Postoperative resting state functional MRI in children with intractable epilepsy has not been quantified in relation to seizure outcome. Therefore, its value as a biomarker for epileptogenic pathology is not well understood.


In a sample of children with intractable epilepsy who underwent prospective resting state guided epilepsy surgery, post‐operative resting state functional MRI was performed 6 to 12 months later. Graded normalization of the post‐operative resting state seizure onset zone was compared to seizure outcomes, patient, surgery, and anatomical MRI characteristics.


A total of 64 cases were evaluated. Post‐operative rs‐fMRI normalization was significantly (p‐value <0.001) correlated with seizure reduction, with Spearman rank correlation coefficient of 0.83. Of 39 cases with post‐operative resting state seizure onset zone normalization, 38 (97%) became completely seizure free. In contrast, of the 25 cases without complete rs‐fMRI SOZ normalization, only 3 (5%) become seizure free. The accuracy of rs‐fMRI as a biomarker predicting seizure freedom is 94%, with 96% sensitivity and 93% specificity.


Among seizure localization techniques in pediatric epilepsy, post‐operative rs‐fMRI normalization has high correlation with seizure freedom. This study shows that pre‐operative resting state functional MRI abnormalities can be used as a biomarker of the epileptogenic zone and the post‐operative rs‐fMRI normalization is a biomarker for seizure onset zone quiescence.

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