01 · The question
What can a brain MRI add?
A seizure is a symptom, and childhood seizures have many possible causes. MRI can show structural differences such as focal cortical dysplasia, hippocampal abnormalities, prior injury, selected vascular or developmental lesions, and some tumours. Finding a relevant cause may help the clinical team understand the seizure pattern and plan follow-up or treatment.
The scan is interpreted together with the child’s history, neurological and developmental assessment, and EEG. MRI does not record the electrical event and cannot confirm or rule out epilepsy on its own.
02 · Choosing imaging
When is imaging considered?
MRI is commonly offered when a structural cause is suspected and for many children diagnosed with epilepsy. It is especially valuable when seizures begin focally, the neurological examination or development is atypical, EEG findings do not fit a recognised self-limited or generalised syndrome, or seizures continue despite appropriate treatment.
Some children with a clearly diagnosed idiopathic generalised epilepsy or self-limited epilepsy with centrotemporal spikes may not need routine MRI, if the history, examination and EEG are typical. Infants need particularly careful, age-specific assessment: recent ILAE recommendations identify features such as focal signs, an abnormal examination, developmental delay or focal EEG abnormalities as factors that can increase the priority for MRI.
A first seizure does not automatically mean epilepsy or require the same scan for every child. The treating team decides whether imaging is needed, how urgently it should happen and whether MRI or, in an acute situation, CT is the right examination.
03 · MRI technique
Why an epilepsy-specific MRI protocol matters
Small abnormalities can be subtle. A dedicated epilepsy MRI uses high-resolution images and careful review of the cerebral cortex, hippocampi and other structures. The ILAE HARNESS-MRI recommendations provide a harmonised structural approach centred on high-resolution three-dimensional acquisitions and a targeted coronal T2 sequence.
The protocol is adapted to the child’s age, scanner, clinical question and ability to stay still. A child-friendly preparation, motion-reduction strategies and specialist paediatric neuroradiology review can improve image quality. Sedation or anaesthesia is considered individually when the child cannot safely complete the examination awake.
- MRI uses no ionising radiation.
- Contrast is not routinely required for every epilepsy MRI; it is added when the clinical question or suspected lesion calls for it.
- An earlier routine MRI may sometimes need specialist re-review or a dedicated repeat study if seizures persist or the clinical picture changes.
04 · Limits and meaning
Images inform care; they do not tell the whole story
A structural finding may be incidental, may not explain the seizures, or may need correlation with EEG and seizure semiology. Conversely, some children have epilepsy without a visible structural abnormality on MRI. The report should therefore describe what is seen and how confidently it relates to the clinical question.
When seizures remain difficult to control and a potentially relevant lesion is identified, a specialist epilepsy team may consider whether further tests or surgical evaluation are appropriate. Imaging can support that discussion, but it does not by itself decide treatment or predict an individual child’s future.
05 · A child-centred pathway
The right study, at the right time
Good imaging begins with a clear clinical question. The team considers the child’s age, seizure history, EEG, examination, development and whether the situation is urgent. When MRI is appropriate, a tailored protocol and experienced interpretation help make the examination as useful as possible.
For families, it can help to ask: What question is the scan intended to answer? Is an epilepsy protocol planned? Will the images be reviewed by a paediatric neuroradiologist if needed? What happens if the scan is normal or shows an unexpected finding?
06 · Evidence