Stepwise Diagnostic Evaluation in Pediatric Epilepsy: Clinical and EEG Predictors of MRI Positivity and Diagnostic Reclassification
Objective: This study aimed to evaluate the predictive value of clinical and electroencephalographic (EEG) findings for identifying epileptogenic structural lesions on cranial magnetic resonance imaging (MRI) in pediatric epilepsy, and to assess the contribution of MRI to diagnostic reclassification.
Methods: A total of 207 pediatric patients with a confirmed diagnosis of epilepsy were retrospectively analyzed. The diagnostic workflow was evaluated through a stepwise model integrating clinical assessment, EEG, and MRI. The primary endpoints comprised the MRI positivity rate, defined by the detection of epileptogenic structural lesions, and the diagnostic reclassification rate, defined as any modification in epilepsy type classification or etiological category following the incorporation of EEG and/or MRI findings. Independent predictors of MRI positivity were identified using multivariable logistic regression analysis.
Results: Epileptogenic structural lesions were identified in 9.7% of patients. Despite a relatively modest MRI positivity rate, imaging significantly contributed to diagnostic refinement. Among cases with normal EEG findings, MRI revealed structural pathology in 12%. The overall diagnostic reclassification rate following the addition of MRI was 9.7%. In multivariable analysis, focal-onset seizures (OR=2.63), developmental delay (OR=2.91), abnormal neurological examination (OR=3.08), and focal epileptiform EEG activity (OR=2.47) emerged as independent predictors of MRI positivity (all P<0.05). Agreement between EEG and MRI lateralization was moderate (κ=0.60).
Conclusion: In pediatric epilepsy, MRI may substantially contribute to etiological classification, particularly in the presence of high-risk clinical and electrophysiological features. These findings support the implementation of a risk-stratified, stepwise diagnostic approach to optimize clinical management.
1. Manokaran RK, Sharma S, Ramachandrannair R. The 2022 International League Against Epilepsy Classification and Definition of Childhood Epilepsy Syndromes: An Update for Pediatricians. Indian Pediatr. 2024;61(2):179-183.
2. Menon RN, Cross JH. Childhood epilepsy. Lancet. 2025;406(10503):636-649. doi: 10.1016/S0140-6736(25)00773-1.
3. Schulze-Bonhage A, Bruno E, Brandt A, et al. Diagnostic yield and limitations of in-hospital documentation in patients with epilepsy. Epilepsia. 2023;64 Suppl 4:S4-S11. doi: 10.1111/epi.17307.
4. Dirican AC, Mutluay B, Eren F, Atakli HD. Importance of Long-term EEG in Seizure-free Patients with Normal Routine EEG. Arch Epilepsy. 2023;29(3):91-95. doi: 10.4274/ArchEpilepsy.2023.23078.
5. Passaro EA. Neuroimaging in Adults and Children With Epilepsy. Continuum (Minneap Minn). 2023;29(1):104-155. doi: 10.1212/CON.0000000000001242.
6. Stern T, Kornreich L, Goldberg H. Yield of Brain Magnetic Resonance Imaging in Epilepsy Diagnosis from 1998 to 2020: A Large Retrospective Cohort Study. Neuropediatrics. 2022;53(1):15-19. doi: 10.1055/s-0041-1732325.
7. Moussa B, Nasreddine W, Abboodi H, et al. The diagnostic value of semiology, EEG and MRI in new-onset pediatric bilateral tonic-clonic seizures: A multimodal analysis. Epilepsia Open. 2026;11(1):259-269. doi: 10.1002/epi4.70203.
8. Senger KPS, Kesavadas C. Imaging in pediatric epilepsy. Semin Roentgenol. 2023;58(1):28-46. doi: 10.1053/j.ro.2022.11.002.
9. Beniczky S, Trinka E, Wirrell E, et al. Updated classification of epileptic seizures: Position paper of the International League Against Epilepsy. Epilepsia. 2025;66(6):1804-1823. doi: 10.1111/epi.18338.
10. Shaikh Z, Torres A, Takeoka M. Neuroimaging in pediatric epilepsy. Brain Sci. 2019;9(8):190. doi: 10.3390/brainsci9080190.
11. Lee YJ, Bae H, Byun JC, Kwon S, Oh SS, Kim S. Clinical Usefulness of Simultaneous Electroencephalography and Functional Magnetic Resonance Imaging in Children With Focal Epilepsy. J Clin Neurol. 2022 Sep;18(5):535-546. doi: 10.3988/jcn.2022.18.5.535.
12. Lemoine É, Toffa D, Xu AQ, et al. Improving diagnostic accuracy of routine EEG for epilepsy using deep learning. Brain Commun. 2025;7(5):fcaf319. doi: 10.1093/braincomms/fcaf319.
13. Pastore LV, De Vita E, Sudhakar SV, et al. Advances in magnetic resonance imaging for the assessment of paediatric focal epilepsy: A narrative review. Transl Pediatr. 2024;13(9):1617-1633. doi: 10.21037/tp-24-166.
14. Pedersen C, Aboian M, Messina SA, Daldrup-Link H, Franceschi AM. PET/MRI Applications in Pediatric Epilepsy. World J Nucl Med. 2023;22(2):78-86. doi: 10.1055/s-0043-1764303.
15. Drenthen GS, Jansen JFA, Gommer E, et al. Predictive value of functional MRI and EEG in epilepsy diagnosis after a first seizure. Epilepsy Behav. 2021;115:107651. doi: 10.1016/j.yebeh.2020.107651.
16. Gill RS, Deleo F, Bernhardt B, Wiebe S, Bernasconi N, Bernasconi A. MRI-negative epilepsy: A systematic review and meta-analysis. Epilepsia. 2025;66(12):4939-4949. doi: 10.1111/epi.18616.
Copyright (c) 2026 The European Research Journal
This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.
Downloads
Article Information
- Article Type Research Article
- Submitted March 5, 2026
- Accepted May 10, 2026
- Published May 14, 2026
- Issue 2026: Online First
- Section Research Article
- Categories
