Epileptic scalp ripples are associated with corticothalamic BOLD changes

Summary Objective Interictal high frequency oscillations (HFOs) in the 40–200 Hz range have been identified in scalp electroencephalography (EEG) recordings of patients with focal epilepsy. HFOs usually co-occur with interictal epileptiform discharges (IEDs), and are specific and accurate markers for the epileptic focus, but the brain regions involved when HFOs are generated are unknown. We investigated this question with combined EEG–functional magnetic resonance imaging (fMRI), measuring the blood oxygenation level–dependent (BOLD) signal, and examined HFOs in the gamma (40–80 Hz) and ripple (80–200 Hz) bands. Methods Twenty-eight consecutive patients with focal epilepsy who underwent HFO and EEG-fMRI studies were selected; six were excluded because of negative EEG-fMRI. The remaining 22 patients were divided into two equal groups (11 patients each) based on the frequency of co-occurrence of gamma or ripples with IEDs: low versus high gamma (LG/HG) and low versus high ripples (LR/HR). Results No significant changes were found in the BOLD characteristics between the LG and HG groups. As a group, HR had a larger IED concordant BOLD cluster than the LR group, despite similar IED rates. In addition, the HR group had significantly more thalamic BOLD changes than the LR group (11/11 vs. 2/11). In HR, 5 of 11 patients had thalamic activation only, 4 of 11 had thalamic deactivation only, and 2 of 11 had activation and deactivation in different thalamic regions. In the LR group, 2 of 11 had thalamic activation. The lateralization of thalamic BOLD responses was concordant with the lateralization of cortical ripples in 12 of 13 patients. Significance Scalp IEDs, when frequently accompanied by HFOs in the ripple but not in the gamma band, are associated with larger cortical metabolic responses and with thalamic involvement lateralized to the side of cortical ripples. We propose that a high rate of epileptic ripples is associated with a more active pathologic cortical-thalamocortical network.