Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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On Sep 2018




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On Sep 2018




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"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



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Lucknow
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Muzaffarnagar.
On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


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Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
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Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011
Anuradha

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.


Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020

Important Notice

Original article / research
Year : 2022 | Month : June | Volume : 16 | Issue : 6 | Page : TC06 - TC10 Full Version

Qualitative Assessment of Cerebral Perfusion in Post Stroke Seizure Patients using Arterial Spin Labeling: A Case-control Study


Published: June 1, 2022 | DOI: https://doi.org/10.7860/JCDR/2022/55267.16473
Anjali B Susan, Uttam B George, Jeyaraj D Pandian

1. Assistant Professor, Department of Radiology, Christian Medical College, Ludhiana, Punjab, India. 2. Professor, Department of Radiology, Christian Medical College, Ludhiana, Punjab, India. 3. Professor, Department of Neurology, Christian Medical College, Ludhiana, Punjab, India.

Correspondence Address :
Dr. Anjali B Susan,
House No. 3, Gateway Terrace, Christian Medical College and Hospital,, Ludhiana, Punjab, India.
E-mail: anjalisusan26@gmail.com

Abstract

Introduction: Arterial Spin Labeling-Perfusion Weighted Imaging (ASL-PWI) assesses cerebral blood flow using magnetically labeled inflowing arterial blood water protons as freely diffusible tracer without exogenous contrast agent. Seizures are one of the sequelae of stroke with its mechanism not well studied.

Aim: Qualitative assessment of cerebral perfusion in post stroke seizure patients using ASL-PWI and comparison of perfusion patterns in post stroke seizure patients and stroke patients.

Materials and Methods: This was a case-control study among 100 stroke patients who underwent Magnetic Resonance Imaging (MRI) of brain in Department of Radiodiagnosis, from Outpatient and Inpatient Department of Neurology, Christian Medical College, Ludhiana, Punjab, India, from 1st January 2018 till 1st January 2020. Total 50 post stroke seizure patients included as cases and 50 age matched post stroke patients without seizure included as controls. Perfusion pattern was compared qualitatively using ASL-PWI. Qualitative variables were associated using Chi-square test/Fisher’s-exact test.

Results: The mean age of the study subjects were 56.38±16.98 years (age range from 19-87 years) and that of controls were 59.66±11.86 years (age range from 19-89 years) (p-value=0.265). Cerebral hypoperfusion was noted in 39 (78%) of total 50 post stroke seizure patients irrespective of type of stroke. Cortical and subcortical area of frontal and parietal lobes was predominantly involved in post stroke seizure patients. Out of 39, 23 (71.88%) early onset seizure and 16 (88.89%) late onset seizure patients had hypoperfusion. There was no significant association of perfusion abnormality with onset of seizure (p-value=0.241). Hypoperfusion was noted in cases and controls without any statistical difference.

Conclusion: Cortical and subcortical area of involvement was noted in post stroke seizure patients. Post stroke seizure patients showed hypoperfusion irrespective of stroke type and onset of seizure. There was no difference seen in perfusion abnormality between post stroke seizure patients and stroke patients without seizure.

Keywords

Hypoperfusion, Magnetic resonance imaging, Neuroimaging

Stroke is one of the common causes of epilepsy in elderly population. Post stroke seizure can be early onset seizure which occurs within 2 weeks of stroke or can be late onset, where the seizure occurs after 2 weeks following the stroke. In seizure there is an increase in metabolic demand of the affected brain parenchyma. As a result there is a temporary increase in cerebral perfusion in the involved region (1). So, analysing the perfusion has become widely accepted in evaluation of seizures. Various nuclear medicine perfusion techniques like Positron Emission Tomography (PET), Single Photon Emission Computed Tomography (SPECT) have showed increased cerebral perfusion during peri-ictal period and decreased perfusion during interictal period following seizure (2). However, clinical utility of these techniques is limited as they are expensive and require multiple patient evaluation and use of radioactive substances. Perfusion computed tomography or dynamic susceptibility contrast Magnetic Resonance Imaging (MRI) scan can also assess cerebral perfusion. However, it require contrast material for the study.

