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NeuroimaginginEpilepsy:Overview,EpilepsyProtocolMRI,EvaluationofaFirstSeizure

Thissiteisintendedforhealthcareprofessionals

NeuroimaginginEpilepsy
Updated:Oct22,2015
Author:ErasmoAPassaro,MD,FAANChiefEditor:SelimRBenbadis,MDmore...

OVERVIEW

Overview
Althoughtheyarenotuniversallyavailable,functionalneuroimagingtechniques,includingpositron
emissiontomography(PET)scanning,singlephotonemissioncomputerizedtomography(SPECT)
scanning,magneticresonancespectroscopy(MRS),magneticsourceimaging(MSI),andfunctional
magneticresonanceimaging(fMRI),canbeveryhelpfulinthelocalizationoftheepileptogeniczone
andformappingfunctionalareasofthebrain,suchasthoseforlanguageandmotorfunction.[1](See
theimagebelow.)

SpoiledgradientrecallMRIshowingrighthippocampalatrophy.

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Theclinicaluseofeachoftheaboveimagingmodalitiesinpatientswithepilepsyisreviewedinthis
article,withanemphasisonMRIstructuralimaging.
Formoreinformation,seethefollowing:
EpilepsyandSeizures
EpilepsySurgery
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EEGinCommonEpilepsySyndromes
EEGinStatusEpilepticus
GeneralizedEpilepsiesonEEG
LocalizationRelatedEpilepsiesonEEG

EpilepsyProtocolMRI
Theimagingofepilepsyhasvastlychangedsincetheendofthe20thcentury.Priorimagingwith
computedtomography(CT)scanninginfrequentlyrevealedthepathologicsubstrateforepilepsy.
Althoughearlylowfieldstrengthmagneticresonanceimaging(MRI)increasedthediagnosticyield,it
couldidentifyonlyobviouspathology,suchasneoplasms,encephalomalacia,andvascular
malformations.
TheadventofhighresolutionMRIwithadedicatedepilepsyprotocolhassignificantlyincreasedthe
frequencywithwhichpathologicsubstratesforepilepsyareidentified.Thishashadadramaticclinical
impactontheevaluationandmanagementofepilepsy,becauseMRIfindingscanassistwith
classification,determineprognosisforremission,predictlongtermintractabilitytoantiepileptic
medications,andidentifypotentialsurgicalcandidates.
TheInternationalLeagueAgainstEpilepsy(ILAE)guidelinesforneuroimaginginpatientswith
epilepsy(1997)recommendsadedicatedepilepsyprotocolMRIforallpatientswithanewonset
seizureornewlydiagnosedepilepsyinanonemergentsetting.[2]Inaddition,theILAECommission
onNeuroimagingrecommendsanepilepsyprotocolMRIinallpatientswithintractableepilepsy.

ConventionalversusepilepsyprotocolMRI
ConventionalMRIisinadequateforpatientswithepilepsy,sincemanyofthefindingsaresubtleand
easilymissed.RoutineMRIconsistsofashortscantime,3to5mmthicksliceswithaninterslicegap
of23mm.Thesestudiesdonotincludespoiledgradientrecalled(SPGR)ormagnetizationprepared
rapidgradientecho(MPRAGE),T1weightedimagesthatenhancegray/whitematterdifferentiation,
whichiscrucialtotheanalysisofcorticalarchitecture.
Theseimagesarealsonotacquiredinacoronalobliqueplaneperpendiculartothelongaxisofthe
hippocampus,whichisparticularlyimportantwhenevaluatingtemporallobeepilepsy(TLE).
EpilepsyprotocolMRIat1.5Tor3.0T,ontheotherhand,includestheentirebrainfromnasionto
inion,T1weightedMPRAGEorSPGRimages1.5mmslicethicknesswithnointerveninggap
obtainedinthecoronalobliqueplane(ifTLEissuspected).Theseimagesareacquiredasa3
dimensional(3D)volume,therebyallowingpostprocessingtocorrectforheadmisalignmentandfor
reformattingimagesintomultipleplanestoconfirmasubtleMCD.
AnepilepsyprotocolMRIalsoincludescoronalandaxialfluidattenuatedinversionrecovery(FLAIR)
sequenceswitha2to3mmslicethicknessanda0to1mminterslicegap.Aconventionalthinslice
(3mm),T2weighted,axialandcoronalsequenceisalsoobtained.
Gadoliniumisnotrequiredunlessapatienthasnewonsetepilepsyorifaknowntumororvascular
malformationisidentified.Gadoliniumisalsousedifcertainneurocutaneoussyndromes,suchas
SturgeWebersyndrome,arepresent,tovisualizeleptomeningealangiomatosis.

BenefitsofepilepsyprotocolMRI
Unfortunately,inmostclinicalpracticesettings,anonepilepsyprotocolMRIisperformed.Whilea
routineMRIexcludesominousstructuralsubstratesthatrequireurgenttreatment,suchashighgrade
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gliomasandarteriovenousmalformations,subtlestructuralsubstrates,suchashippocampalsclerosis
andmalformationsofcorticaldevelopment(MCDs),aremissed.Identificationofthesesubstrateshas
longtermtherapeuticandprognosticimplicationsforremissionversusintractability.
Approximatelyonethirdofpatientswithfocalonsetepilepsyaremedicallyintractable(definedas
failingatleast2firstlineantiepilepticdrugs[AEDs]).Thechanceofbeingconsideredacandidatefor
epilepsysurgeryisgreatlyenhancedwhenastructuralsubstrateisfoundonMRI.[3,4]
Inacrosssectionalstudy,inpatientswithfocalepilepsywhohadastandardMRIscan,an
abnormalitywasfoundin49%,andinpatientswhohadanepilepsyprotocolMRIscan,an
abnormalitywasfoundin72%.[5]Similarfindingsoccurredinanearlierstudy,byLietal.[6]
Inanotherstudy,usingradiologistsconsideredexpertininterpretingepilepsyfindings,focallesion
sensitivityforstandardMRIwas50%,comparedwithasensitivityof91%forepilepsyprotocolMRI.[7]
AstudybyKwanandBrodiein2000foundthatinpatientswithnewlydiagnosedepilepsy,only47%
becameseizurefreewiththefirstAEDandonly14%withthesecondAED.[8]FurtherAEDtrials
achievedseizurefreedominonly5%ofpatients.Thisstudyshowedthatintractableepilepsyismore
commonthangenerallybelievedandcanbeidentifiedearly.However,referralforepilepsysurgeryis
delayedinhalfofpatientswithintractableepilepsywhoarereferredmorethan10yearsfromthe
onsetofintractability.
ThisstudyfurtherunderscorestheimportanceofepilepsyprotocolMRI,whichhasahighyieldfor
identifyingastructuralsubstratethatwouldenablethesepatientstobereferredearlyforanepilepsy
surgeryevaluation,thusprovidingthemwithanoptimalchanceofattainingseizurefreedom.

