Rinsho Shinkeigaku (Clinical Neurology)

Case Report

A case of epileptic seizure that required differentiation from hyper-acute ischemic stroke:
usefulness of comparing DWI and FLAIR

Ryusuke Kizawa1), Takeo Sato, M.D.2), Tadashi Umehara, M.D., Ph.D.2), Teppei Komatsu, M.D., Ph.D.2), Shusaku Omoto, M.D., Ph.D.2) and Yasuyuki Iguchi, M.D., Ph.D.2)

1) The Jikei University School of Medicine
2) Department of Neurology, The Jikei University School of Medicine

A 60-year-old man developed aphasia and transient right upper limb paresis in the presence of chronic subdural hematoma and was transferred to our hospital at an early stage. Cranial MRI within an hour after onset showed diffusion-weighted image (DWI) hyperintensity in the left parietal, temporal, and insular cortex and the pulvinar, and decreased apparent diffusion coefficient (ADC) in the left parietal cortex and pulvinar, suggesting a differential diagnosis of hyper-acute ischemic stroke. However, the distribution and timing of the MRI abnormalities were considered to be atypical for hyper-acute ischemic stroke. The area with both DWI hyperintensity and decreased ADC included the cerebral cortex adjacent to the hematoma and the ipsilateral pulvinar, and fluid-attenuated inversion recovery (FLAIR) hyperintensity co-existed with DWI hyperintensity within only an hour from onset. Furthermore, FLAIR images showed infiltration of the hematoma content into the subarachnoid space, which might have triggered the attack. These findings collectively led us to diagnose an epileptic seizure. The present case suggests that the distribution and timing of MRI abnormalities are essential to differentiate epileptic seizures from hyper-acute ischemic stroke.
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(CLINICA NEUROL, 61: 166−171, 2021)
key words: epileptic seizure, chronic subdural hematoma, hyper-acute ischemic stroke, MRI

(Received: 16-Jun-20)