Cortex on Fire: Infarct Mimicking Ictal.

A 65-year-old woman with treated small cell lung cancer presenting with recurrent stroke-like symptoms and seizures underwent FDG PET/CT and MRI. Brain MRI revealed diffusion restriction. Subsequent 18 F-FDG PET/CT demonstrated an unusual metabolic signature: intense left frontoparietal cortical uptake ("cortex on fire") with discordant ipsilateral thalamic and contralateral cerebellar decreased uptake ("ice in thalamus and cerebellum"). We term this pattern triaxial metabolic diaschisis (TMDS), representing discordant diaschisis, distinct from concordant hypometabolism of ischemic stroke or hypermetabolic cortical and subcortical propagation typical of ictal seizures. The pattern suggests left frontal uptake is not secondary to neuronal activity.