Vidéo
Illustrations
Figure 1
Brain MRI images. (A) Axial T2/FLAIR image showing left temporal encephalomalacia. (B) Coronal T2/FLAIR image again showing left temporal encephalomalacia as well as non-specific, mildly increased FLAIR signal within the right middle temporal gyrus (red circle). (C) Coronal T2/FLAIR image showing bilateral orbitofrontal lobes without any clear pathology.
Figure 1
Figure 2
Scalp EEG. Non-convulsive seizure with unclear onset but maximal evolution over the left anterior quadrant where rhythmic theta is seen (red arrows). Bipolar montage: left temporal chain, left parasagittal chain, central, right parasagittal chain, right temporal chain.
Figure 2
Figure 3
Location of SEEG electrodes on scalp and MRI. L: left; R: right; mOlF: mesial orbitofrontal to lateral frontal; aCaS: anterior cingulate to anterior superior frontal gyrus; mCmS: mid-cingulate to middle superior frontal gyrus; AgpT: amygdala to posterior temporal; AglT: amygdala to lateral temporal; pTlT: posterior temporal to lateral temporal; smG: supramarginal gyrus; HplT: hippocampal to lateral temporal; mTpT: mesial temporal to posterior temporal. The number in parenthesis after each abbreviation indicates the number of electrodes in each lead.
Figure 3
Figure 4
(A-C) SEEG traces. (A) Stereo-EEG showing seizure onset with slow waves in the right mesial orbitofrontal region (seen immediately after montage labeling), followed by diffuse attenuation with overlying gamma activity over the anterior prefrontal region (blue arrows) and then rhythmic alpha activity (red arrows). (B) Seizure evolution with rhythmic alpha activity over the right anterior prefrontal region, with highest amplitude over the right mesial orbitofrontal to lateral frontal area and lower amplitude over the right anterior cingulate area, that evolves to rhythmic beta activity (red arrow), corresponding clinically to a counterclockwise head roll. To a lesser extent, there is rhythmic alpha seen over the left mesial orbitofrontal to lateral frontal region (green arrow). (C) Continuation of the right anterior prefrontal seizure (red arrow) with new-onset independent rapid beta spiking in the L amygdala/ hippocampal region (yellow arrow). L: left; R: right; mOlF: mesial orbitofrontal to lateral frontal; aCaS: anterior cingulate to anterior superior frontal gyrus; AgpT: amygdala to posterior temporal; AglT: amygdala to lateral temporal.
Figure 4
Figure 5
Location of seizure onset on SEEG showing the origin of seizure in the right anterior prefrontal region, encompassing the right mesial orbitofrontal region, innermost four electrodes (RmOlF 1-4) (A) with a spread pattern to the left anterior cingulate region (RaCaS 1-3) (B), finally spreading to the left amygdala region (LAgpT 1-4) (C).
Figure 5
Auteurs
1 Department of Neurology, Mount Sinai Health System, New York
2 Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York
3 Department of Neurosurgery, Mount Sinai Health System, New York, USA
* Correspondence: Gabriela Tantillo
Neurology Department,
Epilepsy Division
1468 Madison Avenue 210d,
New York, NY 10029, USA
Longstanding epilepsy can lead to modulation of cortical networks over time and unexpected seizure onset zones. Frontal lobe seizures, in particular, can have diverse semiologies and evolution patterns. We present a male patient with drug-resistant epilepsy secondary to severe traumatic brain injury who underwent bilateral stereo electroencephalography (SEEG) for surgical planning. SEEG localized an ictal circular head roll to the right anterior prefrontal region. This was followed by spread to the left orbitofrontal region and later the left amygdala and hippocampus, at which point a different semiology with behavioral arrest, lip smacking and oral automatisms began. This case, in which an ictal circular head roll was localized to the anterior prefrontal region, demonstrates the complexity of broad seizure networks that develop over time, leading to remote seizure spread.