Seizures

Q1: What are the common intra cranial conditions causing seizures that would benefit from imaging studies?

• Head trauma
  • Perinatally
  • Depressed skull fracture
  • Intra cerebral/subdural hematoma
• Stroke or vascular malformation
  • Stroke—5-15% in cerebral cortex
  • AVM—without rupture, can cause seizures secondary to local irritation
• Mass lesions
  • Brain tumor-glioblastoma, astrocytoma, meningioma
• Abscess
• Meningitis/encephalitis
• Neurocysticercosis

Q2: Most patients with seizures do not require imaging studies. Which clinical presentations of seizure would warrant imaging study?

• Seizure with clearly focal onset or seizures that begin after age 25 require prompt evaluation to rule out mass lesion (MRI)
• Seizure with abnormal neurological exam
• Progressively worsening seizures

Q3: What are the available imaging procedures for evaluation of seizures?

• MRI and CT can be used, but MRI is superior.
• PET-can help identify focal areas of hypometabolism in temporal lobe as likely origin of seizures (for surgical candidates with medically refractory epilepsy)

Case 1

A 14-year old, previously healthy, male abruptly lost consciousness and fell to the floor.  His muscles stiffened then began jerking and twitching for about two minutes, a period followed by a sleep-like state.  Labs were normal and EEG was abnormal and demonstrated a pattern suggestive of a generalized seizure disorder.

Are imaging procedures necessary for this patient?  If so, what would you order?

Immediately, probably not since in a healthy child this age, it is most likely an idiopathic epileptic seizure. However, out of concern for something uncommon and when dealing with a child, he would probably have a MRI performed.

What is your diagnosis?

Generalized tonic-clonic seizure

Case 2

8 year old boy with 1.5 yr history of seizures. Seizures resolved with medical treatment. No imaging performed. Seizures recurred 3 months ago. Depakote restated. Seizures persisted.

Imaging obtained

• MRI revealed large left anterior frontal hemorrhagic lesion with two contiguous foci and surrounding edema. A third lesion in left corona radiata is also seen.
• MR angio . Lesion consistent with AVM vs cavernoma.

Case 3

A 66 year-old lady presents with a first episode of generalized clonic seizure starting as rhythmical jerking muscle contractions of the arms, neck, and face. Post ictally she complained of numbness involving the left upper and lower extremities. 

Are imaging procedures necessary for this patient?  If so, what would you order?

Yes, MRI

What is your concern?

Mass lesion/tumor

 

 

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