Epilepsia, 16:119-125,1975. Raven Press, New York
Clinical Note: Clinical and Tele-Stereo-EEG Findings in a Patient with Psychomotor Seizures S. Geier, J. Bancaud, J. Talairach, A. Bonk, G. Szikla, and M. Enjelvin Research Unit INSERM U97 and Department of Functional Neurosurgery, Hapita1 Sainte-Anne, 1, Rue Cabanis, 75014 Paris, France (Received in final form July 22,1974) INTRODUCTION Complex automatisms concomitant with paroxysmal discharge in the brain and regarded as an epileptic seizure have long attracted attention. They are usually considered to be temporal lobe epilepsy. We are reporting, apparently for the first time, psychomotor seizures with complex automatisms seen and recorded by telemetered depth EEGs (telestereo-EEGs). Our report is unique since seizures tend to occur in freely moving patients (Geier and Bancaud, 1973), and tele-encephalography is therefore a requisite. We also used depth electrodes to identify precisely the site of the epileptic discharge. In the patient reported here, the discharge originated in the frontal lobe. CASE REPORT
Roger R., 38 yr old, had seizures from the age of 7. They f i t appeared 2 days after a bombing raid, when the patient was buried under rubble and lost consciousness for 2 hr. The patient’s first seizures were adversive, with rotation of the head, eyes, and body to the left followed by fall and cry, with no loss of consciousness. These adversive seizures could be followed by a generalized tonic-clonic convulsion. The patient had fhquent seizures from 7 to 9 yr of age. He was then seizure-’fheuntil Key words: Psychomotor - Seizure Frontal - Telemetry
age 17, when seizures reappeared. Since then, even on regular drug therapy, he has never been seizure-free. At age 26 he began to have psychomotor seizures and “absences” as well. Married and the father of 6 children, the patient had various jobs, first in agriculture, then in construction. When he was hospitalized on our service he had been unemployed for 1.5 YrOn neurological examination he was righthanded and had slight left motor deficit. Neuroradiological studies - bilateral carotid arteriography, lipiodol (heavy contrast) ventriculography, and fractionated pneumoencephalography - revealed no focal space-occupying or atrophic lesion. The history did not suggest any etiology other than the head injury. The patient had been treated twice in a psychiatric hospital for depression. The ictal clinical manifestations were ascertained by questioning the patient and his family and’%y observing seizures during hospitalization after gradual withdrawal of anticonvulsant medication. The seizures could be classified in three categories. (1) Absences. Very brief loss of “contact” that looked like absences. (2) Psychomotor seizures. First the patient usually said “Let’s go” or “Let’s do it” (“All~ns-y’~). Then he performed complex and sometimes active motions. He would move rapidly about, rub his body or inanimate objects, make movements appropriate to his trade, drum on the table with his hands or with cutlery, throw objects into the air and pick them up again, rock back and forth, or jump in place. Sometimes he turned his head to the right and
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had bilateral mydriasis. During some seizures he acted as if he were euphoric. The patient had amnesia for all these psychomotor seizures. (3) Genemlized tonic-clonic seizures. They were preceded either by rotation of the head and eyes to the left or by psychomotor manifestations. These occurred especially after withdrawal of antiepileptic medication. The EEG showed numerous spike-and-slow-wave paroxysms over the right frontoparietal region, sometimes predominantly frontal, and sometimes mainly parietal. We did not succeed in recording during a seizure in 27 EEGs, and not until the fifth tele-EEG session (each lasting 6 hr) were 4 psychomotor seizures finally recorded. Despite pronounced artifacts, the seizures clearly originated in the right frontal region. Electrodes were implanted stereotaxically by the method of Talairach et al. (1967), and a chronic stereo-EEG study was performed by the method of Bancaud et al. (1965,1973). The position of the electrodes in the brain is shown in Fig. 1. The radio-telemetry equipment has recently been described (Geier et al., 1974). The seizures were described by an observer who watched the patient through a glass window and dictated into a tape recorder. Sequential numbers were dictated into the tape recorder and written on the EEG at the same time so the clinical and EEG manifestations could be compared. During the chronic tele-stereo-EEG,study, 3 psychomotor seizures were observed and recorded, 2 of which are described here (Figs. 2 and 3), as well as 1 psychomotor and then generalized tonic-clonic seizure (Fig. 4). The seizures are described in the legends. After seizure no. 1 (Fig. 2) the patient denied having had a seizure, remembered some of his behavior, and gave the reasons for it. A similar disquieting event had occurred previously but had been disregarded since the EEG was not recorded at the same time. As the telencephalographic apparatus was being installed, the patient suddenly rubbed his feet on the floor,
