Indian Journal of Nuclear Medicine

: 2013  |  Volume : 28  |  Issue : 2  |  Page : 93--95

Hemimegalencephaly: A rare cause of hemihypoperfusion on 99m technetium-ethyl cysteinate dimer brain perfusion single-photon emission computed tomography

Nishikant A Damle, Abhinav Singhal, Anirban Mukherjee, Manas Kumar Sahoo, Madhavi Tripathi, Chandrasekhar Bal 
 Department of Nuclear Medicine, All India Institute of Medical Sciences, New Delhi, India

Correspondence Address:
Nishikant A Damle
Department of Nuclear Medicine, All India Institute of Medical Sciences, New Delhi - 110 029


Hemimegalencephaly is a rare congenital neuronal migration disorder that can presents with the equally rare finding of hemihypoperfusion on brain perfusion single-photon emission computed tomography (SPECT). It is an extremely rare cause of intractable epilepsy. Technetium-99m ethyl cysteinate dimer (ECD) brain perfusion SPECT is useful in excluding other foci of hypoperfusion in the contralateral since hemispherectomy has been suggested to be the treatment of choice. Furthermore, hemimegalencephaly may present with hyper as well as hypoperfusion on ECD SPECT. We present the case of an 11-year-old male child with intractable seizures who showed hemihypoperfusion in the hemimegalecephalic hemisphere.

How to cite this article:
Damle NA, Singhal A, Mukherjee A, Sahoo MK, Tripathi M, Bal C. Hemimegalencephaly: A rare cause of hemihypoperfusion on 99m technetium-ethyl cysteinate dimer brain perfusion single-photon emission computed tomography.Indian J Nucl Med 2013;28:93-95

How to cite this URL:
Damle NA, Singhal A, Mukherjee A, Sahoo MK, Tripathi M, Bal C. Hemimegalencephaly: A rare cause of hemihypoperfusion on 99m technetium-ethyl cysteinate dimer brain perfusion single-photon emission computed tomography. Indian J Nucl Med [serial online] 2013 [cited 2023 Feb 3 ];28:93-95
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Full Text


Hemimegalencephaly is a rare congenital neuronal migration disorder characterized by unilateral hypertrophy of a cerebral hemisphere and ipsilateral ventriculomegaly. [1],[2] It can be an isolated abnormality, or it can be associated with neurocutaneous syndromes. [1] Clinical manifestations include intractable motor seizures, impaired psychomotor development, hemiparesis, and hemianopsia. [1] Patients having hemimegalencephaly usually have a very poor prognosis. These patients require early surgical interventions to prevent progression to intractable epilepsy. [3] Hemispherectomy is the treatment of choice. [1] The definition of the dysfunctional areas of dysplastic cortex may affect surgical management of these anomalies. [4] Evaluation of regional cerebral blood flow using technetium-99m ethyl cysteinate dimer (Tc-99m ECD) single-photon emission computed tomography (SPECT) provides useful information in the patient of hemimegalencephaly [5],[6] because it clearly delineates the border of the dysplastic cortex by showing altered blood flow to the dysfunctional areas. [4]

 Case Report

An 11-year-old male child was referred to a tertiary care hospital with history of gradually increasing seizures frequency since infancy. The child had delayed milestones and right hemiparesis. Seizures were mainly right sided, complex partial in nature and refractory to medical treatment over the past decade. The child was born out of non-consanguineous marriage, at term with a normal vaginal delivery. There was no family history of neurologic diseases. Non-contrast computed tomography (CT) of head showed diffuse enlargement of left cerebral hemisphere with midline shift towards right while the right cerebral hemisphere was normal [Figure 1]a. T2W magnetic resonance imaging (MRI) images showed diffuse gyral thickening involving the left cerebral cortex causing midline shift and scalloping of inner table of left calvarium [Figure 1]b.White matter in both cerebral hemispheres show normal myelination. Linear hyperintensities involving the subcortical U fibers of left fronto-parietal region were seen on the fluid attenuation inversion recovery image [Figure 1]c.

