Physicians in Emergency Medicine, Pediatric Neurology, and Radiology at Children’s Hospital Boston, MA studied the risk of intracranial pathology requiring immediate intervention among patients presenting in the ED with a first complex febrile seizure (CFS). Of a total of 526 patients identified with a first CFS between 1995 and 2008, 268 (50.4%) had emergent head CT imaging. Four patients had a clinically significant finding: 2 had intracranial hemorrhage, 1 had ADEM, and 1 had focal cerebral edema. The risk of intracranial pathology was 4 (0.8%). Three of the 4 had other obvious findings: nystagmus, emesis, altered mental status, persistent hemiparesis, bruises suggestive of inflicted injury. Patients presenting with more than one seizure in 24 hours are at very low risk. 
COMMENT. This study suggests that emergency neuroimaging may be unnecessary for children who present in the ED with a first CFS, uncomplicated by other acute signs of neuropathology. Focal and prolonged CFS may be more predictive of pathology than the multiple seizure type, especially when associated with prolonged postictal state.
In a retrospective study of 100 consecutive febrile seizure patient-visits to a university affiliated tertiary hospital, head CT was obtained in 18 patients at time of visit, with normal results in 17 (1 patient had mastoiditis). MRIs performed in 4 patients with CFS were normal. Of the 18 with CT scans, 4 had simple FS (5.8% of 77) and 14 had CFS (60.9% of 23). None had neurological lesions requiring surgery . CFS without neurologic signs of intracranial pathology is insufficient indication for emergent CT scan. Diagnostic criteria for CFS and indications for CT scan may require re-evaluation.