Individualised imaging approaches in pursuit of surgical targets in focal epilepsy

Epilepsy surgery can be an effective treatment option for drug resistant focal epilepsy. For surgery to occur, though, the epileptogenic focus must first be localised. Historically this has been based upon investigations such as seizure semiology, EEG, structural MRI, PET and SPECT imaging. Invasive procedures such as stereo EEG can also be used to further refine localisation, however such invasive procedures should only occur in the context of a strong localisation hypothesis. This talk will review novel, individualised approaches to identifying the seizure onset zone in otherwise difficult to localise drug resistant focal epilepsy, using specific case examples to illustrate salient points. This includes the use of patient specific task fMRI paradigms (e.g. in-scanner toothbrushing in reflex toothbrushing epilepsy), patient specific seizure induction manoeuvres enabling ictal SPECT (e.g. roller-coaster epilepsy), and applications of simultaneous EEG-fMRI to identify candidate seizure onset zones for subsequent exploration via SEEG implantation.