TABLE 2244 ACEP Recommendations for Obtaining Emergent Neuroimaging Following a Seizure5

If the patient does not meet the above criteria, has recovered from the seizure, and no metabolic cause for the seizure has been identified, a head CT may be obtained later as part of the disposition in conjunction with follow up with a neurologist.

Because many important processes, such as metastatic or primary tumors or vascular anomalies, may not be evident on noncontrast studies, a follow-up enhanced CT or MRI may be arranged. MRI is more sensitive than CT in detecting subtle alterations of brain structure and is often the study of choice in the evaluation of patients with seizures. In patients with uncomplicated first seizures, it is reasonable to omit the CT scan and obtain an MRI instead. Consultation with a neurologist or radiologist may be helpful in choosing the best approach and avoiding unnecessary examinations.

Other radiographic studies may be indicated in some cases. Radiographs of the cervical spine or neck should be obtained if there is suspicion for head trauma. Chest x-rays may reveal primary or metastatic tumors. There may be evidence of aspiration, although related radiographic findings are usually delayed. Skull x-rays are generally not indicated. Special examinations, such as angiography, are rarely part of the emergency department evaluation.

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