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Background  Single photon emission computed tomography (SPECT) following injection of radiotracer during a seizure is known as ictal SPECT. Comparison of an ictal SPECT study to a baseline or interictal study can aid identification of a seizure focus.    Case presentation  A young woman with encephalitis and refractory seizures underwent brain SPECT during a period of frequent seizure-like episodes, and during a seizure-free period. A focal area of increased radiotracer uptake present only when she was experiencing frequent seizure-like episodes was originally localized to the brainstem, but with later computerized co-registration of SPECT to MRI, was found to lie outside the brain, in the region of the sphenoid sinus.    Conclusion  Low-resolution SPECT images present difficulties in interpretation, which can be overcome through co-registration to higher-resolution structural images.

The hazards of lack of co-registration of ictal brain SPECT with MRI: A case report of sinusitis mimicking a brainstem seizure focus