High frequency oscillations for lateralizing suspected bitemporal epilepsy

- Bilateral invasive monitoring can help determine epilepsy laterality.
- Intracranial HFO EEG can identify the hemisphere of seizure origin.
- Ictal ripples and interictal fast ripples are better than conventional intracranial EEG.
- Even when MRI is normal, HFOs can supply information on laterality.

ObjectiveIn some cases of single focus epilepsy, conventional video electroencephalography (EEG) cannot reveal the epileptogenic focus even when intracranial electrodes are used. Here, we tested whether analyzing high frequency oscillations (HFOs) can be used to determine the ictal onset zone in suspected bitemporal epilepsy and improve seizure outcome.MethodsWe prospectively studied 13 patients with refractory temporal seizures who were treated over a 4-year period and underwent bilateral placement of intracranial electrodes. Subdural strips were used in all cases, and depth electrodes were implanted into mesial temporal lobes in 10 patients. The mean patient age was 30.92 years, and 30.7% of patients were male. Patients were monitored by conventional and wide-band frequency amplifiers.ResultsConventional invasive EEG monitoring of interictal periods showed bilateral epileptiform abnormalities in 12 patients (92.3%) and unilateral epileptiform abnormalities in one (7.7%), and monitoring of ictal periods revealed unilateral seizure origins in nine patients (69.2%) and bilateral origins in four (30.8%). In contrast, high frequency invasive EEG monitoring of interictal periods showed bilateral HFOs in seven patients (53.8%) and unilateral HFOs in six (46.2%), and monitoring of ictal periods revealed unilateral HFOs in all 10 patients who were tested. Three patients were not monitored during ictal periods because of time limitations. All 13 patients subsequently underwent a standard unilateral temporal lobectomy and have been followed-up for a minimum of 12 months. Eleven (84%) had a Class I outcome, one (8%) a Class II outcome, and one a Class III outcome.SignificanceBilateral placement of subdural strip and depth electrodes for seizure monitoring in patients with suspected bitemporal epilepsy is both safe and effective. Monitoring high frequency oscillations can help determine the laterality of the onset zone when localization using conventional EEG or brain MRI fails.