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Epilepsy & Seizure Epilepsy & Seizure Journal of Japan Epilepsy Society Vol.4 No.1 (2011) pp.15-25 Original Article Usefulness of 123I-iomazenil SPECT for childhood focal epilepsies 1) 1) 1) 1) Kentaro Okamoto, MD , Hirokazu Oguni, MD , Yoshiko Hirano, MD , Makiko Osawa, MD 1Department of Pediatrics, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo 162-8666, Japan Key words: focal epilepsy, children, 123I-iomazenil SPECT, epileptic foci Published online July 29, 2011 Abstract Purpose: We investigated the usefulness of obtained from visualization of IMZ-SPECT 123I-iomazenil (IMZ-) SPECT to detect epilep- images and those speculated based on a com- tic foci in children with symptomatic focal bination of clinical manifestations, EEG find- epilepsy (SFE). ings, and brain MRI. We then verified the Subjects: 21 children with SFE who under- concordance of the results between the two went IMZ-SPECT to identify the epileptic fo- methods. cus were studied. Results: There was concordance in both later- Methods: We retrospectively compared the alization and localization in 9/12 patients with localization and lateralization of epileptic foci temporal lobe epilepsy (75%), in 2/5 patients Correspondence to: Hirokazu Oguni, MD, Department of Pediatrics, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo 162, Japan Tel. 81-3-3353-8111, Fax. 81-3-5269-7338, [email protected] 15 Kentaro Okamoto, et al. IMZ-SPECT for childhood epilepsy with frontal lobe epilepsy (40%), and in 2/4 interictal/ictal cerebral blood flow single pho- patients with parieto-occipital lobe epilepsy ton emission computed tomography (SPECT) (50%). Overall, the epileptic foci detected by [8-12] and interictal 18F-fluorodeoxyglucose IMZ-SPECT was consistent with those positron emission tomography (FDG-PET) [2, speculated based on other findings at least in 3, 7, 10, 13]. 123I-iomazenil SPECT (IMZ- 13 of 21 patients (62%) with SFE. SPECT) was developed based on biochemical Discussion: As IMZ-SPECT is a potentially abnormalities existing in the epileptogenic useful method for detecting epileptic foci, we brain lesion, and is able to detect the original should accumulate cases to verify the limita- epileptic focus effectively in the interictal tions and appropriate application of this state [14, 15]. In the field of epilepsy surgery method in the diagnosis of childhood SFE. in adults, several studies have employed this procedure as a presurgical evaluation, sug- Introduction gesting its usefulness for accurate identifica- In children with focal epilepsy refractory to tion of the epileptogenic lesions [16-18]. antiepileptic drugs for longer than 2 years, However, few studies have examined its use- surgery for epilepsy is considered at any age if fulness in children with intractable focal epi- the epileptic focus is clearly localized in a re- lepsy. In this study, we investigated the use- sectable brain region. As it is difficult to fulness of IMZ-SPECT in children with identify the precise location of an epilepto- symptomatic focal epilepsy who were refrac- genic lesion, a combination of methods in- tory to antiepileptic drug treatment. cluding long-term EEG/video monitoring, neuropsychological analysis, and neuroimag- Subjects and Methods ing is usually employed to achieve this task. In We reviewed the records of patients with particular, when brain magnetic resonance intractable focal epilepsy who were treated in imaging (MRI) reveals a localized structural our hospital and underwent IMZ-SPECT be- abnormality in the assumed epileptogenic tween 2006 and 2008. From these patients, we zone, the postoperative prognosis is the most enrolled those whose epileptic focus was de- favorable [1]. However, some children with termined based on the concordance of at least intractable focal epilepsy do not show any ab- two of the following findings: seizure semiol- normal findings on brain MRI, and it is not ogy with localizing and lateralizing values always straightforward to identify the epilep- [19, 20], interictal EEG, ictal EEG, and brain tic focus precisely based on clinical and EEG MRI findings. findings alone. In such cases, brain functional We examined the concordance in laterali- neuroimaging studies may be useful [2-7]. zation and localization between the estimated Many studies have reported the usefulness of epileptic focus with the decreased IMZ-uptake 16 Epilepsy & Seizure Vol.4 No.1 2011 region visualized on IMZ-SPECT. Localiza- 35 minutes starting from 180 minutes after tion was evaluated as completely concordant, intravenous injection. IMZ-SPECT images partially concordant, or discordant between were visually interpreted by one or two ex- the two methods. When an abnormal site perienced radiologists who were blinded to all visualized on IMZ-SPECT was discordant clinical information. For statistical analysis, with the estimated epileptic area (for example, the chi square test was employed. P<0.05 was