Neuroimaging of Epilepsy

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Presentation transcript:

Neuroimaging of Epilepsy Ruben Kuzniecky, M.D. NYU Comprehensive Epilepsy Center New York University New York Ruben.kuzniecky@med.nyu.edu

Imaging in Epilepsy Neuroimaging in Epilepsy Pathology of Epilepsy 1- Diagnosis 2- Classification 3- Genetics 4- Treatment Strategies 5- Prognosis Pathology of Epilepsy Neoplasia H. Sclerosis Trauma MCD’s Vascular Post-infectious

Neuroimaging in Epilepsy Diagnos Classif Genetics Neurodevel Surgery CT + MRI ++ PET-FDG iSPECT MEG

CT Scans

3.0 Tesla 1.5 Tesla

MR Compatible Incubator

Find the Abnormality…

Hippocampal Sclerosis

Wrong MRI Angulation for HS

Correct MRI Angulation-HS

Where is the focus ? Brian 17 y/o high school boy Traumatic birth, CP Left UL hemiparesis 4/5 CPSz without GTC EEG: Right F-T IQ:101

Temporal Lobe Epilepsy Ganglioglioma Seizure onset 4 years CPSz Surgical Failure Watch out for extensive pathology

Tuberous Sclerosis TSC2 gene (1993) TSC1 gene (1996) 16p13 9q34 Multiple Lesions Multiple or single Epileptogenic areas TSC2 gene (1993) 16p13 Tuberin TSC1 gene (1996) 9q34 Hamartin

Malformation of Cortical Development Intractable Seizures Hemiparesis Developmental Delay Etiology : ? Pathology: Variable Treatment: Mostly effective

Focal Cortical Dysplasia Bottom of Sulcus FCD

Lissencephaly/ DCX

Unilateral Polymicrogyria

Lissencephaly/SBH- DCX 16 y/o Sister 12 y/o Male

Frontal Lobe Epilepsy Normal MRI What do you do to improve Imaging Yield ?

High Resolution 8S-coils Grant et al 2004 MGH

Image Averaging Focal Cortical dysplasia 1 SPGR series 4 SPGR series Knowlton et al

NeuroImaging in Patients with Normal MRI SPECT Ictal Spect and SISCOM PET FDG PET Receptor PET MEG Epilepsy Localization Mapping MR Spectroscopy

DWI in Epilepsy

ICTAL SPECT 6 Months old boy with Frontal lobe FCD

Focal Cortical Dysplasia T1-WT\ FLAIR CISPECT

Temporal Lobe Epilepsy SISCOM

PET PET/CT

PET Techniques in Epilepsy FDG : Glucose metabolism H2O : rCBF [11C]CARFENTANIL: binds to mu-opiate receptors [11C]DOXEPINE: binds to histamine H1 receptors [11C]FLUMAZENIL: binds to benzodiazepine site on GABA-A receptor ALPHA[11C]METHYL-L-TRYPTOPHAN: measures tryptophan metabolism by serotonin and kynurenine pathways

Arrows point to abnormalities FDG-PET Arrows point to abnormalities

FLUMAZENIL PET: NON-LESIONAL CASE A B R L Seizure onset Very frequent spiking Frequent spiking Moderate spiking

3 year old girl with TSC FLAIR AMT PET Children’s Hospital of Michigan Wayne State University

TSC, Autism and Epileptic Spasms (7 year old boy) FLAIR MRI FDG PET AMT PET EEG: spike and wave activity in the right frontal region. Children’s Hospital of Michigan Wayne State University

Magnetic Source Imaging (MSI) Measures magnetic fields generated by electrophysiological activity Analyzes spatial distribution of magnetic field to localize its sources Overlays source locations onto anatomical image to create composite MSI image Provides noninvasive view of cellular function with high spatio-temporal resolution

MEG System 248 Channels Superior Temporal Resolution MEG-NYU Epilepsy Center

Focal Cortical Dysplasia Magnetoencephalography Spike Clustering

Seizure Control in Patients With Partial Epilepsy: The Role of Brain Abnormalities Detected by MRI 54% % of seizure-free patients 50% 46% 42% 30% 24% 11% 3% N=57 Vascular malformation N=26 Post- stroke N=50 Tumor N=268 Normal MRI N=50 Closed Head trauma N=81 Cortical dysgenesis N=224 Isolated HS N=38 Dual pathology HS = hippocampal sclerosis. Semah F, et al. Neurology. 1998;51:1256-1262.