Practice Lesson of the Week

A case of mistaken mesial temporal identity

BMJ 2009; 338 doi: (Published 23 June 2009) Cite this as: BMJ 2009;338:b2258
  1. A Neligan, clinical research fellow1,
  2. D R Holdright, consultant cardiologist2,
  3. F J Rugg-Gunn, consultant neurologist1,
  4. J W Sander, professor of neurology1
  1. 1UCL Institute of Neurology, The National Hospital for Neurology and Neurosurgery, London WC1N 3BG
  2. 2UCLH Heart Hospital, London W1G 8PF
  1. Correspondence to: J W Sander [email protected]
  • Accepted 29 August 2008

Re-examine a diagnosis of epilepsy when there is worsening control and investigations are normal

The accurate diagnosis and treatment of paroxysmal events can be difficult. It requires a detailed eye witness account and a clear description of the circumstances of the event, including location, development, tempo, and duration. Even with this information, a definitive diagnosis may not be attainable.

Case report

A 45 year old left handed man presented with a four year history of paroxysmal events. He was referred by his neurologist for consideration of epilepsy surgery. Previous medical history was unremarkable. The first episode of loss of consciousness occurred while the patient was with friends. It was preceded by a brief period of severe chest pain with profuse sweating, which lasted less than a minute. A 12-lead electrocardiogram was normal. The second episode occurred two years ago and was also preceded by chest pain. During this episode, the patient felt weak, lay on the ground, and lost consciousness. Duration was uncertain, but on regaining consciousness he was sweating profusely. He interpreted these episodes as cardiac in origin as he has a strong family history of coronary artery disease. He was seen by a cardiologist who noted a normal cardiac examination, ambulatory electrocardiogram, exercise stress test, and transthoracic echocardiogram.

He had no further episodes until about nine months before referral. The first new episode started with a sensation of a sweaty smell followed by constricting chest pain for approximately 30 minutes, after which he lost consciousness. His wife described him as being in a profound sleep with heavy snoring. He recovered about 30 minutes later, initially shouting as if waking from a bad dream, but without subsequent confusion. There …

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