Is the clinical semiology of a female patient with episodes of transient unawareness, normal clinical examination, normal prolonged video electroencephalogram (EEG), and magnetic resonance imaging (MRI) findings of focal cortical dyslamination in the left posterior temporal middle cortex and inferior temporal cortex consistent with a seizure disorder or epilepsy?

Clinical Semiology and MRI Findings: Focal Cortical Dyslamination in Left Temporal Lobe

The clinical semiology is NOT fully consistent with typical focal seizures arising from left posterior temporal cortical dyslamination, and the normal prolonged video EEG significantly argues against epilepsy as the primary diagnosis—this presentation warrants strong consideration of functional neurological disorder (dissociative episodes) or other non-epileptic causes.

Key Diagnostic Considerations

Why the Semiology is Atypical for Temporal Lobe Epilepsy

The described episodes lack the hallmark features of temporal lobe seizures:

• Prolonged duration of "several minutes" with complete unawareness is unusual for temporal lobe seizures, which typically last 30 seconds to 2 minutes 1, 2
• Complex purposeful behaviors (walking significant distances, repeatedly turning head) with complete amnesia suggest dissociative episodes rather than ictal automatisms 3
• Sleep-related behavior (holding sharp object during sleep with no awareness) is more consistent with parasomnia or dissociative state than temporal lobe epilepsy 3
• Auditory hallucinations (hearing voice calling repeatedly) could represent temporal lobe phenomena, but the behavioral response (repeatedly turning head) is too organized and sustained for typical ictal behavior 1

The Critical Role of Normal Video EEG

The normal prolonged video EEG is the most important finding that argues against epilepsy:

• Focal cortical dysplasia typically produces epileptiform discharges on interictal EEG in the majority of cases 1, 4
• If these were true seizures, capturing events during prolonged monitoring without EEG correlate strongly suggests psychogenic non-epileptic seizures (PNES) or functional neurological disorder 5
• Video-EEG monitoring is the gold standard for differentiating epileptic from non-epileptic events 5

Differential Diagnosis Framework

1. Functional Neurological Disorder (Dissociative Seizures)

This is the most likely diagnosis given:

• Episodes of impaired awareness lasting several minutes with complex behaviors 3
• Normal prolonged video EEG despite capturing typical events 5
• Young female demographic (though age not specified, pattern suggests this) 3
• Complete amnesia for events with no postictal confusion typical of epilepsy 3
• Denial of stressors does not exclude functional disorder, as these are involuntary conversion phenomena 3

Key features supporting dissociative episodes:

• Movements/behaviors begin after apparent loss of awareness rather than simultaneously 5
• Duration frequently exceeds 5 minutes, unlike typical temporal lobe seizures (30-120 seconds) 5, 2
• Normal EEG during events is diagnostic 3, 5

2. Structural Epilepsy (Less Likely)

The MRI finding of focal cortical dyslamination is epileptogenic, but:

• Focal cortical dysplasia is indeed a structural cause of epilepsy in the ILAE classification 1
• However, 55% of children with focal seizures show MRI abnormalities, meaning the finding could be incidental 6
• The absence of epileptiform activity on prolonged video EEG makes active epilepsy unlikely 1, 4
• Left posterior temporal lesions typically produce different semiology: déjà vu, auditory auras, speech arrest, or memory disturbances—not prolonged ambulatory automatisms 1

3. Parasomnia vs. REM Sleep Behavior Disorder

The sleep episode (holding sharp object) requires consideration of:

• Sleep-related behaviors are distinct from epilepsy and would not explain daytime episodes 3
• This may represent a separate phenomenon requiring polysomnography if recurrent

Recommended Diagnostic Approach

Immediate Steps

1. Review the video EEG recordings to confirm no subtle focal slowing or epileptiform discharges were missed in the left temporal region 1, 4

2. Detailed ictal semiology documentation:

   • Exact duration of each episode (seconds vs. minutes) 5
   • Level of responsiveness during events (can she respond to commands?) 3
   • Presence of automatisms (lip smacking, picking movements) vs. purposeful complex behaviors 1
   • Postictal state: immediate recovery vs. confusion/drowsiness 3, 5

3. Screen for triggers and warning signs:

   • Sensory triggers, emotional states, or patterns preceding episodes 3
   • Despite denial of stressors, functional disorders are involuntary and may occur without conscious psychological distress 3

Additional Testing if Needed

• Repeat video EEG with provocation (sleep deprivation, hyperventilation) if high suspicion for epilepsy persists, though the normal prolonged study is already highly informative 4
• Neuropsychological evaluation to assess for subtle memory deficits that might suggest temporal lobe dysfunction 1
• Psychiatric consultation not to "rule out" functional disorder but to provide appropriate treatment if this is the diagnosis 3

Clinical Management Implications

If Functional Neurological Disorder (Most Likely)

Candid discussion with the patient about the diagnosis is reasonable:

• Explain that episodes are real, involuntary, but not due to epilepsy or structural brain damage 3
• Emphasize the normal EEG during typical events as objective evidence 3, 5
• Frame as a disorder of brain function rather than structure 3

Treatment approach:

• Cognitive behavioral therapy may be beneficial 3
• Sensory grounding techniques to prevent dissociative episodes 3
• Identify and address triggers/warning signs even if not consciously recognized 3

If Epilepsy Cannot Be Excluded

• Do NOT start antiepileptic drugs based solely on MRI findings without EEG confirmation of seizures 1, 2
• The MRI abnormality may be incidental, and inappropriate AED treatment has significant psychosocial implications 1
• Consider epilepsy center referral for magnetoencephalography (MEG) or invasive monitoring only if clinical suspicion remains very high despite normal video EEG 1

Critical Pitfalls to Avoid

1. Do not diagnose epilepsy based on MRI alone without EEG correlation—this leads to unnecessary lifelong treatment and psychosocial consequences 1, 2

2. Do not dismiss functional neurological disorder as "psychiatric" or "not real"—these are involuntary neurological events requiring specific treatment 3

3. Do not assume all episodes are the same phenomenon—the sleep behavior may be unrelated to daytime dissociative episodes 3

4. Recognize that absence of identified stressors does not exclude functional disorder—conversion symptoms are subconscious responses 3