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Seizure-Induced Neglect

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Seizure-Induced Neglect J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.43.11.1035 on 1 November 1980. Downloaded from Journal of Neurology, Neurosurgery, and Psychiatry, 1980, 43. 1035-1040 Seizure-induced neglect KENNETH M HEILMAN AND GREGORY J HOWELL From the Department of Neurology, College of Medicine, University of Florida, and the Veterans Administration Medical Center, Gainesville, Florida, USA SUMMARY A man with intermittent right parieto-occipital seizures was monitored by electro- encephalography while he received 60 trials of being touched on the right, left, or both hands. Half of the trials were given during a focal seizure, and half were given interictally. While the patient was having seizures, he appropriately responded to all 10 stimuli delivered to the right hand, but four of 10 responses were incorrect (allaesthetic) when he was stimulated on the left. With bilateral simultaneous stimulation he neglected the left hand in all 10 trials. His interictal performance was flawless. When given a line-bisection task on two occasions during a seizure, the patient attempted to make a mark to the left of the entire sheet of paper. Immediately postictally he made a mark at the right end of the line. The case illustrates that focal seizures may induce elements of the neglect syndrome and that attention (to contralateral stimuli) and intention to perform (in the contralateral guest. Protected by copyright. hemispatial field) may be dissociable phenomena. Under a variety of stimulus conditions, patients seen in the neglect syndrome, such as hemi- who can detect stimuli fail to report, respond, or spatial neglect, may be induced by an intentional orient to stimuli presented on the side contra- defect.4 6 Recently, we observed a patient with lateral to a cerebral lesion. The failure to report right parietal lobe seizures. The patient showed or respond appropriately to unilateral stimuli has that elements of the neglect syndrome may be been termed "unilateral neglect" or "inatten- associated with focal seizures. He also provided tion."' Sometimes patients with unilateral lesions evidence for the postulate that attentional and respond appropriately to unilateral stimuli but intentional defects are dissociable. fail to report the contralateral stimulus when stimulated on both sides simultaneously. Critch- Case report ley' thought that extinction to simultaneous stimulation is another instance of unilateral A 63 year old man was in good health until two neglect made manifest at a particular moment days before admission when he developed "impair- by the technique of simultaneous stimulation. ment of vision in the left eye." He had had difficulty When touched on the side seeing the chain on a night light. He attributed the opposite to their problem to impaired vision in the left eye because lesion, patients with unilateral neglect often re- the vision in his right eye was already poor secondary ported that they were touched on the side ipsi- to a cataract. He had no other specific complaints http://jnnp.bmj.com/ lateral to their lesion. This has been termed until the next morning when he began to have inter- "allaesthesia."2 Critchley' thought that unilateral mittent episodes of "double vision." During these neglect also was responsible for allaesthesia. episodes, everything seemed to move to the right Because inattention can be induced by a variety and appeared to have constantly fluctuating colours. of cortical and subcortical lesions, we have The patient did not complain of dizziness but did say postulated that many of the behavioural signs that during the two days before admission he had reflect an attention-arousal disorder induced by difficulty in walking, which was most severe during the episodes of "double vision." disruption of a corticolimbic reticular loop.3 4 We Past medical and family histories were non- on October 1, 2021 by have also postulated that some of the behaviour contributory. Medication included spironolactone with hydrochlorothiazide and digoxin. Physical exam- Address for reprint requests: Dr KM Heilman, Box J-236, Depart- ination showed the patient's temperature to be ment of Neurology, College of Medicine, University of Florida, Gainesville, FL 36i7'C; pulse rate, 80 beats per min and regular; 32610, USA. respirations, 16 per min and unlaboured; and blood Accepted 10 July 1980 pressure, 135/90 mmHg without postural change. 