Ictal vomiting in a left hemisphere language-dominant patient with left-sided temporal lobe epilepsy

Seizure semiology: ILAE glossary of terms and their significance

This educational topical review and Task Force report aims to address learning objectives of the International League Against Epilepsy (ILAE) curriculum. We sought to extract detailed features involving semiology from video recordings and interpret semiological signs and symptoms that reflect the likely localization for focal seizures in patients with epilepsy. This glossary was developed by a working group of the ILAE Commission on Diagnostic Methods incorporating the EEG Task Force. This paper identifies commonly used terms to describe seizure semiology, provides definitions, signs and symptoms, and summarizes their clinical value in localizing and lateralizing focal seizures based on consensus in the published literature. Video-EEG examples are included to illustrate important features of semiology in patients with epilepsy.

Ictal nausea and vomiting - Is it left or right?

PURPOSE

Ictal nausea/vomiting has been linked to the non-dominant hemisphere and has been considered a lateralizing sign. However, small case series and single cases have reported seizure localisation in the dominant hemisphere. Here we aimed to determine the seizure localisation and lateralization in cases with ictal nausea/retching/vomiting to test the hypothesis that these signs are of lateralizing value.

METHODS

We searched two large tertiary epilepsy-center video-EEG databases (period: 1980-2017) for reports on ictal nausea/retching/vomiting and retrieved ictal EEG seizure location, lateralization and clinical symptoms.

RESULTS

We identified 13 patients with focal epilepsy and video-EEG-documented ictal nausea (n = 2), nausea and retching (n = 3), retching followed by vomiting (n = 5) or only vomiting (n = 3). Aetiology was genetic (n = 1), structural/metabolic (n = 7) or of unclear origin (n = 5). While in 12/13 patients epileptic discharges were temporal, a single case was parietal. A left-sided seizure origin was more frequent than a right-sided origin (62 vs. 38%). Assuming a left-sided language dominance in the single left-handed patient and in those two patients with unclear handedness (based on the known distribution of hemispheric speech-dominance), the distribution of ictal nausea/retching/vomiting to the dominant vs. non-dominant hemisphere was not significantly different from a random distribution (8 vs. 5, p = 0.581).

CONCLUSION

Ictal nausea/retching/vomiting are most frequently of temporal origin. In contrast to previous studies, our ictal video-EEG data suggests that these signs have no lateralizing value. Thus, video-EEG should be performed and while this clinical sign points to a temporal seizure origin, it does not determine its lateralization.

Presurgical diagnosis of epilepsies – concepts and diagnostic tools

Introduction.Numerous reviews of the currently established concepts, strategies and diagnostic tools used in epilepsy surgery have been published. The focus concept which was initially developed by Forster, Penfield and Jasper and popularised and enriched by Lüders, is still fundamental for epilepsy surgery.

Aim.To present different conceptual views of the focus concept and to discuss more recent network hypothesis, emphasizing so-called “critical modes of an epileptogenic circuit”.

Method.A literature search was conducted using keywords: presurgical evaluation, epileptic focus concepts, cortical zones, diagnostic tools.

Review and remarks.The theoretical concepts of the epileptic focus are opposed to the network hypothesis. The definitions of the various cortical zones have been conceptualized in the presurgical evaluation of candidates for epilepsy surgery: the seizure onset zone versus the epileptogenic zone, the symptomatogenic zone, the irritative and functional deficit zones are characterized. The epileptogenic lesion, the “eloquent cortex” and secondary epileptogenesis (mirror focus) are dealt with. The current diagnostic techniques used in the definition of these cortical zones, such as video-EEG monitoring, non-invasive and invasive EEG recording techniques, magnetic resonance imaging, ictal single photon emission computed tomography, and positron emission tomography, are discussed and illustrated. Potential modern surrogate markers of epileptogenicity, such asHigh frequency oscillations, Ictal slow waves/DC shifts, Magnetic resonance spectroscopy, Functional MRI,the use ofMagnetized nanoparticlesin MRI,Transcranial magnetic stimulation,Optical intrinsic signalimaging, andSeizure predictionare discussed. Particular emphasis is put on the EEG: Scalp EEG, semi-invasive and invasive EEG (Stereoelectroencephalography) and intraoperative electrocorticography are illustrated. Ictal SPECT and18F-FDG PET are very helpful and several other procedures, such as dipole source localization and spike-triggered functional MRI are already widely used. The most important lateralizing and localizing ictal signs and symptoms are summarized. It is anticipated that the other clinically valid surrogate markers of epileptogenesis and epileptogenicity will be further developed in the near future. Until then the concordance of the results of seizure semiology, localization of epileptogenicity by EEG and MRI remains the most important prerequisite for successful epilepsy surgery.

