Voxel-based and surface-based cortical morphometric MRI applications for identifying the epileptogenic zone: A narrative review.

Approximately 40% of patients with drug-resistant epilepsy referred for surgical evaluation have no epileptogenic lesion on MRI (MRI-negative). MRI-negative epilepsy is associated with poorer seizure freedom prognosis and has therefore motivated the development of structural post-processing methods to "convert" MRI-negative to MRI-positive cases. In this article, we review the principles, advances, and challenges of voxel- and surface-based cortical morphometric MRI techniques in detecting the epileptogenic zone. The ground truth for the presumed epileptogenic zone in imaging studies can be classified into lesion-based (MRI lesion mask or histopathology) or epileptogenicity-based ground truth (anatomical-electroclinical correlations or resections that lead to seizure freedom). Voxel-based techniques are reported to have a 13%-97% concordance rate, while surface-based techniques have 67%-92% compared to lesion-based ground truths. Epileptogenicity-based ground truth may be more relevant in the case of MRI-negative cases; however, the sensitivity and concordance rate (voxel-based technique 7.1%-66.7%, and surface-based technique 62%) are limited by the reliance on scalp EEG and qualitative analysis of seizure-onset pattern. The use of stereo-EEG and quantitative EEG analysis may fill this gap to evaluate the correlation between cortical morphometry results and electrophysiological epileptogenic biomarkers of the epileptogenic zone and help improve the yield of structural post-processing tools. PLAIN LANGUAGE SUMMARY: Locating the epileptogenic zone (the brain area that is responsible for seizure generation) is important to diagnose and plan epilepsy treatments. An abnormal brain imaging (MRI) result can help clinical decision-making; however, around 40% of patients have normal MRI results (MRI-negative). We are reviewing the potential of two advanced MRI methods (voxel- and surface-based cortical morphometry) to localize the epileptogenic zone in the presence or absence of visible MRI abnormalities. We also describe the current challenge of applying the above methods in daily clinical practice and propose using advanced brain recording analysis to aid this translation process.