Department of Clinical Radiology and Neuroradiology, University Hospital Muenster, Albert-Schweitzer-Campus 1, Building A1, 48149, Muenster, Germany.
Department of Clinical Radiology, University Hospital Muenster, Albert-Schweitzer-Campus 1, Gebäude A1, 48149, Muenster, Germany.
BMC Neurol. 2020 Mar 24;20(1):108. doi: 10.1186/s12883-020-01665-9.
In the emergency setting of acute ischemic stroke, seizures have been reported in up to 4% of patients. In the absence of arterial occlusion, seizures may also cause abnormalities in CT perfusion in 78% of cases when the time window from onset to imaging is short. Both hyperperfusion and hypoperfusion in the postictal state have been described. Also, though rarely reported, postictal perfusion changes can be uni-hemispheric. In these cases, perfusion maps should be analyzed thoroughly, since perfusion reconstruction software relies heavily on a "normal" contralateral perfusion status.
A 39-year-old man was found on the ground with a minor head injury. On admission, his reactions were generally slow, but there were no other neurological symptoms, and blood pressure was low. The patient had a history of primary generalized epilepsy and admitted to dropping off his anti-epileptic medication. He was transferred to the radiological department for imaging but shortly before began to experience generalized onset tonic-clonic seizures which were brought under control by intravenous therapy with 10 mg diazepam. After approximately 15 min, a multimodal CT scan was performed, revealing marked changes in the perfusion of the brain hemispheres and posterior fossa, with sharp delimitation at the midline. Blood gas analysis was congruent with respiratory acidosis. Clinically, the patient remained awake without developing any new symptoms. He gradually recovered over the following 3 h and, against our medical recommendation, discharged himself from the hospital.
To the authors' knowledge, this is the first report of an early postictal state describing sharply delimited uni-hemispheric hyperperfusion and hemispheric alteration of the cerebellum with an equally split rhombencephalon. Surprisingly, these changes were not associated with any focal neurological signs. To prevent misdiagnosis of perfusion alterations in seizures, radiologists and neurologists should be aware of the limitations of CT perfusion maps and software reconstructions. Novel use of CT perfusion reconstruction using peak enhancement helped in identifying the cerebral pathology.
在急性缺血性脑卒中的急诊环境中，高达 4%的患者会出现癫痫发作。在没有动脉阻塞的情况下，如果从发病到成像的时间窗口较短，78%的情况下癫痫发作也可能导致 CT 灌注异常。在发作后状态下，既可以出现高灌注，也可以出现低灌注。此外，尽管很少有报道，但发作后灌注改变也可以是单侧的。在这些情况下，应该仔细分析灌注图，因为灌注重建软件严重依赖于“正常”对侧灌注状态。
一名 39 岁男子被发现躺在地上，头部有轻微损伤。入院时，他的反应普遍较慢，但没有其他神经系统症状，且血压较低。该患者有原发性全身性癫痫病史，并承认停止服用抗癫痫药物。他被转至放射科进行影像学检查，但在转科前不久开始出现全身性强直阵挛性癫痫发作，通过静脉注射 10mg 地西泮控制发作。大约 15 分钟后，进行了多模态 CT 扫描，显示大脑半球和后颅窝的灌注明显改变，中线处界限分明。血气分析与呼吸性酸中毒一致。临床检查中，患者保持清醒，没有出现任何新的症状。他在接下来的 3 小时内逐渐恢复，尽管我们建议留院观察，但他还是自行出院了。
据作者所知，这是首例描述发作后早期出现界限分明的单侧高灌注和小脑半球双侧改变以及等份分割的脑桥的病例。令人惊讶的是，这些改变与任何局灶性神经体征无关。为了防止在癫痫发作中误诊灌注改变，放射科医生和神经科医生应该意识到 CT 灌注图和软件重建的局限性。使用峰值增强的 CT 灌注重建的新方法有助于识别脑部病变。
