Temporal lobe epilepsy surgery failures: a review

The delta between postoperative seizure freedom and persistence: Automatically detected focal slow waves after epilepsy surgery

OBJECTIVE

In this study, we use a novel automated method for localization and quantitative comparison of magnetoencephalographic (MEG) delta activity in patients with and without recurrent seizures after epilepsy surgery as well as healthy controls.

METHODS

We identified the generators of delta activity by source location in frequency domain between 1 and 4 Hz in spontaneous MEG data. Comparison with healthy control subjects by z-transform emphasized relative changes of activation in patients. The individual results were compared to spike localizations and statistical group analysis was performed. Additionally, MEG results were compared to 1-4 Hz activity in invasive EEG (iEEG) in two patients, in whom this data was available.

RESULTS

Patients with recurrent seizures exhibited significantly increased focal MEG delta activity both in comparison to healthy controls and seizure free patients. This slow activity showed a correlation to interictal epileptic activity and was not explained by consequences of the resection alone. In two patients with iEEG, iEEG analysis was concordant with the MEG findings.

SIGNIFICANCE

The quantity of delta activity could be used as a diagnostic marker for recurrent seizures. The close relation to epileptic spike localizations and the resection volume of patients with successful second surgery imply involvement in seizure recurrence. This initial evidence suggests a potential application in the planning of second epilepsy surgery.

Temporal plus epilepsy: Anatomo-electroclinical subtypes

BACKGROUND

Mesial temporal lobe epilepsy (TLE) is a remediable epileptic syndrome. About 40% of patients continue to have seizures after standard temporal lobectomy. It has been suggested that some of these patients could actually suffer from a more complex epileptogenic network. Because a few papers have been dedicated to this topic, we decided to write an article updating this theme.

METHODS

We performed a literature search using the following terminology: "temporal plus epilepsy and networks," "temporal plus epilepsy," "orbito-temporal epilepsy," "temporo-insular epilepsy," "temporo-parieto-occipital (TPO) epilepsy," "parieto-temporal epilepsy," "intracortical evoked potential and temporal plus epilepsy," "temporal lobe connectivity and epilepsy," "intracortical evoked potential and epilepsy surgery," "role of extratemporal structures in TLE," "surgical failure after temporal lobectomy," "Diffusion tensor imaging (DTI) and temporal epilepsy," and "positron emission tomography (PET) in temporal plus lobe epilepsy" in the existing PubMed databases. We searched only English and Spanish literature. Only papers that fit with the above-mentioned descriptors were included as part of the evidence. Other articles were used to reference some aspects of the temporal plus epilepsy.

RESULTS

A total of 48 papers from 2334 were revised. The most frequently reported auras in these groups of patients are gustatory hallucinations, vestibular illusions, laryngeal and throat constriction, atypical distribution of somatosensory symptoms (perioral and hands, bilaterally hands paresthesias, trunk and other). The most common signs are tonic posturing, hemifacial twist, and frequent bilateral clonic movements. Interictal electroencephalographic (EEG) patterns exhibit regional and frequently bilateral spikes and/or slow waves. The first ictal electrographic change is mostly regional. It is important to note that the evidence is supported by case series or case reports. Thus, most of the data presented could represent the features on these cases and not actually the totality of the iceberg.

CONCLUSION

Temporal plus epilepsy is a diagnosis that can be done only after the invasive recordings have been analyzed but an adequate suspicion may arise based on clinical, EEG and imaging data.

Magnetoencephalographic signatures of insular epileptic spikes based on functional connectivity

Failure to recognize insular cortex seizures has recently been identified as a cause of epilepsy surgeries targeting the temporal, parietal, or frontal lobe. Such failures are partly due to the fact that current noninvasive localization techniques fare poorly in recognizing insular epileptic foci. Our group recently demonstrated that magnetoencephalography (MEG) is sensitive to epileptiform spikes generated by the insula. In this study, we assessed the potential of distributed source imaging and functional connectivity analyses to distinguish insular networks underlying the generation of spikes. Nineteen patients with operculo-insular epilepsy were investigated. Each patient underwent MEG as well as T1-weighted magnetic resonance imaging (MRI) as part of their standard presurgical evaluation. Cortical sources of MEG spikes were reconstructed with the maximum entropy on the mean algorithm, and their time courses served to analyze source functional connectivity. The results indicate that the anterior and posterior subregions of the insula have specific patterns of functional connectivity mainly involving frontal and parietal regions, respectively. In addition, while their connectivity patterns are qualitatively similar during rest and during spikes, couplings within these networks are much stronger during spikes. These results show that MEG can establish functional connectivity-based signatures that could help in the diagnosis of different subtypes of insular cortex epilepsy. Hum Brain Mapp 37:3250-3261, 2016. © 2016 Wiley Periodicals, Inc.

