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Lopez-Rippe J, Schwartz ES, Davis JC, Dennis RA, Francavilla ML, Jalloul M, Kaplan SL. Imaging Stewardship: Triage for Neuroradiology MR During Limited-Resource Hours. J Am Coll Radiol 2024; 21:70-80. [PMID: 37863151 DOI: 10.1016/j.jacr.2023.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2023] [Revised: 10/14/2023] [Accepted: 10/16/2023] [Indexed: 10/22/2023]
Abstract
OBJECTIVES To decrease call burden on pediatric neuroradiologists, we developed guidelines for appropriate use of MR overnight. These guidelines were implemented using triage by in-house generalist pediatric radiologists. Process measures and balancing measures were assessed during implementation. METHODS For this improvement project, interdepartmental consensus guidelines were developed using exploratory mixed-methods design. Implementation of triage used plan-do-study-act cycles. Process measures included reduction in the number of telephone calls, frequency of calls, triage decisions, and number and type of examinations ordered. Balancing measures included burden of time and effort to the generalist radiologists. Differences in examination orders between implementation intervals was assessed using Kruskal-Wallis, with significance at P < .05. RESULTS Consensus defined MR requests as "do," "defer," or "divert" (to CT). Guidelines decreased neuroradiologist calls 74% while adding minimal burden to the generalist radiologists. Most nights had zero or one triage request and the most common triage decision was "do," and the most common examination was routine brain MR. Number of MR ordered and completed overnight did not significantly change with triage. DISCUSSION Multidisciplinary consensus for use of pediatric neurological MR during limited resource hours overnight is an example of imaging stewardship that decreased the burden of calls and burnout for neuroradiologists while maintaining a comparable level of service to the ordering clinicians.
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Affiliation(s)
- Julian Lopez-Rippe
- Research Scholar, Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Erin S Schwartz
- Division Chief Neuroradiology and Associate Chair for Diversity, Equity, and Inclusion, Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Professor of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - J Christopher Davis
- Section Director for Emergency Radiology, Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; and Assistant Professor of Clinical Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Rebecca A Dennis
- Director of Fellowship, Residency and Observership Program, Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; and Assistant Professor of Clinical Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Michael L Francavilla
- Associate Professor and Chief Medical Information Officer for Radiology, Department of Radiology, University of South Alabama, Mobile, Alabama
| | - Mohammad Jalloul
- Research Scholar, Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Summer L Kaplan
- Associate Chair for Quality and Medical Director of Point-of-Care Ultrasound, Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; and Assistant Professor of Clinical Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
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Andrijauskis D, Woolf G, Kuehne A, Al-Dasuqi K, Silva CT, Payabvash S, Malhotra A. Utility of Gadolinium-Based Contrast in Initial Evaluation of Seizures in Children Presenting Emergently. AJNR Am J Neuroradiol 2023; 44:1208-1211. [PMID: 37652579 PMCID: PMC10549952 DOI: 10.3174/ajnr.a7976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 08/02/2023] [Indexed: 09/02/2023]
Abstract
BACKGROUND AND PURPOSE The frequency and utility of gadolinium in evaluation of acute pediatric seizure presentation is not well known. The purpose of this study was to assess the utility of gadolinium-based contrast agents in MR imaging performed for the evaluation of acute pediatric seizure presentation. MATERIALS AND METHODS We identified consecutive pediatric patients with new-onset seizures from October 1, 2016, to September 30, 2021, who presented to the emergency department and/or were admitted to the inpatient unit and had an MR imaging of the brain for the evaluation of seizures. The clinical and imaging data were recorded, including the patient's age and sex, the use of IV gadolinium, and the underlying cause of epilepsy when available. RESULTS A total of 1884 patients were identified for inclusion. Five hundred twenty-four (28%) patients had potential epileptogenic findings on brain MR imaging, while 1153 (61%) patients had studies with normal findings and 207 (11%) patients had nonspecific signal changes. Epileptogenic findings were subclassified as the following: neurodevelopmental lesions, 142 (27%); intracranial hemorrhage (traumatic or germinal matrix), 89 (17%); ischemic/hypoxic, 62 (12%); hippocampal sclerosis, 44 (8%); neoplastic, 38 (7%); immune/infectious, 20 (4%); phakomatoses, 19 (4%); vascular anomalies, 17 (3%); metabolic, 3 (<1%); and other, 90 (17%). Eight hundred seventy-four (46%) patients received IV gadolinium. Of those, only 48 (5%) cases were retrospectively deemed to have necessitated the use of IV gadolinium: Fifteen of 48 (31%) cases were subclassified as immune/infectious, while 33 (69%) were neoplastic. Of the 1010 patients with an initial noncontrast study, 15 (1.5%) required repeat MR imaging with IV contrast to further evaluate the findings. CONCLUSIONS Gadolinium contrast is of limited additive benefit in the imaging of patients with an acute onset of pediatric seizures in most instances.
