Symptomatogenic zone and network of oroalimentary automatisms in mesial temporal lobe epilepsy.

OBJECTIVE: Oroalimentary automatisms (OAAs) are common clinical manifestations of medial temporal lobe epilepsy. Nevertheless, the location of the symptomatogenic zone of OAAs remains unclear. The generation mechanism of OAAs also has not been clarified. We attempt to explain these problems by analyzing interictal [18 F]-fluorodeoxyglucose positron emission tomography (18 FDG-PET) imaging and ictal stereo-electroencephalography (SEEG) recordings in patients with medial temporal lobe epilepsy. METHODS: Fifty-seven patients with mesial temporal lobe epilepsy were analyzed retrospectively. All underwent anterior temporal lobectomy (ATL) and were seizure-free. The patients were divided into OAA (+) and OAA (-) groups according to the occurrence of consistent stereotyped OAAs. The interictal PET data were compared with those of 18 healthy controls and were then compared between groups using statistical parametric mapping (SPM). Functional connectivity using linear regression analysis was performed between the target brain regions. To clarify the network of OAAs, ictal epileptogenicity index (EI) values, and the nonlinear correlation method h2 were performed with SEEG on patients. RESULTS: Compared to OAAs (-), the rolandic operculum was the only area with significant differences. Hippocampus and rolandic operculum showed significant correlations in the OAA (+) group (y = 0.758x+0.470, R2  = 0.456, P = 0.000). No correlation was found in the OAA (-) group (P = 0.486). The EI values of the OAA (+) group (median 0.20) were significantly higher (P < 0.0001) than those of the OAA (-) group (median 0). The h2 in the OAA (+) group (h2  = 0.23 ± 0.13) showed stronger functional connectivity (t = 6.166, P < 0.0001) than that of the OAA (-) group (h2  = 0.08 ± 0.05). SIGNIFICANCE: The rolandic operculum is most likely to be the symptomatogenic zone of OAAs. In medial temporal lobe epilepsy, unilateral functional connection from the hippocampus to the rolandic operculum during seizure onset is the basis for the generation of OAAs.

Intermittent catatonia and complex automatisms caused by frontal lobe epilepsy in dementia.

An 82-year-old man was admitted to the emergency department following bizarre behaviour. Police had noticed him driving erratically through his village. He did not stop when instructed, drove slowly home and appeared 'vacant' on questioning. While in hospital, he had approximately 15 episodes of catatonia, involving rigidity, negativism, mutism except echolalia and perseveration, automatic obedience and utilisation phenomena, lasting 2-20 min each. Between episodes, he was amnestic but otherwise well. Electroencephalography demonstrated bifrontal slowing with left-sided emphasis, and captured two focal onset partial seizures with the clinical correlate of the syndrome described above. He improved rapidly on levetiracetam and lorazepam, was discharged and received a diagnosis of dementia by his community mental health team shortly afterwards, based on chronic short-term memory loss, functional decline and MRI changes. This case has implications for our understanding of the neural correlate of catatonia, specifically frontal lobe pathway dysfunction.

Spontaneous periictal leaving behavior: a potential lateralizing sign in mesial temporal lobe epilepsy.

PURPOSE: Seizure-related spontaneous leaving behavior (LB) is an uncommonly reported phenomenon. The aim of this study was to determine its frequency, clinical significance, and especially its lateralizing value. METHODS: We analyzed retrospectively the spontaneous periictal LB occurring in complex partial seizures (CPS) of 138 patients with medically refractory mesial temporal lobe epilepsy (MTLE) with excellent postoperative seizure outcome and pathologic finding of hippocampal sclerosis. The relation of LB occurring in different phases of CPS to the side of resection was investigated. RESULTS: The overall frequency of periictal LB was 8.3% of 517 CPS and 25.2% of 123 patients. Among the 12 patients with ictal LB, 9 patients had epileptogenic focus ipsilateral to language dominant side, whereas the remaining 3 had seizure onset in the nondominant side. Conversely, 8 of 11 patients with postictal LB had foci in the nondominant side, and only three patients' seizures originated in the dominant side. Therefore, it was more likely for patients with left MTLE to show ictal LB and for those with right foci to display postictal LB (p = 0.03). CONCLUSIONS: LB may represent a potential lateralizing sign. When LB occurs ictally, it may indicate seizure onset in the dominant temporal lobe, and LB occurring postictally indicates nondominant side seizure onset in patients with MTLE.

Foreign language ictal speech automatisms in nondominant temporal lobe epilepsy.

BACKGROUND: Foreign language ictal speech automatism (FLISA) is a rare ictal sign that has been hitherto reported in five unilingual patients, all right handed men with right temporal lobe epilepsy (TLE), only one of whom has benefited from an intracerebral EEG investigation. METHODS: We report three unilingual French patients who consistently presented English spoken ictal speech automatisms and were investigated with intracerebral EEG recordings. RESULTS: All three patients were right-handed men with nondominant TLE originating in the right amygdala. However, FLISA only occurred when the ictal EEG discharge spread to the ipsilateral temporal neocortex or frontal operculum. In addition, FLISA were emotionally salient, referring to the patient's parents or to the intensity of the ongoing seizure. CONCLUSION: Our findings, together with previously published data, suggest that foreign language ictal speech automatisms are more likely to occur in men with nondominant amygdala onset seizures, an observation that might reflect the sexual dimorphism observed in the right amygdala during emotional processing.

Neural network underlying ictal humming demonstrated by very early SPECT: a case report.

We report the case of a 49-year-old right-handed woman with brief partial seizures in which the clinical semiology was marked by an early humming automatism. MRI fusion of the registered ictal and interictal single-photon emission computed tomography (SPECT) substraction exhibited a left neural network involving lateral temporal, inferior frontal, and inferior parietal cortices.

Unusual ipsilateral hyperkinetic automatisms in SMA seizures.

PURPOSE: To describe repetitive movements of the right arm possibly originating from the ipsilateral SMA area in two drug-resistant epileptic patients. METHODS: Two epileptic patients (one female, one male, 35 and 36 years old, respectively) were submitted to pre-surgical evaluation including history, neurological examination, long-term video-EEG monitoring, interictal and ictal SPET, MRI and fMRI, neuropsychological assessment. Invasive recordings (stereoelectroencephalography) were also performed. RESULTS: In both patients ictal semiology was characterized by very stereotyped repetitive right arm movements, i.e. tapping towards the thorax (movement rate of 6-7 Hz and 3-4 Hz for the two subjects, respectively). Seizures in the first patient, whose epilepsy was cryptogenetic, originated from the right pre-SMA area, which was surgically removed. She is seizure free 2 years after the operation. In the second patient, in whom a right pre-frontal post-abscess porencephaly was disclosed, the epileptogenic zone included the lesion and surrounding areas, while the SMA area was involved less consistently. CONCLUSIONS: Even if, according to literature, SMA epilepsy is predominantly characterized by postural manifestations, ipsilateral repetitive movements could be a relevant sign in this kind of epilepsy, as showed in our first patient. The presence of similar semiology in the second patient, might suggest that the symptomatogenic zone involved SMA area.