Pathology-Based Approach to Seizure Outcome After Surgery for Pharmacoresistant Medial Temporal Lobe Epilepsy

BACKGROUND

Hippocampal sclerosis (HS) is the most common cause of drug-resistant medial temporal lobe epilepsy (MTLE). Structural abnormalities such as HS, granule cell pathology (GCP), and focal cortical dysplasia (FCD) have been classified histopathologically, possibly allowing a more accurate assessment of prognostic seizure and neuropsychologic outcomes. We correlated seizure outcome with comprehensive temporal lobe pathologic findings, identified according to the most recent classification systems of HS, GCP, and FCD.

METHODS

All the 83 patients who underwent anterior temporal lobectomy (ATL) for drug-resistant MTLE and with a proven diagnosis of HS between April 2001 and May 2014 were collected. Patients were divided in 2 main groups: 1) isolated HS with/without GCP (HS +/- GCP); and 2) HS associated with FCD with/without GCP (HS+FCD +/- GCP). Patients were followed up at least 1 year, and seizure outcome was reported in accordance with Engel classification.

RESULTS

Group I: HS +/- GCP: Statistical analysis confirmed a better outcome in HS + GCP patients than in HS-no GCP (P < 0.05). Moreover, a better outcome for the patients affected by GCP type I was observed (P < 0.05). Group II: HS+FCD +/- GCP: Patients with HS variant type I presented a better seizure outcome than the patients with HS type II (Engel class IA HS type I vs. type II: 69% vs. 40%).

CONCLUSIONS

A pathology-based approach to epilepsy surgery might improve the interpretation of the results, could predict which cases will enjoy a better seizure outcome, and could help to the comprehension of the causes of failures.

A comparison of occipital and temporal lobe epilepsies

PURPOSE

Differentiating between occipital lobe epilepsy (OLE) and temporal lobe epilepsy (TLE) is often challenging. This retrospective case-control study compares OLE to TLE and explores markers that suggest the diagnosis of OLE.

METHODS

We queried the Jefferson Epilepsy Center surgery database for patients who underwent a resection that involved the occipital lobe. For each patient with OLE, three sequential case-control patients with TLE were matched. Demographic characteristics, symptoms, electrophysiological findings, imaging findings, and surgical outcome were compared.

RESULTS

Nineteen patients with OLE and 57 patients with TLE were included in the study. Visual symptoms were unique to patients with OLE (8/19) and were not reported by patients with TLE (P < 0.0001). Occipital interictal spikes (IIS) were found only in one-third of the patients with OLE (6/19) and in no patients with TLE (P < 0.0001). IIS in the posterior temporal lobe were found in five of 19 patients with OLE vs one of 57 patients with TLE (P = 0.003). IIS involved more than one lobe of the brain in most patients with OLE (11/19) but only in nine of 57 the TLE group. (P = 0.0003) Multilobar resection was needed in most patients with OLE (15/19), typically including the temporal lobe, but in only one of the patients with TLE (P < 0.0001).

CONCLUSION

Occipital lobe epilepsy is difficult to identify and may masquerade as temporal lobe epilepsy. Visual symptoms and occipital findings in the EEG suggest the diagnosis of OLE, but absence of these features, does not exclude the diagnosis. When posterior temporal EEG findings or multilobar involvement occurs, the diagnosis of OLE should be considered.

Factors associated with failed focal neocortical epilepsy surgery

BACKGROUND

Seizure outcomes after focal neocortical epilepsy (FNE) surgery are less favorable than after temporal lobectomy, and the reasons for surgical failure are incompletely understood. Few groups have performed an in-depth examination of seizure recurrences to identify possible reasons for failure.

OBJECTIVE

To elucidate factors contributing to FNE surgery failures.

METHODS

We reviewed resections for drug-resistant FNE performed at our institution between 1998 and 2011. We performed a quantitative analysis of seizure outcome predictors and a detailed qualitative review of failed surgical cases.

