Epilepsy getting the most out of neuroimaging 2019
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This document discusses the use of neuroimaging techniques to evaluate epilepsy. It begins by discussing the technical aspects of modern neuroimaging and how epilepsy appears on imaging studies. It then reviews the role of imaging in pre-operative planning. The document provides examples of different pathologies visible on imaging and emphasizes using a multiparametric approach, including 3T MRI, PET, DTI, fMRI and other modalities to localize the epileptic focus when it is not visible on standard MRI. It stresses using advanced techniques like 3T to increase resolution and minimize motion artifacts. The goal is to identify otherwise "invisible" lesions through pattern recognition and an integrated imaging approach.
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Epilepsy getting the most out of neuroimaging 2019
- 1. Getting the most out of our Neuroimaging felice.d’arco@gosh.nhs.uk
- 2. Summary Technical Aspects of Modern neuroimaging in Epilepsy How a brain with epilepsy looks like… (some fascinating cases) Role of Imaging in pre-operative planning
- 3. What is needed to see the “invisible”? Power!
- 4. 1.5 T 3 T “With 3T comes great sensitivity to motion”
- 5. 11 y old boy, mother refused GA ? 3T scanner is extremely sensitive to flow and motion artefacts Needs expert set up of the sequences and low threshold for scan under GA or deep sedation in epilepsy patients 3D acquisitions with reformats are essential in imaging of epilepsy , but the motion artefacts in the original sequence are also in the reformats!
- 6. ting the most out of our Neuroimaging: alternative ways to increase patient’s complia Inflatable MRI scanner Olivia, 6 y old
- 7. 3 T 1.5 T FCD type II B Volumetric Acquisition 3 T 1.5 T
- 8. MPR and Volume rendering reformats Surface anatomy better for Neurosurgeons!
- 9. Goal of Neuroimages in Epilepsy : To find the Invisible Nuclear medicine: PET & SPECT 3T MRI Functional MRI Diffusion Tensor Imaging: to visualise white matter tracts Perfusion Imaging Stereotactic EEG Magneto encephalograp hy Multidisciplinary Approach!!
- 10. GOSH Epilepsy MRI Protocol 3D T1 3D IR T2 axial T2 cor FLAIR 3D Optional Sequences: - Susceptibility Weighted Images - Diffusion Tensor Imaging - Arterial Spin labelling (perfusion)
- 11. The international consensus classification of Focal Cortical Dysplasia What’s important for the radiologist? FCD type 1 : usually not visible on MRI Look for indirect signs : atrophy, hyperplasia, abnormal sulcation/gyration FCD type II: often seen grey/white matter blurring and hyperintense signal of subcortical white matter Neuropathol Appl Neurobiol 2018 Feb;44(1):18-31
- 13. Isolated FCD type 2B
- 14. Isolated FCD type 2b (infant) Grey/white matter blurring Abnormal signal in T2 of the subcortical white matter Abnormal gyration/sulcation Transmatle sign
- 16. Isolated FCD type 2A Not always seen on MRI Blurring of grey/white matter junction More challenging than IIB
- 17. Slight asymmetry in size and gyration of right (+) vs left frontal hemisphere Blurring of grey/white matter junction??? Isolated FCD type 2A+ Low grade lesion in cerebellum (mTOR somatic mutation?) Shrot et al. Neuroradiology 2018.
- 18. Small hippocampus Bright signal T2 Association with FCD: Type IIIa Mesio-temporal sclerosis Pearl: Inclination of the coronal perpendicularly to the hippocampal axis.
- 19. 1.5 Tesla 3 mm slice thickness 5:21 3 Tesla 2.5 mm slice thickness 5:42 F 12 y febrile conv @ 1 yr; Complex Partial Sz, normal IQ Scans 3 months apart Courtesy Dr. K. Chong
- 20. 13 y F, temporal lobe seizures dysembryoplastic neuroepithelial tumor (DNET) Pearl: Hyperintense rim in FLAIR, no enhancement (DDX with gangliogliomas)
- 21. 7 y F, temporal lobe seizures Enhancement, no FLAIR rim sign: Ganglioglioma! Pearl: FCD associated with DNET or GangliogliomaFCD IIIB Pearl (II): In case of epilepsy associated tumors use contrast!
