Perfusion SPECT, SISCOM and PET <span class="elsevierStyleSup">18</span>F-FDG in the assessment of drug-refractory epilepsy patients candidates for epilepsy surgery | Revista Española de Medicina Nuclear e Imagen Molecular (English Edition)

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of RE patients would be candidates for epilepsy surgery&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">3</span></a> Epilepsy surgery is indicated in RE patients with partial focal epilepsy with an identified epileptogenic focus &#40;EF&#41; without severe neurological deficit&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">An EF is defined as a determined cerebral area with abnormal electrical activity&#44; being responsible for the origin of a focal epileptic seizure&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">2</span></a> The assessment and handling of such patients is complex and should be carried out by multidisciplinary teams in epilepsy departments where specialists from diverse areas evaluate globally and in cooperation the RE patient&#46; These multidisciplinary teams have two fundamental objectives&#44; which in turn will determine the success of the surgery&#58; the appropriate selection of patients and correct localization of EF&#46; The common tests performed are &#40;1&#41; clinical and semiological assessment of the patient and seizures&#44; &#40;2&#41; long-term video-EEG monitoring&#44; &#40;3&#41; MRI and &#40;4&#41; neuropsychological and psychiatric assessment&#46; If&#44; after carrying out these evaluations&#44; the patient is confirmed a suitable candidate for surgery but the EF has not been determined conclusively&#44; functional neuroimaging is employed&#46; Non-invasive tests used to determine FE are ictal&#47;interictal brain perfusion SPECT &#40;<span class="elsevierStyleItalic">single photon emission computed tomography</span>&#41; and PET &#40;<span class="elsevierStyleItalic">positron emission tomography</span>&#41; <span class="elsevierStyleSup">18</span>F-FDG&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">4</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">An EF involves neuronal hyper-excitation&#44; which is accompanied by an increase in metabolic demands and blood flow&#59; it is this physio-pathological base which permits the use of PET-FDG and perfusion SPECT in the study of the epileptic patient&#46;<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">4&#8211;7</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Ictal brain perfusion SPECT detects areas of high uptake&#44; corresponding to the increased blood flow of the EF&#46; The increase in blood flow to EF has been reported as being up to 300&#37; compared to base level&#44; which explains the high sensitivity of ictal SPECT of EF detection&#46;<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">8&#8211;11</span></a> Goffin et al&#46; refer to ictal perfusion as the only non-invasive imaging technique capable of detecting EF&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">12</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">In our centre&#44; ictal and interictal SPECT are used to study the brain perfusion of certain patients&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Interictal perfusion SPECT identifies areas of hypo-perfusion&#44; and in some cases normal blood flow&#44; reflecting the basal &#40;not ictal&#41; perfusion of the EF&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">11</span></a> Although there are authors such as Bonte et al&#46; who refer to interictal SPECT as an isolated tool to identify EF&#44; the sensitivity of the technique is low and only leads to EF identification in about 50&#37; of cases&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">13</span></a> The comparative ictal&#8211;interictal SPECT evaluation allows the delimitation of EF&#44; especially in those patients with large areas of hyper-perfusion or multiple foci in ictal phase&#44; through the assessment of focal areas of hypo-perfusion identified in interictal SPECT&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">The visual analysis of perfusion SPECT is complemented by <span class="elsevierStyleItalic">Subtraction of Ictal SPECT Co-register to MRI</span> &#40;SISCOM&#41; technology&#46; SISCOM combines the functional information from the SPECT with anatomical information from MRI&#44;<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">14&#44;15</span></a> the objective being to increase sensitivity and specificity of perfusion SPECT in the search of EF&#46;<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">7&#44;16</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">RE patients undergo PET <span class="elsevierStyleSup">18</span>F-FDG in interictal phase and the basal cerebral metabolism is evaluated&#46; The metabolism of the EF and surrounding interictal tissue is reduced &#40;hypo-metabolic&#41;&#44;<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">4&#44;17</span></a> the cause of which is under discussion&#46; There have been various hypotheses put forward&#59; in general suggesting it may be secondary to damage to brain tissue due to neuronal loss&#44; diaschisis or fewer synapses&#44; etc&#46; resulting from the electric hyperactivity during the seizure&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">18</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">The Epilepsy Unit was created in our hospital in 2010 and the active participation of the nuclear medicine department was integrated in 2011&#46; The complexity of the methodology&#44; and the difficulty in interpreting these studies resulted in a learning curve where several questions came to mind&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">This project shows the results of two of these questions&#44; which have been studied in two simultaneous studies&#46;</p><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Study 1</span><p id="par0055" class="elsevierStylePara elsevierViewall">In order to evaluate the degree of reproducibility of ictal&#8211;interictal SPECT perfusion SPECT and of SISCOM&#44; &#40;1&#41; the degree of inter-observer agreement was calculated for the visual analysis of ictal&#8211;interictal SPECT&#59; &#40;2&#41; the degree of inter-observer agreement was calculated for SISCOM&#59; and &#40;3&#41; the intra-observer agreement between observers one and two was calculated for the visual analysis of ictal&#8211;interictal SPECT and of SISCOM&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Study 2</span><p id="par0060" class="elsevierStylePara elsevierViewall">Evaluate the role of ictal&#8211;interictal SPECT&#44; SISCOM and interictal PET-FDG in the identification of possible EF in a sample of RE patients who had previously undergone surgery for epilepsy&#46;</p></span></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Material and methods</span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Patients</span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Study 1</span><p id="par0065" class="elsevierStylePara elsevierViewall">A retrospective observational study of 47 patients &#40;24 female&#44; 23 male&#41; with an average age of 36 &#40;19&#8211;60&#41; years who had been referred to the Epilepsy Unit in 2011 and 2012&#46; The inclusion criteria were&#58; diagnosis as drug-refractory epilepsy patients&#44; the epilepsy being of focal origin&#44; and the patients being candidates for epilepsy surgery &#40;ILAE criteria&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">2</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">All patients underwent conventional epilepsy protocol tests which include&#58; semiological evaluation of the seizure&#44; VEEG monitoring&#44; epilepsy protocol MRI and neuro-psychological and psychiatric evaluation&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Cases in which tests for identification of possible EF were inconclusive and having confirmed these patients