Partial epilepsy: A pictorial review of 3 TESLA magnetic resonance imaging features

Epilepsy is a disease with serious consequences for patients and society. In many cases seizures are sufficiently disabling to justify surgical evaluation. In this context, Magnetic Resonance Imaging (MRI) is one of the most valuable tools for the preoperative localization of epileptogenic foci. Because these lesions show a large variety of presentations (including subtle imaging characteristics), their analysis requires careful and systematic interpretation of MRI data. Several studies have shown that 3 Tesla (T) MRI provides a better image quality than 1.5 T MRI regarding the detection and characterization of structural lesions, indicating that high-field-strength imaging should be considered for patients with intractable epilepsy who might benefit from surgery. Likewise, advanced MRI postprocessing and quantitative analysis techniques such as thickness and volume measurements of cortical gray matter have emerged and in the near future, these techniques will routinely enable more precise evaluations of such patients. Finally, the familiarity with radiologic findings of the potential epileptogenic substrates in association with combined use of higher field strengths (3 T, 7 T, and greater) and new quantitative analytical post-processing techniques will lead to improvements regarding the clinical imaging of these patients. We present a pictorial review of the major pathologies related to partial epilepsy, highlighting the key findings of 3 T MRI.

Quantitative Analysis of Simultaneous EEG Features during PET Studies for Childhood Partial Epilepsy

PURPOSE: To demonstrate the significance of simultaneous electroencephalography (EEG) recording during 2-deoxy-2-[18F] fluoro-D-glucose (FDG)-positron emission tomography (PET) in childhood partial epilepsy. MATERIALS AND METHODS: We included 46 children with partial epilepsy who underwent simultaneous EEG during PET. We compared the epileptogenic area of several EEG features including epileptiform discharges, focal polymorphic slow waves, and electrographic seizures, with the abnormal metabolic region on PET. We also compared the epileptogenic area of simultaneous EEG and PET with findings on magnetic resonance imaging (MRI) and video/EEG, as well as the histopathological diagnosis of the resected cortical area, in eight patients who underwent surgical resection of the epileptogenic area. RESULTS: Hypometabolic regions on interictal PET were concordant with epileptogenic areas of epileptiform discharges and focal polymorphic slow waves, according to their frequency and/or severity, with odds ratios of 1.35 and 1.81, respectively (p<0.05). Hypermetabolic PET was also concordant with epileptogenic areas of ictal events longer than 20 seconds during the period of FDG uptake. Among the eight patients who underwent surgical resection, six patients, including two with non-lesional MRI, had concordant EEG and PET findings, were confirmed pathologically, and became seizure-free after surgery. CONCLUSION: Simultaneous EEG is useful in identifying epileptogenic areas due to a high concordance with abnormal PET metabolic areas. Moreover, simultaneous EEG may also prevent false lateralization of PET from postictal and mixed metabolism during ictal events, as well as abnormal hypermetabolism, during frequent interictal epileptiform discharges.

Síndrome convulsivo neonatal: enfoque diagnóstico a propósito de un caso de epilepsia focal sintomática / Neonatal seizure syndrome: diagnostic approach about a case of focal epilepsy symptomatic

INTRODUCCIÓN: Las convulsiones neonatales son una descarga hipersincrónica de un grupo neuronal cortical, cuya sintomatología puede ser motora, sensitiva, neurovegetativa o mixta. De etiología variable, deben ser pesquisadas y estudiadas desde un inicio. PRESENTACIÓN DEL CASO: Recién nacido de término, femenino, 38 semanas de gestación, nacido de parto eutócico con Apgar 9-9. Hijo de madre primigesta de 24 años, sin antecedentes mórbidos ni antecedentes durante el embarazo. Presenta dos cuadros cianóticos súbitos descartándose en ese momento hipoglicemia, hipocalemia o alguna infección. Se hospitaliza presentando una convulsión tónico-clónica manejada con fenobarbital dejando dosis de mantención. Persiste con convulsiones agregándose piridoxina al tratamiento. Luego de48 horas fue dado de alta para su manejo y control ambulatorio con fenobarbital y piridoxina vía oral en espera de evaluación de electroencefalograma. Eco tomografía cerebral normal. Perfil Neonatal Ampliado normal. Luego de una semana presenta nuevamente un cuadro convulsivo por lo que se re-hospitaliza. El primer electroencefalograma fue informado como normal, pero el segundo, cuatro días después, mostró presencia de lentitud continua centro-temporal izquierda asociada a un compromiso cortical focal corroborado por tomografía axial computarizada cerebral posterior, realizando el diagnóstico final de epilepsia focal sintomática. DISCUSIÓN: El abordaje de un cuadro de convulsión neonatal obliga en primera instancia a descartar etiologías potencialmente reversibles y que permitirían la resolución de cuadros convulsivos de forma basal. No siempre una convulsión neonatal corresponde a una causa común, llevando en algunas ocasiones a estudios más acabados y donde cuadros como la epilepsia aparecen como una opción importante de considerar.

