The use of hippocampal volumetric measurements to improve diagnostic accuracy in pediatric patients with mesial temporal sclerosis.
OBJECTIVE Many patients with medically intractable epilepsy have mesial temporal sclerosis (MTS), which significantly affects their quality of life. The surgical excision of MTS lesions can result in marked improvement or even complete resolution of the epileptic episodes. Reliable radiological diagnosis of MTS is a clinical challenge. The purpose of this study was to evaluate the utility of volumetric mapping of the hippocampi for the identification of MTS in a case-controlled series of pediatric patients who underwent resection for medically refractory epilepsy, using pathology as a gold standard. METHODS A cohort of 57 pediatric patients who underwent resection for medically intractable epilepsy between 2005 and 2015 was evaluated. On pathological investigation, this group included 24 patients with MTS and 33 patients with non-MTS findings. Retrospective quantitative volumetric measurements of the hippocampi were acquired for 37 of these 57 patients. Two neuroradiologists with more than 10 years of experience who were blinded to the patients' MTS status performed the retrospective review of MR images. To produce the volumetric data, MR scans were parcellated and segmented using the FreeSurfer software suite. Hippocampal regions of interest were compared against an age-weighted local regression curve generated with data from the pediatric normal cohort. Standard deviations and percentiles of specific subjects were calculated. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were determined for the original clinical read and the expert readers. Receiver operating characteristic curves were generated for the methods of classification to compare results from the readers with the authors' results, and an optimal threshold was determined. From that threshold the sensitivity, specificity, PPV, and NPV were calculated for the volumetric analysis. RESULTS With the use of quantitative volumetry, a sensitivity of 72%, a specificity of 95%, a PPV of 93%, an NPV of 78%, and an area under the curve of 0.84 were obtained using a percentage difference of normalized hippocampal volume. The resulting specificity (95%) and PPV (93%) are superior to the original clinical read and to Reader A and Reader B's findings (range for specificity 74%-86% and for PPV 64%-71%). The sensitivity (72%) and NPV (78%) are comparable to Reader A's findings (73% and 81%, respectively) and are better than those of the original clinical read and of Reader B (sensitivity 45% and 63% and NPV 71% and 70%, respectively). CONCLUSIONS Volumetric measurement of the hippocampi outperforms expert readers in specificity and PPV, and it demonstrates comparable to superior sensitivity and NPV. Volumetric measurements can complement anatomical imaging for the identification of MTS, much like a computer-aided detection tool would. The implementation of this approach in the daily clinical workflow could significantly improve diagnostic accuracy.
Department of Medical Imaging, Neuroradiology Section, University of Arizona, Tucson, Arizona.
Gloria J
GJ
Guzmán Pérez-Carrillo
Neuroradiology Section, Mallinckrodt Institute of Radiology, Washington University.
Christopher
C
Owen
Department of Pathology and Immunology, Washington University.
Katherine E
KE
Schwetye
Neuroradiology Section, Mallinckrodt Institute of Radiology, Washington University.
Spencer
S
McFarlane
Department of Neurosurgery, Pediatric Division, St. Louis Children's Hospital/Washington University; and.
Ananth K
AK
Vellimana
Department of Neurology, Division of Pediatric Neurology, Washington University School of Medicine, St. Louis, Missouri.
Soe
S
Mar
Neuroradiology Section, Mallinckrodt Institute of Radiology, Washington University.
Michelle M
MM
Miller-Thomas
Neuroradiology Section, Mallinckrodt Institute of Radiology, Washington University.
Joshua S
JS
Shimony
Department of Neurosurgery, Pediatric Division, St. Louis Children's Hospital/Washington University; and.
Matthew D
MD
Smyth
Neuroradiology Section, Mallinckrodt Institute of Radiology, Washington University.
Tammie L S
TLS
Benzinger
D000293:Adolescent; D019540:Area Under Curve; D002648:Child; D002675:Child, Preschool; D000069279:Drug Resistant Epilepsy / Q000000981:diagnostic imaging* / Q000601:surgery; D006624:Hippocampus / Q000000981:diagnostic imaging* / Q000601:surgery; D006801:Humans; D007091:Image Processing, Computer-Assisted; D008279:Magnetic Resonance Imaging; D009929:Organ Size; D011379:Prognosis; D012372:ROC Curve; D012189:Retrospective Studies; D012598:Sclerosis / Q000000981:diagnostic imaging / Q000601:surgery; D055815:Young Adult
AUC = area under the curve; LOWESS = locally weighted scatterplot smoothing; MPRAGE = magnetization-prepared rapid acquisition gradient echo; MTS = mesial temporal sclerosis; NPV = negative predictive value; PNC = pediatric normal cohort; PPV = positive predictive value; QC = quality control; advanced imaging techniques; epilepsy surgery; magnetic resonance imaging; mesial temporal sclerosis