Diagnostic added value of electrical source imaging in presurgical evaluation of patients with epilepsy: A prospective study

•We investigated the diagnostic added value of ESI in presurgical evaluation.•ESI provided non-redundant, diagnostic information in 34% of 82 consecutive patients.•Most changes (85.7%) were related to the implantation of intracranial electrodes. To investigate the diagnostic added value of electrical source imaging (ESI) in presurgical evaluation of patients with drug resistant focal epilepsy. Eighty-two consecutive patients were included. We analyzed both low density (LD) and high density (HD) EEG recordings. LD ESI was done on interictal and ictal signals recorded during long-term video-EEG monitoring (LTM), with standard 25 electrodes and age-matched template head models. HD ESI was done on shorter recordings (90–120 min), with 256 electrodes, using individual head model. The multidisciplinary team made decisions first blinded to ESI (based on all other modalities) and then discussed the results of the ESI. We considered that ESI had diagnostic added value, when it provided non-redundant information that changed the patientś management plan. ESI had diagnostic added value in 28 patients (34%). In most cases (85.7%), these changes were related to planning of the invasive recordings. In nine out of 13 patients, invasive recordings confirmed the localization. Out of eight patients in whom the ESI source was resected, six became seizure-free. ESI provides non-redundant information in one third of the patients undergoing presurgical evaluation. This study provides evidence for the diagnostic added value of ESI in presurgical evaluation.