INTRODUCTION: Neonatal seizures are a hypersynchronic depolarization of a finite set of cortical neurons. The symptoms that manifest are motor, sensory, autonomic, or mixed. The etiology must be studied from the beginning. CASE REPORT: Term newborn, female, 38 weeks gestation, born of vaginal delivery with Apgar score 9-9. Mother of 24 years, no history or background morbid during pregnancy. It presents two episodes of sudden cyanosis boxes discarded at the time of hypoglycemia, hypokalemia, or infection. She is hospitalized for study where he presented a tonic-clonic seizure that was treated with Phenobarbital, following a maintenance dose. Persists with convulsions adding pyridoxine to therapy. After 48 hours without convulsions was discharged for outpatient management with oral phenobarbital and pyridoxine. Electroencephalogram pending. Normal brain ultrasound. Profile Expanded Neonatal normal. After a week presents again seizure so she was hospitalized again. The first electroencephalogram was under normal parameters, but the second made four days later showed the presence of slow continuous center-left temporal cortex associated with focal involvement confirmed by computed tomography brain back, so the diagnosis is made symptomatic focal epilepsy. DISCUSSION: The approach of a neonatal seizure box forces us in the first instance to rule out potentially reversible etiologies and those that allow the resolution of convulsions at baseline. Not always a neonatal seizure corresponds to a common cause, leading sometimes to continue studies and where a epilepsy appears as an important option to consider.

Factores pronósticos de recurrencia de la epilepsia focal en el niño / Prognostic factors of recurrence of focal epilepsy in children

INTRODUCCIÓN. El objetivo de este trabajo fue determinar los factores pronósticos de recurrencia de las crisis epilépticas focales a los 2 años del diagnóstico y del inicio del tratamiento. MÉTODOS. Este estudio observacional, analítico y prospectivo incluyó a 207 niños que presentaron dos o más crisis epilépticas focales no provocadas, hospitalizados en el Departamento de Neuropediatría del Hospital William Soler, entre diciembre de 2001 y diciembre de 2003. Al final de los 2 años de seguimiento, 185 pacientes concluyeron el estudio. RESULTADOS. El 33,5 por ciento de los pacientes presentó recurrencias de las crisis epilépticas focales al finalizar el estudio. Constituyeron factores de riesgo de recurrencia de las crisis epilépticas focales los siguientes: edad menor de un año, etiología sintomática, presencia de antecedentes personales de crisis neonatales sintomáticas y discapacidades neurológicas y la persistencia de descargas en el electroencefalograma (EEG) evolutivo. El análisis de regresión logística demostró como variables pronósticas de recurrencia la etiología sintomática (p = 0,000; OR = 3,107), el antecedente personal de crisis neonatales sintomáticas (p = 0,037; OR = 4,623) y la persistencia de descargas en el EEG evolutivo (p = 0,000; OR = 2,109). CONCLUSIONES. El antecedente personal de crisis neonatales sintomáticas constituyó el factor independiente con mayor influencia en las recurrencias de las crisis epilépticas focales

INTRODUCTION: The objective of present paper was to determine the recurrent prognostic factors of focal epileptic crises at 2 years of diagnosis and of treatment onset. METHODS: This prospective, analytical and observational study included 207 children presenting two or more non-provoked epileptic crises, admitted in Neuropediatrics Department of William Soler Hospital between December, 2001 and December, 2003. At a two years follow-up, 185 patients concluded the study. RESULTS: The 33,5 percent of patients had recurrences of focal epileptic crises at the end of the year. Recurrent risk factors of crises above mentioned included: aged under 1 year, symptomatic etiology, presence of personal backgrounds of symptomatic neonatal crises and neurologic disabilities and persistence of the evolutionary electroenphalogram discharges. The logistic regression analysis showed as prognostic variables of symptomatic etiology recurrence (p = 0,000; OR = 3, 107), the persona background of symptomatic neonatal crises (p = 0,037; OR = 4,623) and the discharges persistence in the evolutionary electroencephalogram (p = 0,000; OR = 2,109). CONCLUSIONS: The personal background of symptomatic neonatal crises was the independent factor with a higher influence on recurrent focal epileptic crises

