case_images: PMC11824791_01
case_images: Brain magnetic resonance imaging with and without contrast. Brain MRI: (a) T2 FLAIR showing left parieto-occipital resection cavity with surrounding T2 FLAIR hyperintensity. (b) T1 postcontrast showing nonspecific faint rim of peripheral ribbon like enhancement.
case_images: CRINM2025-3203322.001.jpg
case_images: PMC11824791_01_CRINM2025-3203322.001.jpg
case_images: fig1
case_images: MRI with and without contrast showed a left parieto-occipital resection cavity with a nonspecific faint rim of peripheral enhancement with enhancement having a gyriform pattern and associated T2 fluid-attenuated inversion recovery (FLAIR) hyperintensity (Figure 1). MRI perfusion imaging showed increased cerebral blood volume and blood flow, mainly in the periphery in a cortical pattern (Figure 2).
case_images: Brain magnetic resonance imaging perfusion (a) T1 postcontrast axial MRI showing nonspecific faint rim of peripheral ribbon like enhancement in the left parieto-occipital region. (b) MRI perfusion imaging showing increased cerebral blood flow in the left parieto-occipital region. (c) Increased cerebral blood volume in the left parieto-occipital region in a cortical pattern.
case_images: CRINM2025-3203322.002.jpg
case_images: PMC11824791_01_CRINM2025-3203322.002.jpg
case_images: fig2
case_images: MRI with and without contrast showed a left parieto-occipital resection cavity with a nonspecific faint rim of peripheral enhancement with enhancement having a gyriform pattern and associated T2 fluid-attenuated inversion recovery (FLAIR) hyperintensity (Figure 1). MRI perfusion imaging showed increased cerebral blood volume and blood flow, mainly in the periphery in a cortical pattern (Figure 2).
case_images: Initial electroencephalogram (EEG). (a) The start of a focal seizure. In the box shows left posterior temporal focal slowing (not an ictal pattern). This becomes sharper and quasirhythmic in the 3-6 Hz delta-theta range as the seizure starts, with phase reversal sharps (arrows). (b) Development of a clearer ictal pattern. Focal 4-5 Hz theta slowing spreads broadly over the left parasagittal chain (box). P7 sharps become more apiculate spikes with clear rhythmicity at 6 Hz (arrows). (c) Further ahead in the seizure and on a compressed time scale, left posterior ictal pattern slows from sharp quasirhythmic 3-4 Hz activity (arrows) to 2 Hz discharges (arrowheads). (d) End of seizure:black arrows indicate ongoing left posterior discharges slowing to every 1.5 s, then stopping and as the seizure ends. Total duration of this seizure is 3 min, 27 s. (e) Quantitative EEG trends showing a period of 4 h shortly after the EEG is first connected, with the vertical blue line indicating the start of the index seizure shown. Rhythmicity spectrogram and FFT spectrogram on the left hemisphere, as well as asymmetry spectrogram and amplitude-integrated EEG show greater power (uV) over the left compared to the right. During this 4 h period, there were 16 focal left posterior temporal/occipital seizures.
case_images: CRINM2025-3203322.003.jpg
case_images: PMC11824791_01_CRINM2025-3203322.003.jpg
case_images: fig3
case_images: The patient was started on continuous video electroencephalogram (EEG), which showed left parieto-occipital abundant interictal epileptiform discharges and focal left posterior quadrant seizures occurring at a rate of 3-6 per hour (Figure 3).
case_images: EEG after ketamine infusion. The end of a later seizure after ketamine is started. As the seizure resolves, the ictal pattern is replaced by left posterior delta activity (arrows) and sharps (arrowhead) which improves postictally.
case_images: CRINM2025-3203322.004.jpg
case_images: PMC11824791_01_CRINM2025-3203322.004.jpg
case_images: fig4
case_images: The next day, his seizure frequency decreased further to 0-2 an hour, and eventually, he had no seizures at the end of the second day (Figure 4).
case_images: 72 h ambulatory EEG after discharge. Frequent focal slowing in the left posterior region without epileptiform discharges or seizures.
case_images: CRINM2025-3203322.005.jpg
case_images: PMC11824791_01_CRINM2025-3203322.005.jpg
case_images: fig5
case_images: His repeat 72-h EEG showed no seizures or epileptiform activity (Figure 5).