case_images: PMC11675710_01
case_images: MRI Studies at the Age of 6 Months and 4 Years in a Girl With Refractory Epilepsy Related to Right Anterior Cingulate FCD. Coronal T2 (A and B), coronal fluid attenuated inversion recovery (FLAIR) (C), and axial T1 (D) 1.5T brain MRI performed at 6 months of age showing an arciform ("comma shape") T2 hypointensity in the WM underlying the right anterior cingulate gyrus (white arrows in A and B), missed during initial interpretation. These early changes seemed to better delineate the borders of the malformation extending to the right basal ganglia medially and to the right gyrus rectus caudally (white arrowheads in B) and corresponded well to the pathologic zone of the histologic specimen after surgical excision. Note the lesion has the same signal (white arrows in D) as the internal capsule and optic radiation (black arrows in D), which are normally myelinated at this age suggesting accelerated myelination in the FCD. No cortical thickening or signal abnormality of the cortex was observed on the initial MRI. Coronal T2 (E and F), coronal FLAIR (G), and axial T1 (H) 3T brain MRI scans performed with a specific epilepsy protocol at 4 years of age showing similar changes with high T2/FLAIR and relatively low T1 signal in the same area (white arrows). Note a cortical thickening of the right anterior cingulate gyrus, associated with subtle blurring of the gray-white matter junction (G and H, white arrows), an imaging hallmark of FCD. FCD = focal cortical dysplasia; WM = white matter.
case_images: WNL-2024-102707f1.jpg
case_images: PMC11675710_01_WNL-2024-102707f1.jpg
case_images: F1
case_images: This second MRI demonstrated thickening of the right anterior cingulate cortex associated with subtle blurring of the gray-white matter (G/WM) junction (Figure 1, E-H), suggesting a diagnosis of right mesial frontal FCD. These imaging findings were consistent with the patient's video-scalp EEG (Figure 2A) and interictal positron emission tomography-computed tomography (PET-CT, Figure 2B and C, eFigure 1) findings.
case_images: EEG and PET/CT Images in a Girl With Refractory Epilepsy Related to Right Anterior Cingulate FCD. Ictal EEG (A) showing increased right frontotemporal activity (gain 120 muV/s with filters 4.0-200.0 Hz). Axial interictal fluorodeoxyglucose (FDG) PET-CT (B) and PET-CT/MRI fusion reconstruction (C) also consistent with an epileptic focus in the right frontomesial region (arrows).
case_images: WNL-2024-102707f2.jpg
case_images: PMC11675710_01_WNL-2024-102707f2.jpg
case_images: F2
case_images: These imaging findings were consistent with the patient's video-scalp EEG (Figure 2A) and interictal positron emission tomography-computed tomography (PET-CT, Figure 2B and C, eFigure 1) findings. In view of the patient's refractory epilepsy and the excellent concordance of all assessments (eFigure 2), the multidisciplinary epilepsy team proposed surgical treatment, waiving a phase II investigation.