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February 05, 2019; 92 (6) ArticleOpen Access

Electromagnetic source imaging in presurgical workup of patients with epilepsy

A prospective study

Lene Duez, Hatice Tankisi, Peter Orm Hansen, Per Sidenius, Anne Sabers, Lars H. Pinborg, Martin Fabricius, György Rásonyi, Guido Rubboli, Birthe Pedersen, Anne-Mette Leffers, Peter Uldall, Bo Jespersen, Jannick Brennum, Otto Mølby Henriksen, Anders Fuglsang-Frederiksen, Sándor Beniczky
First published January 4, 2019, DOI: https://doi.org/10.1212/WNL.0000000000006877
Lene Duez
From the Departments of Clinical Neurophysiology (L.D., H.T., P.O.H., A.F.-F., S.B.) and Neurology (P.S.), Aarhus University Hospital; Departments of Neurology (A.S., L.H.P.), Clinical Neurophysiology (M.F., G. Rásonyi), Pediatrics, Child Neurology (P.U.), Neurosurgery (B.J., J.B.), and Clinical Physiology, Nuclear Medicine and PET (O.M.H.), Copenhagen University Hospital Rigshospitalet; Danish Epilepsy Centre (G. Rubboli, B.P., S.B.), Dianalund; and Department of Diagnostic Radiology (A.-M.L.), Hvidovre Hospital, Denmark.
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Hatice Tankisi
From the Departments of Clinical Neurophysiology (L.D., H.T., P.O.H., A.F.-F., S.B.) and Neurology (P.S.), Aarhus University Hospital; Departments of Neurology (A.S., L.H.P.), Clinical Neurophysiology (M.F., G. Rásonyi), Pediatrics, Child Neurology (P.U.), Neurosurgery (B.J., J.B.), and Clinical Physiology, Nuclear Medicine and PET (O.M.H.), Copenhagen University Hospital Rigshospitalet; Danish Epilepsy Centre (G. Rubboli, B.P., S.B.), Dianalund; and Department of Diagnostic Radiology (A.-M.L.), Hvidovre Hospital, Denmark.
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Peter Orm Hansen
From the Departments of Clinical Neurophysiology (L.D., H.T., P.O.H., A.F.-F., S.B.) and Neurology (P.S.), Aarhus University Hospital; Departments of Neurology (A.S., L.H.P.), Clinical Neurophysiology (M.F., G. Rásonyi), Pediatrics, Child Neurology (P.U.), Neurosurgery (B.J., J.B.), and Clinical Physiology, Nuclear Medicine and PET (O.M.H.), Copenhagen University Hospital Rigshospitalet; Danish Epilepsy Centre (G. Rubboli, B.P., S.B.), Dianalund; and Department of Diagnostic Radiology (A.-M.L.), Hvidovre Hospital, Denmark.
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Per Sidenius
From the Departments of Clinical Neurophysiology (L.D., H.T., P.O.H., A.F.-F., S.B.) and Neurology (P.S.), Aarhus University Hospital; Departments of Neurology (A.S., L.H.P.), Clinical Neurophysiology (M.F., G. Rásonyi), Pediatrics, Child Neurology (P.U.), Neurosurgery (B.J., J.B.), and Clinical Physiology, Nuclear Medicine and PET (O.M.H.), Copenhagen University Hospital Rigshospitalet; Danish Epilepsy Centre (G. Rubboli, B.P., S.B.), Dianalund; and Department of Diagnostic Radiology (A.-M.L.), Hvidovre Hospital, Denmark.
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Anne Sabers
From the Departments of Clinical Neurophysiology (L.D., H.T., P.O.H., A.F.-F., S.B.) and Neurology (P.S.), Aarhus University Hospital; Departments of Neurology (A.S., L.H.P.), Clinical Neurophysiology (M.F., G. Rásonyi), Pediatrics, Child Neurology (P.U.), Neurosurgery (B.J., J.B.), and Clinical Physiology, Nuclear Medicine and PET (O.M.H.), Copenhagen University Hospital Rigshospitalet; Danish Epilepsy Centre (G. Rubboli, B.P., S.B.), Dianalund; and Department of Diagnostic Radiology (A.-M.L.), Hvidovre Hospital, Denmark.
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Lars H. Pinborg
