A 52-year-old man with a history of occasional headaches undergoes routine EEG for evaluation. The recording shows arch-shaped, sharply contoured waveforms over the temporal regions (marked **A** in the diagram), occurring as brief isolated bursts lasting 0.5–2 seconds without evolution in frequency or amplitude. These waveforms blend seamlessly with the background temporal rhythm and lack an after-going slow wave. Which of the following is the most appropriate clinical interpretation and management?

Explanation

## Why "Benign temporal variant (wicket spikes); reassure patient and avoid antiepileptic therapy" is right The waveforms described—arch-shaped, sharply contoured, occurring as brief isolated bursts without evolution, lacking an after-going slow wave, and blending with background activity—are pathognomonic for wicket spikes (temporal arciform activity), a well-recognized benign EEG variant. According to Niedermeyer EEG 7e Ch 12, wicket spikes are monophasic, arch-shaped waveforms (6–11 Hz, 60–200 µV) maximal over mid- and anterior temporal leads, occurring in isolation or brief trains without frequency/amplitude evolution. They have NO clinical significance and NO association with epilepsy or structural disease. The critical clinical pearl is recognition to prevent misdiagnosis as epileptiform activity, which would lead to unnecessary anticonvulsant therapy. Adams Neurology 12e Ch 2 emphasizes that wicket spikes are a common source of diagnostic error in non-epileptic patients presenting with headaches or syncope. ## Why each distractor is wrong - **Temporal lobe epileptiform discharge; initiate levetiracetam 500 mg BD**: True temporal lobe epileptiform spikes are followed by an after-going slow wave, show evolution in frequency/amplitude, and disrupt the background rhythm rather than blending with it. The absence of these features rules out epileptiform activity. Initiating antiepileptic therapy based on wicket spikes alone represents a common and harmful diagnostic error. - **Focal temporal lobe structural lesion; order MRI brain with contrast**: Wicket spikes have no association with structural temporal lobe pathology. They are a normal variant and do not warrant neuroimaging. Ordering MRI would be inappropriate and wasteful, creating unnecessary anxiety in the patient. - **Rhythmic mid-temporal theta of drowsiness (RMTD); monitor with repeat EEG in 6 weeks**: RMTD is a distinct benign variant consisting of rhythmic theta activity (4–7 Hz) over the mid-temporal regions during drowsiness, with a smoother morphology and different frequency range than wicket spikes. While both are benign, the morphology described (arch-shaped, sharply contoured) is specific to wickets, not RMTD. Repeat EEG is unnecessary for a recognized benign variant. **High-Yield:** Wicket spikes = arch-shaped temporal waveforms without after-going slow wave or evolution = benign variant = do NOT diagnose epilepsy or prescribe anticonvulsants. [cite: Niedermeyer EEG 7e Ch 12 (Benign EEG Variants); Adams Neurology 12e Ch 2]