The cost-effectiveness and benefit of many diagnostic tests used in the presurgical evaluation for persons with epilepsy is for the most part uncertain as is their influence on decision-making. The options we have at our disposal are ever increasing. Advanced imaging modalities aim to improve surgical candidacy by helping us better define the epileptogenic zone and optimize surgical planning. However, judicious use is important. Randomized controlled trials delineating which mode of investigation is superior are lacking. Presurgical tests do have incremental value by increasing surgical candidacy and refining surgical planning. The yield of additional imaging will increase with complex localization. However, every case must be tailored by hypothesis, cost, and accessibility. Future studies using a quantitative cost-benefit framework are needed to determine the cost-effectiveness of advanced diagnostic tests (beyond magnetic resonance imaging) in the presurgical evaluation of those with epilepsy.
Keywords: MEG; MRI; PET; SPECT; cost-effectiveness; epilepsy surgery; imaging; presurgical work up.