Hemifacial motor and crying seizures of temporal lobe onset: case report and review of electro-clinical localisation

How Can a Focal Seizure Lead to a Dacrystic Behavior? A Case Analyzed with Functional Connectivity in Stereoelectroencephalography

We present a case of a patient with focal non-motor emotional seizures with dacrystic expression in the context of drug-resistant magnetic resonance imaging negative epilepsy. The pre-surgical evaluation suggested a hypothesis of a right fronto-temporal epileptogenic zone. Stereoelectroencephalography recorded dacrystic seizures arising from the right anterior operculo-insular (pars orbitalis) area with secondary propagation to temporal and parietal cortices during the dacrystic behavior. We analyzed functional connectivity during the ictal dacrystic behavior and found an increase of the functional connectivity within a large right fronto-temporo-insular network, broadly similar to the "emotional excitatory" network. It suggests that focal seizure, potentially, from various origins but leading to disorganization of these physiological networks may generate dacrystic behavior.

Somatomotor or somatosensory facial manifestations in patients with temporobasal epilepsies

OBJECTIVE

The semiology of temporo-basal epilepsy has rarely been analysed in the literature. In this paper, we report three patients with proven basal temporal epilepsy with somatomotor or somatosensory facial ictal semiology, highly suggestive of insulo-opercular onset.

METHODS

The three patients had a temporobasal lesion and their drugresistant epilepsy was cured with resection of the lesion (follow-up duration: 7-17 years). We reviewed the medical charts, non-invasive EEG data as well as the stereoelectroencephalography (SEEG) performed in two patients. Quantitative analysis of ictal fast gamma activity was performed for one patient.

RESULTS

Early ictal features were orofacial, either somatomotor in two patients or ipsilateral somatosensory in one. The three patients had prior sensations compatible with a temporal lobe onset. Interictal and ictal EEG pointed to the temporal lobe. The propagation of the discharge to the insula and operculum before the occurrence of facial features was seen on SEEG. Facial features occurred 7-20 seconds after electrical onset. Quantitative analysis of six seizures in one patient confirmed the visual analysis, showing statistically significant fast gamma activity originating from basal areas and then propagating to insuloopercular regions after a few seconds.

SIGNIFICANCE

We report three cases of lesional temporo-basal epilepsy responsible for orofacial semiology related to propagation of insulo-opercular ictal discharge. In MRI-negative patients with facial manifestations, this origin should be suspected when EEG is suggestive. These observations may contribute to our understanding of brain networks.

A Case Report of Dacrystic Seizures in the Psychiatric Emergency Services Department

Epileptiform syndromes are represented by a variety of clinical scenarios. In this context, dacrystic seizures (DS) are characterized by paroxysmal episodes of stereotyped crying and are considered a rare ictal phenomenon. Their neuroanatomical and pathophysiological findings tend to be nonspecific, and to date, there is no consensus on their treatment. Additionally, most of the existing case reports describe that the patients who suffer from them are usually refractory to conventional care. Also, most of the existing literature is approached from a neurological practice perspective; however, there's evidence of patients with these paroxysms that occasionally end up in the hands of psychiatric services due to the uniqueness of their symptoms. However, there is very little information about this phenomenon due to its rarity. For this reason, this manuscript presents the case of a middle-aged man with these seizures who initially attended a psychiatric emergency service and subsequently received neuropsychiatric management and follow-up.

Lacrimation as an Ictal Autonomic Event in a Patient With Seizures Originating From the Right Hemisphere

In dacrystic seizures lacrimation has previously been reported as an ictal autonomic event accompanying emotional and somatic signs. However, it has not been observed as an isolated event in autonomic seizures. We report a patient experiencing complex partial seizures characterized by lacrimation as the initial and most prominent ictal event, with no sign of crying. The patient's ictal electroencephalogram (EEG) suggested a focus in the right hemisphere, along with interictal single-photon emission computed tomographic (SPECT) and positron emission tomographic (PET) studies demonstrating hypoperfusion-hypometabolism in the right temporoparietal lobe. Magnetic resonance imaging (MRI) did not show any structural abnormalities. Involvement of the temporal lobe has been suggested for dacrystic seizures, and both dominant and nondominant hemispheric foci were detected in such cases. Therefore, partially in concordance with previous reports, our case may point to neurobiologic interaction, between the temporoparietal region and the hypothalamus, for mediating lacrimation.

Dacrystic seizures: demographic, semiologic, and etiologic insights from a multicenter study in long-term video-EEG monitoring units

PURPOSE

To provide an estimate of the frequency of dacrystic seizures in video-electroencephalography (EEG) long-term monitoring units of tertiary referral epilepsy centers and to describe the clinical presentation of dacrystic seizures in relationship to the underlying etiology.

METHODS

We screened clinical records and video-EEG reports for the diagnosis of dacrystic seizures of all patients admitted for video-EEG long-term monitoring at five epilepsy referral centers in the United States and Germany. Patients with a potential diagnosis of dacrystic seizures were identified, and their clinical charts and video-EEG recordings were reviewed. We included only patients with: (1) stereotyped lacrimation, sobbing, grimacing, yelling, or sad facial expression; (2) long-term video-EEG recordings (at least 12 h); and (3) at least one brain magnetic resonance imaging (MRI) study.

