Back to Journal

SM Journal of Neurology and Neuroscience

Periictal MRI Findings of Hypervascularity with Restricted Diffusion Contralateral to Gaze Deviation

[ ISSN : 2573-6728 ]

Abstract Introduction Case Report References
Details

Received: 25-Sep-2017

Accepted: 13-Oct-2017

Published: 16-Oct-2017

Rita S Marshall¹*, Sharon Kim and Mary Zupanc

¹Child Neurology PGY 5, Children’s Hospital of Orange County, USA

Corresponding Author:

Rita S Marshall, Child Neurology PGY 5, Children’s Hospital of Orange County, USA, Tel: +1 714-997-3000; Email: shahrk@uci.edu

Abstract

We present a case report of a child who had a seizure that began during a Magnetic Resonance Image (MRI) scan of her brain. The MRI showed restricted diffusion on Apparent Diffusion Coefficient (ADC) and increased perfusion on Maximum Imaging Projection (MIP) sequence correlating with the area of ictal discharges on electroencephalogram (EEG). Neuroimaging has become crucial in the diagnosis and understanding of seizures, however correlating it with an acute seizure is seldom able to be obtained. In particular, MRI sequences such as Diffusion Weighted Image (DWI), ADC, fluid attenuated inversion-recovery (FLAIR) and MIP images have proven useful in determining the extent and severity of cortical injury in various disease processes.

Introduction

It has long been known that hemodynamic changes occur in the brain during a seizure. In periictal MRI, changes in intracerebral perfusion dynamics have allowed us to localize and determine etiologies for epilepsy, although it is difficult to come across such studies given the unpredictable nature of seizures. Due to timing, it is difficult to understand what is happening in the anatomical brain during a seizure. However, we present a case of a seizure that started during an MRI scan. Seizure semiology may help lateralize the seizure focus, as shown by a cohort study which found that unilateral head/eye deviation predicted contralateral ictal focus in 67% of seizures[1]. One study described hyper-perfusion changes in areas involved in focal epilepsy with notable changes on DWI and ADC[2]. Huang et al, found that serial DWI and FLAIR images proved useful in determining the extent and severity of early neuronal damage associated with epileptic discharges in patients with status epilepticus[3]. These findings were also supported by Bonaventura et al. who described transient DWI changes in the area of seizure focus which took up to 90 days to resolve once the seizures resolved [4].

Case Report

A 5-year-old girl was brought to the Emergency Department (ED) for new onset seizures. She was a previously healthy, fully vaccinated and developmentally normal child. Two days prior to admission she developed vomiting, diarrhea and poor appetite. At home, she was lying next to her father on the couch when he woke up and found her unresponsive, with stiff extremities and her eyes open and rolled back. The episode lasted about 10-15 minutes. She was taken to the nearest ED for evaluation. Her parents denied any tonic clonic activity, no urinary incontinence, no tongue biting. She had a temperature of 38.4 C and was admitted for observation. A lumbar puncture revealed an elevated WBC of 22 (Neutrophils 17%, Lymphocytes 61%) with 1 RBC, a protein of 22 mg/dl and glucose of 66 mg/dl. Upon admission, the patient had a similar episode of body stiffening requiring two doses of lorazepam 1mg/kg and a fosphenytoin load of 20mg/Kg. The following day an EEG revealed mild to moderate generalized background slowing without paroxysmal activity. Levetiracetam was initiated at a dose of 30mg/kg/day divided twice daily. On day two of admission, she continued to have altered mental status with new onset of non-purposeful movements of her extremities and could not follow simple commands.

An MRI brain with and without contrast was ordered for further evaluation (Figure 1A, 1B, 1C). She required light sedation for the MRI and therefore was taken to the Post Anesthesia Care Unit (PACU) upon completion of the study. Upon arrival to PACU, she was noted to unresponsive with forced eye deviation to the left. The episode resolved with an emergent dose of lorazepam 2mg and a fosphenytoin load of 20mg/kg. Continuous video EEG monitoring was initiated and showed right fronto-temporal Periodic Lateralizing Epileptiform Discharges (PLEDS) (Figure 2). A review of the MRI was significant for restricted diffusion, mostly on the right side compared to the left, concerning encephalitis versus ictal changes given the distribution, however there was also a consideration of an ischemic insult, though less likely. MRI susceptibility weighted sequence demonstrated darker vessels throughout the right hemisphere compared to the left indicative of increased blood flow in the right hemisphere. The MRI, EEG and clinical findings support a diagnosis of encephalitis with ictal changes and suggest that she likely began seizing during her MRI scan.

