Use of diffusion-weighted imaging to distinguish seizure-related change from limbic encephalitis

Abstract

Objective

To determine whether diffusion-weighted imaging (DWI) can help differentiate peri-ictal signal abnormality from limbic encephalitis (LE) among patients with medial temporal lobe T2-hyperintensity.

Methods

We retrospectively identified patients with peri-ictal medial temporal lobe T2-hyperintensity using a Mayo Clinic database, and reviewed their DWI to look for unique diffusion restriction patterns. We then identified patients with medial temporal lobe T2-hyperintensity and LE, and reviewed their DWI to see if these patterns were ever present. Presence of diffusion restriction patterns was confirmed by a blinded neuro-radiologist.

Results

We identified 10 patients without LE who had peri-ictal unilateral medial temporal lobe T2-hyperintensity, ipsilateral to focal seizure onset. Nine of 10 (90%) had at least one of two diffusion restriction patterns potentially unique to seizure activity; four had gyriform hippocampal diffusion restriction (“Pattern 1”), three had diffuse hippocampal diffusion restriction that spared the most medial temporal lobe structures (“Pattern 2”), and two had both diffusion restriction patterns. The median patient age was 62 years (range 2–76 years) and 3/9 (33%) were female. In comparison, among patients with medial temporal lobe T2-hyperintensity and LE, only 5/57 (9%) had one of the diffusion restriction patterns (“Pattern 2”) identified (P < 0.0001); all five had seizures reported.

Conclusions

In patients with medial temporal lobe T2-hyperintensity and one of the diffusion restriction patterns described herein, the signal abnormality may be a peri-ictal phenomenon rather than indicative of LE and should prompt investigation for seizure. Even in patients with LE, these patterns should raise concern for seizure.

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Availability of data and material

Anonymized data is available for all study patients and will be shared by request from any qualified investigator.

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Funding

There is no funding to report for this research.

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Affiliations

Authors

Contributions

Dr. AB conceptualized and designed the study; drafted manuscript; analyzed and interpreted the data; composed the figures. Dr. JB interpreted the data; revised the manuscript for intellectual content. Dr. GL interpreted the data; revised the manuscript for intellectual content. Dr. DD interpreted the data; revised the manuscript for intellectual content. Dr. AZ interpreted the data; revised the manuscript for intellectual content. Dr. EF interpreted the data; revised the manuscript for intellectual content. Dr. AM interpreted the data; revised the manuscript for intellectual content. Dr. SP interpreted the data; revised the manuscript for intellectual content. Dr. SB interpreted the data; revised the manuscript for intellectual content. Dr. NZ conceptualized and designed the study; analyzed and interpreted the data; revised the manuscript for intellectual content; supervised the study.

Corresponding author

Correspondence to Adrian Budhram.

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Conflicts of interest

Dr. Adrian Budhram has no disclosures to report. Dr. Jeff Britton is a consultant for UCB pharmaceuticals, investigational drug discussion, Rozanolixizumab; a co-investigator, unpaid, for GW Pharma in a double-blind, randomized, placebo-controlled study to investigate the efficacy and safety of cannabidiol (GWP42003-P, CBD) as add-on therapy in patients with tuberous sclerosis complex who experience inadequately-controlled seizures; a co-investigator, unpaid, for Grifols Pharmaceuticals in a Randomized Double-Blind Placebo Controlled Study of IVIG in Patients with Voltage-Gated Potassium Channel Complex Antibody Associated Autoimmune Epilepsy. Dr. Greta Liebo has no disclosures to report. Dr. Divyanshu Dubey has a patent pending for Kelch-like protein 11 as a marker of neurological autoimmunity and has received research support from Grifols, Translational Research Innovation and Test Development Office and, Center for Clinical and Translational Science. Dr. Dubey has consulted for UCB and Astellas. All compensation for consulting activities is paid directly to Mayo Clinic. Dr. Anastasia Zekeridou has a patent pending on PDE10A-IgG as a biomarker of neurological autoimmunity. Dr. Eoin Flanagan is a site principal investigator in a randomized placebo-controlled clinical trial of Inebilizumab (A CD19 inhibitor) in neuromyelitis optica spectrum disorders funded by MedImmune/Viela Bio. He receives no personal compensation and just receives reimbursement for the research activities related to the trial. Dr. Andrew McKeon reports grants from Alexion, grants from Grifols, grants from Euroimmun, outside the submitted work; in addition, Dr. McKeon has a patent Septin-5-IgG pending, a patent PDE10A-IgG pending, a patent MAP1B-IgG pending, and a patent GFAP-IgG pending. Dr. Sean Pittock reports grants, personal fees and non-financial support from Alexion Pharmaceuticals, Inc.; grants from Grifols, Autoimmune Encephalitis Alliance; grants, personal fees, non-financial support and other from MedImmune, Inc.; Dr. Pittock has a patent # 9,891,219 (Application#12-573942) “Methods for Treating Neuromyelitis Optica (NMO) by Administration of Eculizumab to an individual that is Aquaporin-4 (AQP4)-IgG Autoantibody positive”. Dr Pittock also has patents pending for the following IgGs as biomarkers of autoimmune neurological disorders (septin-5, Kelch-like protein 11, GFAP, PDE10A and MAP1B). Dr. Sherri Braksick has no disclosures to report. Dr. Nicholas Zalewski has no disclosures to report.

Ethics approval

The Mayo Clinic Institutional Review Board (IRB) approved the study (IRB number 08‐006647).

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As patients were identified retrospectively informed consent was not specifically obtained for this submission, but the patients did agree to use of their medical records for research purposes and no patient-identifying images have been included.

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The authors consent to the publication of this manuscript. The manuscript and figures have not been published or copyrighted elsewhere.

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Budhram, A., Britton, J.W., Liebo, G.B. et al. Use of diffusion-weighted imaging to distinguish seizure-related change from limbic encephalitis. J Neurol 267, 3337–3342 (2020). https://doi.org/10.1007/s00415-020-10007-1

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Keywords

  • Seizure
  • Peri-ictal
  • Limbic encephalitis
  • Magnetic resonance imaging
  • Diffusion-weighted imaging