Simultaneous high-resolution whole-brain MR spectroscopy and [¹⁸F]FDG PET for temporal lobe epilepsy

Purpose: Precise lateralizing the epileptogenic zone in patients with drug-resistant mesial temporal lobe epilepsy (mTLE) remains challenging, particularly when routine MRI scans are inconclusive (MRI-negative). This study aimed to investigate the synergy of fast, high-resolution, whole-brain MRSI in conjunction with simultaneous [¹⁸F]FDG PET for the lateralization of mTLE. Methods: Forty-eight drug-resistant mTLE patients (M/F 31/17, age 12–58) underwent MRSI and [¹⁸F]FDG PET on a hybrid PET/MR scanner. Lateralization of mTLE was evaluated by visual inspection and statistical classifiers of metabolic mappings against routine MRI. Additionally, this study explored how disease status influences the associations between altered N-acetyl aspartate (NAA) and FDG uptake using hierarchical moderated multiple regression. Results: The high-resolution whole-brain MRSI data offers metabolite maps at comparable resolution to [¹⁸F]FDG PET. Visual examinations of combined MRSI and [¹⁸F]FDG PET showed an mTLE lateralization accuracy rate of 91.7% in a 48-patient cohort, surpassing routine MRI (52.1%). Notably, out of 23 MRI-negative mTLE, combined MRSI and [¹⁸F]FDG PET helped detect 19 cases. Logistical regression models combining hippocampal NAA level and FDG uptake improved lateralization performance (AUC=0.856), while further incorporating extrahippocampal regions such as amygdala, thalamus, and superior temporal gyrus increased the AUC to 0.939. Concurrent MRSI/PET revealed a moderating influence of disease duration and hippocampal atrophy on the association between hippocampal NAA and glucose uptake, providing significant new insights into the disease’s trajectory. Conclusion: This paper reports the first metabolic imaging study using simultaneous high-resolution MRSI and [¹⁸F]FDG PET, which help visualize MRI-unidentifiable lesions and may thus advance diagnostic tools and management strategies for drug-resistant mTLE.