took off his watch, and placed it on a nearby table; later he described what he had done but could not say why he had done it; he thought he had been behaving normally and had not had a seizure. During the 2 psychomotor seizures recorded (Figs. 2 and 3), the frontal discharge did not alter activity of the temporal pole. During the generalized tonic-clonic seizure (Fig. 4), the activity at the temporal pole did not become paroxysmal until 40 sec after the onset of the seizure. DISCUSSION Some comments can be made about this patient. (1) Complex ictal psychomotor behavior may be associated with a frontal lobe epileptiform discharge with no involvement of the temporal lobe. (2) Instead of describing the level of consciousness during an ictal discharge, it would be more informative to describe specifically, e.g., no verbal exchange with the patient, or intact handling of inanimate objects, which would imply that there was no apraxia, agnosia, or amnesia during the attack. (3) The memory disturbances in this patient were complex: during the seizure, he seemed to remember objects and movements. After the seizure, amnesia could be in fact more pronounced than during the seizure, but there could also be no amnesia. (4)Ictal behavior was sometimes complex and appropriate to the circumstances. It involved, however, little or no motivation. The patient's acts seemed not to be colored by affect, as for example when he rubbed his penis there was no evidence of true masturbation in the strict sense of the word -which perhaps meant that his behavior was inappropriate psychologically. (5) During mild seizures the patient accounted for his behavior convincingly as being voluntary. However, it is difficult to consider that the patient had as much freedom of action under such circumstances as he would have shad in displaying the same behavior without an epileptic discharge. '
RECORDING OF PSYCHOMOTOR SEIZURES
121
FIG. 1. Map of brain. Pgsition of the multielectrode needles: top, lateral view; bottom, anteroposterior view. LM A = midline as indicated by arteriograms. D: right hemisphere. G: left hemisphere.
FIG. 2. The patient was sitting in front of a table reading. He was alone. 1: Suddenly he rubbed his feet on the floor, closed his book abruptly, got up very quickly, and walked aiound the table. 2: He said “hm, hm, hm” and walked toward the window, in front of which there was a stand with magazines on it. He put his hands in his pockets and then turned up his pajama jacket. 4: He rubbed his penis. 5: He took his hand out of his pajama trousers. 6: He pulled up his trousers and looked out of the window.?: He turr)ed down his pajama jacket, answered an observer who had come in, and took a magazine. When questioned after the seizure, the patient denied its occurrence and claimed that he had gotten up to change books. However, he did not remember having uttered nonsense syllables or having rubbed his penis.
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FIG. 4. The patient was stretched out o n the bed. 1,2: Suddenly he lifted his head and chest and said “Let’s go (or d o it) if we can, let’s go (or d o it) if we want to” (“Allons-y, si o n peut, allons-y, si on veut”), began to rub the blanket between the fingers of his right hand, and said “hm, hm, hm.” 3: He turned first his head, then his trunk to the right and continued to get up. 4: The rotation continued and twisted the patient completely around, with his head and chest in upright position. 5: H e collapsed face down on the pillow. 6: Tonic-clonic generalization appeared.
RECORDING OF PSYCHOMOTOR SEIZURES
125
SUMMARY
ZUSAMMENFASSUNG
A patient was studied who had posttraumatic epilepsy with adversive, psychomotor, and grand ma1 seizures. During tele-EEG recording from depth electrodes, 4 psychomotor seizures were accompanied by discharge originating in the frontal lobe. The patient sometimes could recall his behavior and believed it to be voluntary. Amnesia was more apt to be total after the seizure than during it.
