Magnetic source imaging and ictal SPECT in MRI-negative neocortical epilepsies: Additional value and comparison with intracranial EEG

Purpose: To investigate the utility of magnetic source imaging (MSI) and ictal single photon emission computed tomography (SPECT), each compared with intracranial electroencephalography (EEG) (ICEEG), to localize the epileptogenic zone (EZ) and predict epilepsy surgery outcome in patients with nonlesional neocortical focal epilepsy. Methods: Studied were 14 consecutive patients with nonlesional neocortical epilepsy who underwent presurgical evaluation including ICEEG, positive MSI, and localizing subtraction Ictal SPECT coregistered to MRI (SISCOM) analysis. Follow-up after epilepsy surgery was ≥24 months. ICEEG, MSI, and SPECT results were classified using a sublobar classification. Key Findings: Of 14 patients, 6 (42.9%) became seizure-free after surgery. Sublobar ICEEG focus was completely resected in 11 patients; 5 (45.5%) of them became seizure- free. Concordance of ICEEG and MSI and complete focus resection was found in 5 (35.7%) patients; 80% of them became seizure-free. Sublobar ICEEG-MSI concordance and complete focus resection significantly increased the chance of seizure freedom after epilepsy surgery (p = 0.038). In contrast, of the 6 patients (42.9%) with concordant ICEEG and SISCOM and complete focus resection, only 66.7% became seizure-free (p = 0.138). Assuming concordant results, the additive value to ICEEG alone for localizing the EZ is higher with ICEEG-MSI (odds ratio 14) compared to ICEEG-SISCOM (odds ratio 6). Significance: This study shows that combination of MSI and/or SISCOM with ICEEG is useful in the presurgical evaluation of patients with nonlesional neocortical epilepsy. Concordant test results of either MSI or SISCOM with ICEEG provide useful additive information for that provided by ICEEG alone to localize the EZ in this most challenging group of patients. When sublobar concordance with ICEEG is observed, MSI is more advantageous compared to SISCOM in predicting seizure-free epilepsy surgery outcome.