Arterial Spin Labeling (ASL) is a non invasive Magnetic Resonance Imaging technique which measures cerebral blood flow using magnetically labelled blood water protons as endogenous tracer. It does not require any contrast material for assessment of perfusion making it suitable for perfusion studies in patients with renal insufficiency, paediatric population or those that need repetitive follow up scans. Combination of Radiofrequency (RF) pulses and gradients invert the longitudinal magnetisation of blood water protons in feeding arteries. After certain transit time, the inverted protons reach the brain parenchyma and generate a labelled image. The transit time depends on the individual’s age and circulatory conditions. A second acquisition is made without prior inversion of water protons and this will generate a control image. Subtraction of labelled and controlled images will produce an absolute measurement of cerebral blood flow (3). ASL can be used to assess perfusion in dementia, especially to determine hypoperfusion in patients with Alzheimer’s disease (4). Perfusion mismatch can also be determined through ASL MR perfusion imaging in cerebrovascular disease. A study has shown the added benefit of inclusion of ASL MR perfusion imaging to conventional MR imaging in stroke patients to predict outcome (5). Another study has also shown the potential use of ASL in identification of arteriovenous malformation and Moyamoya disease (4). The Arterial Spin Labeling -Perfusion Weighted Imaging (ASL-PWI) has been used to determine the perfusion abnormalities in seizure patients and differentiate them from post stroke seizures and seizure mimickers (2). However, more studies on this topic are imperative to establish the role of ASL-PWI. This study aimed for qualitative assessment of cerebral perfusion patterns in post stroke seizure patients using arterial spin labelling and comparison of cerebral perfusion patterns in post stroke seizure patients and stroke patients without seizure.

Material and Methods

This was a case-control observational study conducted among 100 stroke patients in Christian Medical college, Ludhiana, Punjab, India, from 1st January 2018 till 1st January 2020. The study included Outpatients and Inpatients from Department of Neurology who underwent imaging in Department of Radiology. Patients with stroke undergoing MRI study of the brain and who were willing to participate in this study, were enrolled after obtaining an informed voluntary consent. Institutional Ethics approval was obtained for the study (Ref:2017-Dec/CMCL-IEC-450). Depending on the inclusion and exclusion criteria, patients were categorized into cases and controls. Total 50 cases and 50 age matched controls were included for the study.

Sample size calculation: On the basis of pilot study, 100% of controls had hyperperfusion/hypoperfusion abnormality and 80% of cases had hyperperfusion/hypoperfusion abnormality. Taking these values as reference, the minimum required sample size with 90% power of study and 5% level of significance was 42 patients in each study group. To reduce margin of error, total sample size taken was 100 (50 patients per group).

Formula used

n={(pc×(1-pc)+pe×(1-pe)}×(Zα+Zβ)2)/(pc-pe)2

Where, pc=hyperperfusion/hypoperfusion in controls
pe= hyperperfusion/hypoperfusion in cases.
Zα was value of Z at two sided alpha error of 5%
Zβ was value of Z at power of 90%.

Inclusion criteria:

For control

• Stroke patients with seizure.
• Age >18 years.
• Computed tomography/magnetic resonance imaging diagnosis of ischaemic/haemorrhagic stroke/cerebral venous thrombosis.

For cases

• Stroke patients without seizure.
• Age >18 years.
• Computed tomography/magnetic resonance imaging diagnosis of ischaemic/haemorrhagic stroke/cerebral venous thrombosis.

Exclusion criteria: Patients with known epilepsy prior to stroke event and patients with general contraindications for MRI such as pacemaker, aneurysmal clips, metal implants and claustrophobia were excluded from the study.

Study definition:

Seizure: Transient occurrence of signs or symptoms due to excessive or synchronous neuronal activity in the brain (6).

Epilepsy
1. At least two unprovoked (or reflex) seizures occurring >24 hour apart.
2. One unprovoked (or reflex) and a probability of further seizures similar to the general recurrence risk (at least 60 %) after two unprovoked seizures, occurring over the next 10 years.
3. Diagnosis of epilepsy syndrome (7).

Early post stroke seizure: These are seizures, which occur within the second week following stroke (8).

Late post stroke seizure: These are seizures that begin after a latent period of variable duration following stroke, usually more than 2 weeks to years (8).

Magnetic Resonance Imaging (MRI) Protocols

The MRI was performed on 3 Tesla MRI Scanner (Magnetom Spectra Siemens) using 16 channel head coil. The imaging protocol included axial Fluid Attenuated Inversion Recovery (FLAIR) Diffusion Weighted Imaging (DWI) and Arterial Spin Labeling- Perfusion weighted Imaging (ASL-PWI) with image acquisition protocol as given in (Table/Fig 1). The ASL-PWI was performed using pseudocontinous labeling with labeling duration as 1800 ms and postlabeling delay as 2000 ms. The 3D T1 weighted images were used for registration and segmentation purpose.

Qualitative Image Analysis

The ASL-PWI images were generated through automated color maps. The images were visually analysed by two independent radiologists of 3 years and 18 years of experience for the presence or absence of the following parameters.

i. Diffusion restriction on diffusion weighted imaging (DWI)
ii. Hyperintensity on Fluid attenuated inversion (FLAIR)
iii. Perfusion abnormality on ASL-PWI

Perfusion abnormalities when detected will be further analysed in terms of the following.

i. Pattern (hyperperfusion or hypoperfusion compared to gray matter of normal contralateral parenchyma at the same slice).
ii. Multifocality (focal, multifocal or hemispheric).
iii. Atypical distribution against vascular territories (territorial if perfusion abnormality corresponded to one or more vascular territories or non territorial if not).

