Pharmacoresistant temporal lobe epilepsy - a diagnostic performance of standardized MRI protocol in detection of epileptogenic lesion Poster No.: C-2226 Congress: ECR 2013 Type: Scientific Exhibit Authors: B. Vasi# 1, S. Lavrnic 1, D. Damjanovic 1, I. Nikolic 1, M. Jovanovic 1, M. Jaksic 1, D. Ristic-Balos 1, Z. Bukumiric 1, T. Stosic-Opincal 2 ; 1 Belgrade/RS, 2 Beograd/RS Keywords: DOI: Neuroradiology brain, CNS, MR, Imaging sequences, Seizure disorders 10.1594/ecr2013/C-2226 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. www.myesr.org Page 1 of 13
Purpose To show the diagnostic performance of a standardized MRI protocol in visualization of brain lesion in patients with pharmacoresistant temporal lobe epilepsy. Temporal lobe epilepsy is the most common type of drug resistant epilepsy with a broad spectrum of findings. Precise localization of epileptogenic lesion is of a particular importance in planning of surgical treatment. Page 2 of 13
Methods and Materials The study included 83 patients aged 19 to 59 years. The video-eeg test based diagnosis of temporal lobe epilepsy was established in 29 patients with pharmacoresistant epilepsy. The control group consisted of 54 subjects without clinical signs of epilepsy. All MR studies were performed on a 1.5T MRI system. The following sequences were included in the standardized MRI protocol: Magnetization Prepared Rapid Acquisition Gradient Echo - 3D T1-MPRAGE (0.9 mm slice thickness, sagittal orientation), axial T2W, T2W* GRE and Fluid Attenuated Inversion Recovery (FLAIR) with 5 mm slice thickness, coronal T2W and FLAIR (3 mm) and coronal T1W Inversion Recovery tomograms (5 mm), with or without paramagnetic contrast agent administration (3D T1-MPRAGE). Two radiologists independently reviewed the MR imaging findings. Page 3 of 13
Results The epileptogenic lesion of temporal lobe was found in 24 of 29 patients. Findings include hippocampal sclerosis (14), cortical dysplasia (4), dysembryoplastic neuroepithelial tumor (DNET) (4), cortical dysplasia+ DNET (1) and gliosis with blood products as a posttraumatic sequelae (1). The sensitivity of the standardized protocol was 82,8%, specificity 98,1%, positive predictive value (PPV) 96,0%, negative predictive value (NPV) 91,4%, +LR 44,7 and -LR 0,2. The sensitivity of a routine MRI protocol was 37%. Since the study was based on a small sample, to confirm the results, it is necessary to increase the number of examinees. The results should be correlated with the findings of advanced MRI techniques, particularly Diffusion tensor imaging (DTI), is considered more accurate in detecting subtle lesions in temporal lobe epilepsy, which is imperative for our further research. Page 4 of 13
Images for this section: Fig. 1: MRI findings in patients with pharmacoresistant temporal lobe epilepsy Table 1: Sensitivity and specificity of standardized MRI protocol. Page 5 of 13
Fig. 2: A 23-year old woman with a hipocampal sclerosis in the left temporal lobe. T2W/ FLAIR images show the increased signal intensity within the hippocampus, disruption of the internal structure of the hippocampus. T1W IR image shows a hippocampal atrophy. Fig. 3: A 50-year old woman with a hipocampal sclerosis in the right temporal lobe. Hippocampal atrophy and sclerosis, dilatation of the right temporal horn and bilateral frontal cortical reduction. Page 6 of 13
Fig. 4: A 33-year old woman with a hipocampal sclerosis and atrophy in the left temporal lobe. Fig. 5: A 47-year old man with a hipocampal atrophy and sclerosis in the right temporal lobe and a bilateral frontal cortical reduction more pronounced on the right side. Page 7 of 13
Fig. 6: A 46-year-old woman with a gliosis and blood products as well as a post-traumatic sequelae in the right temporal lobe. Fig. 7: A 41-year old woman with a cortical dysplasia in the left temporal lobe. Thickening of the cortex. T2W/FLAIR images show the increased signal intensity GM and WM. Page 8 of 13
Fig. 8: A 32-year old woman with a dysembryoplastic neuroepithelial tumor (DNET) in the right temporal lobe. Circumscribed cortical mass with subcortical extension, high signal on T2W and low signal intensity on T1W. Fig. 9: A 48-year old woman with a dysembryoplastic neuroepithelial tumor (DNET) and cortical dysplasia in the right temporal lobe. Fig. 10: A 31year old man with a dysembryoplastic neuroepithelial tumor (DNET) in the left temporal lobe and MRI after parcial left temporal lobectomy with amygdalohippocampectomy. Result: 16 months after surgery still without seizures. Page 9 of 13
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Conclusion Standardized MRI protocol provides more accurate detection of epileptogenic lesions of the temporal lobe in patients with pharmacoresistant epilepsy compared to the routine MRI examination, allowing thereat optimal planning of surgical treatment and therefore better control of disease. Page 11 of 13
References 1. Woermann FG, Vollmar C. Clinical MRI in children and adults with focal epilepsy: a critical review. Epilepsy Behav 2009 May;15(1):40-9. 2. Malmgren K, Thom M. Hippocampal sclerosis--origins and imaging. Epilepsia 2012 Sep;53 Suppl 4:19-33. 3. Kabat J, Krol P. Focal cortical dysplasia - review. Pol J Radiol 2012 Apr;77(2):35-43. 4. Hanamiya M, Korogi Y, Kakeda S, Ohnari N, Kamada K, Moriya J, et al. Partial loss of hippocampal striation in medial temporal lobe epilepsy: pilot evaluation with high-spatial-resolution T2-weighted MR imaging at 3.0 T. Radiology 2009 Jun;251(3):873-81. 5. Bote RP, Blazquez-Llorca L, Fernandez-Gil MA, Alonso-Nanclares L, Munoz A, De FJ. Hippocampal sclerosis: histopathology substrate and magnetic resonance imaging. Semin Ultrasound CT MR 2008 Feb;29(1):2-14 6. Howe KL, Dimitri D, Heyn C, Kiehl TR, Mikulis D, Valiante T. Histologically Confirmed Hippocampal Structural Features Revealed by 3T MR Imaging: Potential to Increase Diagnostic Specificity of Mesial Temporal Sclerosis. AJNR Am J Neuroradiol 2010 31: 1682-1689originally published online on June 10, 2010, 10.3174/ajnr.A2154. 7. Hogan E, Wang L, Bertrand ME, Willmore LJ, Bucholz RD, Nassif AS, Csernansky JG. Predictive Value of Hippocampal MR Imaging-Based High- Dimensional Mapping in Mesial Temporal Epilepsy: Preliminary Findings. AJNR Am J Neuroradiol November 2006 27: 2149-2154. 8. Braga B, Yasuda CL, Cendes F. White Matter Atrophy in Patients with Mesial Temporal Lobe Epilepsy: Voxel-Based Morphometry Analysis of T1- and T2-Weighted MR Images. Radiol Res Pract 2012;2012:481378. 9. Burneo JG, Tellez-Zenteno J, Steven DA, Niaz N, Hader W, Pillay N, et al. Adult-onset epilepsy associated with dysembryoplastic neuroepithelial tumors. Seizure 2008 Sep;17(6):498-504. Page 12 of 13
Personal Information Brankica Vasic Clinical Center of Serbia Belgrade, Serbia e mail: vasic.brankica@gmail.com Page 13 of 13