Abstracts

To document a case of isolated hemifacial movements due to epileptic seizures of medial temporal onset, and document the probable neuroanatomical pathways responsible for ictal semiology. A 28 year-old right-handed man presented with onset of epilepsy at age 8. Seizures began with a [ldquo]tightening[rdquo] feeling over the right side of the face. During these symptoms, the patient reported that the right side of his face [ldquo]drew up[rdquo] which would sometimes progress to involve [ldquo]twitching.[rdquo] During these symptoms, he was unable to speak, but did not lose consciousness. Typical seizure duration was 15-30 seconds. Occasionally, more prolonged seizures involved [ldquo]grunting[rdquo] respirations, and a degree of loss of consciousness. At presentation, his simple partial seizures were occurring 3-4 times per day. His seizures were refractory to multiple AEDs. Neurological examination was non-focal. Routine interictal EEG showed left fronto-temporal epileptiform discharges. Video EEG telemetry monitoring revealed multiple seizures, beginning with tonic contraction of the right hemi-face, lasting 15-30 seconds, with preservation of consciousness. Scalp ictal EEG showed onset of left anterior temporal theta range slowing approximately 10 seconds after clinical seizure onset. MRI was normal. FDG-PET showed hypometabolism in the left anterior and medial temporal regions. Extensive subdural electrode coverage over the left frontal and temporal regions localized the epileptogenic zone to the medial temporal region, and showed propagation of the ictal discharge to the ipsilateral cingulate region. Clinical onset of contralateral hemi-facial movements correlated with propagation of the ictal discharge in the cingulate gyrus in all recorded seizures. The patient underwent a left anterior temporal lobectomy with resection of the amygdala and adjoining hippocampus, with sparing of hippocampal body. Post-surgical pathology revealed focal glial nodules and patchy neuronal loss in the amygdala. The patient has been seizure-free for 4 years postoperatively. This case respresents a rare example of epileptic seizures of medial temporal onset presenting with isolated somatomotor manifestations, successfully treated with epilepsy surgery, which stresses the importance of this semiologic presentation. Anatomo-electro-clinical correlations of this case with cortical regions controlling facial movements (Morecraft et al, Brain (2001), 124, 176-208) are highly suggestive that this case represents secondary activation of M3 an M4 (rostral and caudal cingulate motor cortex), giving rise to focal hemi-facial movements.