F-FDG PET and high-resolution MRI co-registration for pre-surgical evaluation of patients with conventional MRI-negative refractory extra-temporal lobe epilepsy.

Purpose: Epilepsy that originates outside of the temporal lobe can present some of the most challenging problems for surgical therapy, especially for patients with conventional magnetic resonance imaging (MRI)-negative refractory extra-temporal lobe epilepsy (ETLE). This study aimed to evaluate the clinical value of pre-surgical F-fluoro-deoxy-glucose positron emission tomography (F-FDG PET) and high-resolution MRI (HR-MRI) co-registration in patients with conventional MRI-negative refractory ETLE, and compare their surgical outcomes.

Methods: Sixty-seven patients with conventional MRI-negative refractory ETLE were prospectively included for pre-surgical F-FDG PET and HR-MRI examinations. Under the guidance of F-FDG PET and HR-MRI co-registration, HR-MRI images were re-read. Based on the image result changes from first reading to re-reading, patients were divided into three groups: Change-1 (lesions of subtle abnormality could be identified in re-read), Change-2 (non-specific abnormalities reported in the first reading were considered as lesions on HR-MRI re-read) and No-change. Post-surgical follow-ups were conducted for up to 59 months.

Results: Visual analysis of F-FDG PET showed focal or regional abnormality in 46 patients (68.6%), while the abnormal rate increased to 94.0% (P < 0.05) by co-registration. Of the 67 patients, 46.3% of them were identified as Change-1, and 11.9% as Change-2 after co-registration and HR-MRI re-read. Patients with Change-1 and -2 were more likely to be recommended to receive surgical resection (P < 0.001). In the 17 post-surgical patients, 88% had good outcomes, whereas 11.7% had poor outcomes during our study period.

Conclusion: Pre-surgical evaluation by co-registration of F-FDG PET and HR-MRI could improve the identification of the epileptogenic onset zone (EOZ), and may further guide the surgical decision-making and improve the outcome of the refractory ETLE with normal conventional MRI; therefore, it should be recommended as a standard procedure for pre-surgical evaluation of these patients.