Section I:

Summary of the Proposed Research Plan This page should serve as a succinct and
accurate description of the proposed plan.
The abstract should include the long-term goals of the proposed work and the
methods to be used.
Data collection and analysis should be summarized along with the potential clinical
significance and future clinical impact of this work.

1. Title
Utility of combining Resting-State Functional Magnetic Resonance Imaging
Connectivity and Arterial Spin Labeling in the detection of epileptogenic zones in
children with refractory epilepsy

2. Abstract (not to exceed 300 words).

Section II Investigator(s) 1. Applicant Principal Investigator (PI)Data

Applicant Principal Investigator (PI) Data
• Institution: Clinica Alemana de Santiago
• Department: Imagenes
• Radiologist, certificated by Facultad de Medicina, Universidad de Chile (2008-2011,
Santiago, Chile)
Neurorradiologist, certificated by Facultad de Medicina de la Universidad del
Desarrollo/Clinica Alemana de Santiago (2013-2015, Santiago, Chile)
Current faculty position/rank.
• Full-time equivalent (FTE) status: please list your employment status.
• Grants received for this project. Please Include all sources of funding, including
internal funding. Specify the amount and percent effort from each source.
• Contact Information (hospital affiliation and hospital address, institution’s research
administration office, and name and email address of the grant manager)

NIH Biosketch
3. Priority Statement:
As a neuroradiologist, my area of interest has been two: pediatric neuroradiology and
epilepsy.

Describe your area of professional/scientific interest(s) and long-term career goals and
objectives. Briefly describe the relevance of the proposed research plan to the
priorities of the host institution and departmental research program(s). This section
should not exceed 1000 words.

For some years now, the team of neuroradiologists dedicated to epilepsy has been
incorporating advanced MRI studies to improve the detection of patients with focal
epilepsy and negative MRI. In this regard, in 2016 we implemented the use of MAP
image post-processing software, which allows us to identify focal chordal dysplasias
that were not perceived by a visual analysis. PET studies are used in some cases, with
refractory focal epilepsies to identify the epileptogenic focus. However, this technique
involves ionizing radiation and the administration of a radiotracer, whose deleterious
effect, especially in children, is known. This is why we have been working on improving
non-contrast perfusion studies (ASL), which is part of our protocol since the year ... In
particular, we are working on incorporating a quantitative analysis, which allows us to
systematically recognize areas of lower perfusion, and therefore, in correlation with
EEG, could correspond to epileptogenic areas. Finally, we have been performing
functional MRI studies since 2014 and we have several published works related to
neurodevelopment as well as to identify eloquent areas in pre-surgical context (see
reference). Our interest is to combine advanced non-invasive MRI techniques, Resting
state and ASL, to increase the detection of epileptogenic areas, which determines
better post-surgical prognosis of patients with refractory focal epilepsy.
To our knowledge, no other similar studies have been published.

4. Other Investigators:
Ximena Stecher: neuroradiologist dedicated to epilepsy, pediatrics, advances MRI,
investigation.
Fernando Carreño: neuroradiologist dedicated to epilepsy and PET
Francisco Zamorano: P in He will al to do with processing imaging.
Gonzalo Araya

5. Mentor for the PI:

Ximena Stecher
Claudio Silva

The team has been incorporating advanced MRI studies to improve the detection of
patients with focal epilepsy and negative MRI. In this regard, in 2016 we implemented
the use of MAP image post-processing software, which allows us to identify focal
chordal dysplasias that were not perceived by a visual analysis. PET studies are used in
some cases, with refractory focal epilepsies to identify the epileptogenic focus.
However, this technique involves ionizing radiation and the administration of a
radiotracer, whose deleterious effect, especially in children, is known. This is why we
have been working on improving non-contrast perfusion studies (ASL), which is part of
our protocol since the year ... In particular, we are working on incorporating a
quantitative analysis, which allows us to systematically recognize areas of lower
perfusion, and therefore, in correlation with EEG, could correspond to epileptogenic
areas. Finally, we have been performing functional MRI studies since 2014 and we
have several published works related to neurodevelopment as well as to identify
eloquent areas in pre-surgical context (see reference). Our interest is to combine
advanced non-invasive MRI techniques, Resting state and ASL, to increase the
detection of epileptogenic areas, which determines better post-surgical prognosis of
patients with refractory focal epilepsy.
To our knowledge, no other similar studies have been published.

