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P154 Audit of electroencephalogram (EEG) referrals from a paediatric department
S68 8 children who did not necessitate any change in headache management. The lesions demonstrated were sinusitis (1), gliotic changes (2), Chiari malformation type I (1), intracranial calcification (2), periventricular leucomalacia (1), arachnoid cyst (1). The headache in two children was related to active intracranial pathology which was predictable on clinical findings in 1 child (craniopharyngioma) but was unexpected until a late stage in the other (tuberculoma). Conclusions: Neuroimaging in children with recurrent headaches is not a useful diagnostic aid even in the developing world and should be used very selectively while managing these cases on day to day practice. Reference(s) [1] Maytal J, Bienkowski RS, Patel M, Eviatar L. The value of brain imaging in children with headaches. Pediatrics 1995; 96:413 416. [2] Lewis DW, Dahl AG, Hirtz DD, Prensky A, Jarjour I. Practice parameter: Evaluation of children and adolescents with recurrent headaches: Report of the Quality Standards Subcommittee of the American Academy Neurology and the Practice Committee of the Child Neurology Society. Neurology 2002; 59:490 498. [3] Graf WD, Kayyali HR, Alexander JJ, Simon SD, Morriss MC. Neuroimaging − use trends in nonacute pediatric headache before and after clinical practice parameters. Pediatrics 2008; 122:e1001e1005 [4] Evans RW. Diagnostic testing for migraine and other primary headaches. Neurol Clin 2009;27: 393 495.
P154 Audit of electroencephalogram (EEG) referrals from a paediatric department V. Palanivel2 *, M.A. Anjay1 , S. Nirmal1 . 1 Paediatrics, James Paget University Hospital, Great Yarmouth, United Kingdom; 2 Paediatrics, Addenbrooke’s Hospital, Cambridge, United Kingdom Objective: Inappropriate EEG referrals overload the neurophysiology service and increase waiting times. We aimed to audit: • Whether EEG referrals from our paediatric department are being made according to the standards set down in the National Institute of Clinical Excellence (NICE) epilepsy guidelines and a related audit tool available in the NICE ‘shared learning’ database • Whether EEGs are performed within 4 weeks of referral as recommended by NICE. Method: All referral forms received over a period of 6 months were analysed. Results: 38 referrals were made. 10 (26%) were not in accordance with NICE criteria. These included referrals for probable non-epileptic events like reflex anoxic seizures as well as first episode of generalised seizures. Only 22 (57%) EEGs were done within 4 weeks. Discussion: An EEG should be performed only to support a clinical diagnosis of epilepsy. Our audit confirms that EEGs are still used inappropriately, with consequent adverse impact on waiting times. Measures were implemented to increase awareness among clinicians. A new referral pathway was formulated. Anecdotally, this has reduced the waiting times to less than 4 weeks and a re-audit is planned. Conclusion: Improving awareness among clinicians about appropriate use of EEGs can significantly reduce waiting times. P155 Insignificant brain abnormalities in neurologically normal children with headache M.A.S. Ahmed1 , F. Kagalwala1 *, S. Chawda2 , K. Ibrahim3 . 1 Paediatric Department, Queen’s Hospital, London, UK; 2 Neuroradiology Department, Queen’s Hospital, London, UK; 3 Paediatric Neurology Department, The Royal London Hospital, London, UK Introduction: Varieties of insignificant brain abnormalities (IBA) have been found in neurologically normal children with headache [1].
