Rolandic seizure starting with focal tonic-clonic convulsions progressing to secondarily generalized tonic clonic seizures

The seizure occurred 5 minutes from onset of sleep. The first manifestation was a tonic contraction of left facial muscles (see onset of muscle artifact over the left temporal channels in the EEG), with the head moving left and upwards. Simultaneous with the tonic contraction, there was fast clonic jerking only of the left eyelids while both eyes were semi-open. Within seconds and while the face was in tonic contraction to the left and the left eyelid showed fast clonic contractions, there was a tonic backwards arching of the trunk, with flexion of the legs at the knees. This tonic phase was followed by a prolonged clonic phase that lasted for 4 minutes and 39 seconds. During this phase, the child was stiff with fast, low-range flexion clonic spasms of the proximal muscles of all limbs and jaw. Gradually, the clonic convulsions became less intense and slower, more apparent in the upper limbs and jaw. The electrical event lasted for 6.5 minutes. It started in the right central and mid-temporal regions with 2 to 3 Hz slow waves and irregular, random, and monophasic medium-voltage spikes intermixed and superimposed on the slow waves. This activity tended to spread, and the amplitude of the spikes rapidly increased before the first clinical manifestation, which occurred 30 seconds from the onset of the EEG ictal changes. The clonic phase was characterized by generalized polyspikes interrupted by slow waves at 5 to 7 Hz, gradually slowing to 4 to 5 Hz and finally to 1 to 2 Hz. The polyspike discharges were maximal posteriorly, with some right-sided emphasis. The electrical event of polyspikes and slow wave at 1 to 1.5 Hz continued for 60 seconds after the cessation of the clinical events. Postictally, the record was dominated by generalized 1 to 2.5 Hz slow activity. Postictal centrotemporal spikes appeared after five seconds and were of longer duration and of rather higher amplitude. The first run of sleep spindles was recorded 28 minutes postictally. (From Panayiotopoulos CP. The Epilepsies: Seizures, Syndromes and Management. Oxford: Bladon Medical Publishing, 2005. Used with permission of the publisher.)