EvaluationofaFirstSeizure
Theauthor'spracticeisthatallpatientspresentingwithafirstseizureinadulthoodshouldbe
evaluatedwithhighresolutionepilepsyprotocolMRI.Inonestudyof300consecutivepatients
presentingwithafirstseizure,anepileptogeniclesionwasidentifiedbyMRIin14%.[9]Inanother
study,MRIdetectedetiologicallyrelevantstructuralabnormalitiesin12.7%.[10]Thus,eveninpatients
withasingleseizure,asignificantnumberofpatientshadanabnormalMRIthatcorrelatedwiththeir
epilepsy.
Inintractableepilepsy,ontheotherhand,MRIidentifiesthepathologicsubstratein8286%of
patients.ChildrenpresentingwithfocalseizuresalsoshouldbeevaluatedbyMRIscanning.Children
oradultswithclinicallyevidentidiopathicgeneralizedepilepsies(eg,childhoodabsenceepilepsy,
juvenilemyoclonicepilepsy)probablycanforgoMRIscanning,althoughinclinicalpractice,being
confidentofthediagnosisatthetimeofpresentationisoftendifficult.ThepresenceofMRI
abnormalitiesinpatientswithnewonsetepilepsyispredictiveofseizurerecurrenceandalsopredicts
lackofseizurecontrolwithmedicaltherapy.
Mostimportantly,MRIscanninginthissettingdetectsabnormalities,suchasbraintumors,
arteriovenousmalformations,orcryptogenicinfarctions,thatmayrequirefurtherdiagnosticand
therapeuticinterventionstopreventneurologicdeterioration.CTscanningisusedwidelyinpatients
presentingwithafirstseizure,usuallybecauseitismorereadilyavailablethanMRIinmost
emergencydepartments.However,patientsshouldbereferredforanepilepsyprotocolMRIscanning
asanoutpatient.

MRIoftheTemporalLobe
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Hippocampalsclerosis
Hippocampalsclerosis(HS)ischaracterizedbyneuronallossandgliosis.HSisthemostcommon
pathologicsubstrateofsurgicallytreatedepilepsyinadultsandisseenin67%ofpatients.Inpatients
withnewlydiagnosedepilepsy,ithasbeenreportedin1.53%ofadults.Whenevaluatingthemedial
temporalstructures(hippocampus,amygdala,entorhinalcortex,andparahippocampalgyrus),one
shouldevaluatethesize,signal,shape,anddualpathology(SSSD).
ThetypicalMRIfindingsofHSincludeatrophyofthehippocampusonT1weightedSPGR(typically
seenin9095%ofcases).Theatrophyismostprominentinthehippocampalbody.
OnFLAIRimaging,increasedsignalisobservedinthehippocampus(seetheimagebelow).FLAIRis
ideallysuitedtoidentifysignalchangesinthehippocampus,sinceglioticchangeshaveincreased
watercontentappearingasincreasedsignalonT2weightedMRI.TheFLAIRsequencenullsthe
increasedsignalintensityofthecerebrospinalfluid(CSF)inthetemporalhornofthelateralventricle
andthechoroidalfissurethatcandwarftheincreasedsignalinthehippocampusonaconventional
thinsliceT2weightedspinechoimage.

Fluidattenuatedinversionrecovery(FLAIR)MRIshowingincreasedsignalwithinthelefthippocampus.

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ThebaselinesignalofthehippocampusonFLAIRMRIisgreaterthanthatofthecortexandcanbe
mistakenlyinterpretedasbilateralHS.Inthesecases,thinslicecoronalT2weightedimagesshould
bereviewedforconfirmation.
Hippocampalatrophyandincreasedsignalarenotalwaysseentogetherinthesamepatient.For
example,somepatientshaveanincreasedFLAIRorT2signalwithoutaccompanyingatrophy.The
increasedT2signalisfelttoreflectgliosisratherthanneuronalcellloss.Occasionally,secondary
findingsofhippocampalsclerosisareobserved,suchas(1)enlargementoftheipsilateraltemporal
horn,(2)thinningofthefornix,(3)mamillarybodyatrophy,(4)lossofnormalinterdigitationsofthe
hippocampalhead,and(5)atrophyofthecollateralwhitematterbetweenthehippocampusandthe
collateralsulcus.
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HighresolutionMRIis8090%sensitiveforidentifyinghippocampalsclerosisbyqualitative
interpretation.Bilateralhippocampalatrophyisseenin1020%ofpatients,butitmaybedifficultto
visualizeunlessquantitativemeasuresaredone.
Inchildren,HSisobservedin21%ofpatientswithnewlydiagnosedTLEandinupto57%ofpatients
withintractableTLE.MorecommonfindingsinchildrenwithintractableTLEincludeMCDsand
developmentaltumors.

Hippocampalsclerosisanddualpathology
Approximately1520%ofpatientswithHShavedualpathology,thatis,anotherpathologicsubstrate
withinoroutsidethetemporallobeinadditiontoHS.
Dualpathologyismorecommonlyobservedwithmalformationsofcorticaldevelopmentand
developmentallesions,suchasporencephaly.Itislesscommonlyseenwithvascularmalformations
(7%)andneoplasms(2%).Withvascularmalformations,HSismorelikelytobepresentifthelesionis
incloseproximitytothehippocampus.

Pitfallsintheevaluationofhippocampalsclerosis
OnemustalsobevigilantnottoattributeallcasesofincreasedsignalwithinthehippocampustoHS.
WhileincreasedsignalonFLAIRindicativeofHSisnotalwaysaccompaniedbyhippocampalatrophy,
thehippocampusshouldneverbeabnormallyenlarged,sincethisindicatesalowgradeneoplasm,
hamartoma,orhippocampaldysplasiaandnotHS.

Entorhinalcortexatrophy
Whilequantitativeassessmentoftheentorhinalcortex(ERC)isideal,ERCsizecanbeevaluatedby
visualassessment.ERCatrophyisoftenseenconcomitantlywithhippocampalatrophy,butitcanalso
beseenindependently.ItischaracterizedbythinningERCgraymatterandtheunderlyingcollateral
whitematter.

Amygdalaatrophyanddysplasia
Theamygdalashouldbeevaluatedforsymmetry.Occasionally,theamygdalamaybereducedinsize
alongwithhippocampalatrophy.However,thisisdifficulttoobservevisually.Amygdalaatrophy
accompanyingHShasbeenidentifiedwithvolumetricanalysisin12%ofpathologicallyconfirmed
patientswithHS.AnotherstudyidentifiedipsilateralamygdalaatrophybyvolumetryaccompaniedHS
in20%ofpatients.However,itwasalsofoundthatamygdalaatrophywascontralateraltoHSin15%
ofpatients.
Sometimes,theamygdalaispathologicallyenlargedconsistentwithamygdaladysplasia,hamartoma,
oralowgradeneoplasm.Thisenlargementmayormaynotbeassociatedwithincreasedsignalon
FLAIRMRI.Usually,inthesettingofalowgradegliomaoradevelopmentaltumor,accompanyingT2
signalchangesarepresent.
Amygdalaenlargementisnotassociatedwithhippocampalatrophyandisseeninimagingnegative
TLE.However,sometimesamygdalaenlargementisaccompaniedbyhippocampalenlargementand
likelyrepresentshamartomatousenlargementofthehippocampusandtheamygdala.
Viewingtheimagesintheaxialplanemayalsoincreasetheyieldofidentifyingenlargementofthe
amygdala.Onegrouprecommendedthatabnormalamygdalarenlargementcanbevisuallyassessed
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byevaluatingforprominentamygdalagraymatterextendingmedially,anteriortothesylvianfissure.
[11]

