DOI: 10.18410/jebmh/2015/770
ORIGINAL ARTICLE
CT SCAN FINDINGS IN PATIENTS WITH SEIZURES IN NOTHERN
CHHATTISGARH: A RETROSPECTIVE STUDY
Archana Singh1, Bhanu P. Singh2, Apurv Garewal3
HOW TO CITE THIS ARTICLE:
Archana Singh, Bhanu P. Singh, Apurv Garewal. “CT Scan Findings in Patients with Seizures in Nothern
Chhattisgarh: A Retrospective Study”. Journal of Evidence based Medicine and Healthcare; Volume 2,
Issue 36, September 07, 2015; Page: 5555-5562, DOI: 10.18410/jebmh/2015/770
ABSTRACT: A five years study of CT scan findings in seizure patients is carried out to know the
different etiology. Seizure is a finite event of altered cerebral function because of excessive and
abnormal electrical discharges of the brain cells. Epilepsy is a chronic condition predisposing a
person to recurrent seizures. This study is designed to establish usefulness of CT in defining the
etiology of seizures in various age groups in people of Northern Chhattisgarh. This is a
retrospective hospital-based study conducted in Radio- diagnosis Department of Chhattisgarh
Institute of Medical Sciences, Bilaspur, Chhattisgarh. The study was carried out over a 5 year
period. Hospital admissions with history of seizures are very common. Almost 3-9% per 1000
population of total hospital emergencies is seizure cases. Epilepsy is an important health problem
in developing countries, where its prevalence can be up to 57 per 1000 population. This study
has high prevalence of seizures in First, second, third and fourth decades with decreasing pattern
with increasing age. Prevalence in first decade is low as compare to second and third decades.
Tuberculoma (9.39%) and Neurocysticercosis (3.60%) has highest prevalence in partial seizures
followed by Focal Cerebral Edema (6.22%) whereas Diffuse Cerebral edema (4.91%) seen with
Generalised Seizures Cerebral infarct has equally seen in both types of seizures. Brain tumour
presented mostly with Generalised seizure (2.07%) than in partial seizures (0.98%). Other
abnormal findings like Cerebral calcifications, Diffuse cortical atrophy, Focal cortical atrophy, Sub
Arachnoid hemorrhage, Intracerebral Hemorrhage, Hypoxic Ischemic Encephalopathy,
Hydrocephalus and few rare diseases like Fahr disease and Tuberous sclerosis have also seen in
CT scan in seizure patients. CT scan is valuable in making a diagnosis particularly in Indian
subcontinent, where infective causes in form of space occupying lesions and infections are most
important causes of seizure.
KEYWORDS: CT scan, Seizure, Tuberculoma, Neurocysticercosis, Brain tumor.
INTRODUCTION: A seizure is a finite event of altered cerebral function because of excessive
and abnormal electrical discharges of the brain cells. Epilepsy is a chronic condition predisposing
a person to recurrent seizures. The clinical manifestation consists of sudden and transitory
abnormal phenomena which may include alterations of consciousness, motor, sensory, autonomic
or psychic events, perceived by the patient or by an observer.(1) Seizures are classified into
different types. The classification is important because etiologic diagnosis, appropriate treatment,
and accurate prognostication all depend on the correct identification of seizures and epilepsy.
There are 2 main types of seizures: generalized and focal. The separation of “focal” from
“generalized” seizures is a useful construct—even if this separation is not truly distinct. Focal
seizures are those arising within networks of a single cerebral hemisphere and may remain
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ORIGINAL ARTICLE
localized or subsequently become more widely distributed. Generalized seizures rapidly affect
both hemispheres as well as both sides of the body-even when caused by a “focal” lesion.
