Comparative analysis of MR imaging, Ictal SPECT and EEG in temporal lobe epilepsy: a prospective IAEA multi-center study

  • John J. ZaknunEmail author
  • Chandrasekhar Bal
  • Alex Maes
  • Supatporn Tepmongkol
  • Silvia Vazquez
  • Patrick Dupont
  • Maurizio Dondi
Original article


Background and purpose

MR imaging, ictal single-photon emission CT (SPECT) and ictal EEG play important roles in the presurgical localization of epileptic foci. This multi-center study was established to investigate whether the complementary role of perfusion SPECT, MRI and EEG for presurgical localization of temporal lobe epilepsy could be confirmed in a prospective setting involving centers from India, Thailand, Italy and Argentina.


We studied 74 patients who underwent interictal and ictal EEG, interictal and ictal SPECT and MRI before surgery of the temporal lobe. In all but three patients, histology was reported. The clinical outcome was assessed using Engel’s classification. Sensitivity values of all imaging modalities were calculated, and the add-on value of SPECT was assessed.


Outcome (Engel’s classification) in 74 patients was class I, 89%; class II, 7%; class III, 3%; and IV, 1%. Regarding the localization of seizure origin, sensitivity was 84% for ictal SPECT, 70% for ictal EEG, 86% for MRI, 55% for interictal SPECT and 40% for interictal EEG. Add-on value of ictal SPECT was shown by its ability to correctly localize 17/22 (77%) of the seizure foci missed by ictal EEG and 8/10 (80%) of the seizure foci not detected by MRI.


This prospective multi-center trial, involving centers from different parts of the world, confirms that ictal perfusion SPECT is an effective diagnostic modality for correctly identifying seizure origin in temporal lobe epilepsy, providing complementary information to ictal EEG and MRI.


Refractory epilepsy Epilepsy surgery Ictal SPECT MRI EEG 



The authors wish to thank the Nuclear Medicine Section, Division of Human Health, of the International Atomic Energy Agency (IAEA) for the efforts made to bring investigators together from around the world and for initiating, coordinating and financing this multi-center study (CRP: E1.30.21). The authors also wish to thank Dr. James Warwick, University of Stellenbosch, South Africa, and Dr. Gonca Civi, Cerrahpasa University, Turkey, for their interest in the study. The authors also wish to thank Mr. Bert Vanbilloen for the appreciated technical assistance.