as candidates for epilepsy surgery were selected for ictal and interictal perfusion SPECT&#44; with SISCOM testing&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Two programmes were used to process SISCOM&#58; Analyze 7&#46;0 &#40;<span class="elsevierStyleItalic">Biomedical Imaging Resource&#44; Mayo Foundation&#44; Rochester&#44; MN&#44; USA</span>&#41;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">14</span></a> and then FocusDET &#40;<a href="http://www.ciber-bbn.es/focusdet">www&#46;ciber-bbn&#46;es&#47;focusdet</a>&#41;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">19</span></a> in 13 patients with inconclusive results from Analyze 7&#46;0&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Study 2</span><p id="par0085" class="elsevierStylePara elsevierViewall">Retrospective study of a subgroup of 16 patients &#40;10 female&#44; 6 male&#41; from the 47 in the study&#46; The average age of the patients who underwent surgery for epilepsy was 38 &#40;25&#8211;51&#41;&#46; The capacities of SPECT&#44; SISCOM and PET-FDG to identify EF were evaluated individually and jointly &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>10&#41;&#46; The results were correlated in unclear or inconclusive cases with SEEG and in the remainder with the localization of the surgically resected area and post-surgical follow-up over 10&#8211;40 months according to the scale of Engel &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; Pathological findings of resected pieces are presented&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Ictal and interictal perfusion SPECT</span><p id="par0090" class="elsevierStylePara elsevierViewall">Ictal perfusion SPECT was carried out on in-patients of the Epilepsy Monitoring Unit after the reduction or withdrawal of anti-epileptic drugs&#46; Being monitored with VEEG and under the watch of a specialist epilepsy nurse&#44; at the moment in which the start of a seizure was identified&#44; 18&#8211;30<span class="elsevierStyleHsp" style=""></span>mCi &#40;666&#8211;1&#46;110<span class="elsevierStyleHsp" style=""></span>MBq&#41; of <span class="elsevierStyleSup">99m</span>Tc HMPAO was administered&#46; The type of seizure&#44; time of tracer administration since electric or semiological start of the seizure &#40;latency&#41; and duration of the seizure were noted&#46; Images were obtained 15&#8211;90<span class="elsevierStyleHsp" style=""></span>min after the end of the seizure&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Images were obtained using Siemens ECAM double headed camera&#59; parameters being high resolution collimator&#44; matrix 128<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>128&#44; 120 projections per 30<span class="elsevierStyleHsp" style=""></span>s&#46; The images were reconstructed with filtered-back projection using Butterworth filter &#40;cut-off frequency 0&#46;55&#44; 5th order&#41;&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Interictal perfusion SPECT was carried out under medication&#44; confirming the absence of seizure during the injection of the tracer&#46; The tracer was administered to those patients with a high frequency of seizures under the guidance of ECG monitoring&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">A minimum of 48<span class="elsevierStyleHsp" style=""></span>h was left between the realization of ictal and interictal SPECTs&#46; The protocol followed regarding the acquisition and processing of images was the same as in ictal SPECT&#46; The term perfusion SPECT in this article will refer to the joint evaluation of ictal and interictal perfusion SPECT&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">SISCOM</span><p id="par0110" class="elsevierStylePara elsevierViewall">SISCOM post-processing was carried out using Analyze 7&#46;0 following the method described by O&#8217;Brian et al&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">13</span></a> FocusDET was used in 13 patients in which Analyze 7&#46;0 did not yield conclusive results&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">In general&#44; the SISCOM procedure consists of the following steps&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1&#41;</span><p id="par0120" class="elsevierStylePara elsevierViewall">Normalization of the degree of SPECT tracer uptake&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2&#41;</span><p id="par0125" class="elsevierStylePara elsevierViewall">Subtraction of ictal SPECT with interictal&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">3&#41;</span><p id="par0130" class="elsevierStylePara elsevierViewall">Generation of a mask for the brain to reduce artefacts due to extra-cerebral activity&#46;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">4&#41;</span><p id="par0135" class="elsevierStylePara elsevierViewall">MRI substracted registration&#44; images showing areas of uptake intensity over the established threshold &#40;1&#44; 5&#8211;2 SD&#41;&#46;</p></li></ul></p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Interictal PET-FDG</span><p id="par0140" class="elsevierStylePara elsevierViewall">PET-FDG brain images were obtained using a General Electric Medical systems 4-slices PET&#47;CT Discovery ST scanner 40&#8211;45<span class="elsevierStyleHsp" style=""></span>min after intravenous administration of 5<span class="elsevierStyleHsp" style=""></span>MBq&#47;kg of <span class="elsevierStyleSup">18</span>F-FDG&#46; The tracer was administered with the patient in basal state &#40;crisis free&#41; under pharmaceutical treatment&#46; Images were obtained in 3D mode&#46; Low-dose CT scan &#40;120&#8211;130<span class="elsevierStyleHsp" style=""></span>keV&#41; was used for attenuation correction&#46; Ordered subset expectation maximization &#40;OSEM&#41; iterative algorithm &#40;6 iterations&#44; 16 subsets&#41; was used to reconstruct the images&#46;</p><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Image analysis</span><p id="par0145" class="elsevierStylePara elsevierViewall">Neuroimaging studies were visually interpreted by two independent nuclear medicine specialists &#40;observers 1 and 2&#41; both blinded with regard to clinical history and results of other studies&#46; The SPECT and PET images were interpreted by evaluating the intensity level of tracer uptake on a polychromatic colour scale&#46; Ictal and interictal studies were always analyzed conjointly in the perfusion SPECT&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">The possible EF was identified as the focal area of hyper-perfusion in SPECT and hypo-metabolic area in PET-FDG &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; In the studies with Analyze 7&#46;0 SISCOM areas of hyper-perfusion &#40;more than 2 standard deviations &#40;SD&#41; from the mean&#41; were considered suggestive of possible EF&#46; In SISCOM Focus DET studies&#44; the pathological threshold was considered from 1&#46;5 to 2 SD from the mean &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0155" class="elsevierStylePara elsevierViewall">In study 1&#44; results where the visual analysis of ictal and interictal SPECT and SISCOM coincided in the anatomical localization of possible EF were considered concordant&#46; Results showing discrepancy between perfusion PECT and SISCOM analyses were considered non-concordant&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">In study 2&#44; results which allowed the identification of a possible EF&#44; coinciding with the localization of surgically resected area&#44; obtaining good clinical results &#40;Engel Epilepsy Surgery Outcome Scale I or II&#41; were considered true positives &#40;TP&#41;&#46; Results which were non-concordant and&#47;or which did not coincide with the surgically resected area were considered false positives &#40;FP&#41;&#46; Results which were inconclusive or which did not allow the identification of an EF were considered false negatives &#40;FN&#41;&#46; True negatives &#40;TN&#41; were considered when