Purpose of Review: This review discusses the MRI and functional imaging findings in patients with focal seizures, practical ways to improve the detection of subtle lesions, and limitations and pitfalls of the various imaging techniques in this context.
Recent Findings: A proper MRI investigation of patients with focal epilepsy requires the use of specific protocols, selected based on identification of the region of onset by clinical and EEG information. For practical purposes, the focal epilepsies are divided here into mesial temporal lobe epilepsies and neocortical epilepsies. The majority of patients with mesial temporal lobe epilepsies associated with hippocampal sclerosis undergoing presurgical evaluation will have a clear-cut unilateral atrophic hippocampus with increased T2 signal and a normal-appearing contralateral hippocampus. Among the several types of neocortical lesions, focal cortical dysplasias deserve especial attention because these lesions are often missed on routine MRIs. The focal cortical dysplasias include a gradient of morphologic changes from dysplastic lesions that can be easily identified by conventional MRI techniques to minor structural abnormalities with small areas of discrete cortical thickening and blurring of the gray/white matter interface that often go unrecognized.
Summary: The use of MRI protocols targeted for the study of patients with epilepsy allows the diagnosis of the etiology of epilepsy in most patients with focal seizures. However, in a considerable number of patients with epilepsy, MRI results are considered normal. Although the etiology remains unclear in these cases, the malformations of cortical development (mainly focal cortical dysplasias) have been identified as most likely pathologic substrates. The effort involved in trying to increase the detection of these “invisible” lesions involves the improvement of structural imaging techniques and the combination of metabolic and functional studies, including 18F-fluorodeoxyglucose–positron emission tomography (18F-FDG-PET), ictal single-photon emission computed tomography (SPECT), diffusion MRI, and magnetic resonance spectroscopy (MRS). The methods used to enhance the detection of subtle cortical abnormalities by improving the structural images have addressed two basic aspects of the examination by MRI: signal acquisition and imaging postprocessing.