cases in which the former was present in the regarded as significant. The protocol of this fronto-temporal regions, but the latter was study was approved by the Ethics Review present in the frontal region), or when the for- Board of Tokyo Women’s Medical Univer- mer involved 2 independent sites and 1 of sity. these was concordant with the latter, the lo- calization was regarded as partially concor- Results dant between the two methods. Overall concordance Furthermore, as it has been shown that the A total of 45 patients with intractable epi- administration of benzodiazepines may influ- lepsies underwent IMZ-SPECT, and 21 who ence the results of IMZ-SPECT [21], we in- satisfied the selection criteria were enrolled in vestigated the consistency of lateralization this study. Before IMZ-SPECT, the 21 pa- and localization with respect to the presence tients were classified into those with temporal or absence of these agents. lobe (n=12), frontal lobe (n=5), and parieto- EEGs with a zygomatic/supraorbital lead occipital lobe (n=4) epilepsy based on seizure were repeatedly performed. In most patients, manifestations, interictal /ictal EEG, and brain long-term EEG/video monitoring was con- MRI findings. Their ages at onset of epilepsy ducted to record seizures. Horizontal and cor- ranged from 2 months to 13 years and 9 onal sections of high-resolution (1.5 T) T1/ months (mean: 6 years and 2 months, standard T2-weighted and FLAIR MRI of the head deviation [SD]: 4 years and 6 months). Ages at were evaluated. IMZ-SPECT study ranged from 1 year and 2 For IMZ-SPECT, a 3-detector-type months to 18 years and 1 month (mean: 11 gamma camera (GCA9300 PI, Toshiba Co., years and 4 months, SD: 4 years and 4 Ltd.) and FAN BEAM LEHR high-resolution months). collimator were used. For rearrangement, In the temporal lobe epilepsy group, the Butterworth (cutoff: 0.10 cycles/pixel, order mean ages at epilepsy onset and IMZ-SPECT 8) and Shepp & Logan filters were employed study were 6 years and 11 months, and 11 as pretreatment and rearrangement filters, re- years and 11 months, respectively (Table 1). spectively. The attenuation-correction method Auras such as palpitation and an uprising gas- was not used. IMZ at 167 MBq was injected tric sensation characteristic of temporal lobe intravenously, and imaging was performed for 17 Table 1. Demographic and clinical data of the 21 patients Age at Age at Case Epilepsy Gen- Seizure Interictal EEG Estimated Decreased Use of Concordance Concordance IMZ- epilepsy Aura Seizure symptoms Ictal EEG Brain MRI No. types der frequency discharge epileptic focus iomazenil-uptake BZD of lateralization of localization SPECT onset Clouding of consciousness T1 TLE 7y1m F 5y10m - with twitching of corner of Weekly Lt. temporal Lt. temporal Thickening of gyrus in Lt. temporal lobe Lt. medial CLB Y Y mouth and eye deviation region region Lt. temporal lobe temporal lobe Arrest of motion with oral T2 TLE 7y7m M 6y7m - automatism Weekly _ Lt. rolandic Hypoplasia of Lt. Lt. temporal lobe Lt. temporal - Y Y Rt. clonic convulsion spike temporal lobe lobe Loss of consciousness Lt. hippocampal Lt. temporal T3 TLE 9y6m F 8y9m Nausea with atonic posture Monthly _ None atrophy Lt. temporal lobe lobe - Y Y Oral automatism Lt. temporal Lt. hippocampal Lt. temporal T4 TLE 10y7m M 1y6m - Dream-like state Monthly _ region atrophy Lt. temporal lobe lobe - Y Y Lt. temporal Lt. temporal T5 TLE 11y4m F 2y10m - Oral automatism Monthly _ region Normal Lt. temporal lobe lobe CLB Y Y Rt. superior Rt. hippocampal frontal lobe, Rt. Partially T6 TLE 11y9m F 10y5m - Oral automatism Monthly _ None atrophy Rt. temporal lobe inferior temporal - Y concordant lobe Palpitation Rt. temporal Thickening of Rt. Rt. temporal T7 TLE 13y2m M 12y11m Impatience Verbal automatism Monthly _ region temporal neocortex Rt. temporal lobe lobe - Y Y Floating Bilateral R>L hippo- Bilateral Rt. temporal T8 TLE 13y6m M 4y10m feeling Oral automatism Monthly _ None campal sclerosis temporal lobes lobe CLB N Y Lt. temporal re- Lt. temporal Lt. hippocampal Lt. temporal T9 TLE 13y10m M 3y5m - Loss of consciousness Monthly gion region atrophy Lt. temporal lobe lobe CLB Y Y Lt. anterior-inferior 18 ＞ T10 TLE 13y10m F 11y6m Ascending Loss of consciousness Weekly Lt. hemisphere Lt. temporal Lt. hippocampal Lt. temporal lobe temporal lobe CLB Y Y nausea Oral automatism region atrophy Lt. superior-frontal lobe Loss of consciousness Rt. temporal Dysplasia of Rt. tempo- T11 TLE 15y0m F 13y9m Palpitation Dream-like state Monthly _ region ral neocortex Rt. temporal lobe Rt. temporal lobe - Y Y Loss of consciousness T12 TLE 15y9m M 1y11m - Oral automatism Monthly _ Lt. central, Lt. hippocampal Lt. temporal lobe Rt. frontal lobe, CLB N N Visual hallucination temporal regions atrophy Rt. parietal lobe Groaning with eye-rolling- F1 FLE 1y9m F 10m - up and elevation of both Weekly _ Bilateral frontal Thickening of gyrus in Rt.>Lt.
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