Conclusions and future perspectives.Resective epilepsy surgery is a widely accepted and successful therapeutic approach, rendering up to 80% of selected patients seizure free. Although other therapies, such as radiosurgery, and responsive neurostimulation will increasingly play a role in patients with an unresectable lesion, it is unlikely that they will replace selective resective surgery. The hope is that new diagnostic techniques will be developed that permit more direct definition and measurement of the epileptogenic zone.

Ictal vomiting as a sign of temporal lobe epilepsy confirmed by stereo-EEG and surgical outcome

Vomiting is uncommon in patients with epilepsy and has been reported in both idiopathic and symptomatic epilepsies. It is presumed to originate in the anterior part of the temporal lobe or insula. To date, 44 cases of nonidiopathic focal epilepsy and seizures associated with ictal vomiting have been reported. Of the 44 cases, eight were studied using invasive exploration (3 stereo-EEG/5 subdural grids). Here, we report a 4-year-and-7-month-old patient with a history of febrile convulsion in the second year of life and who developed episodes of vomiting and complex partial seizures at 3 years of age. Scalp EEG showed no electrical modification during vomiting while the complex partial seizure displayed a clear right temporal origin. Brain MR showed hippocampal volume reduction with mild diffuse blurring of the temporal lobe. Stereoelectroencephalography study confirmed the mesiotemporal origin of the seizures and showed that the episodes of vomiting were strictly related to an ictal discharge originating in the mesial temporal structures without insular diffusion. The patient is now seizure-free (18 months) after removal of the right anterior and mesial temporal structures. In all the reported patients, seizures seemed to start in mesial temporal structures. The grid subgroup is more homogeneous, and the most prominent characteristic (4/5) is the involvement of both mesial and lateral temporal structures at the time of vomiting. In the S-EEG group, there is evidence of involvement of either the anterior temporal structures alone (2/3) or both insular cortices (1/3). Our case confirms that vomiting could occur when the ictal discharge is limited to the anterior temporal structure without insular involvement. Regarding the pathophysiology of vomiting, the role of subcortical structures such as the dorsal vagal complex and the central pattern generators (CPG) located in the reticular area is well established. Vomiting as an epileptic phenomenon seems to be related to the involvement of temporal structures, mainly mesial structures (amygdala) and with an uncertain role of the insula. An intriguing hypothesis is that the ictal discharge in mesial structures determines seizure manifestation that could be explained not only by tonic activation of the cortex, but also by 'release' (reduction of inhibition?) of the CPG responsible for involuntary motor behaviors.

Defective auditory processing in a child with temporal epileptic focus

A 9-year-old boy presented with intolerance to noise that was a trigger for violent temper tantrums that occasionally resembled complex partial seizures. The condition was also a cause for withdrawal from all activities and settings that could potentially be associated with noise. Both electroencephalography and magnetoencephalography clearly demonstrated a left temporal (T5) epileptic focus, although the child never had convulsive seizures. Genetic studies failed to reveal a GRIN2A mutation. We suggest that the hyperacusis in the reported child is another variation of the Landau-Kleffner spectrum.

Peri-ictal water drinking and other ictal vegetative symptoms: Localizing and lateralizing the epileptogenic zone in temporal lobe epilepsy? Two case reports and review of the literature

Peri-ictal behavior disorders can be helpful in localizing and lateralizing seizure onset in partial epilepsies, especially those originating in the temporal lobe. In this paper, we present the case of two right-handed women aged 36 and 42 years who presented with partial seizures of mesial temporal type. Both of the patients had drug resistant epilepsy and undergone presurgical evaluation tests including brain magnetic resonance imaging, video-EEG monitoring and neuropsychological testing. The two patients had hippocampal sclerosis in the right temporal lobe and exhibited PIWD behavior concomitant with right temporal lobe discharges documented during video-EEG recordings. Anterior temporal lobectomy was performed in one case with an excellent outcome after surgery. The patient was free of seizures at 3 years follow-up. We reviewed other publications of peri-ictal autonomic symptoms considered to have a lateralizing significance, such as peri-ictal vomiting, urinary urge, ictal pilo-erection. Clinicians should search for these symptoms, even if not spontaneously reported by the patient, because they are often under-estimated, both by the patients themselves and by physicians. Additionally, patients with lateralizing auras during seizures have a significantly better outcome after epilepsy surgery than those without lateralizing features.

Localizing and lateralizing value of ictal flatulence

OBJECTIVE

Autonomic seizures have been associated with seizure onset in the temporal or insular lobe and consist of variations in blood pressure and heart rate, sweating, flushing, piloerection, hypersalivation, vomiting, spitting, and alterations in bladder and bowel functions. The aim of this study was to evaluate the localizing and lateralizing value of ictal flatulence.

