European Journal of Cardiovascular Medicine

Epilepsy is a chronic neurological disorder characterized by recurrent, unprovoked seizures resulting from abnormal electrical discharges in the brain. It represents a major public health issue worldwide, particularly in low- and middle-income countries (LMICs) like India, where diagnostic and therapeutic gaps persist. According to the International League Against Epilepsy (ILAE), epilepsy is defined as the occurrence of at least two unprovoked seizures more than 24 hours apart, one unprovoked seizure with a high risk of recurrence, or a diagnosis of an epilepsy syndrome.¹ In India, epilepsy affects an estimated 12 million people, accounting for nearly one-sixth of the global burden. The prevalence ranges from 3 to 11.9 per 1,000 population depending on geographical and socio-economic factors.² Despite this burden, underdiagnosis and inadequate treatment remain prevalent due to limited awareness and diagnostic infrastructure, particularly in semi-urban and rural regions like Rohilkhand in western Uttar Pradesh.

Neuroimaging plays a pivotal role in the etiological evaluation and management of epilepsy, especially in detecting structural lesions in focal epilepsy or medically intractable cases. Computed tomography (CT) has utility in emergency scenarios but lacks the sensitivity to detect subtle cortical abnormalities. Magnetic resonance imaging (MRI), with its superior soft-tissue resolution and multiplanar capabilities, has emerged as the imaging modality of choice for patients with epilepsy.³ With technological advancements, high-field MRI, especially 3 Tesla (3T) scanners, have greatly improved lesion detectability. Compared to 1.5T MRI, 3T systems provide higher signal-to-noise ratio, better spatial resolution, and enhanced contrast differentiation, making them ideal for evaluating subtle abnormalities such as focal cortical dysplasia (FCD), mesial temporal sclerosis (MTS), heterotopias, and other malformations of cortical development.^4,5

In a study by Verma et al., MRI revealed abnormalities in 39% of paediatric patients with non-febrile seizures, granulomatous lesions and hypoxic-ischemic encephalopathy being the most frequent findings. Notably, partial seizures had a higher rate of abnormal MRI findings compared to generalized seizures². Similarly, Dhar et al. found MRI abnormalities in 53.6% of patients, with neurocysticercosis, tuberculoma, and cortical malformations being the leading causes.¹

The diagnostic yield of MRI is particularly enhanced when used in conjunction with clinical evaluation and electroencephalography (EEG). Studies have shown a moderate to strong correlation between EEG abnormalities and MRI findings, especially in focal epilepsies.^3,6 In developing regions, infections such as neurocysticercosis and tuberculoma remain common causes of epilepsy, reflecting poor hygiene and inadequate public health systems.^2,7 Early and accurate detection of such lesions has important therapeutic and prognostic implications, especially in drug-resistant epilepsy where surgical intervention may be considered.

In the western Uttar Pradesh region, access to 3T MRI is limited, and data on its diagnostic utility in epilepsy remain scarce. This study aims to evaluate the role of 3 Tesla MRI in the etiological assessment of epilepsy patients in a tertiary care hospital setting in Rohilkhand. By correlating clinical seizure types and EEG findings with high-resolution MRI results, this research seeks to establish the value of 3T MRI in improving diagnostic accuracy and patient outcomes in a semi-urban Indian context.

Objective

To assess the diagnostic utility of 3 Tesla Magnetic Resonance Imaging (MRI) in identifying structural abnormalities in patients with epilepsy at a tertiary care teaching hospital in the western Uttar Pradesh region.

This hospital based observational study was conducted in the department of Radio diagnosis in a tertiary care teaching hospital in Rohilkhand region of western Uttar Pradesh for period of 6 months and included total 75 patients after approval from the institutional ethical committe. Patients of either sex, both adults and children attending the medicine OPD with complaints of at least two episodes of unprovoked seizures in the past 6 months will be evaluated on MRI.

In all these patients, relevant clinical history including age of onset, frequency of seizure,

type of seizure will be taken.

Inclusion Criteria:

1. All patients with clinical diagnosis of epilepsy.
2. Patients of any age and either gender.

Exclusion Criteria:

1. Any patients with contraindication to MRI like patients with cardiac pacemaker, adverse reactions to contrast.
2. Patients in which follow up was not possible.

Imaging:

Magnetic Resonance Imaging:

Multiplanar MR imaging of the brain on Siemens Magnetom Skyra 3 Tesla wide bore 48

Channel using head coil.

Following sequences will be taken:

• T1 weighted (axial)
• Axial T2 weighted
• High resolution fluid attenuated inversion recovery (FLAIR) sequence
• IR sequence
• High resolution T2 weighted FSE through temporal lobe (oblique coronal)
• Susceptibility weightage imaging (SWI)
• Diffusion weighted imaging

Additional Sequences done as required:

• Post gadolinium T1 weighted
• 3D sequences
• Magnetic Resonance Spectroscopy (MRS)

RESULTS

The generalized tonic –clonic seizures were the most common type while the simple partial seizures were most uncommon type.