no evidence of a possible EF was found and epilepsy was not confirmed&#46;</p></span></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">SEEG</span><p id="par0165" class="elsevierStylePara elsevierViewall">SEEG is a deep electrode implantation technique developed in France in the 1960s by Bancaud and Talairachin the Hospital of Sainte-Anne&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">20</span></a> It involves the design and placement of multiple intra-cerebral microelectrodes with aim to study the time-space dynamic of epileptic seizures and relate them with ictal semiology&#46; It is a high precision technique and is used in cases of high surgical complexity&#46; It allows 3D study of EEG activity and we have used this technique in our centre since 2012 by means of a robotic implantation technique &#40;Robot RosaTM&#46; Medtech&#44; France&#41;&#46;</p><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Statistical analysis</span><p id="par0170" class="elsevierStylePara elsevierViewall">The Kappa Cohen index was used to calculate interobserver concordance in visual analysis of SPECT and SISCOM&#44; carried out with SPSS version 18&#46;0 &#40;SPSS Inc&#46;&#44; Chicago&#44; IL&#44; USA&#41;&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">Two-way ANOVA was used to evaluate possible differences between seizure duration and time lapsed in administration of tracer from the onset of the seizure &#40;latency&#41; and the detection or not of an EF in perfusion SPECT and SISCOM&#46;</p></span></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Results</span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Study 1</span><p id="par0180" class="elsevierStylePara elsevierViewall">For the ictal SPECT&#44; tracer was administrated 17 &#40;4&#8211;50&#41;<span class="elsevierStyleHsp" style=""></span>s after the onset of seizure&#46; Types of seizure seen during administration of seizure were&#58; 40 complex partial seizures &#40;CPS&#41;&#44; 3 simple partial seizures &#40;SPS&#41; and 4 secondarily generalized seizures &#40;2nd GS&#41;&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">Considering reproducibility of the visual analysis of perfusion SPECT&#44; conjoint assessment of ictal and interictal studies showed an interobserver concordance of 91&#37;&#44; Kappa index 0&#46;86&#46; Analyze 7&#46;0 SISCOM showed resulted lower reproducibility with respect to the visual analysis of SPECT&#44; with an observer concordance of 82&#37;&#44; Kappa index 0&#46;80 &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0190" class="elsevierStylePara elsevierViewall">SPECT-SISCOM intra-observer concordance of the observers was 70&#37; and 80&#37; respectively&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall">The results of Analyze 7&#46;0 SISCOM gave 14 &#40;30&#37;&#41; and 18 &#40;39&#37;&#41; non-conclusive results for observers 1 and 2 respectively&#46; These non-conclusive results were more than double those obtained in the visual analysis of SPECT 6 &#40;13&#37;&#41; and 4 &#40;9&#37;&#41; respectively for observers 1 and 2 &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46; The high percentage of non-conclusive results with Analyze 7&#46;0 SISCOM led to suggestion of using another SISCOM programme to increase diagnostic performance of the visual analysis&#46; FocusDET was selected to repeat the SISCOM in 13 patients with non-conclusive results&#46; The degree of interobserver accordance for the FocusDET SISCOM was 92&#37; &#40;12&#47;13&#41;&#44; Kappa index 0&#46;87&#44; evidently superior to that of Analyze 7&#46;0 SISCOM and in the visual analysis&#46; The percentage of non-conclusive results was 33&#37; &#40;3&#47;13&#41;&#44; which improved on those of Analyze 7&#46;0&#46;</p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Study 2</span><p id="par0200" class="elsevierStylePara elsevierViewall">Surgery for epilepsy was carried in 15 of 16 patients after ictal&#8211;interictal perfusion SPECT&#44; SISCOM and PET-FDG in 10 patients&#46; Surgery was not carried out in one patient with non-conclusive and non-concordant neuroimaging results after identifying multi-EF in the SEEG&#46; <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a> summarizes individual results of each of these patients&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0205" class="elsevierStylePara elsevierViewall">Global evaluation of these techniques allowed for greater diagnostic yield in the identification of possible EF &#40;14&#47;16&#41;&#46; Sensitivity was 87&#37;&#44; out-performing the values obtained individually in the analysis of perfusion SPECT &#40;83&#37;&#41; and PET &#40;78&#37;&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><p id="par0210" class="elsevierStylePara elsevierViewall">One patient considered FP &#40;patient 16&#41; in the global evaluation of the 3 techniques was reported as Engel level III 3 months after the surgery &#40;not clinically satisfactory&#41;&#46; This patient had non-conclusive results in SPECT and in SISCOM and right frontal hypo-metabolism in the PET&#44; suggesting possible EF&#46; The surgical resection carried out was a lesionectomy of the right frontal premotor area&#44; in concordance with the area with greater hypo-metabolism described in the PET&#46; The histopathologic study revealed type I A cortical dysplasia&#46; The seizures reoccurred three months post-surgery&#46; A control MRI showed persistence of part of the lesion&#46; SISCOM was carried out again after surgery&#59; an area of hyper-perfusion close to the resected cavity was detected in the same area as the suspicious MRI image&#46; The other FP patient &#40;number 21&#41; was the patient who was diagnosed as multifocal by the SEEG&#44; ruling out surgery&#46; The neuroimaging techniques identified an area compatible with EF in spite of the multiple foci&#46;</p><p id="par0215" class="elsevierStylePara elsevierViewall">PET allowed the resolution of non-conclusive or discordant cases of visual analysis and of SISCOM &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>4&#41;&#46; However 2 non-conclusive results were obtained in PET&#44; in which SPECT and SISCOM had been identified as left temporal&#46; These two PET were interpreted as within normal range&#44; not identifying clear focal areas of hypo-metabolism which could have corresponded with an EF&#46;</p><p id="par0220" class="elsevierStylePara elsevierViewall">No significant difference was found between the latency of tracer administration&#44; or length of the seizure and the detection or not of the EF in SPECT &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;32&#41;&#46;</p><p id="par0225" class="elsevierStylePara elsevierViewall">The majority of the EF&#44; as described in the literature&#44; are localized in the temporal region 79&#37; &#40;12&#47;15&#41; in this sample with a clear left lateralization &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; 13&#37; &#40;2&#47;15&#41; of patients were found to have parietal&#8211;temporal foci followed by frontal in 7&#37; &#40;1&#47;15&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0230" class="elsevierStylePara elsevierViewall">Pathological findings revealed mesial sclerosis in 6 of 15 resected pieces&#44; focal dysplasia in 4&#47;15 other alterations in 3&#47;15 and in 2 patients no pathological findings were revealed in the resected piece&#46; The anatomo-pathological findings and follow-up using the Engel Epilepsy Surgery Outcome Scale are shown in <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#46; A significant reduction in epileptic seizures was obtained &#40;Engel I and II&#41; in all patients except two who reported Engel III at 12 and 3 months post-surgery respectively&#46; The histopathology of the resected pieces in these two cases showed grade I astrocytoma and hippocampal sclerosis in one patient and in the other patient IA cortical dysplasia&#44; partially resected as demonstrated in posterior