Combined electroencephalography–functional magnetic resonance imaging and electrical source imaging improves localization of pediatric focal epilepsy

Objective Surgical treatment in epilepsy is effective if the epileptogenic zone (EZ) can be correctly localized and characterized. Here we use simultaneous electroencephalography–functional magnetic resonance imaging (EEG‐fMRI) data to derive EEG‐fMRI and electrical source imaging (ESI) maps. Their yield and their individual and combined ability to (1) localize the EZ and (2) predict seizure outcome were then evaluated. Methods Fifty‐three children with drug‐resistant epilepsy underwent EEG‐fMRI. Interictal discharges were mapped using both EEG‐fMRI hemodynamic responses and ESI. A single localization was derived from each individual test (EEG‐fMRI global maxima [GM]/ESI maximum) and from the combination of both maps (EEG‐fMRI/ESI spatial intersection). To determine the localization accuracy and its predictive performance, the individual and combined test localizations were compared to the presumed EZ and to the postsurgical outcome. Results Fifty‐two of 53 patients had significant maps: 47 of 53 for EEG‐fMRI, 44 of 53 for ESI, and 34 of 53 for both. The EZ was well characterized in 29 patients; 26 had an EEG‐fMRI GM localization that was correct in 11, 22 patients had ESI localization that was correct in 17, and 12 patients had combined EEG‐fMRI and ESI that was correct in 11. Seizure outcome following resection was correctly predicted by EEG‐fMRI GM in 8 of 20 patients, and by the ESI maximum in 13 of 16. The combined EEG‐fMRI/ESI region entirely predicted outcome in 9 of 9 patients, including 3 with no lesion visible on MRI. Interpretation EEG‐fMRI combined with ESI provides a simple unbiased localization that may predict surgery better than each individual test, including in MRI‐negative patients. Ann Neurol 2017;82:278–287.