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“Now you see it...” A broadly-distributed ictal rhythm easily missed on bipolar montage. Teaching NeuroImages Neurology Resident and Fellow Section © 2014.

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Presentation on theme: "“Now you see it...” A broadly-distributed ictal rhythm easily missed on bipolar montage. Teaching NeuroImages Neurology Resident and Fellow Section © 2014."— Presentation transcript:

1 “Now you see it...” A broadly-distributed ictal rhythm easily missed on bipolar montage. Teaching NeuroImages Neurology Resident and Fellow Section © 2014 American Academy of Neurology

2 Vignette A 23 year-old woman was admitted for brief, recurrent spells of intense fear, and visual hallucinations. © 2014 American Academy of Neurology Sainju et. al

3 Ictal onset: Seen on Cz reference but not on longitudinal bipolar montage Sainju et. al © 2014 American Academy of Neurology Longitudinal Bipolar (right side) Cz Reference (right side) Longitudinal Bipolar (right side) Cz Reference (right side) A B Ongoing ictal rhythm on Cz reference montage Imaging

4 Sainju et. al © 2014 American Academy of Neurology “Now you see it...” A broadly-distributed ictal rhythm easily missed on bipolar montage. During video-EEG study, one of the spells showed no definite ictal EEG changes on longitudinal bipolar montage for 26 seconds while evolving rhythmic discharges were readily visible on Cz reference. Because the pattern was evenly distributed in the temporal region at onset (Figure), it “canceled out” in the bipolar montage. It is conceivable that a shorter seizure would have been completely missed if reviewed only in bipolar montage.

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