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In the center of the city, in the center of life, with passion for care
Neuroimaging of EpilepsyFrom the first seizure to the disease
P. Jissendi Tchofo, MD, PhD
Radiologie CHU Saint-Pierre, Bruxelles
In the center of the city, in the center of life, with passion for care 4
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)
In the center of the city, in the center of life, with passion for care
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
In the center of the city, in the center of life, with passion for care
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)
In the center of the city, in the center of life, with passion for care
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/
In the center of the city, in the center of life, with passion for care
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
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
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
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
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
In the center of the city, in the center of life, with passion for care
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
In the center of the city, in the center of life, with passion for care10/12/2007
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
In the center of the city, in the center of life, with passion for care10/12/2007 23
Brain CT - hypodensity
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Brain metastasis (Lung): C- / C+
Brain CT - hypodensity
In the center of the city, in the center of life, with passion for care10/12/2007 26
Brain CT - hyperdensity
In the center of the city, in the center of life, with passion for care10/12/2007 27
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
In the center of the city, in the center of life, with passion for care
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
In the center of the city, in the center of life, with passion for care
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
In the center of the city, in the center of life, with passion for care10/12/2007
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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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
In the center of the city, in the center of life, with passion for care
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
In the center of the city, in the center of life, with passion for care10/12/2007
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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