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Images in Neurology |

Restricted Diffusion on Magnetic Resonance Imaging in Partial Status Epilepticus

Teresa Buracchio, MD; Steven L. Lewis, MD; Miral Jhaveri, MD; Donna Bergen, MD
Arch Neurol. 2008;65(2):278-279. doi:10.1001/archneurol.2007.54.
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An 82-year-old woman with hypertension and bipolar disorder was admitted with new-onset generalized tonic-clonic seizures. On admission, magnetic resonance imaging (MRI) results were normal and electroencephalography showed right posterior quadrant slowing. She was started on valproic acid. One week later, she was found to have a left hemiparesis and 20 hours of continuous rhythmic jerks of the left leg, arm, and abdomen with retained consciousness, consistent with partial status epilepticus. Magnetic resonance imaging (Figure 1) showed restricted diffusion in the right parietal, occipital, and medial frontal cortices, with corresponding low signal on apparent diffusion coefficient maps. Magnetic resonance angiography results were normal. Electroencephalography (Figure 2) showed right posterior quadrant epileptiform activity that correlated with the area of restricted diffusion. The seizures and hemiparesis resolved after treatment with phenytoin and lorazepam. Repeat MRI 4 weeks later showed resolution of the diffusion abnormality and near-complete resolution of the hyperintensities seen on fluid-attenuated inversion recovery images.

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Figure 1.

Diffusion-weighted magnetic resonance images during partial status epilepticus show restricted diffusion in a gyriform pattern in the right parietal and occipital cortices (A), with resolution of the diffusion-weighted image abnormality on follow-up 4 weeks later (B). Fluid-attenuated inversion recovery images during partial status epilepticus show hyperintensities in the same regions (C), with near-complete resolution on follow-up 4 weeks later (D). Similar findings were also seen in the right medial frontal cortex (not shown). The presence of diffusion-weighted image abnormalities in multiple vascular distributions is suggestive of ictal or postictal restricted diffusion rather than an acute infarct. D, The interval development of a subdural hematoma due to an intercurrent fall is incidentally noted on the follow-up fluid-attenuated inversion recovery image.

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Figure 2.

Electroencephalography performed immediately after lorazepam infusion shows focal slowing and multifocal sharp waves (arrows) in the right posterior quadrant correlating with the area of restricted diffusion seen on magnetic resonance imaging.

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