What are we really predicting with fMRI in epilepsy surgery?

While memory and language functional magnetic resonance imaging (fMRI) paradigms are becoming evermore refined, the measures of outcome they predict following epilepsy surgery tend to remain single scores on pencil and paper tests that were developed decades ago and have been repeatedly shown to bear little relation to patients' subjective reports of memory problems in the real world. The growing imbalance between the increasing sophistication of the predictive paradigms on the one hand and the vintage measures of the outcome on the other in the fMRI epilepsy surgery literature threatens the clinical relevance of studies employing these technologies. This paper examines some of the core principles of assessing neuropsychological outcomes following epilepsy surgery and explores how these may be adapted and applied in fMRI study designs to maximize the clinical relevance of these studies.