Recommendations for structural magnetic resonance imaging in infants with first afebrile seizure or new onset epilepsy: Evidence-based recommendations from the ILAE Neuroimaging Task Force

The Neuroimaging Task Force of the ILAE Diagnostic Methods Commission has developed evidence-based recommendations for structural magnetic resonance imaging in infants with first afebrile seizure or new onset epilepsy. Three PICO questions were defined and answered with a systematic review. We are seeking your comments prior to submitting to a journal for peer review.

Our literature review identified 17 studies leading to a recommendation for the use of MRI in infants with first afebrile seizure or new-onset epilepsy, and the identification of clinical features such as focal seizures or EEG abnormalities, abnormal examination, seizures >5 minutes that increase risk of MRI abnormality. However, we did not find sufficient data to answer our third question on the optimal MRI protocol which will be separately addressed with an expert-based Delphi process.

Draft: Recommendations for structural magnetic resonance imaging in infants with first afebrile seizure or new onset epilepsy: evidence-based recommendations from the ILAE Neuroimaging Task Force

Supplementary Material

Public comments on the draft position paper are now closed and available for review.

Comments

21 January 2026

In a full term newborn with unifocal clonic seizure, cerebral infarction or hemorrhage, or focal brain dysgenesis are the differentials, MRI should be recommended in these children. It is often done for immediate evaluation. Hence, newborns with focal clonic seizures should not be excluded from the study group.

Devina Singh

18 January 2026

Very nice overview of an area with limited data. I have just 2 comments.

  1. In an infant presenting with a single afebrile seizure, a lesion on MRI associated with high risk of recurrent seizures is very relevant, as it means the infant has epilepsy, not just a single seizure, and thus may direct treatment.
  2. Can you comment on the need for MRI in the following two scenarios:
    • An infant with a prior history of acute symptomatic seizures and a known acquired brain structural injury based on CT at that time (ie perinatal HIE, neonatal stroke), who then develops new onset epilepsy several months later
    • An infant who has a history of developmental impairment preceding seizures, with a prior known pathogenic monogenic variant that is highly associated with seizures.

Elaine Wirrell (United States)

16 January 2026

These recommendations will be highly valuable for clinicians managing infants with first afebrile seizure or new-onset epilepsy, particularly in settings where imaging decisions may be delayed or inconsistent, Especially in LMIC like ours. To Identify the clinical features associated with higher likelihood of MRI abnormalities provides practical guidance while maintaining a universal imaging recommendation. This balance between evidence and clinical applicability is commendable.

Dr.Sadiq Ali Shah (Pakistan)

5 January 2026

Any new onset seizure in infants ought to be assessed thoroughly including imaging with MR angiogram as a part of complete MRI studies. This would not only help differentiate between structural and functional causes of MRI, but it will also help create a database for future reference as seizure manifestation in infants is different than that of an adult. An imaging at baseline guarantees a proper assessment, and helps identify any developing lesion at the earliest.

Dr Faryal R. Abdy

22 December 2025

Always if focal seizure. Not necesarry in self-limited syndromes when the localization of epileptic activity in the EEG is on the left and on the right

Gemma Aznar-Laín

21 December 2025

The study is laudable and the continued work on optimising outcome is also highly applauded. In my view, routine brain MRI as proposed in the new guideline is likely untenable, particularly in least-resourced settings, because of the risks and logistical demands of sedation or general anaesthesia, other resource challenges and safety. The marginal clinical benefit of universal MRI, compared with current practice, appears limited and difficult to justify in the context of competing treatment priorities. Furthermore, interpretation of these scans will present an additional challenge, given the limited number of radiologists and the potential for substantial variation in reporting. For now, I believe MRI use should be restricted to clear clinical indications, with future refinements to the recommendation guided by emerging evidence and improvements in capacity.

Dr. Efe Obasohan

18 December 2025

In this guidelines it is better to add a few lines on Neuroethical issues during the management of seizures in infants at intensive care unit.

M.A.Aleem (India)

12 December 2025

MRI for:
First afebrile seizure in otherwise normal child-NO
New Onset Benign Syndromic Epilepsy: NO
Other first afebrile seizure or new onset epilepsy: YES

Gurbani