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A previously healthy 16-year-old boy presented to the emergency department with a peculiar, paroxysmal, stereotypical facial gesture (figure 1). One year earlier, he had first developed a sudden, involuntary ‘coarsening’ of his facial expression lasting several seconds. During this, he retained consciousness and was aware of the facial posture. He had no accompanying aura, fearfulness, anguish or autonomic disturbances. Over the following first 9 months, he had same facial grimace only twice, each time while at school during the daytime. However, in the 3 months before presentation, the paroxysms increased in frequency and became daily in the last month. His neurological examination was normal. Interictal electroencephalography was normal, but 3-day video electroencephalography captured multiple seizures with a possible right frontotemporal origin, each lasting less than 1 min (figure …
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