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(Simple Partial) Status Epilepticus

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(Simple Partial) Status Epilepticus 7147ournal of Neurology, Neurosurgery, and Psychiatry 1992;55:714-716 J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.55.8.714 on 1 August 1992. Downloaded from SHORT REPORT Prolonged sensory or visceral symptoms: an under-diagnosed form of non-convulsive focal (simple partial) status epilepticus M Manford, S D Shorvon Abstract slow waves, negative in the right frontocentral Four patients had prolonged, sensory, leads. Postictally the continuation of the but- simple partial seizures (SPS), lasting up terfly sensation was characterised by a period to several days, without associated behav- of frontocentral, electrographic status epilepti- ioural impairment. In three patients, the cus (figure). During this episode there was no SPS often occurred as a prolonged objective behavioural abnormality. "aura" before a more overt seizure. Intracranial ictal EEG revealed a build up of Descriptions included: "butterflies", ris- spike and wave at the deepest medial frontal ing epigastric sensation; "a thought in the electrode, which spread to the rest of the stomach", and an olfactory sensation. frontal lobe, to the temporal neocortex and to Seizure localisation was frontal in one the hippocampus. There were frequent, wide- case, temporal in two cases and uncertain spread, interictal spikes that were not clearly in one case. These sensations may repre- correlated with the butterfly sensation. He did sent an under-reported form of continu- not, however, experience such a prolonged ous, focal seizure activity, which arises feeling as during scalp recording. from various cerebral regions. He had right frontal lobectomy with intra- operative electrocorticography. The resected (7 Neurol Neurosurg Psychiatry 1992;55:7 14-716) tissue showed histological evidence of a neu- ronal maturation defect. One year later, he had suffered a single cluster of seizures, and no The epileptic aura is generally considered to be further prolonged auras. a short-lived phenomenon, representing the early stages of build up of abnormal, synchro- Case 2: "Thought in the stomach". nous electrical activity. This usually develops Case 2, a twenty five year old, right handed further into a more obvious seizure or else halts male motor mechanic had a normal neonatal abruptly, with reversion to the interictal state. and early childhood history. At five years of age We present four cases of prolonged, sensory he suffered a GTCS without obvious precipi- SPS, without invariable ictal progression, pre- tant. He was treated with phenobarbitone, and senting to us over the course of one year. had no further attacks until the age of eleven http://jnnp.bmj.com/ years, when he started to experience CPS. These started with an aura of a "thought in his stomach", lasting up to one minute. A brief Case reports speech arrest with blankness, was followed by Case 1: "Butterfly sensation" hand rubbing automatisms, dysphasia and This was a twenty three year old, right handed amnesia, lasting a few minutes. He was seizure male motor mechanic. Complex partial seiz- free from 16-20 years of age, but seizures then on September 25, 2021 by guest. Protected copyright. ures (CPS) first occurred when he was six recurred in the same pattern. When he was 24 years old, in association with fever and a head years old, his medication was changed and his injury but they did not become regular until he overt seizures ceased. However, at roughly was 10. They were frequently preceded, for up monthly intervals (the same frequency as his to two days, by a butterfly sensation, often felt seizures one year previously) he experiences in the abdomen but not specifically localised, the same sensation of a "thought in his Institute of Neurology, which sometimes persisted after the seizure. stomach". This fluctuates over several days, National Hospitals for Attacks were recorded with video-EEG-tele- not disappearing and not reaching the severity Neurology and metry, before and after stereotactic EEG elec- he associates with an impending attack. Dur- Neurosurgery and The National Society for trode insertion. They started with dizziness ing this time he remains fully alert and able to Epilepsy Research and pallor, followed by a single loud scream, carry out his normal work and duties. Group, Chalfont abduction of his legs, bilateral upper limb Interictal EEG consistently showed mild M Manford com- over S D Shorvon posturing, then rocking movements and sharp and slow wave abnormalities the plex motor activity, for example, bicycling right anterior temporal region. CT and MRI Correspondence to: Dr Manford, Institute of movements. After their recurrence, CPS were normal. We have not obtained an EEG Neurology, Queen Square, occurred in