Clinical Reasoning: A 16-year-old girl with fixed unilateral grimace

Abstract

A 16-year-old girl was referred from the epilepsy clinic for urgent admission to the long-term EEG monitoring unit. She had a prior history of both epileptic and nonepileptic seizures of multiple types, but presented to the clinic for evaluation of a new type of movement, present for 1 month. Over that time period her home antiseizure regimen (levetiracetam and topiramate) had been serially increased with no relief. She described (and demonstrated) a tonic spasm of the right lower face which had a sudden onset and lasted 30–90 seconds. In retrospect, her parents reported small facial twitches which preceded the full-blown spasms by 2 months. These spells appeared to worsen with stress and attention. Short episodes were not painful, but as the episodes became more frequent she developed progressively worsening masseter pain. On the day of admission, she experienced these spasms every 5–10 minutes, more frequently during the examination. Between episodes, her neurologic examination had normal results, with no sensory or motor changes to the face. The video on the Neurology ® Web site at www.neurology.org provides an example. ### Questions for consideration: 1. What is your differential for this facial spasm? 2. How would you evaluate this movement? GO TO SECTION 2 At the top of our differential were true seizures and nonepileptic events, including pseudoseizures. Review of the first day's awake EEG supported our initial clinical suspicion; her facial spasms had no electrographic correlate. On the first morning following admission, we began a discussion with her mother regarding nonepileptic seizures. On that day, the patient had 2 nontraumatic falls which her parents agreed were identical to her previously characterized nonepileptic events. Upon review of her overnight EEG (figure 1), however, we were forced to rethink her presentation and expand our differential. Figure 1 A typical EEG during the facial spasm Overnight EEG illustrating a typical facial spasm. Sleep spindles …