Posters Objective: To examine the incidence and varieties of IBAs in children with headaches and to evaluate these abnormalities according to headache diagnosis in a hospital based clinical practice. Methods: IBA is defined as brain abnormality that requires no urgent or prompt intervention. Reports of brain imaging (BI) in our patients were prospectively examined. Children with significant neuroradiological abnormalities, abnormal neurological signs, epilepsy and neuro-disability were excluded. Headache was classified on the basis of the HIHC 2004. Results: A total of 752/771 children with headache (394 females; 299 from ethnic minority communities; age range 3.2 16.2 years) were included. 428/752 (57%) children had BI. IBAs were found in 22/428 (5.1%) children. Headache diagnosis included migraine in 13/22 (59%) and other headaches in 9/22 (41%). IBAs included white matter lesions in 12/22 (55%). Of these 12 children, 10 had (84%) migraine, one had medication over use headache and one had unspecified headache. Headache diagnosis in the remaining 10/22 children included migraine in 4 children (sphenoidal sinus polyps, pineal cyst, right temporal lobe old infarct, left corpus striatum/caudate nucleus high signal), chronic daily headaches in 3 (sphenoidal sinus polyps, left frontal infarct, bilateral extra-cerebral effusion), tension type headaches in 2 (bilateral mastoid effusion, basal ganglia low signals) and unspecified headache in a child with arachnoid cyst. Conclusion: The study highlights two points. First: Routine BI of children with headaches may cause significant difficulties that clinicians will face because of need to explain IBAs to the caregivers. Second: Diagnosis of migraine was made in 84% with non-specific white matter lesions. These findings may provide a further clue to the understanding of migraine pathogenesis. Reference(s) [1] Lewis DW et al. The utility of neuroimaging in the evaluation of children with migraine or chronic daily headache who have normal neurological examinations. Arch Dis Child 2008; 93: 105−11.
P156 Frontal lobe epilepsy caused by focal cortical dysplasia type II in left precentral region − considerations prior to surgery N. Bariˇsic´ 1 *, S. Kessler2 , B. Bunoza1 , T. Pieper2 , M. Kudernatsch2 , M. Staudt2 , H. Holthausen2 . 1 Department for Pediatrics, Zagreb Medical School, Zagreb, Croatia; 2 Behandlungszentrum Vogtareuth, Neuropediatric Clinic and Clinic for Neurorehabilitation/Epilepsy Center, Germany Objective: Patients with FCD type II (Taylor’s type FCD) are excellent candidates for epilepsy surgery − when the lesion is located outside eloquent cortical areas. Results with respect to postoperative seizure-outcome are less favourable in patients with FCD type II overlapping or bordering eloquent cortical areas. Results: 3 patients with FCD type II with drug-resistant seizures caused by focal cortical dyplasia type II left frontocentral, bordering and/or overlapping eloquent cortical areas, are presented. General remarks: Risk benefit considerations prior to presurgical work-up: chances to become seizure-free would be very good − if lesions could be resected completely; this seems to be very difficult in all three of them. Invasive recording with subdural grids or depth electrodes will be necessary, after first surface-electrodes evaluation. Recent reports have shown that complete type II-FCD resection, in particular of FCD type II b (with balloon-cells) seems to be unnecessary in all cases with FCD type II. Ad patient 1: There is increased hemiparesis risk, not as much as close neighbourhood to primary cortical hand area is concerned, but with respect to descending fibers from this
P154 Audit of electroencephalogram (EEG) referrals from a paediatric department V. Palanivel2 *, M.A. Anjay1 , S. Nirmal1 . 1 Paediatrics, James Paget University Hospital, Great Yarmouth, United Kingdom; 2 Paediatrics, Addenbrooke’s Hospital, Cambridge, United Kingdom Objective: Inappropriate EEG referrals overload the neurophysiology service and increase waiting times. We aimed to audit: • Whether EEG referrals from our paediatric department are being made according to the standards set down in the National Institute of Clinical Excellence (NICE) epilepsy guidelines and a related audit tool available in the NICE ‘shared learning’ database • Whether EEGs are performed within 4 weeks of referral as recommended by NICE. Method: All referral forms received over a period of 6 months were analysed. Results: 38 referrals were made. 10 (26%) were not in accordance with NICE criteria. These included referrals for probable non-epileptic events like reflex anoxic seizures as well as first episode of generalised seizures. Only 22 (57%) EEGs were done within 4 weeks. Discussion: An EEG should be performed only to support a clinical diagnosis of epilepsy. Our audit confirms that EEGs are still used inappropriately, with consequent adverse impact on waiting times. Measures were implemented to increase awareness among clinicians. A new referral pathway was formulated. Anecdotally, this has reduced the waiting times to less than 4 weeks and a re-audit is planned. Conclusion: Improving awareness among clinicians about appropriate use of EEGs can significantly reduce waiting times. P155 Insignificant brain abnormalities in neurologically normal children with headache M.A.S. Ahmed1 , F. Kagalwala1 *, S. Chawda2 , K. Ibrahim3 . 1 Paediatric Department, Queen’s Hospital, London, UK; 2 Neuroradiology Department, Queen’s Hospital, London, UK; 3 Paediatric Neurology Department, The Royal London Hospital, London, UK Introduction: Varieties of insignificant brain abnormalities (IBA) have been found in neurologically normal children with headache [1].
