Neuroimaging in Adults and Children With Epilepsy

Erasmo A. Passaro, MD Neuroimaging p. 104-155 February 2023, Vol.29, No.1 doi: 10.1212/CON.0000000000001242
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OBJECTIVE This article discusses the fundamental importance of optimal epilepsy imaging using the International League Against Epilepsy–endorsed Harmonized Neuroimaging of Epilepsy Structural Sequences (HARNESS) protocol and the use of multimodality imaging in the evaluation of patients with drug-resistant epilepsy. It outlines a methodical approach to evaluating these images, particularly in the context of clinical information.

LATEST DEVELOPMENTS Epilepsy imaging is rapidly evolving, and a high-resolution epilepsy protocol MRI is essential in evaluating newly diagnosed, chronic, and drug-resistant epilepsy. The article reviews the spectrum of relevant MRI findings in epilepsy and their clinical significance. Integrating multimodality imaging is a powerful tool in the presurgical evaluation of epilepsy, particularly in “MRI-negative” cases. For example, correlation of clinical phenomenology, video-EEG with positron emission tomography (PET), ictal subtraction single-photon emission computerized tomography (SPECT), magnetoencephalography (MEG), functional MRI, and advanced neuroimaging such as MRI texture analysis and voxel-based morphometry enhances the identification of subtle cortical lesions such as focal cortical dysplasias to optimize epilepsy localization and selection of optimal surgical candidates.

ESSENTIAL POINTS The neurologist has a unique role in understanding the clinical history and seizure phenomenology, which are the cornerstones of neuroanatomic localization. When integrated with advanced neuroimaging, the clinical context has a profound impact on identifying subtle MRI lesions or finding the “epileptogenic” lesion when multiple lesions are present. Patients with an identified lesion on MRI have a 2.5-fold improved chance of achieving seizure freedom with epilepsy surgery compared with those without a lesion.

 This clinical–radiographic integration is essential to accurate classification, localization, determination of long-term prognosis for seizure control, and identification of candidates for epilepsy surgery to reduce seizure burden or attain seizure freedom.

Address correspondence to Dr Erasmo A. Passaro, 1607 Dr. Martin Luther King Jr St N, St Petersburg, FL 33704-4203, [email protected].

RELATIONSHIP DISCLOSURE: Dr Passaro has received personal compensation in the range of $0 to $499 for serving on a speakers bureau and as a consultant for Neurelis, Inc; in the range of $500 to $4999 for serving on speakers bureaus and as a consultant for Eisai Co, Ltd, and Sunovion Pharmaceuticals, Inc; and in the range of $5000 to $9999 for serving on speakers bureaus and as a consultant for SK Life Science, Inc, and UCB, Inc.


© 2023 American Academy of Neurology.