RESULTS

Of 138 resections in 125 FNE patients, 91 (66%) resulted in freedom from disabling seizures (Engel I outcome). Mean ± SEM patient age was 20.0 ± 1.2 years; mean follow-up was 3.8 years (range, 1-17 years); and 57% of patients were male. Less favorable (Engel II-IV) seizure outcome was predicted by higher preoperative seizure frequency (odds ratio = 0.85; 95% confidence interval, 0.78-0.93), a history of generalized tonic-clonic seizures (odds ratio = 0.42; 95% confidence interval, 0.18-0.97), and normal magnetic resonance imaging (odds ratio = 0.30; 95% confidence interval, 0.09-1.02). Among 36 surgical failures examined, 26 (72%) were related to extent of resection, with residual epileptic focus at the resection margins, whereas 10 (28%) involved location of resection, with an additional epileptogenic zone distant from the resection. Of 16 patients who received reoperation after seizure recurrence, 10 (63%) achieved seizure freedom.

CONCLUSION

Insufficient extent of resection is the most common reason for recurrent seizures after FNE surgery, although some patients harbor a remote epileptic focus. Many patients with incomplete seizure control are candidates for reoperation.

Automated Seizure Onset Zone Approximation Based on Nonharmonic High-Frequency Oscillations in Human Interictal Intracranial EEGs

A novel automated algorithm is proposed to approximate the seizure onset zone (SOZ), while providing reproducible output. The SOZ, a surrogate marker for the epileptogenic zone (EZ), was approximated from intracranial electroencephalograms (iEEG) of nine people with temporal lobe epilepsy (TLE), using three methods: (1) Total ripple length (TRL): Manually segmented high-frequency oscillations, (2) Rippleness (R): Area under the curve (AUC) of the autocorrelation functions envelope, and (3) Autoregressive model residual variation (ARR, novel algorithm): Time-variation of residuals from autoregressive models of iEEG windows. TRL, R, and ARR results were compared in terms of separability, using Kolmogorov–Smirnov tests, and performance, using receiver operating characteristic (ROC) curves, to the gold standard for SOZ delineation: visual observation of ictal video-iEEGs. TRL, R, and ARR can distinguish signals from iEEG channels located within the SOZ from those outside it (p < 0.01). The ROC AUC was 0.82 for ARR, while it was 0.79 for TRL, and 0.64 for R. ARR outperforms TRL and R, and may be applied to identify channels in the SOZ automatically in interictal iEEGs of people with TLE. ARR, interpreted as evidence for nonharmonicity of high-frequency EEG components, could provide a new way to delineate the EZ, thus contributing to presurgical workup.

Thalamotemporal alteration and postoperative seizures in temporal lobe epilepsy

Objective

There are competing explanations for persistent postoperative seizures after temporal lobe surgery. One is that 1 or more particular subtypes of mesial temporal lobe epilepsy (mTLE) exist that are particularly resistant to surgery. We sought to identify a common brain structural and connectivity alteration in patients with persistent postoperative seizures using preoperative quantitative magnetic resonance imaging and diffusion tensor imaging (DTI).

Methods

We performed a series of studies in 87 patients with mTLE (47 subsequently rendered seizure free, 40 who continued to experience postoperative seizures) and 80 healthy controls. We investigated the relationship between imaging variables and postoperative seizure outcome. All patients had unilateral temporal lobe seizure onset, had ipsilateral hippocampal sclerosis as the only brain lesion, and underwent amygdalohippocampectomy.

Results

Quantitative imaging factors found not to be significantly associated with persistent seizures were volumes of ipsilateral and contralateral mesial temporal lobe structures, generalized brain atrophy, and extent of resection. There were nonsignificant trends for larger amygdala and entorhinal resections to be associated with improved outcome. However, patients with persistent seizures had significant atrophy of bilateral dorsomedial and pulvinar thalamic regions, and significant alterations of DTI‐derived thalamotemporal probabilistic paths bilaterally relative to those patients rendered seizure free and controls, even when corrected for extent of mesial temporal lobe resection.

Interpretation

Patients with bihemispheric alterations of thalamotemporal structural networks may represent a subtype of mTLE that is resistant to temporal lobe surgery. Increasingly sensitive multimodal imaging techniques should endeavor to transform these group‐based findings to individualize prediction of patient outcomes. Ann Neurol 2015;77:760–774

Clinical correlates of graph theory findings in temporal lobe epilepsy

PURPOSE

Temporal lobe epilepsy (TLE) is considered a brain network disorder, additionally representing the most common form of pharmaco-resistant epilepsy in adults. There is increasing evidence that seizures in TLE arise from abnormal epileptogenic networks, which extend beyond the clinico-radiologically determined epileptogenic zone and may contribute to the failure rate of 30-50% following epilepsy surgery. Graph theory allows for a network-based representation of TLE brain networks using several neuroimaging and electrophysiologic modalities, and has potential to provide clinicians with clinically useful biomarkers for diagnostic and prognostic purposes.

