The enigma of reflex eating epilepsy: A cohort study of 50 patients with insights from multimodal evaluation

To evaluate the clinical, electroencephalographic (EEG), neuroimaging characteristics, and treatment outcomes of patients diagnosed with eating epilepsy (EE).

This retrospective study was conducted at a tertiary care epilepsy referral center in India. Patients diagnosed with EE between 2002 and 2025, with at least one EEG and magnetic resonance imaging (MRI) available for review, were consecutively included. Clinical data and multimodal evaluation findings including video EEG, brain MRI, positron emission tomography-MRI (PET-MRI), and magnetoencephalography (MEG) were systematically collected using a structured proforma. Seizure outcomes and treatment strategies were subsequently analyzed.

A total of 50 patients (35 male) were included in this cohort, with a mean age at onset of epilepsy being 11.91 ± 8.18 years. All patients had drug-refractory epilepsy. Focal impaired consciousness seizure was the commonest seizure type (90%). MRI imaging was abnormal in 25 (50%), and the commonest finding was perisylvian gliosis. Patients with a history of perinatal insult (OR = 22.15, 95% CI: 2.58-189.95, p < 0.001) and intellectual disability (OR = 5.09, 95% CI: 1.45-17.92, p = 0.009) were more likely to have MRI abnormalities. Multimodal investigations most consistently implicated the perisylvian epileptic networks, as demonstrated by Video Electro Encephlaogram (VEEG) (52%), MRI (32%), PET-MRI (38.1%), and MEG (57.9%). Approximately one-fourth of the patients were seizure-free at their last follow-up.

EE is a disabling form of reflex epilepsy with heterogeneous clinical, EEG and neuroimaging features, which are not necessarily substrate-specific. Findings from our study point to the presence of a wide epileptogenic network prominently involving perisylvian regions. Treatment outcomes in drug-refractory EE remain suboptimal, and further studies are needed for a better understanding and management of this complex entity.