From the Departments of Clinical Neurophysiology (L.D., H.T., P.O.H., A.F.-F., S.B.) and Neurology (P.S.), Aarhus University Hospital; Departments of Neurology (A.S., L.H.P.), Clinical Neurophysiology (M.F., G. Rásonyi), Pediatrics, Child Neurology (P.U.), Neurosurgery (B.J., J.B.), and Clinical Physiology, Nuclear Medicine and PET (O.M.H.), Copenhagen University Hospital Rigshospitalet; Danish Epilepsy Centre (G. Rubboli, B.P., S.B.), Dianalund; and Department of Diagnostic Radiology (A.-M.L.), Hvidovre Hospital, Denmark.
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Martin Fabricius
From the Departments of Clinical Neurophysiology (L.D., H.T., P.O.H., A.F.-F., S.B.) and Neurology (P.S.), Aarhus University Hospital; Departments of Neurology (A.S., L.H.P.), Clinical Neurophysiology (M.F., G. Rásonyi), Pediatrics, Child Neurology (P.U.), Neurosurgery (B.J., J.B.), and Clinical Physiology, Nuclear Medicine and PET (O.M.H.), Copenhagen University Hospital Rigshospitalet; Danish Epilepsy Centre (G. Rubboli, B.P., S.B.), Dianalund; and Department of Diagnostic Radiology (A.-M.L.), Hvidovre Hospital, Denmark.
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György Rásonyi
From the Departments of Clinical Neurophysiology (L.D., H.T., P.O.H., A.F.-F., S.B.) and Neurology (P.S.), Aarhus University Hospital; Departments of Neurology (A.S., L.H.P.), Clinical Neurophysiology (M.F., G. Rásonyi), Pediatrics, Child Neurology (P.U.), Neurosurgery (B.J., J.B.), and Clinical Physiology, Nuclear Medicine and PET (O.M.H.), Copenhagen University Hospital Rigshospitalet; Danish Epilepsy Centre (G. Rubboli, B.P., S.B.), Dianalund; and Department of Diagnostic Radiology (A.-M.L.), Hvidovre Hospital, Denmark.
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Guido Rubboli
From the Departments of Clinical Neurophysiology (L.D., H.T., P.O.H., A.F.-F., S.B.) and Neurology (P.S.), Aarhus University Hospital; Departments of Neurology (A.S., L.H.P.), Clinical Neurophysiology (M.F., G. Rásonyi), Pediatrics, Child Neurology (P.U.), Neurosurgery (B.J., J.B.), and Clinical Physiology, Nuclear Medicine and PET (O.M.H.), Copenhagen University Hospital Rigshospitalet; Danish Epilepsy Centre (G. Rubboli, B.P., S.B.), Dianalund; and Department of Diagnostic Radiology (A.-M.L.), Hvidovre Hospital, Denmark.
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Birthe Pedersen
From the Departments of Clinical Neurophysiology (L.D., H.T., P.O.H., A.F.-F., S.B.) and Neurology (P.S.), Aarhus University Hospital; Departments of Neurology (A.S., L.H.P.), Clinical Neurophysiology (M.F., G. Rásonyi), Pediatrics, Child Neurology (P.U.), Neurosurgery (B.J., J.B.), and Clinical Physiology, Nuclear Medicine and PET (O.M.H.), Copenhagen University Hospital Rigshospitalet; Danish Epilepsy Centre (G. Rubboli, B.P., S.B.), Dianalund; and Department of Diagnostic Radiology (A.-M.L.), Hvidovre Hospital, Denmark.
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Anne-Mette Leffers
From the Departments of Clinical Neurophysiology (L.D., H.T., P.O.H., A.F.-F., S.B.) and Neurology (P.S.), Aarhus University Hospital; Departments of Neurology (A.S., L.H.P.), Clinical Neurophysiology (M.F., G. Rásonyi), Pediatrics, Child Neurology (P.U.), Neurosurgery (B.J., J.B.), and Clinical Physiology, Nuclear Medicine and PET (O.M.H.), Copenhagen University Hospital Rigshospitalet; Danish Epilepsy Centre (G. Rubboli, B.P., S.B.), Dianalund; and Department of Diagnostic Radiology (A.-M.L.), Hvidovre Hospital, Denmark.
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Peter Uldall
From the Departments of Clinical Neurophysiology (L.D., H.T., P.O.H., A.F.-F., S.B.) and Neurology (P.S.), Aarhus University Hospital; Departments of Neurology (A.S., L.H.P.), Clinical Neurophysiology (M.F., G. Rásonyi), Pediatrics, Child Neurology (P.U.), Neurosurgery (B.J., J.B.), and Clinical Physiology, Nuclear Medicine and PET (O.M.H.), Copenhagen University Hospital Rigshospitalet; Danish Epilepsy Centre (G. Rubboli, B.P., S.B.), Dianalund; and Department of Diagnostic Radiology (A.-M.L.), Hvidovre Hospital, Denmark.