METHODS

We performed a review of the current state of graph theory findings in TLE as they pertain to localization of the epileptogenic zone, prediction of pre- and post-surgical seizure frequency and cognitive performance, and monitoring cognitive decline in TLE.

RESULTS

Although different neuroimaging and electrophysiologic modalities have yielded occasionally conflicting results, several potential biomarkers have been characterized for identifying the epileptogenic zone, pre-/post-surgical seizure prediction, and assessing cognitive performance. For localization, graph theory measures of centrality have shown the most potential, including betweenness centrality, outdegree, and graph index complexity, whereas for prediction of seizure frequency, measures of synchronizability have shown the most potential. The utility of clustering coefficient and characteristic path length for assessing cognitive performance in TLE is also discussed.

CONCLUSIONS

Future studies integrating data from multiple modalities and testing predictive models are needed to clarify findings and develop graph theory for its clinical utility.

Temporal lobectomy with delayed amnesia following a new lesion on the other side

PURPOSE

To describe a delayed severe complication of temporal lobectomy for intractable epilepsy.

METHOD

A case of amnesia occurring 24 years after surgery is described and five similar cases from the literature reviewed.

RESULTS

Mean age at surgery (5 right) was 40 years (19-62 years), 3 female. Four of five tested had impaired visual and verbal memory preoperatively but not sufficient to contraindicate surgery. Pathology was mesial temporal sclerosis in 3, 1 cavernoma, 1 dysembryoplastic neuroepithelial tumor (DNET) and 1 normal. Postoperatively, four were seizure free 3-12 years off medication and two continued with seizures. There was no unexpected postoperative memory change until incapacitating anterograde amnesia developed 1-24 years after surgery. In five patients, including ours, this followed definite or possible status epilepticus with new mesial temporal sclerosis on the opposite side in the four that were investigated by MRI. One patient developed a glioblastoma in the opposite temporal lobe.

CONCLUSION

Continuing or late recurrence of seizures from the remaining temporal lobe after temporal lobectomy can result in incapacitating amnesia if status epilepticus occurs. Other new lesions on the opposite side to surgery can have the same effect.

Identifying the affected hemisphere with a multimodal approach in MRI-positive or negative, unilateral or bilateral temporal lobe epilepsy

Patients with non-lesional or bilateral temporal-lobe epilepsy (TLE) are often excluded from surgical treatment. This study investigated focus lateralization in TLE to understand identification of the affected hemisphere with regard to non-lesional or bilateral affection and postsurgical outcome. A total of 24 TLE patients underwent presurgical evaluation with magnetic resonance imaging (MRI), proton magnetic resonance spectroscopy ((1)H-MRS), video-electroencephalogram (video-EEG), and/or intracranial EEG (icEEG), and they were classified as MRI-positive or negative, unilateral or bilateral TLE cases. In patients with positive-MRI, MRI and (1)H-MRS indicated high (100%) concordant lateralization to EEG findings in unilateral TLE, and moderate (75%) concordance to icEEG findings in bilateral TLE; whereas in patients with negative-MRI, (1)H-MRS indicated moderate (60%-75%) concordance to EEG and/or icEEG in unilateral TLE, and relatively low (50%) concordance to icEEG in bilateral TLE. Ninety point nine percent of patients with unilateral TLE and 41.7% of patients with bilateral TLE (including 50% of MRI-negative bilateral TLE) became seizure-free. The MRS findings were not correlated with seizure outcome, while non-seizure-free patients had an insignificantly higher percentage of contralateral N-acetyl aspartate (NAA) reduction compared with seizure-free patients, indicating the relatively low predictive value of (1)H-MRS for surgical outcome. Further, EEG and icEEG findings were significantly correlated with seizure outcome, and for patients with positive MRI, MRI findings were also correlated with seizure outcome, indicating the predictive value of these modalities. The results suggested that a multimodal approach including neuroimaging, EEG, and/or icEEG could identify seizure focus in most cases, and provide surgical options for non-lesional or bilateral TLE patients with a possible good outcome.

