| PurposeIn this study,by comparing the imaging data of single MR,single PET and PET/MR fusion in patients with refractory temporal lobe epilepsy,and taking the postoperative pathology and follow-up results as the gold standard,to explore the value of integrated 18F-FDGPET/MRI brain imaging in the sensitivity and accuracy of preoperative localization of epileptogenic foci in patients with refractory temporal lobe epilepsy.MethodsResearch objectsIn this study,patients with refractory temporal lobe epilepsy diagnosed in the Department of Neurology of our hospital from December 2019 to December 2021 were comprehensively evaluated and located in one side of the temporal lobe by multi-departments(inner mind,mind outside,imaging and other departments).Patients with epileptogenic foci were operated under the guidanceof intracranial cortical EEG;patients with suspected epileptogenic foci were treated by stereotactic EEG.All patients underwent integrated PET/MR brain imaging before operation.Inclusion criteria:1)meet the diagnostic criteria of clinical refractory epilepsy;2)informed consent and voluntary PET/MR examination,and no seizures occurred 2 days before PET/MR examination;3)surgery was performed within 1 month after the completion of PET/MR examination,cortical EEG or stereotactic EEG showed that there were epileptiform discharges in unilateral temporal lobe and hippocampus;4)clinical data were complete and compliance was good.Exclusion criteria:1)do not meet the diagnostic criteria of clinical refractory epilepsy;2)patients with poor blood glucose control(fasting blood glucose before examination is greater than 11.1mmol/L),poor compliance,PET/MR contraindications,etc.can not complete PET/MR examination;3)PET/MR image quality is poor,can not be included in statistics;4)patients with incomplete clinical data,imperfect related examinations and loss of follow-up.5)patients with definite birth defects and genetic metabolic diseases;6)patients with intraoperative cortical electroencephalogram or stereotactic electroencephalogram indicating the presence of unilateral temporal lobe and extra-hippocampal epileptiform discharge areas or patients without operation within 1 month after PET/MR examination.Inspection method1.18F-FDG PET/MR image acquisition and analysisThe scanner uses a joint photo uPMR790PET/MR,and the imaging agent is 18F FDG PET and MR scanning at the same time.The original data after scanning are processed and reconstructed and transmitted to the workstation.Four senior attending doctors of nuclear medicine department or radiology department were combined with clinical data and other examinations without communication with each other’s group.Single MRI image and single PET image in the data obtained by integrated PET/MR scan were double-blind read,and the results of PET/MR fusion imaging were discussed by four doctors.Single PET brain metabolic image analysis was performed by visual judgment and semi-quantitative analysis,and the positive results were abnormal brain areas such as metabolic deficiency,decrease or increase.Single PET examination can localize unilateral single focus(the lesion is limited to the temporal lobe and hippocampal region of unilateral brain),while bilateral single focus(the lesion is limited to bilateral temporal lobe and hippocampal region)regards the side with higher metabolic changes as epileptogenic focus.Unilateral multiple foci(unilateral hemispheres with metabolic abnormalities in other brain regions except temporal lobe and hippocampus)or bilateral multiple foci(bilateral hemispheres with metabolic abnormalities in other brain regions except temporal lobe and hippocampus)were regarded as unable to locate.The positive findings of single MRI examination were as follows:1)local cortical structural changes(thickening,thinning,unclear boundary with white matter),2)local cortical signal abnormalities,3)hippocampal formation or/and signal abnormalities,4)sulcus widening or temporal horn asymmetry,5)subcortical gray and white matter signals or structural abnormalities.Single MRI examination can locate the unilateral focus(the lesion area is shown as the temporal lobe and hippocampal region of the unilateral cerebral hemisphere)with brain structure or signal changes,and negative MRI results or multiple abnormalities are regarded as unable to locate.The positive result of PET/MR fusion imaging means that any result of MRI or PET is positive.PET/MR fusion imaging confirms that there are two abnormalities of MRI and PET in the same part of the fusion image,or any one of MRI or PET can be located.The patients were followed up through outpatient clinic and telephone at 3 months,6 months and 1 year after operation.the final results were used to understand the control of postoperative seizures.2.Statistical processingThe data were analyzed by SPSS26.0 software.The measurement data in accordance with normal distribution were expressed as mean±standard deviation(x±s),and the counting data were expressed as cases and percentages.Fisher accurate probability experiment(sample size less than 40 cases)was used for comparison between groups,and the difference was statistically significant.Results1.Participants were finally included in the results:During the study period,a total of 67 patients with clinically diagnosed intractable temporal lobe epilepsy completed integrated 18F-FDG PET/MR brain imaging.Multidisciplinary consultation suggested that 62 patients could locate the epileptogenic focus,including 26 patients who underwent surgery within one month,and 36 patients who did or did not undergo surgery after one month.Another 5 patients who were difficult to locate after consultation underwent "stereotactic electrode embedding assisted by robot".Among them,3 patients who were clearly located were finally treated by surgery,and 2 patients were still unable to locate clearly and did not undergo surgery.Finally,29 surgical patients were included in this study.2.Surgical and pathological results:Among the 29 patients who underwent surgery,there were 16 males