Section III - Research Plan

A. Detailed Research Plan
Not to exceed 5 pages, including figures, tables, etc. Use 0.5" margins and size 11 Arial
font. Additional pages may be included for the bibliography.

(((theKnowing where the epileptic focal point is located together with a good quality of
the study is also fundamental in this process Conventional MRI plays an important role
in evaluation of children with epilepsy, in particular, those with localized or remote
sympthomatic epilepsy but also in their management and treatment. Advanced
imaging techniques—including magnetic resonance spectroscopy, functional MRI, ,
single photon emission computed tomography and perfusion techniques- have
contributed to localize the epileptic focus, when conventional MR imaging cannot
detect a structural epileptogenic lesion, and are important tools in the characterization
of structural lesions and in the planification of surgery. Arterial spine labeling (ASL) is
MRI technique for assessing cerebral blood flow by magnetically labeling protons from
the inflowing blood as an endogenous diffusible tracer. The advantages of the ASL
techniques, including their non-invasiveness and the absence of intravenous contrast
agents, make them particularly suitable tool in the evaluation of epilepsy in
children.))))

Specific Aims List the broad, long-term objectives and specific research proposed.

Objetives: To compare resting-state functional magnetic resonance imaging with ASL

for detecting epileptogenic zones (EZs).

the goal: To demonstrated that hypoperfundes areas in ASL correlate with

epileptogenic inersting state suggestive of epileptogenic focus.

Objetivos secundarios:

 Determinar la exactitud diagnóstica de ASL en la identificación del foco

epileptogénico en pacientes con epilepsia focal.
 Determinar la exactitud diagnóstica de resting state en la identificación del foco
epileptogénico en pacientes con epilepsia focal.
 Comparar exactitud diagnóstica del análisis visual versus el análisis cuantitativo
basado en la comparación con el lado contralateral en ASL.

2. Significance
Briefly sketch the background leading to the present application, critically evaluate
existing knowledge, and specifically identify the gaps that the project is intended to fill.
State concisely the importance and relevance of the research described in this
application by relating the specific aims to the broad, long-term objectives. If the aims
of the application are achieved, state how scientific knowledge or clinical practice will
be advanced. Describe the effect of these studies on the concepts, methods,
technologies, treatments, services, or preventative interventions that drive this field.

Epilepsy is the most frequent chronic neurologic condition in childhood. If the epilepsy
is refractory, the patient has surgical indication, and the prognosis is conditioned by
previous identification of a structural lesion in the MRI. However, in ... % of the cases,
conventional MRI does not detect lesions. In these cases, the study with advanced MRI
techniques can help to localize the epileptogenic focus. Among them are PET and
SPECT, however, these techniques involve ionizing radiation and the administration of
radioactive tracers.

ASL es una técnica de perfusión de resonancia magnética que no requiere del uso de
contraste endovenoso. Desde hace varios se ha descrito su uso en epilepsia, para
identificar los focos epileptógenos durante el periodo postictal. En forma ictal, se
manifiesta como focos de hiperperfusión, pero su valor en determinar el foco
epileptógeno es errático y técnicamente complejo.
Los estudios respecto del exactitud diagnóstica de ASL en detectar focos epilepticos
entregan resultados variables. Esto debe a múltiples factores, entre ellos, que ASL es
una técnica muy suspectible de artefactos y de baja resolución cuando se realiza una
evaluación visual de las imágenes. Hay ciertos grupos que han realizado evaluaciones
cuantitativas de las imágenes, pero hay dipersión respecto de la forma de analisis,
algunos comparan con el lado contralateral y otros con un template de normalidad. Sin
emabrgo, en niños esta última metodología resulta de mayor complejidad, puesto que
la perfusión varian con la edad del paciente, por lo que se requerían templates
especificos para cada rango etario.
Recently, several studies have indicated that resting-state functional MRI (rs-fMRI)
localizes where seizures originate in the brain, and its implementation improves
surgical outcome. Agreement of rs-fMRI SOZ and intracranial electroencephalography
(EEG) SOZ localization is 90%.
También se ha demostrado que la resección de el área epileptógena demostrada en
resting state, condiciona un mejor pronóstico clinio. Additionally, connectivity results
may increase the proportion of patients considered eligible for surgery while
optimizing the need for further testing.

