Presx eval

MS
• 35% of patients with partial-onset seizures are resistant to AED therapy
• Goal : to find epileptogenic zone
• The epileptogenic zone is defined as the zone whose resection is necessary and
sufficient to eliminate seizures
• The ictal onset zone (also called seizure onset zone or pacemaker zone) is the area
of cortex that is generating seizures
• contained within the epileptogenic zone but may be smaller than the epileptogenic
zone
• Identifying and defining the ictal onset zone can be challenging, since the earliest
detected ictal activity may have already undergone considerable spread from
where the seizure actually originated.
• The irritative zone is the zone that generates interictal epileptiform discharges
• Localized within epileptogenic zone
• multiple irritative zones possible
• The ictal symptomatogenic zone is the region that produces the seizure
manifestations
• Corresponds to ictal onset zone usually
• The epileptogenic lesion is a structural brain abnormality that is presumed to be
the cause of the epilepsy and is usually identified on MRI

• identification of an epileptogenic lesion greatly improves the confidence of

congruent electrical localization of the ictal onset and irritative zones
• The functional deficit zone, responsible for functional deficits, can be measured in
a variety of ways including neurological examination, neuropsychological testing,
interictal EEG focal attenuation and slow activity, local glucose uptake by PET, or
local cerebral blood flow by interictal PET or interictal single-photon emission
computed tomography (SPECT).
Neurological History
• Description of the seizure aura and other early seizure semiology
helps with the localization of the ictal symptomatogenic zone.
• Certain auras are characteristic of mesial temporal localization, while
elementary auditory hallucinations at seizure onset favor a lateral
temporal localization, and elementary visual hallucinations favor an
occipital localization
• examination is most often noncontributory.
EEG/video-EEG
• EEG/video-EEG is a cornerstone of the presurgical evaluation,
contributing to the localization of four zones
• The interictal focal attenuation and focal slow activity contribute to
the definition of the functional deficit zone;
• the fields of the interictal epileptiform discharges define the irritative
zones;
• the electrographic localization of seizure onset helps define the ictal
onset zone.
• The analysis of seizure semiology by video-EEG provides several
localizing and lateralizing signs that help define the ictal
symptomatogenic zone
• early head turning in temporal lobe epilepsy tends to be ipsilateral to
the seizure focus, and late head turning preceding secondary
generalization tends to be contralateral
• Lip smacking and other oroalimentary automatisms are characteristic
of temporal lobe involvement.
• Extremity dystonic posturing is a strong contralateral lateralizing sign
• Ictal vomiting, ictal spitting, ictal drinking, and postictal urinary
urgency have all been associated with right temporal lobe origin
• Unilateral eye blinking same side
• Post ictal aphasia : dominant side
• MRI
• 1.5 mm thickness
• 3 tesla better
• for FCD
• DTI for altered connectivity in FCD
PET CT
• most commonly used ligand is 18F-fluorodeoxyglucose (FDG), which
allows the imaging of glucose uptake/metabolism in the brain.
• Interictal
• FDG-PET contributes to the definition of the functional deficit zone
• PET hypometabolism has a greater correlation with the ictal onset zone
than scalp EEG-defined ictal onset
• The identification of temporal hypometabolism corresponding to well-
localized electrographic ictal onset and interictal epileptiform activity
on EEG may permit sufficient confidence to proceed with epilepsy
surgery without invasive monitoring
Ictal SPECT
• The main benefit of SPECT is ictal imaging.
• When the ligand is injected intravenously (IV) at the very onset of
seizures, greater uptake is noted in the ictal onset zone
• fMRI: BOLD
• MEG : 3 to 4 cm2
• WADA: intracarotid amobarbital
• Neuropsychological testing
• Invasive eeg