Table 1: Distribution of Patients Based on Clinical Diagnosis of Seizures

Table 2: Sex-wise Distribution of Patients Presenting with Seizures

Table 3: Distribution of Patients Based on MRI Findings

Table 4: Age-wise Distribution of Patients Presenting with Seizures

Table 5: Distribution of Abnormality on MRI and EEG as per Seizure Type

In our study involving 75 patients with epilepsy, we aimed to evaluate the diagnostic utility of 3 Tesla (3T) MRI and its correlation with clinical and electroencephalographic data. Our findings align with previous regional and global studies and highlight the relevance of high-resolution neuroimaging in epilepsy workup. We observed a male predominance (57.3%), which is consistent with trends reported by Sahdev et al. and Kaur et al., where males represented over 65% of cases in paediatric and adult-onset seizures respectively^9,10. The most affected age group in our study was 11–20 years (44%), indicating early age of onset, especially in developing regions where CNS infections are prevalent⁹. Similar age patterns were seen in paediatric-focused studies where seizures frequently occurred below the age of 12 due to inflammatory and hypoxic etiologies.⁹ The most common seizure type in our cohort was generalized tonic-clonic seizures (GTCS) at 48%, followed by complex partial (18.7%) and simple partial seizures (12%). This mirrors findings by Desai et al., who reported that generalized seizures were the most frequent presentation in both paediatric and adult cases, though focal seizures tended to have higher association with structural lesions on MRI.¹¹ MRI abnormalities were found in 56% of our patients, consistent with the 54.3% positive yield reported by Desai et al. in adults with new-onset seizures¹¹. The most frequent abnormalities in our study included granulomatous diseases including neurocysticercosis & tuberculoma (18.6%), mesial temporal sclerosis (10.7%) and focal cortical dysplasia (9.3%). Infectious aetiologies were notably represented in our cohort. Neurocysticercosis and tuberculomas together accounted for over 33.3% of abnormal MRI findings, consistent with data from Indian studies where parasitic and tubercular infections are common causes of symptomatic epilepsy^11,12. Sahdev et al. also found inflammatory granulomas to be the most common lesions in children presenting with seizures.⁹ MTS, a hallmark of temporal lobe epilepsy, is frequently seen in drug-resistant cases and has critical implications for surgical intervention. Focal cortical dysplasia, often subtle, benefits from the enhanced resolution of 3T MRI for detection^11,13. Correlation between MRI and EEG was observed in a majority of patients. In our study, among the 52 patients who underwent EEG, 65.4% of those with abnormal EEG findings also had MRI abnormalities. This supports findings by Verma et al., who documented moderate concordance between EEG and MRI, particularly in partial seizures². EEG remains a valuable complementary tool, particularly when MRI is inconclusive or unavailable. The role of high-field MRI in detecting subtle epileptogenic foci is well-documented. Compared to 1.5T MRI, 3T systems provide better resolution and lesion conspicuity. Desale et al. emphasized that 3T MRI, especially when combined with magnetic resonance spectroscopy (MRS), can detect both structural and metabolic changes in epileptic zones, improving diagnostic accuracy and surgical planning.¹²

Overall, our findings underscore the clinical relevance of 3T MRI in epilepsy, especially in young patients and those with focal seizures. It aids in early identification of treatable causes such as infections and developmental abnormalities. In semi-urban regions, the accessibility of high-quality neuroimaging can significantly improve patient outcomes through timely diagnosis and individualized treatment.

This study demonstrates the effectiveness of 3 Tesla MRI in detecting structural abnormalities in epilepsy patients, with a diagnostic yield of 56%. Lesions such as neurocysticercosis, tuberculoma, mesial temporal sclerosis and focal cortical dysplasia were commonly identified, especially in patients with partial seizures. A moderate correlation between EEG and MRI findings further supports the combined use of both modalities in epilepsy evaluation. Given its superior imaging capability, 3T MRI should be incorporated into routine diagnostic protocols, particularly in semi-urban regions like Rohilkhand, to enhance early diagnosis, optimize treatment, and improve outcomes in patients with epilepsy.

1. Dhar N, Magotra V. Role of Magnetic Resonance Imaging in the Evaluation of Seizures. Int J Res Med Sci. 2022;10(11):2409–15.
2. Verma SR, Sardana V. Evaluation of Non-Febrile Seizure Disorder on MRI with Correlation with Seizure Type and EEG Records in Children. IOSR J Dent Med Sci. 2017;16(6):13–16.
3. Duncan JS. Imaging in the surgical treatment of epilepsy. Nat Rev Neurol. 2010;6(10):537–550.
4. Coan AC, Kubota B, Bergo FP, et al. 3 Tesla MRI in patients with epilepsy and normal 1.5 Tesla MRI. Epilepsia. 2014;55(2): e56–e60.
5. Bernasconi A, Bernasconi N, Andermann F, Dubeau F. Entorhinal cortex in temporal lobe epilepsy: a quantitative MRI study. Neurology. 1999;52(9):1870–6.
6. Berg AT, Testa FM, Levy SR, Shinnar S. Neuroimaging in children with newly diagnosed epilepsy: a community-based study. Pediatrics. 2000;106(3):527–32.
7. Senanayake N, Roman GC. Epidemiology of epilepsy in developing countries. Bull World Health Organ. 1993;71(2):247–58.
8. Hirtz D, Ashwal S, Berg A, et al. Practice parameter: evaluating a first nonfebrile seizure in children. Neurology. 2000;55(5):616–23
9. Sahdev R, Rao A, Sinha S. Neuroimaging in pediatric seizures. Int J Res Med Sci. 2017;5(1):295–9.
10. Kaur S, Garg R, Aggarwal S, et al. Adult onset seizures: Clinical, etiological, and radiological profile. J Family Med Prim Care. 2018;7(1):191–7.
11. Desai KN, Ravi N. MRI of the brain in adults with new-onset seizures. SSRG Int J Med Sci. 2015;2(3):23–5.
12. Pannag D, Ravi N. MRI Spectrum of Neurocysticercosis in Seizure Patients. SSRG Int J Med Sci. 2015;2(3):23–25.
13. Desale P, Dhande R, Parihar P, et al. Navigating Neural Landscapes: A Comprehensive Review of MRI and MRS in Epilepsy. Cureus. 2024;16(3):e56927.