Abstract
Up to 30% of patients with epilepsy may not respond to antiepileptic drugs. Patients with drug-resistant epilepsy (DRE) should undergo evaluation for seizure onset zone (SOZ) localization to consider surgical treatment. Cases of drug-resistant nonlesional extratemporal lobe epilepsy (ETLE) pose the biggest challenge in localizing the SOZ and require multiple noninvasive diagnostic investigations before planning the intracranial monitoring (ICM) or direct resection. Ictal Single Photon Emission Computed Tomography (i-SPECT) is a unique functional diagnostic tool that assesses the SOZ using the localized hyperperfusion that occurs early in the seizure. Subtraction ictal SPECT coregistered to MRI (SISCOM), statistical ictal SPECT coregistered to MRI (STATISCOM), and PET interictal subtracted ictal SPECT coregistered with MRI (PISCOM) are innovative SPECT methods for the determination of the SOZ. This article comprehensively reviews SPECT and sheds light on its vital role in the presurgical evaluation of the nonlesional extratemporal DRE.
Highlights
Antiepileptic drugs are the mainstay treatment for seizures in patients with epilepsy
Extratemporal lobe epilepsy (ETLE) may be classified as lesional when associated with a structural lesion on MR imaging, or nonlesional when there is no structural abnormality associated with EEG epileptiform abnormalities [15]
The new processing technique known as PISCOM (PET interictal subtracted ictal Single Photon Emission Computed Tomography (SPECT) coregistered with Magnetic Resonance Imaging (MRI)) uses interictal Positron Emission Tomography (PET) and subtracts ictal SPECT and coregisters it on MRI
Summary
Antiepileptic drugs are the mainstay treatment for seizures in patients with epilepsy. Complete surgical resection of the epileptogenic focus is an optimal treatment and the only potential cure in selected patients with focal Drug-Resistant Epilepsy (DRE) [3] In such cases, accurate resection of the epileptogenic focus is imperative for successful seizure control and minimizing the risk of postsurgical neurological deficits [4, 5]. Multiple tools are used to localize the seizure onset zone (SOZ), including videoelectroencephalogram (V-EEG), Magnetic Resonance Imaging (MRI), Magnetoencephalography (MEG), Positron Emission Tomography (PET) scans, Single Photon Emission Computed Tomography (SPECT), and neuropsychological testing [9]. None of these tools alone has the needed sensitivity and specificity for localizing SOZ. We review the challenges associated with nonlesional extratemporal DRE and SPECT’s logistical advancements and its current role in this demanding clinical scenario
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