Untersuchung eines Patienten mit posttraumatischer Epilepsie in Form adversiver,psychomotorischer und grosser Anfiille. Wiihrend der telencephalographischen Ableitung mit Tiefenelektroden wurden 4 psychomotorische Anfiille von Entladungen begleitet, die ihren Ursprung im Frontallappen hatten. Der Patient konnte sich an sein Verhalten erinnern und hielt es fur beabsichtigt. Eine totale Amnesie nach dem Anfall war wahrscheinlicher als wahrend desselben. (D. Scheffner, Heidelberg)
RESUME Les auteurs ehdient une observation d’Gpilepsie post-traumatique chez un sujet atteint de crises versives, psychomotrices, et tonicocloniques genCalis6es. Au cows d’enregistrements EEG par t618me‘trie A partir d’Blectrodes profondes, 4 crises psychomotrices s’accompagnaient de decharges apparaissant dans le lobe frontal. Le malade pouvait pidois se rappeler,lui-m6mepn comportement et le croire volontaire. Les troubles de la memoire 6taient plus marques apr& les crises que pendant celles-ci.
REFERENCES
Bancaud J, Talairach J, Bonis A. Schaub G, Szikla G, Morel P and Bordas-Ferrer M. La stkrko-klectroenckphalographiedans 1 ‘kpilepsie. Masson, Paris, 1965,315 pp. Bancaud J, Talairach J, Geier S and Scarabin JM. EEG et SEEG duns les tumeur ckrkbrales et l’kpilepsie. Edifor, Paris, 1973,346 pp. RESUMEN Geier S and Bancaud J. Etude du mode Se ha estudiado un enfermo que padecia d’apparition des 159 premihes crises Bpilepepilepsia con ataques adversivos, psicomotores tiques partielles enregistrbs en tQ6-EEG. y gran mal. Durante 10s registros telencefaloRev d %EG Neurophysiol3:343-352,1973. gr6ficos mediante electrodos . implantados en Geier S, Bancaud J, Talairach J and Enjelvin M. profundidad, 4 ataques psicomotores clinicos se A complete EEG radio-telemetry equipasociaron a una descarga que se originaba en el ment. Electroencephalogr Clin Neurophysiol 16bulo frontal. El enfermo pudo recordar su 1:89-92,1974. comportamiento y creia que era voluntario. Talairach J, Szikla G, Tournoux P, Prossalentis Amnesia despub del ataque era m b completa A, Bordas-Ferrer M, Covello L, Iacob M and que durante el episodio. Mempel E. Atlas d ‘anatomie stkrkotaxique du telencephale. Masson, Paris, 1967, 323 (A. Portera Sanchez, Madrid) PP*
Clinical Note: Clinical and Tele-Stereo-EEG Findings in a Patient with Psychomotor Seizures S. Geier, J. Bancaud, J. Talairach, A. Bonk, G. Szikla, and M. Enjelvin Research Unit INSERM U97 and Department of Functional Neurosurgery, Hapita1 Sainte-Anne, 1, Rue Cabanis, 75014 Paris, France (Received in final form July 22,1974) INTRODUCTION Complex automatisms concomitant with paroxysmal discharge in the brain and regarded as an epileptic seizure have long attracted attention. They are usually considered to be temporal lobe epilepsy. We are reporting, apparently for the first time, psychomotor seizures with complex automatisms seen and recorded by telemetered depth EEGs (telestereo-EEGs). Our report is unique since seizures tend to occur in freely moving patients (Geier and Bancaud, 1973), and tele-encephalography is therefore a requisite. We also used depth electrodes to identify precisely the site of the epileptic discharge. In the patient reported here, the discharge originated in the frontal lobe. CASE REPORT
Roger R., 38 yr old, had seizures from the age of 7. They f i t appeared 2 days after a bombing raid, when the patient was buried under rubble and lost consciousness for 2 hr. The patient’s first seizures were adversive, with rotation of the head, eyes, and body to the left followed by fall and cry, with no loss of consciousness. These adversive seizures could be followed by a generalized tonic-clonic convulsion. The patient had fhquent seizures from 7 to 9 yr of age. He was then seizure-’fheuntil Key words: Psychomotor - Seizure Frontal - Telemetry
age 17, when seizures reappeared. Since then, even on regular drug therapy, he has never been seizure-free. At age 26 he began to have psychomotor seizures and “absences” as well. Married and the father of 6 children, the patient had various jobs, first in agriculture, then in construction. When he was hospitalized on our service he had been unemployed for 1.5 YrOn neurological examination he was righthanded and had slight left motor deficit. Neuroradiological studies - bilateral carotid arteriography, lipiodol (heavy contrast) ventriculography, and fractionated pneumoencephalography - revealed no focal space-occupying or atrophic lesion. The history did not suggest any etiology other than the head injury. The patient had been treated twice in a psychiatric hospital for depression. The ictal clinical manifestations were ascertained by questioning the patient and his family and’%y observing seizures during hospitalization after gradual withdrawal of anticonvulsant medication. The seizures could be classified in three categories. (1) Absences. Very brief loss of “contact” that looked like absences. (2) Psychomotor seizures. First the patient usually said “Let’s go” or “Let’s do it” (“All~ns-y’~). Then he performed complex and sometimes active motions. He would move rapidly about, rub his body or inanimate objects, make movements appropriate to his trade, drum on the table with his hands or with cutlery, throw objects into the air and pick them up again, rock back and forth, or jump in place. Sometimes he turned his head to the right and
