A 13-year-old girl presented with refractory seizures since the age of 5 years. Clinical exam and MRI studies were normal. Ictal EEG discharges suggested possible left posterior quadrant distribution but were not well localized with standard methods. A seizure was recorded during 128-channel EEG video long-term monitoring prior to invasive recordings. Applying a source analysis method, seizure onset and propagation patterns were calculated and displayed on an MRI model. The onset was localized to the left inferior posterior occipital cortex, followed by propagation to the right, then left, posterior cerebral hemispheres, and finally to the left superior-medial parietal lobe. These patterns were replicated closely on subsequent invasive recordings. Surgery was based on intracranial findings and she is seizure-free 30 months after resection. Noninvasive dense-array EEG, used in conjunction with realistic source analysis methods, may have the potential to assist in localizing seizure onsets when standard methods fail.

Keywords:
Refractory epilepsy, Extratemporal seizures, Source analysis, Dense-array EEG, Epilepsy surgery
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