1. Innovation

Existen estudio que demuestra que las áreas de hipoperfusión ASL se

correlacionan con las áreas de hipometabolismo PET, cuya utilidad en la
detección de los focos epileptógenos está ampliamente demostrada. Esto
porque existe un acoplamiento entre el metabolismo y la perfusión cerebral.
Hasta donde sabemos, no hay estudios que comparen ASL con resting state en
la determinación del foco epiléptico. De correlacionar las áreas
hipoperfundidas en ASL sugerentes de zonas epileptógenas con las áreas
epileptógenas del resting state, se obtiene un mapa que permite establecer el
acoplamiento de la perfusión con la funcionalidad del tejido epileptogenico.
Por otro lado, este estudio prospectivo nos permitiría conocer la exactitud
diagnóstica de ASL y resting state en forma independiente y en su combinación,
para identificar los focos epileticos en casos de epilepsias refractarias, en
reemplazo del PET, a candidatas a cirugia.

Explain how the application challenges and seeks to shift current research or clinical
practice paradigms. Describe any novel theoretical concepts, approaches or
methodologies, instrumentation or interventions to be developed or used, and any
advantage over existing methodologies, instrumentation, or interventions. Explain any
refinements, improvements, or new applications of theoretical concepts, approaches
or methodologies, instrumentation, or interventions.

4. Approach
Research Design and Methods

Nuestro centro (CAS) tiene convenio con la liga de la epilepsia, centro de derivación
nacional de pacientes con epilepsia , de manera que las resonancias magnéticas son
realizadas en nuestra institución. Por otro lado, muchos de los médicos epileptólogos
de nuestra institución trabajan además en la liga. A partir de los registros clínicos de
CAS y de la liga, se reclutarán todos aquellos pacientes sobre 6 años, que sean capaces
de tolerar la resonancia magnética sin anestesia ni sedación y que tengan un claro foco
epileptógeno y cuyas resonancias previas no presentaban hallazgos significativos (RM).
El foco epileptogenico, corresponde al Goldstandar, y será definido por el equipo de
epileptólogos pediátricos basado en la clínica del paciente y la EEG.
Las resonancias magnéticas informadas como negativas, serán reevaluadas por un
neurorradiologo dedicado a epilepsia, para corroborar que no hayan lesiones
estructurales.
A los pacientes de menor edad se les realizará una aproximación previa al resonador,
para que se encuentren familiarizados con el resonador.
Epileptic focus
The clinical seizure focus was determined by two experienced pediatric epileptology neurologists based on a localization hypothesis
using
clinical history, ictal semiology, psychological assessment, and EEG
findings. The degree of concordance was assessed by comparing the area of
ASL changes to that of the presumed seizure focus. Concordance was
defined when the presumed seizure focus overlapped entirely with the
area of ASL changes, even if the area of ASL changes was more extended,
and the most prominent ASL changes matched the seizure foci.
If some, but not all, of the seizure focus overlapped with the area of ASL
changes, this was considered as partial concordance. Discordance was
defined when the seizure focus and the area of perfusion change area
were in different regions of the same hemisphere or in opposite hemispheres.
In addition, discordance was also assigned when there were no
ASL abnormalities in patients with seizure focus.(LEE).
Adquisicion de las imágenes
Images were acquired on a 3T MRI scanner (Siemens, Skyra) equipped with a 32-
channel head coil. ASL Resting-state fMRI parameters included TR 2000 msec, TE 30
msec, matrix size 80 × 80, flip angle 80°, number of slices 46, slice thickness 3.4 mm
with no gap, in-plane resolution 3 × 3 mm, interleaved acquisition, and number of total
volumes 600, in two 10-minute runs, totaling 20 minutes. For anatomical reference, a
T1- weighted turbo field echo whole-brain MRI sequence was obtained using the
following parameters: TR 9 msec, TE 4 msec, flip angle 8°, slice thickness 0.9 mm, and
in-plane resolution 0.9 × 0.9 mm.

