History of treated suprasellar hypothalamic/optic tract glioma with surgery complicated with panhypopituitarism and diabetes mellitus for 3 years (on insulin glargine). Acute presentation with convulsions and hypoglycemia. Admitted to PICU.
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Areas of grey matter evident diffusion restriction, high T2 and FLAIR signals as well as hypointensity on T1 and no postcontrast enhancement, seen evidently at both parietal lobes, more the right one, less evident at both frontal and occipital lobes and left caudate nucleus and lentiform nucleus.
Shunt tube is noted at the right posterior parietal region draining the left lateral ventricle. Adequately decompressed supratentorial ventricular system.
Focal thinning of the proximal segment of body of corpus callosum, mostly postsurgical sequels.
Mildly dilated 3rd ventricle, likely chronic mild (non-obstructive) dilatation - residual dilatation.
Suprasellar cistern heterogeneous FLAIR signal with no enhancement or diffusion restriction, likely post-surgical sequels. Stretched infundibulum and deviated to the left side. Normal size, shape and signal of the pituitary gland; with no foci of abnormal enhancement detected. Intact optic chiasm and both optic nerves.
MRI study shows multifocal gyral and basal ganglia diffusion restriction with no enhancement and no white matter affection. The differential diagnosis for this appearance include seizures, CO poisoning, hypoglycemia, hyperammonemia, hypoxic-ischemic encephalopathy and Creutzfeldt-Jakob disease 1.
The history and imaging features are suggestive of acute evident ischemic changes, most likely sequel to status epilepticus due to hypoglycemia. Diffusion restriction occurs in severe attacks in which sustained seizure activity, results in hypoxia and eventually cell death. Diffusion-weighted imaging has a prognostic role in status epilepticus. Unfortunately, when T2 signal elevation is associated with significant (>10%) drop in ADC values, follow-up is likely to reflect permanent damage 2.
- 1. Finelli PF. Diagnostic approach to restricted-diffusion patterns on MR imaging. (2012) Neurology. Clinical practice. 2 (4): 287-293. doi:10.1212/CPJ.0b013e318278bee1 - Pubmed
- 2. Kim JA, Chung JI, Yoon PH, Kim DI, Chung TS, Kim EJ, Jeong EK. Transient MR signal changes in patients with generalized tonicoclonic seizure or status epilepticus: periictal diffusion-weighted imaging. (2001) AJNR. American journal of neuroradiology. 22 (6): 1149-60. Pubmed