Frontal lobe epilepsy mimicking panic attacks
Three year history of episodes initially diagnosed and treated as panic attacks. These were characterised by sweating, palpitations, dry mouth, dyspnoea and a sense of impending doom. His wife noticed he had repetitive finger rubbing and lip smacking during the episodes. There was a past history of head injury 20 years ago necessitating a right frontal craniotomy.
MRI brain non contrast
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There is a large area of encephalomalacia in the right posterior frontal lobe, behind the region of the previous craniotomy, as well as signal abnormality in the right mesial temporal region.
Video-EEG was performed. Several typical events were recorded during monitoring which were accompanied on the EEG by focal rhythmic seizure activity over the right posterior frontal region. There were frequent epileptiform spikes over this region during inter-ictal recording.
His panic attacks were rediagnosed as complex partial seizures and he was commenced on carbamazepine with resolution of episodes for the next 12 months. His seizures appear to have genesis in the right posterior frontal lobe, although MRI also showed abnormalities in the right mesial temporal lobe. Seizures in the posterior frontal lobe may also spread to the temporal region. This explains why his symptoms were consistent with temporal lobe epilepsy.
Frontal or temporal lobe epilepsies can have symptomology that mimics panic attacks. This case demonstrates the importance of a careful clinical evaluation and investigation of patients presenting with possible panic attacks, especially if panic attacks are treatment resistent or have atypical features (for example automatisms).