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Neuroimaging of EpilepsyFrom the first seizure to the disease

P. Jissendi Tchofo, MD, PhD

Radiologie CHU Saint-Pierre, Bruxelles

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EEG: definite diagnosis - TLE

REST PRE SEIZURE SEIZURE

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Epilepsy-related words definitions

• Convulsion: a sudden and involuntary contraction of the striate muscles

(symptom)

• Seizure: a transient occurrence of signs and/or symptoms due to

abnormal excessive or synchronous neuronal activity in the brain. The

term transient is used as demarcated in time, with a clear start and finish

• Convulsive seizure: a seizure which clinical expression is convulsion

• Epileptic seizure: a seizure which clinical expression is variable: motor

(convulsion), sensorial, vegetative, psycho/psychiatric, disturbances of

consciousness

• Epilepsy: recurrence of seizures

• Intractable epilepsy: recurrence of seizures despite treatment (AED)

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Idiopatic

Spec. Syndr

Unclassified

Partial, Foc Epil.

Gen. Diff. Epil.

Symptomatic

Cryptogenic

Miscell.

Clin-EEG

NI

ILAE, 1989, 2001; Engel, 2006

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GeneticmTOR

Spec. Syndr

Unclassified

Focal Epil. Nw within 1hem

Gen. Epil.Nws origin with

rapid diffusion to

both hem

Structural/MetabolicGenetic (scdry E.) vs acquired

DCX-MCD vs Disrupt-MCD

Unknown

Miscell.??

Clin-EEG

Etiology

ILAE, Berg & Scheffer, 2011

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GeneticmTOR

Spec. Syndr

Unclassified

Focal Epil. Nw within 1hem

Gen. Epil.Nws origin with

rapid diffusion to

both hem

Structural/MetabolicGenetic (scdry E.) vs acquired

DCX-MCD vs Disrupt-MCD

Unknown

Miscell.??

Clin-EEG

Etiology

ILAE, Berg & Scheffer, 2011

Spontaneous

resolution (BRE)

Pharmaco-

responsiveSurgical cure

(ETLE)

Intractable (TLE)

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L’épilepsie en Afrique

« (…) lorsqu'un père de famille voulait obtenir une très grande récolte, ou un autre

avantage, il devait offrir la vie de l'un de ses enfants en échange de ce service. Dès

que le pacte était conclu, l'enfant mourrait subitement pour des raisons dites

inconnues ou il devenait aliéné ou épileptique. » http://www.lueur.org/textes/sorcellerie-epilepsie.html

Epilepsie: conséquences sociales et aspects économique

Aide-mémoire N°166

La peur, l'incompréhension, l'opprobre et la discrimination sociale que suscite

l'épilepsie poussent souvent les malades à «se cacher dans l'ombre». Les

conséquences sociales de l'épilepsie peuvent varier d'un pays à l'autre ou d'une

culture à l'autre, mais il est certain que partout dans le monde, elles sont souvent

plus difficiles à supporter que les crises elles-mêmes.

Les problèmes qui en découlent se rencontrent en particulier dans les domaines des

relations interpersonnelles et parfois même de la législation. Ces problèmes nuisent

au traitement de l'épilepsie.http://www.who.int/mediacentre/factsheets/fs166/fr/

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L’épilepsie en Afrique

« (…) lorsqu'un père de famille voulait obtenir une très grande récolte, ou un autre

avantage, il devait offrir la vie de l'un de ses enfants en échange de ce service. Dès

que le pacte était conclu, l'enfant mourrait subitement pour des raisons dites

inconnues ou il devenait aliéné ou épileptique. » http://www.lueur.org/textes/sorcellerie-epilepsie.html

Epilepsie: conséquences sociales et aspects économique

Aide-mémoire N°166

La peur, l'incompréhension, l'opprobre et la discrimination sociale que suscite

l'épilepsie poussent souvent les malades à «se cacher dans l'ombre». Les

conséquences sociales de l'épilepsie peuvent varier d'un pays à l'autre ou d'une

culture à l'autre, mais il est certain que partout dans le monde, elles sont souvent

plus difficiles à supporter que les crises elles-mêmes.

