Neuroinflammatory PET in Epilepsy: Prospects for Epileptogenic Zone Localization and Presurgical Planning

Neuroinflammatory PET offers a direct in vivo means of quantifying neuroinflammatory processes through molecular targets expressed by activated glia, including the 18 kDa translocator protein (TSPO), monoamine oxidase B, and the P2X7 receptor. This review synthesizes current evidence for neuroinflammatory PET in epileptogenic zone (EZ) localization across these and emerging targets. TSPO PET demonstrates ipsilateral uptake in temporal lobe and neocortical epilepsy, detects the EZ in MRI-negative cases, and shows strong concordance with intracranial electroencephalography, with complete resection of TSPO-positive regions associated with seizure-free outcomes. Monoamine oxidase B PET identifies the epileptogenic hippocampus through astrogliosis-specific signaling, whereas P2X7 receptor PET shows promise in preclinical models and ex vivo resected tissue. Emerging targets further expand the repertoire for neuroinflammatory characterization of the EZ. Neuroinflammatory PET has the potential to improve EZ localization, better inform surgical eligibility, and guide resection extent in patients where conventional imaging is insufficient.