Atypical presentation of mesial temporal lobe epilepsy: A case report

Mesial temporal lobe epilepsy (MTLE) typically presents with focal seizures, commonly with impaired awareness, auras, or autonomic symptoms, and is often linked to hippocampal sclerosis in drug-resistant cases. We present a rare case of MTLE in a 24-year-old male who initially presented with generalized tonic-clonic seizures (GTCS) without any preceding focal seizures, auras, febrile seizures, or family history of epilepsy. Initial investigations, including an electroencephalogram, showed mild electrophysiological dysfunction over the right temporal region. Magnetic resonance imaging (MRI) of the brain revealed hyperintensity in the right hippocampus, suggestive of mesial temporal sclerosis. Despite anti-epileptic pharmacological treatment, the patient had a breakthrough seizure. A follow-up MRI revealed cortical thickening in the left uncus and amygdala, indicating possible malformation of cortical development. This case highlights the rare initial presentation of MTLE with GTCS and the absence of typical risk factors such as focal seizures, auras, febrile seizures, and family history, making it an unusual and clinically significant presentation.