Contradictory imaging and EEG results in resection surgery of bitemporal lobe epilepsy: A case report

The present study describes the case of a 27-year-old, right-handed female with bilateral mesial temporal lobe epilepsy. Electroencephalogram (EEG) monitoring from implanted electrodes displayed two different and independent onsets on the two sides of the mesial temporal structures, which specifically included clinical generalized tonic clonic seizure (GTCS) discharges originating from the left mesial temporal lobe, as well as complex partial seizure (CPS) discharges arising from the right mesial region. However, fluid-attenuated inversion recovery magnetic resonance imaging (FLAIR MRI) showed a unilateral abnormality, as in right mesial temporal lobe sclerosis. A decision was made to resect one side of the mesial temporal lobe, in order to avoid memory function impairment, and, relying on the MRI results, the right side was selected. However, surgery did not leave the patient seizure-free. The CPSs gradually eased, while the GTCSs originating from the left side became severely aggravated. In describing this case, the drawbacks of current epileptic diagnostic methods and surgical strategies for bitemporal lobe epilepsy are discussed, and the requirement for more treatment options is emphasized.

Identification of common predictors of surgical outcomes for epilepsy surgery

Although epilepsy surgery is an effective treatment for patients with drug-resistant epilepsy, surgical outcomes vary across patient groups and studies. Identification of reliable prognostic factors for surgical outcome is important for outcome research. In this study, recent systematic reviews and meta-analyses on prediction of seizure outcome have been analyzed, and common predictors of seizure outcome or unrelated factors for temporal lobe epilepsy (TLE), lesional extratemporal lobe epilepsy (ETLE), and tuberous sclerosis complex have been identified. Clinical factors such as lesional epilepsy, abnormal magnetic resonance imaging, partial seizures, and complete resection were found to be common positive predictors, and factors such as nonlesional epilepsy, poorly defined and localized epileptic focus, generalized seizures, and incomplete resection are common negative predictors, while factors such as age at surgery and side of surgery are unrelated to seizure outcome for TLE and lesional ETLE. In addition, diagnostic neuroimaging and resection are among the most important predictors of seizure outcome. However, common predictors of seizure outcome could not be identified in nonlesional ETLE because no predictors were found to be significant in adult patients (by meta-analysis), and outcome prediction is difficult in this case. Meta-analysis of other outcomes, such as neuropsychologic outcomes, is rare due to lack of evaluation standards. Further studies on identification of reliable predictors of surgical outcomes are needed.

Structural abnormalities in patients with insular/peri-insular epilepsy: spectrum, frequency, and pharmacoresistance

SUMMARY

Between 2002 and 2010, a total of 48 patients were seen at our epilepsy clinic with insular/peri-insular cortex epilepsy. Review of their MR imaging scans revealed a neoplastic lesion in 27% of patients, a malformation of cortical development in 21%, a vascular malformation in 19%, and atrophy/gliosis from an acquired insult in 17%. MR imaging results were normal in 4 patients. Other miscellaneous findings included a case of Rasmussen encephalitis, a nonspecific insular millimetric T2 signal abnormality, a neuroepithelial cyst, and hippocampal sclerosis without MR imaging evidence of dual insular pathologic features (despite depth electrode-proven insular seizures). Refractoriness to antiepileptic drug treatment was present in 56% of patients: 100% for patients with malformations of cortical development (1.0; 95% CI, 0.72-1.0), 50.0% (0.5; 95% CI, 0.21-0.78) in the presence of atrophy/gliosis from acquired insults, 39% (0.39; 95% CI, 0.14-0.68) for neoplastic lesions, and 22.2% (0.22; 95% CI, 0.06-0.55) for vascular malformations.

Multimodal neuroimaging in presurgical evaluation of drug-resistant epilepsy

Intracranial EEG (icEEG) monitoring is critical in epilepsy surgical planning, but it has limitations. The advances of neuroimaging have made it possible to reveal epileptic abnormalities that could not be identified previously and improve the localization of the seizure focus and the vital cortex. A frequently asked question in the field is whether non-invasive neuroimaging could replace invasive icEEG or reduce the need for icEEG in presurgical evaluation. This review considers promising neuroimaging techniques in epilepsy presurgical assessment in order to address this question. In addition, due to large variations in the accuracies of neuroimaging across epilepsy centers, multicenter neuroimaging studies are reviewed, and there is much need for randomized controlled trials (RCTs) to better reveal the utility of presurgical neuroimaging. The results of multiple studies indicate that non-invasive neuroimaging could not replace invasive icEEG in surgical planning especially in non-lesional or extratemporal lobe epilepsies, but it could reduce the need for icEEG in certain cases. With technical advances, multimodal neuroimaging may play a greater role in presurgical evaluation to reduce the costs and risks of epilepsy surgery, and provide surgical options for more patients with drug-resistant epilepsy.