MRI&#46;</p></span></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Discussion</span><p id="par0235" class="elsevierStylePara elsevierViewall">Since the 1886 publication of <span class="elsevierStyleItalic">The modern era of epilepsy surgery</span><a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">21</span></a> by Horsley&#44; epilepsy surgery has run a long road&#44; closely linked to technological advances in neuroimaging&#46; This path has allowed more precision in the localization of the EF&#44; therefore facilitating surgery in patients with no lesions or initially no lesions&#44; reducing the adverse effects of surgery for epilepsy and above all has led to a therapeutic option for RE patients&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">22</span></a> Currently&#44; the decision to opt for surgery is taken in the context of the hospital epilepsy units&#46; The objective of this study is to present results obtained in the beginning stages of the Hospital del Mar&#44; focusing on two neuroimaging techniques&#59; perfusion SPECT and PET-FDG&#46;</p><p id="par0240" class="elsevierStylePara elsevierViewall">The first question formed concerned the reproducibility of the results of ictal&#8211;interictal perfusion SPECT&#44; considering both visual analysis and SISCOM &#40;initially Analyse 7&#46;0 and later FocusDET&#41;&#46; The results of the visual analysis of SPECT showed high inter-observer reproducibility 43&#47;47 &#40;91&#37;&#41;&#46; We are not aware of published works which demonstrate the reproducibility of perfusion SPECT in RE patients&#44; and thus have not been able to compare our results&#46; The high reproducibility demonstrated in the study confirms the consistency of the test in our group&#46; The visual analysis of SPECT to localize the EF is complex&#44; which is why it is usually carried out with SISCOM in order to facilitate interpretation&#46; The aim of SISCOM is to increase the precision in diagnosis and localization of the EF and to be able to resolve discrepant or non-conclusive visual analysis cases&#46;<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">14&#44;15&#44;23&#44;24</span></a> The results from Analyze 7&#46;0 SISCOM did not allow this optimization of visual analysis results&#44; with an inter-observer concordance of 39&#47;47 &#40;82&#37;&#41; and with a high number of non-conclusive results&#44; higher than the visual analysis&#46;</p><p id="par0245" class="elsevierStylePara elsevierViewall">The visual analysis of SPECT generated 13&#37; non-conclusive results and SISCOM analysis 38&#37; &#40;both observers&#41;&#46; The results published using SISCOM methodology usually shows a similar or higher sensitivity with respect to visual analysis&#44; resolving non-conclusive visual analysis cases&#46;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">24</span></a> Some authors have related this sensibility to the epileptogenic area&#44; obtaining better results in temporal&#44; and occipital lobe epilepsies&#46; However&#44; Matsuda et al&#46; in a study of 123 patients obtained better SISCOM analysis results in patients with extra-temporal rather than temporal epilepsies&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">16</span></a> Extra-temporal originating epilepsies commonly spread quicker than temporal epilepsies&#44; resulting in less focused areas of hyper-perfusion&#44; typically more difficult to identify in the visual analysis of SPECT&#46;</p><p id="par0250" class="elsevierStylePara elsevierViewall">The majority of the EF identified in this study was temporal originated&#44; meaning that this would not have been a reason to justify the results of Analyze 7&#46;0 SISCOM&#46;</p><p id="par0255" class="elsevierStylePara elsevierViewall">Other factors to bear in mind&#44; such as the type of seizure&#44; did not justify the variability in the Analyze 7&#46;0 results either&#44; seeing as the sample of patients in this regard was quite homogeneous&#44; and the majority of the seizures were CPS &#40;85&#37;&#41;&#44; the seizures which yield better results with SISCOM in the identification of EF&#46;</p><p id="par0260" class="elsevierStylePara elsevierViewall">With this in mind it became evident that Analyze 7&#46;0 was of little use in resolving doubts arising from visual analysis and even increased uncertainty of diagnosis&#46; Analyze 7&#46;0 is a methodologically complex time consuming technique&#46; Global evaluation of Analyze 7&#46;0 SISCOM in our patient sample revealed clearly inferior diagnostic performance compared to visual analysis and it was deemed impractical&#46; The new programme trialled with the aim of improving the results of Analyze 7&#46;0 was FocusDET&#46; FocusDET SISCOM was run on a selected group of patients with non-conclusive results with Analyze 7&#46;0&#44; obtaining an interobserver concordance of 92 and 33&#37; non-conclusive results&#46; These results&#44; is spite of the complexity of the selected&#44; sample substantially improved upon those obtained with Analyze 7&#46;0&#46; FocusDET facilitated the improvement in diagnostic performance of SISCOM and the increase of diagnostic validity of SPECT in the detection of EF&#46; Both programmes are valuable tools in the analysis of SPECT images&#59; however&#44; the more automated characteristics of FocusDET facilitated the SISCOM process and led to better results than with Analyze 7&#46;0&#46; Although not an objective of this study&#44; one of the image processing algorithms might be specifically responsible for the differences observed between these programmes&#46; Future studies will look into the methodology of the programmes with the aim to explain these differences&#46;</p><p id="par0265" class="elsevierStylePara elsevierViewall">The combined forces of SPECT&#44; SISCOM and PET-FDG resulted in good diagnostic performance&#44; resulting in the identification of an EF 14&#47;16 &#40;87&#37;&#41; of patients&#44; higher than that obtained with each technique individually&#46; The performance of ictal perfusion SPECT depends on methodology and the type of seizure&#46; The methodology of ictal SPECT is demanding and requires a trained&#44; synchronized and multidiscipline team capable of rapidly detecting the onset of the seizure and correct administration of radiopharmaceuticals&#46;<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">4&#44;22&#44;25&#44;26</span></a></p><p id="par0270" class="elsevierStylePara elsevierViewall">The type of seizures with best diagnostic yield is CPS which involve greater change in brain perfusion&#44; and therefore a reduced FN in perfusion SPECT&#46; 87&#37; &#40;14&#47;16&#41; of the studies &#40;study two patients&#41; during the administration of ictal SPECT tracer were CPS&#44; which would lead us to assume that type of seizure is not a source of variability in the results herein presented&#46;</p><p id="par0275" class="elsevierStylePara elsevierViewall">One of the most influencing factors in the methodology of the ictal SPECT was the administration of the tracer&#44; with two limiting factors&#58; a&#41; the delay in administration&#44; optimally minimizing the time lapsed from start of seizure &#40;latency&#41; and b&#41; the duration of the seizure&#44; After the administration of the tracer in ictal phase approximately 1&#8211;2<span class="elsevierStyleHsp" style=""></span>min would lapse until its arrival at the brain and subsequent intracellular incorporation of the tracer&#46; This means that slow administration of tracer with high latency or even quick administration in short lasting seizures prevents the identification of the neurons responsible for starting the seizure&#46; The perfusion pattern seen in these cases is post-ictal&#44; the ictal activity having finished&#44; which shows areas where electrical activity is propagated&#46;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">25</span></a> There are publications which recommend that the seizure length be longer than 10<span