Electroencephalography–functional magnetic resonance imaging of epileptiform discharges: Noninvasive investigation of the whole brain

Abstract Simultaneous electroencephalography–functional magnetic resonance imaging (EEG‐fMRI) is a unique and noninvasive method for investigating epileptic activity. Interictal epileptiform discharge‐related EEG‐fMRI provides cortical and subcortical blood oxygen level‐dependent (BOLD) signal changes specific to epileptic discharges. As a result, EEG‐fMRI has revealed insights into generators and networks involved in epileptic activity in different types of epilepsy, demonstrating—for instance—the implication of the thalamus in human generalized spike and wave discharges and the role of the default mode network in absences and focal epilepsy, and has suggested a mechanism for the cortico‐subcortical interactions in Lennox–Gastaut syndrome discharges. EEG‐fMRI can find deep sources of epileptic activity not available to scalp EEG or magnetoencephalography, and provides critical new information to delineate the epileptic focus when considering surgical treatment or electrode implantation. In recent years, methodological advances, such as artifact removal and automatic detection of events, have rendered this method easier to implement, and its clinical potential has since been established by evidence of the impact of BOLD response on clinical decision‐making and of the relationship between concordance of BOLD responses with extent of resection and surgical outcome. This review presents the recent developments in EEG‐fMRI methodology and EEG‐fMRI studies in different types of epileptic disorders as follows: EEG‐fMRI acquisition, gradient and pulse artifact removal, statistical analysis, clinical applications, presurgical evaluation, altered physiological state in generalized genetic epilepsy, and pediatric EEG‐fMRI studies.