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

Infants aged 1-24 months with new onset epilepsy frequently present with structural brain abnormalities, yet no updated evidence-based magnetic resonance imaging (MRI) guidelines exist for this population. The International League Against Epilepsy (ILAE) Neuroimaging Task Force developed evidence-based recommendations for structural brain MRI in infants with a first afebrile seizure or new onset epilepsy. A multidisciplinary panel defined three PICO (patients, intervention, comparison group, outcome under consideration) questions, conducted a systematic review (PROSPERO [Prospective Register of Systematic Reviews] CRD42024592653), and reported the results in line with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) 2020 guidelines. Risk of bias was evaluated using the JBI (Joanna Briggs Institute) checklist. GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) methodology was used to assess certainty of evidence and formulate recommendations for the following: (1) the effectiveness of MRI in identifying underlying etiologies, (2) clinical predictors of MRI abnormalities, and (3) MRI protocols. Seventeen studies (n = 1209) were included. Among 753 infants who underwent MRI, 438 (58.2%) had abnormal findings. Despite heterogeneity in MRI protocols and reporting, the evidence supports the utility of MRI in this population. Specific clinical features (focal seizure semiology, abnormal neurological examination, seizure duration > 5 min, focal electroencephalographic abnormalities, developmental delay, and perinatal complications) were associated with abnormal MRI findings, although methodological limitations reduce certainty. Only six studies provided data on MRI sequences; however, none reported findings specifically in relation to the diagnostic accuracy or yield of individual protocols, precluding the development of evidence-based recommendations on MRI protocol selection. MRI is conditionally recommended in all infants with a first afebrile seizure or new onset epilepsy. MRI could be prioritized in those with specific clinical features indicative of higher likelihood of abnormal findings. Recommendations are based on very low certainty of evidence. These are the first ILAE-endorsed, evidence-based recommendations for MRI in infants with first afebrile seizure or new onset epilepsy. Further prospective studies with standardized protocols are needed to refine MRI indications and optimize diagnostic yield in this age group.