class="elsevierStyleHsp" style=""></span>s or with an administration latency of less than 45<span class="elsevierStyleHsp" style=""></span>s&#46;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">27</span></a></p><p id="par0280" class="elsevierStylePara elsevierViewall">No correlation was found between seizure length and tracer administration latency and the detection or not of EF in this patient simple&#46; It should be taken into account that our sample size was limited and that the only patient with a latency of over 45<span class="elsevierStyleHsp" style=""></span>s &#40;number 3&#41; was injected at 53<span class="elsevierStyleHsp" style=""></span>s with a seizure length of 125<span class="elsevierStyleHsp" style=""></span>s&#46; To this regard there are studies such as that of Oertzen&#44; sample size of 130 patients&#44; which&#44; in spite of a wide range of latency periods &#40;1&#8211;153<span class="elsevierStyleHsp" style=""></span>s&#41;&#44; did not find a correlation between latency period and the success or failure in identification of EF&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">28</span></a> One possible explanation for this could have been that they did not record the total seizure length&#44; a factor just as conditioning as the administration latency period&#46;</p><p id="par0285" class="elsevierStylePara elsevierViewall">It is not only the methodology of ictal perfusion SPECT which is complex but also the interpretation of the images&#46; Ictal perfusion SPECT is carried out under circumstances of pathological neuronal activity and consequent increased blood flow&#46; Ictal perfusion SPECT aims to identify this focal increase in perfusion&#44; which would translate as a possible EF&#46; This area of hyper-perfusion is often surrounded by an area of hypo-perfusion&#46; This hypo-perfusion can be explained by several mechanisms including &#8220;arterial steal&#8221; from the EF or a disconnection protection mechanism in other cerebral zones which are not responsible for the seizure&#46;<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">4&#44;29</span></a></p><p id="par0290" class="elsevierStylePara elsevierViewall">It is also common to identify &#40;ipsi- or contralateral&#41; zones of hypo-perfusion different to that of the EF due to a greater propagation of electrical activity or physiological activity in other cerebral areas during CPS&#46;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">29</span></a> In our centre&#44; in order to facilitate the interpretation of ictal SPECT and help define the brain area in which the possible EF is located&#44; the ictal perfusion study is always carried out along with an interictal perfusion study&#46;</p><p id="par0295" class="elsevierStylePara elsevierViewall">The findings in the interictal perfusion SPECT are sometimes within normal range&#44; but frequently hypo-perfusion areas can be identified&#46;</p><p id="par0300" class="elsevierStylePara elsevierViewall">These areas of interictal hypo-perfusion may be attributed to an epileptogenic area &#40;EF&#41; or could be hypo-functioning brain tissue due to damage suffered from recurrent seizures&#46; Frequency and duration of seizures and the length of time suffering from seizures are factors which will influence the functionality of surrounding brain tissue&#46; PET-FDG through the metabolic study of the brain along with other resources &#40;such as neurological exploration&#44; neuro-psychological tests and functional MRI&#41; will evaluate this functional deficit&#46;</p><p id="par0305" class="elsevierStylePara elsevierViewall">In patients where perfusion SPECT resulted non-conclusive&#44; an interictal PET-FDG was carried out&#46; PET-FDG identified a possible EF in 7&#47;10 patients&#44; which in conjoint evaluation with the rest of the imaging techniques was considered decisive for the surgical context&#46; Two of these patients were reported as having negative results in perfusion SPECT and in SISCOM&#44; another two patients presented discrepancies between visual analysis of SPECT and SISCOM&#46; PET analysis did not show hypo-metabolisms which would have suggested possible EF in two patients&#59; these were categorized as non-conclusive PET studies&#46; These two patients however had concordant results in the visual analysis of SPECT and the SISCOM which suggested an EF in the left temporal lobe in one patient and in the right temporal lobe of the other patient&#46; Retrospectively&#44; except for the implicit difficulty of PET-FDG interpretation&#44; no other explanation for these results can be offered&#44; a learning curve&#46; These two patients were part of the initial group of patients studied in the hospital unit&#46; Khul et al&#46;&#44; 1978 recognized the metabolic alterations related with epilepsy&#58; ictal hyper-metabolism and ictal hypo-metabolism&#46;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">29</span></a> This hypo-metabolism in the interictal PET could be a result of various mechanisms&#44; neuronal loss&#44; synapse loss&#44; diaschisis&#44; etc&#46;&#44; which are alterations closely related to the type and duration of the seizures&#46; Hypo-metabolic areas seen in PET vary from very subtle to widespread areas&#44; not only the EF but surrounding tissue and ipsilateral or contralateral hypo-functioning areas&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">18</span></a> This explains why PET imaging may be complex&#44; with findings ranging from barely detectable patterns&#44; complicating identification of EF to widespread detection&#44; complicating interpretation&#46; The fact that PET images are not non-ictal means that the role of the interictal PET for detection of EF is limited without other studies&#46; Recently&#44; we have incorporated PET-MRI to facilitate the localization of possible FE&#44; in this series&#59; we carried out this procedure in two patients &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0310" class="elsevierStylePara elsevierViewall">Perfusion SPECT and interictal PET-FDG are not discriminating tests&#59; they offer different and complementary information&#46;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">30</span></a> RE patients are a clear example of multimodal clinical work-up&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">4</span></a> Not only does PET FDG offer information on the localization of EF but also information on the global functioning of the brain&#44; allowing a first approximation of functioning post-surgery&#46;</p><p id="par0315" class="elsevierStylePara elsevierViewall">The availability of information from the three sources&#44; perfusion SPECT&#44; SISCOM and PET-FDG is of great utility in the pre-surgical evaluation of a patient&#44; not only permitting the identification of EF but also functionality testing&#46;</p><p id="par0320" class="elsevierStylePara elsevierViewall">This study is focused on the role of nuclear medicine neuroimaging techniques in the pre-surgical assessment of EF&#46; However it is understood that the evaluation of the pre-surgical RE patient is not exclusively dependant on functional neuroimaging&#59; it is a multidisciplinary task&#44; as can be appreciated with the conjoint studies such as MRI and SPECT and MRI and PET-FDG &#8211; the means to obtain the most information possible&#46;</p><p id="par0325" class="elsevierStylePara elsevierViewall">This global method of evaluating the RE patient is practiced in specialized epilepsy units providing treatment options to even the more complex patients who would perhaps otherwise be left incapacitated by epilepsy&#46;</p><p id="par0330" class="elsevierStylePara elsevierViewall">The reduced number of patients and lack of long-term clinical follow-up in study 2 are possible limitations of the study&#44; reducing the statistical potential in the correlation of our findings&#46;</p><p id="par0335" class="elsevierStylePara elsevierViewall">Further study to correlate &#40;functional