P17-T Hippocampal sclerosis (HS) with frontal lobe seizure semiology. Case presentation

• Published in: Clinical neurophysiology 2019-07, Vol.130 (7), p.e43-e43
• Main Authors: Brimble, Glen, Thomas, Benny, Montes Pena, Vizmary J., Hamandi, Khalid, Gray, William, Gwynn, Richard
• Format: Article
• Language: English
• ISSN: 1388-2457; 1872-8952
• DOI: 10.1016/j.clinph.2019.04.380

54-year-old lady with drug resistant epilepsy. Seizure onset aged 10. No history of febrile convulsions. Head injury aged 4. Medication; Lamotrigine, Topiramate and Levetiracetam. Seizure Description: Onset (20–30 s) comprised butterfly feeling in stomach associated with déjà-vu and abnormal taste/smell/warm feeling. Majority progress to un-coordinated kicking or thrashing movements of 4 limbs. Cluster around menstruation/ovulation. Telemetry workups: 2003: Three seizure with frontal lobe semiology. Electrographic onset clearly localises activity to left hemisphere. Discordant with MRI (right HS). Patient did not progress to surgical investigations. 2011: One ‘Hyper-motor’ seizure preceded by vocalisation. EEG showed left temporal rhythmic delta. 2012: Epileptic seizures captured with left temporal EEG changes. 2017: temporal onset seizures. Lack of robust electrographic lateralisation. Imaging 2017: PET: Bilateral temporal hypo-metabolism. MRI: Right HS. Stereotactic –EEG(SEEG): 2017: Bilateral hippocampal and right frontal lobe insertion. SEEG findings in keeping with right mesial temporal onset. Frontal semiology 28 s following electrographic onset. First clinical symptoms were of deja-vu. Schedule Surgery: Trans-Sylvian selective right amygdalo-hippocampectomy performed June 2018. Patient reports a single possible seizure (non habitual) since then and is pleased with the surgical outcomes. Initial telemetry suggested the patients seizures were probable frontal in lobe origin. We propose this was due to the rapid propagation of hippocampal seizure to the orbitofrontal, insula,and premotor cortex resulting in a ‘hyper-motor’ seizure. Demonstrates the importance of multimodal evaluation and imaging, robust semiological description and the value of SEEG in lateralisation of seizure onset.