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Ruben Kuzniecky, M.D.
NYU Comprehensive Epilepsy Center
New York University
New York
Ruben.kuzniecky@med.nyu.edu
Neuroimaging in Epilepsy
Where we were and where we are
Going
Ibn al-Haytham 1027
Skull XR and PNEG
1900-1974
CT Scan in Epilepsy
Pioneering MRI Unit
Raymond Damadian 1977
0
200
400
600
800
1000
1200
1980-1990 1991-2000
2001-2011
Epilepsy Neuroimaging Articles (1990 - 2011)
PubMed Search
Lesional Temporal Lobe Epilepsy
Kuzniecky et al Annals Neuro 1987
Early demonstration of MTS
Hippocampal Sclerosis
Hippocampal Sclerosis Plus
Kuzniecky R, et al. Neurology 1998
Asymmetric - with or without other lesions
Symmetric - usually no other lesions
TL Epilepsy based on MRI
Volumetric and Morphometry Temporal Lobe Epilepsy
Malformation of Cortical Development
Focal Cortical Dysplasia with balloon cells
Focal Cortical Dysplasia (BSCD)
0
25
50
75
100
N=26
Post-
stroke
N=57
Vascular
malformation
N=50
Tumor
N=268
Normal
MRI
N=50
Closed
Head
trauma
N=81
Cortical
dysgenesis
N=224
Isolated
HS
N=38
Dual
pathology
54% 50%
46% 42%
30% 24%
11%
3%
% o
f seiz
ure
-fre
e p
atients
Seizure Control in Patients With Partial Epilepsy:
The Role of Brain Abnormalities Detected by MRI
Semah F, et al. Neurology. 1998;51:1256-1262.
HS = hippocampal sclerosis.
Frontal Lobe Epilepsy
Normal MRI
What tools do we have to improve Diagnosis ?
High Resolution 8S-coils
• 32 y/o Female
• Epilepsy at age 13
• EEG: Multifocal
• Normal MRI
• Daughter with SBH
Grant et al 2004 MGH
R
Image Averaging Focal Cortical dysplasia
Knowlton et al
4 SPGR series 1 SPGR series
Curvilinear Reformatting
PMG
Voxel Based Morphometry
Identification of Abnormal Brain
MRI morphometry FreeSurfer
White matter surface
Cortical Thickness
• Distance between white and pial surfaces
• One value per vertex
white/gray
surface
pial surface
4.0
1.8
mm
younger
middle-aged
older
NY123
Thickness
z=9.4
Normative comparison of cortical thickness
Compared to 12 normal controls
DTI
Automated Fiber Tracking
Track-density imaging (TDI): Thalamus
inferior
superior
ante
rior
posterio
r
TDI (250µm resolution)
Calamante F et al, NeuroImage 53:1233-1243 (2010) Highly localized seed ROIs
Tracking from seed ROIs
TDI (250µm isotropic resolution)
fMRI Language/ Memory Activation in TLE
Language Memory Activation
Controls Patients L/R
Functional Connectivity in TLE
Pravata et al 2010
Functional Connectivity in GGE
Blumenfeld et al
Ictal EEG fMRI showing increased BOLD in the FCD
(seizure onset zone), and in the frontal lobe (seizure
propagation) corresponding to seizure semiology.
R
DTI demonstrating significant reduction of WM fibers connecting the two areas of increased ictal BOLD (A) compared to the
same areas in the contralateral (B) hemisphere
Patient with FCD in the right parietal region
B
R L
A
Coan, Cendes et. al. unpublished
Functional Connectivty fMRI in
Focal Epilepsy Predicts Surgery
SISCOM
Ictal SPECT SPM
• Ictal SPECT, interictal SPECT, Subtraction ictal SPECT co-registered to MRI (SISCOM), and Statistical parametric mapping (SPM) analysis of ictal SPECT images (from left to right)
• Increased perfusion in right temporal lobe
• Ictal SPECT correctly localized 12 of 15 patients (80%)
Seizure 14:213-220, 2005
Ictal SPECT
MSI n=27
FDG-PET n=27
Ictal SPECT n=27
Sensitivity 54% (31.3, 73.6) 46% (24.4, 62.3) 54% (31.3, 69.9)
Specificity 64% (43.3, 82.7) 79% (58.4, 93.5) 79% (57.6, 93.5)
PPV 58% (33.9, 79.8) 67% (35.3, 89.9) 70% (40.7, 90.8)
NPV 60% (40.4, 77.1) 61% (45.4, 72.8) 65% (47.5, 77.0)
Epilepsy Surgical Outcome- Seizure Free
Knowlton et al 2008
Large Magellanic Cloud. Hubble Telescope August 2008
Abnormal Structural Changes in
Epilepsy
Tosun et al 2011
Bernasconi et al 2011
LRE
GGE
7 T HRI TSE
0.1 mm Resolution Grant et al 2004
Hippocampal Anatomy at 7 Tesla
14 min Courtesy A. George, MD NYU Imaging
11C-PBR PET Increased TSPO Binding
Suggesting Inflammation in TLE/FLE
Tracy Buttler, MD , NYU CEC
PK11195
Epilepsy and Depakote
Increased Cerebral Glutamine
Pan JW, Magn Reson Med. 2010 Nov;64(5):1237-46
Fetal MRI –Tensor Diffusion
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