BACKGROUND: Advanced imaging is one of the main modalities utilized in the diagnostic investigation of a first-time epileptic ictus, as well as in the evaluation of a patient suspected of having an ischemic stroke.

CASE REPORT: We report the case of a 7-year-old boy who was admitted to our hospital because of a depressed skull fracture. Soon after its initial evaluation, he had an episode of generalized tonic-clonic seizures; therefore, a detailed diagnostic work up was scheduled, which raised the diagnostic dilemma of ischemic stroke versus imaging alterations related to status epilepticus. He underwent surgical exploration, and a few days later the repeat MRI verified that the initial signal changes should be attributed to the ictus.

CONCLUSIONS: Brain edema, most commonly affecting a cerebral hemisphere in its entirety, is a rare post-ictal imaging finding that is causally related to focal-onset status epilepticus. The aforementioned perfusion changes can aid in the differentiation of ictal-related brain abnormalities from acute ischemic stroke, if regional or more diffuse areas of increased perfusion are shown on MRI. Consequently, MRI should be considered the preferred imaging modality when we are confronted with cases of post-ictal signal changes that could masquerade as acute ischemic stroke.

Keywords: Brain Edema, Status epilepticus, Stroke, Child, Diagnosis, Differential, ischemic stroke, Seizures, Skull Fracture, Depressed