Patient is a thirty-four year old female with focal epilepsy refractory to medications and vagus nerve stimulation (VNS).  The semiology consisted of stereotyped rhythmic high amplitude flailing like movement of right upper extremity, followed by behavioral arrest, lip smacking and head turn to the left. On the scalp EEG, there were late changes in the right temporal region.  MRI brain showed a moderate sized arachnoid cyst in the left middle cranial fossa and mass effect on the temporal lobe with hypoplasia and displacement of the left hippocampus. sEEG was performed with implantation in the bilateral limbic network, frontal and parietal cortex. The seizures were found to originate in the right premotor cortex in association with arm movement. This was followed by spread to the right hippocampus when she had behavioral arrest and lip smacking. There was one instance where the originating focus was in the right temporal region with no involvement of the right precentral cortex.

There is an unusual presentation of ipsilateral arm movement due to pre-central seizures and quick spread of the extra temporal seizures to the limbic network. It is reported that parietal lobe, insular and supplementary motor area (SMA) seizures can produce seizures with ipsilateral arm movement. However, to our knowledge, this is the first case to report ipsilateral arm movement with premotor cortex. This case shows the close connectivity between the extratemporal and temporal network. It provides insight to the development of secondary multi-focal epileptic focus in cases with refractory epilepsy.