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Bo Jespersen
From the Departments of Clinical Neurophysiology (L.D., H.T., P.O.H., A.F.-F., S.B.) and Neurology (P.S.), Aarhus University Hospital; Departments of Neurology (A.S., L.H.P.), Clinical Neurophysiology (M.F., G. Rásonyi), Pediatrics, Child Neurology (P.U.), Neurosurgery (B.J., J.B.), and Clinical Physiology, Nuclear Medicine and PET (O.M.H.), Copenhagen University Hospital Rigshospitalet; Danish Epilepsy Centre (G. Rubboli, B.P., S.B.), Dianalund; and Department of Diagnostic Radiology (A.-M.L.), Hvidovre Hospital, Denmark.
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Jannick Brennum
From the Departments of Clinical Neurophysiology (L.D., H.T., P.O.H., A.F.-F., S.B.) and Neurology (P.S.), Aarhus University Hospital; Departments of Neurology (A.S., L.H.P.), Clinical Neurophysiology (M.F., G. Rásonyi), Pediatrics, Child Neurology (P.U.), Neurosurgery (B.J., J.B.), and Clinical Physiology, Nuclear Medicine and PET (O.M.H.), Copenhagen University Hospital Rigshospitalet; Danish Epilepsy Centre (G. Rubboli, B.P., S.B.), Dianalund; and Department of Diagnostic Radiology (A.-M.L.), Hvidovre Hospital, Denmark.
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Otto Mølby Henriksen
From the Departments of Clinical Neurophysiology (L.D., H.T., P.O.H., A.F.-F., S.B.) and Neurology (P.S.), Aarhus University Hospital; Departments of Neurology (A.S., L.H.P.), Clinical Neurophysiology (M.F., G. Rásonyi), Pediatrics, Child Neurology (P.U.), Neurosurgery (B.J., J.B.), and Clinical Physiology, Nuclear Medicine and PET (O.M.H.), Copenhagen University Hospital Rigshospitalet; Danish Epilepsy Centre (G. Rubboli, B.P., S.B.), Dianalund; and Department of Diagnostic Radiology (A.-M.L.), Hvidovre Hospital, Denmark.
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Anders Fuglsang-Frederiksen
From the Departments of Clinical Neurophysiology (L.D., H.T., P.O.H., A.F.-F., S.B.) and Neurology (P.S.), Aarhus University Hospital; Departments of Neurology (A.S., L.H.P.), Clinical Neurophysiology (M.F., G. Rásonyi), Pediatrics, Child Neurology (P.U.), Neurosurgery (B.J., J.B.), and Clinical Physiology, Nuclear Medicine and PET (O.M.H.), Copenhagen University Hospital Rigshospitalet; Danish Epilepsy Centre (G. Rubboli, B.P., S.B.), Dianalund; and Department of Diagnostic Radiology (A.-M.L.), Hvidovre Hospital, Denmark.
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Sándor Beniczky
From the Departments of Clinical Neurophysiology (L.D., H.T., P.O.H., A.F.-F., S.B.) and Neurology (P.S.), Aarhus University Hospital; Departments of Neurology (A.S., L.H.P.), Clinical Neurophysiology (M.F., G. Rásonyi), Pediatrics, Child Neurology (P.U.), Neurosurgery (B.J., J.B.), and Clinical Physiology, Nuclear Medicine and PET (O.M.H.), Copenhagen University Hospital Rigshospitalet; Danish Epilepsy Centre (G. Rubboli, B.P., S.B.), Dianalund; and Department of Diagnostic Radiology (A.-M.L.), Hvidovre Hospital, Denmark.
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Citation
Electromagnetic source imaging in presurgical workup of patients with epilepsy
A prospective study
Lene Duez, Hatice Tankisi, Peter Orm Hansen, Per Sidenius, Anne Sabers, Lars H. Pinborg, Martin Fabricius, György Rásonyi, Guido Rubboli, Birthe Pedersen, Anne-Mette Leffers, Peter Uldall, Bo Jespersen, Jannick Brennum, Otto Mølby Henriksen, Anders Fuglsang-Frederiksen, Sándor Beniczky
Neurology Feb 2019, 92 (6) e576-e586; DOI: 10.1212/WNL.0000000000006877