and 13 females,aged 4-47 years(average 14.07 11.28 years),the onset age was 2-38 years(average 9.06 3.69 years),and the course of disease was 3-30 years(average 10.21 7.16 years).Among the 29 cases,24 cases underwent unilateral anterior temporal lobectomy,4 cases underwent unilateral hippocampal amygdala resection,and 1 case underwent partial resection of left temporal arachnoid cyst wall and subarachnoid communication.Postoperative pathological diagnosis showed that there were 13 cases of focal cerebral cortical dysplasia(Ⅰa3,Ⅱa7,Ⅱb1 and Ⅲa2),4 cases of hippocampal sclerosis,3 cases of astrocytoma,2 cases of oligodendroglioma,2 cases of ganglioglioma,1 case of glioblastoma,1 case of meningioma,1 case of meningioma,1 case of cavernous hemangioma and 1 case of arachnoid cyst.All patients were followed up after operation(the shortest period is 3 months,the longest period is 17 months),and the evaluation has been effective so far.During the follow-up period,there were 20 cases without epilepsy and 9 cases with epilepsy..3.Results of positive changes in single MRI,single PET and PET/MR fusion imaging:In the 18F-FDG PET/MR examination of brain,17 cases were found to have positive changes in single MRI image(13 cases were unilateral single focus,4 cases were unilateral multiple focus),and the positive focus detection rate was 58.62%(17/29);Single PET image showed positive changes in 29 cases(unilateral single lesion in 14 cases,bilateral single lesion in 1 case,unilateral multiple lesions in 14 cases),and the positive lesion detection rate was 100%(29/29);PET/MR fusion imaging showed positive changes in 29 cases,and the positive lesion detection rate was 100%(29/29).Among them,PET/MR fusion images showed positive changes in 29 cases(unilateral single lesion in 14 cases,bilateral single lesion in 1 case,unilateral multiple lesions in 14 cases),MRI positive changes in 24 cases(unilateral single lesion in 20 cases,unilateral multiple lesions in 4 cases),and PET/MR fusion images showed positive changes.The positive detection rates of PET/MR fusion imaging and single PET imaging were higher than those of single MRI imaging,and the differences were statistically significant(P=0.000,p<0.05).4.Results of preoperative image reading of single MRI,single PET and PET/MR fusion imaging can be located:17 patients with positive changes were found by single MRI in 18F-FDG PET/MR examination of brain integration,of which 13 cases could be located(all were unilateral single focus)and 4 cases could not be located.The preoperative localization rate was 44.83%(13/29).There were 29 patients with single positive changes found by PET,of which 15 cases could be located(14 cases with unilateral single lesion,1 case with bilateral single lesion),and 14 cases could not be located.The preoperative localization rate was 51.72%(15/29).Finally,26 patients could be located by PET/MR fusion imaging,and the preoperative localization rate was 89.65%(26/29).Compared with the results of single MRI and single PET,PET/MR fusion imaging increased the number of localizable patients by 4,and increased the localizable rate of lesions by 13.79%(4/29).Statistical analysis showed that the preoperative localization rate of PET/MR fusion images was higher than that of single PET imaging(P=0.003,p<0.05)and single MRI imaging(P=0.001,p<0.05),and the differences were statistically significant.The localization rate of single MRI before operation was slightly higher than that of single PET,and the difference was not statistically significant(P=0.793,p>0.05).5.In 29 patients with integrated brain 18F-FDG PET/MR examination,single MRI found preoperative localization in 13 cases,11 cases were consistent with surgery,2 cases were inconsistent,and the final preoperative localization accuracy of single MRI was 37.93%(11/29).Single PET imaging can locate 15 cases before operation,15 cases are consistent with operation,0 cases are inconsistent,and the accuracy rate of preoperative location is 51.72%(15/29).There were 26 patients who could be located before PET/MR fusion imaging,all of which were consistent with the surgical site.The final localization accuracy of PET/MR fusion imaging was 89.66%(26/29),which was higher than that of single MRI(P=0.000,P<0.05)and single PET(P=0.003,P<0.05),respectively.The differences were as follows The preoperative localization accuracy of single PET imaging is slightly higher than that of single MRI,but the difference is not statistically significant(P=0.429,p>0.05).Conclusion1.Single MRI examination can find the changes of brain morphology,structural abnormalities and tissue signal intensity,single PET imaging can find the changes of brain glucose metabolism,while integrated PET/MRI imaging can simultaneously obtain brain anatomy and metabolism information in patients with temporal lobe epilepsy.The positive rate of focus detection is significantly higher than that of single MR imaging and slightly higher than that of PET imaging,which can be used for preoperative evaluation of refractory temporal lobe epilepsy.2.Through abnormal metabolic brain regions,PET/MRI fusion imaging is helpful to find mild morphological or structural abnormalities that are difficult to be observed by a single MRI,and can make up for the lack of low sensitivity in the detection of epileptic foci caused by a single MRI.The improvement of the detection rate of structural abnormalities in MRI is helpful to help PET imaging to locate epileptogenic foci more accurately,and to make up for the lack of high sensitivity but low specificity in the localization of epileptic foci in PET.3.Integrated PET/MR imaging can significantly improve the accuracy of preoperative localization of epileptogenic foci in patients with temporal lobe epilepsy by complementary detection of high sensitivity of PET lesions and high specificity of MRI lesions and accurate fusion of the two images,and has important application value in preoperative evaluation of patients with refractory temporal lobe epilepsy.. |
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