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Affiliation(s)
- Denas Andrijauskis
- From the Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, Connecticut
| | - Graham Woolf
- From the Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, Connecticut
| | - Alexander Kuehne
- From the Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, Connecticut
| | - Khalid Al-Dasuqi
- From the Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, Connecticut
| | - Cicero T Silva
- From the Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, Connecticut
| | - Seyedmehdi Payabvash
- From the Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, Connecticut
| | - Ajay Malhotra
- From the Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, Connecticut
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Pijpers JA, Au PYB, Weeke LC, Vein AA, Smit LS, Vilan A, Jacobs E, de Vries LS, Steggerda SJ, Cilio MR, Carapancea E, Cornet MC, Appendino JP, Peeters-Scholte CMPCD. Early recognition of characteristic conventional and amplitude-integrated EEG patterns of seizures in SCN2A and KCNQ3-related epilepsy in neonates. Seizure 2023; 110:212-219. [PMID: 37429183 DOI: 10.1016/j.seizure.2023.06.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2023] [Revised: 05/30/2023] [Accepted: 06/19/2023] [Indexed: 07/12/2023] Open
Abstract
PURPOSE Early recognition of seizures in neonates secondary to pathogenic variants in potassium or sodium channel coding genes is crucial, as these seizures are often resistant to commonly used anti-seizure medications but respond well to sodium channel blockers. Recently, a characteristic ictal amplitude-integrated electroencephalogram (aEEG) pattern was described in neonates with KCNQ2-related epilepsy. We report a similar aEEG pattern in seizures caused by SCN2A- and KCNQ3-pathogenic variants, as well as conventional EEG (cEEG) descriptions. METHODS International multicentre descriptive study, reporting clinical characteristics, aEEG and cEEG findings of 13 neonates with seizures due to pathogenic SCN2A- and KCNQ3-variants. As a comparison group, aEEGs and cEEGs of neonates with seizures due to hypoxic-ischemic encephalopathy (n = 117) and other confirmed genetic causes affecting channel function (n = 55) were reviewed. RESULTS In 12 out of 13 patients, the aEEG showed a characteristic sequence of brief onset with a decrease, followed by a quick rise, and then postictal amplitude attenuation. This pattern correlated with bilateral EEG onset attenuation, followed by rhythmic discharges ending in several seconds of post-ictal amplitude suppression. Apart from patients with KCNQ2-related epilepsy, none of the patients in the comparison groups had a similar aEEG or cEEG pattern. DISCUSSION Seizures in SCN2A- and KCNQ3-related epilepsy in neonates can usually be recognized by a characteristic ictal aEEG pattern, previously reported only in KCNQ2-related epilepsy, extending this unique feature to other channelopathies. Awareness of this pattern facilitates the prompt initiation of precision treatment with sodium channel blockers even before genetic results are available.