Les problèmes qui en découlent se rencontrent en particulier dans les domaines des

relations interpersonnelles et parfois même de la législation. Ces problèmes nuisent

au traitement de l'épilepsie.http://www.who.int/mediacentre/factsheets/fs166/fr/

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Epilepsy in Africa

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Epilepsy in Africa

1. Hereditary/genetic2. Pre/Perinatal injuries3. Adult injuries

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Objectives

1. Neuroimaging: provide good answers to good clinical

questions (anatomic clinical correlation)

2. MRI features of epileptic lesions

3. Advanced MRI techniques

4. Status epilepticus

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Neuroimaging of epilepsy

Seizures

Epilepsy

Genetic / Syndromic

CT-MRI: - / +

Brainmalformation

/ lesion

CT-MRI: +

Circumstances

Clinicalmanagement

Brain imaging not required exceptunder serious

conditions

• History• Neurology• Biology• EEG

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Neuroimaging of epilepsy

Seizures

Epilepsy

Genetic / Syndromic

CT-MRI: - / +

Brainmalformation

/ lesion

CT-MRI: +

Circumstances

Clinicalmanagement

Brain imaging not required exceptunder serious

conditions

• History• Neurology• Biology• EEG

In the center of the city, in the center of life, with passion for care

Neuroimaging of epilepsy

Seizures

Epilepsy

Genetic / Syndromic

CT-MRI: - / +

Brainmalformation

/ lesion

CT-MRI: +

Circumstances

Clinicalmanagement

Brain imaging not required exceptunder serious

conditions

• History• Neurology• Biology• EEG

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Neuroimaging-negative epilepsies

1. Epileptic syndromes of the newborn: hyperthermic convulsions; epileptic

encephalopathy (metabolic, toxic, infectious; other…)

2. Epileptic syndromes in the infancy:

1. West syndrome

2. Dravet syndrome

3. Benign myoclonic epilepsy

4. Partial migrating seizures E

5. Partial benign epilepsy of the infant

3. Epileptic syndromes in the childhood

1. Generalized idiopathic E: E-absences, myoclonic absences, straight

generalized E (“grand-mal”)

2. Partial complex idiopathic E: centro-temporal peaks (CTPE) , occipital

paroxysms

3. Symptomatic or cryptogenic generalized E: Lennox-Gastaut syndrome,

myoclonic astatic (Doose syndrome, encephalopathic E)

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• Complicated hyperthermic seizures (<1yr, half body)

• Infantile spasms + hypsarrhythmia (EEG) + MR (West syndrome)

• Persistent Partial Epilepsy (Kojewnikow S): vascular, immune,

neoplasic or metabolic-toxic

1. Many epileptic syndromes are specific to

childhood

2. Many forms of childhood onset epilepsies

resolve by adolescence or adulthood

Neuroimaging-pediatric epilepsies

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Épilepsie myoclonique

juvénileCrise tonico-clonique

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Neuroimaging of epilepsyFirst seizure: Brain CT scan

1. Hypodensity: ischemia, edema-lesion, cyst, pericerebral

collections,…

2. Hyperdensity: hemorrhage, calcifications, thrombosis,

vascular malformation,…

3. Enhancement

4. Mass effect

5. Malformation

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Brain CT - hypodensity

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Brain CT - hypodensity

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Brain CT - hypodensity

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Brain metastasis (Lung): C- / C+

Brain CT - hypodensity

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Brain CT - hypodensity

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Brain CT - hyperdensity

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Brain CT - hyperdensity

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Brain CT - hyperdensity

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Brain CT - hyperdensity

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STB SWS

Brain CT - hyperdensity

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Mass effect (Tumor): C-

Brain CT – mixed densities

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Brain CT – mixed densitiesHIV Neurocysticercosis

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Neuroimaging of epilepsy

Epilepsy assessment: MRI >>> CT

Seizures

Epilepsy

Genetic / Syndromic

CT-MRI: - / +

Brainmalformation

/ lesion

CT-MRI: +

Circumstances

Clinicalmanagement

Brain imaging not required exceptunder serious

conditions

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Epilepsie de l’enfant

Lésions séquellaires • Porencéphalie

• Atrophie focale

• Sclérose mésiotemporale (hippocampique)

