Teaching NeuroImages: Increasing SPECTations for Ictal SPECT in Epilepsy Surgical Evaluation.

We report a 15-year-old boy with chromosome 19p13.3 microdeletion, intellectual disability, colobomas, and drug-resistant epilepsy. He had near daily seizures characterized by eyelid fluttering, behavioral arrest, and unawareness with occasional progression to generalized tonic activity. Brain MRI showed diffuse white matter hyperintensities with a predilection for subcortical U-fibers. Video-EEG monitoring showed multifocal interictal discharges but a consistent ictal onset grossly in the left posterior temporal and occipital regions but with up to 10 seconds of electroclinical delay. Brain PET was unremarkable, but ictal SPECT (figures 1 and 2) revealed a discrete functional lesion in the left ventral occipital cortex. Here, ictal SPECT delineated the 3D borders of the seizure onset zone in the deep occipital cortex. This information can be used to further refine the epileptogenic zone (EZ) in a targeted stereo-EEG investigation to optimize surgical outcome1 and decrease SUDEP risk.2