Abstracts

Rationale: Reversible periictal MRI abnormalities have been recently studied and are believed to be the consequence of the epileptic activity rather than its cause (2) and the prevalence is very low 0.007%. Usually manifested as gray and white matter signal changes, focal gray matter swelling, white matter edema, mass effect and leptomeningeal enhancement,(2), but restricted diffusion changes have been also reported. Gadolinium-enhanced T2-weighted fluid-attenuated inversion-recovery (FLAIR) imaging (GEF) has shown increased sensitivity for detection of both parenchymal and leptomeningeal disease. This case illustrates findings seen with GEF not previously recognized in acute seizure. Methods: Case report with neuroimaging and review of the literature. Results: 69 yo male with history of diabetes, found down with altered mental status. On arrival to the ER he had a witnessed generalized seizure. Results of an examination were consistent with fluctuating receptive aphasia and mild right sided hemiparesis. Electroencephalogram (EEG) showed frequent left hemispheric PLEDs which was aggressively treated as seizures and his aphasia and hemipareis improved. A cerebrospinal fluid sample contained elevated protein 220 and a WBC of 14 with 91% neutrophil predominance.His work up included magnetic resonance imaging which revealed on the T2-weighted post contrast FLAIR images, abnormal subarachnoid space and leptomeningeal enhancement and adjacent cortical signal hyperintensity in the left cerebral hemisphere and less so in the high right parietal hemisphere as well as some mild enhancement in the left prepontine leptomeninges/subarachnoid space. A follow up Magnetic resonance imaging study was performed within a week and about 3 days after electrographical improvement showing almost complete resolution of the increased signal on post-constrast T2 FLAIR from the left cerebral hemisphere. Conclusions: T2 FLAIR with gadolinium may be more sensitive in demonstrating previously unrecognized MRI findings in the periictal state. These reversible periictal MRI abnormalities are recently believed to be the consequence of the epileptic activity rather than its cause and needs strongly to be in consideration.