Teaching Video NeuroImages: Atypical childhood epilepsy with centrotemporal spikes: Seizures often discussed, rarely seen

A 7-year-old right-handed boy with poorly controlled epilepsy presented to the epilepsy monitoring unit for further clarification of his diagnosis. Seizure onset was at 3 years with focal motor seizures of left face and arm followed by confusion and aphasia. Prominent behavioral and school difficulties were also reported. Valproic acid monotherapy (23 mg/kg/d) was weaned by day 2 and a habitual event captured on day 5 (figure, video 1). Brain MRI and an epilepsy gene panel (including GRIN2A) were nonrevealing. The diagnosis was therefore consistent with atypical childhood epilepsy with centrotemporal spikes. This differs from benign rolandic epilepsy because of earlier seizure onset, increased seizure burden, EEG with background slowing (figure) with stereotyped discharges, seizure semiology, and more prominent comorbidities.^1,2