Post-gadolinium T1W image in axial plane showed no abnormal enhancement [Figure 1]d. Tc-99m ECD brain perfusion SPECT revealed diffusely decreased tracer uptake in the left cerebral hemisphere, with normal uptake in the right hemisphere suggestive of left cerebral hemihypoperfusion [Figure 2]a-c.{Figure 1}{Figure 2}


Tc-99m ECD is a perfusion agent similar to Tc-99m hexamethylpropyleneamine oxime (HMPAO). Regional differences in perfusion within the affected hemisphere with relative interictal hypoperfusion and ictal hyperperfusion of the seizure focus in a neonate with hemimegalencephaly has been reported on Tc-99m HMPAO brain SPECT imaging. [7] Ictal SPECT using Tc-99m HMPAO is also useful in demonstrating the site of epileptogenesis and its spread. [2] Sometimes it has been found that brain SPECT shows increased radiotracer uptake in the pathological hemisphere in the early part of life, which gets reversed in the later stage with decreased radiotracer uptake in the pathological hemisphere. These serial changes of radiotracer uptake on SPECT probably reflect either changes in epileptic activity or maturational changes in cerebral perfusion in hemimegalencephaly. [8] Brain SPECT helps in excluding seizure foci or other perfusion abnormalities in the contralateral side before surgery. [1] Considering recent recommendations for hemispherectomy in these patients, Tc-99m ECD/HMPAO SPECT scan should be used to complement electroencephalogram (EEG) as a method to define the extent of abnormality, which may be more relevant to long-term prognosis than EEG alone. [9] Also, while interpreting a brain SPECT, hemimegalencephaly must be considered as a differential in hemihypoperfusion, for which CT/MRI correlation should be sought before reporting. The other differentials for hemispheric hypoperfusion are Rasmussen's encephalitis, [10] Sturge Weber syndrome, [11] Aspergers syndrome, [12] exanthema subitum [13] and gliomatosis cerebri, [14] which can even be mistaken for hemimegalencephaly.


1Bar-Sever Z, Connolly LP, Barnes PD, Treves ST. Brain SPECT evaluation of cerebral perfusion in hemimegalencephaly. Clin Nucl Med 1997;22:250-2.
2Tanaka Y, Hamano S, Nara T, Nakanishi Y. A case of hemimegalencephaly: Ictal EEG and SPECT. No To Hattatsu 1994;26:528.
3Uematsu M, Haginoya K, Togashi N, Hino-Fukuyo N, Nakayama T, Kikuchi A, et al. Unique discrepancy between cerebral blood flow and glucose metabolism in hemimegalencephaly. Epilepsy Res 2010;92:201-8.
4Tutuncuoglu S, Tekgul H, Duman Y, Kayalioglu M. 99m Tc HMPAO-SPECT in patients with neuronal migration anomalies. Turkish Journal of Nuclear Medicine 1996;5:165-9.
5Podreka I, Suess E, Goldenberg G, Steiner M, Brücke T, Müller C, et al. Initial experience with technetium-99m HM-PAO brain SPECT. J Nucl Med 1987;28:1657-66.
6Ozkiriş A, Evereklioglu C, Kula M, Somdaş M, Erkiliç K, Coşkun A. Tc-99m HMPAO brain SPECT in linear nevus sebaceous syndrome. Ann Nucl Med 2003;17:703-6.
7Alfonso I, Harvey S, Acuña A, Velez E, Papazian O, Litt R, et al. Interictal and ictal SPECT in a neonate with hemimegalencephaly. Clin Nucl Med 1997;22:323-4.
8Tagawa T, Otani K, Futagi Y, Wakayama A, Morimoto K, Morita Y. Serial IMP-SPECT and EEG studies in an infant with hemimegalencephaly. Brain Dev 1994;16:475-9.
9Konkol RJ, Maister BH, Wells RG, Sty JR. Hemimegalencephaly: Clinical, EEG, neuroimaging, and IMP-SPECT correlation. Pediatr Neurol 1990;6:414-8.
10Tessonnier L, Thomas P, Benisvy D, Chanalet S, Chaborel JP, Bussière F, et al. Perfusion SPECT findings in a suspected case of Rasmussen encephalitis. J Neuroimaging 2009;19:378-80.
11Aylett SE, Neville BG, Cross JH, Boyd S, Chong WK, Kirkham FJ. Sturge-Weber syndrome: Cerebral haemodynamics during seizure activity. Dev Med Child Neurol 1999;41:480-5.
12Yang WH, Jing J, Xiu LJ, Cheng MH, Wang X, Bao P, et al. Regional cerebral blood flow in children with autism spectrum disorders: A quantitative 99mTc-ECD brain SPECT study with statistical parametric mapping evaluation. Chin Med J (Engl) 2011;124:1362-6.
13Ohta H, Watanabe Y, Sumimoto S, Kojima N, Ishigaki T, Todo G, et al. Hypoperfusion of right hemisphere on brain SPECT in a patient with exanthem subitum and left hemiparesis. Ann Nucl Med 2000;14:223-5.
14Maton B, Resnick T, Jayakar P, Morrison G, Duchowny M. Epilepsy surgery in children with gliomatosis cerebri. Epilepsia 2007;48:1485-90.