Pontine hyperperfusion associated with ictal central apnea

We report ictal SPECT findings in a patient with focal epilepsy and ictal central apnea (ICA). We describe the history, EEG findings, and SPECT analysis of a 38-year-old female with left posterior quadrant epilepsy post intracerebral hemorrhage due to ruptured aneurysm, whose seizures are accompanied by ICA. The patient underwent continuous EEG monitoring as a presurgical candidate for her epilepsy, during which several typical seizures associated with ICA were captured. Ictal SPECT was performed during a typical seizure with ICA, with tracer administration 15 s after the ICA onset, 14 s after the EEG onset, 7 s after the first video-appreciated clinical change, and 24 s before evolution to focal-to-bilateral tonic-clonic seizure. Ictal SPECT revealed significant hyperperfusion in the anterior pons with mild left > right lateralization. Ictal SPECT hereby demonstrates the potential to highlight ICA-associated regions in patients with focal epilepsy. Vigilance for similar imaging markers is recommended in centers that have access to SPECT without incorporating respiratory monitoring during routine EMU procedures, as pontine hyperperfusion may suggest underlying ICA and considerable risk of sudden unexpected death in epilepsy.