Typical ictal pattern on MR perfusion scan for patients on the ictal–interictal continuum

A 59-year-old man with a history of intraparenchymal hemorrhage presented in status epilepticus with new onset left temporal electrographic seizures. Due to continued seizure activity, he received levetiracetam, lacosamide, clobazam, and a midazolam infusion. Afterwards, the EEG showed continuous 1–2 Hz lateralized periodic discharges (LPDs), maximal at P7/O1, consistent with the ictal-interictal continuum (IIC) (Figure 1). Brain MRI on admission showed post-ictal changes in the left temporo-occipital cortex and left thalamus, and chronic left temporal encephalomalacia. After the patient remained in IIC for 8 days, MR perfusion showed increased relative cerebral blood flow and blood volume in the left temporo-occipital lobe concerning ongoing ictal activity (Figure 2). Despite treatment, the patient's mental status did not improve and passed away after withdrawal of care. MR perfusion can help determine if an IIC pattern is more ictal than interictal and may alter clinical management.1-5 This study was not funded. Dr. Irfan Sheikh is an associate editor for the Epileptic Disorders Journal and is Assistant Program Leader for the EPD Internship Program. All other listed authors have no conflicts of interest to disclose. Patient consent was unable to be collected due to the patient being intubated at the time of his admission and subsequently deceased with no family or next of kin available in contact to attain consent. The study was approved by the UTSW IRB as IRB Exempt status STU27031. Data sharing is not applicable to this article as no new data were created or analyzed in this study. Data S1. Data S2. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article. Which of the following electrographic patterns would qualify as part of the ictal-interictal continuum (IIC)? Which of the following best describes a typical finding on MR perfusion during the ictal phase of a seizure? Which of the following best describes a typical finding on MR perfusion during the postictal state after a seizure? Answers may be found in the supporting information