I saw Tony first in the autumn of 1994, when he was 30 years of age. In June 1994, two major seizures, which were preceded by right facial twitching, had led to admission elsewhere; an MR scan of his brain (unenhanced) and spinal fluid analysis were normal, but an electroencephalogram (EEG) showed a left temporal slow wave focus. He had been treated with carbamazepine but ongoing focal seizures, which involved jerking of the right face, neck, and shoulder, had led to the addition of phenytoin, gabapentin, and clonazepam (none of which appeared to influence the frequency of his attacks).

During the consultation there were repeated episodes of right perioral twitching, without change of awareness or his speech. Examination revealed minor uncoordination of his right hand but no other abnormal neurological signs. Systemic examination was normal. His blood count and biochemical profile were normal; he was immunocompetent. His EEG showed continuous irregular slow activity over the left temporal lobe, associated with local spike and theta wave complexes, which were enhanced by drowsiness. There was, however, no correlation between these discharges and the episodes of right facial twitching associated with head turning to the right, which occurred during the recording. Normal rhythmic activity was attenuated over the left hemisphere. Somatosensory testing, stimulating the right median nerve, evoked giant cortical potentials on the left.

Computed tomograpy showed an area of low attenuation in relation to the left Sylvian fissure; there was no enhancement following contrast (fig 1). A second MR brain scan showed an area of high signal on T2 weighted images, again in relation to the Sylvian fissure (fig 2). There appeared to be slight mass effect and enhancement following gadolinium. A glioma was thought likely and, in January 1995, he underwent stereotactic biopsy. The tissue obtained showed minor astrocytosis and perivascular …