  1. 1.
    Engel J Jr. Surgery for seizures. N Engl J Med 1996;334:647–53.PubMedCrossRefGoogle Scholar
  2. 2.
    Begley CE, Annegers JF, Lairson DR, Reynolds TF, Hauser WA. Cost of epilepsy in the United States: a model based on incidence and prognosis. Epilepsia 1994;35:1230–43.PubMedCrossRefGoogle Scholar
  3. 3.
    Wiebe S, Blume WT, Girvin JP, Eliasziw M. Effectiveness and efficiency of surgery for temporal lobe epilepsy study group. A randomized, controlled trial of surgery for temporal lobe epilepsy. N Engl J Med 2001;345:311–8.PubMedCrossRefGoogle Scholar
  4. 4.
    Engel J Jr, Wiebe S, French J, Sperling M, Williamson P, Spencer D, et al. Practice parameter: temporal lobe and localized neocortical resections for epilepsy: report of the quality standards subcommittee of the American Academy of Neurology, in association with the American Epilepsy Society and the American Association of Neurological Surgeons. Neurology 2003;60:538–47.PubMedGoogle Scholar
  5. 5.
    Cucherat M. Meta-analysis of surgery trials in refractory epilepsy. Rev Neurol (Paris) 2004;160(Spec No 1):5S232–40.Google Scholar
  6. 6.
    Nohria V, Lee N, Tien RD, Heinz ER, Smith JS, DeLong GR, et al. Magnetic resonance imaging evidence of hippocampal sclerosis in progression: a case report. Epilepsia 1994;35:1332–6.PubMedCrossRefGoogle Scholar
  7. 7.
    Fuerst D, Shah J, Shah A, Watson C. Hippocampal sclerosis is a progressive disorder: a longitudinal volumetric MRI study. Ann Neurol 2003;53:413–6.PubMedCrossRefGoogle Scholar
  8. 8.
    Deasy NP, Jarosz JM, Elwes RC, Polkey CE, Cox TC. Thalamic changes with mesial temporal sclerosis: MRI. Neuroradiology 2000;42:346–51.PubMedCrossRefGoogle Scholar
  9. 9.
    Breier JI, Mullani NA, Thomas AB, Whelees JW, Penger PM, Gould KL, et al. Effects of duration of epilepsy on the uncoupling of metabolism and blood flow in complex partial seizures. Neurology 1997;48:1047–53.PubMedGoogle Scholar
  10. 10.
    Jokeit H, Ebner A, Arnold S, Schuller M, Antke C, Huang Y, et al. Bilateral reductions of hippocampal volume, glucose metabolism, and Wada hemispheric memory performance are related to the duration of mesial temporal lobe epilepsy. J Neurol 1999;246:926–33.PubMedCrossRefGoogle Scholar
  11. 11.
    Spanaki MV, Kopylev L, DeCarli C, Gaillard WD, Liow K, Fazilat S, et al. Postoperative changes in cerebral metabolism in temporal lobe epilepsy. Arch Neurol 2000;57:1447–52.PubMedCrossRefGoogle Scholar
  12. 12.
    Vermathen P, Ende G, Laxer KD, Walker JA, Knowlton RC, Barbaro NM, et al. Temporal lobectomy for epilepsy: recovery of the contralateral hippocampus measured by 1H MRS. Neurology 2002;59:633–6.PubMedGoogle Scholar
  13. 13.
    Helmstaedter C, Kurthen M, Lux S, Reuber M, Elger CE. Chronic epilepsy and cognition: a longitudinal study in temporal lobe epilepsy. Ann Neurol 2003;54:425–32.PubMedCrossRefGoogle Scholar
  14. 14.
    Shukla G, Bhatia M, Singh VP, Jaiswal A, Tripathi M, Gaikwad S, et al. Successful selection of patients with intractable extratemporal epilepsy using non-invasive investigations. Seizure 2003;12:573–6.PubMedCrossRefGoogle Scholar
  15. 15.
    Rosenow F, Lueders H. Presurgical evaluation of epilepsy. Brain 2001;124:1683–700.PubMedCrossRefGoogle Scholar
  16. 16.
    Siegel AM. Presurgical evaluation and surgical treatment of medically refractory epilepsy. Neurosurg Rev 2004;27:1–18.PubMedCrossRefGoogle Scholar
  17. 17.
    Koslowsky IL, Brake SE, Bitner SJ. Evaluation of the stability of (99 m)Tc-ECD and stabilized (99m)Tc-HMPAO stored in syringes. Nucl Med Technol 2001;29:197–200.Google Scholar
  18. 18.
    Vanbilloen H, Dupont P, Mesotten L, Mortelmans L, Verbeke K, Verbruggen A, et al. Simple design for rapid self-injection ictal SPET during aura. Eur J Nucl Med 1999;26:1380–1.PubMedCrossRefGoogle Scholar
  19. 19.
    Engel JJ, Van Ness PC, Rasmussen TB, Ojemann LM. Outcome with respect to epileptic seizures. In: Engel JJ, editors. Surgical treatment of the epilepsies. New York: Raven Press; 1993. p. 609–22.Google Scholar
  20. 20.
    Hwang S, Kim J, Park S, Han M, Yu I, Lee S, et al. Comparative analysis of MR imaging, positron emission tomography, and Ictal single-photon emission CT in patients with neocortical epilepsy. AJNR 2001;22:937–46.PubMedGoogle Scholar
  21. 21.
    Henry T, Van Heertum. Positron emission tomography and single photon emission computed tomography in epilepsy care. Semin Nucl Med 2003;33:88–104.PubMedCrossRefGoogle Scholar
  22. 22.
    Markand ON. Pearls, perils, and pitfalls in the use of the electroencephalogram. Semin Neurol 2003;23:7–46.PubMedCrossRefGoogle Scholar
  23. 23.
    Lancman ME, Morris HH 3rd, Raja S, Sullivan MJ, Saha G, Go R. Usefulness of ictal and interictal 99 mTc ethyl cysteinate dimer single photon emission computed tomography in patients with refractory partial epilepsy. Epilepsia 1997;38:466–71.PubMedCrossRefGoogle Scholar
  24. 24.
    O’Brien TJ, So EL, Mullan BP, Hauser MF, Brinkmann BH, Bohnen NI, et al. Subtraction ictal SPECT co-registered to MRI improves clinical usefulness of SPECT in localizing the surgical seizure focus. Neurology 1998;50:445–54.PubMedGoogle Scholar
  25. 25.
    Ho SS, Berkovic SF, McKay WJ, Kalnins RM, Bladin PF. Temporal lobe epilepsy subtypes: differential patterns of cerebral perfusion on ictal SPECT. Epilepsia 1996;37:788–95.PubMedCrossRefGoogle Scholar
  26. 26.
    Harvey AS, Hopkins IJ, Bowe JM, Cook DJ, Shield LK, Berkovic SF. Frontal lobe epilepsy: clinical seizure characteristics and localization with ictal 99mTc-HMPAO SPECT. Neurology 1993;43:1966–80.PubMedGoogle Scholar
  27. 27.
    Ho SS, Berkovic SF, Newton MR, Austin MC, McKay WJ, Bladin PF. Parietal lobe epilepsy: clinical features and seizure localization by ictal SPECT. Neurology 1994;44:2277–84.PubMedGoogle Scholar
  28. 28.
    Duncan R, Biraben A, Patterson J, Hadley D, Bernard AM, Lecloirec J, et al. Ictal single photon emission computed tomography in occipital lobe seizures. Epilepsia 1997;38:839–43.PubMedCrossRefGoogle Scholar
  29. 29.
    Berkovic SF, McIntosh AM, Kalnins RM, Jackson GD, Fabinyi GC, Brazenor GA, et al. Preoperative MRI predicts outcome of temporal lobectomy. Neurology 1995;45:1358–63.PubMedGoogle Scholar
  30. 30.
    Radhakrishnan K, So EL, Silbert PL, Jack CR Jr, Cascino GD, Sharbrough FW, et al. Predictors of outcome of anterior temporal lobectomy for intractable epilepsy: a multivariate study. Neurology 1998;51:465–71.PubMedGoogle Scholar
  31. 31.
    Spencer SS. The relative contributions of MRI, SPECT, and PET imaging in epilepsy. Epilepsia 1994;35:S72–89.PubMedCrossRefGoogle Scholar
  32. 32.
    Devous MD Sr, Thisted RA, Morgan GF, Leroy RF, Rowe CC. SPECT brain imaging in epilepsy: a meta-analysis. J Nucl Med 1998;39:285–93.PubMedGoogle Scholar
  33. 33.
    Oliveira AJ, Da Costa JC, Hilario LN, Anselmi OE, Palmini A. Localization of the epileptogenic zone by ictal and interictal SPECT with 99mTc-ethyl cysteinate dimmer in patients with medically refractory epilepsy. Epilepsia 1999;40:693–702.PubMedCrossRefGoogle Scholar
  34. 34.
    Lee SK, Lee SH, Kim SK, Lee DS, Kim H. The clinical usefulness of ictal SPECT in temporal lobe epilepsy: the lateralization of seizure focus and correlation with EEG. Epilepsia 2000;41:955–62.PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag 2007

