The use of Artificial Intelligence in Magnetic Resonance Imaging of Epilepsy: A Systematic Review and Meta-Analysis

BackgroundThe application of artificial intelligence (AI)/machine learning (ML) to MRI can be a powerful tool to streamline clinical decision-making, yet variability amongst MRI sequences and algorithms have hindered appropriate assessment of reliability and generalizability. MethodsWe conducted a systematic review and meta-analysis of the ability of current AI/ML models operating on MRI data for: 1) epilepsy diagnosis, 2) temporal lobe epilepsy lateralization, 3) lesion localization, and 4) post-surgical outcome prediction. Searches were conducted across PubMed, Medline, and Embase databases from inception until January 1, 2025. We selected studies that employed AI/ML models trained on any MRI modality to classify at least ten patients across the four main objectives for qualitative assessment, and further included in the meta-analysis if they reported an accuracy rate. The primary outcome of the meta-analysis was the overall accuracy of AI/ML models trained on MRI data. The secondary outcome was the concomitant risk of bias evaluation using PROBAST. FindingsWe identified 158 studies for qualitative evaluation and 127 studies for inclusion in the meta-analysis. AI/ML on multimodal MRI could accurately distinguish epilepsy patients from healthy controls (overall accuracy: 88% [85-90]), lateralize temporal lobe epilepsy (90% [87-93]), localize epileptogenic lesions (82% [74-88]), and predict post-surgical seizure-freedom (83% [78-87]). Overall, a high risk of bias remains in the literature; participant bias remained high across all outcomes (64-87%), as well as predictor (88-100%) and analysis (83-100%) bias. Outcome bias was low only for AI/ML studies predicting post-surgical outcomes. InterpretationOur results support promising accuracy of AI/ML models in epilepsy diagnostics and prognostics but remain highly susceptible to bias in participants, predictors, outcome, and analysis domains which limits current translation to routine clinical practice. We encourage closer interdisciplinary collaboration between clinical and scientific groups to improve validation studies based on thorough study design, analysis, and reporting.