Relación entre electroencefalograma y neuroimagen en niños con epilepsia focal de difícil control / Relation between electroencephalogram and neuroimaging present in children with epilepsy of difficult control

Las epilepsias focales son las màs frecuentes en los niños, y la resistencia al tratamiento farmacológico puede estar presente hasta en el 30 por ciento de los pacientes. Se realizó este estudio con el objetivo de dirigir la atención hacia la coincidencia topográfica de los paroxismos electroencefalográficos, con lesiones estructurales demostrables por neuroimagen, para facilitar el diseño de estrategias terapéuticas futuras. MÉTODOS. Se realizó un estudio descriptivo, longitudinal prospectivo, con 44 niños con diagnóstico de epilepsia focal de difícil control, ingresados en el Servicio de Neuropediatría del Hospital Pediátrico Docente Juan M Márquez, entre enero de 2003 y junio de 2007. Se realizaron estudios por electroencefalograma (EEG) al ingreso y videoelectroencefalograma, además de estudios de neuroimagen por tomografía axial o resonancia magnética nuclear. RESULTADOS. Los paroxismos en EEG involucraron el lóbulo frontal hasta en el 68 por ciento de los pacientes. En el 48 por ciento de los pacientes, los paroxismos electroencefalográficos coinciden con zonas de alteración estructural según neuroimagen, más frecuentes en el lóbulo frontal. En el 25 por ciento no hay coincidencia topográfica y en el 27 por ciento no se precisan alteraciones estructurales. CONCLUSIONES. En las epilepsias focales de difícil control se debe prestar especial atención a las zonas elocuentes con coincidencia entre el EEG y la neuroimagen, para evaluar de forma temprana las alternativas quirúrgicas de tratamiento.

Focal epilepsies are the more frequent conditions in children and a pharmacologic treatment resistance could be present up to 30 percent of patients. Aim of present paper was to direct the attention to topographic coincidence of electroencephalographic paroxysms with structural lesions by neuroimaging facilitating the future therapeutical strategies design. METHODS: A descriptive, longitudinal, prospective study was conducted in 44 children diagnosed with epilepsy of difficult control admitted in Neuropediatrics Service of Juan Manuel Marquez Teaching Children Hospital from January, 2003 to June, 2007. At admission, we made electroencephalogram (EEG) and videoelectroencephalogram (VEEG) studies as well as neuroimaging studies by axial tomography (AT) or nuclear magnetic resonance (NMR). RESULTS: Paroxysms in EEG involved frontal lobule up to the 68 percent of patients. In 48 percent, electroencephalographic paroxysms coincide with structural alteration zones according neuroimaging, more frequent in frontal lobule. In 25 percent there is not topographic coincidence, and in 27 percent there are not specified structural alterations. CONCLUSIONS: In focal epilepsies of difficult control, we must to take care of eloquent zones with coincident between EEG and neuroimaging to assess in time the surgical treatment options.

Seizure in non-HIV cryptococcal meningitis.

OBJECTIVE: The authors studied the prevalence of seizure in non-HIV cryptococcal meningitis. MATERIAL AND METHOD: The records of non-HIV adult patients (age >15 years) diagnosed as cryptococcal meningitis in Srinagarind Hospital (Khon Kaen University) from 1990 to 1994 were reviewed All subjects were studied for the rate, pattern, and long-term result ofseizure. RESULTS: There were 105 cases. Eight patients (7.6%) had seizures at initial presentation. The pattern of seizure of six patients was generalized tonic-clonic seizure (GTC) and the others were focal seizure. Only one case still had seizures after treatment with conventional therapy of cryptococcal meningitis. At ten years follow up, ten cases had died, one patient still had seizures (the same case that had seizures after treatment) and one case with developed GTC after improvement of meningitis. CONCLUSION: GTC was the common pattern of seizure in non-HIV cryptococcal meningitis and mostly controlled by standard regimen of therapy for cryptococcal meningitis without any antiepileptic drugs.