Generalized seizures are further subdivided into tonic-clonic, absence, myclonic, clonic, tonic, and
atonic. The older classification terms for focal seizures (“simple partial,” “complex partial” and
“partial”) have been supplanted, and these distinctions have been removed.(2) The perception
generally is that seizures occur most often in infants but rarely in older adults. The raised
incidence of epilepsy with onset at over 50 years of age, in relation to the total number of new
cases of epilepsy, has been ignored in the literature in recent decades.(3) Over the years imaging
has been established as the most important modality for diagnosis of diseases leading to
seizures. Imaging modalities used in the evaluation of seizures can be subdivided into those
evaluating brain structure, metabolism, perfusion, and electrical activity. Magnetic resonance
imaging (MRI) and computed tomography (CT) are the primary modalities used in the evaluation
of structural lesions known to induce seizures.(4) CT scan, though surpassed by MRI as the
technique of choice, has a significant role in the acute seizure scenario and peri-operative period.
In both these situations the ability of the CT Scan to detect trauma, hemorrhage, hydrocephalus,
tumors etc. can profoundly influence the mode of treatment provided for the benefit of the
patient.(5) This study is designed to establish usefulness of CT in defining the etiology of seizures
in various age groups in people of Northern Chhattisgarh.
METHODS: This is a retrospective hospital-based study conducted in Radio- diagnosis
Department of Chhattisgarh Institute of Medical Sciences, Bilaspur, Chhattisgarh. The study was
carried out over a 5 year period i.e. from January 2009 to December 2014. Patients admitted with
history of seizure disorder were admitted in the emergency medicine department and it was
managed there for emergencies. Detailed history and thorough clinical examination with CNS was
undertaken. After the settlement of vitals and other parameters patients referred to the
Department of Radio-diagnosis for CT scan Brain/Skull with appropriate history. This study
doesn’t involve traumatic skull or brain injuries. CT scan was done using Siemens Spiral CT
machine Somatom Emotion and regular CT protocols were followed. CT protocols include supine
position with head first and axial section of head. Plain CT Scan with 8 mm slice thickness were
taken and thin sections up to 2 to 5 mm were also done in particular aspects. CECT was also
carried out whenever required. The CT patterns were then assessed. In the 05 years of
retrospective study total 915 patients with history of seizures were referred for brain CT scan.
Among these 515 male and were 400 females. Patient’s records were reviewed to assess the
following-age, sex, seizure type, neurological examination. In this study the lowest age of the
patient was 2 days and the highest age was 85 years. Age was divided in decade wise and
analyzed from 1 day to 10 years then 11 years to 20 years likewise up to 90 years for both the
sex. After the CT scan the diagnosis were confirmed with co-relation with clinical history and
different Pathology, Microbiology and Biochemical investigations and tests available in the
laboratory services in the hospital. Tuberculoma was confirmed with clinical history, Mantoux test
and ADA titer of CSF. Neurocysticercosis was confirmed by ELISA test from department of
Microbiology. CT scan is the diagnostic investigation for cerebral edema, Cerebral Infarct, Cortical
atrophy, Calcification, Hydrocephalus Intracerebral hemorrhage and Hypoxic ischemic
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ORIGINAL ARTICLE
encephalopathy. These findings were also correlate with clinically. Few cases were also referred
for MRI to confirm the diagnosis.
OBSERVATION:
Sex
Partial Seizure Generalized Seizure
Total
Male
255
260
515(56.28 %)
Female
191
209
400(43.72 %)
Total 446(48.74 %)
469(51.26 %)
915(100 %)
Table 1: Distribution of patients according to sex and presentation
Table 1: Out of Total 915 cases 515 were male and 400 were female. Generalizes seizure
observed little more in male and female.
Presentation
Partial Seizure
Generalized Seizure
Total
No. of Patients
446
469
915
Abnormal CT
239(53.59%)
151(32.20%)
390(42.62%)
Normal CT
207(46, 41%)
318(67.80%)
525(57.38%)
Table 2: Distribution of Both groups according to Abnormal and Normal CT findings
Table 2: In Cases of 469 Generalizes seizures CT scan findings were abnormal in 151 cases and
Normal finding observed in 318 cases. In cases of partial seizures out of 446 cases 239 cases
were abnormal and 207 having normal CT scan findings.
