Non-dominant, Non-lesional Orbitofrontal-Plus Epilepsy

We present a patient with pharmacoresistant non-lesional epilepsy who underwent non-dominant orbitofrontal and temporal pole resective surgery. We review the post-operative outcomes in orbitofrontal lobe-related epilepsies and multilobar resective surgeries. We also discuss the significance of widespread hypometabolism observed on an interictal PET scan, the utility of SPECT in the surgical work-up, the undersampling of ictal onset nodes during intracranial monitoring, the similarity of specific propagation patterns to ictal onset patterns, interictal epileptiform discharges and spiking rate during intracranial monitoring, and rhythmic delta slowing observed during ictal propagation. We summarize the different EEG findings in patients with orbitofrontal, temporal pole, and insular epilepsies. We review the association between prematurity and developing epilepsy. We highlight the importance of multimodal non-invasive modalities that constitute an integral part of the surgical investigational armamentarium. Lastly, we analyze semiologies such as ictal head turn, gyration or body turn or rotation around the horizontal axis, dystonic versus tonic seizures, post-ictal laughter, and post-ictal psychiatric manifestations.