Abstracts

Rationale: A novel case of complex semiology of Visual Hallucinations with Nystagmus Epilepticus and Status Migrainosus (VHNESM), which is a rare phenomenon of transient, rapid and repetitive saccades associated with epileptic seizures presenting as protracted migrainous headaches. We present a unique cluster of VHNESM. With less than 50 cases of nystagmus epilepticus published in literature, to the best of our knowledge; such a complex semiology of VHNESM has never been reported before. Methods: A clinical case report of 43 y/o right handed Hispanic female with history of right MCA stroke with residual mild left sided weakness, Systemic Lupus Erythematosus (SLE), Antiphospholipid Antibody Syndrome on warfarin, “Bipolar Disorder” presented with two day acute worsening of chronic intermittent migrainous headaches with new onset distressing visual aura and “Dancing Eyes”. Patient reported seeing bright yellow light with mute, non-interacting and dancing “Creepy legless Clowns” in left lower visual field without oscillopsia, palinopsia, vertigo, alteration in speech, consciousness or motor symptoms. Results: Cluster of events with semiology of left conjugate eye deviation, horizontal nystagmus with a rapid leftward component and rightward slow phase with slightly crossing mid-line. Video EEG showed high frequency (beta-gamma) ictal onset in the right posterior temporo-occipito-parietal T6>O2=P4 region lasting up to 110 seconds. Comprehensive imaging, serum and CSF workup was unremarkable for any acute abnormalities. Migraine headache regimen provided partial relief. Visual hallucinations, Nystagmus, EEG seizures and headaches improved with levetiracetam but totally resolved with lacosamide monotherapy and did not recur at 12 months follow-up. Conclusions: VHNESM without any motor seizure or vertigo is a rare phenomenon. A few cases of NE due to ictal discharges from the posterior quadrant have been reported but none with the VHNESM semiology. This may be explained as exclusive epileptic activation of the hodological network of visual association cortex, cortical saccade regions (including the supplementary and parietal eye fields) causing a rapid phase of nystagmus contralateral to the ictal onset zone and a slow ipsilateral phase and at the same time sparing the motor strip/network and frontal eye fields. A significant number of patients can get pre-ictal (20%) and post-ictal (45%) headaches, occuring most frequently after tonic-clonic seizures but can also happen with simple and complex partial seizures. This case also highlights how mood disorders and headaches are often misdiagnosed. Note: If selected for platform presentation, a clinical video may also be presented. References: 1. Visual Hallucination and Illusion Disorders: A Clinical Guide. ACNR Vol 4, Number 2, 2004- ffytche, D.H.  2. The hodology of hallucinations. Cortex 2008 Sep;44(8):1067-83- ffytche, D.H.3. The hallucinating brain: A review of structural and functional neuroimaging studies of hallucinations. – Neuroscience and Biobehavioral Reviews 32 (2008) Paul Allen et al.  Funding: None.