Age in
Years
01-10
11 – 20
21 – 30
31 – 40
41 – 50
51 – 60
61 – 70
71 – 80
81 – 90
Total
Partial
Generalized
Abnormal
NAD
Patients
Seizure
Seizure
CT findings
155(16.94%)
78(50.32%)
77(49.68 %)
68(43.68 %)
87(56.13%)
284(31.04 %) 132(46.48%) 152(53.52%)
108(38.03%) 176(61.97%)
198(21.64%) 87(43.94 %) 111(56.06 %)
86(43.43 %) 112(56.57%)
115(12.57%)
58(50.43%)
57(49, 57%)
39(33.91%)
76(66.09%)
94(10.27%)
52(55.32%)
42(44.68%)
49(52.13%)
45(47.87%)
42(4.59%)
22(52.38%)
20(47.62%)
22(52.38%)
20(47.62%)
24(2.62%)
16(66.67%)
8(33.33%)
17(70.83%)
7(29.17%)
1(0.11%)
1(100%)
1(100%)
2(0, 22%)
2(100%)
2(100%)
Table 3: Distribution of Patients according to various age group, their
presentation and Abnormal/Normal CT Findings
Table 3: Age wise distribution shows highest number of cases in between 11 to 20 years I,e,
31.04% then followed by 21 to 30 years-21.64%, 1 to 10 years-16.94%, 31 to 40 years-12.57%,
41 to 50 years-10.27%, 51 to 60 years- 4.59% and 61 to 70 years-2.62%. With Increasing the
age cases of seizures were less.
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CT Scan Findings
Partial Seizure Generalized Seizure Total
Tuberculoma
86
86
Cerebral Infarct
29
30
59
Focal Cerebral Edema
57
57
Diffuse Cerebral Edema
45
45
Neurocysticercosis
33
33
Brain Tumor
9
19
28
Calcification (1 – 2)
12
5
17
Diffuse Cortical Atrophy
15
15
Focal Cortical Atrophy
11
11
Sub Arachnoid Hemorrhage
11
11
Intra Cerebral Hemorrhage
10
10
Hypoxic Ischemic Encephalopathy
7
7
Multiple Calcification
2
4
6
Hydrocephalus
3
3
Fahr Disease
1
1
Tuberous Sclerosis
1
1
Table 4: Abnormal CT Findings in cases of Generalized Seizure and Partial Seizure
Table 4: Tuberculoma have the highest incidence and the commonest findings in partial seizures
cases followed by Cerebral Infarct have almost equal in both types of seizures. Other abnormal
findings like Focal cerebral edema, Diffuse cerebral edema Neurocysticercosis, Brain tumor,
Cerebral calcifications, Diffuse cortical atrophy, Focal cortical atrophy, SAH, ICH, HIE,
Hydrocephalus and few rare diseases like Fahr disease and Tuberous sclerosis have also seen in
CT scan seizure’s patients.
Age (Yrs)
1-10 11-20 21-30 31-40 41-50 51-60 61-70 71-80 81-90
Abnormal findings
Tuberculoma
25
36
17
05
03
Infarct
03
07
09
07
14
13
06
Focal cerebral edema
06
22
16
08
04
01
Diffuse cerebral edema
13
12
13
02
04
01
Neurocysticercosis
01
08
09
09
04
01
01
Brain tumor
01
08
07
06
03
01
02
Calcification
04
06
01
03
01
02
Diffuse cortical atrophy
13
12
13
02
04
01
Focal cortical atrophy
06
22
16
08
04
01
Sub Arachnoid
05
01
02
01
02
Hemorrhage
Intra Cerebral Hemorrhage
01
01
05
02
01
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ORIGINAL ARTICLE
Hypoxic Ischemic
Encephalopathy
Multiple calcification
Hydrocephalus
Fahr disease
Tuberous sclerosis
06
-
01
-
-
-
-
-
-
03
-
02
-
01
01
01
-
03
-
-
-
-
-
Table 5: Age specific CT scan Findings in cases of Seizure
Table 5: Highest cases Tuberculoma seen in the age group of 11 to 20 years followed by 1 to 10
years then among 21 to 30 years. Second commonest findings Focal Cerebral Edema was also
highest among 11 to 20 years then in 21 to 30 years then 1 to 10 years. Diffuse Cortical Atrophy,
Diffuse Cerebral Edema, SAH, HIE and Hydrocephalus was seen only in lower age group
particularly among 1-10 years. No Abnormal CT scans findings observed in cases of seizures in
the age group of 81-90 years. However incidence of Neurocysticercosis seen almost in all age
group but it was highest among 11 to 50 years.
