Neurology · Year 3 · from Neurology

Case 2: Focal Epilepsy with Secondary Generalization

Patient Demographics

  • Age: 45 years
  • Sex: Female
  • Occupation: Accountant

Chief Complaint

"My right arm starts jerking, then I lose consciousness."

History of Present Illness

The patient has experienced recurrent episodes over the past 6 months. Each episode begins with a strange "rising" sensation in her stomach, followed by an unusual smell (described as "burning rubber"). She then notices her right arm begins jerking rhythmically while maintaining awareness. If she cannot suppress it, the jerking spreads to involve the whole right side, then she loses consciousness and has a generalized convulsion. Episodes last 2-3 minutes total. She has no memory of the generalized phase. Afterward, she has difficulty speaking for 30-60 minutes (post-ictal aphasia). She had a severe head injury (motor vehicle accident) 10 years ago with prolonged unconsciousness. No recent illness, medication changes, or substance use.

Neurological Examination Findings (Interictal)

Mental Status:

  • Alert, oriented, fluent speech
  • Normal cognition

Cranial Nerves:

  • Intact II-XII

Motor Examination:

  • 5/5 strength throughout
  • Normal tone

Sensory Examination:

  • Intact to all modalities

Reflexes:

  • 2+ symmetric
  • Plantar responses flexor

Coordination:

  • Normal finger-to-nose and heel-to-shin
  • Normal gait

Seizure Classification

Focal onset seizure with retained awareness (aura) → Focal motor seizure → Focal to bilateral tonic-clonic seizure

  • Aura (epigastric rising, olfactory hallucination) = temporal lobe origin
  • Focal motor (right arm jerking) = left motor cortex spread
  • Secondary generalization

Neuro Workup

  • MRI Brain with epilepsy protocol:
  • Left temporal lobe encephalomalacia (post-traumatic)
  • Left hippocampal sclerosis with volume loss and increased T2 signal
  • EEG (routine): Left temporal intermittent rhythmic delta activity (TIRDA), left temporal sharp waves
  • Video-EEG monitoring (5 days): Captured 3 seizures, all with left temporal onset (F7/T3)
  • PET scan: Left temporal hypometabolism (interictal)

Diagnosis

Left temporal lobe epilepsy secondary to post-traumatic encephalomalacia and mesial temporal sclerosis

  • Drug-resistant epilepsy (failed 2+ appropriately chosen AEDs)

Management

Antiepileptic Drug Therapy:

  1. Current: Levetiracetam 1500 mg BID, carbamazepine 400 mg BID
  2. Prior trials: Phenytoin (allergic), lamotrigine (breakthrough seizures)
  3. Addition of third drug considered (lacosamide, brivaracetam)

Epilepsy Surgery Evaluation:

  1. Patient is a surgical candidate - focal, drug-resistant epilepsy with concordant data
  2. Concordance: Semiology (left temporal), MRI (left MTS), EEG (left temporal), PET (left temporal hypometabolism)
  3. Neuropsychology: Left temporal memory deficits, good right temporal function
  4. Wada test: Right hemisphere language and memory dominant
  5. Recommendation: Left anterior temporal lobectomy with amygdalohippocampectomy
  6. Expected outcome: 60-80% seizure-free rate

Counseling:

  1. Driving restrictions until 6-12 months seizure-free (state-dependent)
  2. Medication adherence
  3. Avoid seizure triggers (sleep deprivation, alcohol)
  4. SUDEP risk counseling
  5. Reproductive counseling (teratogenicity of AEDs)

Clinical Image

Image Description: Coronal T2-weighted MRI showing left mesial temporal sclerosis with hippocampal atrophy and increased signal intensity compared to the right hippocampus.

Attribution: Image from Radiopaedia.org, Case courtesy of Dr. David Cuete. Licensed under CC BY-NC-SA 3.0. Source: https://radiopaedia.org/cases/mesial-temporal-sclerosis-3

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