Ruben Kuzniecky, M.D.NYU Comprehensive Epilepsy Center

New York University

New York

Ruben.kuzniecky@med.nyu.edu

Neuroimaging of Epilepsy

Imaging in EpilepsyImaging in Epilepsy

• Neuroimaging in 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 EpilepsyNeuroimaging in Epilepsy

Diagnos Classif Genetics Neurodevel Surgery

CT +

MRI ++ ++ ++ ++ ++

PET-FDG ++ + + ++

iSPECT + + ++

MEG + + + ++

CT Scans

3.0 Tesla1.5 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

Multiple LesionsMultiple or single Epileptogenic areas

TSC2 gene (1993)16p13 Tuberin

TSC1 gene (1996)9q34Hamartin

Malformation of Cortical Development

Hemimegalencephaly

Intractable SeizuresHemiparesisDevelopmental Delay

Etiology : ?Pathology: VariableTreatment: Mostly effective

Focal Cortical Dysplasia

Bottom of Sulcus FCD

Lissencephaly/ DCX

Unilateral Polymicrogyria

Lissencephaly/SBH- DCX

12 y/o Male 16 y/o Sister

Frontal Lobe EpilepsyNormal MRI

What do you do to improve Imaging Yield ?

High Resolution 8S-coils

Grant et al 2004 MGH

Image AveragingFocal Cortical dysplasiaFocal Cortical dysplasia

Knowlton et al

4 SPGR series1 SPGR series

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

6 Months old boy with Frontal lobe FCD

ICTAL SPECT

Focal Cortical Dysplasia

T1-WT\ FLAIR CISPECT

Temporal Lobe EpilepsySISCOM

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

FDG-PET

Arrows point to abnormalities

R L

A B

Seizure onsetVery frequent spikingFrequent spikingModerate spiking

FLUMAZENIL PET: NON-LESIONAL CASE

3 year old girl with TSC

FLAIR AMT PET

Children’s Hospital of MichiganWayne State University

TSC, Autism and Epileptic Spasms (7 year old boy)

AMT PETFDG PETFLAIR MRI

EEG: spike and wave activity in the right frontal region.

Children’s Hospital of MichiganWayne State University

• Measures magnetic fields generated by Measures magnetic fields generated by

electrophysiological activityelectrophysiological activity

• Analyzes spatial distribution of magnetic field to Analyzes spatial distribution of magnetic field to

localize its sourceslocalize its sources

• Overlays source locations onto anatomical Overlays source locations onto anatomical

image to create composite MSI imageimage to create composite MSI image

• Provides noninvasive view of cellular function Provides noninvasive view of cellular function

with high spatio-temporal resolutionwith high spatio-temporal resolution

• Measures magnetic fields generated by Measures magnetic fields generated by

electrophysiological activityelectrophysiological activity

• Analyzes spatial distribution of magnetic field to Analyzes spatial distribution of magnetic field to

localize its sourceslocalize its sources

• Overlays source locations onto anatomical Overlays source locations onto anatomical

image to create composite MSI imageimage to create composite MSI image

• Provides noninvasive view of cellular function Provides noninvasive view of cellular function

with high spatio-temporal resolutionwith high spatio-temporal resolution

Magnetic Source Imaging Magnetic Source Imaging (MSI)(MSI)Magnetic Source Imaging Magnetic Source Imaging (MSI)(MSI)

MEG System 248 Channels

Superior Temporal Resolution

MEG-NYU Epilepsy Center

Focal Cortical DysplasiaMagnetoencephalography

Spike Clustering

Focal Diffuse

Medical Tx Response

No Response

PET/MEG

Response AEDyes

No Response

Concordant

Surgery

Discordant

Surgery

Localized

PETIctal SPECT

MEGMRS

Localization

MRInormal

Abnormal MRI

EPILEPSYDIAGNOSIS

0

25

50

75

100

N=26Post-stroke

N=57Vascular

malformation

N=50Tumor

N=268Normal

MRI

N=50Closed Head trauma

N=81Cortical

dysgenesis

N=224Isolated

HS

N=38Dual

pathology

54%50%

46%42%

30%24%

11%3%

% o

f se

izur

e-fr

ee p

atie

nts

Seizure Control in Patients With Partial Epilepsy: The Role of Brain Abnormalities Detected by MRI

Semah F, et al. Neurology. 1998;51:1256-1262.

HS = hippocampal sclerosis.