Statistical Analysis

Data were entered into Microsoft Excel Sheet. Cases and controls were matched according to age. ASL perfusion parameters were analysed in two groups of the study. Categorical variables were presented in number and percentage (%) and continuous variables were presented as mean±SD and median. Normality of data was tested by Kolmogorov-Smirnov test. Non parametric test was used when the normality was rejected. Quantitative variables were compared using independent t-test (as the data sets were normally distributed) between the two groups. Association between qualitative variables was evaluated using Chi-square test/Fisher’s-exact test. The determined p-value was considered statistically significant for values <0.05 for all the statistics. Data analysis was performed in Statistical Package for Social Sciences (SPSS) version 21.0.

Results

Demographic profile: The mean age of the study subjects were 56.38±16.98 years (age range from 19-87 years) and that of controls were 59.66±11.86 years (age range from 19-89 years) with p value of 0.265. The study included 41 (82%) males as cases and 35 (70%) males as controls. The mean duration between stroke and seizure was 18.36±10.98 hours and 28 (56%) post stroke patients had seizures within 24 hours of stroke. Majority of patients had ischaemic stroke in post stroke seizure patient group as well as in control group, followed by haemorrhagic stroke and few had cerebral venous thrombosis (p-value=0.042) (Table/Fig 2).

Imaging findings: Cortical and subcortical area of involvement had statistically significant association with post stroke seizure (p-value=0.050) (Table/Fig 2). Statistically significant association with T2 FLAIR signal changes and onset of seizure was present (p-value=0.041) (Table/Fig 3). There was also statistically significant T2 FLAIR signal changes in frontal and parietal lobe. There was no significant restricted diffusion involving temporal lobe in post stroke seizure patients (p-value >0.05) (Table/Fig 4). Hypoperfusion was noted in 39 (78%) post stroke seizure patients. Arterial Spin Labeling (ASL) hyperperfusion was seen in 7 patients (14%); out of which most them had ischaemic type of stroke (p-value <0.001) (Table/Fig 5). There was no statistically significant association of perfusion abnormality with onset of seizure was obtained. There was no statistically significant territorial distribution of perfusion abnormality in post stroke patients. The imaging details are summarized in (Table/Fig 4). Representative MR images including ASL-PWI are shown in (Table/Fig 6), (Table/Fig 7), (Table/Fig 8), (Table/Fig 9).

Discussion

This study showed significant association of cortical and subcortical area of involvement with seizure in post stroke patients. Majority of post stroke seizure patients had ischaemic stroke. Most of patients with early onset seizure showed T2 FLAIR hyperintensity in the affected region while patients with late onset seizure showed T2 FLAIR hypointensity. There was no significant involvement of temporal lobe in post stroke seizure patients. Majority of post stroke seizure patients showed hypoperfusion on ASL-PWI irrespective of type of stroke. There was no significant association of perfusion abnormality with onset of seizure seen in this study. The study also did not show any statistical difference in perfusion abnormality between stroke and post stroke seizure patients.

In this study, it was noted that 52% of post stroke seizure patients had ischaemic stroke, 38% had haemorrhagic and lastly 10% had cortical venous thrombosis. In a study conducted among 66 post stroke patients by Proccacianti G et al., 87% of patients had ischaemic stroke as compared to 12% having haemorrhagic stroke (9). According to Zhao Y et al., 10-20% of stroke patients developed seizure after haemorrhagic stroke when compared with 2-14% patients developing seizure after ischaemic stroke (10). In study by Beghi E et al., that enrolled 714 post stroke patients, reported Odds ratio of 7.2 for haemorrhagic stroke to develop post stroke seizure (11). There are many variations in the type of stroke among post stroke seizure patients. This study showed post stroke seizure to be seen following predominantly in ischaemic stroke rather than in haemorrhagic stroke which was similar to study by Proccacianti G et al., (9). It could be because of greater extent of cortical involvement in ischaemic stroke as compared to haemorrhagic stroke as the former has vascular territorial distribution. Moreover, haemorrhagic stroke may involve deep gray matter and subcortical area as in cases of hypertensive bleed with lesser area of involvement. So, type of stroke cannot be taken as sole risk factor for post stroke seizure, other factors like area of involvement and even duration of follow-up should also be considered.

