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We investigated whether integrating quantitative spatial patterns of regional atrophy and hypometabolism, along with clinical features, could provide complementary prognostic information for postoperative seizure freedom. T1\u2010weighted MRI,\n                    <jats:sup>18<\/jats:sup>\n                    F\u2010FDG\u2010PET, and postoperative CT scans of patients with TLE\u2010HS were retrospectively analyzed against a validated healthy control cohort to compute age\u2010 and gender\u2010adjusted\n                    <jats:italic>W<\/jats:italic>\n                    \u2010score maps. Regional relationships of atrophy and hypometabolism were assessed using bivariate correlations and multiple regression analyses. Machine learning models integrating laterality of seizure onset, preoperative (extra\u2010)temporal atrophy\/hypometabolism extent, seizure frequency, focal to bilateral tonic\u2013clonic seizures during the preceding year, and resection volume were developed to predict seizure freedom 1\u2009year after surgery. Model interpretability was assessed via permutation\u2010based variable importance analysis. The cohort comprised 101 patients with TLE\u2010HS (48 left, LHS; 53 right, RHS), including 72 patients who underwent anterior temporal lobectomy. Distinct modality\u2010specific patterns emerged: hypometabolism was significantly greater than local atrophy in left temporo\u2010limbic cortex in TLE\u2010LHS, while atrophy exceeded hypometabolism in bilateral occipital regions in TLE\u2010RHS. Positive correlations between local atrophy and hypometabolism were more robust in ipsilateral temporo\u2010limbic cortex in TLE\u2010LHS. The combined model integrating preoperative atrophy and hypometabolism features (AUC: 0.56\u20130.64) significantly outperformed single\u2010modality models (\n                    <jats:italic>p<\/jats:italic>\n                    <jats:sub>fdr<\/jats:sub>\n                    &lt;\u20090.05). Notably, incorporating clinical factors further enhanced predictive performance (AUC: 0.63\u20130.70) and model calibration. This comprehensive preoperative clinical\u2010imaging model achieved robust prognostic efficacy that was not significantly improved by the addition of actual postoperative resection volumes. Structural MRI and\n                    <jats:sup>18<\/jats:sup>\n                    F\u2010FDG\u2010PET reveal complementary facets of the epileptogenic network in TLE\u2010HS. While integrating multimodal imaging with clinical metrics demonstrates significant synergistic potential for predicting surgical outcomes, our models remain exploratory. External validation in independent multi\u2010center cohorts is required before translating these findings into precise clinical tools for surgical planning.\n                  <\/jats:p>","DOI":"10.1002\/hbm.70630","type":"journal-article","created":{"date-parts":[[2026,8,13]],"date-time":"2026-08-13T10:40:51Z","timestamp":1786617651000},"update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["The Spatial Divergence of Hypometabolism and Atrophy in Mesial Temporal Lobe Epilepsy: Combining\n                    <scp>\n                      <sup>18<\/sup>\n                      F\n                    <\/scp>\n                    \u2010\n                    <scp>FDG PET<\/scp>\n                    and Structural\n                    <scp>MRI<\/scp>\n                    for Predicting Postoperative Seizure Freedom"],"prefix":"10.1002","volume":"47","author":[{"given":"Yuming","family":"Li","sequence":"first","affiliation":[{"name":"Department of Neurology West China Hospital of Sichuan University  Chengdu China"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-4286-8417","authenticated-orcid":false,"given":"Fanglan","family":"Li","sequence":"additional","affiliation":[{"name":"Department of Nuclear Medicine West China Hospital of Sichuan University  Chengdu China"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Danyang","family":"Cao","sequence":"additional","affiliation":[{"name":"Department of Neurology West China Hospital of Sichuan University  Chengdu China"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Qiuxing","family":"Lin","sequence":"additional","affiliation":[{"name":"Department of Cerebrovascular Disease Fujian Medical University Union Hospital  Fuzhou Fujian China"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Peiwen","family":"Liu","sequence":"additional","affiliation":[{"name":"Department of Neurology West China Hospital of Sichuan University  Chengdu China"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Wei","family":"Li","sequence":"additional","affiliation":[{"name":"Department of Gerontology West China Hospital of Sichuan University  Chengdu China"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Yingying","family":"Zhang","sequence":"additional","affiliation":[{"name":"Department of Neurology West China Hospital of Sichuan University  Chengdu China"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Xiang","family":"Huang","sequence":"additional","affiliation":[{"name":"Department of Neurology West China Hospital of Sichuan University  Chengdu China"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-7666-9558","authenticated-orcid":false,"given":"Kailing","family":"Huang","sequence":"additional","affiliation":[{"name":"Department of Neurology West China Hospital of Sichuan University  Chengdu China"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Wenhao","family":"Li","sequence":"additional","affiliation":[{"name":"Department of Neurology West China Hospital of Sichuan University  Chengdu China"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Xiuli","family":"Li","sequence":"additional","affiliation":[{"name":"Huaxi MR Research Center, Department of Radiology West China Hospital of Sichuan University  Chengdu China"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Rang","family":"Li","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery West China Hospital of Sichuan University  Chengdu China"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Xiutian","family":"Sima","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery West China Hospital of Sichuan University  Chengdu China"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-5912-4871","authenticated-orcid":false,"given":"Qiyong","family":"Gong","sequence":"additional","affiliation":[{"name":"Huaxi MR Research Center, Department of Radiology West China Hospital of Sichuan University  Chengdu China"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-7101-4125","authenticated-orcid":false,"given":"Dong","family":"Zhou","sequence":"additional","affiliation":[{"name":"Department of Neurology West China Hospital of Sichuan University  Chengdu 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