Abdominal epilepsy with peri-ictal MRI abnormality

Abdominal epilepsy is rare but under-recognised, characterised by paroxysmal abdominal symptoms with no identifiable gastrointestinal cause. A 77-year-old woman had a lifelong history of brief nocturnal episodes of abdominal cramping followed by transient confusion and speech difficulty. An MR scan of brain within 24 hours of an event identified cortical diffusion restriction and increased FLAIR signal in the left frontal operculum and insular cortex, consistent with peri-ictal MRI abnormalities. Electroencephalography was normal. Her symptoms completely resolved after starting antiseizure medication. This case highlights the importance of considering neurological causes in unexplained recurrent abdominal pain and expands the phenotypic and radiological spectrum of abdominal epilepsy. The involvement of the insular cortex, a central hub for autonomic and viscerosensory processing, provides imaging-based evidence supporting its role as a key anatomical substrate in abdominal epilepsy.