A cohort study by Conrad J et al., in that included 593 patients reported that location of stroke, whether in cortical or subcortical region did not influence the risk of seizure (12). But in study that enrolled 714 post stroke patients by Beghi E et al., reported that 41% of post stroke seizure patients had cortical involvement (11). This study showed that majority of seizure patients had involvement of both cortical and subcortical area which was inconsistent with other studies. These differences could be because of the larger extent of involvement in post stroke seizure rather than the precise area of involvement. In haemorrhagic stroke, haemorrhage volume and blood products could have triggered the onset of seizure rather than its location. There were also few patients with isolated subcortical white matter or deep grey matter involvement with post stroke seizure in this study. Such cases could be due to release of glutamate from axonal terminals arising from affected thalamocortical neurons (13).

As per study by Cheung CM et al., anterior circulation and partial anterior circulation stroke had significant association with post stroke seizure (14). Graham NSN et al., reported that temporal lobe followed by frontal lobe was mostly affected in post stroke seizures (15). However, in this study most patients did not show significant temporal lobe involvement as observed through absence of restricted diffusion or T2 FLAIR signal changes involving temporal lobe. Most patients in our study had frontal lobe and parietal lobe involvement as observed through T2 FLAIR signal changes and cerebral hypoperfusion. This could be because of larger area of involvement of cortex when frontal and parietal lobe is involved as few studies had shown larger cortical area being a risk factor for post stroke seizure (11),(15).

Most of early onset seizure patients showed T2 FLAIR hyperintense signal intensity and majority of late onset seizure patients showed T2 FLAIR signal hypointensity. Majority of early onset seizure patients had seizure within 24 hours of stroke. Hence, the T2 FLAIR hyperintensity could be due to vasogenic oedema or good collateral formation in acute phase. As in case of haemorrhagic stroke, T2 FLAIR signal intensities alter with time. Acute onset of stroke within 48 hours showed T2 FLAIR hyperintensity mainly attributed to oxyhaemoglobin and later on degradation occurs and deoxyhaemoglobin and methaemoglobin contents in blood cause variable signal intensities. Patients with T2 FLAIR hypointensity had encephalomalacia which may have caused late onset post stroke seizure. Study by Yoo R et al., reported that early onset post stroke seizure patients particularly that occurred within 24 hours had hyperintense T2 FLAIR signal changes which was consistent with our study findings (2).

In this study, hypoperfusion of affected area was the predominant finding in both cases and control group irrespective of type of stroke. Hypoperfusion may be due to ischaemic penumbra or areas of encephalomalacia in the affected region. Yoo R et al., reported combination pattern of hypoperfusion and hyperperfusion was observed in early onset post stroke seizure patients (2). Study also reported territorial distribution of hypoperfusion in post stroke seizure patients. These were inconsistent with our study findings. As per study by Miyaji Y et al., on late post stroke seizure, focal hyperperfusion was noted in patients during peri-ictal phase of seizure (16). In this study there was no statistically significant difference in perfusion pattern neither in between post stroke seizure patients and stroke patients without stroke nor in between early onset seizure and late onset seizure patients. These differences could be due to differences in study design and time difference in MRI acquisition following seizure. White matter has delayed arterial transit time and cerebral blood flow compared to grey matter and hence ASL is less sensitive to white matter lesions (3). Susceptibility artifacts from air/bone of base of skull hinders the qualitative perfusion assessment in posterior cranial fossa structures.

This study has some noteworthy strengths. There are limited studies in the literature which have assessed the perfusion parameters in post stroke seizure patients using ASL, as discussed above. Also, since no exogenous contrast agent was required for the study, it enabled inclusion of patients with renal impairment and had added advantage of lack of risk of contrast induced reactions or development of nephrogenic systemic fibrosis to patients.

Limitation(s)

There were several limitations in the study, having been conducted as a single-centre study in a tertiary care hospital. Uniformity in time interval between stroke and scan between cases and control group could not be obtained due to limited number of patients with the disease process. Data regarding follow up of stroke patients were unavailable.

Although the risk factors of development of post stroke seizures are being researched, not much emphasis on the perfusion abnormality and its potential of being risk factor is being given. The ASL perfusion studies are also upcoming imaging modalities whose clinical applications are still being researched. This study may help in further research studies with better study design including quantitative analysis with cerebral blood flow parameters in near future.

Conclusion

Cortical and subcortical area of involvement was noted in post stroke seizure patients. Post stroke seizure patients showed hypoperfusion irrespective of stroke type and onset of seizure. There was no difference seen in perfusion abnormality between post stroke seizure patients and stroke patients without seizure.

Acknowledgement

Authors thank Dr Mahesh P Kate (University of Alberta, Edmonton, Canada) for his contribution to the study design and concept.

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DOI and Others

DOI: 10.7860/JCDR/2022/55267.16473

Date of Submission: Jan 27, 2022
Date of Peer Review: Mar 13, 2022
Date of Acceptance: Apr 7, 2022
Date of Publishing: Jun 01, 2022

AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. Yes

PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Feb 01, 2022
• Manual Googling: Apr 02, 2022
• iThenticate Software: Apr 04, 2022 (11%)

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