Abstract
BackgroundTo prospectively analyze factors associated with detecting epileptogenic lesions on MRI within the work-sharing process of neurologists, epileptologists, radiologists and neuroradiologists.MethodsWe assembled four sets of six MRI scans, each set representing five typical epileptogenic lesions (hippocampal sclerosis or limbic encephalitis; focal cortical dysplasias; periventricular nodular or other heterotopias; long-term epilepsy associated tumors; gliotic scar, hemosiderin or cavernoma), and non - lesional epilepsy.At professional conferences, we invited neurologists, epileptologists, radiologists, and neuroradiologists to read two out of four MRI sets, one of which was presented with a clinical focus hypothesis. Participants were randomly assigned to MRI sets. Effects of examiners’ specialty, duration of training and professional experience on detection rate of epileptogenic lesions were investigated.ResultsFourty-eight neurologists, 22 epileptologists, 20 radiologists and 21 neuroradiologists read 1323 MRI scans. Overall, 613 of 1101 (55.7%) epileptogenic lesions were detected. Long-term epilepsy associated tumors (182/221, 82.4%) were found more frequently than gliotic scar, hemosiderin or cavernoma (157/220, 71.4%), hippocampal sclerosis or limbic encephalitis (141/220, 64.1%), nodular heterotopia (68/220, 30.9%) and focal cortical dysplasias (65/220, 29.5%, p < 0.001). Provision of a focus hypothesis improved the detection of hippocampal sclerosis or limbic encephalitis (86/110, 78.2% vs 55/110, 50%, p < 0.001) and focal cortical dysplasias (40/110, 36.4% vs 25/110, 22.7%, p = 0.037). Neuroradiologists and epileptologists were more likely than radiologists and neurologists to be amongst the most successful readers. In multivariable analysis, type of epileptogenic lesion, specialty of MRI reader, and provision of focus hypothesis predicted correct identification of epileptogenic lesions.ConclusionsEpileptogenic lesions are often not recognized on MRI even by expert readers. Their detection can be improved by providing a focus hypothesis. These results stress the need for training in the MRI characteristics of epilepsy - specific pathology, and, most importantly, interdisciplinary communication between neurologists/epileptologists and (neuro)radiologists to improve detection of epileptogenic lesions.
Highlights
Brain MRI is one of three cornerstones in the diagnostic workup of people with epilepsy, in addition to seizure semiology and interictal and ictal EEG
Participants Using a poster booth at international, national and regional medical conferences, annual meetings and summer schools, we invited adult and pediatric NEU, EPI certified by their International League Against Epilepsy (ILAE) chapter, RAD and NRAD to participate in the study
Participants were asked about their medical specialty, time since graduation from medical school, personal experience with creating a clinical focus hypothesis (FH) in epilepsy based on seizure semiology and EEG, experience with reading MRIs of people with epilepsy, experience with reading MRIs at different magnetic field strengths, and training in epilepsy specific MRI
Summary
Brain MRI is one of three cornerstones in the diagnostic workup of people with epilepsy, in addition to seizure semiology and interictal and ictal EEG It allows diagnosing epilepsy after a first unprovoked seizure [1], and it is crucial to detect epileptogenic lesions (EL) potentially amenable to causative treatment options, such as immunomodulatory treatment in limbic encephalitis, or epilepsy surgery. Unlike EEG and video EEG, the acquisition and interpretation of MRI for neurological purposes is typically performed by radiologists (RAD) or neuroradiologists (NRAD) at the request of adult or pediatric neurologists (NEU) or epileptologists (EPI). This “dissociation” of treating and diagnosing physician may be justified by the expertise of the RAD and NRAD with regards to the respective examination technique. To prospectively analyze factors associated with detecting epileptogenic lesions on MRI within the work-sharing process of neurologists, epileptologists, radiologists and neuroradiologists
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