case_images: PMC10543690_01
case_images: Head computed tomography (CT) and cervical spine magnetic resonance imaging (MRI). (A, B) Axial CT of the head before (A) and 7 days after (B) surgery. Note the absence of recurrence of the subdural hematoma and the absence of any apparent lesions in the brain on the left side (arrows). (C) Sagittal MRI of the cervical spine 3 days after symptom onset. Neither spinal cord compression nor intra-axial lesions were observed.
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case_images: Computed tomography (CT) of the head showed bilateral cSDH, larger on the left side (Fig. 1A). The patient had had no postsurgical deficits until 7 days after the procedure, when he experienced a brief episode of a clonic seizure of the right hand without any postoperative recurrence of cSDH on CT (Fig. 1B). Another differential diagnosis besides Todd's paralysis was cervical spondylotic radiculopathy, but magnetic resonance imaging of the neck on the same day showed no cervical lesion (Fig. 1C).
case_images: Epileptiform pattern shown on a transverse bipolar montage 3 days after symptom onset. (A) Epileptiform patterns immediately before an electrographic seizure starts. Phase reversals are seen at C3. (B-E) Each epileptiform discharge. (B) Delta or theta waves superimposed with low-voltage fast activities (arrowheads) of approximately 25-30 Hz, lasting <= 0.4 s, which are sometimes followed by slow waves. Sharp waves are also observed. (C) A 15- to 25-Hz polyspike-and-slow-wave complex. (D) Low-voltage fast activities (arrowheads) followed by a polyspike complex (arrows). (E) Brief potentially ictal rhythmic discharges.
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case_images: The video-EEG showed occasional epileptiform patterns (Fig. 2A), as well as an electrographic seizure (Fig. 3A-E). Epileptiform patterns were observed occasionally, peaking at the C3 electrode; low-voltage fast activities and sharp waves (Fig. 2B), polyspikes (Fig. 2C, D), and brief potentially ictal rhythmic discharges (Fig. 2E) were found. An electrographic seizure was recorded as follows: quasi-rhythmic spikes and theta waves at approximately 6 Hz appeared in the left centroparietal region and were maximal at the C3 electrode (Fig. 3A, open arrowhead; Fig. 3A is a continuation of Fig. 2A).
case_images: Electrographic seizure shown on a transverse bipolar montage 3 days after symptom onset. (A) Continuation of Fig. 2A, showing the start of an electrographic seizure (open arrowhead). Quasi-rhythmic spikes and theta waves of approximately 6 Hz appear in the left centroparietal region. Phase reversals are seen at C3. Quasi-rhythmic spikes increase in frequency (~8 Hz) and decrease in amplitude, at which time the right hand of the patient felt strange and he rubbed his right thumb and index finger (at the arrowhead). The quasi-rhythmic spikes further increase in frequency (~15 Hz) and decrease in amplitude, and the patient slightly moved his mouth and arms because of the start of a tingling sensation, pain, and stiffness in the right upper extremity, which resulted in interference from muscle activity on the EEG (arrow). The quasi-rhythmic spikes fluctuate in frequency and amplitude in the latter part of the trace. (B) The quasi-rhythmic spikes are interposed with larger spikes or polyspike complexes. (C) The lower-amplitude quasi-rhythmic spikes fade out, with the interposed spikes or polyspike complexes appearing more clearly. (D) The ictal discharges change into 3-Hz quasi-periodic polyspike complexes. (E) The quasi-periodic polyspike complexes exhibit a gradual decrease in frequency (from 3 to 2 Hz) and change in morphology, and they stop 50 s after the onset of ictal activity. (F) Continuation of (E). After the end of the electrographic seizure, the background activity is almost symmetric in voltage, and no breach rhythm is observed. Each arrowhead in (B-E) indicates the time after the onset of ictal activity.
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case_images: An electrographic seizure was recorded as follows: quasi-rhythmic spikes and theta waves at approximately 6 Hz appeared in the left centroparietal region and were maximal at the C3 electrode (Fig. 3A, open arrowhead; Fig. 3A is a continuation of Fig. 2A). The frequency of the quasi-rhythmic spikes increased (~8 Hz) and their amplitude decreased (Fig. 3A, arrowhead), at which time the right hand of the patient felt strange and he rubbed his right thumb and index finger, as recorded in the video and retrospectively reported by the patient. The frequency of the quasi-rhythmic spikes then increased further (~15 Hz) and their amplitude decreased, at which time the patient moved his mouth and arms slightly because of the start of the tingling sensation, pain, and stiffness in the right upper extremity, with the muscle activity interfering with the EEG (Fig. 3A, arrow). The frequency and amplitude of the quasi-rhythmic spikes then fluctuated (Fig. 3A, latter part), and these spikes were interposed with larger spikes or polyspike complexes (Fig. 3B). The lower-amplitude quasi-rhythmic spikes faded out, with the interposed spikes or polyspike complexes appearing more clearly (Fig. 3C), and the pattern then changed into 3-Hz quasi-periodic polyspike complexes (Fig. 3D). The quasi-periodic polyspike complexes showed a gradual decrease in frequency (from 3 to 2 Hz) and change in morphology, and they stopped 50 s after the onset of ictal activity (Fig. 3E). In addition to the epileptiform patterns or the electrographic seizure, single theta waves were frequently observed at C3, but the background activity was almost symmetric in voltage, and no breach rhythm was observed (Fig. 3F).