Figure 1A: T1 weighted images of her MRI brain were unremarkable.

Figure 1B: ADC shows restricted diffusion in the right hemisphere.

Figure 1C: MIP demonstrating increased perfusion in the right hemisphere.

Figure 2: EEG: Right fronto-temporal Periodic Lateralized Epileptiform Discharges (PLEDS): Rhythmic spike and wave discharges were seen in the right hemisphere, maximum in the right temporal head region T4/T6, about once per second.

Over her hospital course, the patient had progressively worsening encephalopathy with seizures requiring multiple rescue medications and was eventually started on phenobarbital and fosphenytoin maintenance, along with continuing her levetiracetam. She also developed Increased Intracranial Pressure (ICP) with max pressure of 30mmHg, requiring multiple doses of mannitol, versed, fentanyl and eventually vecuronium to bring her ICP to less than 15 mmHg. After achieving seizure control her fosphenytoin was discontinued and she was maintained on phenobarbital and levetiracetam which she continued upon hospital discharge. To date, the cause of her encephalitis remains unknown, with negative serum and CSF bacterial, fungal and viral cultures. However, the patient is now able to participate in activities of daily living, speaks in full sentences, is attending school and is seizure free. She continues to have mild behavioral difficulties and inattention issues, but is responding well to therapy.

References

1. Di Bonaventura C, Bonini F, Fattouch J, Mari F, Petrucci S, Carnì M, et al. Supplement – Italian League against Epilepsy. Diffusion-weighted magnetic resonance imaging in patients with partial status epilepticus. Epilepsia. 2009; 50: 45-52.

2. Szabo K, Poepel A, Pohlmann-eden B, Hirsch J, Back T, Sedlaczek O, et al. Diffusion-weighted and perfusion MRI demonstrates parenchymal changes in complex partial status epilepticus. Brain. 2005: 1369-1376.

3. Briellmann RS, Wellard RM, Jackson GD. Seizure-associated Abnormalities in Epilepsy : Evidence from MR Imaging. Epilepsia. 2005; 46: 760-766.

4. Chaudhary UJ, Centeno M, Thornton RC. Mapping human preictal and ictal haemodynamic networks using simultaneous intracranial EEG-fMRI. NeuroImage Clin. 2016; 11: 486-493.

5. Cole AJ. Status Epilepticus and Periictal Imaging. Epilepsia. 2004; 45: 72-77.

6. Dupont S, Samson Y, Nguyen-Michel VH, Zavanone C, Navarro V, Baulac M, et al. Lateralizing value of semiology in medial temporal lobe epilepsy. Acta Neurol Scand. 2015; 132: 401-409.

7. García-Morales I, García MT, Galán-Dávila L, Gómez-Escalonilla C, SaizDíaz R, Martínez-Salio A, et al. Periodic lateralized epileptiform discharges: etiology, clinical aspects, seizures, and evolution in 130 patients. J Clin Neurophysiol. 2002; 19: 172-177.

8. Gil Moreno MJ, Martínez Menéndez B, Martínez Sarriés FJ, Ruiz Jiménez M. Status with periictal changes in cerebral magnetic resonance versus encephalitis. An Pediatr. 2013; 79: 337-339.

9. Kim J, Chung JI, Yoon PH. Transient MR Signal Changes in Patients with Generalized Tonicoclonic Seizure or Status Epilepticus: Periictal Diffusionweighted Imaging. 2001; 1149-1160.

10. Loehrer E, Vernooij MW, van der Lugt A, Hofman A, Ikram MA. Migraine and cerebral blood flow in the general population. Cephalalgia. 2015; 35: 190- 198.

11. Huang YC, Weng HH, Tsai YT, Huang YC, Hsiao MC, Wu CY, et al. Periictal magnetic resonance imaging in status epilecticus. Epilepsy Research. 2009; 86: 72-81.

12. Magiorkinis E, Aristidis D, Kalliopi S, Christos P. Highlights in the History of Epilepsy: The Last 200 Years. Epilepsy Research and Treatment. 2014.

Citation

Marshall RS, Kim S and Zupanc M. Periictal MRI Findings of Hypervascularity with Restricted Diffusion Contralateral to Gaze Deviation. SM J Neurol Neurosci. 2017; 3(3): 1015.

