Imaging in Epilepsy. Nucharin Supakul, MD Ramathibodi Hospital, Mahidol University August 22, 2015

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Transcription:

Imaging in Epilepsy Nucharin Supakul, MD Ramathibodi Hospital, Mahidol University August 22, 2015

Nothing to disclose

Outline Role of Imaging and pitfalls Imaging protocol Case scenarios

Clinical & Electrophysiologic diagnosis Identify and Locate Structural Abnormality

IMAGING IN EPILEPSY: Structural/Anatomical vs Physiologic CT SPECT Conventional MRI PET MEG fmri MRS DTI

IMAGING: conventional study Identify and Locate Structural Abnormality Visible abnormalities Invisible abnormalities Too subtle to identify: microdysgenesis/ molecular or chemical abnormities MRI pitfalls: widespread abnormalities, multiple lesions, dual pathologies

MEDICATION Fail medication Identify localization related epilepsy Surgery

MEDICATION Fail medication Identify localization related epilepsy Negative conventional MRI Functional Imaging: Combine physiologic data: SPECT, PET, DTI Higher Magnet field

Sensitivity MRI 95% vs CT 32%

Future

CT EMERGENCY situation

Role of Imaging Pre-surgery Identify structural abnormality Plan for surgery Help confirm epileptogenicity Relationship with eloquent areas Predict resectivity and Prognostication Post-surgery Evaluate residual lesion Surveillance

MRI protocol

Ideal Imaging Distinguish abnormal from normal -> High resolution Tell etiology/nature of abnormality -> Good Characterization Allow assessment of relationship with eloquent structures -> Functional/Microstructural derangement Evaluate epileptogenicity -> Physiologic data

Good clinical history and EEG findings High magnet field Appropriate protocol How to maximize MRI sensitivity? Good technologist Experienced radiologist

Seizure protocol Contrast vs non contrast Standard sequences Sagittal T1 Axial T2, FLAIR, DWI Coronal T2 GRE/SWI (axial or coronal) Seizure sequences: Coronal T2, FLAIR through hippocampi Coronal T1 3D SPGR through hippocampi T1 3D SPGR T1W whole brain ± 3D FLAIR with 3 planes reformation 1-2 mm thickness

T1 3D SPGR Gray matter dark

Imaging pitfalls Widespread abnormalities Multiple lesions Dual pathologies

Case scenarios

Etiologies/Epileptogenic Substrates Identifiable with MRI PEDIATRIC Congenital Malformation Inborn-error of metabolism Mesial temporal sclerosis Birth-related/ post trauma ADULT Vascular (Stroke, AVM, cavernoma) Tumor (primary and mets) Prior brain injury Mesial temporal sclerosis Infection Neoplasm Vascular (malformation) Neurocutaneous syndrome

Cortically based tumor

Cortical malformation

Polymicrogyria Pachygyria: thick, smooth cortex Polymicrogyria: small cobblestone or micronodular appearing gyri

Cortical Dysplasia

Schizencephaly CSF cleft extending to ventricular epedyma GM lined Associated with absent septum pellucidum and septo-optic dysplasia

Heterotropia: nodular type

Heterotropia: Band heterotropia

Hippocampal Sclerosis 1 st sign: abnormal T2 hyperintensity, hippocampal volume loss/atrophy, obscuration of internal architecture 2 nd signs: ipsilateral fornix and mammillary body atrophy, enlarged ipsilateral temporal horn and choroidal fissure

Dysembryoplastic Neuroepithelial Tumor (DNET) High epileptogenicity Cortically-based tumor Medial temporal lobe (MCC location) Associated with cortical dysplasia Imaging: Bubbly corticallybased tumor No enhancement or calcification

Oligodendroglioma Partially calcified subcortical/cortical mass in middle-aged adult

Tuberous sclerosis Clinical triad Facial angiofibromas (90%) Mental retardation (50-80%) Seizure (80-90%) Classic Radiographic Findings: Cortical tuber Subependymal nodule (<1.3 cm) Subepedymal giant cell astrocytoma (> 1.3 cm)

Sturge Weber syndrome Clinical presentation Port wine stain (CN V1 98%) Seizure (75-90%) Hemiparesis (30-66%) Imaging findings Ipsilateral to port wine stain Gyral/subcortical white matter calcifications (tram-track calcification) hemispheric brain atrophy Serpentine leptomeningeal enhancement Engorged/enlarged enhancing choroid plexi

AVM

Summary

Role of Imaging Pre-surgery Identify structural abnormality Plan for surgery Help confirm epileptogenicity Relationship with eloquent areas Predict resectivity and Prognostication Post-surgery Evaluate residual lesion Surveillance

Seizure protocol Contrast vs non contrast Standard sequences Sagittal T1 Axial T2, FLAIR, DWI Coronal T2 GRE/SWI (axial or coronal) Seizure sequences: Coronal T2, FLAIR through hippocampi Coronal T1 3D SPGR through hippocampi T1 3D SPGR T1W whole brain ± 3D FLAIR with 3 planes reformation 1-2 mm thickness

Thank you