case_images: PMC9900650_01
case_images: Top: Routine interictal EEG at 6 months old in a 10-20 scalp placement
  longitudinal montage with left sided posterior sharp waves visualized best
  in T3-T5 and T5-O1 electrode readings. Bottom: Long term ictal EEG at 7
  months old in a 10-20 scalp placement longitudinal montage showing a segment
  of an electrographic seizure, demonstrating moderate amplitude
  polyspike/spike and wave complexes best appreciated posteriorly, with 1-3 Hz
  frequency.
case_images: 10.1177_2329048X231153781-fig1.jpg
case_images: PMC9900650_01_10.1177_2329048X231153781-fig1.jpg
case_images: fig1-2329048X231153781
case_images: Her initial interictal routine EEG at the time demonstrated age-appropriate organization but was notable for frequent left posterior spikes and sharp waves (Figure 1), prompting initiation of levetiracetam. She had 3 separate stereotyped electrographic seizures (1) bi-occipital fast polyspikes spreading temporally with better evolution on the right, (2) left centro-temporal 8 Hz activity spreading to the right centro-temporal areas, and (3) focal right occipital fast polyspikes that evolved in amplitude and frequency (Figure 1).
case_images: EEG prior to (top) and after (bottom) initiation of phenobarbital.
case_images: 10.1177_2329048X231153781-fig2.jpg
case_images: PMC9900650_01_10.1177_2329048X231153781-fig2.jpg
case_images: fig2-2329048X231153781
case_images: After initiation of phenobarbital, there was a dramatic electroclinical improvement (Figure 2).
case_images: Left: MRI obtained at 6 months old T2 weighted imaging axial cut
  demonstrating mild atrophy without migration abnormalities. Right: Sagittal
  cut T2 FLAIR weighted imaging demonstrating thinning brainstem.
case_images: 10.1177_2329048X231153781-fig3.jpg
case_images: PMC9900650_01_10.1177_2329048X231153781-fig3.jpg
case_images: fig3-2329048X231153781
case_images: An MRI was obtained, which demonstrated mild to moderate atrophy, thinning of the brainstem, abnormal myelination for age with no migration abnormalities appreciated (Figure 3).