MRI, PET, and SPECT are all used to image abnormalities in the epileptic brain. Comparison of the techniques is difficult because they measure different aspects of the epileptic process--structure, metabolism, and perfusion. SPECT is the only one that can be systematically applied during seizures, while all three are used to image interictal abnormalities. Literature review suggests that of interictal techniques, PET has the highest diagnostic sensitivity in temporal lobe epilepsy (TLE) (84% vs. 66% for SPECT, 55% for qualitative MRI, 71% for quantitative MRI) while SPECT has the highest sensitivity in extratemporal epilepsy (ETE) (60% vs. 43% for MRI and 33% for PET). The highest diagnostic sensitivity and specificity were achieved by ictal imaging with SPECT (90% in TLE, 81% in ETE). The techniques, however, were not always redundant. One reason for the wide discrepancy of results in TLE and ETE might be the differing pathologic substrates. A literature review of imaging findings associated with mesial temporal sclerosis (MTS), developmental lesion or tumor as the underlying abnormality associated with epilepsy supports this explanation. PET and MRI are much more sensitive to MTS than SPECT (100%, 95% vs. 70%). On the other hand, in developmental lesions the three techniques are equally sensitive (88-92%) and in tumors, MRI was most sensitive (96%) and SPECT least (82%). A study at NIH explains the differing sensitivities: using PET to measure both blood flow and metabolism revealed discrepant findings in the same patients. Preliminary evidence also indicates that the distribution of hyperperfusion on ictal SPECT can differentiate subtypes of TLE. Combining the results of refined imaging techniques holds great promise in epilepsy localization and diagnosis.