ClassificationofMalformationsofCorticalDevelopment
MCDsareclassifiedintothefollowing3categoriesbasedonthestagetheMCDoccurred:
CorticaldysplasiaNeuronalandglialproliferationorapoptosis<10wk
HeterotopiasAbnormalneuronalmigration1020wk
PolymicrogyriaAbnormallatecorticalmigrationandorganization>20wk
Somedegreeofcorticalorganizationalsooccurspostnatally.[12]

MRIofMalformationsofCorticalDevelopment
Malformationsduetoabnormalneuronalandglialproliferationorapoptosis
Microlissencephalyandmicrocephalywithsimplifiedgyralpatternhasbeendescribedinpatientswith
profoundcongenitalmicrocephaly(headcircumferencethatismorethan3standarddeviationsbelow
normalatbirth).Theseconditionsarefelttoresultfromabnormallydecreasedcellularproliferationor
pathologicallyincreasedapoptosis.Thesulcalpatternissimilartothesulcalpatterninhealthy
patientshowever,therearetoofewsulci.Ifthecortexisofnormalthickness(3mm),adiagnosisof
microcephalywithsimplifiedgyralpatterncanbemade.Ifthecortexisabnormallythick,thena
diagnosisofmicrolissencephalyismade.
Hemimegalencephalyischaracterizedbyabnormalenlargementofalobe,multiplelobes,ora
hemisphereduetomarkeddysplasia.Thisconditioncanbeanisolatedfindingorcanbeseenwith
neurocutaneoussyndromessuchas(1)epidermalnevussyndrome,(2)hypomelanosisofIto,(3)
neurofibromatosistype1,(4)KlippelTrenaunayWebersyndrome,or(5)tuberoussclerosis.Imaging
findingsincludelargeclumpsofgraymatterthatextendfromthepialsurfacetotheventricle.The
affectedlobeorhemisphereisenlarged,thewhitemattershowsincreasedsignalonT2weighted
images,andusuallythelateralventricleisenlargedinthedysplasticregion.

Corticaldysplasias
Palminietaldescribedaconsensuspanelontheterminologyofcorticaldysplasiasbasedon
histopathologic,clinical,andimagingfindings.[13]Corticaldysplasiasareseparatedintominor
malformationsofcorticaldevelopment(mMCDs)andmoreseverefocalcorticaldysplasias(FCDs).
(Seetheimagebelow.)[14]

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Corticaldysplasiainthelingualgyrusextendinganteriorlyintotheposteriorparahippocampalgyrus.Notethe
thickenedcortexandthelossofthegraywhitematterinterfaceascomparedtothecontralateralside.

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ThemMCDsconsistofderangementsoffocalcorticalarchitecture,withtype1mMCDlesions
representingectopicneuronsinvolvingoradjacenttocorticallayer1andtypeIImMCDsrepresenting
microscopicneuronalheterotopiasoutsidelayer1.
FCDsaredividedintothosewithoutdysmorphicneuronsorballooncells(type1)andthosewith
dysmorphicneurons(type2).Type1FCDsarefurtherdividedintothosewitharchitectural
abnormalitiesonly(type1A)andthosewithgiantorimmature(butnotdysplastic)neurons(type1B).
Type2FCDclassificationisbasedontheabsence(type2A)orpresence(type2B)ofballooncells.
[13]

ThemMCDsareusuallynotidentifiableonepilepsyprotocolMRI,buttheycansometimesbeseenat
3TMRIwithphasearraycoils.[15]Type2BFCDsarenearlyidenticalonMRItothoseseenin
tuberoussclerosis.
FCDs,particularlythetype2variety,aremorelikelytobevisualizedonMRI.Ofallmalformationsof
corticaldevelopment,FCDsarethemostlikelytobeamenabletosurgicalresection.Sometimes,the
corticaldysplasiaextendsfromthepiatotheventricle(transmantledysplasia).
MRIfindingsinpatientswithFCDincludethefollowing:
Corticalthickeningobservedonatleast3ormorecontiguousslices
Blurringofthegraywhitematterjunction
IncreasedsignaloftheunderlyingwhitematteronT2weightedimage/FLAIR
Often,alinear,curvilinear,orfunnelshapedtaperingofabnormalsignalintensityextendingfrom
thecorticalwhitematterjunctiontotheependymalsurfaceofthelateralventricle
Adeeporwidesulcus,withthickenedgraymatteratthedepthofasulcus
Broadeningofagyrus

Malformationduetoabnormalneuronalmigration
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Classiclissencephaly(smoothbrain)isdefinedasreducedsulcation,andthecorticalsurfaceshows
reducednumberanddepthofsulci.Insomecases,thereiscompleteabsenceofsulcationinothers,
thereisareductionofsulcation.
ThisconditionisduetoamutationofeithertheLIS1geneatchromosome17p13.3ortheDCXgene
atXq22.Bothmutationsarebelievedtocauselissencephalybyinterferingwithtranslocationof
migratingneuronsastheyadvancealongradialglialcells.WiththeLIS1mutation,theabnormalityis
mostsevereintheparietooccipitallobes,andwiththeDCXmutation,thegyralabnormalityismost
severeinthemiddleandanteriorhalfofthefrontallobes.
Heterotopiareferstoacollectionofneuronsinanabnormallocation.Theneuronscanbelocatedin
thesubcorticalwhitematterorinthesubependymalregion(periventricular),ortheycanbeunderlying
thenormalappearingcortexinalaminarpattern(SBH).Thecollectionsofcellsexistasroundto
ovoidnodulesthatconsistofneuronalandglialcells.OnMRI,theyaregraymatterisointenseonT1
andT2weightedimaging.
Subcorticalheterotopiascanrangefromsingletomultiplegraymatternodulesthatmayextendfrom
theventricularwalltothecorticalmantle.Occasionally,theremaybedimplingofthecortexoverlying
theregionoftheheterotopia.Theyareusuallyunilateralbutcanbebilateral,inwhichcasetheyare
associatedwithcognitivedelay.
Subcorticalbandheterotopia(SBH)representsamilderformoftheLIS1orDCXmutation.OnMRI,
eitherathickorathinbandofcortexisseeninthewhitematterunderlyingandrunningparalleltothe
normalappearingcortex.
IftheSBHismainlyfrontal,theDCXmutationisthelikelycause,whereasifitisobservedinthe
parietooccipitalregion,theLIS1mutationismorelikely.Othermutationshavealsobeendescribed,
andthereaderisreferredtoareviewbyBarkovich.[16]
SBHcaneasilybemissedwhenitconsistsofathinbandofcortex.Clinically,someofthesepatients
appeartohavelocalizationrelatedepilepsyfromanotherregion.However,surgicaloutcomeinthis
groupispoor,sincetheSBHisamarkerofdiffuseepileptogenicity.
Periventricularnodularheterotopias(PVNs)aremostcommonlyseeninthelateralventricles,withthe
trigonesandthefrontalhornsbeingthemostfrequentlocations.PVNsareroundorovalandcanliein
thewalloftheventricleandprotrudeintotheventricularspaceorsometimesarepresentinthe
periventricularwhitematter.
InmildcasesofPVN,onlyafewnodulesareseen,whereas,inmoreseverecases,acontinuous
layercanbeseenliningtheventricularwall.ThesenodulesaregraymatterisointenseonallMRI
sequences.Whilemanycasesaresporadic,somecasesareduetoamutationoftheFLNAgenethat
codesforfilamin1,whichisinvolvedinthemigrationoftheneuronfromthegerminalzoneontothe
radialglialfibers,andislocatedonbandXq28.
IdentificationofPVNsisclinicallyimportant,becauseseizurefreeoutcomeafteranteromedial
temporalispoorinpatientswithPVNswithclinicalandEEGfeaturesofTLE.Thereasonforthisis
thatthesenodulesareepileptogenicsmallserieshavedemonstratedthatagoodsurgicaloutcome
canbeobtainedwhenthePVNsareunilateralandseizureslocalizetothenodule(s)andare
resected.