1035 J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.43.11.1035 on 1 November 1980. Downloaded from 1036 Kenneth M Heilman and Gregory J Howell Neurological examination showed an alert but half of the state. He would write his name in the indifferent right-handed man who was oriented in right upper quadrant of a sheet of paper and would time, place and person. He accurately named some incorrectly bisect a line too far to the right even of the preceding presidents and recalled major when he was able to identify correctly the left side current events. Despite distraction, he was able to re- of the line by searching for a letter at that end.5 call three objects five minutes after presentation, and His mood was generally eufphoric, but when told he he could recall seven numbers forward and four in was having seizures, he adamantly denied he was reverse order. There was no aphasia, acalculia, finger having anything but brief spells of "double vision." agnosia, or right-left confusion. Reading and writing When we tested for auditory extinction, the patient also were normal. The patient had difficulty drawing was asked to close his eyes. In the unilateral con- a cube, a square, and a triangle. He also appeared ditions (unilateral left, unilateral right), the examiner to have an indifferent affect. Several other tests simultaneously snapped the fingers of both the right of right-hemisphere function were performed. The and left hand approximately 5 cm from the patient's ability to judge mood from pictures of faces patient's right or left ear. In the bilateral condition, was incorrect6 in nine of 12 trials; he correctly the fingers of both hands were simultaneously identified only happy faces. In judging verbal mood, snapped; however, one hand was placed behind each he was incorrect in five of 12 trials; he would judge of the patient's ears. We randomised the order in what was said rather than how it was said. His which these three conditions were given. Tests for ability to create a mood with his own voice was tactile extinction were performed in a similar manner. impaired except for happy moods. Song recognition In the unilateral conditions, the back of the right or and spontaneous singing were normal. When asked left hand was touched. In the bilateral condition both to tell whether two pictures of unfamiliar faces were hands were simultaneously touched on the back. The the same or different, he made four errors in 12 order in which these conditions were given was trials. randomised. guest. Protected by copyright. The pupils were equal in size, round, and reacted Interictally, the patient was given 18 auditory to light and accommodation. Visual acuity in the trials, six in each condition, and 24 tactile trials, left eye was 20/70 with glasses; the patient could eight each condition. He flawlessly performed all of see only hand movements with the right eye because these trials. While he was having a seizure, he was of a dense cataract. There was a dense left homony- also given 18 auditory trials, six in each condition. mous visual field defect. The remainder of the cranial He flawlessly detected and lateralised all unilateral nerves were normal. Motor examination, including stimuli; however, with bilateral simultaneous auditory muscle strength, tone, and coordination, was normal stimuli, he neglected the left-side stimulus in all six except for a tendency for the outstretched left arm trials. During a seizure he was also given 14 uni- to rise. Cerebellar testing, including finger-to-nose, lateral tactile stimuli (seven to each hand) and six heel-to-shin, and rapid alternating movements, was bilateral stimultaneous tactile stimuli. With unilateral normal. The patient walked cautiously and appeared right-hand tactile stimuli, his performance was flaw- to have slight bradykinesia of the left limbs. Deep less. With unilateral left-hand tactile stimuli, he tendon reflexes were normal except for absent ankle detected all seven stimuli, but on two of these trials jerks. The right plantar response was flexor, and the he thought he was being touched on the right hand left was equivocal. There were no other pathologic (allaesthetic response). With bilateral stimuli he reflexes. Sensory examination, including pain, pos- neglected left-hand stimulation in all six trials. ition, vibration, and graphesthesia, was normal except An EEG performed on the day of admission dis- for mild impairment of vibration in the distal portion closed occasional spikes and an occasional slow wave of both lower extremities. focus in the right parieto-occipital region. With the During the neurological examination the patient onset of the patient's sensation of diplopia, the complained that an episode of "double vision" was record revealed polyspikes from the right parieto- http://jnnp.bmj.com/ beginning. His head and eyes then began to deviate occipital area that gradually increased in amplitude to the left. On command he could momentarily and rhythm with a decrease in frequency to approxi- return his head and eyes to the right; however, they mately two to three Hz sharp and slow wave dis- again promptly deviated to the left. The sensation charge that became generalised before returning to of diplopia was present even with his eyes closed. baseline rhythms (see figure). During this seizure the previously noted tendency While being monitored with the EEG, the patient for the outstretched left arm to rise increased, and received 60 trials of being touched on the right, the patient was slow to respond to questions but left, or both hands.
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