METHODS

Medical records of patients with focal epilepsies who were monitored at the Interdisciplinary Epilepsy Center Marburg between 2006 and 2009 were reviewed for the occurrence of ictal flatulence. Clinical, electrophysiological, and imaging data were reviewed and compared with data for previously reported cases of ictal flatulence.

RESULTS

Two patients with ictal flatulence were identified (0.6%). In both patients, ictal flatulence was associated with a seizure pattern in the temporal lobe of the dominant hemisphere. Our cases and previously reported cases point toward activation of insular cortex because of such additional autonomic symptoms as unilateral piloerection, tachycardia, profound sweating, and flushing of the face.

CONCLUSIONS

Ictal flatulence is a rare manifestation of autonomic seizures and a localizing sign for temporal or/and insular lobe epilepsies. In general, ictal flatulence seems to have no lateralizing value.

Biopsychosocial approaches to a patient with vomiting of 10 years' duration--a case of temporal lobe epilepsy

Background

Vomiting is commonly encountered in clinical medicine. When organic gastrointestinal, metabolic, and brain diseases are ruled out, many cases are considered to be functional. We experienced an adult patient with epilepsy whose main symptom was vomiting. Biopsychosocial approaches were needed to control the symptoms.

Case presentation

A 26-year-old female with a 10-year history of persistent vomiting was found to have temporal lobe epilepsy (TLE). Throughout this time, during which the vomiting had become part of a vicious cycle, her epilepsy was poorly controlled by medication. Biopsychosocial approaches were employed successfully and the patient subsequently undertook training to become a home-helper, started a job, and was able to leave her parents' house and live independently. All of her symptoms resolved after she became self-sufficient.

Discussion

Vomiting without impaired consciousness is seldom considered to be a manifestation of epilepsy. Difficulty in recording an electroencephalogram (EEG) because of the presence of persistent vomiting delayed the diagnosis. The improvement of symptoms was thought to have been due to the patient's emotional stabilization and physical improvement, which may have stabilized the limbic system.

Conclusion

When an illness persists for many years and conditioning and a vicious cycle occur secondarily, systematic biopsychosocial approaches are needed in addition to general treatment. Also, secondary symptoms make the diagnosis more difficult when efforts at treatment are ineffective.

The role of the anterior insular cortex in ictal vomiting: a stereotactic electroencephalography study

Ictal vomiting is a rare manifestation most often associated with right temporal lobe epilepsy. The implication of the anterior insula in the occurrence of this symptom has been suggested based on the role of this region in swallowing and on the observation that electrical insular stimulation can elicit nausea and vomiting. We report the first case, to our knowledge, of a patient presenting with ictal vomiting who underwent bilateral intracranial exploration including insular depth electrodes. The seizure onset zone was localized in the left temporomesial structures, but the occurrence of ictal vomiting correlated in time with a discharge affecting exclusively the anterior part of both insular lobes. It is concluded that the occurrence of ictal vomiting reflects a propagation of the discharge to the insular cortex. Observation of this symptom at the very onset of the seizures in a patient with temporal lobe epilepsy is highly suggestive of an insular seizure onset zone.

Ictal nausea with vomiting as the major symptom of simple partial seizures: electroencephalographic and magnetoencephalographic analysis

Autonomic symptoms and signs rarely occur as isolated phenomena without impaired consciousness. Ictal nausea with vomiting is a rare clinical manifestation of seizures. Ictal vomiting is considered a localizing sign in patients with partial seizures of temporal origin. We encountered two patients with simple partial seizures that produced nausea with vomiting as the sole symptom, and we describe the interictal electroencephalographic and magnetoencephalographic findings. The episodes were paroxysmal and stereotypical in nature, and patients showed symptomatic response to a trial of antiepilepsy medication. In both patients, the diagnosis was simple partial seizures with autonomic symptomatology. Although interictal electroencephalography did not reveal focal spikes and focal slowing, estimated magnetoencephalographic dipoles were clustered in the parietal lobe. Interictal magnetoencephalographic foci may serve only as subsidiary evidence for the parietal origin of the episodes. However, our findings provide evidence of additional involvement of the parietal lobe in ictal vomiting.

The "sensed presence": an epileptic aura with religious overtones

"Sensed presence," a religious emotion, has been the focus of recent neurotheological research because it has been claimed that weak transcranial magnetic stimulation can evoke such experiences. Some researchers have recently questioned this claim. However, religion and epilepsy have been linked through history, clinical observations, and research. This article describes the "sensed presence" as an aura in one patient who did not interpret his experience in a religious way. He had bilateral hypoperfusion of the temporal lobes when investigated by SPECT, and hypoplasia of the dorsal part of the left hippocampus when examined by magnetic resonance imaging. This case report illustrates that "sensed presence" can occur as an epileptic aura with or without religious interpretation.