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CT perfusion measurement of postictal hypoperfusion: localization of the seizure onset zone and patterns of spread

  • Diagnostic Neuroradiology
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Abstract

Purpose

Seizures are often followed by a period of transient neurological dysfunction and postictal alterations in cerebral blood flow may underlie these symptoms. Recent animal studies have shown reduced local cerebral blood flow at the seizure onset zone (SOZ) lasting approximately 1 h following seizures. Using arterial spin labelling (ASL) MRI, we observed postictal hypoperfusion at the SOZ in 75% of patients. The clinical implementation of ASL as a tool to identify the SOZ is hampered by the limited availability of MRI on short notice. Computed tomography perfusion (CTP) also measures blood flow and may circumvent the logistical limitations of MRI. Thus, we aimed to measure the extent of postictal hypoperfusion using CTP.

Methods

Fourteen adult patients with refractory focal epilepsy admitted for presurgical evaluation were prospectively recruited and underwent CTP scanning within 80 min of a habitual seizure. Patients also underwent a baseline scan after they were seizure-free for > 24 h. The acquired scans were qualitatively assessed by two reviewers by visual inspection and quantitatively assessed through a subtraction pipeline to identify areas of significant postictal hypoperfusion.

Results

Postictal blood flow reductions of > 15 ml/100 g−1/min−1 were seen in 12/13 patients using the quantitative method of analysis. In 10/12 patients, the location of the hypoperfusion was partially or fully concordant with the presumed SOZ. In all patients, additional areas of scattered hypoperfusion were seen in areas corresponding to seizure spread.

Conclusion

CTP can reliably measure postictal hypoperfusion which is maximal at the presumed SOZ.

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Abbreviations

ASL:

Arterial spin labeling

CBF:

Cerebral blood flow

SOZ:

Seizure onset zone

CTP:

Computed tomography perfusion

SPECT:

Single photon emission computed tomography

PET:

Positron emission tomography

EEG:

Electroencephalography

VEEG:

Video-electroencephalography

PPV:

Positive predictive value

sCTP:

Subtraction CTP

ROI:

Region of interest

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Funding

This study was funded by the Canadian Institutes of Health Research (FRN-156020) and the University of Calgary Brain and Mental Health Strategic Research Fund.

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Authors and Affiliations

  1. Departments of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Room C1214a, Foothills Medical Centre, 1403 29th Street NW, Calgary, AB, T2N 2T9, Canada

    E. Li, C. D. d’Esterre, I. Gaxiola-Valdez, B. Menon, N. Jetté, C. B. Josephson, S. Wiebe, G. C. Teskey & Paolo Federico

  2. Seaman Family MR Research Centre, Cumming School of Medicine, University of Calgary, Calgary, Canada

    E. Li, C. D. d’Esterre & I. Gaxiola-Valdez

  3. Department of Radiology, Cumming School of Medicine, University of Calgary, Calgary, Canada

    T-Y Lee

  4. Lawson Health Research Institute and Robarts Research Institute, The University of Western Ontario, London, ON, Canada

    T-Y Lee

  5. Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Canada

    B. Menon, J. S. Peedicail, C. B. Josephson, S. Wiebe, Paolo Federico, Y. Agha-Khani, R. Avendano, S. Hanna, W. F. Murphy & N. Pillay

  6. Department of Neurology, Icahn School of Medicine, Mount Sinai Hospital, New York, NY, USA

    N. Jetté

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  1. E. Li
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  2. C. D. d’Esterre
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  3. I. Gaxiola-Valdez
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  4. T-Y Lee
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  5. B. Menon
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  6. J. S. Peedicail
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  7. N. Jetté
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  8. C. B. Josephson
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  9. S. Wiebe
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  10. G. C. Teskey
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  11. Paolo Federico
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  12. Y. Agha-Khani
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  13. R. Avendano
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  14. S. Hanna
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  15. W. F. Murphy
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  16. N. Pillay
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Corresponding author

Correspondence to Paolo Federico.

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Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

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Informed consent was obtained from all individual participants included in the study.

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Y. Agha-Khani, R. Avendano, S. Hanna, W. F. Murphy and N. Pillay to be collectively listed as The Calgary Comprehensive Epilepsy Program collaborators

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Li, E., d’Esterre, C.D., Gaxiola-Valdez, I. et al. CT perfusion measurement of postictal hypoperfusion: localization of the seizure onset zone and patterns of spread. Neuroradiology 61, 991–1010 (2019). https://doi.org/10.1007/s00234-019-02227-8

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  • DOI: https://doi.org/10.1007/s00234-019-02227-8

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