Reflex “toothbrushing” epilepsy: Seizure freedom after focal ablation assisted by ictal fMRI

Abstract

A 22-year-old female presented with drug-resistant focal motor seizures with onset at age 14. This manifested as daily episodes of right facial dystonia triggered by toothbrushing, but also by eating, talking, and strenuous exercise. On ictal scalp EEG, there was low-voltage fast activity over the left pericentral area. Structural MRI did not identify a definite lesion. Functional MRI (fMRI) of a reflex seizure, as well as task-based fMRI during toothbrushing, both demonstrated focal activation at the left low pericentral cortex. Stereoelectroencephalography (sEEG) showed recurrent ictal trains of focal spiking concordant with the fMRI activation. Radiofrequency (RF) thermocoagulation was ap..