Adrian Budhram1,2, Jeffrey W Britton3, Greta B Liebo4, Divyanshu Dubey3,5, Anastasia Zekeridou3,5, Eoin P Flanagan3,5, Andrew McKeon3,5, Sean J Pittock3,5, Sherri A Braksick3, Nicholas L Zalewski3. 1. Department of Neurology, Mayo Clinic, 200 1st St SW, Rochester, MN, 55905, USA. adrian.budhram@medportal.ca. 2. Department of Clinical Neurological Sciences, London Health Sciences Centre, Western University, London, ON, Canada. adrian.budhram@medportal.ca. 3. Department of Neurology, Mayo Clinic, 200 1st St SW, Rochester, MN, 55905, USA. 4. Department of Radiology, Mayo Clinic, Rochester, MN, USA. 5. Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA.
Abstract
OBJECTIVE: To determine whether diffusion-weighted imaging (DWI) can help differentiate peri-ictal signal abnormality from limbic encephalitis (LE) among patients with medial temporal lobe T2-hyperintensity. METHODS: We retrospectively identified patients with peri-ictal medial temporal lobe T2-hyperintensity using a Mayo Clinic database, and reviewed their DWI to look for unique diffusion restriction patterns. We then identified patients with medial temporal lobe T2-hyperintensity and LE, and reviewed their DWI to see if these patterns were ever present. Presence of diffusion restriction patterns was confirmed by a blinded neuro-radiologist. RESULTS: We identified 10 patients without LE who had peri-ictal unilateral medial temporal lobe T2-hyperintensity, ipsilateral to focal seizure onset. Nine of 10 (90%) had at least one of two diffusion restriction patterns potentially unique to seizure activity; four had gyriform hippocampal diffusion restriction ("Pattern 1"), three had diffuse hippocampal diffusion restriction that spared the most medial temporal lobe structures ("Pattern 2"), and two had both diffusion restriction patterns. The median patient age was 62 years (range 2-76 years) and 3/9 (33%) were female. In comparison, among patients with medial temporal lobe T2-hyperintensity and LE, only 5/57 (9%) had one of the diffusion restriction patterns ("Pattern 2") identified (P < 0.0001); all five had seizures reported. CONCLUSIONS: In patients with medial temporal lobe T2-hyperintensity and one of the diffusion restriction patterns described herein, the signal abnormality may be a peri-ictal phenomenon rather than indicative of LE and should prompt investigation for seizure. Even in patients with LE, these patterns should raise concern for seizure.
OBJECTIVE: To determine whether diffusion-weighted imaging (DWI) can help differentiate peri-ictal signal abnormality from limbic encephalitis (LE) among patients with medial temporal lobe T2-hyperintensity. METHODS: We retrospectively identified patients with peri-ictal medial temporal lobe T2-hyperintensity using a Mayo Clinic database, and reviewed their DWI to look for unique diffusion restriction patterns. We then identified patients with medial temporal lobe T2-hyperintensity and LE, and reviewed their DWI to see if these patterns were ever present. Presence of diffusion restriction patterns was confirmed by a blinded neuro-radiologist. RESULTS: We identified 10 patients without LE who had peri-ictal unilateral medial temporal lobe T2-hyperintensity, ipsilateral to focal seizure onset. Nine of 10 (90%) had at least one of two diffusion restriction patterns potentially unique to seizure activity; four had gyriform hippocampal diffusion restriction ("Pattern 1"), three had diffuse hippocampal diffusion restriction that spared the most medial temporal lobe structures ("Pattern 2"), and two had both diffusion restriction patterns. The median patient age was 62 years (range 2-76 years) and 3/9 (33%) were female. In comparison, among patients with medial temporal lobe T2-hyperintensity and LE, only 5/57 (9%) had one of the diffusion restriction patterns ("Pattern 2") identified (P < 0.0001); all five had seizures reported. CONCLUSIONS: In patients with medial temporal lobe T2-hyperintensity and one of the diffusion restriction patterns described herein, the signal abnormality may be a peri-ictal phenomenon rather than indicative of LE and should prompt investigation for seizure. Even in patients with LE, these patterns should raise concern for seizure.
Entities:
Keywords:
Diffusion-weighted imaging; Limbic encephalitis; Magnetic resonance imaging; Peri-ictal; Seizure
Authors: Gregory S Day; Melanie Y Yarbrough; Peter Körtvelyessy; Harald Prüss; Robert C Bucelli; Marvin J Fritzler; Warren Mason; David F Tang-Wai; Claude Steriade; Julien Hébert; Rachel L Henson; Elizabeth M Herries; Jack H Ladenson; A Sebastian Lopez-Chiriboga; Neill R Graff-Radford; John C Morris; Anne Fagan Journal: Neurology Date: 2021-04-01 Impact factor: 9.910