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Brain Advance Access originally published online on June 24, 2007
Brain 2007 130(9):2343-2353; doi:10.1093/brain/awm141
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© The Author (2007). Published by Oxford University Press on behalf of the Guarantors of Brain. All rights reserved. For Permissions, please email: journals.permissions@oxfordjournals.org

EEG-fMRI in the preoperative work-up for epilepsy surgery

Maeike Zijlmans1, Geertjan Huiskamp1, Maaike Hersevoort1, Jan-Henry Seppenwoolde2, Alexander C. van Huffelen1 and Frans S. S. Leijten1

1Department of Clinical Neurophysiology, Rudolf Magnus Institute of Neuroscience and 2Image Sciences Institute, Department of Radiology, University Medical Center Utrecht, The Netherlands

Correspondence to: M. Zijlmans, Department of Clinical Neurophysiology, F02.230, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht E-mail: g.j.m.zijlmans{at}umcutrecht.nl

Epilepsy surgery requires precise localization of the epileptic source. EEG-correlated functional MRI (EEG-fMRI) is a new technique showing the haemodynamic effects of interictal epileptiform activity. This study assesses its potential added value in the presurgical evaluation of patients with complex source localization. Adult surgical candidates considered ineligible because of an unclear focus and/or presumed multifocality on the basis of EEG underwent EEG-fMRI. Interictal epileptic discharges (IEDs) in the EEG during fMRI were identified by consensus between two observers. Topographically distinct IED sets were analysed separately. Only patients with significant, positive blood oxygen level-dependent (BOLD) responses that were topographically related to the EEG were re-evaluated for surgery.

Forty-six IED sets from 29 patients were analysed. In eight patients, at least one BOLD response was significant, positive and topographically related to the IEDs. These patients were rejected for surgery because of an unclear focus (n = 3), presumed multifocality (n = 2) or a combination of both (n = 3). EEG-fMRI improved localization in four out of six unclear foci. In patients with presumed multifocality, EEG-fMRI advocated one of the foci in one patient and confirmed multifocality in four out of five patients. In four patients EEG-fMRI opened new prospects for surgery and in two of these patients intracranial EEG supported the EEG-fMRI results. In these complex cases, EEG-fMRI either improved source localization or corroborated a negative decision regarding surgical candidacy. It is thus a valuable tool in the presurgical evaluation of patients. Guidelines for the use of EEG-fMRI in clinical practice are proposed.

Key Words: electroencephalography; functional MRI; epilepsy; epilepsy surgery; epileptic source localization

Abbreviations: BOLD, blood oxygen level-dependent; GFT, Gaussian field theory; IED, interictal epileptic discharge

Received February 2, 2007. Revised May 22, 2007. Accepted May 25, 2007.


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