Anterior Cingulate Gyrus Epilepsy: The Role of Ictal rCBF SPECT in Seizure Localization

• Published in: Epilepsia (Copenhagen) 2000-05, Vol.41 (5), p.594-600
• Main Authors: San Pedro, Elmer C., Mountz, James M., Ojha, Buddhiwardhan, Khan, Adil A., Liu, Hong‐Gang, Kuzniecky, Ruben I.
• Format: Article
• Language: English
• Subjects: Adult; Biological and medical sciences; Cingulate; Diagnosis, Computer-Assisted; Electrodes, Implanted; Electroencephalography - methods; Electroencephalography - statistics & numerical data; Epilepsy; Epilepsy, Complex Partial - diagnosis; Epilepsy, Complex Partial - diagnostic imaging; Epilepsy, Complex Partial - surgery; Gyrus Cinguli - blood supply; Gyrus Cinguli - diagnostic imaging; Gyrus Cinguli - surgery; Headache. Facial pains. Syncopes. Epilepsia. Intracranial hypertension. Brain oedema. Cerebral palsy; Humans; Ictal brain SPECT; Magnetic Resonance Imaging - statistics & numerical data; Male; Medical sciences; Monitoring, Physiologic; MRI; Nervous system (semeiology, syndromes); Neurology; Neuropsychological Tests; Regional Blood Flow - physiology; SPM; Tc‐99m HMPAO; Technetium Tc 99m Exametazime; Tomography, Emission-Computed, Single-Photon - statistics & numerical data; Treatment Outcome; Videotape Recording
• ISSN: 0013-9580; 1528-1167
• DOI: 10.1111/j.1528-1157.2000.tb00214.x

Purpose: The goal of this report is to demonstrate the utility of ictal brain single photon emission tomography (SPECT) in a 39‐year‐old man with complex partial seizures arising from the anterior cingulate gyrus. Seizures originating from the anterior cingulate gyrus are difficult to localize because they have variable ictal semiology, are usually brief, and have rapid cortical propagation. Methods: Clinical neurologic examination, electroencephalography, extended video‐electroencephalography with scalp and sphenoidal electrodes, magnetic resonance imaging, computed tomography, and ictal brain SPECT with Tc‐99m HMPAO were performed to identify the seizure focus. The patient's regional cerebral blood flow (rCBF) findings were compared with those of eight normal controls, and changes in rCBF were assessed by comparing the patient's ictal scan with those of normal controls at rest by using statistical parametric mapping (SPM). Results: Clinical and neurologic evaluations failed to demonstrate the epileptogenic focus. Ictal rCBF brain SPECT showed a focal region of hyperperfusion in the anterior cingulate gyrus. By using SPM, the ictal blood flow increase in the right anterior cingulate gyrus (x, y, z, –6, 42, 24 mm) was found to be statistically significant when compared with normal controls (z score, 4.88, p < 0.001). Subdural EEG recordings with intracranial electrodes positioned over this location confirmed that the cingulate gyrus was the origin of the seizures, and surgical resection resulted in >90% seizure reduction. Conclusions: We concluded that ictal brain SPECT localization in conjunction with subdural electrode confirmation is a useful test in the presurgical evaluation of difficult to localize cingulate epilepsy.