Análisis de ASL
Las adquisiciones ASL serán evaluadas de 2 formas:
Analisis cualitativo (visual)
Analisis cuantitativo comparando con el lado contralateral.
Se compararán las concordancias respecto de la hipótesis epiléptica focal.
Analisis de resting state
Analysis of rs-fMRI data will be carried out using ….the Oxford Centre FMRIB
(Functional MRI of the Brain) Software Library tool MELODIC. Standard preprocessing
steps will be applied.
Individual rs-fMRI data sets will undergoing independent component analysis (ICA) as
previously reported in boerwinkler), that is, the eesulting components were
categorized as noise, healthy resting-state network (RSN), atypical RSN, or rs-fMRI SOZ.

Corregistration
Individual rs-fMRI and ASL scans were registered to the patient’s high-resolution
anatomical scan using linear registration and optimized using boundary-based
registration.
Muestra
 Pacientes con epilepsia focal que se hayan realizado RM con protocolo
epilepsia en CAS.
 Deben presentar una clara localización del foco epiléptico, basados en los
criterios clínicos y electro-encefalográficos.
 Muestra estimada en 270 pacientes (4 pacientes al mes por 5 años).

Estimación del tamaño del subgrupo de pacientes con claro foco epiléptico e imagen
sugerente de DCF: 90 pacientes (1 al mes por 5 años) y del subgrupo de pacientes con
claro foco epiléptico con RM- : 180 (3 al mes por 5 años)

Criterios de Inclusión
1. Con resonancia magnética protocolo epilepsia realizadas en CAS.
2. Paciente con epilepsia focal y clara sospecha clínica-electro-encefalográfica del
foco epiléptico.
3. Entre 6 y 18 años.
Criterios de exclusión
1. Pacientes con otra patología neurológica conocida.
2. Pacientes cuya RM previa demuestre alteración estructural significaiva
3. Pacientes con antecedetes de cirugía cerebral.

Variables
• Edad: perfusión cerebral varia con la edad. ¿Debe ser ajustada?.
• Sexo: determinar si perfusión cerebral varia con el sexo.
• Intervalo desde última convulsión ( > o < de 48 hrs) y severidad (status verus no
status epiléptico)
• Localización del foco epiléptico
• Uso de anestesia
• Teslaje del equipo de RM
Fuente de recolecciónd de datos:
A partir de las resonancias magnéticas protocolo epilepsia realizadas en CAS, se
identifican los pacientes con diagnóstico de epilepsia focal. La localización del foco
epiléptico será determinada por epileptólogos de CAS y entregados a la investigadora a
cargo (Dra. Schonstedt).
Preliminary Studies
Use this section to provide an account of the PI's preliminary studies pertinent to this
application. This information will also help establish the experience and competence of
the investigator to pursue the proposed project. Preliminary data are welcome but not
required. If there are no preliminary data, provide supporting evidence in the existing
literature.
Timeline of events
As part of this section, provide a tentative sequence or timetable for the project. A 12-
month timeline for completion of the study will be favored.

Bibliography
B. Resources and Environment (Not to exceed 1 page)
Todos los estudios se realizaran en alguno de ls 3 resonadores 3 Tesla (skyra).
Se dispone de todos los computadores y espacio fisicos.

Section IV – Budget (Not to exceed 1 page)

1. Detailed Budget
Provide a complete budget for the proposed project, including, where applicable,
information on equipment that will be purchased or rented, supplies and materials,
other (including salary support and benefits if a laboratory or other assistant will be
paid by this grant). All direct costs and equipment costs should be included with
justification for each item.
El servicio de imagenes costeará todos los costos indirectos, que tiene que ver con
horas secretaria para el agendamiento de pacientes, horas de trabajo de los
investigdores a cargo

2. No hay otras fuentes de financiamiento

3. Award Payment Information

Please supply the payee information and mailing addressas provided through the
institution’s research administration office. I
dentify who to make grant checks payable to. Include the contact name, mailing
address, phone number, and email address.