Diagnostic accuracy of neuroimaging in children with first-time afebrile seizures presenting to the emergency department: a systematic review

Background: Neuroimaging after a first afebrile seizure addresses urgent intracranial disease and longer term etiological diagnosis. These objectives require distinct outcome definitions and our review examined imaging yield, urgent findings, and reported diagnostic performance in children presenting to emergency care. Methods: Original articles available through 31 Jan 2026 were examined. Computed tomography and magnetic resonance imaging findings were classified by clinical relevance and urgency. Study populations, imaging denominators, additional magnetic resonance findings, and clinical prediction measures were synthesized narratively, with attention to selection and incomplete diagnostic verification. Results: Ten original articles described heterogeneous pediatric emergency and acute care populations. In a multicenter prospective cohort, clinically relevant abnormalities occurred in 40 of 354 imaged children, including three urgent findings. A focal seizure cohort identified urgent abnormalities in 13 of 319 children. In an infant cohort, computed tomography findings required acute management in 27 of 298 examinations. MRI identified additional abnormalities following normal computed tomography, although immediate management changed infrequently. One recent clinical rule achieved 100% sensitivity and 39.7% specificity for emergent magnetic resonance findings. These estimates described clinical risk stratification rather than imaging accuracy. Conclusion: Imaging urgency depended on neurological examination, seizure characteristics, developmental history, and population selection. MRI contributed additional structural diagnoses. The available reports supported differentiated imaging pathways without establishing pooled sensitivity or specificity for either imaging modality.