1. Neuroimaging of Epilepsy
Ruben Kuzniecky, M.D.
NYU Comprehensive Epilepsy Center
New York University
New York

2. 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

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

4. CT Scans

5. 3.0 Tesla
1.5 Tesla

6. MR Compatible Incubator

7. Find the Abnormality…

9. Hippocampal Sclerosis

10. Wrong MRI Angulation for HS

11. Correct MRI Angulation-HS

12. 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

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

14. 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

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

16. Focal Cortical Dysplasia
Bottom of Sulcus FCD

17. Lissencephaly/ DCX

18. Unilateral Polymicrogyria

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

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

21. High Resolution 8S-coils
Grant et al 2004 MGH

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

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

24. DWI in Epilepsy

25. ICTAL SPECT
6 Months old boy with Frontal lobe FCD

26. Focal Cortical Dysplasia
T1-WT\
FLAIR
CISPECT

27. Temporal Lobe Epilepsy SISCOM

29. PET
PET/CT

30. 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

31. Arrows point to abnormalities
FDG-PET
Arrows point to abnormalities

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

33. 3 year old girl with TSC FLAIR AMT PET Children’s Hospital of Michigan
Wayne State University

34. 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

35. 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

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

37. Focal Cortical Dysplasia Magnetoencephalography
Spike Clustering

39. 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: