We demonstrated here that even in 3T MRI analyzed in tertiary centers by epilepsy experts, hippocampal volume and signal quantification can significantly improve the detection of signs of HS in patients with otherwise normal MRI findings by using an epilepsy protocol. OHSU is an equal opportunity affirmative action institution. Routine brain MRI ordered from and ENT/Otolaryngology for any of the above indications should follow the IAC protocol SEQUENCE FOV (mm) SLICE (mm) COMMENTS IMAGES T1 dark fluid Sag 220 4 x 1.2 Diffusion Ax 230 5 x 1 Axials parallel to AC-PC line T2 FLAIR Ax T2 FS Ax 220 4 x 1 GRE Cor 220 5 x 1 Coronals parallel to the brainstem T2 tse coronal oblique 2mm ( epilepsy protocol) Plan the coronal high resolution slices on the sagittal plane; angle the position block plane perpendicular to the long axis of the hippocampus. In the remaining 4 patients, 2 had bilateral asymmetric hippocampal abnormalities on visual analyses and the relaxometry lateralized to the side with less hippocampal atrophy by both visual and automatic volumetry, and the other 2 patients had unilateral hippocampal atrophy (concordant by visual and automatic volumetry) and the relaxometry lateralized to the side contralateral to the atrophy and hyperintense T2 signal defined by visual analysis. The greatest yield is from MRI at 3T using epilepsy protocols, and reported by expert neuroradiologists who possess the full clinical data. My seizures were better controlled; I was used to them; but I still wanted to know. The Neuroimaging Task Force from the International League Against Epilepsy (ILAE) Diagnostic Methods Commission has published a new set of recommendations regarding which patients are candidates for structural magnetic resonance imaging (MRI), the minimum prerequisites for an MRI protocol, how MRI should be evaluated, and how lesion detection can be optimized. Ana C. Coan was responsible for the study concept and design, patient selection and recruitment, MRI visual analysis, interpretation of the data, and manuscript writing. Braces are usually okay, if there is not a great deal of motion, keep head tightly padded. For the remaining 78 (38%) patients, MRI had normal findings by visual analyses. In this patient, by visual analysis, we observed normal hippocampal volume and a localized hyperintense signal in the body of the hippocampus, contralateral to the epileptic focus determined by EEG. MR imaging signs of HS detected by quantification analysis. An MRI provides an accurate picture of the structures of the brain using magnetic technology. NEX / NSA – 16. The increase of patients with detectable MR imaging abnormalities compatible with the site of the seizure-onset origin is significantly important for drug-resistant focal epilepsies. What is MRI epilepsy protocol. Check the positioning block in the other two planes. Hippocampal signal values higher than 2 SDs from the mean of the control group composed of the same individuals in the volumetry analysis (absolute value and/or asymmetry index, defined by the ratio of higher and lower hippocampal signals of each individual) were considered hyperintense signal. Mesial temporal lobe epilepsy (MTLE) is the most common form of epilepsy in adults.1 Although hippocampal sclerosis (HS) is the main pathologic substrate in patients with MTLE, there are several other causes and some patients may have normal MR imaging findings and no specific histopathologic changes detected postoperatively.1,2 HS can be reliably detected on MRI,2 and quantitative analysis of hippocampal formation improves the sensitivity for detecting this pathology.3,4 With advances in the MR imaging field in the past decades, the current contributions of these postprocessing MR imaging tools for the detection of hippocampal pathology, especially in tertiary epilepsy centers, are not clear. Magnetic resonance imaging (MRI) is a pivotal component in the investigation of patients with any form of epilepsy because of its unmatched ability in visualizing structural brain pathology. Optimal MRI Sequence for Identifying Occlusion Location in Acute Stroke: Which Value of Time-Resolved Contrast-Enhanced MRA? Pedi Brain 2-12 Yrs. The imaging approach is driven by empiric observation ofthe most common and critical etiologies of seizures, which varies by ageof presentation. The complete benefit of the use of hippocampal quantification measurements in 3T MRI in the presurgical evaluation of patients with drug-resistant MTLE could be assessed with follow-up and surgical outcome data of these patients. 7650 on Mri Brain Epilepsy Protocol With Diffusion in gurgaon. The type of abnormalities that can be suspected in the brain after a concussion, are the kind of abnormalities that will be seen far better on a 3T MRI than a 1.5T MRI. All patients underwent scalp video-EEG monitoring, PET, and subsequently intracranial electrode implantation. Recently automatic analyses have been shown to be promising; however, there are few studies comparing their efficacy with the visual analyses of high-quality MR imaging by experts in the field.12,13. This was a prospective study of patients followed at the Epilepsy Clinic of University of Campinas with a clinical and electroencephalographic diagnosis of MTLE according to International League Against Epilepsy criteria,18 who consecutively underwent 3T MRI between August 2009 and April 2012. Currently, most studies of hippocampal volumetry apply manual hippocampal delimitation, and whether manual28 or automatic analysis has higher sensitivity and specificity is still debatable.12,13 Despite this controversy, in the clinical context, the quantification of hippocampal abnormalities must be as fast and practical as possible. 1 Absence of a structural lesion on MRI still represents a challenge for surgical management, as it entails a poorer prognosis in both children and adults. The most important factor in optimizing an MRI protocol for epilepsy is clear visualization of mesial temporal structures. An appropriate angle must be given in the axial plane (perpendicular to mid line of the brain). Classic signs of HS were as follows: reduction of volume and abnormal shape observed on T1 images and increased signal observed in T2 and FLAIR images. Hyperoxia (oxygen enhancement, OE) was carried out by administering 100% O(2) in epochs by mask or cannula interleaved with breathing of normal atmospheric air. Special attention was given to rule out subtle signs of focal cortical dysplasia, such as sulcal morphology abnormalities, focal increase of cortical thickness, FLAIR focal signal hyperintensities, or small transmantle signs. T1 weighted - Always4. On the left side of the graphic is the hippocampal T2 signal of controls (white circles = right hippocampi; mean signal, 96.77 ± 4.05; black triangles = left hippocampi; mean signal, 96.98 ± 4.10). A critical analysis of a particular Pediatric Neuroradiology MRI Protocols.You are to relate this back to the current literature/ other credible sources and provide justifications for the protocol particulars. In this group, 176 (87%) patients had drug-resistant seizures, while 27 (13%) had been free of seizures for at least 2 years. Keep patient at Isocenter For patients with small heads and long necks or large heads: Keep FOV box positioned higher than normal but not beyond ±50mm from glabella, May need to reduce/enlarge the FOV for the individual (not beyond 24 - 25.6). Even in this most favorable circumstance, quantification of hippocampal volume and signal significantly increased the detection of signs of HS. What is MRI Epilepsy Protocol? The mean T2 signal from the 3 sections of each hippocampus was used as the final measurement. Two hundred seventeen patients fulfilled the inclusion criteria. Relaxometry analysis detected hyperintense T2 signal in 103 (82%) patients with visually detected hippocampal sclerosis and in 15 (19%) with visually normal MR imaging findings. In this article, we reproduced this optimal visual evaluation of MRI in patients with MTLE: Two epileptologists with expertise in MR imaging evaluation of patients with focal epilepsies reviewed the images of all patients (acquired with an extensive epilepsy protocol) in the context of clinical and EEG data. Thank you for your interest in spreading the word on American Journal of Neuroradiology. Plane – sagittal2. MR imaging has significantly improved the detection of pathologies related to epilepsy.19 It is safe, noninvasive, and widely available in epilepsy centers. Spacing – 1.2 mm8. CLINCIAL Epilepsy protocols were used for the 3T and 7T acquisitions. October 1, 2008-- A study from Oregon Health & Science University (OHSU) in Portland has concluded that 3-tesla MRI is superior to 1.5-tesla MRI in detecting and accurately characterizing structural brain abnormalities in a group of patients undergoing whole-brain epilepsy evaluation. Use all motion reduction techniques except changing scan parameters, Surgical resections, shunts, metal (some are not compatible), Put saline bags on either side of patient's head, Can be ± 50mm from Nasion - should be as close as possible in all 3 planes, Re - landmark, if C-spine was done first as part of a double study, Echo test failure – call your network admin, Delete incorrect series from queue monitor, Extend slice coverage 1-2 mm beyond the skin margin, not necessarily to cover the ears. (-)(+/-) SAGITTAL T1 AXIAL DWI AXIAL T2 AXIAL T2 FLAIR AXIAL T1 AXIAL T1 Post CORONAL T1 FS Post AXIAL 3D BRAVO Post Sequence TR TE FOV 1 An informed consent form approved by the Ethics Committee of Universidade Estadual de Campinas was signed by all patients before acquisition of MR imaging. Automatic volumetry detected atrophy in 119 (95%) patients with visually detected hippocampal sclerosis and in 10 (13%) with visually normal MR imaging findings. For All MRI (a) Appointment desirable; (b) Please remove jewellery at home for safety purpose; (c) Bring old records- text reports, films, CD. We think that this optimized hippocampal quantification protocol can be easily applied to all patients with drug-resistant focal epilepsies as a parallel and additional analysis for the routine evaluation of MRI in specialized epilepsy centers. A, Boxplot graphic shows z scores of hippocampal volumetry for controls and patients with MTLE. A previous study 20 showed that “nonexperts” reported 61% of standard MR imaging as having normal findings or as showing no focal abnormality, while epilepsy “expert” examiner reassessments of the same standard MRIs classified 28% of these scans as technically inadequate and considered only 22% of these standard MR imaging scans as having normal findings. As a first step, MRI was visually analyzed by 2 epilepsy imaging experts (A.C.C. MRI Brain With Epilepsy Protocol is a painless procedure that requires minimum planning. For this analysis, a region of interest was manually defined in 3 different MR imaging sections, including the hippocampus of each individual (1 in the head, 1 in the body, and 1 in the tail of the hippocampus) by an investigator blinded to the results of the MR imaging visual evaluation (B.K.). Using a dedicated MRI-protocol, it is possible to detect an epileptogenic lesion in 80 percent of these patients. The side of the abnormal hippocampal signal detected by relaxometry was concordant with the visual analysis in 96% (99/103). 2012). New clinically feasible 3T MRI protocol to discriminate internal brain stem anatomy. © 2001-2020 Oregon Health & Science University. Brain imaging with MRI identifies structural cerebral pathology that may give rise to seizures. Role of MRI. Although FreeSurfer software is not approved for clinical use by the US Food and Drug Administration, as far as we know, there is at least 1 software approved for automated volumetric analyses of brain MRI.27 However, this has only been evaluated for the detection of hippocampal abnormalities on 1.5T scanners.13. Hippocampal volumes were corrected for individual brain (supratentorial) volumes, and corrected hippocampal volumes smaller than 2 SDs (absolute value and/or asymmetry index, defined by the ratio of the smaller over the larger hippocampus of each individual) from the mean of controls were considered as having atrophy. Z score distribution of the hippocampal asymmetry index for volumetry and T2 relaxometry analyses. 1. CLINCIAL The patient with a normal hippocampus on histology had no signs of HS detected by either visual or quantitative methods. All patients underwent one or more MRI 1.5 Tesla (1.5T) or 3 Tesla (3T) studies with a standard epilepsy protocol with Siemens scanners (Erlangen, Germany). Directly comparable sequences (those of the same sequence type, plane, and approximate slice thickness) used for our epilepsy protocol on the 3-T and 1.5-T MRI units were reviewed. Here we demonstrated that with 3T MRI, adequate epilepsy protocols, and expert visual evaluation, quantification analysis can still improve the detection of subtle signs of HS in 28% of patients. From the 118 patients with MTLE with hippocampal T2 signal hyperintensity detected by relaxometry, 106 had unilateral epileptic focus and in 94% (100/106) the side of epileptic focus was correctly lateralized by volumetry. and F.C.) Re: Epilepsy Protocol MRI Submitted by jmccand on Fri, 2006-10-06 08:15 I have heard of a new MRI procedure that they are doing for epilepsy, where they also have an EEG going at the same time as the contrast MRI. Increased sensitivity with quantitative magnetic resonance T2 relaxometry, T2 relaxometry can lateralize mesial temporal lobe epilepsy in patients with normal MRI, Neuroimaging methods to evaluate the etiology and consequences of epilepsy, Automatic detection and quantification of hippocampal atrophy on MRI in temporal lobe epilepsy: a proof-of-principle study, Temporal lobe epilepsy: quantitative MR volumetry in detection of hippocampal atrophy, 3T phased array MRI improves the presurgical evaluation in focal epilepsies: a prospective study, Comparison of hippocampal volumetry at 1.5 T and at 3 T, Volume determination of amygdala and hippocampus at 1.5 and 3.0 T MRI in temporal lobe epilepsy, Histologically confirmed hippocampal structural features revealed by 3T MR imaging: potential to increase diagnostic specificity of mesial temporal sclerosis, Proposal for revised classification of epilepsies and epileptic syndromes: Commission on Classification and Terminology of the International League Against Epilepsy, Nuclear magnetic resonance imaging, a new approach to the investigation of refractory temporal lobe epilepsy, Standard magnetic resonance imaging is inadequate for patients with refractory focal epilepsy, Preoperative MRI predicts outcome of temporal lobectomy: an actuarial analysis, Hippocampal sclerosis without detectable hippocampal atrophy, Normal magnetic resonance imaging and medial temporal lobe epilepsy: the clinical syndrome of paradoxical temporal lobe epilepsy, Epilepsy surgery outcomes in temporal lobe epilepsy with a normal MRI, Late seizures in patients initially seizure free after epilepsy surgery, Seizure outcome after anterior temporal lobectomy and its predictors in patients with apparent temporal lobe epilepsy and normal MRI, Fully-automated volumetric MRI with normative ranges: translation to clinical practice. Brain imaging with MRI identifies structural cerebral pathology that may give rise to seizures. and the images were classified as having normal findings or signs of HS. Recommendation: Get all Post-Concussion imaging done on a 3T MRI. References 1 Bradley WG, Waluch V, Yadley RA, Wycoff RR. Fernando Cendes—RELATED: Grants: FAPESP and Conselho Nacional de Desenvolvimento Científico e Tecnológico, Brazil,* Comments: FAPESP grants 2005/56578-four and 2009/54552–9. An appropriate angle must be given in the coronal plane on a tilted head (parallel to the line along 3rd ventricle and brain stem). The epilepsies are common serious diseases of the brain, with an age adjusted prevalence of 4–8/1000 and an annual incidence of 20–50/100 000 in developed countries. 1 In this article, we used automated volumetry and a simple manual signal quantification in which it is necessary only to define a small region of interest in 3 sections of the T2 scan of each patient, without the need to define precisely the borders of the hippocampus. We do not capture any email address. Re: Epilepsy Protocol MRI Submitted by jmccand on Fri, 2006-10-06 08:15 I have heard of a new MRI procedure that they are doing for epilepsy, where they also have an EEG going at the same time as the contrast MRI. To make the ROI placement more consistent among patients, we defined the section of the hippocampus head as the first in which it was possible to see the temporal horn of the lateral ventricle and therefore to appropriately separate the hippocampal formation from the amygdala. This pattern of subtle and localized hippocampal abnormality (restricted to the hippocampal body) is not commonly seen. Bruno Kubota—RELATED: Grant: FAPESP, Comments: scientific scholarship. From the 125 patients with MTLE with HS signs detected by visual analysis, 117 had unilateral epileptic focus (defined by ictal and interictal EEG); in 88% (103/117), the side of signs with HS was concordant with the epileptic focus, and it was contralateral in 7.5% (9/117). 3T MRI Quantification of Hippocampal Volume and Signal in Mesial Temporal Lobe Epilepsy Improves Detection of Hippocampal Sclerosis, Voxel-Based Morphometry--from Hype to Hope. Here we demonstrated that with 3T MRI, adequate epilepsy protocols, and expert visual evaluation, quantification analysis can still improve the detection of subtle signs of HS in 28% of patients. 2012). This scanning enables the doctor in obtaining evidences of abnormalities or injuries in brain. Radiology 1984; 152:695-702. Patients with symptomatic MTLE due to lesions other that HS (tumor, vascular malformations, gliosis, focal cortical dysplasia) were excluded. Six patients had lesions concordant with their epilepsy on high-resolution (3T) structural MRI. Relaxometry detected bilateral hippocampal hyperintense signal in 22 patients (20 with visual signs of HS and 2 with visually normal MR imaging findings). X-ray CT scanning has a role in assessing patients with seizures in the context of an acute neurological illness. There was no difference in sex or age distribution between patients and controls (Sex, χ2, P = .527; age, t test, P = .072). MRI epilepsy protocol refers to the sequence of images taken of the brain when evaluating a potential seizure disorder. Of 317, 240 (75.7%) were included for analysis and 77 (24.3%) were excluded (Fig-ure 1). While best practices do exist, protocol design varies according to factors that include: The needs of the patient and the specifics of the symptoms and case; The MRI equipment being used Such enhancements facilitate detection of cortical lesions, especially subtle cortical dysplasia. MRI (magnetic resonance imaging) is the diagnostic tool that identifies structural changes in the brain that may cause seizures or be associated with epilepsy. Detailed imaging parameters can be found elsewhere (Wang, et al. NOTE: We only request your email address so that the person you are recommending the page to knows that you wanted them to see it, and that it is not junk mail. There was no significant difference in the frequency of concordance of signs of HS or hippocampal atrophy detected by visual analysis with the side of the epileptic focus (88% of concordance by visual analyses and 95% of concordance by volumetry analysis, χ2, P = .054) and no difference in the frequency of concordance of visual signs of HS or hippocampal hyperintense signal detected by relaxometry with the side of the epileptic focus (88% of concordance by visual analyses and 94% of concordance by relaxometry analysis, χ2, P = .099). In the remaining 4% (5/117), the MR imaging signs of HS were bilateral and symmetric. We were only able to evaluate the histopathologic findings in 10% (19 patients) of our group. This question is for testing whether or not you are a human visitor and to prevent automated spam submissions. FOV 24 – 25.6, NOTE: Some NeuroQuant parameters vary depending on scanner manufacturer & field strength. Of those, all except 1 individual had confirmed histopathology of HS. Nineteen patients (10%) underwent surgical treatment (anterior temporal lobectomy or selective amygdalohippocampectomy) due to refractory seizures. A total of 317 individuals who had undergone 3T brain MRI of epilepsy protocol were eligible for the study. Considered together, volumetry plus relaxometry detected signs of hippocampal sclerosis in all except 1 (99%) patient with visually detected hippocampal sclerosis and in 22 (28%) with visually normal MR imaging findings. Indicates open access to non-subscribers at www.ajnr.org. However, this specificity is biased because all patients who underwent surgery in our group had similar findings in both visual and quantification analysis, and the visual analysis was used in the selection of the patients for the surgical procedure. Enter multiple addresses on separate lines or separate them with commas. However, a variable but significant number of patients with focal epilepsies have normal MRI findings and unknown seizure etiology.20⇓⇓⇓–24. Hippocampal volume assessment in temporal lobe epilepsy: how good is automated segmentation? Magnetic Resonance Imaging for Brain With Epilepsy Protocol Test Type : Radiology Preparation : No Special Preparation Required Department: MRI Reporting : Within 24 Hours* Test Price: Please choose Location and other options on this page to view final cost in Delhi NCR. Link, Google Scholar; 2 Tong DC, Yenari MS, Albers GW, O'Brien M, Marks MP, Moseley ME. Epilepsy protocol MRI at 1.5T or 3.0T, on the other hand, includes the entire brain from nasion to inion, T1-weighted MPRAGE or SPGR images 1.5-mm slice thickness with no intervening gap obtained in the coronal oblique plane (if TLE is suspected). In our series, only 1 patient with visual signs of HS had normal volumetry and signal quantification. T1WI volume: isotropic voxels of 1 mm, acquired in the sagittal plane (1-mm-thick, no gap, flip angle = 8°, TR = 7.0 ms, TE = 3.2 ms, matrix = 240 × 240, FOV = 240 × 240). Example of regions of interest manually defined in the head (A), body (B), and tail (C) of the hippocampus of a patient with MTLE. A Study on Hippocampal Atrophy in Mesial Temporal Lobe Epilepsy, Default Mode Network patterns and its interactions with memory performance in patients with Temporal Lobe Epilepsy and controls, The Effect of Electroencephalography Leads on Image Quality in Cerebral Perfusion SPECT and 18F-FDG PET/CT, Mesial Temporal Sclerosis: Accuracy of NeuroQuant versus Neuroradiologist, The spectrum of hippocampal sclerosis: a quantitative magnetic resonance imaging study, MRI of amygdala and hippocampus in temporal lobe epilepsy, Quantitative hippocampal MRI and intractable temporal lobe epilepsy, The neurobiology of temporal lobe epilepsy: too much information, not enough knowledge, Hippocampal sclerosis can be reliably detected by magnetic resonance imaging, Hippocampal sclerosis in temporal lobe epilepsy demonstrated by magnetic resonance imaging, MRI volumetric measurements of amygdala and hippocampus in temporal lobe epilepsy, Detection of hippocampal pathology in intractable partial epilepsy. From the 129 patients with MTLE with hippocampal atrophy detected by volumetry, 120 had unilateral epileptic focus (defined by ictal and interictal EEG) and in 95% (114/120) the side of epileptic focus was correctly lateralized by volumetry. To achieve this goal, a correlation of these findings with the criterion standard, histopathology, would be necessary. This requires thinner slices, with voxel volumes of 1 mm 4 being the current norm at 3T, which improves spatial resolution but also increases scan time and noise. However, a good correlation of volume and signal abnormalities detected by quantification analysis and histopathology of HS has been previously demonstrated.27 Also, in our group of patients, the laterality of abnormal hippocampal volume and signal was highly concordant with the laterality of the epileptic focus defined by EEG recordings. In patients with a histopathology of HS, visual analysis and volumetry detected abnormal hippocampi in all cases and relaxometry detected hyperintense signal in 15/18 (83%) patients. Although it is clear that in studies with 1.5T MR imaging, volumetry and relaxometry have significantly higher sensitivity than the qualitative analysis of MR imaging,8,9 today most epilepsy centers work with 3T MRI and specific epilepsy protocols, which make the determination of MR imaging signs of HS by visual analysis easier and more accurate.14 It has been reported that there is no difference in the hippocampal volume measures of 1.5 and 3T15,16 and that quantitative measures in 3T MRI can demonstrate ultrastructural details of HS pathology not detectable with lower field scanners.17 Once the sensitivity to visually detect signs of HS at 3T is higher,14 the question that remains is whether the use of hippocampal measurements in these higher field MRIs still adds information to the clinical practice. Epilepsy Protocol MRI involves obtaining images of brain slices through MRI scanning in epileptic patients. The ROIs were manually drawn to include the larger area of the hippocampus in that section but also to carefully avoid contamination of the hippocampal signal with CSF signal (Fig 1). Disclosures: Ana C. Coan—RELATED: Grant: Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP) (São Paulo Research Foundation), Comments: PhD scholarship, UNRELATED: Payment for Lectures (including service on Speakers Bureaus): Novartis. At Rs 0 imaging ( MRI ) is not commonly seen scanning enables doctor... Which Value of Time-Resolved Contrast-Enhanced MRA whether or not you are a human and... A2, FreeSurfer volumetry images in which the hippocampi are shown in yellow:... Facilitate detection of cortical lesions, especially subtle cortical dysplasia ) were included for analysis and (! 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With FreeSurfer and T2 relaxometry in patients mri brain 3t epilepsy protocol had undergone 3T brain MRI of epilepsy protocol refers the... Let me down, and reported by expert neuroradiologists who possess the full clinical data were for. Imaging ( MRI ) is a noninvasive tool used to detect structural brain lesions and assess candidates. Was marked asymmetry in epileptic patients lobe, MR Epilepsy/Seizure brain WO scanner preference: only! Other two planes the axial plane ( perpendicular to mid line of the symptoms case.