Other Articles

Article Image 1

Brain-derived neurotrophic factor (BDNF) Val66Met polymorphism and Obsessive Compulsive Disorder Risk

Brain-Derived Neurotrophic Factor (BDNF) is required for neuron growth and maintenance. Single nucleotide polymorphisms (SNP) are reported in BDNF gene, which reduces proteins activity, Val66Met polymorphism is very well studied and reported as a risk factor for psychiatric diseases. Numerous case-control studies have evaluated the role BDNF Val 66Met (dbSNP: rs6265;196G>A) polymorphism in OCD susceptibility and provided ambiguous findings, hence present meta-analysis was designed to get an exact association between BDNF Val66Met polymorphism and OCD risk. A total of 14 case - control articles were identified through PubMed, Google Scholar, Science Direct and Springer link databases search, up to July 11, 2024. Odds ratios (ORs) with 95% con¬fidence intervals (CIs) were used as association measure. All statistical analyses were done by MetaDiSc (version 1.4).

Fourteen case-control studies involving 2,765 OCD cases and 5,585 controls were included in present meta-analysis. The results showed that the BDNF Val66Met polymorphism was not associated with OCD risk (allele contrast odds ratio ORAvsG = 0.96, 95% CI= 0.82-1.12, p= 0.000; homozygote ORAAvsGG = = 0.79, 95%CI= 0.59-1.06, p= 0.0058; dominant model ORAA+GAvsGG = 0.96, 95%CI= 0.86-1. 06, p= 0.17). In conclusion, the BDNF Val66Met polymorphism was not related to increased OCD susceptibility.

Vandana Rai, Pradeep Kumar, and Abhishek Kannojiya*


Article Image 1

The F-Wave and H-Reflex Patterns with Increased Stimulus Intensity in Patients with Cerebrovascular Disease for the Neurological Evaluation of Affected Arm or Leg

The F-wave is a result of α-motor neurons backfiring following an antidromic invasion of propagated impulses across the axon hillock.

Suzuki T*


Article Image 1

A Typical Anatomy of the Hand Representation in Adults who Stutter

Atypical hand preference may be more common in Adults Who Stutter (AWS). One implication is that stuttering may be a manifestation of a more general dysfunction in motor organization and planning. This study was designed to determine whether AWS have atypical motor cortical anatomy compared to controls, and whether there are group differences in handedness that correlate with anatomical measures. Volumetric MRI was used to measure the anterior bank of the Central Sulcus (CS) and Motor Knob (MK), a structure that corresponds precisely to the motor hand representation, in Adults Who Stutter (AWS) and fluent, matched controls divided into three groups (right-handed and left-handed men, right-handed women). There was an interaction between fluency group and handedness-sex group (p=0.024) with reduced CS volume in right-handed men who stutter (p=0.001). For MK volume there was an interaction with the right MK larger in the left-handed male controls, and the left MK larger in the left-handed AWS (p=0.024). AWS and controls did not differ in hand preference score or finger tapping rate. There was a relationship between CS asymmetry and finger-tapping laterality (p=0.042) with a faster right-hand tapping speed associated with a larger left CS and vice-versa. When controls were examined independently, there were no correlations between finger-tapping laterality and anatomical asymmetry; there was a correlation in the AWS (r= 0.642; p= 0.007). Left hander AWS tapped faster with the right hand and had a larger left CS (atypical). One subgroup of right handed AWS (atypical) tapped faster with the left hand and had a larger right CS. Another subgroup of right handed AWS (typical) tapped faster with the right hand and had a larger left CS. These results show that handedness may systematically influence cortical motor representations in AWS. Further study is warranted in a larger sample of adults and in children who stutter.

Foundas LA¹*, Baucom CC², Knaus TA³, and Corey DM⁴


Article Image 1

Ischemic Stroke at Jordan University Hospital: A One-Year Hospital-Based Study of Subtypes and Risk Factors

Objective: To study the ischemic stroke subtypes and risk factors in 100 patients observed at Jordan University Hospital (JUH) over a one-year-period, and to compare the results with another 100 age-and –sex matched controls as well as with studies from other Arab countries.

Methods: One hundred patients with first-ever ischemic stroke admitted to JUH over a one-year period (between January 2013 to January 2014) were studied.

Results: There were 62 males and 38 females (M/F ratio=1. 6), with a mean age of 66 years (range 22-90 years), the majority (80/100) between the age 51-80 years. The most common stroke subtype was lacunar infarcts (36 patients). Fourty-two out of 51 patients had intracranial atherosclerosis. The most common risk factor was hypertension (85%) followed by hyperlipidemia (71%) and diabetes mellitus (65%).

