A review of neuroimaging in epilepsy: Diagnostic strategies and clinical decision framework

Abstract

Epilepsy, a chronic neurological disorder characterized by recurrent unprovoked seizures, demands precise diagnostic imaging. This review critically examines both structural and functional neuroimaging modalities MRI, CT, PET, SPECT, MEG, fMRI, MRS, DTI, and ASL in terms of diagnostic accuracy, patient comfort, cost-effectiveness, and accessibility. Structural MRI continues to serve as the cornerstone of epilepsy imaging, while functional and metabolic techniques offer vital insights in MRI-negative or drug-resistant cases. A clinical decision-making framework is proposed, guiding imaging selection based on seizure presentation and resource context. The review also addresses the implementation challenges in low- and middle-income countries (LMICs), including infrastructure limitations, economic barriers, and workforce shortages, while offering feasible strategies to improve access. Emphasis is placed on the integration of multimodal imaging and the development of context-sensitive, tiered approaches to optimize epilepsy care globally.