Hemifacial Spasms or Focal Aware Seizures: The Role of Video-EEG

Hemifacial spasms (HFS) are common in neurological practice but can be mistaken for focal aware seizures without appropriate diagnostic workup. We present the case of a man in his 60s admitted for congestive heart failure (CHF) exacerbation, who developed left-sided weakness and HFS during hospitalization. Although his motor symptoms improved after receiving tenecteplase (TNK), the HFS persisted, prompting the use of continuous video-EEG to differentiate between cortical myoclonus and HFS. Video-EEG is essential for distinguishing HFS from focal aware seizures, identifying high-frequency ipsilateral muscle artifacts in HFS versus interictal or ictal EEG patterns contralateral to facial contractions in seizures. This case highlights key features to aid neurologists in differentiating these conditions.