KEY FINDINGS

Nine patients (four female) with dacrystic seizures were identified. Dacrystic seizures were identified in 0.06-0.53% of the patients admitted for long-term video-EEG monitoring depending on the specific center. Considering our study population as a whole, the frequency was 0.13%. The presence of dacrystic seizures without other accompanying clinical features was found in only one patient. Gelastic seizures accompanied dacrystic seizures in five cases, and a hypothalamic hamartoma was found in all of these five patients. The underlying etiology in the four patients with dacrystic seizures without gelastic seizures was left mesial temporal sclerosis (three patients) and a frontal glioblastoma (one patient). All patients had a difficult-to-control epilepsy as demonstrated by the following: (1) at least three different antiepileptic drugs were tried in each patient, (2) epilepsy was well controlled with antiepileptic drugs in only two patients, (3) six patients were considered for epilepsy surgery and three of them underwent a surgical/radiosurgical or radioablative procedure. Regarding outcome, antiepileptic drugs alone achieved seizure freedom in two patients and did not change seizure frequency in another patient. Radiosurgery led to moderately good seizure control in one patient and did not improve seizure control in another patient. Three patients were or are being considered for epilepsy surgery on last follow-up. One patient remains seizure free 3 years after epilepsy surgery.

SIGNIFICANCE

Dacrystic seizures are a rare but clinically relevant finding during video-EEG monitoring. Our data show that when the patient has dacrystic and gelastic seizures, the cause is a hypothalamic hamartoma. In contrast, when dacrystic seizures are not accompanied by gelastic seizures the underlying lesion is most commonly located in the temporal cortex.

Chronic isolated hemifacial spasm as a manifestation of epilepsia partialis continua

The objective of this case study was to describe the clinical and electroencephalography (EEG)/functional magnetic resonance imaging (fMRI) data of a case of isolated hemifacial spasm due to epilepsia partialis continua in a 59-year-old man with abnormal hemifacial movements that disappeared during voluntary tasks, were absent during sleep, and responded to carbamazepine. His neurological examination was normal; EEG revealed right inferior frontal epileptiform discharges. EEG/fMRI demonstrated increased blood oxygenation level-dependent contrast in the right inferior and middle frontal gyri corresponding to the contralateral motor and premotor cortex responsible for facial movements (BA 44, 45, 45, 9), with widespread BOLD signal deactivations suggestive of epileptic network involvement despite a very focal epileptogenic process. We hypothesize that the response of some cases of hemifacial spasm to carbamazepine, a first-line treatment in the pre-botulinum toxin era, may have been due to its antiepileptic effects, rather than to modulation of facial nerve hyperexcitability.

Facial paresis in patients with mesial temporal sclerosis: clinical and quantitative MRI-based evidence of widespread disease

PURPOSE

To assess the frequency and significance of facial paresis (FP) in a well-defined cohort of mesial temporal lobe epilepsy (MTLE) patients.

METHODS

One hundred consecutive patients with MRI findings consistent with mesial temporal sclerosis (MTS) and concordant electroclinical data underwent facial motor examination at rest, with voluntary expression, and with spontaneous smiling. Hippocampal, amygdaloid, and temporopolar (TP) volumetric measures were acquired. Thirty healthy subjects, matched according to age and sex, were taken as controls.

RESULTS

Central-type FP was found in 46 patients. In 41 (89%) of 46, it was visualized at rest, with voluntary and emotional expression characterizing true facial motor paresis. In 33 (72%) of 46 patients, FP was contralateral to the side of MTS. By using a 2-SD cutoff from the mean of normal controls, we found reduction in TP volume ipsilateral to MTS in 61% of patients with FP and in 33% of those without (p = 0.01). Febrile seizures as initial precipitating injury (IPI) were observed in 34% of the patients and were classified as complex in 12 (26%) of 46 of those with FP and in five (9%) of 54 of those without (p = 0.02). The presence of FP was significantly associated with a shorter latent period and younger age at onset of habitual seizures, in particular, with secondarily generalized tonic-clonic seizures.

CONCLUSIONS

Facial paresis is a reliable lateralizing sign in MTLE and was associated with history of complex febrile seizures as IPI, younger age at onset of disease, and atrophy of temporal pole ipsilateral to MTS, indicating more widespread disease.

Amygdala interconnections with the cingulate motor cortex in the rhesus monkey

Amygdala interconnections with the cingulate motor cortices were investigated in the rhesus monkey. Using multiple tracing approaches, we found a robust projection from the lateral basal nucleus of the amygdala to Layers II, IIIa, and V of the rostral cingulate motor cortex (M3). A smaller source of amygdala input arose from the accessory basal, cortical, and lateral nuclei, which targeted only the rostral region of M3. We also found a light projection from the lateral basal nucleus to the same layers of the caudal cingulate motor cortex (M4). Experiments examining this projection to cingulate somatotopy using combined neural tracing strategies and stereology to estimate the total number of terminal-like immunoreactive particles demonstrated that the amygdala projection terminates heavily in the face representation of M3 and moderately in its arm representation. Fewer terminal profiles were found in the leg representation of M3 and the face, arm, and leg representations of M4. Anterograde tracers placed directly into M3 and M4 revealed the amygdala connection to be reciprocal and documented corticofugal projections to the facial nucleus, surrounding pontine reticular formation, and spinal cord. Clinically, such pathways would be in a position to contribute to mediating movements in the face, neck, and upper extremity accompanying medial temporal lobe seizures that have historically characterized this syndrome. Alterations within or disruption of the amygdalo-cingulate projection to the rostral part of M3 may also have an adverse effect on facial expression in patients presenting with neurological or neuropsychiatric abnormalities of medial temporal lobe involvement. Finally, the prominent amygdala projection to the face region of M3 may significantly influence the outcome of higher-order facial expressions associated with social communication and emotional constructs such as fear, anger, happiness, and sadness.