Increased cerebral blood flow on arterial spin labeling magnetic resonance imaging can localize to seizure focus in newborns: A report of 3 cases

Abstract

Arterial spin labeling (ASL) magnetic resonance imaging (MRI) can assess cerebral blood flow (CBF) without using radiolabeled tracers. It is unknown whether regional increases in CBF on ASL MRI correlate with seizure location in newborns. We report 3 newborns with focal seizures localized on continuous video electroencephalogram (cEEG), anatomical brain MRI, and ASL MRI. Each patient underwent pseudocontinuous ASL with segmented 3-dimensional fast spin echo readout as part of standard care. Case 1 is a term male infant presenting with left temporal status epilepticus and recurrent cEEG seizures from an idiopathic large left intraventricular hemorrhage. ASL images demonstrated left mesial temporal lobe increased CBF. Case 2 is a late preterm male infant presenting with recurrent cEEG seizures due to focal right megalencephaly. Ictal EEG and ASL images coincided with the focal dysplasia. Case 3 is a dysmorphic term female infant with nonconvulsive partial status epilepticus identified by focal increased CBF of the left temporal lobe on ASL images. The area of increased CBF was within an area of extensive left hemisphere dysplasia. To our knowledge, this is the first report of regional increases in CBF on ASL MRI correlating with ictal cEEG in newborns.

Diagnostic usefulness of arterial spin labeling in MR negative children with new onset seizures

“…Several recent studies have evaluated the utility of ASL in children with seizures. However, sample sizes in these studies were small, and most investigations focused on the utility in patients with structural abnormalities such as focal cortical dysplasia (FCD) and cortical tubers [7][8][9][10]19]. In one study of nine children, hypoperfusion on ASL was colocalized with structural MRI abnormalities in all cases, with PET hypometabolism in 5/6 cases, and with histologically proven FCD type IIb in 5/5 cases [7].…”

“…Previous studies assessing CBF in relation to seizures yielded inconsistent results about reporting hypoperfusion and hyperperfusion depending on the acquisition time. Several studies reported that hyperperfusion could persist for several days, even though ictal EEG findings and clinical seizures showed complete improvement [10,20,29]. However, another study showed hyperperfusion 1-5 hours after seizures and hypoperfusion interictally [30].…”

“…However, only a few case series have reported the diagnostic utility of ASL on seizure evaluation in pediatric epilepsy. Furthermore, these reports were analyzed in patients with brain structural abnormalities [7][8][9][10]. Notwithstanding the significantly higher proportion of MR negative cases in children than in adults, there has been no report on the diagnostic performance of ASL in pediatric epilepsy without obvious structural brain lesions.…”

Arterial spin labeling in neonatal magnetic resonance imaging – first experience and new observations

“…1 ( Figure 2 ). We found a similar case in the only publication in the PubMed database devoted to this topic, which described 3 neonates, the remaining 2 with abnormalities on standard sequences as well [ 4 ]. The addition of ASL to the brain MRI protocol can localize the seizure onset zone without the necessity to perform ictal single photon emission computed tomography (SPECT), which implies radiation exposure.…”

Recent developments in imaging of epilepsy

“…ASL perfusion revealed areas of focal hyperperfusion that corresponded to the presumed seizure onset zone in newborns [34] and in children who presented with a first seizure and normal MRI [35 ▪ ]. Perfusion changes were detected in 58% of children (focal in 36 and generalized in seven patients) with an overlapping area between the TPMA and the suspected seizure onset zone in 76%.…”