Malformationssecondarytoabnormallatemigrationandorganization
Polymicrogyria(PMG)consistsofanexcessivenumberofsmallgyriwithshallowsulci.PMGcanbe
(1)focalandlimited,(2)focalunilateralandextensive,(3)bilateralandsymmetrical,(4)bilateraland
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asymmetrical,(5)multifocal,or(6)diffuse.OnMRI,numeroussmallgyriwithshallowsulciareseen.
Sometimes,thecortexhasanirregular,bumpyinnerandoutercorticalsurfacewithbroadgyriand
shallowsulci.Thecorticalsubcorticaljunctionisoftenirregular.
SchizencephalyconsistsofaCSFcleftextendingfromthesubarachnoidspacetothelateralventricle.
Thewallofthecleftislinedwithdysplasticcortexand/orpolymicrogyria.Thelipsofthecleftcanbe
closed(type1)oropen(type2).Themostcommonlocationisposteriorperisylviancortex.Twothirds
ofcasesareunilateral,andonethirdofcasesarebilateral.Schizencephalyiscommonlyassociated
withpolymicrogyria,opticnervehypoplasia,andabsenceoftheseptumpellucidum.AlthoughPMG
andschizencephalyarestrikinglyabnormalonMRI,theyoftencontainprimarymotor,sensory,or
visualfunction.
Focalcorticaldysplasia(FCD)withoutballooncellsconsistsofafocalabnormalityofcortical
laminationofthecerebralcortexandtheunderlyingwhitematterwithabnormalcorticalneuronsbut
withoutthepresenceofballooncellsorcellsextendingfromthepialsurfacetotheventricularsurface.
MRIfindingsincludecorticalthickeningon3ormorecontiguousslices,blurringofthegraywhite
matterjunction,andfocalcorticalthinningwithvolumelossoftheunderlyingwhitematter.An
increasedsignalonT2weightedimagingmaybeseenhowever,thesignaldoesnotextendtothe
ventricularsurface.
Anoccasionalhelpfulfindingisthe"cleftdimple"complex,inwhichthesizeofthesubarachnoid
spaceoverlyingtheFCDisenlargedandthecortexappearstobuckleawayfromthesubarachnoid
space.Theneuroimagermustbeawarethatnormalcortexmayappearthickenedwhensliced
obliquelycrossasulcus.Inthisregard,itisimperativetomakesurethatthefindingsseenon
numerouscontiguousslicesarestillpresentwhenreformattedintomultipleplanesandcorrelatedwith
clinical,EEG,andfunctionalimagingdata.OnemustalsobeawarethatthemildestformsofFCD
characterizedbydyslaminationalonemaynotshowanyabnormalityevenonhighresolutionMRI.

MRIofNeoplasmsAssociatedWithEpilepsy
Neoplasmsarethestructuralsubstratein34%ofpatientswithepilepsyinthegeneralpopulation.In
patientswithintractableepilepsytreatedwithepilepsysurgery,neoplasmsaccountforapproximately
20%ofcases.Neoplasmsassociatedwithchronicepilepsyareusuallylocatedinthecortexandare
notusuallyassociatedwithmasseffectorvasogenicedema.Thetemporallobeisthemostcommon
location(68%).
Neoplasmsfoundinpatientswithchronicepilepsyinclude(1)lowgradeastrocytictumors,(2)
oligodendroglioma,(3)gangliogliomas,(4)dysembryoplasticneuroepithelialtumor(DNET),and(5)a
pleomorphicxanthoastrocytoma(PXA).
MostneoplasmsarehypointenseonT1weightedimagesandhyperintenseonT2weightedimages.
However,distinguishingtheseneoplasmsisoftendifficult,unlessspecificimagingcharacteristicsfor
eachtumorarepresentonMRI.
Astrocytomas,fibrillarysubtype(WorldHealthOrganization[WHO]grade2),areusuallyilldefined,
infiltrativetumorsthatusuallydonotenhancewithgadolinium.Pilocyticastrocytomas,ontheother
hand,arewelldefined,althoughnotencapsulated,andamuralnoduleisseenaftergadolinium
enhancement.
Oligodendrogliomasareusuallyperipherallylocatedandmayappearcorticallybasedwithgyriform
calcificationsandadjacentchangesinthecalvaria.Theyarecommonlyseeninthefrontalortemporal
lobe.Gadoliniumenhancementisvariable.

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Gangliogliomasaremostcommonlyseeninthetemporallobeofpatientsyoungerthanage30years.
Theyaremixedsolidandcysticlesionsthatarecorticallybased,withminimalornomasseffect.
Calcificationisoftenpresent.Gadoliniumenhancementisvariable.Thefindingofcalcificationand
cysticchangesinacorticallybasedlesionraisesthepossibilityofthisneoplasm.Theselesionscan
beassociatedwithconcomitantcorticaldysplasia.
Dysembryoplasticneuroepithelialtumors(DNET)arebenign,lowgrade,multicystic,andmultinodular
corticalbasedtumorsthatareseenprimarilyinchildrenandyoungadults.Acorticallybased
hypointensenodulecanbeseenonT1weightedimages.Calvarialremodelingmaybeseen.Cortical
dysplasiacanbeseenin2030%ofthesetumors.Gadoliniumenhancementisvariable.Ifacortically
based,multicystictumorisseenonMRI,aDNETshouldbeconsidered.
Pleomorphicxanthoastrocytomas(PXAs)aresuperficiallylocatedtumorsadjacenttothe
leptomeningeswithanenhancingmuralnodule.Leptomeningealinvolvementischaracteristicofthis
tumor.Localrecurrenceandmalignanttransformationcanoccurwiththistumorin50%ofpatients.

