Background <p>Seizures are among the most frequent neurological emergencies in paediatric populations, often requiring comprehensive diagnostic approaches that include Electroencephalography (EEG) and Magnetic Resonance Imaging (MRI). While EEG captures the brain’s electrical activity, MRI is critical for identifying structural abnormalities underlying seizures. The necessity of repeat MRI imaging, particularly after negative initial findings, remains uncertain. This study investigates the correlation between repeat MRI findings and EEG abnormalities, focusing on their combined role in guiding clinical management of paediatric seizures.</p> Methods <p>This retrospective cohort study included paediatric patients aged 1 month to 16 years with a clinical diagnosis of seizures who underwent MRI imaging at University Hospital Limerick between January 2022 and January 2024. Data collected included patient demographics, seizure types, initial and repeat MRI findings, and EEG results. Repeat MRI findings were analysed for new abnormalities, while correlations between MRI abnormalities and EEG findings were evaluated. Statistical analyses included Pearson correlation, chi-square tests, and logistic regression to identify predictors of abnormal repeat MRI findings.</p> Results <p>Among 260 patients, 28 (10.8%) underwent repeat MRI imaging. Of these, 18 (64.3%) showed new abnormalities, including cortical dysplasia, gliosis, and hippocampal sclerosis. Generalized tonic-clonic seizures were most frequently associated with abnormal repeat findings. There was a significant correlation between abnormal EEG findings and positive repeat MRI results (p &lt; 0.05), indicating that EEG abnormalities are predictive of structural changes detectable on repeat MRI. No significant correlations were found between initial MRI results and seizure type, age, or initial EEG findings. The average time interval between initial and repeat MRI was 537 days.</p> Conclusions <p>Repeat MRI is a valuable diagnostic tool in paediatric seizure management, particularly in patients with generalized tonic-clonic seizures and abnormal EEG findings. Abnormal repeat imaging findings frequently revealed new structural abnormalities, highlighting the importance of repeat MRI in cases with persistent clinical or EEG abnormalities. These results underscore the utility of combining EEG and MRI to optimize diagnostic accuracy and guide treatment decisions. Future studies are needed to establish standardized criteria for the timing and indications of repeat MRI in pediatric seizure care.</p>