18 F-FDG-PET hypometabolic pattern reveals multifocal epileptic foci despite limited unique stereotyped seizures

•Interictal 18F-FDG PET has been proved as useful in epilepsy surgery.•It has a good prognostic value when semiology is focal and hypometabolism limited.•Extended hypometablism associated with focal ictal semiology is rarely encountered.•Extended hypometabolism despite focal semiology can reflect multifocal epilepsy.•In those cases PET could have a better prognostic value than ictal EEG. Interictal positron emission tomography (PET) with 18F-FDG has largely proved its utility in presurgical evaluation of drug-resistant epilepsies (DRE) and in the surgical outcomes. Interictal hypometabolism topography is related to the neuronal networks involved in the seizure onset zone (SOZ) and spread pathways. 18F-FDG PET has a good prognostic value for post-surgical outcome, especially in cases with unique focal ictal semiology and a limited extent of hypometabolism. Surprisingly few patients have similar limited ictal features but extended hypometabolism. The objective of this study is to show that stereoelectro encephalography (SEEG) provides an explanation for this large hypometabolism, which impacts the surgical strategy. A cohort of 248 patients underwent 18F-FDG PET and SEEG to explore for refractory epilepsy in two close tertiary epilepsy centers between January 2009 and December 2017. From this cohort, a subset of patients was selected with extended PET metabolism despite showing unique and limited ictal features in scalp EEG. The surgical outcome of this subset of patients has been analysed with respect to their FDG-PET and SEEG to understand the relationship between PET/SEEG/ presentation and surgical outcome. We report a series of seven patients with DRE and unique stereotyped ictal semiology but extensive 18F-FDG-PET hypometabolism revealing unexpected multifocal SOZ using SEEG. All SOZ were encompassed by the hypometabolic area. Our results demonstrate the necessity of accounting for the discrepancy between limited symptoms and widespread hypometabolism which can reveal multifocal SOZ. In those patients, surgical possibilities should be considered carefully.