- 22. 14 y M, sudden onset of seizures, vomiting, lethargy Familiar Cerebral Cavernous Malformation: look for mutation in CCM; KRIT1, CCM2 and PDCD10 Pearl: Use specific sequences sensible to calcium/blood (SWI, T2*)
- 23. Companion case: 8 months, 4 limbs motor disorder and microcephaly, deafness Diffuse Polymicrogyria due to Congenital CMV
- 24. Companion case: 2 weeks old seizures and hypotonia. Localized polymicrogyria Hypomyelination (trust me) Zellweger Syndrome: PEX1 gene
- 25. MRI Pattern Recognition: seizure + brain appearances Hypoglycaemia SWS MCA infarction Lissencephaly Vigabatrin toxicity
- 26. PET scan is used to localize the part of the brain that is causing the seizure activity
- 27. 8 y M, focal seizures but MRI initially negative. Inter-ictal PET Nooraine J et al. 2013
- 28. Left inferior frontal abnormality? 2005 2006 2008 2016 3T :
- 29. MEG (magnetoencephalography) MEG measures small electrical currents arising inside the neurons of the brain. Skull and soft tissue affect MEG less than EEG Combination with MRI, EEG and PET
- 30. PET: confirmation Multiparametric Approach to Find the Epileptic Focus !
- 31. DTI and tractography: we see the white matter tracts in the brain “Diffusion tensor imaging (DTI) tractography allows perform virtual dissections of white matter pathways in the living human brain” Catani M. We use the diffusion of the water along tubular structures to visualise white matter fibres corticospinal tract is a white matter motor pathway controlling movements of the limbs and trunk
- 32. Neurosurgery. 2017;64(CN_suppl_1):1-10. Pre-Operative Planning: Diffusion tensor Imaging Cortico-Spinal tract FCD
- 33. fMRI: we see the neuronal activity in the brain: motor Hand movement feet movement
- 34. Normal left Lateralisation of the language Language fMRI in a patient with epilepsy and a lesion. (Beers CA and Federico P. 2012)
- 35. Intra-operative techniques to identify eloquence Anatomical Orientation Ant Sup
- 36. Take home messages Technical Aspect: you need high resolution images, with 3T MRI and without artefacts Pattern recognition: DDX epileptogenic pathologies, look for the “invisible”. Multiparametric approach: find the lesion and aid surgery http://www.slideshare.net/bluetango84
- 37. Thank you Pompei and Ercolano Ruins - Naples
Editor's Notes
- Thank you organisers
- FIRST THING NECESSARY TO SEE THE “INVISIBLE”
- A powerful MRI is like a Ferrari difficult to drive
- This scan will be diagnostic for major of pathologies including tumour but is not in case of epilepsy. Of course this means money and some slightly increased risks
- Inflatable
- Isotropic high resolution acquisition is important because 1mm resolution allows to pick up very small lesions. Note also that this specific lesion being a FCD type 2 B was visible in T2 already but the grey white matter contrast is far better in 3T
- Multi modality , we will see some example later on.
- Gosh epilepsy protocol
- Consensus images FCD
- TSC visible extremely easy , we will start with the type II b which is the easiest.
- Same entity but isolated, difficult but still visible. Histo: complete dyslamination with large Taylor-type “balloon” neurons in dysplastic cortex
- Less or more evident.
- Histo: disorganised layers and dysmorphic neurons.
- Fcd 1 a in mtor, invisible but we have other clue
- Another example, brighter but not so small
- 874202 if you have suspect of something specific we need to know because not all the MRI are the same and we need specific sequences.
- Dipende dal momento in cui l’infezione si e’ sviluppata: 2 semestre hanno malformazioni a fine gestazione hanno anomalie della bianca. Tutte possono avere ceclificazioni
- can be due to different diseases with different MRI appearances