DISCUSSION: Hospital admissions with history of seizures are very common. Almost 3-9 % per
1000 population of total hospital emergencies is seizure cases. Epilepsy is an important health
problem in developing countries, where its prevalence can be up to 57 per 1000 population.(5)
Chhattisgarh Institute of medical sciences caters Northern Chhattisgarh i.e. 40% area of the
state. This 5 years retrospective study involve 915 cases of seizures including both generalized
and partial which have referred to the department of Radio diagnosis for evaluation of
morphological changes in brain to know the possibilities and causes of seizures. Out of Total 915
cases 515 were male and 400 were female. Generalized seizure observed little more in male and
female. Male to Female ratio is in Generalized Seizure is 1.24:1 and in Partial seizure is 1.33:1.
The difference is not statistically significant. Male Female ratio is also not statistically significant in
different studies.(6)
Out of the total cases 469(51.26%) of Generalizes seizures CT scan findings were
abnormal in 151(16.50%) cases and normal finding were observed in 318(34.75%) cases. In
cases of partial seizures out of 446 (48.74%) cases 239(26.12%) cases were abnormal and
207(22.62%) were having normal CT scan findings. Similar study is done in other part of country
by different researchers at Bangalore, Bombay, Madras, Kashmir and Varanasi.(7,8,9) Study done at
Bangalore, Bombay, Madras and Varanasi shows high ratio of CT scan abnormalities in partial
seizure. Age specific prevalence of seizures increases with the age, reaching a peak in the third
and fourth decades of life observed in Ethiopia and Nigeria. Highest prevalence occurs in the
second decade of life in Sri Lanka.(6) Study done at South India by Venkateswara Murthy N. et al
shows high prevalence rate of seizure in second and third decades.(10)
This study has high prevalence of seizures in first, second, third and in fourth decades
with decreasing pattern in higher age. Prevalence in first decade is low as compare to second and
third decades. Tuberculoma (9.39%) and Neurocysticercosis (3.60%) has highest prevalence in
partial seizures followed by Focal Cerebral Edema (6.22%) whereas Diffuse Cerebral edema
(4.91%) seen with Generalised Seizures Cerebral infarct has equally seen in both types of
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ORIGINAL ARTICLE
seizures. Brain tumour presented mostly with Generalised seizure (2.07%) than in partial seizures
(0.98%). Other abnormal findings like Cerebral calcifications, Diffuse cortical atrophy, Focal
cortical atrophy, Sub Arachnoid Hemorrhage, Intracerebral Hemorrhage, Hypoxic Ischemic
Encephalopathy, Hydrocephalus and few rare diseases like Fahr disease and Tuberous sclerosis
have also seen in CT scan in seizure patients. Study of R. Baheti et al done at Western Rajasthan
of India has the similar causes for seizures. In Western Rajasthan normal CT scan was 50% in
case of partial seizures and 65.4% in case of generalized seizures. An Abnormal CT finding was
50% in Partial and 34.6% in generalized seizures. Other causes for both types of seizure
observed are Cerebral edema, Tuberculoma, Calcifications, Cerebral atrophy, Hydrocephalus,
Subdural Effusion, Hypodence lesion, Hypoplasia of Thalamus, Infarction of basal ganglion and
Neurocysticercosis in different frequency.(11) We observed Highest cases of Tuberculoma and is
seen in the age group of 11 to 20 years followed by 1 to 10 years and then among 21 to 30
years. Epilepsy is also a common manifestation of intracranial Tuberculoma that present as slow
growing, space-occupying lesions.(12) Tuberculoma can also be discovered accidentally in
asymptomatic individuals and in children with focal or generalized seizures.(13,14) In India, ring or
disc-like enhancing lesions, which are thought to be of Tubercular origin, have been identified in
CT scan of patients who presented with simple partial epilepsy.(15) Puri and Gupta, in their study
on seizure patients, found that Tuberculoma and NCC patients presented with partial seizures
more than the generalized seizures (16) Second commonest finding Focal Cerebral Edema was also
highest among 11 to 20 years followed by 21 to 30 years & then 1 to 10 years. Diffuse Cortical
Atrophy, Diffuse Cerebral Edema, Sub-Arachnoid Haemorrhage, Hypoxic Ischemic
Encephalopathy and Hydrocephalus were seen only in lower age group particularly among 1-10
years. No Abnormal CT scans findings were observed in cases of seizures in the age group of 8190 years. In our study incidence of Neurocysticercosis seen almost in all age group but it was
highest among 11 to 40 years. Seizures were the commonest clinical presentation (100%). The
Maximum incidence of Neurocysticercosis was found in the age group between 21- 30 years
(43.41%) (17). Brain tumours has highest incidence in between 11-30 years in this study. Spaceoccupying lesions were the most common finding and were more commonly associated with
simple seizures with or without generalization.(18) An increased presence of infective lesions in
developing countries, which has also been suggested by Hopkins et al.(19) The presence of these
lesions is easily picked up by the CT scanner due to increased incidence of calcification in these
lesions. In about half of the seizure patients, it is able to diagnose or identify the type and site of
the lesion as well as involvement of the surrounding structures.
