In neonatal seizures, which imaging modality is preferred for evaluation in the first hours, and when is CT used?

• A. MRI is preferred; CT used if hemorrhage suspected
• B. CT is preferred; MRI used later
• C. Ultrasound is preferred; MRI also used
• D. X-ray is preferred; CT for abdominal bleed

Answer: (A)

In neonates with seizures, the initial imaging goal is to detect early brain injury with the most sensitive modality. MRI is preferred in the first hours because diffusion-weighted imaging can pick up acute hypoxic-ischemic injury and it provides detailed assessment of cortical and white-matter involvement, giving a clearer picture of injury extent and pattern than CT. CT is reserved for situations where there is concern for hemorrhage or when a rapid assessment is needed and MRI is not feasible—because CT excels at identifying acute intraparenchymal or intraventricular hemorrhage, it serves as a fast, targeted tool in those scenarios. Ultrasound can be useful at the bedside for a quick screen, but MRI remains the better option for a comprehensive early evaluation.