The changing landscape in epilepsy imaging: Unmasking subtle and unique entities

Dramatic changes have occurred recently in the field of epilepsy, including a fundamental shift in the etiology of epileptogenic substrates found at surgery. Hippocampal sclerosis (HS) is no longer the most common etiology found at epilepsy surgery and this decrease has been associated with an increase in the incidence of focal cortical dysplasia and encephaloceles. Significant advances have been made in molecular biology and genetics underlying the basis of malformations of cortical development (MCD), and our ability to detect epileptogenic abnormalities with magnetic resonance imaging has markedly improved. This article begins with a discussion of these trends and reviews imaging techniques essential for detecting subtle epilepsy findings. Representative examples of subtle imaging findings are presented, which are often overlooked but should not be missed. These include temporal lobe encephaloceles, MCD, especially focal cortical dysplasia, HS, hippocampal malformation (also known as HIMAL), ulegyria, autoimmune encephalitis, and Rasmussen’s encephalitis. Recent findings on the pathophysiology and genetic underpinnings of several causes of localization-related epilepsy are incorporated. For instance, it has been recently found that focal cortical dysplasia IIb, tuberous sclerosis, hemimegalencephaly, and gangliogliomas are all the result of mutations of the mammalian target of rapamycin pathway for cell growth.