Ictal PET in presurgical workup of refractory extratemporal epilepsy Javeria Nooraine, Rajesh B. Iyer, Seetharam Raghavendra Department of Neurology, Vikram Hospital, Bengaluru, Karnataka, India Abstract Ictal Pet in presurgical workup of refractory epilepsy is seldom performed and limited due to technical difficulties. In carefully selected patient subset with frequent extratemporal seizures, ictal PET depicts ‘seizure onset zone’ with high spatial resolution even within a widespread pathology. We here depict a four year old with posterior quadrant dysplasia evaluated with ictal PET.

Key Words Epilepsy, Ictal PET, presurgical workup, refractory For correspondence: Dr. S. Raghavendra, Department of Neurology, Vikram Hospital, Bengaluru ‑ 560 010, Karnataka, India.

E‑mail: [email protected]

Ann Indian Acad Neurol 2013;16:676-7

Introduction Ictal PET studies are limited by several technical difficulties but tend to have high spatial resolution and utility in a selected patient subset. We here report a case with refractory epilepsy evaluated by ictal PET.

Case A 4‑year‑girl was evaluated for medically refractory daily seizures of 2 years duration. Seizures started with ocular deviation to left with nystagmoid eye movements, followed by brief posturing of both limbs, kicking movements of the legs and restlessness lasting less than a minute. She was on five antiepileptic medications at evaluation. Examination was normal except for doubtful right hemifield visual deficit.

quadrant dysplasia [Figure 1]. Video‑EEG showed right posterior head region slowing and interictal epileptiform discharges with typical complex partial seizures arising from the right posterior head regions [Figure 2, see video]. Planned ictal positron emission tomography (PET) showed increased ictal metabolism in the right lateral parietal‑occipital region [Figure 3]. She underwent right posterior quadrant disconnection to remain seizure free at 2 year follow‑up.

Discussion FDG‑PET is a standard non‑invasive tool in presurgical refractory epilepsy evaluation with high spatial resolution

Magnetic resonance imaging (MRI) showed right posterior Videos available at

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DOI: 10.4103/0972-2327.120475

Figure 1: MRI brain (1.5T‑FLAIR sequence) showing right parietal‑temporal‑occiptal dysplasia with poor gray white differentiation (arrows)

Annals of Indian Academy of Neurology, October-December 2013, Vol 16, Issue 4

Nooraine, et al.: Ictal PET in refractory epilepsy presurgical workup


Figure 2: EEG during one during video‑EEG (bipolar showing right‑occipital 15 theta activity over the right onset

of the complex partial seizure anterior to posterior montage) hz rhythm evolving to 5‑7 hz posterior head region at seizure



Figure 3: PET imaging showing right temporo‑parietal interictal hypometabolism (a) that during seizure demonstrates hypermetabolism (b). Note the mildly increased metabolism in bilateral thalamus and basal ganglia with widespread hypometabolism diffusely in the ictal PET


than ictal SPECT.[1] Commonly, interictal PET is performed due to short 110‑minute FDG ligand half‑life. PET abnormalities are dynamic and variable. Interictal PET may show widespread hypometabolism than the ‘ictal onset zone’. This can be accurately clarified with ictal PET in selective patients with high seizure frequency more so in extratemporal epilepsies.[2] In patients with widespread or large area of MRI abnormality, ictal PET or ictal SPECT help localize ‘seizure onset zone’ within this abnormality that help planning invasive recordings, surgical resection, and prognosticate seizure outcomes after surgery. PET imaging is considered integral of the pediatric refractory epilepsy presurgical workup.[3]

1. 2. 3.

Van Paesschen W, Dupont P, Sunaert S, Goffin K, Van Laere K. The use of SPECT and PET in routineclinical practice in epilepsy. Curr Opin Neurol 2007;20:194‑202. Meltzer CC, Adelson PD, Brenner RP, Crumrine PK, Van Cott A, Schiff DP, et al. Planned ictal FDG PET imaging for localization of extratemporal epileptic foci. Epilepsia 2000;41:193‑200. Ollenberger GP, Byrne AJ, Berlangieri SU, Rowe CC, Pathmaraj K, Reutens DC, et al. Assessment of the role of FDG PET in the diagnosis and management of children with refractory epilepsy. Eur J Nucl Med Mol Imaging 2005;32:1311‑6. How to cite this article: Nooraine J, Iyer RB, Raghavendra S. Ictal PET in presurgical workup of refractory extratemporal epilepsy. Ann Indian Acad Neurol 2013;16:676-7. Received: 09‑05‑13, Revised: 23‑06‑13, Accepted: 23‑06‑13 Source of Support: Nil, Conflict of Interest: Nil

Annals of Indian Academy of Neurology, October-December 2013, Vol 16, Issue 4

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Ictal PET in presurgical workup of refractory extratemporal epilepsy.

Ictal Pet in presurgical workup of refractory epilepsy is seldom performed and limited due to technical difficulties. In carefully selected patient su...
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