Right mesial temporal sclerosis and left temporal seizures? Description of a case

Objective To report the diagnostic problems in the non-invasive presurgical evaluation of a patient with temporal lobe epilepsy. Materials and methods We studied a 34-year-old woman who presented prolonged febrile convulsions at 2 years of age, suffering from daily automotor seizures since the age of 3. The patient underwent sleep and awake EEG recordings, prolonged video-EEG monitoring and cranial MRI. Results MRI disclosed right mesial temporal sclerosis. Interjetai EEG showed paroxysmal activities over the right temporal region and less frequent independent left temporal spikes. We recorded by means of videoEEG five seizures. Clinical ictal semiology was characterized by an epigastric aura followed by right head and eye deviation, oro-alimentary and right arm automatisms together with a distonic posturing of the left arm and finally a right hand nose-wiping. These findings suggested a right temporal lobe involvement. Ictal EEG was characterized by a rhythmic sharp theta activity on the left temporal regions. Conclusions Ictal seizure semiology and neuroradiological data in accordance suggested right temporal lobe involvement. On the contrary ictal EEG suggested a left temporal seizure onset. With such a discrepancy, are deep electrode studies mandatory to localize the epileptogenic area?