Abstracts

Rationale: Nonketotic hyperglycemia (NKH) –related seizures are increasingly recognized. The most common NKH-related seizure type is focal motor seizures and epilepsia partialis continua, but occipital lobe seizures, temporal lobe seizures, and generalized seizures have also been reported (Maccario, Messis et al. 1965, Harden, Rosenbaum et al. 1991, Batista, Silva et al. 1998). In contrast to classical MR findings of seizure, MR imaging of these patients may show transient T2/FLAR white matter hypointensity involving the parietal lobe, the parieto-occipital lobe, or rarely, the precentral gyrus (Goto, Kumagai et al. 2011, Lee, Kim et al. 2016, Nissa, Siddiqi et al. 2016). This specific associated imaging feature has not been reported in the prefrontal cortex. Methods: We present a case of NKH–related focal seizures with associated transient T2 white matter hypointensity in the prefrontal cortex on MRI. We discuss the history and presentation, hospital course, imaging and EEG findings, treatment, follow up, and review of the literature. Results: A 56-year-old female presented with multiple electroclinical focal seizures with impaired awareness in the setting of hyperglycemia and elevated HbA1c of 14.7%. She had varying seizure semiology, consisting of early forced head turn to the left and speech arrest, left facial twitching and altered mental status MRI showed T2/FLAIR hypointensity in the right frontotemporal white matter, most prominently in the prefrontal cortex (image 1). EEG long-term monitoring revealed multiple seizures arising from the right frontotemporal region, spreading to the neighboring channels and then involving the left hemisphere (image 2). She was treated with insulin, but levetiracetam and lacosamide were added due to continuous seizure activity. Repeat MR imaging of the brain two months after discharge showed resolution of the white matter T2/FLAIR hypointensities. Patient has been seizure free for 6 months and anti-seizure medications are slowly being weaned. Conclusions: MR T2/FLAIR white matter hypointensity in the setting of focal seizure or altered mental status should raise suspicion for NKH-related seizures. The imaging abnormalities are usually transient and may be located in the prefrontal cortex, in addition to the previously described regions. Acutely, these patients may require anti-seizure medications as seizures may continue despite an optimal treatment of hyperglycemia. Funding: No funding