The International League Against Epilepsy (ILAE) Subcommittee for Pediatric Neuroimaging examined the value of, and indications for, neuroimaging in the evaluation of children with newly diagnosed epilepsy. Retrospective and prospective published series with 30 or more subjects receiving CT and MRI to evaluate new-onset seizures were reviewed. Imaging studies were abnormal in nearly 50% of children with localization-related new-onset seizures, 15-20% of imaging studies provided information on etiology and/or seizure focus, and 2-4% potentially altered immediate management. A significant imaging abnormality was almost always associated with a history of a localization-related seizure, abnormal neurologic examination, or focal EEG. Childhood absence epilepsy, juvenile absence epilepsy, juvenile myoclonic epilepsy, and benign childhood epilepsy with centrotemporal spikes were not associated with a structural imaging abnormality. Imaging is helpful in establishing seizure etiology, predicting prognosis, and in treatment. Imaging is recommended in children with new-onset localization-related epilepsy, when epilepsy classification is in doubt, and when an epilepsy syndrome with remore symptomatic cause is suspected. MRI is preferred to CT because of superior resolution, and lack of radiation. 
COMMENT. Imaging is most useful for children with localization-related or remote symptomatic generalized epilepsy. MRI abnormalities are more frequent in infants with seizures than in older children because of presentation of cortical malformations. The authors advise that children younger than 2 years require special MRI sequences because immature myelination may obscure the diagnosis of cortical dysplasia. If the MRI is interpreted as normal and seizures persist, repeat imaging at 6-month intervals is advised, when myelination is more mature and dysplasias can be distinguished. Gadolinium contrast is reserved for suspected tumor, vascular malformation, inflammation, and infectious disorders.