Pediatric Focal Epilepsy In-patient Monitoring

Pediatric Focal Epilepsy with Visual Auras: Localizing Left Hemisphere Irritative Zones through Video-EEG Monitoring

 

Patient History

 

The patient, a 10-year-old female, was completely well after birth with no history of seizures, NICU stay, or neonatal jaundice. The first seizure episode occurred in 2022, preceded by an aura described as a weird sensation. Clinically, the seizure manifested as a right focal event with eye deviation and facial deviation towards the right side. The patient also reported intermittent rainbow-colored visual illusions in the right eye. A prior routine EEG did not reveal any epileptiform discharges and was reported as normal. Following the second seizure episode, the treating doctor recommended long-term Video EEG monitoring. The monitoring demonstrated left fronto-temporal spike-and-wave epileptiform discharges. Based on these findings, the patient was started on antiepileptic medications (AEDs). For the past two years, the patient has been continuing the medication and remained seizure-free until approximately four months ago. The Mocxa EEG again demonstrated the same localization of focal seizure activity with similar semiology. This case highlights Mocxa’s capability to perform extended EEG monitoring in children across varied environments while effectively capturing clinically relevant epileptiform activity.

 

Procedure Details

 

Location	In-patient
Duration	9 Hours
EEG Type	Ambulatory, 21 Channels, With Video

 

Report

 

Interictal: Background activity in the posterior cerebral (PC) leads shows predominantly alpha rhythm of 11–12 Hz, bilaterally symmetrical, intermixed with beta activity of 14–16 Hz. This activity spreads anteriorly to the fronto-temporal leads and shows normal reactivity to visual stimulation. Hyperventilation and photic stimulation were not performed during the recording.

The patient entered spontaneous sleep during the study, during which the background activity slowed with typical EEG sleep architecture including sleep spindles and vertex waves, suggestive of Stage N2 NREM sleep.

Interictal EEG abnormalities noted were:

• Occasional sharp waves over the left hemisphere involving FP1–F7, F7–T3, T3–T5, T5–O1, and P3–O1, with spread to midline central and right parietal leads (CZ–PZ, P4–O2).
• Bursts of high-amplitude slow sharp waves originating from the left fronto-temporal region with partial generalization.

Clinical Attacks: During the recording, two clinical seizure events and three visual aura episodes described as “rainbow” visual phenomena were observed.

Ictal Events:

Event 1:
The episode began with fearfulness (aura) followed by impaired awareness and unresponsiveness, with the patient staring toward the right side for approximately 3–4 minutes. A questionable immobility of the right hand was also noted.

Event 2:
The patient again reported fearfulness as an aura, followed by impaired awareness and unresponsiveness.

Additionally, the patient reported three visual aura episodes described as seeing rainbow-like visual phenomena. During these aura episodes, the patient remained fully conscious, alert, and responsive, answering questions appropriately. No other abnormal movements were observed.

Ictal EEG:

• Event 1: EEG demonstrated 4–5 Hz rhythmic activity over the left temporo-frontal region, evolving into high-amplitude slow sharp waves, followed by spike/polyspike-and-wave discharges spreading to the midline central and right parieto-occipital regions. The episode lasted approximately 3–4 minutes.
• Event 2: Similar 4–5 Hz rhythmic activity over the left hemisphere evolving into spike-and-slow-wave discharges with spread to midline central and right parieto-occipital regions.

Impression: This 9-hour short-term Video EEG recording with spontaneous sleep captured two ictal events and three visual aura episodes (“rainbows”).

Interictal EEG findings are abnormal, indicating an irritative epileptogenic zone over the left hemisphere.

The clinical semiology and corresponding EEG findings are suggestive of focal seizures arising from the left hemisphere, with subsequent spread to adjacent and contralateral regions.