MRIofVascularMalformations
Vascularmalformationsconstitute5%ofepileptogenicsubstratesinthegeneralpopulationofpatients
withepilepsy.InsurgicallytreatedpatientswithTLE,vascularmalformationsconstituteapproximately
10%ofcases.Arteriovenousmalformations(AVM)andcavernousmalformationsarethemost
commonvascularmalformationscausingseizures.
AVMsconsistofatangleofbloodvesselslackinganinterveningcapillarynetwork,leadingtodirect
arteriovenousshuntingofblood.T1andT2weightedimagesdemonstrateserpiginousflowvoids
withareasofT2prolongationinadjacentbrain.Thehighvelocityflowmasksgadolinium
enhancement.
Cavernousmalformations(CMs)arecomposedofwellcircumscribedvascularspaceswithbloodin
varyingstagesofevolution.Acharacteristicfeatureistheabsenceofinterveningbraintissue.Most
CMsaresporadic,but1030%arefamilial.Anassociateddevelopmentalvenousanomalyisseenin
25%.
HemorrhageismorecommoninwomenwithCMs,aswellasinlesionswithanassociated
developmentalvenousanomaly.CMsareslowflowlesionsandarethereforeangiographicallyoccult.
FamilialcasesoftenhavemultipleCMs.
InCMimaging,hemosiderinresultsinmagneticsusceptibilityartifacts,whichappearasflowvoidson
MRI.Therefore,gradientechoimagesthatareaffectedbymagneticsusceptibilityarehighlysensitive
toidentifyoccultCM.Sincetheinternalbleedingisofdifferentages,theremaybeconversionfrom
hemoglobintomethemoglobin,whichproducesfociofhyperintensityonT1weightedimages.The
peripheralhemosiderinproducesT2shortening,causingablackhalotosurroundthelesion.
T2*gradientrecallecho(GRE)sequenceisexcellentforaugmentingtheappearanceofmagnetic
susceptibilityartifactthatisseenwithlesionsassociatedwithhemosiderin.Withthistechnique,focal
regionsofocculthypointensitycanbeidentified,indicatingregionsofremotetraumaorcavernous
malformations.Thistechniqueisessentialinpatientswithcavernousmalformations,sinceitcan
identifyotheroccult,cavernousmalformationsmanifestingastinycircularregionsofhypointensity.
Susceptibilityweightedimaging(SWI)isevenmoresensitivethanT2*GREinidentifyinglesionsthat
producemagneticsusceptibilityartifact.[17]Inthisregard,eitherT2*GREorSWI(ifavailable)mustbe
acomponentofanyepilepsyprotocolMRI.

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DiffusionTensorImaging
Diffusiontensorimaging(DTI)allowsinformationonthemagnitudeanddirectionofwaterdiffusionto
becollected.Theapparentdiffusioncoefficientmaprepresentsthemagnitudeofdiffusioninagiven
voxel.Thefractionalanisotropy(FA)mapreflectstheaveragedirectionalbiasofthediffusionina
givenvoxel.
FAisaratiowitharangeof0to1,with0representingnodirectionalbiasand1representingthe
theoreticallimitofalldiffusionin1direction.Inthewhitematter,diffusionisdirectionalitydetermined
primarilybythemyelinandthecellmembranesoftheaxons.Thus,byevaluatingthedirectionalbias
ofdiffusioninadjacentvoxels,thepathofwhitemattertractscanbeinferred.
Intheepilepsysurgeryevaluationprocess,DTIhelpstoidentifypotentiallyimportantwhitematter
tractswithfunctionalimplicationstohelpguideepilepsysurgeryresections.Inaddition,DTIcanbe
helpfulindetectingtheextentofwhitematterinvolvementbeyondareasofvisuallydetectablesignal
change.[18]

PositronEmissionTomographyScanning
FluorodeoxyglucosePETscanning
FluorodeoxyglucosePET(FDGPET)scanningrevealsinterictalhypometabolismoftheepileptogenic
temporallobeinmorethan85%ofcases.Thiszoneofhypometabolismismuchlargerthantheictal
onsetzonedefinedelectrophysiologicallyandtheepileptogenicregiondefinedpathologically.[19]
FDGPETscanningismoresensitivewhenanasymmetryindexiscalculated,comparingthe
quantitativemetabolismofeachtemporallobethetestpreventsmisinterpretationduetopartial
volumeaveragingartifact.Thedegreeofhypometabolismdoesnotcorrelatewiththedegreeofcell
lossorthedegreeofhippocampalatrophyidentifiedbyMRI.InpatientswithTLE,unilateral
hippocampalatrophy,andconcordantEEGdata,FDGPETscanningprovidesredundantdata.
However,itmayprovideadditionalinformationinpatientswhoseMRIandEEGfindingsare
discordantandinpatientswhoseMRIfindingsarenormal.
VisualanalysisofFDGPETscansislesssensitiveinfrontallobeepilepsy,withfewerthan50%of
casesshowinglocalizedabnormalities.Inthesecases,quantitative,normalizedanalysismayimprove
sensitivityofthistest.
Techniquessuchasstatisticalparametricmapping(SPM)and3Dstereotacticsurfaceprojection(3
DSSP)images,maybemoresensitivethanconventionalFDGPETanalysis.
WiththeSPMtechnique,thesubject'sPETscanissubtractedonapixelbypixelbasisfromanormal
databaseofcontrolsubjects.Thistechniquemayprovidelocalizinginformationinpatientswitheither
extratemporalepilepsyorTLEwithanormalMRI.
CoregistrationwithMRIimprovesthesensitivityandspecificityofFDGPETscanningbycorrectingfor
partialvolumeeffectsandenablesclosecorrelationwithsubtlemalformationsofcorticaldevelopment.
[20] Furthermore,suchcoregistrationcanalsopredictwhichcorticaltubers,whichareoftenmultiple,in
tuberoussclerosisareepileptogenicandcanimprovesurgicalseizurefreeoutcomes.
11CflumazenilPET

EarlyevidencesuggestedthatradioligandPETscanswiththebenzodiazepineantagonist11C
flumazenil(FMZ)mayhavegreatersensitivityinidentifyingtheepileptogenicregionthandoFDGPET
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scans.FMZlabelscentralGABAreceptors.
EarlystudiesattheUniversityofMichiganshowedareductioninFMZbindinginthetemporallobeof
patientswithintractableTLE,whichismorerestrictedthantheregionofhypometabolismseenwith
FDGPETscanning.ThisreductioninFMZbindingcorrelateswithneuronlossinthehippocampus.
TechniquesusingSPMandanMRIbasedmethodforpartialvolumeeffectcorrectionhaveshown
thatthereductioninFMZbindingisgreaterthanthereductionthatwouldbeexpectedfromvolume
lossalone.Thisfindingsuggeststhat,inadditiontoneuronalloss,GABAbindingintheepileptogenic
hippocampusisreduced.
FMZPETscanningalsoshowsenhancedsensitivityinpatientswithMCDs.
Studieshaveshowneitherincreasesordecreasesinbenzodiazepinereceptordensityinregionsof
MCDs.However,surgicaloutcomeinpatientswithalocalizedabnormalityonFMZPETscansand
normalMRIfindingsisnotyetknown.
Thedifficultyofcreatingsuchtracerswithashorthalflifelimitsthepracticalityandtheavailabilityof
thistechniquetoahandfulofcenters.Furthermore,thelackofoutcomedataandthecostpreventthe
routineclinicaluseofthistechnique.

