5. Anand G, Shefler A, McShane T. Diagnosis and outcome of children admitted to a paediatric intensive care unit with unexplained coma. Arch Dis Child 2011; 96: 1091. 6. McKenny-Fick NM, Ferrie CD, Livingston JH, Taylor JC, Allen JE. Prolonged recovery of consciousness in children following symptomatic epileptic seizures. Seizure 2009; 18: 180–3. 7. Allen JE, Ferrie CD, Livingston JH, Feltbower RG. Recov- ery of consciousness after epileptic seizures in children. Arch Dis Child 2007; 92: 39–42. 8. The Paediatric Accident and Emergency Research Group. The Management of a Child (aged 0–18 years) with a Decreased Conscious Level. An evidence-based guideline for health professionals based in the hospital setting. Available at: http://www.nottingham.ac.uk/paediatric-guideline/Guide- line%20algorithm.pdf (accessed 16 January 2012). Magnetic resonance imaging in pediatric status epilepticus: not a routine, but a more focused indication ANDREA PORETTI 1 | ADAM L HARTMAN 2 | THIERRY AGM HUISMAN 1 1 Division of Pediatric Radiology, Russell H Morgan Department of Radiology and Radiological Science, The Johns Hopkins School of Medicine, Baltimore. 2 Departments of Neurology and Pediatrics, The Johns Hopkins School of Medicine, Baltimore, MD, USA. doi: 10.1111/j.1469-8749.2011.04202.x This commentary is on the original article by Yoong et al. on pages 328–333 of this issue. Status epilepticus in children is one of the most common life-threatening emergencies in pediatric neurology. It is asso- ciated with significant mortality and also morbidity that may impact on daily activities and health-related quality of life. Severe sequelae of status epilepticus include recurrent epileptic seizures, impairment of cognitive function, behavioral problems, and focal neurological deficits. Etiology and prior neurological abnormalities are predictors of mortality; whereas young age, etiology, and long duration are predictors of morbidity in pediatric status epilepticus. 1 The outcome is better in children with either febrile or idiopathic status epilepticus, rather than symptomatic status epilepticus. There- fore, the diagnosis of the underlying etiology plays a key role for the evaluation of prognosis in pediatric status epilepticus. Several articles and textbooks proposing diagnostic guidelines for pediatric status epilepticus are available in the literature and usually include laboratory studies, electro- encephalography, and neuroimaging. 2,3 The recommenda- tions of the American Academy of Neurology (AAN) mention that neuroimaging may be considered for the evaluation of children with status epilepticus if there are clinical indications or the etiology is unknown. 2 The evidence of this recommen- dation is, however, low and indicates the need for new prospective studies. Additionally, the AAN report notes there is insufficient evidence to support or refute recommending routine neuroimaging. 2 Yoong et al. 4 focus on the role of magnetic resonance imag- ing (MRI) and aim to identify clinical predictors of abnormal imaging. To achieve this goal, they aimed to prospectively col- lect a population-based sample of children within 1 to 13 weeks after status epilepticus. Unfortunately, they could only include 80 children (36%) over a collecting period of 3 years due to well-known recruitment difficulties, and of course the high number of patients not enrolled may bias the results. The prospective study design and the systematic approach are, however, innovative for this study population. The authors found abnormal MRI findings including sequelae after hypoxic-ischemic injuries or meningitis, cortical malfor- mations, stigmata of tuberous sclerosis, mesial temporal sclerosis, and features suggesting a neurometabolic disorder in about 30% of the patients. 4 This result matches the higher range of previous studies. An abnormal neurological examina- tion after status epilepticus, seizures not due to prolonged febrile status epilepticus, and continuous status epilepticus were identified as specific predictive factors for abnormal MRI findings. 4 These results suggest that routine neuroimaging in pediatric status epilepticus is not necessary, but a more focused approach only on children with risk factors for abnormal MR could be justified. The article by Yoong et al. cannot give a definitive answer to the insufficient evidence question and fur- ther prospective studies with larger cohorts of patients are needed. Nonetheless, the results of this study are important for the clinicians who treat children with status epilepticus and advance our knowledge about the role of neuroimaging in pediatric status epilepticus. Even if the authors do not discuss the role of head com- puted tomography in the emergency department, about half of the patients received head computed tomography during their acute admission. Children are at a greater risk than adults to suffer from radiation-induced side effects both because they are inherently more radiosensitive and because they have more years of life remaining during which a radia- tion-induced complication might develop. 5 Additionally, the impact of ionizing radiation on the developing brain and radiosensitive structures like the eye lens should not be under- estimated. In the study by Yoong et al., only seven of 30 patients had an abnormal acute computed tomography and none of these children required emergency neurosurgery. Additionally, the authors showed that a normal computed tomography in the acute setting does not offer complete reas- surance of a normal MRI. Thus, we emphasize that every effort should be made to limit the use of computed tomo- graphy to patients who may need emergency neurosurgery based on their clinical history (e.g. history of trauma, signs of Commentaries 295