REASON FOR EEG:  Refractory seizures.
CLINICAL HISTORY:  This is a 42-year-old man with a history of epilepsy since he was 5 years old, who presents noncompliant with medications and with recurrent refractory seizures.  EEG to quantify and differentiate seizures.
MEDICATIONS:  Tegretol and Depakote, as well as Keppra.
INTRODUCTION:  A long-term EEG was performed using the standard 10-20 electrode placement system with anterior temporal and single lead EKG electrode.  The patient was recorded during wakefulness and sleep.  No activation procedures were performed.
TECHNICAL DIFFICULTIES:  At about 11 p.m., the patient started becoming agitated and moving and disconnected multiple of his leads and by 1 in the morning, unfortunately the majority of his leads were lost and the recording could not be continued.  This is only a 17-hour recording.
DESCRIPTION OF THE RECORD:  The record opens to a diffusely slow background with a posterior dominant rhythm that reaches at best 6-7 Hz which is reactive to eye opening.  There is some frontal central beta.  The patient does appear to go into sleep, but the sleep architecture is not typical.  No activating procedures were performed.
ABNORMAL DISCHARGES:
There are rare bifrontal sharp waves seen in sleep, which appear to be maximal at possibly F4 with a prefrontal field.
Generalized slowing at 5-7 Hz seen continuously throughout the recording.
SEIZURES:  Three seizures were recorded during this long-term monitoring.  The first one occurred at 10:15 in the morning.  Clinically, the patient is laying in bed and appears to grunt and suddenly jerks.  It lasts for what appears to be 20 seconds.  Electrographically at the beginning of the seizure, there is predominantly frontal beta discharge with associated attenuation that appears in both frontal regions and appears to continue as it is obscured by muscle artifact.  Afterwards, there appears to be some slowing in the frontal region.  Although the slowing is difficult to distinguish from its usual background.  The second seizure occurred at 2:41 p.m., lasting for 30 seconds.  This one occurs from sleep.  The patient suddenly moves his right arm and the right hand clearly becomes dystonic suddenly, the right arm then becomes forcefully extended, he grunts, and suddenly the seizure stops.  The nurse came into the room, but did not test him until the seizure had clinically and electrographically stopped.  Electrographically at onset there appears to be again a frontal predominant beta discharge and diffuse attenuation, which continues to evolve and then gets obscured by muscle artifact.  After the event, there appears to be some more prominent diffuse slowing.  Seizure number 3 occurs at 8:51 p.m., about 40 seconds after waking up.  The patient suddenly grunts and his right arm moves underneath the covers and cannot be seen.  This lasts about 30 seconds and then suddenly stops.  Electrographically again there is a frontal beta discharge, which is associated with diffuse attenuation and appears to continue to evolve and then no longer seen due to muscle artifact.  After the seizure appears to clinically end, there seems to be some diffuse slowing.
Heart rate is 86.
IMPRESSION:  Abnormal EEG due to 3 seizures likely arising from either frontal lobe in addition to diffuse slowing.
CLINICAL CORRELATION:  This EEG is consistent with a diagnosis of localization related epilepsy with 3 seizures likely arising from the frontal region with unclear lateralization.  The right arm dystonic posture in one of them suggests a possible left frontal onset, although this cannot be certain.  These seizures were communicated to the team as the EEG was performed.  Lastly, there is evidence of moderate diffuse cerebral dysfunction, which is nonspecific with regards to etiology.