Abstract
BACKGROUND AND OBJECTIVES: To assess the utility of EEG-fMRI for epilepsy surgery, we evaluated surgical outcome in relation to the resection of the most significant EEG-fMRI response. METHODS: Patients with postoperative neuroimaging and follow-up of at least 1 year were included. In EEG-fMRI responses, we defined as primary the cluster with the highest absolute t value located in the cortex and evaluated 3 levels of confidence for the results. The threshold for low confidence was t ≥ 3.1 (p < 0.005); the one for medium confidence corresponded to correction for multiple comparisons with a false discovery rate of 0.05; and a result reached high confidence when the primary cluster was much more significant than the next highest cluster. Concordance with the resection was determined by comparison to postoperative neuroimaging. RESULTS: We evaluated 106 epilepsy surgeries in 84 patients. An increasing association between concordance and surgical outcome with higher levels of confidence was demonstrated. If the peak response was not resected, the surgical outcome was likely to be poor: for the high confidence level, no patient had a good outcome; for the medium and low levels, only 18% and 28% had a good outcome. The positive predictive value remained low for all confidence levels, indicating that removing the maximum cluster did not ensure seizure freedom. DISCUSSION: Resection of the primary EEG-fMRI cluster, especially in high confidence cases, is necessary to obtain a good outcome but not sufficient. CLASSIFICATION OF EVIDENCE: This study provides Class II evidence that failure to resect the primary EEG-fMRI cluster is associated with poorer epilepsy surgery outcomes.