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Italasrctu Aityi J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.47.3.319 on 1 March 1984. Downloaded from Letters 319 Weingarten K. Tics (Chap. 30). In: Vinken PJ, the symptoms. The phenytoin was reduced; trigeminal neuralgia and tonic-clonic seiz- Bruyn GW, eds. Handbook of Clinical this was followed by increasingly frequent ures have been described in association Neurology, Vol. 6. Amsterdam: North- attacks of nocturnal left facial pain which with multiple sclerosis,'3 the absence of any Holland Publishing Co. 1968;796. were followed by a typi- other evidence after eleven years makes Bonduelle M. The myoclonias (Chap. 29). In: on most occasions Vinken PJ, Bruyn GW, eds. Handbook of cal tonic-clonic seizure. The EEG showed this diagnosis unlikely. This is the first Clirncal Neurology, Vol. 6. Amsterdam: repetitive focal sharp and slow wave dis- instance, to our knowledge, in which North-Holland Publishing Co., 1968;770. charges in the right mid-temporal region. epileptic pain has been associated with a "Owens DGC, Johnstone EC. Spontaneous During one recording he fell asleep and focal EEG abnormality in the temporal involuntary disorders of movement. Arch experienced a typical episode of his left lobe and thus pain associated with epilepsy Gen Psych 1982;39:.460. facial pain which was followed by a brief is not necessarily a localising feature of 12 Gowers WR. Epilepsy and Other Chronic tonic-clonic seizure. Phenytoin was re- parietal lobe lesions. Convulsive Diseases: Their Causes Symp- introduced with the subsequent control of The characteristics of epileptic pain as toms and Treatnent. New York: Dover Pub- lications Inc., 1964;37, 46-7. symptoms. A CT scan performed both with described in 20 cases are that it may be "Penfield W, Jasper H. Epilepsy and Functional and without contrast was normal. either localised to the contralateral face or Anatomy ofthe Human Brain Boston: Little In 1901 Gowers3 in his review of three limbs rarely to the genitals9 or it may be Brown & Co., 1941;396. thousand cases of epilepsy wrote "sensa- diffuse.' The pain may begin in one area "Cushing H. A note upon the faradic stimula- tions referred to the head preceded fits in but subsequently spread to other parts of tion of the post-central gyrus in conscious 90 cases ... local pain may stimulate the body as the electrical activity spreads patients. Brain 1909;32:44-53. neuralgia". Thus in his experience epilepsy across the cortex.6' Epileptic pain is typi- Accepted 14 October 1983 was associated with pain in 1% of patients. cally brief, lasting only seconds but may Russell4 reviewed 266 patients with focal persist for some minutes, and it is almost epilepsy and found pain as the aura in only invariably associated with either focal or Epileptic pain: a temporal lobe focus six (2-2%) whilst in a further case pain was generalised seizures; however it is possible preceded by a focal motor seizure. Details that patients suffering from epileptic pain Sir: Pain as a manifestation of epilepsy is of the site of pain and underlying pathology may not have been recognised in the most unusual. When described it has often were not discussed in his article. In the absence of more obvious evidence of seiz- been associated with a structural lesion in majority of patients with epileptic pain ure activity. In those cases where treatmentProtected by copyright. the parietal lobe.' We recently encoun- there is a structural abnormality. Of 20 was discussed epileptic pain responded well tered a 30-year-old man who had suffered patients (including the present case) in the to anti-convulsant therapy. paroxysms of left facial pain for eleven literature, only two suffered from years; a diagnosis of trigeminal neuralgia idiopathic epilepsy. In a further two the We thank the staff of the EEG Department had been made and he had been treated cause of epilepsy was not stated whilst of the Newcastle General Hospital for their accordingly with anticonvulsants. He tumour (eight), stroke (five), trauma (two) invaluable assistance. responded to treatment with car- and cysticercosis (one) caused epilepsy in bamazepine and phenytoin. The true the remainder.' 5-'0 P GATES nature of his pain was established when he Penfield" on the basis of cortical stimu- T NAYERNOURI was admitted for elective posterior fossa lation experiments stated "the fact that RP SENGUPTA exploration and microvascular decompres- only 11 times out of well over 800 sion of the trigeminal nerve.2 responses did the patient use the word pain Regional Neurological Centre, In July 1982 a 30-year-old man was to describe a cortical sensation, probably Newcastle General Hospital, admitted for microvascular decompression indicates that pain had little if any cortical Westgate Road, of the left trigeminal nerve. His symptoms representation". Ten years later, however, Newcastle Upon Tyne NE4 6BE, had begun eleven years prior to this and a Penfield together