The kainic acid model of temporal lobe epilepsy

The kainic acid model of temporal lobe epilepsy has greatly contributed to the understanding of the molecular, cellular and pharmacological mechanisms underlying epileptogenesis and ictogenesis. This model presents with neuropathological and electroencephalographic features that are seen in patients with temporal lobe epilepsy. It is also characterized by a latent period that follows the initial precipitating injury (i.e., status epilepticus) until the appearance of recurrent seizures, as observed in the human condition. Finally, the kainic acid model can be reproduced in a variety of species using either systemic, intrahippocampal or intra-amygdaloid administrations. In this review, we describe the various methodological procedures and evaluate their differences with respect to the behavioral, electroencephalographic and neuropathological correlates. In addition, we compare the kainic acid model with other animal models of temporal lobe epilepsy such as the pilocarpine and the kindling model. We conclude that the kainic acid model is a reliable tool for understanding temporal lobe epilepsy, provided that the differences existing between methodological procedures are taken into account.

Triple pathology in patients with temporal lobe epilepsy: A case report and review of the literature

The coexistence of three intracranial lesions related to epileptic pathogenesis is known as ‘triple pathology’ and has rarely been reported. In this study we report a case of temporal lobe epilepsy (TLE) with the coexistence of hippocampal sclerosis (HS), focal cortical dysplasia (FCD) and ganglioglioma in the temporal lobe. A 29-year-old male who had experienced recurrent seizures for four years was admitted to hospital. Cerebral magnetic resonance imaging (MRI) was conducted and T2-weighted and fluid-attenuated inversion recovery sequence (FLAIR) images revealed a reduced hippocampal volume with an increased FLAIR signal on the right side and a slightly enlarged temporal horn, which are typical imaging findings for HS and FCD. The patient underwent resectioning of the right anterior temporal lobe, hippocampus and amygdala, in addition to the lesion located in the medial temporal lobe. Immunohistochemical analysis of the medial temporal lobe lesion confirmed a ganglioglioma (WHO grade I) in the medial temporal lobe. During the first eight months following surgery, the patient's seizures were controlled with zonisamide and phenytoin. Electroencephalogram (EEG) assessment post-surgery confirmed the absence of epileptic discharges. Based on a literature review and a detailed review of this case, we postulate two possible explanations for the pathogenesis of ‘triple pathology’: i) ‘triple pathology’ is a combination of pathological progression and occasionality; and ii) ‘triple pathology’ lesions have similar pathological origins.

Presurgical EEG-fMRI in a complex clinical case with seizure recurrence after epilepsy surgery

Epilepsy surgery has improved over the last decade, but non-seizure-free outcome remains at 10%-40% in temporal lobe epilepsy (TLE) and 40%-60% in extratemporal lobe epilepsy (ETLE). This paper reports a complex multifocal case. With a normal magnetic resonance imaging (MRI) result and nonlocalizing electroencephalography (EEG) findings (bilateral TLE and ETLE, with more interictal epileptiform discharges [IEDs] in the right frontal and temporal regions), a presurgical EEG-functional MRI (fMRI) was performed before the intraoperative intracranial EEG (icEEG) monitoring (icEEG with right hemispheric coverage). Our previous EEG-fMRI analysis results (IEDs in the left hemisphere alone) were contradictory to the EEG and icEEG findings (IEDs in the right frontal and temporal regions). Thus, the EEG-fMRI data were reanalyzed with newly identified IED onsets and different fMRI model options. The reanalyzed EEG-fMRI findings were largely concordant with those of EEG and icEEG, and the failure of our previous EEG-fMRI analysis may lie in the inaccurate identification of IEDs and wrong usage of model options. The right frontal and temporal regions were resected in surgery, and dual pathology (hippocampus sclerosis and focal cortical dysplasia in the extrahippocampal region) was found. The patient became seizure-free for 3 months, but his seizures restarted after antiepileptic drugs (AEDs) were stopped. The seizures were not well controlled after resuming AEDs. Postsurgical EEGs indicated that ictal spikes in the right frontal and temporal regions reduced, while those in the left hemisphere became prominent. This case suggested that (1) EEG-fMRI is valuable in presurgical evaluation, but requires caution; and (2) the intact seizure focus in the remaining brain may cause the non-seizure-free outcome.