Arterial spin labeling (ASL) perfusion images allow noninvasive visualization of periictal hyperperfusion in epileptically activated areas occurring secondary to seizures in structural focal epilepsy, and demonstrate a close anatomical relationship between epileptogenic lesions and the activated area. A 27-year-old female patient with epilepsy presented with focal to bilateral tonic-clonic seizures. She had an extensive traumatic lesion in the perfusion area of the right middle cerebral artery (MCA), which occurred at 3 years of age. ASL with triple postlabeling delays (PLDs) imaged 1 hour after the seizure failed to reveal periictal hyperperfusion around the lesion. It was possible that because of the underdevelopment of the right internal carotid artery and MCA, the blood supply to the right hemisphere was not adequate to demonstrate ictal hypermetabolism. ASL results should be interpreted comprehensively by combining the clinical manifestations, electroencephalographic findings, and magnetic resonance (MR) imaging findings of various modalities including MR angiography.

Purpose: To describe the clinical features of postoperative involuntary movements including convulsions resulting from use of intravenous high-dose tranexamic acid (TXA) in patients undergoing cardiac and thoracic aortic surgery. We also aimed to identify associated risk factors.

Methods: This retrospective single-center study examined 191 patients who received intravenous TXA during cardiac and/or thoracic aortic surgery with cardiopulmonary bypass in our institution. Multivariable logistic regression was performed to identify independent predictors of postoperative involuntary movements/convulsions.

Results: TXA-associated involuntary movements/convulsions were observed in 25 patients (13.1%). Involuntary movements included convulsions, myoclonic jerks of limbs and/or facial muscles, and action tremors of the body, especially the head and hands. The median time from the last dose of TXA to the first involuntary movement/convulsion was 7.3 hours. The median duration of involuntary movements/convulsions was 1 day. Convulsions did not progress to status epilepticus. Intensive care unit (ICU) stay was significantly longer in patients with involuntary movements/convulsions than in those without (p < 0.001). In multivariate analysis, the following variables were independent predictors of involuntary movements/convulsions: total TXA dose (odds ratio [OR], 1.10; p = 0.047), dialysis treatment (OR, 5.32; p = 0.016), and a history of stroke (OR, 3.30; p = 0.021).

Conclusions: In addition to convulsions, myoclonus and tremors were also observed as TXA-associated involuntary movements. Although these abnormal movements generally disappeared within a short period of time, they were associated with longer ICU stay. Caution should be exercised when administering high doses of TXA to dialysis patients and patients with a history of stroke.

Vagus nerve stimulation (VNS) was performed in three patients with drug-resistant epilepsy after treatment for arteriovenous malformation (AVM). A male patient in his 40s had undergone craniotomy for a ruptured right parietal AVM in his 30s. A female patient in her 40s, and a male patient in his 50s had undergone gamma knife surgery. After VNS, all patients achieved seizure control. These results suggest that VNS is effective for controlling drug-resistant epilepsy that developed after treatment for AVM.

Background: We investigated the usefulness of the addition of arterial spin labeling (ASL) perfusion imaging to 1.5-Tesla magnetic resonance imaging (MRI) during the periictal period for the pathophysiological diagnosis of focal to bilateral tonic-clonic seizures (FBTCS) in dementia patients presenting at neurological emergency, to compensate for the weaknesses of electroencephalography (EEG).

Patients & Methods: We retrospectively examined the performance status and findings of EEG and MRI in eight dementia patients who were transported to our hospital immediately after first-onset generalized convulsive seizures.

Results: Five of the eight patients were transported outside of consultation hours, while three were transported within consultation hours. MRI was performed 1 to 7 h (mean, 2.8 h) after arrival, while EEG 2 h to 2 days (mean, 15.1 h). In addition, MRI was performed first in seven patients, and EEG was done first in only one patient. ASL demonstrated focal hyperperfusion in all patients. In Patients 1 and 2, periictal hyperperfusion was observed around the organic lesions, indicating the pathophysiology of structural focal epilepsy and acute symptomatic seizure, respectively. In Patients 3–8, periictal hyperperfusion was noted in one cerebral hemisphere or the apex of bilateral frontotemporal lobes unrelated to the organic lesions, which led to a suspicion of dementia-related epilepsy. In contrast, paroxysmal discharges were observed on EEG in only three patients, and their locations were consistent with the hyperperfusion identified on ASL. Focal slow waves, the location of which matched the ASL findings, were observed in one patient. However, a pathophysiological diagnosis could not be made from the EEG findings alone in the other patients.

Conclusion: At our hospital, ASL was almost always performed prior to EEG. Capturing periictal ASL hyperperfusion first may improve the ability to make a prompt pathophysiological diagnosis of FBTCS associated with dementia.