AlphamethylLtryptophanandserotoninreceptorPETimaging
Inviewofevidencethatserotoninplaysaroleinepilepsy,PETimagingwithserotoninprecursorsor
serotoninagonistshasbeenusedinhopesofimprovingthedetectionoftheepileptogeniczone.
Forexample,reducedconcentrationsofbrainserotoninarefoundinthebrainsofthegenetically
epilepsypronerat(GEPR).Inaddition,treatmentwithagentsthatfacilitateserotonergictransmission
inhibitsseizuresinmanyanimalmodelsofepilepsy.Reductionofbrainserotoninconcentrations,on
theotherhand,increasesseizuresusceptibilityinanimalmodelsofepilepsy.Furthermore,inhuman
epilepticbraintissueresectedforthetreatmentofepilepsy,increasedserotoninwasfound.
AlphamethylLtryptophan,likeLtryptophan,isaserotoninprecursorthatcanhelptomeasurebrain
serotoninsynthesisrates.Liketryptophan,AMTismetabolizedintoserotonin,butunliketryptophan,it
isnotconvertedintoprotein.AMTisconvertedtoalphamethylserotonin,butunlikeserotonin,itisnot
metabolizedbymonoamineoxidase.
ChuganiandcolleaguesusedAMTinpatientswithtuberoussclerosisandfoundreducedAMTuptake
incorticaltubersascomparedwithnormalcortex.However,epileptogenictubersconfirmedbyictal
onsetregiondemonstratedincreaseduptake.[21]
InastudybyFediandcolleaguesinvolvingpatientswitheithercorticaldysplasiaonMRIoranormal
MRI,theinvestigatorsidentifiedanincreasedAMTuptakein60%ofthepatientswithcortical
dysplasiaandin30%ofthepatientswithnormalMRI.[22]Juhaszetalreportedsimilarfindings.[23]
AMThasalsobeenstudiedinpatientswhofailedepilepsysurgery,andintracranialEEGwasableto
identifyincreasedAMTuptakeinresidualepileptogeniccortex.However,itcouldonlyidentifythe
epileptogenicregionin43%ofpatients.[24]
Serotonin5HT1AreceptorbindinghasalsobeenstudiedwiththePETligands(18F)FCWAYand
(11C)WAY.Toczeketalfoundreduced5HT1Abindinginthemedialandlateraltemporalregions
ipsilateraltotheepileptogenictemporallobe.[25]Savicandcolleaguesreportedsimilarfindings,but
theyalsoreportedreducedbindinginlimbicconnections,suchasthecingulatecortexandtheinsula.
[26]
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SinglePhotonEmissionComputerizedTomographyScanning
Despitegreatprogressinstructuralneuroimaging,inmostspecializedepilepsycenters,the
epileptogeniczoneremainsunlocalizedbyMRIscanninginapproximately2050%ofpatientswith
medicallyintractableepilepsy.Thisproblemhasstimulatedeffortstodevelopfunctionalneuroimaging
techniquesthatcandemonstratetransientphysiologicdisturbances,notjuststaticstructuralones.
SPECTscanning,aftertheadministrationoftechnetium99mhexamethylpropyleneamineoxime(99m
TcHMPAO,Ceretec)or(99mTcECD,Neurolite),isareadilyavailableandrelativelyinexpensive
methodofmeasuringregionalcerebralbloodflow.
Theradiotracersaretakenuprapidlybythebrainduringthefirstpassand,afterenteringneuralcells,
areconvertedrapidlytohydrophiliccompoundsthataretrappedintracellularlyandarestablefor
severalhours.Thus,SPECTscanningcanprovideasemiquantitativeimageofcerebralbloodflow
3060secondsafterintravenousinjection.
SPECTscanningisperformedduringtheictalperiodtohelpdelineatetheepileptogeniczone.Itis
particularlyhelpfulinpatientswithnormalMRIfindings,aswellasinpatientswithabnormalMRI
findingsandanonlocalizingEEG.
Becauseseizuresareassociatedwithincreasedglucosemetabolism(metabolismiscloselycoupled
tocerebralbloodflow),ictalSPECTscansshowincreasedperfusionintheregionofseizureonset.
However,obtainingatrueictalinjectionisimportant,particularlyforextratemporallobeseizures,
becausewithlateinjections,theareasofincreasedperfusionmayrepresentseizurespreadrather
thanseizureonset.
Obtainingasnapshotofcerebralbloodflowduringtheepilepticseizure(ictalSPECT)andcomparing
thattotheresultsofaninjectionwhenthepatientisfreeofseizures(interictalSPECTscanning)is
relativelyconvenient.Anareaofincreasedbloodflowduringtheseizurethatdemonstratesdecreased
bloodflowduringtheinterictalperiodismorelikelytobethesiteofseizureonsetandcorrelates
highly(approximately90%sensitivity)withMRIabnormalities.
InTLE,ictalSPECTscanninghas90%sensitivityinlocalizingseizures,withgoodinterobserver
reliability.Ictalincreasedperfusionisseeninthemedialandthelateraltemporallobe(as
demonstratedintheimagebelow).Intheimmediatepostictalperiod(60seconds),hyperperfusionof
themedialtemporallobewithhypoperfusionofthelateraltemporallobearenoted.Inthelatepostictal
period(upto20minutespostictally),perfusioninthemedialandlateraltemporallobesmaybe
decreased.

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Subtractionictalsinglephotonemissioncomputedtomography(SPECT)ofalefttemporallobecomplexpartial
seizureshowingincreasedperfusionintheleftmedialandlateraltemporalcortex.

ViewMediaGallery
Fromapracticalpointofview,however,SPECTscanningaddslittleusefulinformationwithregardto
patientswhohavelesionsdetectedbyMRIandlocalizingorlateralizedEEGfindings.
Inaddition,ictalSPECTscanningisnothelpfulinlocalizingseizuresinpatientswithbilaterally
independenttemporallobeseizures,sincetheproceduresamplesonly1seizureatatime.Moreover,
falselateralizationwithictalSPECTmayoccuriftheseizureceasesinthetemporallobeoforigin
whilecontinuinginthecontralateraltemporallobeatthetimeoftracerinjection.
Forextratemporallobeseizure,suchasfrontalandparietallobeseizures,ictalSPECThassensitivity
ashighas90%inlocalizingseizuresifictalinjectionoccursshortlyafterictalonset(ie,within20s).

