Objective

Localization of seizure onset zone in focal epilepsy patients is a crucial step prior to surgical planning. Noninvasively achieving this goal would have a tremendous impact on clinical management of intractable seizure.

Methods

In a total of 39 focal epilepsy patients, we recorded and extracted 138 seizures and 1,325 interictal epileptic discharges using high-density EEG. We have investigated a novel approach for directly imaging sources of seizures and interictal spikes from high density EEG recordings, and rigorously validated it for noninvasive localization of seizure onset zone (SOZ) determined from intracranial EEG findings and surgical resection volume. Conventional source imaging analyses were also performed for comparison.

Results

Ictal source imaging showed a concordance rate of 95% when compared to intracranial EEG or resection results. The average distance from estimation to seizure onset (intracranial) electrodes is 1.35 cm in patients with concordant results, and 0.74 cm to surgical resection boundary in patients with successful surgery. About 41% of the patients were found to have multiple types of interictal activities; coincidentally, a lower concordance rate and a significantly worse performance in localizing SOZ were observed in these patients.

Interpretation

Noninvasive ictal source imaging with high-density EEG recording can provide highly concordant results with clinical decisions obtained by invasive monitoring or confirmed by resective surgery. By means of direct seizure imaging using high-density scalp EEG recordings, the added value of ictal source imaging is particularly high in patients with complex interictal activity patterns, who may represent the most challenging cases with poor prognosis.