For children trapped in cycles of drug-resistant seizures, the difference between a life-changing surgery and continued suffering often hinges on whether imaging can pinpoint the responsible brain lesion. When standard MRI returns negative or inconclusive results, surgical candidates are frequently turned away — making advanced imaging not merely a technical upgrade but a potential gateway to cure.
This prospective cohort study enrolled 79 pediatric patients (mean age 9.5 years) with focal epilepsy who had already received negative or inconclusive 3-Tesla MRI results and were under surgical evaluation. Using integrated [18F]FDG PET/MRI — which co-registers metabolic glucose uptake data with high-resolution structural brain imaging in a single session — researchers conducted a structured four-phase analysis. Critically, joint PET/MRI reading identified concordant PET-positive/MRI-positive findings in 58% of patients, while an additional 30% showed PET-positive signal despite MRI-negative results, meaning the metabolic data alone flagged lesions the anatomical scan missed. Only 10% of patients remained negative on both modalities. Surgical outcomes and electroencephalographic concordance were used to validate the imaging-identified epileptogenic zones.
The clinical significance here is substantial. Focal cortical dysplasias — the most common surgically treatable epilepsy substrate in children — are notoriously MRI-occult, especially in young children where myelination is incomplete. FDG-PET has long been used adjunctively in epilepsy presurgical workup, but its integration with simultaneous MRI acquisition reduces co-registration errors and shortens evaluation timelines. This study adds meaningful pediatric-specific evidence to a growing body of literature supporting multimodal imaging in MRI-negative epilepsy. Key limitations include the single-center design, absence of a randomized comparison arm, and the inherent selection bias of a surgical referral population. Nevertheless, the finding that nearly one-third of MRI-negative children harbored PET-detectable lesions suggests this modality deserves broader consideration in pediatric epilepsy surgery programs, particularly where stereoEEG implantation decisions depend on imaging hypotheses.