Episodic nausea and abdominal sensations as sole manifestations of simple partial seizures

In adults, seizures manifesting with abdominal complaints are usually associated with complex partial or secondary generalized seizures. Also, seizure periodicity is not expected in postmenopausal women. We encountered a 72-year-old woman with episodic nausea and abdominal pain that usually occurred with predictable regularity. When symptoms persisted after extensive gastrointestinal investigations and cholecystectomy, she was referred to us and the diagnosis of simple partial seizures was suspected. Both EEG and brain MRI were normal. The diagnosis was established by video/ EEG monitoring, which recorded several typical clinical events associated with right temporal ictal discharges. Because treatment with several antiepileptic medications caused intolerable side effects, the patient is now maintained on a low dose of Lamotrigine, which reduced seizure frequency and severity. This patient demonstrates that "abdominal" complaints, although rare, may be the sole manifestation of simple partial seizures. Unless considered in the differential diagnosis, the patient may undergo unnecessary and potentially harmful procedures

Análise da associação entre a presença de lesão estrutural do encéfalo e ocorrência de crise epiléptica e epilepsia / Trajectory of a Sentinel Event Assistance: evaluation of a full diabetic user attention in SUS from Severe Diabetic Retinopathy

A pesquisa de lesão estrutural do cérebro em pacientes com crise epiléptica e epilepsia é fundamental no diagnóstico e tratamento da síndrome epiléptica. O objetivo do estudo foi determinar freqüência e associação entre características clínicas e presença de lesões estruturais do encéfalo detectadas no exame de ressonância magnética, com o status e as formas clínicas da epilepsia. Avaliou-se o perfil clínico dos pacientes e das lesões estruturais do encéfalo na imagem por ressonância magnética em 140 pacientes com epilepsia ou crise epiléptica, encaminhados para exame de ressonância magnética e catalogados por demanda espontânea, desde outubro de 2003 até janeiro de 2005. O estudo foi do tipo caso-controle com casos prevalentes. A idade variou de um a 59 anos (mediana de 15,0 anos), sendo 51,6 por cento do gênero masculino. A crise epiléptica foi focal em 55 por cento, a freqüência mensal de até 10 crises foi registrada em 77,6 por cento e o exame neurológico foi normal em 64,2 por cento dos pacientes. Epilepsia farmacoresistente foi identificada em 76,3 por cento e crise epiléptica única em 15,7 por cento. A imagem por ressonância magnética foi anormal em 72,8 por cento dos pacientes. O lobo temporal foi local para 50,5 por cento das alterações. As mais encontradas foram: anormalidades no hipocampo (41,1 por cento); malformações do desenvolvimento cortical (19.6 por cento); isquemia (5,8 por cento); tumor (6,8 por cento); cavernoma(2,9 por cento); facomatose (4,9 por cento); cicatriz (4,9 por cento); inflamatório (4,9 por cento); outras (8,8 por cento). A alteração estrutural na imagem de ressonância magnética foi mais presente entre os pacientes com epilepsia focal e farmacorresistente, sendo o lobo temporal a região com mais alterações. Os pacientes com tumor cerebral apresentaram mais CE focal e a atrofia do córtex cerebral foi alteração freqüente na IRM de pacientes com epilepsia farmacorresistente. Os pacientes com idade maior de 15 anos, número mensal maior de crises e epilepsia sintomática apresentaram maior risco para CE focal e aqueles com crise epiléptica única apresentaram mais CE generalizada. O risco para epilepsia farmacorresistente foi maior entre os pacientes com anormalidades no exame de ressonância magnética, antecedente pessoal e exame neurológico anormais.