• Cicatrice gliale

Anomalies du développement• Dysplasie corticale

• Hétérotopies de substance grise

• Kyste arachnoïdien

• Hamartome hypothalamique

Lésions évolutives • Neurofibromatoses

• Sclérose tubéreuse de Bourneville

• Sturge-Weber

• Erreurs innées du métabolisme

Tumeurs • Temporales (DNET, Gangliogliomes, Astrocytome)

• Autres

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SMT55%

SHI27%

T12%

MV2%

GC2%

AD2%

Fréquence (%)

10/12/2007

Epilepsie de l’adulte

• Epilepsie débutante

• Lésion évolutive (Tumeur)

• MAV, cavernome

• Hématome

• Séquelle: anoxie néonatale, encéphalite, trauma

• Epilepsie pharmacorésistante

• Sclérose de l'hippocampe

• Dysplasie

• DNET

• Cavernome

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Epilepsie autre

IRM - Protocole

Axial 3D T1

Axial FLAIR

(Axial T1-IR vs 3D DIR)

Coronal T2 HR

Diffusion / DTI

Spectroscopie

(+ Gd)

Epilepsie temporale

Coronal T2 HR

Coronal T1-IR

Coronal FLAIR

Axial FLAIR

Spectroscopie

Diffusion / DTI

Axial 3D T1 (+ Gd)

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IRM - TLE

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Bb garçon 7sem, epilepsie à 4sem

Lissencephalie - Agyrie

Jissendi-Tchofo, 2009

Malformations du développement cortical

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MGS (PC: -3DS)

Verloes, 2007; Murray, 2012

Malformations du développement cortical

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Malformations du développement corticalDCX

Jissendi-Tchofo, 2009

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subependymal single or multiple nodular heterotopia

Malformations du développement cortical

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Malformations du développement cortical

DCF

Fauser, 2009

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Malformations du développement cortical

(DD)

STBDCF

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Malformations du développement cortical

(DD)

DCFDWI

AVCI

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DNET(dysembryoplastic neuroepithelial tumor)

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Séquelles traumatiques

1. Atrophie loco-régionale

2. Gliose cicatricielle

3. Sidérose superficielle

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Sclérose

Mésio-Temporale

• Hypersignal T2

hippocampe

• Atrophie

hippocampe

• Elargissement

asymétrique corne

temporale

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Temporal lobe tumors

DNET GangliogliomaDNET

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Encéphalopathie métabolique

• anomalies symmétriques de la SB/SG

• Cytopathie mitochondriale (anomalies NGC, spectro-lactate)

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Encéphalopathie métabolique

• anomalies symmétriques de la SB/SG

• Cytopathie mitochondriale (anomalies NGC, spectro-lactate)

CO

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Encéphalopathie métabolique

• anomalies symmétriques de la SB/SG

• Cytopathie mitochondriale (anomalies NGC, spectro-lactate)

SV TE 144ms

Leigh

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Status Epilepticus

Trinka et al, 2015

SE is a condition resulting either from the failure of the mechanisms responsible for seizure termination or from the

initiation of mechanisms which lead to abnormally prolonged seizures (after time point t1 ).

It’s a condition that can have long-term consequences (after time point t2 ), including neuronal death, neuronal

injury, and alteration of neuronal networks, depending on the type and duration of seizures.

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1. Perfusion disturbances (PRESS syndrome)

2. Glutamate-mediated excitotoxicity (DWI/ADC anomalies, Diaschisis)

3. Cortical neuronal necrosis (Wallerian/Pulvinar degeneration)

Status Epilepticus

1

2

3

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Neuroimaging of epilepsy

Seizures

Epilepsy

Cryptogenic

CT-MRI -

Genetic / Syndromic

CT-MRI: - / +

Brainmalformation

/ lesion

CT-MRI: +

Circumstances

Clinicalmanagement

Brain imaging not required exceptunder serious

conditions

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HREEG - IRMf

F. Babiloni et al. /

NeuroImage 19 (2003) 1–15

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Conclusion: neuroimagerie de l’épilepsie

1. Bien connaitre la maladie

2. Connaitre les objectifs de l’imagerie dans ce contexte

3. Utiliser au mieux les techniques disponibles (CT – IRM)

pour permettre un diagnostic correct et une prise en

charge adéquate du patient

4. Les anomalies observées peuvent être les

conséquences de l’épilepsie

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Conclusion: neuroimaging of epilepsy