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Affiliation(s)
- Judith A Pijpers
- Departments of Neurology and Clinical Neurophysiology, Leiden University Medical Center, PO Box 9600, Leiden 2300 RC, the Netherlands.
| | - Ping Yee Billie Au
- Departments of Medical Genetics, Cumming School of Medicine, University of Calgary, Canada
| | - Lauren C Weeke
- Departments of Neonatology, Erasmus Medical Center, the Netherlands
| | - Alla A Vein
- Departments of Neurology and Clinical Neurophysiology, Leiden University Medical Center, PO Box 9600, Leiden 2300 RC, the Netherlands
| | - Liesbeth S Smit
- Departments of Neonatology, Erasmus Medical Center, the Netherlands; Departments of Neurology, Erasmus Medical Center, the Netherlands
| | - Ana Vilan
- Department of Neonatology, Centro Hospitalar Universitário São João, Faculty of Medicine, University of Porto, Portugal
| | - Elke Jacobs
- Departments of Neurology, Erasmus Medical Center, the Netherlands
| | - Linda S de Vries
- Departments of Neonatology, Leiden University Medical Center, the Netherlands
| | - Sylke J Steggerda
- Departments of Neonatology, Leiden University Medical Center, the Netherlands
| | - Maria Roberta Cilio
- Division of Pediatric Neurology, Department of Pediatrics, Catholic University of Louvain, Brussels, Belgium
| | - Evelina Carapancea
- Division of Pediatric Neurology, Department of Pediatrics, Catholic University of Louvain, Brussels, Belgium
| | - Marie-Coralie Cornet
- Division of Neonatology, Department of Pediatrics, Benioff Children's Hospital, University of California, San Francisco, CA, USA
| | - Juan P Appendino
- Departments of Pediatric Neurology, Cumming School of Medicine, University of Calgary, Canada
| | - Cacha M P C D Peeters-Scholte
- Departments of Neurology and Clinical Neurophysiology, Leiden University Medical Center, PO Box 9600, Leiden 2300 RC, the Netherlands
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Figueiro Longo MG, Jaimes C, Machado F, Delgado J, Gee MS. Pediatric Emergency MRI. Magn Reson Imaging Clin N Am 2022; 30:533-552. [PMID: 35995478 DOI: 10.1016/j.mric.2022.05.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
Abstract
There is an overall increase in the use of imaging in the pediatric emergency room setting, which is accompanied by a reduction in computed tomography examinations performed mainly due to the increased awareness of the risks of ionizing radiation. Advances in MRI technology have led to shortened scan time, decreased motion sensitivity, and improved spatial resolution. With increased access to MRI in the emergency room setting, the goal of this article is to review major applications of MR in pediatric emergency room patients.
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Affiliation(s)
- Maria Gabriela Figueiro Longo
- Division of Pediatric Radiology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA.
| | - Camilo Jaimes
- Department of Radiology, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA
| | - Fedel Machado
- Department of Radiology, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA
| | - Jorge Delgado
- Division of MSK Radiology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA
| | - Michael S Gee
- Division of Pediatric Radiology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA
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Merison K, Victorio MCC. Approach to the Diagnosis of Pediatric Headache. Semin Pediatr Neurol 2021; 40:100920. [PMID: 34749917 DOI: 10.1016/j.spen.2021.100920] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 08/09/2021] [Accepted: 08/15/2021] [Indexed: 10/20/2022]
Abstract
Headache in children and adolescents is a common symptom that can be worrisome to patients, their parents and clinicians due to the myriad of underlying etiologies, both benign and life-threatening. The evaluation of headache must be directed primarily to exclude secondary causes. A detailed headache history, recognition of headache patterns and red flags and thorough physical and neurological examinations are essential in the diagnosis; and identifies patients requiring further workup. Considerations for neuroimaging and ancillary testing are also discussed.
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Affiliation(s)
- Kelsey Merison
- NeuroDevelopmental Science Center Akron Children's Hospital, Akron, OH.
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