Conclusion: In accordance with other Arab studies and controls, hypertension was the predominant risk factor but lacunar infarcts were more common than in most reports from other Arab countries . This shows the importance of appropriate management of hypertension to reduce the incidence of stroke in Jordan.

Bahou Y*, Ajour M, and Jaber M


Article Image 1

Longitudinal Language Changes Associated with MRI Anatomy in Children with Autism Spectrum Disorder

Background: Language ability is one of the strongest predictors of prognosis and developmental course in Autism Spectrum Disorder (ASD). A range of language abilities occur in ASD and although many have delays in language it remains unclear why some children’s language continues to lag, while others do not. Abnormal anatomy and function of language-related regions has been found in ASD, however, how these differences relate to language development over time is undetermined.

Methods: This study examined longitudinal changes in language functions in children with ASD and investigated whether cortical language region anatomy was related to these changes in language. Eighteen boys with ASD, 2-8 years old were evaluated (Time 1) and re-examined about 3.5 years later (Time 2) at ages 7-10. MRIs were collected at Time 2 to evaluate gray matter volume of anterior (Pars Triangularis, PTR; pars opercularis, POP) and posterior (Planum Temporale, PT; Posterior Superior Temporal Gyrus, pSTG) language regions and the microstructure of the arcuate fasciculus.

Results: Eleven boys had relative decline in language functions (decline group) and 7 boys had no relative change in language (no change group). The no change group had larger PT and right PTR volume relative to the decline group. In addition, the right PTR was correlated with the language change score, with larger right PTR associated with less language decline. There was a trend for non-right-handers to have more language decline than right-handers.

Conclusions: Results suggest differences in cortical language anatomy may play a role in language development, with further studies warranted.

Tracey A Knaus¹˒²*, Jodi Kamps³˒⁴, and Anne L Foundas⁵


Article Image 1

A New Analysis Method of F-Waves to Obtain

From the observation of different F-wave waveforms, we introduce a new method of differentiating these waveforms, by assigning each with an “F-wave waveform value”, which can be used in the clinic to evaluate the effects of rehabilitation. F-wave waveform values were determined by creating a window from minimum onset latency to maximum onset latency in measurable waveforms. We then calculated the correlation coefficient of each waveform, using Microsoft Excel, and identified F-waves as those with a correlation coefficient of greater than 0.9 or equal to 1.0. The number of different F-wave waveforms types was determined from the number of identified waveforms. We applied F-wave waveform values to evaluate neurophysiological change and the effects of rehabilitation following hemiplegia. In the future, F-wave waveform values should be considered as an important tool when assessing the effects of rehabilitation on impaired neurological responses.

Toshiaki Suzuki¹˒²*, Yoshibumi Bunno¹˒², Makiko Tani¹˒², Chieko Onigata², Yuuki Fukumoto¹, Marina Todo², Hirofumi Watanabe³, Toshihiro Ohnuma¹˒²˒³, and Naoko Komatsu³


Article Image 1

Neuroprotective Effect of Organic and Conventional White Grape Juice against Carbon Tetrachloride Damage in Different Brain Areas of Rats

The consumption of nutrients containing phenolic compounds has been reported due to the benefits they produce on human health. Therefore, the objective of this study was to investigate the antioxidant and neuroprotective effect of the administration of organic (OGJ) and conventional (CGJ) white grape juices from Niagara variety on the oxidative stress in cerebral cortex, hippocampus and cerebellum after the treatment with carbon tetrachloride (CCl4 ) as well as on some biochemical parameters in serum of rats. Adult male rats (~300g; n=6-8/group) were orally treated (gavage) with 7μL/g of OGJ, CGJ or water, for a period of 14 days. On the 15th day it was administered CCl4 (3.0mL/kg). After 4h the animals were euthanized and the cerebral cortex, hippocampus and cerebellum were dissected and used for the analysis of oxidative stress parameters. We observed that CCl4 enhanced lipid peroxidation (TBARS) and protein damage (carbonyl), reduced the nonenzymatic antioxidants defenses (sulfhydryl), and changed the activity of the enzymatic antioxidants defenses catalase (CAT), Superoxide Dismutase (SOD) in the brain of rats. CCl4 also enhanced glucose, Alanine Aminotransferase (ALT), Aspartate Aminotransferase (AST) and Gamma-Glutamyl (GGT) and decreased total cholesterol and High-Density Lipoprotein (HDL) in serum of rats. CGJ and OGJ were able to prevent or ameliorate most of these alterations. Consequently, regular intake of white grape juice could be considered as an adjuvant in the therapy of oxidative damages, revealing a possible antioxidant and neuroprotective agent.

