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نمایش مقاله

Title:

Beyond Spikes: Scalable Multimodal Brain Mapping to Personalize Epilepsy Surgery in Children and Adults—An Iran-Ready Pathway

Subject:

Brain Mapping Applications in Epilepsy – Across Pediatric and Adult Populations

Presenter Author:
Name:	MohammadHassan Falahat

Author:
Name 1:	MohammadHassan Falahat - Corresponding - Presenter
Affiliation 1:	School of medicine, Tehran University of Medical Sciences, Tehran, Iran.

Name 2:	Arman Baghbanzadeh
Affiliation 2:	School of medicine, Tehran University of Medical Sciences, Tehran, Iran.

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Abstract

Original Research

introduction :

Drug-resistant epilepsy (DRE) is a significant indication for brain mapping in both children and adults, yet MRI-negative or equivocal cases, deep foci, and the need to balance epileptogenic versus eloquent cortex still prolong presurgical pathways. In Iran, an extensive nationwide door-to-door survey (n=68,035) estimated lifetime epilepsy prevalence at 16.6 per 1,000 people and active epilepsy at 9.5 per 1,000, highlighting a substantial population that may benefit from streamlined presurgical evaluation. A rapidly evolving trend is moving from spike-only localisation toward multimodal, high-frequency, and semi- or fully automated mapping to deliver quantitative millimetre-scale targets and actionable surgical planning. For countries such as Iran—where access to MEG and 7T MRI is limited in many centers—evidence on ‘high-yield, feasible’ mapping steps is especially relevant for optimizing referrals, shortening admissions, and reducing the burden of invasive monitoring.

Methods:

This narrative review synthesises evidence from focused literature searches across PubMed and Scopus, covering the period from 2021 to December 2025. The search strategy combined keywords and controlled terms including “epilepsy”, “drug-resistant epilepsy”, “brain mapping”, “electrical source imaging (ESI)”, “high-density EEG”, “EEG-fMRI”, “magnetoencephalography (MEG)”, “optically pumped magnetometers (OPM)”, “high-frequency oscillations (HFO)”, and “7T MRI”. Inclusion criteria prioritised peer-reviewed, human studies reporting quantitative clinical performance of noninvasive or presurgical epilepsy-mapping approaches, including original investigations and clinical cohort studies.

Results:

In recent presurgical cohorts, advanced brain mapping has shown clinically useful added value without always requiring the highest-cost infrastructure. Parallel-transmit 7T MRI in MRI-negative/equivocal adults (n=31) revealed new lesions in **29%** and changed management in **58%**, showing its role in difficult cases when available. However, in Iran—where MEG and 7T are limited—scalable EEG-based approaches are especially relevant. In an Iran-linked EEG-fMRI cohort (n=30), concordant BOLD responses were seen in **97%** and supported seizure-onset zone definition in **80%**, positioning EEG-fMRI as a high-yield tertiary adjunct. Streamlined electrode strategies can still approximate high-density performance: targeted-density EEG achieved **93%** sublobar concordance with traditional HD-ESI with ~**13 mm** typical localization differences. Portability is also emerging, with OPM-MEG showing ~**91%** agreement for interictal discharge detection versus conventional systems, while invasive biomarkers remain relevant as complete removal of an HFO-defined area has been linked to higher long-term seizure freedom (~**69% vs. ~43%**). Overall, evidence supports an “Iran-ready” stepwise pathway prioritising optimised EEG/ESI and selective EEG-fMRI, reserving 7T/MEG and HFO-guided strategies for complex or MRI-negative cases.

Conclusion:

Together, recent quantitative studies support a pragmatic precision-mapping stack for DRE: (1) streamline scalp-based ESI (including targeted-density montages) as a first-line, (2) add EEG-fMRI when deep network involvement is suspected, or MRI is nondiagnostic, (3) consider OPM-MEG as a lower-cost pathway where SQUID-MEG is unavailable, and (4) reserve 7T (preferably parallel transmit) and invasive HFO-guided strategies for complex or MRI-negative cases. Reported management changes (45–58%) and consistent mm-scale concordance (~12–14 mm) indicate that these tools can meaningfully tighten targeting for sEEG, resection, or ablation across pediatric and adult populations, with clear implementation relevance for Iranian epilepsy surgery pathways.

Keywords:

Brain Mapping; Electroencephalography; Epilepsy, Refractory; Epilepsy Surgery; Magnetic Resonance Imaging