Neocortical epilepsy surgery fails to achieve post-operative seizure freedom in 30-40% of cases. It is not fully understood why surgery in some patients is unsuccessful. Comparing interictal MEG bandpower from patients to normative maps, which describe healthy spatial and population variability, we identify patient specific abnormalities relating to surgical failure. We propose three mechanisms contributing to poor surgical outcome; 1) failure to resect abnormalities, 2) failing to remove all epileptogenic abnormalities, and 3) insufficiently impacting the overall cortical abnormality. We develop markers of these mechanisms, validating them against patient outcomes. Resting-state MEG data were acquired for 70 healthy controls and 32 patients with refractory neocortical epilepsy. Relative bandpower maps were computed using source localised recordings from healthy controls. Patient and region-specific bandpower abnormalities were estimated as the maximum absolute z-score, using healthy data as a baseline. Resected regions were identified from post-operative MRI. We hypothesised our mechanism markers would discriminate patient's post-surgery seizure outcomes. Mechanisms of surgical failure discriminate surgical outcome groups (Abnormalities not targeted: AUC=0.80, Partial resection of the epileptogenic zone: AUC=0.68, Insufficient cortical abnormality impact: AUC=0.64). Leveraging all markers together found that 95% of those who were not seizure free had markers of surgical failure in at least one of the three proposed mechanisms. In contrast, of those patients markers for any mechanism, 80% were seizure-free. Abnormality mapping across the brain is important for a wide range of neurological conditions. Here we demonstrated that interictal MEG bandpower mapping has merit for localising pathology and improving our mechanistic understanding of epilepsy.
