypometabolism of the left temporal lobe <img src='img/arrows/WS.png'/>, indicative of a seizure focus. Interpretation of functional brain imaging is aided by the fact that perfusion (SPECT) and metabolism (F-18 FDG) should be symmetric between the cerebral hemispheres and between the cerebellar hemispheres.*
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*Coronal FLAIR MR in a 16-year-old boy with intractable epilepsy shows an area of gliosis in the left parietal lobe related to remote trauma <img src='img/arrows/CS.png'/>.*
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*Coronal F-18 FDG PET in the same patient shows hypometabolism corresponding to the left parietal gliosis <img src='img/arrows/WS.png'/>, as well as hypometabolism (relative to the right) of adjacent parietal lobe <img src='img/arrows/CS.png'/>. This corroborates SPECT findings and suggests a seizure focus.*
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*Interictal Tc-99m ECD SPECT in the same patient shows hypoperfusion corresponding to the left parietal gliosis <img src='img/arrows/WS.png'/> and involving the adjacent parietal lobe <img src='img/arrows/CS.png'/>.*
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*Ictal Tc-99m ECD SPECT in the same patient shows hypoperfusion corresponding to the left parietal gliosis <img src='img/arrows/WS.png'/>. The adjacent parietal lobe <img src='img/arrows/CS.png'/>, however, is hyperperfused (relative to the right), reflecting seizure activity.*
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*Sagittal T1 C+ MR in a 17-year-old girl shows a frontal dysembryoplastic neuroepithelial tumor (DNET) as a nonenhancing, low-signal lesion <img src='img/arrows/CS.png'/>.*
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*Sagittal F-18 FDG PET in the same patient shows focal hypometabolism associated with the DNET <img src='img/arrows/WS.png'/>. In this case, the hypometabolism is reflective of both the low grade of this tumor and its epileptogenicity.*
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*Axial T2 MR in a 12-year-old girl with epilepsy shows a right temporal focal cortical dysplasia (FCD), apparent as cortical and subcortical increased signal <img src='img/arrows/CS.png'/>.*
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*Axial F-18 FDG PET in the same patient shows hypometabolism associated with the FCD <img src='img/arrows/WS.png'/>, supporting the epileptogenic nature of this lesion.*
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*Coronal F-18 FDG PET in the same patient shows global hypometabolism of the right temporal lobe <img src='img/arrows/WS.png'/> with more conspicuous hypometabolism of the hippocampus <img src='img/arrows/WC.png'/>. These findings support a right temporal localization of the seizure focus.*
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*Interictal Tc-99m ECD SPECT in a 2-year-old with intractable epilepsy shows enlargement of the left lateral ventricle <img src='img/arrows/WS.png'/> and hypoperfusion of the left temporal lobe <img src='img/arrows/CS.png'/>.*
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*Ictal Tc-99m ECD SPECT in the same patient shows an area of relative hyperperfusion <img src='img/arrows/WO.png'/> in the overall hypoperfused left temporal lobe, suggesting a seizure focus.*
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*Coronal SISCOM derived from the interictal and ictal SPECT and T1 MR in the same patient confirms an area of abnormal perfusion in the left temporal lobe <img src='img/arrows/WO.png'/>, suggestive of a seizure focus. The left lateral ventricle is dilated <img src='img/arrows/WS.png'/> due to extensive white matter loss.*
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*Axial FLAIR MR in a 12-year-old with tuberous sclerosis and increasing seizure frequency shows multiple cortical tubers <img src='img/arrows/CS.png'/>.*
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*Axial interictal F-18 FDG PET in the same patient at the same level shows hypometabolism associated with the cortical tubers <img src='img/arrows/WS.png'/>.*
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*Axial interictal Tc-99m ECD SPECT in the same patient shows hypoperfusion corresponding to the cortical tubers <img src='img/arrows/WS.png'/>.*
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*Fused axial F-18 FDG PET and FLAIR MR in the same patient shows correspondence between areas of hypometabolism and the cortical tubers <img src='img/arrows/CS.png'/>. Hypometabolism is similar in extent to the tubers. Areas of hypometabolism larger than underlying lesions can suggest an epileptogenic focus.*
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*Coronal interictal F-18 FDG PET in a 7-year-old with intractable seizures shows hypometabolism in the right temporal lobe <img src='img/arrows/CS.png'/>, particularly mesially in the hippocampal formation <img src='img/arrows/WS.png'/>.*
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*Coronal T2 FLAIR MR at the same level in the same patient shows abnormally increased signal in the right hippocampal formation <img src='img/arrows/WS.png'/> in this child with mesial temporal sclerosis.*
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### Additional Images
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*Fused FDG PET MR in a 9-year-old boy with left lower extremity clonic movements shows a focal region of hypometabolism <img src='img/arrows/WS.png'/> within the right paracentral lobule (left-foot motor control).*
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*FDG PET MR postprocessing demonstrates same area of hypometabolism <img src='img/arrows/WS.png'/> localized within the right paracentral lobule.*
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*Coronal T2 MR in the same patient shows focal area of blurring of the gray matter-white matter junction <img src='img/arrows/CS.png'/> and abnormal gyration in the right paracentral lobule, suggesting FCD (initially missed on MR).*
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*Left ankle flexion fMRI activated the right superior frontal gyrus <img src='img/arrows/CC.png'/> anterior to the expected location of the left paracentral lobule, suggesting motor remapping distant to FCD <img src='img/arrows/CS.png'/>. Normal right foot motor activation centered about the left paracentral lobule <img src='img/arrows/CO.png'/>.*
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Reference in New Issue
Block a user