Purpose of review: MRI has a crucial position in the diagnostic routine of epilepsy patients. It relevantly contributes to etiological diagnostics and is indispensable in presurgical evaluation. As modern MRI research has been a boon to clinical neuroscience in general, it also holds the promise of enhancing diagnostics of epilepsy patients; i.e. increasing the diagnostic yield while decreasing the number of MRI-negative patients. Its rapid progress, however, has caused uncertainty about which of its latest developments already are of clinical interest and which still are of academic interest. It is the purpose of this review to clarify what, to the authors' mind, good practice of MRI in epilepsy patient care is today and what it might be tomorrow.
Recent findings: Progress of diagnostic MRI in epilepsy patients is driven by development of scanner hardware, scanner sequence and data postprocessing. Ultra high-field MRI and elaborate sequences provide datasets of novel quality which can be fed into postprocessing programs extracting pathognomonic features of structural or functional anatomy. The integration of these features by means of computerized classifiers yield previously unsurpassed diagnostic validity. Enthusiasm about Diffusion Tensor Imaging and functional MRI in the evaluation before epilepsy surgery is quelled.
Summary: The application of an epilepsy tailored MRI protocol at 3 Tesla followed by meticulous expert evaluation early after the onset of epilepsy is most crucial. It is hoped that future research will result in MRI workups more standardized than today and widely used postprocessing routines analyzing co-registered three-dimensional volumes from different modalities.