Clarice M. Peripolli, Tatiane Gabardo, Fernanda de Souza Machado, Mariane Wohlenberg, Juliana D.O. Lima, Alice S. Oliveira, Marina Rocha Frusciante, Niara da Silva Medeiros, Sheila Pereira Feijó, Filipe V.V. Nascimento, Caroline Dani, and Cláudia Funchal


Article Image 1

Global Evidence for the Key Role of the Dopamine D2 Receptor Gene (DRD2) and DRD2 Receptors in Alcoholism

It has been over 27 years since Blum & Noble discovered the first association of the DRD2 A1 allele in severe alcoholism, suggesting reward as the real phenotype, not alcoholism. This has been acknowledged by an explosion of research in the arena of Psychiatric Genetics. To date, a PubMed search listed 6,839 studies (5-15- 17). The A1 allele has been associated with substance use disorders other than alcoholism, including cocaine, nicotine dependence, polysubstance abuse and many Reward Deficiency Syndrome (RDS) behaviors substance and non-substance related. Certainly following extensive controversy, the emerging evidence suggests that the DRD2 is a reinforcement or reward gene. In fact, it could represent one of the most prominent single-gene determinants of susceptibility to severe substance abuse/reward deficiency. While, however, the environment through epigenetic impact and other genes, when combined, still play the larger role, targeting the DRD2 gene through the novel genetic rewriting of the DNA code at the mRNA level may hold the greatest promise to date for potentially “curing” the RDS phenotype.

Kenneth Blum¹⁻⁹˒¹²*, Mark S Gold²˒¹⁵, Lloyd G Mitchell¹⁰˒¹¹, Kareem W Washington¹⁰, David Baron², Panayotis K Thanos¹³, Bruce Steinberg¹⁴, Edward J Modestino¹⁴, Lyle Fried⁷, and Rajendra D Badgaiyan¹²


Article Image 1

Depression in Alzheimer

Background: Pharmacological treatment for AD and depression are unfortunately few and of limited efficacy to cure the disease.

Objectives: To assess the combined effects of rivastigmine and citalopram on Alzheimer’s Disease.

Methods: Longitudinal clinical prospective study with 1278 AD patients on rivastigmine 9,5mg/patch and citalopram 20-40 mg/day over 48 months was assessed on the basis of NINCDS-ADRDA, MMSE, DSM-IV, FRSSD, GDS, HRS-D and follow up of the patients.

Results: Four years after the baseline assessment, there were no significant differences in MMSE, Geriatric depression scale and Hamilton rating scale for depression between patients treated with rivastigmine alone or combined rivastigmine with citalopram with or without depression (p>0.05). Functional Rating Scale for symptoms of dementia, Activities of Daily Living of patients with AD and depression treated with rivastigmine was significantly worse than patients treated with rivastigmine and no depression (p=0.027).

Conclusions: The combination of rivastigmine and citalopram had no better results than rivastigmine alone in patients with AD.

Magda Tsolaki*, Krishna Prasad Pathak, Eleni Verikouki, Chaido Zchou Messini, Tara Gaire, and Paschalis Devranis


Article Image 1

Anxiety and Its Features in Parkinson

Anxiety is one of the most clinically significant psychiatric syndromes in Parkinson’s Disease (PD). It is estimated to affect up to 50% of individuals with PD and is associated with higher levels of dependency and poorer quality of life. Although it is common, it remains widely under recognised by patients, carers and clinicians, and has not been extensively studied [1]. Therefore, in spite of its significant impact, the symptomatology, chronology, and neurobiology of anxiety in PD are not well understood.

Recently, anxiety in PD has been associated with increases in motor fluctuations and gait disturbances including freezing. Freezing of gait (FOG) is the temporary inability to walk and is one of the most debilitating symptoms of PD. It is associated with an increase in falls, injuries and dependency. The associations with motor symptoms have significant consequences for the quality of life of people living with PD. This review summarizes the most recent data on the epidemiology, associated features and possible mechanisms underlying anxiety in PD.

Perri Carlson-Hawke¹˒²*, Belinda Brown², and Simon Hammond¹