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Abstract

Objective To determine the diagnostic accuracy and clinical utility of electromagnetic source imaging (EMSI) in presurgical evaluation of patients with epilepsy.

Methods We prospectively recorded magnetoencephalography (MEG) simultaneously with EEG and performed EMSI, comprising electric source imaging, magnetic source imaging, and analysis of combined MEG-EEG datasets, using 2 different software packages. As reference standard for irritative zone (IZ) and seizure onset zone (SOZ), we used intracranial recordings and for localization accuracy, outcome 1 year after operation.

Results We included 141 consecutive patients. EMSI showed localized epileptiform discharges in 94 patients (67%). Most of the epileptiform discharge clusters (72%) were identified by both modalities, 15% only by EEG, and 14% only by MEG. Agreement was substantial between inverse solutions and moderate between software packages. EMSI provided new information that changed the management plan in 34% of the patients, and these changes were useful in 80%. Depending on the method, EMSI had a concordance of 53% to 89% with IZ and 35% to 73% with SOZ. Localization accuracy of EMSI was between 44% and 57%, which was not significantly different from MRI (49%–76%) and PET (54%–85%). Combined EMSI achieved significantly higher odds ratio compared to electric source imaging and magnetic source imaging.

Conclusion EMSI has accuracy similar to established imaging methods and provides clinically useful, new information in 34% of the patients.

Classification of evidence This study provides Class IV evidence that EMSI had a concordance of 53%–89% and 35%–73% (depending on analysis) for the localization of epileptic focus as compared with intracranial recordings—IZ and SOZ, respectively.

Glossary

BESA=
Brain Electrical Source Analysis;
cEMSI=
combined electromagnetic source imaging;
DSM=
distributed source model;
ECD=
equivalent current dipole;
ED=
epileptiform discharge;
EMSI=
electromagnetic source imaging;
ESI=
EEG source imaging;
FDG=
18F-fluorodeoxyglucose;
FLAIR=
fluid-attenuated inversion recovery;
FN=
false negative;
FP=
false positive;
GLM=
generalized linear model;
ICR=
intracranial recording;
IZ=
irritative zone;
MDT=
multidisciplinary team;
MEG=
magnetoencephalography;
MPRAGE=
magnetization-prepared rapid-acquisition gradient echo;
MSI=
magnetoencephalography source imaging;
NPV=
negative predictive value;
OR=
odds ratio;
PPV=
positive predictive value;
SOZ=
seizure onset zone;
TN=
true negative;
TP=
true positive

Footnotes

  • Go to Neurology.org/N for full disclosures. Funding information and disclosures deemed relevant by the authors, if any, are provided at the end of the article.

  • ↵* These authors contributed equally to this work.

  • The Article Processing Charge was funded by the Danish Epilepsy Centre, Filadelfia.

  • CME Course: NPub.org/cmelist

  • Class of Evidence: NPub.org/coe

  • Received April 11, 2018.
  • Accepted in final form October 2, 2018.
  • Copyright © 2019 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the American Academy of Neurology.

This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives License 4.0 (CC BY-NC-ND), which permits downloading and sharing the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.

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