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Timing of Peri-Ictal MRI Abnormalities in Status Epilepticus - One Size Does Not Fit All
Pilar Bosque Varela1, Lukas Machegger2, Tanja Prüwasser1,3
1Department of Neurology, Neurocritical Care and Neurorehabilitation, Christian Doppler University Hospital, Centre for Cognitive Neuroscience, Member of the European Reference Network EpiCARE, Paracelsus Medical University of Salzburg, Salzburg, Austria.
Objective:
We aimed to investigate timing of occurrence of peri-ictal MRI abnormalities - a potential risk biomarker of status epilepticus-related cerebral injury (t2).
Methods:
This prospective study enrolled adult patients with status epilepticus and acute magnetic resonance imaging (MRI); patients with peri-ictal MRI abnormalities underwent follow-up MRI 4 weeks later. Predictive model, using logistic regression, integrated clinical factors (duration, semiology, and etiology of status epilepticus and the patients' level of consciousness) to prognosticate occurrence of peri-ictal MRI abnormalities. Cerebral injury due to status epilepticus was assessed by comparative volumetric analysis of acute and follow-up MRIs.
Results:
Among 256 patients, 137 (53%) had peri-ictal MRI abnormalities. The likelihood of their occurrence increased over time under the influence of semiology and etiology of status epilepticus as well as the patients' level of consciousness: it was highest in non-convulsive status epilepticus caused by acute primary or secondary etiologies at 10 minutes after onset in patients with stupor/coma (81-85%); it increased at 24 hours to 92%; and at 48 hours to 95%. Conversely, in alert/somnolent patients with prominent motor symptoms and acute triggering factors associated with epilepsy, the possibility of developing peri-ictal MRI abnormalities at 24 hours was 4 to 5% and at 48 hours it was 6 to 11%. In 28 of 45 (62%) of follow-up MRIs, structural long-term consequences of status epilepticus were observed in the form of either cortical and hippocampal atrophy or global cerebral volume loss.
Interpretation:
In this novel multimodal approach based on MRI data, the patients' level of consciousness, etiology, and duration of status epilepticus offers insights into the risk of possible brain injury in status epilepticus. ANN NEUROL 2026;99:523-534.
Insights
Peri-ictal MRI abnormalities can indicate brain injury from status epilepticus. Timing, patient consciousness, and seizure cause influence the risk of these MRI findings.
Area of Science:
- Neurology
- Radiology
- Neuroimaging
Background:
- Status epilepticus (SE) can lead to cerebral injury.
- Peri-ictal MRI abnormalities are potential biomarkers for SE-related brain damage.
- Understanding the timing and predictors of these abnormalities is crucial for risk assessment.
Purpose of the Study:
- To investigate the timing of peri-ictal MRI abnormalities in patients with status epilepticus.
- To identify clinical factors that predict the occurrence of these abnormalities.
- To assess the relationship between peri-ictal MRI abnormalities and long-term cerebral injury.
Main Methods:
- Prospective study of adult patients with status epilepticus (SE) undergoing acute MRI.
- Follow-up MRI at 4 weeks for patients with peri-ictal abnormalities.
- Logistic regression model incorporating clinical factors (duration, semiology, etiology, consciousness) to predict abnormalities.
- Volumetric analysis of serial MRIs to assess cerebral injury.
Main Results:
- 53% of 256 patients showed peri-ictal MRI abnormalities.
- Likelihood of abnormalities increased with SE duration, specific semiology/etiology, and lower consciousness levels.
- In high-risk groups (non-convulsive SE, coma, acute etiology), abnormality likelihood reached 95% by 48 hours.
- In lower-risk groups, likelihood remained below 11% at 48 hours.
- 62% of follow-up MRIs revealed long-term injury (atrophy, volume loss).
Conclusions:
- A multimodal approach using MRI, consciousness level, etiology, and SE duration predicts brain injury risk.
- Early identification of peri-ictal MRI abnormalities aids in assessing SE-related cerebral injury.
- Findings highlight the importance of neuroimaging in managing status epilepticus.
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