SubtractionictalSPECTscanningcoregisteredtoMRI
ThesensitivityofictalSPECTscanningisincreasedsignificantlywhenictalandinterictalimagesare
subtracted.ThissubtractedimageisthensuperimposedonhighresolutionMRI,whichfurther
increasesthesensitivityandspecificityoftheinterpretation.Surgicaloutcomesinpatientswhose
seizurefocusislocalizedwiththistechniqueareunderstudy.
Inaddition,postictalsubtractionSPECTscanningcoregisteredtoMRIhasbeenstudiedasamethod
oflocalizingtheepileptogeniczone.
Otherimagingtechniquesincludestatisticalparametricmappinginwhichacontroldatabaseof
interictalSPECTscansaresubtractedfromthepatient'sictalSPECTscanandazscoreis
generated.ThissubtractionimageissubsequentlycoregisteredtoMRI.
AstudybyKazemietaldeterminedthatstatisticalictalSPECTscanningcoregisteredtoMRIwas
superiortosubtractionictalSPECTscanningcoregisteredtoMRIforseizurelocalizationbeforeTLE
surgery,withgreaterinterraterreliability.(Seetheimagebelow.)[27]

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CoregistrationofsubduralgridelectrodestothepreoperativeMRI.

ViewMediaGallery

MagneticSourceImaging
Magnetoencephalography(MEG)detectsthemagneticfieldsproducedbytheelectricalcurrentsof
neuronalactivity.Unliketheelectricalcurrentsofneuronalactivity,whichareextracellular,magnetic
fieldsareproducedbytheintracellularcurrentsofapicaldendrites,whicharerecordedfromthescalp
byMEG.UnlikeconventionalEEGthatdetectsradiallyorientedelectricalactivitythatisattenuatedin
strengthandspatiallydistortedbytissuesbetweenthebrainandscalpsurface,magneticfieldsare
minimallyaffectedbyinterveningtissuelayers.Furthermore,MEGmeasuresasubsetofneuronal
activitythatistangentialtothescalp.
ThesemagneticdipolesgeneratedbyMEGarethensuperimposedonstructuralMRimages,creating
magneticsourceimaging(MSI).Numerousstudieshaveshownthatthistechniqueishelpfulin
patientswithneocorticalepilepsiestomapinterictalepileptiformactivity,whichinconjunctionwith
othernoninvasivestructuralandimagingdata,guideintracranialsubduralgridplacementtoimprove
surgicaloutcome.
Alargeseriesof455patientsshowedthatMSIidentifiedthelobetobetreatedin89%ofpatients.In
allextratemporalcases,MSIidentifiedthecorrectlobe.OnemightarguethatMSIprovidesredundant
data.However,inthisstudy,MSIprovidedadditionalinformationabouttheepileptogeniczonein35%
ofpatients,anditprovidedcrucialinformationforsurgicaldecisionmakingin11%ofcases.[28]
Thus,MSIisapromisingmodalityforseizurelocalizationinthatitcanconfirmtheepileptogeniczone,
alongwithotherfunctionalimagingdataaidintheidentificationofasubtlecorticalabnormalityon
MRIandprovidelocalizinginformationnotobtainablefromotherimagingmodalities.Inthisregard,it
caneitherobviatetheneedforinvasivemonitoringincaseswithastructurallesionwithoutlocalizing
orlateralizingictalEEGdataorguideintracranialsubduralelectrodeplacementtoimprove
localizationoftheepileptogeniczoneandimproveseizurefreeoutcome.
Knowltonandcolleagues(2008)comparedthepositivepredictivevalueofMSIwithSPECTandPET
scanning,usingintracranialEEG(ICEEG)localizationasthecriterionstandard.MSIdemonstrateda
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highpredictivevalueforseizureslocalizedbyICEEG.Localizationconcordanceimprovedwitheither
MSIandPETscanningorMSIandSPECTscanning.[29]
Inasecondstudy,KnowltonandcolleaguesfoundthatMSIconclusivelylocalizedepileptiformactivity
55%ofthetime.Theoddsratioforpredictingaseizurefreesurgicaloutcomewas4.4,butit
increasedto9.1whenictalSPECTscanning,PETscanning,andMSIwereusedtogether.[30]
ThedisadvantageinusingMSIisthatitislimitedtoafewcentersitisperformedintheoutpatient
settingintheUnitedStates,whereantiepilepticdrugscannotalwaysbetaperedordiscontinued
safelyandrecordingtimeislimited,whichreducesthechanceofobtainingsufficientinterictaldata,
withtheexceptionofpatientswhohavefrequentinterictalactivity.
Furthermore,althoughictalMSIhasbeenrecordedandishighlylocalizing,thechanceofcapturinga
seizureduringastudyissmallanddatacanbeaffectedbymotionartifact.Somecenterspartially
taperAEDsand/orgiveclonidinetoenhancetheyieldofidentifyinginterictalepileptiformactivity.
MSIismostusefulinpatientswithrelativelyfrequentinterictalepileptiformactivity.

MRS,fMRI,andNovelStructuralMRITechniques
Protonmagneticresonancespectroscopicimaging
ThistechniqueisbasedontheprinciplethatNacetylaspartate(NAA)isfoundprimarilywithin
neuronsandprecursorcellsareductioninNAAisusuallyregardedasindicatinglossordysfunction
ofneurons.
Creatinine(CR)andcholine(Cho)arepresentinmuchhigherconcentrationsingliathaninneurons.
PatientswithTLEhavereductionsintheNAA/(Cho+CR)ratio.Thisreductionhasbeenshownto
correlatewiththepresenceofhippocampalsclerosisandtocorrectlylateralizethesideofseizure
onsetin97%ofpatients.About2040%ofpatientshavebilateralmetabolicdisturbances,and
preliminaryevidencesuggeststhatthisfindingisassociatedwithahigherprobabilityofsurgical
failure.
WhetherthistechniqueisusefulinpatientswithnolesionsonMRI,particularlythosewith
extratemporalepilepsy,islessclear.MRSalsohasbeenusedtomeasurelactatelevelspostictally,
althoughitsclinicalusehasyettobeestablished.

FunctionalMRI
FunctionalMRIevaluatescerebralbloodflowbylookingatthedifferencebetweenvenous
oxyhemoglobinanddeoxyhemoglobinthisiscalledthebloodoxygenleveldependent(BOLD)
contrasttechnique.Duringcorticalactivation,cerebralbloodflowtotheeloquentcortexincreases
focallyasaresponsetothestimulus,butoxygenextractionchangeslittle.Thisresultsinarelatively
increasedconcentrationofoxyhemoglobinandarelativelydecreasedconcentrationof
deoxyhemoglobindrainingtheactivatedcortex.
Deoxyhemoglobinisparamagneticitexertsmagneticsusceptibilityeffectsonlocaltissue,whichare
detectedbyT2weightedimagingasdecreasedsignalintensity.Oxyhemoglobin,ontheotherhand,is
diamagneticandhaslittleeffectonT2weightedimages.
Thus,corticalactivationresultsinarelativedecreaseoftheloweredsignalintensityproducedbythe
decreasedconcentrationofdeoxyhemoglobin,whichleadstoarelativeincreaseinsignalinthe
activatedcortexrelativetocontiguouscortex.
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FunctionalMRIhasbeenusedtomaplanguage,motorfunction,andinterictalspikes.Italsomaybe
usefulforseizurelocalizationandhassuccessfullybeenusedtomapsimplepartialseizures.
However,capturingseizureswithfMRIisdifficult,becauseseizuresareunpredictableandcomplex
partialseizuresareusuallyassociatedwithmovementthatobscuresthefMRIimage.
AstudybyMoelleretalprovidedsupportthatEEGfMRImayhelptodelineatetheepilepticfocusin
patientswithnonlesionalfrontallobeepilepsy.[31]

