PMC9807991_01
Representative findings of investigations. Longitudinal bipolar montage of electroencephalography (EEG), showing interictal right temporal spikes (A), and right temporal seizure onset (B, C) during paroxysmal chest discomfort associated with chest rubbing with the right hand with sequential consciousness loss (D). Dots represent right anterior temporal interictal spike (A), or ictal seizure onset from the right temporal region (B). Coronal images of fluid-attenuated inversion recovery magnetic resonance imaging taken at admission (E) and one year follow-up after becoming seizure-free (F) showing improvement of the right amygdala enlargement (arrowheads).
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LTVEM showed interictal spikes in the right anterior temporal region (Fig. 1A). One habitual spell of chest discomfort was recorded, followed by him rubbing his chest with his right hand (Fig. 1B) accompanied by tachycardia of 144 bpm from the baseline of 65 bpm. EEG change started in the right temporal region (Fig. 1C, 1D) 6 s before the clinical onset. 3 T brain MRI showed right amygdala enlargement (Fig. 1E). Examination of the cerebrospinal fluid by indirect immunofluorescence using commercially available kits (Euroimmun, Lubeck, Germany) identified no known autoimmune antibody causing epilepsy, such as antibodies to N-methyl-d-aspartate receptor (NMDA), alpha-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid receptor (AMPAR), leucine-rich glioma-inactivated ptotein-1 (LGI-1), contactin-associated-protein-receptor-2 (CASPAR2), and gamma-aminobutyric acid-B receptor (GABABR). Therefore, the final diagnosis was right mesial temporal lobe epilepsy (mTLE) with amygdala enlargement. He has been seizure-free until the latest follow-up at 1 year after initiation of 300 mg lacosamide, when MRI showed improvement of the right amygdala enlargement (Fig. 1F).