and morphological&#41; neuroimaging findings with the rest of the information provided by other medical tests &#40;EEG&#44; neuropsychological tests&#44; SEEG and histology reports&#41; would be interesting&#46;</p></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0150">Conclusion</span><p id="par0340" class="elsevierStylePara elsevierViewall">Perfusion SPECT in the study of the RE patient is a useful tool with good reproducibility&#46; SISCOM analysis aids the often complex interpretation of SPECT&#44; improving the sensitivity of the perfusion study&#46;</p><p id="par0345" class="elsevierStylePara elsevierViewall">Each epilepsy unit should utilize tools which best fit their needs when processing SISCOM&#46;</p><p id="par0350" class="elsevierStylePara elsevierViewall">The results of this study showed better diagnostic performance in the conjoint evaluation of the nuclear medicine functional imaging &#40;SPECT and PET&#41; clearly superior to isolated evaluation&#46;</p></span><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0155">Conflict of interest</span><p id="par0355" class="elsevierStylePara elsevierViewall">The authors declare no conflict of interest&#46;</p></span></span>"
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          "titulo" => "Ictal and interictal perfusion SPECT"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Aims</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Brain perfusion SPECT &#40;ictal&#8211;interictal&#41;&#44; SPECT images and subtraction ictal SPECT coregistered to MRI &#40;SISCOM&#41; and <span class="elsevierStyleSup">18</span>F-FDG-PET &#40;interictal&#41; play an important role in the pre-surgical diagnosis of patients with medically refractory epilepsy&#46;</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">This study aimed to establish the reproducibility of visual ictal&#8211;interictal SPECT and SISCOM analysis altogether with the capacity of SPECT&#44; SISCOM and PET to determine the epileptogenic zone&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Material and methods</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleSup">99m</span>Tc-HMPAO SPECT ictal&#8211;interictal and SISCOM &#40;Analyze 7&#46;0&#41; were performed on 47 refractory epilepsy patients &#40;24 F&#44; 19&#8211;60 yrs&#41;&#46; In 13 patients&#44; SISCOM was also performed using a new programme &#40;Focus DET&#41;&#46; Ictal&#8211;interictal SPECT and SISCOM images were analyzed independently by two nuclear medicine physicians &#40;observers 1 and 2&#41;&#46; Kappa concordance coefficient was used to evaluate the reproducibility&#46; In sixteen patients&#44; SPECT&#44; SISCOM and PET findings were compared with the resected area during the surgery&#44; and surgical outcome using Engel scale or with the stereo EEG-&#40;SEEG&#41;&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">The ictal&#8211;interictal SPECT interobserver agreement was 91&#37;&#44; Kappa index 0&#46;86&#44; SISCOM &#40;Analyze 7&#46;0&#41; interobserver agreement percentage was 82&#37;&#44; Kappa index 0&#46;80&#44; Analyze 7&#46;0 showed a higher inconclusive results than visual SPECT analysis&#46; SISCOM FocusDET interobserver agreement was 92&#37;&#44; Kappa index 0&#46;87&#44; with lower inconclusive results than Analyze 7&#46;0&#46; SPECT&#44; SISCOM and PET combined findings identified 87&#37; seizure onset zone&#58; 79&#37; temporal&#44; 26&#37; parieto-temporal and 7&#37; frontal&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Ictal&#8211;interictal SPECT and SISCOM showed a high reproducibility in this sample of patients with drug-refractory epilepsy&#46; SPECT&#44; SISCOM and PET combined findings improved detection of epileptogenic zone in comparison with the individual assessment&#46;</p></span>"
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">La SPECT de perfusi&#243;n ictal-interictal&#44; subtraction ictal SPECT coregistered to MRI &#40;SISCOM&#41; y <span class="elsevierStyleSup">18</span>F-FDG-PET &#40;interictal&#41;&#44; desempe&#241;an un papel fundamental en la valoraci&#243;n prequir&#250;rgica del paciente epil&#233;ptico f&#225;rmaco-resistente&#46;</p><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Los objetivos de este trabajo fueron establecer la reproducibilidad del an&#225;lisis visual de la SPECT y SISCOM y la capacidad de la SPECT&#44; SISCOM y PET en la identificaci&#243;n del foco epilept&#243;geno&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Material y m&#233;todos</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Se realiz&#243; una SPECT <span class="elsevierStyleSup">99m</span>Tc-HMPAO &#40;ictal-interictal&#41; y SISCOM &#40;Analyze 7&#46;0&#41; en 47 pacientes epil&#233;pticos f&#225;rmaco-resistentes &#40;24<span class="elsevierStyleHsp" style=""></span>M&#44; 19&#8211;60 a&#241;os&#41;&#46; En 13 pacientes se repiti&#243; el SISCOM utilizando el programa FocusDET&#46; El an&#225;lisis de las im&#225;genes fue realizado por 2 observadores&#46; Se valor&#243; la reproducibilidad utilizando el &#237;ndice Kappa&#46; Los resultados conjuntos de la SPECT&#44; SISCOM y PET&#44; en 16 pacientes&#44; fueron comparados con la localizaci&#243;n del &#225;rea resecada y el seguimiento cl&#237;nico poscirug&#237;a &#40;escala de Engel&#41; o con la estereo-EEG&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Grado de acuerdo interobservador de la SPECT 91&#37; &#237;ndice Kappa 0&#44;86&#46; Grado de acuerdo interobservador SISCOM Analyze 7&#46;0 82&#37;&#44; &#237;ndice Kappa 0&#44;80&#46; El Analyze 7&#46;0 mostr&#243; un elevado n&#250;mero de resultados no concluyentes&#44; superior al del an&#225;lisis visual&#46; El SISCOM FocusDET mostr&#243; un grado de acuerdo interobservador 92&#37; con un &#237;ndice Kappa 0&#44;87 y menor n&#250;mero de resultados no concluyentes que el Analyze&#46; La valoraci&#243;n conjunta SPECT&#44; SISCOM y PET permiti&#243; identificar 87&#37; focos epilept&#243;genos&#58; 79&#37; temporales&#44; 26&#37; parieto-temporales y 7&#37; frontales&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusi&#243;n</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">La SPECT ictal-interictal y el SISCOM mostraron una elevada reproducibilidad&#46; La valoraci&#243;n conjunta de la SPECT ictal-interictal&#44; SISCOM y PET permiti&#243; mejorar la rentabilidad diagn&#243;stica de la valoraci&#243;n individualizada&#46;</p></span>"
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        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Su&#225;rez-Pi&#241;era M&#44; Mestre-Fusco A&#44; Ley M&#44; Gonz&#225;lez S&#44; Medrano S&#44; Principe A&#44; et al&#46; SPECT de perfusi&#243;n&#44; SISCOM y PET <span class="elsevierStyleSup">18</span>F-FDG en la valoraci&#243;n del paciente epil&#233;ptico f&#225;rmaco-resistente candidato a cirug&#237;a de epilepsia&#46; Rev Esp Med Nucl Imagen Mol&#46; 2015&#46; <span class="elsevierStyleInterRef" id="intr0005" href="doi:10.1016/j.remn.2015.05.002">http&#58;&#47;&#47;dx&#46;doi&#46;org&#47;10&#46;1016&#47;j&#46;remn&#46;2015&#46;05&#46;002</span></p>"
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          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Images of a patient diagnosed with epilepsy&#46; &#40;A&#41; Coronal slices from the interictal &#40;top row&#41; and ictal &#40;bottom row&#41; SPECT with <span class="elsevierStyleSup">99m</span>Tc-HMPAO&#46; &#40;B&#41; Axial sections of interictal and ictal SPECT&#46; A focus of hyper-perfusion &#40;ictal&#41; and hypo-perfusion &#40;interictal&#41; can be seen in the right &#40;predominantly mesial&#41; temporal lobe propagating to the contralateral temporal lobe&#46; &#40;E&#41; SISCOM &#40;FocusDET&#41;&#58; Focus in the right mesial temporal lobe&#46; &#40;C and D&#41; PET <span class="elsevierStyleSup">18</span>F-FDG&#44; coronal and axial slices&#58; asymmetric FDG uptake with a hypo-metabolic area seen in the right mesial &#40;and to a lesser extent lateral&#41; temporal lobe&#46;</p>"
