A 25-year-old female with a prior history of syncope (lightheadedness, followed by LOC for a few seconds, and no ictal or post ictal phenomena) presented with a witnessed generalized tonic clonic (GTC) seizure. She had recently returned from Switzerland and was otherwise well. She had eaten. She was walking, followed by running on a treadmill, felt a little faint for a second or so and then lost consciousness. She was unable to brace herself, fell backwards and sustained a head laceration on the posterior, right back of her head. The event was witnessed by a physician, and she was noted to have rhythmic shaking for 30 to 45 s. She bit her tongue, had post-ictal confusion, but no bowel or bladder incontinence.
The head and cervical spine CT scans were unremarkable. Her brain MRI with contrast was notable for 2 enhancing lesions in the left frontal and temporal lobes (Fig. 1A, B). It was unclear whether these lesions were intra-axial or extra-axial given their small size and peripheral location. Differential of prior infection/granulomatous disease including tuberculosis and sarcoid, small meningiomas, and neoplastic seeding was raised. Her electroencephalogram (EEG) was notable for left temporal slowing with some sharp features (Fig. 1C). Lumbar puncture showed zero red blood cells and white blood cells. Tests for cerebrospinal fluid protein, glucose, gram stain and culture, acid-fast bacilli, cytologic examination, angiotensin-converting enzyme (ACE), and cysticercosis antibody were all negative. Blood erythrocyte sedimentation rate, C-reactive protein, ACE, anti-nuclear antibody (ANA) and antineutrophil cytoplasmic antibodies (ANCA) were only notable for positive ANA of 1:320. EKG showed no PR shortening, ST wave abnormalities or QTC prolongation.
The patient underwent repeat imaging and testing 1 month post event. Her head CT was notable for a small region of encephalomalacia in the left frontal region (Fig. 2A). No enhancement was seen on axial T1-weighted MRI following contrast administration (Fig. 2B, C). Her sleep-deprived EEG was normal. The patient was not initiated on anti-convulsant medication and has done well since.