Posters Objective: To examine the incidence and varieties of IBAs in children with headaches and to evaluate these abnormalities according to headache diagnosis in a hospital based clinical practice. Methods: IBA is defined as brain abnormality that requires no urgent or prompt intervention. Reports of brain imaging (BI) in our patients were prospectively examined. Children with significant neuroradiological abnormalities, abnormal neurological signs, epilepsy and neuro-disability were excluded. Headache was classified on the basis of the HIHC 2004. Results: A total of 752/771 children with headache (394 females; 299 from ethnic minority communities; age range 3.2 16.2 years) were included. 428/752 (57%) children had BI. IBAs were found in 22/428 (5.1%) children. Headache diagnosis included migraine in 13/22 (59%) and other headaches in 9/22 (41%). IBAs included white matter lesions in 12/22 (55%). Of these 12 children, 10 had (84%) migraine, one had medication over use headache and one had unspecified headache. Headache diagnosis in the remaining 10/22 children included migraine in 4 children (sphenoidal sinus polyps, pineal cyst, right temporal lobe old infarct, left corpus striatum/caudate nucleus high signal), chronic daily headaches in 3 (sphenoidal sinus polyps, left frontal infarct, bilateral extra-cerebral effusion), tension type headaches in 2 (bilateral mastoid effusion, basal ganglia low signals) and unspecified headache in a child with arachnoid cyst. Conclusion: The study highlights two points. First: Routine BI of children with headaches may cause significant difficulties that clinicians will face because of need to explain IBAs to the caregivers. Second: Diagnosis of migraine was made in 84% with non-specific white matter lesions. These findings may provide a further clue to the understanding of migraine pathogenesis. Reference(s) [1] Lewis DW et al. The utility of neuroimaging in the evaluation of children with migraine or chronic daily headache who have normal neurological examinations. Arch Dis Child 2008; 93: 105−11.
P156 Frontal lobe epilepsy caused by focal cortical dysplasia type II in left precentral region − considerations prior to surgery N. Bariˇsic´ 1 *, S. Kessler2 , B. Bunoza1 , T. Pieper2 , M. Kudernatsch2 , M. Staudt2 , H. Holthausen2 . 1 Department for Pediatrics, Zagreb Medical School, Zagreb, Croatia; 2 Behandlungszentrum Vogtareuth, Neuropediatric Clinic and Clinic for Neurorehabilitation/Epilepsy Center, Germany Objective: Patients with FCD type II (Taylor’s type FCD) are excellent candidates for epilepsy surgery − when the lesion is located outside eloquent cortical areas. Results with respect to postoperative seizure-outcome are less favourable in patients with FCD type II overlapping or bordering eloquent cortical areas. Results: 3 patients with FCD type II with drug-resistant seizures caused by focal cortical dyplasia type II left frontocentral, bordering and/or overlapping eloquent cortical areas, are presented. General remarks: Risk benefit considerations prior to presurgical work-up: chances to become seizure-free would be very good − if lesions could be resected completely; this seems to be very difficult in all three of them. Invasive recording with subdural grids or depth electrodes will be necessary, after first surface-electrodes evaluation. Recent reports have shown that complete type II-FCD resection, in particular of FCD type II b (with balloon-cells) seems to be unnecessary in all cases with FCD type II. Ad patient 1: There is increased hemiparesis risk, not as much as close neighbourhood to primary cortical hand area is concerned, but with respect to descending fibers from this