2.5 yr old focal febrile fit 2nd episode

Complex febrile seizures — Complex febrile seizures (focal onset, prolonged, or recurrent within 24 hours) are less prevalent, making up approximately 20 percent of febrile seizures in most series. Prolonged seizures occur in less than 10 percent and focal features in less than 5 percent of children with febrile seizures. An initial simple febrile seizure may be followed by complex seizures, but the majority of children who develop complex febrile seizures do so with their first seizure. However, an initial complex febrile seizure does not necessarily indicate that all subsequent seizures will be complex.

Transient hemiparesis following a febrile seizure (Todd paresis), usually of complex or focal type, is rare, occurring in 0.4 to 2 percent of cases [9,55].
Children with complex febrile seizures are often younger and more likely to have abnormal development. In one study of 158 children with a first febrile seizure, prolonged seizures (>10 minutes) occurred in 18 percent and were associated with developmental delay and younger age at first seizure [7].

Neuroimaging — Neuroimaging with computed tomography (CT) or MRI is not required for children with simple febrile seizures [3,84,92]. The incidence of intracranial pathology in children presenting with complex febrile seizures also appears to be very low [60,93]. Urgent neuroimaging (CT with contrast or MRI) should be done in children with abnormally large heads, a persistently abnormal neurologic examination, particularly with focal features, or signs and symptoms of increased intracranial pressure [84,92,93].

While not necessary in the emergent setting, high-resolution MRI is often obtained in the outpatient setting in children with focal or prolonged febrile seizures, particularly those with a history of abnormal development, since these children have a higher risk of developing afebrile seizures [94].

Electroencephalography — Routine EEG is not warranted, particularly in the setting of a neurologically healthy child with a simple febrile seizure [3,4].

In children with complex febrile seizures, the need for an EEG depends on several factors and clinical judgement. A short, generalized seizure repeated twice in 24 hours is, by definition, complex but would not necessitate an EEG unless the neurologic examination were abnormal. A prolonged seizure, or one that has focal features, warrants an EEG and neurologic follow-up since the risk of future epilepsy (repeated afebrile seizures) is higher. The optimal timing of EEG is not well defined, but a study utilizing recordings performed within 72 hours of FSE suggest this may be a useful timeframe for prognostic purposes