NovelstructuralMRItechniques
SurfacecoilMRIand3Dsurfacerenderingmayincreasetheyieldinidentifyingfocalareasofcortical
thickening.Theuseofmultichannelphasedarrayheadcoilsispreferredoverconventionalquadrature
coils.
Othertechniques,suchasT1andT2weightedinversionrecovery,alsomayincreasethesensitivity
toidentifysubtlecorticalmalformations.Moreover,3Tphasedarray(PA)MRIcanfurtherincreasethe
signaltonoiseratio68fold,ascomparedwithnonphasearraycoil1.5TMRI.Astudyfoundimproved
lesiondetectionwith3TPAMRIinpatientswithintractableepilepsy.[32]
Preliminarydatasuggestthat3Dpreoperativemapsofhippocampicanhelptopredictsurgical
outcome.However,futurestudiesareneededtodeterminewhetherthiswillbeanindependent
predictorofsurgicaloutcome.
Invoxelbasedmorphometry(VBM),awholebraingraymatter,voxelbasedcomparisonismade
betweenthepatientandthecontrolgroup.Azscoremapisthengeneratedforthepatient.This
methoddemonstratesenhancedsensitivityinidentifyingsubtlegraymatterabnormalitiesandfor
identifyingadditionalareasofgraymatterabnormalitiesinpatientswithfocalcorticaldysplasia.

SummaryandConclusions
Thecareofpatientswithepilepsy,aswiththatofmostotherpatientswithneurologicdiseases,has
beenrevolutionizedbydevelopmentsinneuroimagingsincethelate20thcentury.Thishasledtoafar
moreaccuratediagnosisofthepathologicsubstrateofepilepsy,whichisessentialforaccurate
classification,determinationofprognosis,andsurgicalcandidacy.
StructuralMRIhasgreatlyreducedtheneedforinvasiveelectroencephalographicevaluationof
patientswithintractableepilepsyandhasthereforereducedmorbidity.
Althoughgeneralconsensusexistsamongneurologistsspecializinginepilepsyastowhenandwhat
typeofneuroimagingstudiesshouldbeperformedinpatientswithepilepsy,theseviewshavenotyet
beenacceptedcompletelybygeneralneurologicandmedicalpractitioners,despitethe
recommendationsoftheILAE(1997).[2]
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MediaGallery
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SpoiledgradientrecallMRIshowingrighthippocampalatrophy.

Fluidattenuatedinversionrecovery(FLAIR)MRIshowingincreasedsignalwithintheleft
hippocampus.

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Corticaldysplasiainthelingualgyrusextendinganteriorlyintotheposteriorparahippocampal
gyrus.Notethethickenedcortexandthelossofthegraywhitematterinterfaceascomparedto
thecontralateralside.

Subtractionictalsinglephotonemissioncomputedtomography(SPECT)ofalefttemporallobe
complexpartialseizureshowingincreasedperfusionintheleftmedialandlateraltemporal
cortex.

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CoregistrationofsubduralgridelectrodestothepreoperativeMRI.
of5

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ContributorInformationandDisclosures

Author
ErasmoAPassaro,MD,FAANDirector,ComprehensiveEpilepsyProgram/ClinicalNeurophysiology
Lab,BayfrontHealthSystem,FloridaCenterforNeurology
ErasmoAPassaro,MD,FAANisamemberofthefollowingmedicalsocieties:AmericanAcademyof
Neurology,AmericanSocietyofNeuroimaging,AmericanAcademyofSleepMedicine,American
ClinicalNeurophysiologySociety,AmericanEpilepsySociety,AmericanMedicalAssociation
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Disclosure:Serve(d)asaspeakeroramemberofaspeakersbureaufor:UCBSunovion.
SpecialtyEditorBoard
FranciscoTalavera,PharmD,PhDAdjunctAssistantProfessor,UniversityofNebraskaMedical
CenterCollegeofPharmacyEditorinChief,MedscapeDrugReference
Disclosure:ReceivedsalaryfromMedscapeforemployment.for:Medscape.
JoseECavazos,MD,PhD,FAAN,FANA,FACNSProfessorwithTenure,DepartmentsofNeurology,
Pharmacology,andPhysiology,AssistantDeanfortheMD/PhDProgram,ProgramDirectorofthe
ClinicalNeurophysiologyFellowship,UniversityofTexasSchoolofMedicineatSanAntonioCo
Director,SouthTexasComprehensiveEpilepsyCenter,UniversityHospitalSystemDirector,San
AntonioVeteransAffairsEpilepsyCenterofExcellenceandNeurodiagnosticCenters,AudieLMurphy
VeteransAffairsMedicalCenter
JoseECavazos,MD,PhD,FAAN,FANA,FACNSisamemberofthefollowingmedicalsocieties:
AmericanAcademyofNeurology,AmericanClinicalNeurophysiologySociety,AmericanNeurological
Association,SocietyforNeuroscience,AmericanEpilepsySociety
Disclosure:Serve(d)asadirector,officer,partner,employee,advisor,consultantortrusteefor:Brain
Sentinel,consultant.<br/>Stakeholder(<5%),Cofounderfor:BrainSentinel.
ChiefEditor
SelimRBenbadis,MDProfessor,DirectorofComprehensiveEpilepsyProgram,Departmentsof
NeurologyandNeurosurgery,TampaGeneralHospital,UniversityofSouthFloridaMorsaniCollegeof
Medicine
SelimRBenbadis,MDisamemberofthefollowingmedicalsocieties:AmericanAcademyof
Neurology,AmericanAcademyofSleepMedicine,AmericanClinicalNeurophysiologySociety,
AmericanEpilepsySociety,AmericanMedicalAssociation
Disclosure:Serve(d)asadirector,officer,partner,employee,advisor,consultantortrusteefor:
CyberonicsEisaiLundbeckSunovionUCBUpsherSmith<br/>Serve(d)asaspeakeroramember
ofaspeakersbureaufor:Cyberonics(Livanova)EisaiLundbeckSunovionUCB<br/>Received
researchgrantfrom:Cyberonics(Livanova)GW,LundbeckSunovionUCBUpsherSmith.
AdditionalContributors
ClaudeGWasterlain,MD,MScChair,DepartmentofNeurology,VAGreaterLosAngelesHealth
CareSystemDistinguishedProfessorandViceChair,DepartmentofNeurology,Universityof
California,LosAngeles,DavidGeffenSchoolofMedicine
ClaudeGWasterlain,MD,MScisamemberofthefollowingmedicalsocieties:AmericanAcademyof
Neurology,AmericanEpilepsySociety,AmericanFederationforMedicalResearch,American
NeurologicalAssociation,RoyalSocietyofMedicine,SocietyforNeuroscience
Disclosure:Nothingtodisclose.
Acknowledgements
TheauthorsandeditorsofMedscapeReferencegratefullyacknowledgethecontributionsofprevious
authorRamonDiazArrastia,MD,PhD,tothedevelopmentandwritingofthesourcearticle.
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