An almost 13 month old boy born at 34 weeks gestationwith a history of macrocephaly had a seemingly minor head injury. He cried immediately but then became less responsive, leading to evaluation. A cranial CT showed bilateral extraaxial fluid collections with superimposed acute hemorrhage. Bilateral subdural drains were placed.
Focal seizures involving the left hand occurred. Levetiracetam and subsequently fosphenytoin wereadministered, as well as lorazepam and midazolam. Videoelectroencephalographic monitoring showed multiple focal seizures arising from the right posterior quadrant associated with rhythmic eye blinking, and one with left foot movements. There were independent focal seizures from the left hemisphere without clear clinical correlate. The interictal background showed diffuse slowing, and lack of organizational features.
On the fourth day a cranial MRI was obtained showing on diffusion imaging a diffuse pattern of cytotoxic edema/diffusion restriction extending throughout the bilateral cerebral hemispheres, with some sparing of the anterior temporal and anterior/inferior frontal lobes. A diffuse pattern of white matter involvement, with transcortical extension was most conspicuous in the posterior temporal, occipital, and parietal lobes. There was notable focal involvement of the caudate nuclei, bilaterally.
When the MRI was repeated after 5 days, the widespread diffusion changes were no longer present.
In their stead were bilateral diffusion and T2 changes involving the posterior limb of the internal capsule and the ventral cerebral penduncles.
Seizure activity abated clinically and electrographically. A skeletal survey showed no bony injury. There were bilateral retinal hemorrhages.