Presurgical language fMRI: Current practices and patient outcomes in epilepsy surgical planning

The goal of this study was to document current clinical practice and report patient outcomes in presurgical language functional MRI (fMRI) for epilepsy surgery. Epilepsy surgical programs worldwide were surveyed as to the utility, implementation, and efficacy of language fMRI in the clinic; 82 programs responded between July 2015 and January 2016. Respondents were predominantly from the US (61%), were academic programs (85%), and predominantly evaluated adults (44%), both adults and children (40%), or children only (16%). Nearly all (96%) respondents reported using language fMRI. fMRI is used for language lateralization (100%) and for localizing (44%) language cortex to guide surgical margins. While typically considered useful, programs often reported at least one instance of disagreement with other measures (56%). When used to localize language cortex, direct brain stimulation typically confirmed fMRI findings (74%) but instances of unpredicted decline were reported by 17% of programs and unexpected preservation of function were reported by 54%. Programs reporting unexpected decline did not clearly differ from those which did not. Clinicians using fMRI to guide surgical margins typically map Brocas and Wernickes areas but not other known language areas. Language fMRI is widely used for lateralizing language cortex in patients with medically intractable epilepsy. It is also frequently used to localize language cortex though it is not yet well validated for this purpose. Many centers report cases of unexpected language preservation when fMRI activation is resected, and cases of language decline when it is not. Care will almost certainly be improved by standardizing protocols and accurately detailing the relationship between fMRI-positive areas and post-surgical language decline.