PMC9052233_01
Cerebral MRI images of Patient 1 at age 7 years old. DWI (Figure 1A), ADC (Figure 1B), and T2 FLAIR (Figure 1C) images demonstrate subtle restricted diffusion involving the right occipital cortex and the immediately subjacent subcortical white matter, consistent with an acute ischemic cerebrovascular accident.
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At the age of 7 years, the patient had another seizure and brain MRI showed subtle restricted diffusion involving the right occipital cortex, indicative of an acute ischemic cerebrovascular accident (Figure 1).
Cerebral MRI images of Patient 1 at age 11 years old. DWI (Figures 2A, 2B), ADC (Figures 2C, 2D), and T2 FLAIR (Figure 2E) images demonstrate signal abnormalities in the left temporal, parietal, frontal, and lateral occipital lobes, consistent with acute or subacute ischemia.
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ED with sudden-onset right sided weakness after a seizure, and brain MRI demonstrated acute ischemic cerebrovascular accident (Figure 2). EEG at this time demonstrated moderate to severe background slowing, slowing of the left hemisphere more prominently in the temporal and occipital areas, and multiple subclinical focal seizures in the left temporo-occipital area with rare extension to the frontal electrodes.
Cerebral T2 FLAIR MRI of Patient 1 at age 11 years old, 1 month after the CVA identified in Figure 2. Findings are consistent with late subacute cortical infarcts in the left temporo-occipital and parietal lobes and correspond to areas of diffusion restriction seen in Figure 2.
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T2 FLAIR hyperintensities consistent with a late subacute cortical infarct (Figure 3). To prevent ischemic infarcts with future episodes of SE, the patient was started on Verapamil 0.2-0.3mg/kg/day divided into three doses daily and has not had a recurrence of cerebrovascular accidents to date.
PMC9052233_02
Cerebral T2 FLAIR MRI of Patient 2 at the age of 4 years old demonstrates biparietal periventricular white matter T2 hyperintensity consistent with leukoencephalopathy from prior ischemic/hypoxic insult.
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At the age of 4 years old, she had a follow up brain MRI performed which was stable from prior imaging and continued to show evidence of periventricular leukomalacia (Figure 4).
Cerebral T2 FLAIR MRI of Patient 2 at age 5 years old demonstrates marked supratentorial white matter volume loss, encephalomalacia, and associated ex vacuo dilatation of the ventricular system, particularly posteriorly.
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Yet another month later, two months after the 18-hour episode of SE, she returned to our practice and had another brain MRI performed which confirmed she had marked supratentorial white matter volume loss, encephalomalacia, and associated ex vacuo dilatation of the ventricular system, particularly posteriorly (Figure 5).
Cerebral MRI of Patient 2 at age 8 years old. DWI (Figure 6A), ADC (Figure 6B), and T2 FLAIR (Figure 6C) demonstrate leukomalacia within the periventricular white matter, as well as T2 hyperintensity in patchy areas of the cortex, potentially related to subacute infarcts.
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At 8 years old, following another episode of SE where the patient was found unresponsive, the patient underwent another brain MRI which showed T2 hyperintensities in patchy areas of cortex (Figure 6).
Cerebral T2 FLAIR MRI of Patient 2 at age 9 years old demonstrated persistent, moderate to severe supratentorial ventriculomegaly that was unchanged from the MRI findings in Figure 6. There was no evidence of acute ischemic or hemorrhagic cerebrovascular accident in this study, despite a new onset hemiparesis.
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Brain MRI demonstrated continued, chronic hydrocephalus without acute cerebrovascular injury (Figure 7).