clusters up to one an aura. London WClN 3BG, UK lasting week, during with a cluster often followed a Received 23 August 1991 by generalised and in revised form tonic-clonic seizure (GTCS). Case 3: Epigastric sensation 11 November 1991. Ictal EEG showed a 20 This was a 36 year old right handed, male Accepted 20 November scalp recording 1991 second build up of high amplitude sharp and housing officer with a normal perinatal and Prolonged sensory or visceral symptoms: an under-diagnosed form of non-convulsive focal (simple partial) status epilepticus 715 J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.55.8.714 on 1 August 1992. Downloaded from EEG (P4/A2) __4 o o -VW EEG (Cz/Oz) Left eye Right eye VA%4\A. Chin EMG Left ant tib. Right ant tib. I-P I 4 6 Left nostril Right nostril ECG 1 sec Figure I Case 1: Standard 10-20 scalp EEG during a prolonged epigastric sensation, showing rhythmical slow activity, predominantly in the right frontocentral leads. early childhood history. Seizures started at the carbamazepine made no impact on his attacks, age of 18 and have been present once a week and subsequently phenytoin was only tran- for the past 13 years. On the day he is due to siently effective. have a seizure, he awakes with an epigastric sensation, which persists for hours and a few seconds before an attack, it rapidly rises to his Discussion chest. He shouts "Oh God" and is unaware for An aura represents a focal epileptic discharge, several seconds. There follows up to one manifesting as a sensory SPS, which may minute of manual automatisms. Recovery progress to a more overt seizure. The first three occurs within two minutes, with no dysphasia. cases clearly satisfy the International League Sometimes the epigastric sensation persists Against Epilepsy criteria for an aura;' a ster- after the seizure when he knows he will have a eotyped sensation, without impairment of further seizure that day. consciousness, temporally closely related to CT scan was normal but MRI, with planes seizures. The fourth is also epileptic in view of orientated parallel to the long hippocampal clinical features, EEG and MRI findings and axis, showed substantial loss of right response to anticonvulsants. They are, how- hippocampal substance. Interictal EEG on a ever, unusual in that the phenomena may normal day showed diffuse delta and sharper persist for a considerable period without devel- components anteriorly with a left-sided pre- opment of an overt seizure. This can be http://jnnp.bmj.com/ ponderance. Video telemetry was performed: classified as "simple partial status epilepticus", there was no EEG abnormality during an aura non-convulsive as distinct from epilepsia par- or a seizure, but postictally there was diffuse tialis continua (EPC) or other motor seizure right sided slow activity. phenomena. For case 1, the sensation was clearly asso- Case 4: Olfactory sensation ciated with electrical seizure activity on surface A right handed 55 year old male electronics but not on intracranial EEG. Up to half of on September 25, 2021 by guest. Protected copyright. engineer had experienced occasional microp- auras may be missed on intracranial recording, sia, with the illusion of progressive diminution probably because of the small volume of tissue of the size of objects since the age of four years. sampled.2 'The diagnosis of an aura is clinical; This lasted for two minutes, with no alteration not affected by the absence of localising EEG of consciousness and was associated with a abnormality, either ictal (cases 3, 4) or inter- pleasurable sensation. Since 1984 he has suf- ictal (case 2). fered frequent, strong, olfactory hallucinations Evidence for a frontal focus is strong in case of a variable nature, but usually a chemical 1, and cases 3 and 4 strongly suggest temporal odour, resembling paint or hot oil. These lobe epilepsy. These results present evidence would persist for several days with numerous that prolonged, sensory SPS is not a property exacerbations lasting up to 30 minutes. There of a single cerebral region. have not been any more overt seizures and his Psychomotor complex partial and focal work and concentration remain unimpaired. motor status epilepticus are well accepted Interictal EEG consistently showed a left- entities, but despite series amounting to thou- sided spike focus between the anterior and sands of cases with careful analysis of seizure midtemporal regions, which did not change in semiology," ' we have found few reports of association with the hallucinations. CT scan sensory status epilepticus. Hughlings-Jack- was normal but volumetric MRI showed son"' described a case in which: "sometimes reduction in volume of the anterior portion of when the attacks are about, she has a sensation the left hippocampus. Initial treatment with of smell or of taste at the back
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