Computerized transverse axial tomography (CTAT) of the brain has been used routinely,
to study patients with epilepsy. In patients with the various electro-clinical types of epilepsy primary, secondary, and partial - it gave accurate information about the frequency, topography,
and severity of morphological abnormalities. In the various types of organic lesion - tumor, posttraumatic, post ischemic, post infectious, etc. - it markedly increased the ability to establish
etiology.(20) Contrast-enhanced images are very valuable in making a diagnosis. Although CT gives
ionizing radiation to the patient, but its increasing wide spread availability, patient affordability,
and short scan time makes it very valuable tool in diagnostic work up of a seizure patient. Its
benefit outweighs the risk. CT scan plays a very important role as a preliminary tool in
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ORIGINAL ARTICLE
radiological assessment of patients presenting with seizure. In about half of the seizure patients,
it is able to diagnose or suggest the abnormality. It is valuable in making a diagnosis particularly
in Indian subcontinent, where infective causes in form of space occupying lesions and infections
are most important cause of seizures.
CONCLUSION: Computerized transverse axial tomography is very commonly indicated in cases
of seizures. It is one of the best investigations to rule out the etiological causes of seizures hence
treatment modalities can be decided immediately. Northern Chhattisgarh has high prevalence of
Tuberculoma and fare number of Neurocysticercosis in cases of partial seizures. Cerebral edemas,
Calcifications, Cerebral atrophy, Hydrocephalus, Sub Arachnoid Hemorrhage, Intracerebral
Hemorrhage, Hypoxic Ischemic Encephalopathy, Infarction of basal ganglion are other etiological
factors for seizures. CT scan plays a very important role as a preliminary tool in radiological
assessment of patients presenting with seizures. In about half of the seizure patients, it is able to
diagnose or suggest the abnormality.
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AUTHORS:
1. Archana Singh
2. Bhanu P. Singh
3. Apurv Garewal
PARTICULARS OF CONTRIBUTORS:
1. Associate Professor, Department of
Radio-diagnosis, Chhattisgarh Institute
of Medical Sciences, Bilaspur,
Chhattisgarh.
2. Associate Professor, Department of
Pathology, Chhattisgarh Institute of
Medical Sciences, Bilaspur,
Chhattisgarh.
3. Demonstrator, Department of Radiodiagnosis, Chhattisgarh Institute of
Medical Sciences, Bilaspur,
Chhattisgarh.
NAME ADDRESS EMAIL ID OF THE
CORRESPONDING AUTHOR:
Dr. Archana Singh,
Associate Professor,
Department of Radio-diagnosis,
Chhattisgarh Institute of Medical Sciences,
Bilaspur-495001, Chhattisgarh.
E-mail: radiodiagnosiscimsbilaspur@gmail.com
Date
Date
Date
Date
of
of
of
of
Submission: 21/08/2015.
Peer Review: 22/08/2015.
Acceptance: 28/08/2015.
Publishing: 02/09/2015.
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