title: Does performing image registration and subtraction in ictal brain SPECT help localize neocortical seizures?
abstract: Ictal brain SPECT (IS) findings in neocortical epilepsy (patients without mesiotemporal sclerosis) can be subtle. This study is aimed at assessing how the seizure focus identification was improved by the inclusion of individual IS and interictal brain SPECT (ITS)-MRI image registration as well as performing IS - ITS image subtraction.
  
  
  METHODS
  The study involved the posthoc analysis of 64 IS scans using 99mTc-ethyl cysteinate dimer that were obtained in 38 patients without mesiotemporal sclerosis but with or without other abnormalities on MRI. Radiotracer injection occurred during video-electroencephalographic (EEG) monitoring. Patients were injected 2-80 s (median time, 13 s) after clinical or EEG seizure onset. All patients had sufficient follow-up to correlate findings with the SPECT results. All patients had ITS and MRI, including a coronal volume sequence used for registration. Image registration (IS and ITS to MRI) was performed using automated software. After normalization, IS - ITS subtraction was performed. The IS, ITS, and subtraction studies were read by 2 experienced observers who were unaware of the clinical data and who assessed the presence and localization of an identifiable seizure focus before and after image registration and subtraction. Correlation was made with video-EEG (surface and invasive) and clinical and surgical follow-up.
  
  
  RESULTS
  Probable or definite foci were identified in 38 (59%) studies in 33 (87%) patients. In 52% of the studies, the image registration aided localization, and in 58% the subtraction images contributed additional information. In 9%, the subtraction images confused the interpretation. In follow-up after surgery, intracranial EEG or video-EEG monitoring (or both) has confirmed close or reasonable localization in 28 (74%) patients. In 6 (16%) patients, SPECT indicated false seizure localization.
  
  
  CONCLUSIONS
  Image registration and image subtraction improve the localization of neocortical seizure foci using IS, but close correlation with the original images is required. False localizations occur in a minority of patients.
authors.affiliation: Department of Radiology, Dartmouth-Hitchcock Medical Center; Lebanon, New Hampshire 03766, USA.
authors.forename: P J
authors.initials: PJ
authors.lastname: Lewis
authors.forename: A
authors.initials: A
authors.lastname: Siegel
authors.forename: A M
authors.initials: AM
authors.lastname: Siegel
authors.forename: C
authors.initials: C
authors.lastname: Studholme
authors.forename: J
authors.initials: J
authors.lastname: Sojkova
authors.forename: D W
authors.initials: DW
authors.lastname: Roberts
authors.forename: V M
authors.initials: VM
authors.lastname: Thadani
authors.forename: K L
authors.initials: KL
authors.lastname: Gilbert
authors.forename: T M
authors.initials: TM
authors.lastname: Darcey
authors.forename: P D
authors.initials: PD
authors.lastname: Williamson
mesh_terms: D000328:Adult; D001921:Brain / Q000000981:diagnostic imaging* / Q000473:pathology; D003545:Cysteine / Q000031:analogs & derivatives; D004569:Electroencephalography; D004827:Epilepsy / Q000175:diagnosis / Q000000981:diagnostic imaging*; D005260:Female; D006801:Humans; D007091:Image Processing, Computer-Assisted; D008279:Magnetic Resonance Imaging; D008297:Male; D019579:Neocortex / Q000000981:diagnostic imaging*; D015609:Organotechnetium Compounds; D019275:Radiopharmaceuticals; D012189:Retrospective Studies; D012680:Sensitivity and Specificity; D013382:Subtraction Technique; D015899:Tomography, Emission-Computed, Single-Photon / Q000379:methods
chemical_list: D015609:Organotechnetium Compounds; D019275:Radiopharmaceuticals; C059659:technetium Tc 99m bicisate; D003545:Cysteine