Brain, Vol 120, Issue 2 339-377, Copyright © 1997 by Oxford University Press
JS Duncan
MRI has been applied to the investigation of epilepsy for 12 years. The
principle role of MRI is in the definition of structural abnormalities that
underly seizure disorders. Hippocampal sclerosis may be reliably
identified, quantitative studies are useful for research and, in equivocal
cases, for clinical purposes. A range of malformations of cortical
development (MCD) may be determined. In patients with refractory partial
seizures who are candidates for surgical treatment, a relevant abnormality
is identifiable using MRI in 85%, it is likely that subtle MCD or gliosis
accounts for the majority of the remainder. The proportion of cryptogenic
cases will decrease with improvements in MRI hardware, signal acquisition
techniques and post-processing methodologies. Functional MRI is used to
identify the cerebral areas that are responsible for specific cognitive
processes, and is of importance in planning resections close to eloquent
cortical areas. Magnetic resonance spectroscopy (MRS) provides a means of
investigating cerebral metabolites and some neurotransmitters,
non-invasively. The concentrations of N-acetyl-aspartate (NAA), creatine
and choline- containing compounds may be estimated using proton MRS.
Reduction of the ratio of NAA/(creatine+choline) is a feature of cerebral
regions that include epileptic foci. Cerebral concentrations of GABA and
glutamate, and the effects of antiepileptic drugs on these, may be
estimated. Concentrations of high energy phosphate compounds, inorganic
phosphate and pH may be assessed using 31P-MRS. In general, epileptic foci
are associated with an increase in pH, increased inorganic phosphate and
decreased phosphate monoesters. Carbon-13 spectroscopy promises to be a
useful method for investigating cerebral metabolism in vivo. PET may
provide data on regional cerebral blood flow (rCBF), glucose metabolism and
the binding of specific ligands to receptors. Correlation of functional and
structural imaging data is necessary for adequate interpretation. The
hallmark of an epileptic focus is an area of reduced glucose metabolism,
identified using [18F]fluorodeoxyglucose (18FDG), that is commonly more
extensive than the underlying anatomical abnormality. The clinical role of
18FDG-PET requires re-evaluation in the light of the advances in structural
imaging with MRI. Specific ligands are used to investigate specific
receptors. Benzodiazepine and opioid receptors have been studied most.
Reduced benzodiazepine receptor binding is commonly seen at an epileptic
focus, in a more restricted distribution than an area of hypometabolism.
Focal increases and decreases in benzodiazepine receptor binding have been
demonstrated in MCD in areas that appear normal on MRI, indicating the
widespread nature of the abnormalities. It has been found that mu-opioid
receptors are increased in temporal neocortex overlying mesial temporal
epileptic foci. Dynamic studies of ligand-receptor binding are possible
using PET, for example the release of cerebral endogenous opioids has been
implied at the time of serial absences. The main use of single photon
emission computed tomography (SPECT) is to produce images reflecting rCBF.
Interictal studies alone are not reliable. A strength of SPECT is the
ability to obtain images related to rCBF at the time of seizures.
Concomitant video-EEG recording is necessary. Ictal scans need to be
considered in comparison with an interictal scan and an MRI. Interpretation
must be cautious, but may yield data that is useful in the investigation of
patients for possible surgical treatment.
REVIEWS
Imaging and epilepsy
Epilepsy Research Group, University Department of Clinical Neurology, National Hospital for Neurology and Neurosurgery, London, UK.
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