120
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had bilateral mydriasis. During some seizures he acted as if he were euphoric. The patient had amnesia for all these psychomotor seizures. (3) Genemlized tonic-clonic seizures. They were preceded either by rotation of the head and eyes to the left or by psychomotor manifestations. These occurred especially after withdrawal of antiepileptic medication. The EEG showed numerous spike-and-slow-wave paroxysms over the right frontoparietal region, sometimes predominantly frontal, and sometimes mainly parietal. We did not succeed in recording during a seizure in 27 EEGs, and not until the fifth tele-EEG session (each lasting 6 hr) were 4 psychomotor seizures finally recorded. Despite pronounced artifacts, the seizures clearly originated in the right frontal region. Electrodes were implanted stereotaxically by the method of Talairach et al. (1967), and a chronic stereo-EEG study was performed by the method of Bancaud et al. (1965,1973). The position of the electrodes in the brain is shown in Fig. 1. The radio-telemetry equipment has recently been described (Geier et al., 1974). The seizures were described by an observer who watched the patient through a glass window and dictated into a tape recorder. Sequential numbers were dictated into the tape recorder and written on the EEG at the same time so the clinical and EEG manifestations could be compared. During the chronic tele-stereo-EEG,study, 3 psychomotor seizures were observed and recorded, 2 of which are described here (Figs. 2 and 3), as well as 1 psychomotor and then generalized tonic-clonic seizure (Fig. 4). The seizures are described in the legends. After seizure no. 1 (Fig. 2) the patient denied having had a seizure, remembered some of his behavior, and gave the reasons for it. A similar disquieting event had occurred previously but had been disregarded since the EEG was not recorded at the same time. As the telencephalographic apparatus was being installed, the patient suddenly rubbed his feet on the floor,
took off his watch, and placed it on a nearby table; later he described what he had done but could not say why he had done it; he thought he had been behaving normally and had not had a seizure. During the 2 psychomotor seizures recorded (Figs. 2 and 3), the frontal discharge did not alter activity of the temporal pole. During the generalized tonic-clonic seizure (Fig. 4), the activity at the temporal pole did not become paroxysmal until 40 sec after the onset of the seizure. DISCUSSION Some comments can be made about this patient. (1) Complex ictal psychomotor behavior may be associated with a frontal lobe epileptiform discharge with no involvement of the temporal lobe. (2) Instead of describing the level of consciousness during an ictal discharge, it would be more informative to describe specifically, e.g., no verbal exchange with the patient, or intact handling of inanimate objects, which would imply that there was no apraxia, agnosia, or amnesia during the attack. (3) The memory disturbances in this patient were complex: during the seizure, he seemed to remember objects and movements. After the seizure, amnesia could be in fact more pronounced than during the seizure, but there could also be no amnesia. (4)Ictal behavior was sometimes complex and appropriate to the circumstances. It involved, however, little or no motivation. The patient's acts seemed not to be colored by affect, as for example when he rubbed his penis there was no evidence of true masturbation in the strict sense of the word -which perhaps meant that his behavior was inappropriate psychologically. (5) During mild seizures the patient accounted for his behavior convincingly as being voluntary. However, it is difficult to consider that the patient had as much freedom of action under such circumstances as he would have shad in displaying the same behavior without an epileptic discharge. '
RECORDING OF PSYCHOMOTOR SEIZURES
121
FIG. 1. Map of brain. Pgsition of the multielectrode needles: top, lateral view; bottom, anteroposterior view. LM A = midline as indicated by arteriograms. D: right hemisphere. G: left hemisphere.
