Diagnosis: Benign Rolandic Epilepsy (Self-Limited Epilepsy with Centrotemporal Spikes)
The diagnosis is B - Benign Rolandic syndrome, based on the characteristic clinical presentation of brief focal seizures with orofacial involvement and mouth deviation, triggered by specific activities (combing hair), occurring in a neurologically normal child, combined with the pathognomonic EEG finding of focal sharp spikes in the centrotemporal region. 1, 2
Clinical Features That Confirm This Diagnosis
The presentation is classic for benign rolandic epilepsy:
Brief tonic-clonic movements with mouth deviation are the hallmark motor manifestations, representing hemifacial motor seizures with oropharyngolaryngeal involvement 2, 3
Seizures triggered by specific motor activities (combing hair in the morning) and occurring during sleep transitions are characteristic, as these seizures are frequently related to sleep and drowsiness 2, 3
Self-resolving episodes without intervention lasting only seconds fits the typical brief, simple partial seizure pattern 2, 3
Neurologically normal examination with unremarkable systemic review is essential for this diagnosis, as children with benign rolandic epilepsy are neurologically and cognitively normal 2
EEG Findings Are Pathognomonic
The focal sharp spikes in the centrotemporal area are the defining EEG characteristic that distinguishes benign rolandic epilepsy from other seizure disorders 2, 3. These high-voltage sharp waves in centrotemporal regions are activated with drowsiness and sleep, and several seizure syndromes including benign rolandic seizures are sufficiently characteristic to be diagnosed clinically or through specific EEG patterns 1
Why Other Options Are Incorrect
West syndrome (A) presents in infancy (typically 3-12 months) with infantile spasms, developmental regression, and hypsarrhythmia on EEG—none of which are present here 2
Lennox-Gastaut syndrome (C) occurs in younger children with multiple seizure types (tonic, atonic, atypical absence), developmental delay, and slow spike-wave complexes on EEG, not focal centrotemporal spikes 2
Absence epilepsy (D) presents with brief staring spells without motor activity or mouth deviation, and shows generalized 3-Hz spike-wave discharges on EEG, not focal centrotemporal spikes 2
Management Implications
Imaging is not routinely required when clinical and EEG findings are typical, as this case demonstrates 1. The ACR Appropriateness Criteria specifically state that benign rolandic seizures with classic EEG findings are sufficiently characteristic to be diagnosed clinically and usually do not require imaging 1
The prognosis is excellent, with essentially all children entering long-term remission by mid-adolescence 2. Seizures are usually infrequent and may not require antiepileptic drugs, but if treated, they tend to be easily controlled 2, 3
Common Pitfall to Avoid
Do not order unnecessary neuroimaging in typical cases—the combination of characteristic clinical features (brief hemifacial seizures with mouth deviation, sleep-related, neurologically normal child) plus pathognomonic EEG findings (centrotemporal sharp spikes) is diagnostic 1, 2. Neuroimaging would only be indicated in atypical cases to rule out other pathology 2