Abstracts

Rationale: Aggression and violent behavior have been associated with epilepsy. However, this behavior is rare in the ictal state and when seen, usually occurs in the context of patients physically restrained during the postictal phase. Interactive behavior with the ability to appropriately respond to verbal or visual stimuli is also rare in complex-partial seizures. We report a case of a patient with seizures maifesting with both behaviors. Methods: This is a clinical case report detailing the epilepsy evaluation of an 18 year-old right-handed male seeking a second opinion for a diagnosis of Tourette's syndrome after being suspended from college for threatening to shoot his teacher and classmates. Patient was born prematurely and sustained a grade 1 periventricular hemorrhage. Motor mildstones were delayed by 4 months, but development was otherwise normal. He had a generalized tonic-clonic seizure at age 9, and subsequently had complex-partial seizures characterized by confusion, hand automatisms and drawing of the legs. These events were controlled on carbamazepine, which was withdrawn after two years. At age 15, he began having stereotyped episodes characterized by verbal profanities and using his hand as a stylized gun to "shoot" people and objects in his environment. An outpatient EEG was interpreted as normal and the patient was diagnosed with Tourette's syndrome (TS). Events increased to daily in frequency despite multiple medication trials to treat TS. Patient was admitted to the Epilepsy Monitoring Unit to capture and characterize the spells. Video-EEG analysis involved second-by-second review of both clinical behavior and electrographic activity. Ictal SPECT study was also performed. Results: Video-EEG monitoring captured 11 seizures in the awake state and 3 seizures during sleep. All seizures were stereotyped and last between 30-45 seconds. Physician testing during the entire seizure occurred with 2 seizures. Analysis of seizures demonstrated profane language with threatened aggression, using his hands as stylized guns to track moving people and "shoot" them, striking a hand held three feet from him, and the ability to alter his actions in reaction to external verbal and visual stimuli. Patient was amnestic for the major portion of his seizures. EEG analysis demonstrated bifrontal 5 hertz rhythmic activity during his seizures, and many of his clinical behaviors occurred simultaneously with electrographic rhythmic activity. Ictal SPECT showed a focal area of hyperperfusion in the right medial frontal lobe. Carbamazepine was re-instituted. The patient is seizure-free at 4 months of follow-up. Conclusions: This study demonstrates a rare case of directed and interactive aggressive verbal and physical behavior during a frontal lobe seizure. This case highlights the potential for certain frontal lobe seizures to cause behavior with significant adverse legal ramifications.