Subtraction ictal single photon emission computed tomography (SPECT) images, provided by filtered back-projection (FBP), may exhibit a confusing high level of noise. This study was aimed at assessing an optimized three-dimensional ordered subset expectation maximization (3D-OSEM) iterative reconstruction in this setting.On phantom images, parameters of 3D-OSEM reconstruction were selected as those providing the higher signal/noise ratio but a high enough spatial resolution, equivalent to that of conventional FBP reconstruction (full width at half-maximum = 11 mm). Thereafter, subtraction ictal ethylene cysteine dimer-SPECT coregistered to MRI and reconstructed with either FBP or 3D-OSEM were compared in 21 patients with well-characterized temporal epilepsy foci (subsequent successful surgical treatment).On subtraction images, the use of the selected 3D-OSEM reconstruction (five iterations, 16 subsets and a 9 mm Gauss filter) instead of FBP was associated with: (i) marked reductions in background activity (0.05 ± 0.09 vs. 0.25 ± 0.18 cps, P < 0.001) and in the size of temporal foci (10 ± 7 vs. 14 ± 11 cm, P = 0.01) and (ii) a trend toward higher accuracy in identifying the involved temporal lobes (86 vs. 76%).Localization of temporal epilepsy foci by subtraction ictal SPECT is likely to be enhanced by using 3D-OSEM rather than FBP reconstruction because of marked reductions in background activity and in the size of detected foci.
Observability of electrical potentials from deep brain sources to surface EEG remains unclear and debated among the neuroscience community. This question is particularly crucial in the temporal lobe epilepsies investigations because they involve complex (mesial and/or lateral) epileptogenic networks (Maillard et al., 2004; Bartolomei et al, 2008). At present, when mesial structures are supposed to be epileptogenic only clinical indirect evidences are used to diagnose mesial temporal lobe (MTL) epilepsy. Based on this methodology and on drug resistance evidence, surgical treatment can be proposed without the need of invasive intracerebral investigation. Reported results of this surgery demonstrate an incomplete success (70-80%; McIntosh et al. 2012) which indicate that indirect evidences of the contribution of mesial sources are not sufficient. Seven patients undergoing pre-surgical evaluation of drug resistant epilepsy were selected from a prospective series of twenty eight patients in whom simultaneous depth and surface EEG recordings had been performed since 2009. Above these patients, three had right temporal lobe (TLE) epilepsy and four left TLE. Simultaneous SEEG-EEG signals were recorded using 128 channels placed on the same acquisition system that avoids the need to synchronize both signals. Intracerebral interictal spikes (IIS) were selected on depth EEG signals blinded to EEG signals. These IIS were triggered as temporally known (T0) brain sources due to their specific waveform and the high signal to noise ratio. Then, after IIS characterization and classification, EEG signals were automatically averaged according to the T0 markers. Averaged EEG signals were finally characterized (3D mapping, duration, amplitude and statistics) and clustered using hierarchical clustering method. Overview of the data collection and analysis process is presented in figure 1. In mean in our population, 9 depth EEG electrodes and 16 surface EEG electrodes were simultaneously used. 684±186 IIS were selected by patient for a total number of spikes in our population of 4787. According to the anatomical distribution of the IIS, 21 foci were defined and classified according to three categories: mesial (limbic structures plus collateral fissure; M, 9 foci), mesial and neocortical (M+NC, 5 foci) and neocortical part of the temporal lobe (NC, 7 foci). Comparison between SEEG spikes and averaged EEG spikes on the most activated electrode at T0 was presented in table 1. Concerning 3D Map amplitude, negative pole were always seen in the temporo-basal region for both M, M+NC and NC foci and positive pole were only observed for M+NC and NC foci. Using Walsh statistical test, 8 EEG channels in mean was presented averaged amplitude at t0 statistically different of the averaged background activity. Three different clusters were fund using the hierarchical clustering method on averaged EEG signals: 1) all patients included in the M foci class and 2) all patients included in the M+NC and NC foci class and 3) one patient with an atypical brain source. Observability of deep sources with surface EEG recordings is possible. Electrical sources from mesial temporal lobe cannot be considered as closed electrical field structures. The main problem to observe signals from these deep structures concern the signal to noise ratio. Indeed, spontaneous surface spikes originated from mesial structures cannot be seen without averaging. Hierarchical clustering method and 3D map amplitude of average EEG signals at t0 seems to indicate that M contributions was different to M+NC and NC contributions. So ICA method associated with a predetermined topography constraint should detect (without the need of simultaneous depth EEG) the mesial contribution in raw EEG signals.
We aimed to prospectively assess the anatomical concordance of electric source localizations of interictal discharges with the epileptogenic zone (EZ) estimated by stereo-electroencephalography (SEEG) according to different subgroups: the type of epilepsy, the presence of a structural MRI lesion, the aetiology and the depth of the EZ.In a prospective multicentric observational study, we enrolled 85 consecutive patients undergoing pre-surgical SEEG investigation for focal drug-resistant epilepsy. Electric source imaging (ESI) was performed before SEEG. Source localizations were obtained from dipolar and distributed source methods. Anatomical concordance between ESI and EZ was defined according to 36 predefined sublobar regions. ESI was interpreted blinded to- and subsequently compared with SEEG estimated EZ.74 patients were finally analyzed. 38 patients had temporal and 36 extra-temporal lobe epilepsy. MRI was positive in 52. 41 patients had malformation of cortical development (MCD), 33 had another or an unknown aetiology. EZ was medial in 27, lateral in 13, and medio-lateral in 34. In the overall cohort, ESI completely or partly localized the EZ in 85%: full concordance in 13 cases and partial concordance in 50 cases. The rate of ESI full concordance with EZ was significantly higher in (i) frontal lobe epilepsy (46%; p = 0.05), (ii) cases of negative MRI (36%; p = 0.01) and (iii) MCD (27%; p = 0.03). The rate of ESI full concordance with EZ was not statistically different according to the depth of the EZ.We prospectively demonstrated that ESI more accurately estimated the EZ in subgroups of patients who are often the most difficult cases in epilepsy surgery: frontal lobe epilepsy, negative MRI and the presence of MCD.