The research of structural lesion of the brain in patients with epilepsy is fundamental to diagnosis and treatment of the epileptic syndrome. The authors evaluated the patients clinical profile and structural lesions of the brain in magnetic resonance image of 140 patients with epilepsy and classified by spontaneous demand, since October of 2003 to January of 2005. The study was a case-control with prevalent cases and aged between 1 and 59 years (medium 15,0 years), being 51,6% of masculine gender. Epileptic seizure was focal in 55%, monthly frequency of 10 or less was registered in 77,6% and neurological exam was normal in 64,2% of patients. Refractory Epilepsy was identified in 76,3% and single seizure in 15,7%. Magnetic resonance image was abnormal in 72,8% of patients. Temporal lobe was the local for 50,5% of the alterations, presented as: hypocampal abnormalities (41,1%); malformations of the cortical development (19.6%); stroke (5,8%); tumor (6,8%); cavernoma (2,9%); facomatoses (4,9%); scar (4,9%); inflammatory (4,9%); others (8,8%). The structural alteration in the image of magnetic resonance was more present among patients with focal and refractory epilepsy, being the temporal lobe the area with more alterations. Patiensts with focal seizures presented more cerebral tumor and those with refractory epilepsy presented cerebral cortex atrophy in magnetic resonance image. Patients more than 15 years old had high frequency of seizures and with syntomatic epilepsy,also presented more risk for focal seizures. Generalized seizure was presented mostin those with a single resonance image, abnormal personal antecedent and neurological alterations.

Autonomic seizures and autonomic status epilepticus in early onset benign childhood occipital epilepsy (Panayiotopoulos syndrome) / Crises autonômicas e status epilepticus autonômico na epilepsia occipital benigna da infância de início precoce (síndrome de Panayiotopoulos)

To study clinical and EEG features of children with ictal vomiting and no underlying brain lesions (Panayiotopoulos syndrome). The subjects were 36 children aged 2-13 years. The onset of seizures occurred between 1 and 5 years of age. Fourteen children (38.8 percent) had a single seizure. Fourteen children (38.8 percent) had autonomic status epilepticus. Impairment of consciousness was reported in 30 (83.3 percent) children, eye deviation in 10 (27.7 percent) other autonomic symptoms and head deviation in 9, generalization in 8, visual symptoms in one child, and, speech arrest or hemifacial motor symptoms in 8 cases. The EEG showed occipital spikes or spike-wave complexes in 27 (75.0 percent) children, blocked by opening of the eyes in 8 (22.2 percent) cases. Nine patients (25 percent) also had rolandic spikes and 3 had extraoccipital spikes. Six (16.6 percent) patients had normal EEG. No clinical differences were observed between patients having occipital or extraoccipital spikes. In children only with autonomic seizures, the spikes are predominantly occipital but blockage by opening of the eyes is a less frequent feature. In some children there is an overlapping of different focal childhood idiopathic syndromes.

Estudar aspectos clínico-eletrencefalográficos de crianças com vômito ictal e sem sinais de lesão cerebral (síndrome de Panayiotopoulos). Foram estudadas 36 crianças na faixa etária de 2-13 anos. O início das crises ocorreu entre 1 e 5 anos de idade. Quatorze crianças tiveram crise única. Status epilepticus foi observado em 14 (38,8 por cento) casos. Distúrbio da consciência foi relatado em 83,3 por cento das crianças, desvio ocular em 27,7 por cento, outros sintomas autonômicos e desvio da cabeça em 26,4 por cento, generalização em 23,5 por cento, bloqueio da fala ou sintomas motores da hemiface em 23,5 por cento das crianças e sintomas visuais em um caso. O EEG mostrou pontas ou complexos de ponta-onda em 27 (75,0 por cento) casos, bloqueados pela abertura dos olhos em 8 (22,2 por cento) pacientes. Nove pacientes tiveram também pontas rolândicas e 3, pontas extraoccipitais outras. O EEG foi normal em 6 crianças. Não houve diferença clínica entre as crianças com pontas occipitais e extraoccipitais. Em crianças com crises autonômicas as pontas foram de predomínio occipital, mas bloqueio pela abertura dos olhos foi pouco freqüente. Em alguns casos houve sobreposição de diferentes síndromes idiopáticas focais da infância.

Successful resection of Hypothalamic Hamartoma with intractable gelastic seizures--by transcallosal subchoroidal approach.

