1. Setting & Design A retrospective chart review was conducted on two pediatric patients at the Comprehensive Epilepsy Center at Florida Hospital for Children. This study was approved by IRB at Florida Hospital. Subjects Patient 1: 3 year old, previously healthy female was diagnosed with panic attacks by her pediatrician. She presented with daily episodes of intense fear coupled with screaming and inconsolable crying that developed 5 weeks prior to admission. Patient 2: 13 year old male was initially diagnosed with panic disorder by his primary neurologist. In addition, at age 7, he was diagnosed with recurrent seizures characterized by sudden frightened facial grimaces, followed by episodes of hyperventilation, repetitive wrist slapping, and walking in circles. Cingulate Epilepsy Manifesting as Panic Disorder: Multimodal Approach to Diagnosis Michelle Tall, RN 1 ; Milena Korostenskaja, PhD 1,2,4 ; Tanya R. Grace, PsyD 3,4 ; Michael Westerveld, PhD, ABPP-CN 3,4 ; Joo-Hee Seo, MD 4 ; Jane C. Cook, DO 5 ; Po-Ching Chen, PhD 1,2,4 ; Christine M. Salinas, PsyD 3,4 ; Ki Hyeong Lee, MD 4 Background & Significance Anterior Cingulate Epilepsy (ACE) is a diagnostic and therapeutic challenge with a wide range of nonspecific symptoms that can negatively impact an individual’s cognition, behavior, and emotions. Scalp EEG and brain MRI may not be helpful because of the deep midline location of Anterior Cingulate Gyrus (ACG). Study Aims Primary objective: To demonstrate the utility of a multimodal approach to diagnose ACE. Secondary objective: To raise awareness to the medical community about the complexity of this disorder and associated treatment delay. Comprehensive Epilepsy Evaluation: Long-term video-EEG monitoring 3T-MRI with epilepsy protocol FDG-PET, subtraction ictal SPECT co-registered to MRI (SISCOM) Neuropsychological testing Patient #1 Evaluation: Previous EEG and 1.5T-MRI was reported as normal. Patient’s typical episode was captured during long-term video-EEG that showed diffuse ictal onset (Fig 1). 3T-MRI revealed high T2 signal in the right anterior cingulate gyrus (Fig. 2.A). SISCOM demonstrated a significant focal hyperperfusion in the right medial parafalcine frontal lobe and cingulate gyrus (Fig. 2.B). Neuropsychological test scores were normal. Follow up: Patient became seizure-free with oxcarbazepine monotherapy. ACE can be misdiagnosed as generalized anxiety, behavioral problems, or other psychiatric conditions because of diverse clinical manifestation of ACE. Early identification of ACE can improve outcomes in cognition, behavior, and quality of life. MRI and EEG alone may not be sufficiently sensitive for diagnosis and localization of ACE in some cases. Our findings indicate that a combined multimodal diagnostic approach is useful for the diagnosis of ACE. Patient #2 Baseline: Previous EEG and brain MRI was reported as normal. Patient’s typical episode was associated with diffuse bilateral rhythmic spikes (Fig. 3A). Ictal SPECT and SISCOM demonstrated focal hyperperfusion in the left ACG and medial frontal region (Figure 3B). Neuropsychological evaluation revealed cognitive impairments associated with frontal lobe dysfunction. Follow up: Patient is seizure-free with topiramate monotherapy. Fig. 3. Patient #2. A: Ictal EEG pattern arising from left frontal and midline vertex areas on long-term video-EEG monitoring; B: Ictal SPECT and SISCOM demonstrated focal hyperperfusion in the left medial parafalcine frontal lobe and ACG. Fig. 2. Patient #1. A: 3T-MRI revealed high T2 signal in the right medial frontal lobe cingulated gyrus; B: SISCOM demonstrated a significant focal hyperperfusion in the right medial parafalcine frontal lobe and cingulate gyrus. 1 Functional Brain Mapping and Brain-Computer Interface Lab, Florida Hospital for Children, Orlando, Florida; 2 MEG Lab, Florida Hospital for Children, Orlando, Florida; 2 Dirivion of Neuropsychology, Florida Hospital for Children, Orlando, Florida; 4 Comprehensive Pediatric Epilepsy Center, Florida Hospital for Children, Orlando, Florida; 5 Department of Radiology, Florida Hospital, Orlando, Florida INTRODUCTION METHOD RESULTS CONCLUSIONS Fig. 1: Ictal EEG showed diffuse bilateral rhythmic spikes with frontal dominance.