with Kristiansen'2 United Kingdom diagnosis of trigeminal neuralgia had been reported two patients who described pain made. He responded to treatment with as the initial sensory phenomena. Both References http://jnnp.bmj.com/ carbamazepine and phenytoin. The pain patients had their lesion in the precentral always came on during early sleep and gyrus and electrical stimulation at this site 'Wilkinson HA. Epileptic pain. An uncommon would waken him. The pain was sharp, reproduced the aura. Wilkinson' however manifestation with localising value. Neurol- usually confined to the left cheek but occa- felt that epileptic pain was of localising ogy (Minneap) 1973;23:518-20. sionally radiating behind the left ear. The value indicating a lesion in the parietal 2 Gardner WJ, Miklos MV. Response of trigem- inal neuralgia to decompression of sensory duration of each paroxysm was variable lobe. Where enough details were provided root. Discussion of cause of trigeminal and could last for fifteen seconds, and was a parietal lobe abnormality was present in neuralgia. JAMA 1959;170:1773-6. 12 of the cases. In two the proposed site of 3 Gowers WR. Epilepsy and Other Chronic Con- occasionally associated with twitching of on September 28, 2021 by guest. either the left side of the face or the left leg. the origin of the pain was not stated whilst vulsive Diseases. Their Causes, Symptoms He also admitted to frequent brief episodes in a further four the epilepsy occurred in and Treatment. 2nd ed. London: JA Chur- of unpleasant taste, although he denied any patients who had suffered a hemiplegia and chill, 1901. episodes of deja vu, jamais vu, olfactory the EEG had revealed a mid-hemisphere Russell WR. Brain Memory and Learning. con- focus' on each occasion. In York's patient London: Oxford University Press, 1959, hallucinations or episodes of loss of 85-87. withoutwithou a structural the EEGEE ' sciousness. As both carbamazepine and asrctu abnormalitythe. 5Fine W. Post-hemiplegic epilepsy in the phenytoin had been commenced simul- revealed ictahital activityaityiin the rghte.centralr elderly. Br Med J 1967;1: 199-200. taneously, it was uncertain whether two region. The present case however showed a 6 Head H, Holmes G. Sensory disturbances from anti-convulsants were required to control right mid-temporal focus. Although cerebral lesions. Brain 191 1;34:102-254. J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.47.3.319 on 1 March 1984. Downloaded from 320 Letters Lewin W, Phillips CG. Observations on partial sion extending into the left intervertebral removal of the post-central gyrus for Quast U, Hennessen W, Widmark RM. Mono- pain. J foramen at the level C 5/C 6. This was and Neurol. Neurosurg and Psychiatry polyneuntis after tetunus vaccination thought to be consistent with a diagnosis of (1970-1977). International Symposium on 1952;15: 143-7. Immunization: Penfield W, Erickson TC. Epilepsy and cere- a left-sided C 6 root compression syndrome Benefit versus risk factors, and the patient was referred to our Brussels 1978. Develop Bio! Standard 1979; bral localisation, treatment and prevention 43:25-32. of epileptic seizures. London: Bailliere, Tin- neurosurgical unit to undergo a cervical 8Hopf HCh. Guiliain-Barr6-Syndrome nach dall and Cox, 1941, 99. Cloward procedure. On admission the Tetanus-Schutz-Impfung. Akt Neurol 1980; York GK, Gabor AJ, Dreyfus PM. Paroxysmal patient presented with a complete paresis 7:195-200. genital pain: An unusual manifestation of on the left deltoid muscle, a severe weak- epilepsy. Neurology (Minneap) 1979; Accepted 8 October 1983 29:516-9. ness of the left triceps, and moderate Michelsen JJ. Subjective disturbances of the weakness of the left pronator teres. The left sense of pain from lesions of the cortex. Res triceps reflex was absent with all other Publ Assoc Ner Ment Dis 1943;25:86-99. reflexes being normal. No sensory deficit Painful hyperaesthesia following resection Penfield W, Boldrey B. Somatic motor and could be found and thorough neurological ofthe lateral cutaneous nerve of the thigh sensory representation in the cerebral cortex examination revealed no other abnormali- of man as studied by electrical stimulation. ties. Electromyographic studies showed Sir: A patient is described in whom hyper- Brain 1937;60:389-443. denervation of the affected muscles the 12 aesthesia followed resection of a peripheral Penfield W, Kristiansen K. Epileptic seizure sensory pathways not being affected. We patterns. A study of the localising value of nerve. Functional reorganisation of the initial phenomena in focal cortical seizures. repeated the cervical CT scan and per- dorsal horn neurons seemed to be the best Springfield, Illinois: CC Thomas, 1951, 37, formed a cervical myelogram with consecu- explanation for this phenomenon. 39, 81. tive CT,6 both of which were normal. In 1980 the patient, a 25-year-old married 3 McAlpine D, Lumsden CE, Acheson ED.
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