Authors and Affiliations

  • John J. Zaknun
    • 1
    • 8
    • 9
    Email author
  • Chandrasekhar Bal
    • 2
  • Alex Maes
    • 3
    • 4
  • Supatporn Tepmongkol
    • 5
  • Silvia Vazquez
    • 6
  • Patrick Dupont
    • 3
  • Maurizio Dondi
    • 7
    • 8
  1. 1.Department of Nuclear MedicineUniversity Hospital of InnsbruckInnsbruckAustria
  2. 2.Department of Nuclear MedicineAll India Institute of Medical SciencesNew DelhiIndia
  3. 3.Katholieke Universiteit LeuvenLeuvenBelgium
  4. 4.Department of Nuclear MedicineAZ GroeningeKortrijkBelgium
  5. 5.Nuclear Medicine Division, Department of RadiologyChulalongkorn UniversityBangkokThailand
  6. 6.Department of RadiologyInstituto de Investigaciones Neurologicas, FLENIBuenos AiresArgentina
  7. 7.Department of Nuclear MedicineOspedale MaggioreBolognaItaly
  8. 8.Nuclear Medicine Section, Division of Human HealthInternational Atomic Energy Agency (IAEA)ViennaAustria
  9. 9.Nuclear Medicine Section, Division of Human HealthIAEAWienAustria

Personalised recommendations