FIG. 2. The patient was sitting in front of a table reading. He was alone. 1: Suddenly he rubbed his feet on the floor, closed his book abruptly, got up very quickly, and walked aiound the table. 2: He said “hm, hm, hm” and walked toward the window, in front of which there was a stand with magazines on it. He put his hands in his pockets and then turned up his pajama jacket. 4: He rubbed his penis. 5: He took his hand out of his pajama trousers. 6: He pulled up his trousers and looked out of the window.?: He turr)ed down his pajama jacket, answered an observer who had come in, and took a magazine. When questioned after the seizure, the patient denied its occurrence and claimed that he had gotten up to change books. However, he did not remember having uttered nonsense syllables or having rubbed his penis.
CTlOl
FIG. 4. The patient was stretched out o n the bed. 1,2: Suddenly he lifted his head and chest and said “Let’s go (or d o it) if we can, let’s go (or d o it) if we want to” (“Allons-y, si o n peut, allons-y, si on veut”), began to rub the blanket between the fingers of his right hand, and said “hm, hm, hm.” 3: He turned first his head, then his trunk to the right and continued to get up. 4: The rotation continued and twisted the patient completely around, with his head and chest in upright position. 5: H e collapsed face down on the pillow. 6: Tonic-clonic generalization appeared.
RECORDING OF PSYCHOMOTOR SEIZURES
125
SUMMARY
ZUSAMMENFASSUNG
A patient was studied who had posttraumatic epilepsy with adversive, psychomotor, and grand ma1 seizures. During tele-EEG recording from depth electrodes, 4 psychomotor seizures were accompanied by discharge originating in the frontal lobe. The patient sometimes could recall his behavior and believed it to be voluntary. Amnesia was more apt to be total after the seizure than during it.
Untersuchung eines Patienten mit posttraumatischer Epilepsie in Form adversiver,psychomotorischer und grosser Anfiille. Wiihrend der telencephalographischen Ableitung mit Tiefenelektroden wurden 4 psychomotorische Anfiille von Entladungen begleitet, die ihren Ursprung im Frontallappen hatten. Der Patient konnte sich an sein Verhalten erinnern und hielt es fur beabsichtigt. Eine totale Amnesie nach dem Anfall war wahrscheinlicher als wahrend desselben. (D. Scheffner, Heidelberg)
RESUME Les auteurs ehdient une observation d’Gpilepsie post-traumatique chez un sujet atteint de crises versives, psychomotrices, et tonicocloniques genCalis6es. Au cows d’enregistrements EEG par t618me‘trie A partir d’Blectrodes profondes, 4 crises psychomotrices s’accompagnaient de decharges apparaissant dans le lobe frontal. Le malade pouvait pidois se rappeler,lui-m6mepn comportement et le croire volontaire. Les troubles de la memoire 6taient plus marques apr& les crises que pendant celles-ci.
REFERENCES
Bancaud J, Talairach J, Bonis A. Schaub G, Szikla G, Morel P and Bordas-Ferrer M. La stkrko-klectroenckphalographiedans 1 ‘kpilepsie. Masson, Paris, 1965,315 pp. Bancaud J, Talairach J, Geier S and Scarabin JM. EEG et SEEG duns les tumeur ckrkbrales et l’kpilepsie. Edifor, Paris, 1973,346 pp. RESUMEN Geier S and Bancaud J. Etude du mode Se ha estudiado un enfermo que padecia d’apparition des 159 premihes crises Bpilepepilepsia con ataques adversivos, psicomotores tiques partielles enregistrbs en tQ6-EEG. y gran mal. Durante 10s registros telencefaloRev d %EG Neurophysiol3:343-352,1973. gr6ficos mediante electrodos . implantados en Geier S, Bancaud J, Talairach J and Enjelvin M. profundidad, 4 ataques psicomotores clinicos se A complete EEG radio-telemetry equipasociaron a una descarga que se originaba en el ment. Electroencephalogr Clin Neurophysiol 16bulo frontal. El enfermo pudo recordar su 1:89-92,1974. comportamiento y creia que era voluntario. Talairach J, Szikla G, Tournoux P, Prossalentis Amnesia despub del ataque era m b completa A, Bordas-Ferrer M, Covello L, Iacob M and que durante el episodio. Mempel E. Atlas d ‘anatomie stkrkotaxique du telencephale. Masson, Paris, 1967, 323 (A. Portera Sanchez, Madrid) PP*
