To investigate the patterns of ictal perfusion and related clinical factors, single photon emission computed tomography (SPECT) subtraction was performed in 61 patients who had undergone epilepsy surgery. In addition to the ictal hyperperfusion region, the ictal hypoperfusion area was obtained by SPECT subtraction. The ictal perfusion patterns of subtracted SPECT were classified into focal hyperperfusion, hyperperfusion-plus, combined hyperperfusion–hypoperfusion and focal hypoperfusion only. The concordance rate of seizure localization was 91.8% in the combined analysis of ictal hyperperfusion–hypoperfusion by SPECT subtraction, 85.2% in hyper- perfusion images of SPECT subtraction and 68.9% in the visual inspection of ictal SPECT. Ictal hypoperfusion occurred less frequently in temporal lobe epilepsy (TLE) than in extra-TLE. Mesial temporal hyperperfusion alone was seen only in mesial TLE while lateral temporal hyperperfusion alone was observed only in neocortical TLE. Hippocampal sclerosis had a much lower incidence of ictal hypoperfusion than other pathologies. Some patients showed ictal hypoperfusion at the epileptic focus with ictal hyperperfusion in the neighbouring brain regions where ictal discharges propagated. Hypoperfusion as well as hyperperfusion in ictal SPECT should be considered for localizing epileptic focus. The mechanism of ictal hypoperfusion could be an intra-ictal early exhaustion of seizure focus or a steal phenomenon associated with the propagation of ictal discharges to adjacent brain areas.