Neuroimaging in the definition and organization of the epilepsies: we're not there yet

Neuroimaging significantly affects the diagnosis and treatment of patients with patients. Despite its importance, magnetic resonance imaging (MRI) has been marginally incorporated into concepts used to define epilepsy etiologies by the International League Against Epilepsy (ILAE) Classification Commission. We propose that Structural etiology be defined as positive neuroimaging abnormalities likely causing the seizures. This would contrast with Genetic and Unknown etiologies, where imaging shows no overt structural abnormality that explains the seizures. It is further recommended that Structural and Metabolic be separated into individual categories, as the outcomes and therapies are different. It is advocated that Structural etiology be subdivided into subgroups based on MRI and surgical syndromes. With this approach, the ILAE should acknowledge that both MRI and electroencephalography (EEG) are necessary diagnostic tools in the classification of epilepsy syndromes and etiologies in the modern era. Promoting the use of neuroimaging into concepts that determine terminology will promote the notion that epilepsy classification should consider structural etiology of the seizures, along with the frequency of the most common epilepsy syndromes, and prognosis for spontaneous and treated remission and cure.