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      1 => array:7 [
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        "etiqueta" => "Fig&#46; 2"
        "tipo" => "MULTIMEDIAFIGURA"
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          "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Distribution of the localization of the EF by each technique&#46;</p>"
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          "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Fusion images PET-MRI &#40;T1 3D&#41;&#44; &#40;A&#41; coronal and axial &#40;B&#41; slices&#58; hypo-metabolic area in the right hippocampus &#40;triangulated&#41;&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Class I&#58; free of seizures&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">A&#46; Completely seizure free after surgeryB&#46; Only aura sensations after surgeryC&#46; Some seizures&#44; but seizure-free for at least 2 yearsD&#46; Seizures upon drug withdrawal only&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Class II&#58; rare seizures&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">A&#46; Initially free of seizures&#44; but rare seizures now&#59;B&#46; Rare seizures since surgery&#59;C&#46; Seizures now but rare seizures for at least 2 yearsD&#46; Nocturnal seizures only&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Class III&#58; worthwhile improvement&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">A&#46; Worthwhile seizure reduction &#40;&#62;90&#37;&#41;B&#46; Prolonged seizure-free periods but less than 2 years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Class IV&#58; no worthwhile improvement&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">A&#46; Significant reduction in seizures &#40;50&#8211;90&#37;&#41;B&#46; Little apparent change &#40;&#60;50&#37; reduction&#41;C&#46; Worsening of the seizures&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Modified Engel epilepsy surgery outcome scale&#46;</p>"
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        "tipo" => "MULTIMEDIATABLA"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col">Inter observer concordance&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col"><span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>47 &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col">Kappa index&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Non-conclusive</th></tr><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Observer 1 &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Observer 2 &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Ictal&#8211;interictal SPECT&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">43 &#40;91&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;86&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6 &#40;13&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4 &#40;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">SISCOM &#40;Analyze 7&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">39 &#40;82&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;80&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">14 &#40;30&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">18 &#40;39&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Degree of inter-observer accordance&#44; Kappa index and non-conclusive results from visual analysis of ictal&#8211;interictal SPECT and SISCOM &#40;Analyze 7&#46;0&#41;&#46;</p>"
        ]
      ]
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        "tabla" => array:2 [
          "leyenda" => "<p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">CPS&#58; complex partial seizures&#59; 2nd GS&#58; secondarily generalized seizures&#59; R Fr&#58; right frontal&#59; Pat&#58; patient&#59; R PT&#58; right parietal temporal&#59; Non-concl&#58; non-conclusive&#59; R PARIE&#58; right parietal&#59; R AMTR right anteromedial temporal resection&#59; L AMTR&#58; left anteromedial temporal resection L TEMP&#58; left temporal&#59; R TEMP&#58; right temporal&#59; BIL TEMP&#58; bilateral temporal&#59; 0&#58; not carried out&#46;</p>"
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Pat&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Seizure type&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Seizure s&#42;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Latency &#40;s&#41;&#42;&#42;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Visual analysis SPECT&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">SISCOM&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">PET-FDG&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Surgery &#40;resected area&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Histology&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Engel &#40;months&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CPS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">47&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">22&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">L TEMP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">L TEMP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Non-concl&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">L AMTR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Cortical dysplasia IIA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">II &#40;40&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CPS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">170&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">33&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">L TEMP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">L TEMP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">L AMTR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Focal mesial sclerosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">IB &#40;10&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2nd GS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">125&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">53&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">R TEMP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Non-Concl&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">R PT&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">R posterior PT&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Cortical dysplasia IA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">II &#40;16&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CPS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">94&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">18&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">R TEMP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">R TEMP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Non-concl&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">R TEMP Lobectomy &#40;2&#47;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Mesial sclerosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">II &#40;19&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CPS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">59&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">L TEMP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">L TEMP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">L Hippocampus-amygdala&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Hippocampal sclerosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">IB &#40;28&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CPS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">50&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">31&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">L TEMP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">L TEMP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">L AMTR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Focal mesial sclerosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">IB &#40;10&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CPS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">36&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">25&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">L TEMP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">L TEMP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">L Hippocampus-amygdala&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Hippocampal sclerosis and astrocytoma grade I&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">III &#40;16&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2nd GS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">110&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">17&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">L TEMP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">L TEMP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">L AMTR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No alteration&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">II &#40;17&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2nd GS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">42&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">16&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">L TEMP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">R TEMP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">R TEMP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">R anterior TEMP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Gliosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">IA &#40;17&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CPS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">31&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">R PT&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">R PARIE&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">R PARIE&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">R PT&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Lamination defects&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">IB &#40;22&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CPS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">49&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">R TEMP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Non-concl&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">R TEMP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">R TEMP Lobectomy &#40;2&#47;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No alteration&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">IB &#40;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CFC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">178&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">28&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Non-concl&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Non-concl&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">L TEMP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Bitemporal&#42; &#40;no surgery&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CPS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">56&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">30&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">L TEMP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">L TEMP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">L Hippocampus-amygdala&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Mesial sclerosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">IA &#40;19&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CPS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">42&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">30&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">R TEMP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">R TEMP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">R TEMP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">R AMTR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Cortical dysplasia IA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">IA &#40;19&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CPS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">56&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">BIL TEMP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">BIL TEMP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">L TEMP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">L temporal pole &#40;not hippocampus&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Vascular malformation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">IA &#40;16&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">16&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CPS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">64&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Non-concl&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Non-concl&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">R FR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">R FR &#40;incomplete resection&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Cortical dysplasia IA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">III &#40;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Results of 16 initial candidates for surgery&#44; finally 15 who underwent surgery&#58; SPECT&#44; SISCOM&#44; PET-FDG&#44; resected area&#44; anatomo-pathological findings&#44; Engel scale follow-up&#46; Table also shows type of seizure&#44; duration and tracer administration latency time&#46;</p>"
        ]
      ]
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        "etiqueta" => "Table 4"
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Technique&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">S</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">FP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">FN&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">SPECT<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>SISCOM&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">83&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">PET-FDG &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>10&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">78&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">SPECT&#43;SISCOM&#43;PET&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">87&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Total patients<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>16&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Patients who underwent intervention<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">SEEG<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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        "descripcion" => array:1 [
          "en" => "<p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">Sensitivity&#44; FP and FN results in SPECT<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>SISCOM&#44; PET-FDG and of the joint evaluation of the results of the two techniques and SISCOM analysis&#46;</p>"
        ]
      ]
    ]
    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0005"
          "bibliografiaReferencia" => array:30 [
            0 => array:3 [
              "identificador" => "bib0155"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "FEEN&#58; informe sociosanitario FEEN sobre la epilepsia en Espa&#241;a"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "R&#46; Garc&#237;a-Ramos"
                            1 => "A&#46; Garc&#237;a-Pastor"
                            2 => "J&#46; Masjuan"
                            3 => "C&#46; S&#225;nchez"
                            4 => "A&#46; Gil"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.nrl.2011.04.002"
                      "Revista" => array:6 [
                        "tituloSerie" => "Neurolog&#237;a"
                        "fecha" => "2011"
                        "volumen" => "26"
                        "paginaInicial" => "548"
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