Clinical background
Seizures began at age 5, with two anti-seizure medicines tried at adequate doses without sustained control. EEG showed a left temporal focus. A 1.5T MRI was reported as showing no structural abnormality.
Paediatric neurology · United Kingdom
Second read of MRI in a child with focal seizures
Parents of a 7-year-old with drug-resistant focal seizures requested an independent read of the brain MRI reported as normal, before a planned change of anti-seizure medication.
Paediatric neurology United Kingdom Specialist report issued in 5 days
The referral question
“Has the imaging been acquired and reported using a protocol suited to identifying subtle epileptogenic lesions in a child with a defined electrographic focus?”
Anonymised clinical timeline
Dates are expressed as intervals rather than calendar dates, and identifying details have been altered, so that the sequence of care can be followed without identifying the patient.
Age 5
First seizure
Focal seizure with impaired awareness, described as behavioural arrest with oral automatisms lasting around 90 seconds.
Age 5 + 2 months
Initial EEG
Interictal epileptiform discharges over the left temporal region.
Age 5 + 3 months
First anti-seizure medicine
Started and titrated to an adequate maintenance dose; partial response only.
Age 6
MRI brain (1.5T)
Standard paediatric brain protocol reported as showing no structural abnormality.
Age 6 + 5 months
Second anti-seizure medicine
Added after continued seizures; adherence confirmed and levels checked where applicable. Seizure control remained incomplete.
Age 7
Drug-resistant epilepsy recorded
Two appropriately chosen and adequately dosed medicines had failed to achieve sustained seizure freedom.
Age 7 + 1 month
MedReview 365 case opened
Parents uploaded DICOM imaging, EEG reports and clinic letters ahead of a planned third medication change.
Age 7 + 1 month, 5 days
Dual specialist report issued
Reviewed jointly by a paediatric neurologist and a neuroradiologist, with a plain-language family section and a separate technical section for the treating team.
Age 7 + 3 months
Repeat imaging arranged
Treating service arranged repeat MRI using a dedicated epilepsy protocol and made a tertiary referral.
Documents reviewed
Every item supplied by the patient was indexed before review. Nothing was assessed in isolation from the rest of the record.
MRI brain DICOM images (1.5T) and radiology report
Acquisition parameters compared against published epilepsy-protocol recommendations.
EEG reports (three studies) including sleep-deprived recording
Electrographic focus localisation cross-referenced with the imaging coverage.
Paediatric neurology clinic letters
Reviewed for dose adequacy, adherence and the definition of treatment failure applied.
Seizure diary maintained by parents
Used to characterise semiology and frequency over 24 months.
Developmental and school reports
Reviewed for cognitive and behavioural trajectory alongside seizure burden.
Medication history with doses and dates
Confirmed both medicines had been trialled at adequate maintenance doses.
Questions raised for the treating team
Every report ends with a prepared question list. The questions are written to be asked of the patient's own clinician — they are prompts for discussion, not recommendations.
- Was the MRI acquired using a dedicated epilepsy protocol, and if not, should it be repeated with one?
- Are thin-slice coronal sequences angled to the hippocampus, and 3T imaging, available for my child?
- Does a normal MRI rule out a lesion that could be treated surgically?
- Given two medicines have failed, what is the referral pathway to a specialist paediatric epilepsy service?
- Should a third medicine be started before or after repeat imaging and specialist assessment?
- What monitoring is recommended for learning and behaviour while seizures remain uncontrolled?
Structured report highlights
Extracts from the signed specialist report, reproduced in the same section order used in every MedReview 365 report.
Imaging protocol gap
- The scan was a standard brain protocol rather than a dedicated epilepsy protocol.
- Thin-slice coronal sequences angled perpendicular to the long axis of the hippocampus were not included.
Why the protocol matters
- Subtle focal cortical dysplasia is a recognised cause of drug-resistant focal epilepsy and can be missed without targeted sequences and, where available, 3T imaging.
- A normal MRI does not exclude a surgically treatable lesion.
Pathway information
- Referral routes to specialist paediatric epilepsy services in the family's own health system were described.
- The report noted that the timing and choice of any further medicine is a decision for the treating neurologist.
Safety-netting
- Prolonged-seizure and status epilepticus red flags were restated in plain language, with instruction to follow the child's existing rescue-medication plan and call emergency services as advised by the treating team.
What happened next
The family raised the protocol question at their next appointment. The treating team arranged repeat imaging with an epilepsy protocol and a tertiary referral. All clinical decisions remained with the treating service.
This case study is anonymised, published with patient consent and altered where necessary to prevent identification. It describes how one written second opinion was prepared and discussed. It is not a treatment recommendation, not a diagnosis, and not an indication of any expected result in another patient. Always discuss your care with your own treating clinician, and seek emergency care for urgent or deteriorating symptoms.