A 19-year old female with intractable gelastic seizures was found to have 0.7 x 1.8 x 1.8 cm elliptical mass on the floor of the third ventricle. The signal intensity on the Magnetic Resonance Imaging (MRI) was consistent with the Hypothalamic Hamartoma (HH). Ictal EEG demonstrated rhythmic 7 Hz waves over Fp2, F4, and C4 with spreading to the right temporal region and then bilaterally. Ictal Single Photon Emission Computerized Tomography (SPECT) showed hyperperfusion at hypothalamic and medial frontopolar regions. The patient underwent surgical resection using Trans Callosal Subchoroidal Approach (TCSA) to the third ventricle. Pathological finding confirmed the diagnosis of hypothalamic hamartoma. Following the operation, she has been seizure free up to 12 months. Thereafter, provoked seizures seldom occurred and there has been improvement in her memory, emotional control and independence. This appears to be the first report of this surgical approach for HH, which is less likely to disturb memory function compared to previously described interfoniceal approach.

Atypical benign partial epilepsy of childhood (pseudo-Lennox syndrome): report of two brothers.

Two brothers (3 and 2 year old) with characteristic findings of atypical benign partial epilepsy of childhood (pseudo-Lennox syndrome) are reported, to emphasize the presence of a possibility of a genetic basis of this disorder and the importance of intravenous immune globulin (IVIG), vigabatrin (VGB) and lamotrigine (LTG) therapy. Sleep EEGs of both the patients showed typical features of Lennox-Gastaut syndrome. On follow-up, the convulsions were found to be resistant to numerous antiepileptic agents in one patient while they were easily controlled with LTG monotherapy in the other patient. In the elder brother, who was diagnosed as intractable epilepsy, the convulsions disappeared with IVIG and VGB. During the long term follow-up, they were seizure free for five and two years respectively, and their mental motor development was excellent.

Topiramate: a new safe and effective antiepileptic.

Twenty patients of either sex, with refractory partial epilepsy with or without secondary generalisation were entered in an open label study to evaluate the efficacy and safety of topiramate in them. Topiramate was used as an adjunctive therapy with an initial starting dose of 50 mg/day. The dose was then titrated upwards with increments of 50 mg per week, till a time the most effective and the best tolerated dose was reached. This most effective/tolerated dose was then continued for 6 months. Of the 17 patients entering the maintenance phase, 4 patients (24%) became seizure free, while a total of 14 patients (83%) out of 17 cases responded with a reduction in monthly seizures rate by 50% or more. Mean reduction of 68.9% was observed in monthly seizure rate during the maintenance phase. The median effective dose of topiramate was 600 mg per day. Five patients dropped out of the study due to adverse events such as anxiety, aggressiveness, rash, lethargy, etc. The central nervous system (CNS) related side effects such as dizziness, headache, and tremor were reported, which are commonly seen with other presently available antiepileptics like carbamazepine, phenytoin sodium, sodium valproate, etc, as well. Most adverse events, however, were mild and transient and did not interfere with the day to day activity of the patients. Topiramate was not associated with any abnormality in laboratory or neurological examination findings. The excellent response with topiramate therapy in Indian patients, uncontrolled with the available antiepileptics, as well as its good safety profile endorse the international efficacious and safe image of topiramate.

Resonancia magnetica y localización clínica y electroencefalográfica en la epilepsia focal / Magnetic resonance and clinical and electroencephalographical localization in focal epilepsy

Magnetic Resonance Imaging (MRI) is the method of choice to search for epileptogenic lesions. We correlated MRI findings with the epileptogenic zone (EZ) depicted by clinical and electroencephalographic (EEG) data. We studied 400 clinical records of patients who had been submitted to MRI studies and we analyzed, retrospectively, their ictal semiology, EEG characteristics and response to treatment. They were classified into 3 groups: A) temporal lobe epilepsy, B) frontal lobe epilepsy and C) parieto-occipital epilepsy. We included 155 patients: Group A) 68 cases (43.9 per cent), 28 men (41.1 per cent), mean age 32 +/- 11 years old, abnormal IMR in 44 (64.7 per cent), refractory to treatment 48 (70.5 per cent). Group B) 68 cases (43.9 per cent), 38 men (55.8 per cent), mean age 30 +/- 15 years old, abnormal IMR in 26 (38.2 per cent), refractory to treatment 30 (44.1 per cent). Group C) 19 cases (12.2 per cent), 13 men (68.4 per cent), mean age 27 +/- 11 years old, abnormal IMR in 11 (57.8 per cent), refractory to treatment 12 (63.1 per cent). Results showed that there were higher possibilities of detecting lesions which correlate with EZ in temporal than in frontal or parieto-occipital lobes epilepsy. The chances to find abnormalities on the MRI were 5 times higher in refractory patients than in those who were non-refractory.