Hyperacute Seizure 12 - Clinical Case Summary
Hyperacute Seizure 12 - Clinical Case Summary
Hyperacute Seizure 12 - Clinical Case Summary
SummaryHistory
76 yo male intermittent slurred speech and trouble with typing. Then developed acute arm weakness and starring spell with unresponsiveness. Patient had a full head MR exam, which was interpreted as having features of acute stroke. No dominant mass was identified to suspect CNS tumor. Based on the imaging and the acute right arm paresis, the patient underwent angiography for possible stroke therapy; the angio, however, was negative. The patient was then referred as an unknown diagnostic problem.
Exams Performed
MR T1-w pre and/or post contrast; MR Coronal T2-w spin echo and MR FLAIR; MR diffusion
Prior available imaging reports
CT Head was not obtained.
MR T1-w exam
1. There is evidence of a diffusely infiltrative process apparently arising in the left parietotemporal area with extension to the left insula, the left orbitofrontal area and possibly the contralateral frontal periventricular region. 2. These findings are most consistent with malignant gliomatosis. There is tumor in the subcortical left motor area, which if generating a seizure would account for the patients acute arm paresis and starring spells.
T2-w MR
1. Diffuse mainly white matter T2-w signal change combined with mulinodular enhancement is most consistent with malignant gliomatosis.
MR diffusion (DWI)
1. Minimal background T2-w signal increase (i.e. brighter signal) on the MR diffusion as was seen on the MR flair; the tumor has the same distribution on both sequences. There is no evidence of tumoral AV shunting nor hemorrhagic transformation.
MR Susceptibility (SWI) is not available
MR T1-w exam
1. There is evidence of a diffusely infiltrative process apparently arising in the left parietotemporal area with extension to the left insula, the left orbitofrontal area and possibly the contralateral frontal periventricular region. 2. These findings are most consistent with malignant gliomatosis. There is tumor in the subcortical left motor area, which if generating a seizure would account for the patients acute arm paresis and starring spells.
T2-w MR
1. Diffuse mainly white matter T2-w signal change combined with mulinodular enhancement is most consistent with malignant gliomatosis.
MR diffusion (DWI)
1. Minimal background T2-w signal increase (i.e. brighter signal) on the MR diffusion as was seen on the MR flair; the tumor has the same distribution on both sequences. There is no evidence of tumoral AV shunting nor hemorrhagic transformation.
MR Susceptibility (SWI) is not available
Overall impression
1. The patient, who was in his middle 70's, presented with acute arm paresis and was thought to have had a stroke. MR imaging demonstrated multicentric areas of white matter T2 change and multiple sites of nonspecific enhancement, some in white matter and some in gray matter. MR diffusion appeared positive in the posterior left temporal area. The MR was interpreted as evidence of stroke. A stroke team was called and found no arterial thrombus. The patient was worse after the angio. The imaging features demonstrated a diffuse infiltrative process without a dominant mass. The differential is that of malignant gliomatosis or possibly vasculitis. The MR diffusion restriction was not in the arm area of cortex. In all probability, this patient had a cortically based seizure with post seizure paresis of the arm. The diagnosis of diffuse malignant gliomatosis was made on subsequent biopsy. Diffuse gliomatosis or diffuse CNS lymphoma often present with seizures, and should be considered a possibility in any older patient presenting with acute post ictal paresis.