Abstracts

Rationale: Dacrystic seizures clinically present with ictal crying and tearing. Although ictal crying has first been described over 100 years ago by Trousseau, previous descriptions are mostly limited to isolated case reports. The objective of our study was to determine the incidence and clinical presentation of patients with dacrystic seizures. Methods: Consecutive admissions to epilepsy monitoring units at four centers were reviewed for dacrystic seizures. 1164 cases over a 3 year period at the University of South Florida, 3153 over 6 years at Cleveland Clinic, 557 in 2 years at Northwestern University Chicago and 1500 over 10 years in Freiburg, Germany, were considered. Altogether, we screened 6374 long term video EEG monitoring (V-EEG) patients. Clinical records, V-EEG, imaging and treatment of these patients were reviewed. Results: Six patients (2 females) were identified among a total of 6374 patients (0.1%). 2 out of 3153 (0.06%) were seen at Cleveland Clinic, 2 out of 1500 (0.13%) at University of Freiburg, 1 out of 1164 (0.086%) at University of South Florida and 1 out of 557 (0.18%) at Northwestern University. Age at V-EEG ranged from 4 to 70 years. Age of seizure onset ranged from first months of life to 70 years. Additional clinical features during Video recordings included gelastic seizures (4), loss of consciousness/dyscognitive seizures (4), secondarily generalized motor seizures (4), and postictal aphasia (1). Interictal epileptiform discharges included frontal (1), temporal (3), parieto-occipital (1), and generalized sharp waves and polyspikes (1), as well as no discharges (1). Additional interictal EEG findings included background slow (1) and fronto-temporal slow (2). Ictal EEG features included generalized (1), right temporal (1), bifronto-temporal (2), and left temporal (2) EEG seizures and semi-rhythmic slow. MRI was lesional in all patients and suggestive of hypothalamic hamartomas (4), left mesial temporal atrophy and FLAIR hyperintensity (1), and bilateral antero-medial temporal FLAIR hyperintensity (1). Interictal PET in 4 patients revealed hypometabolism left temporal (2), left parietal and bilateral temporal (1). Ictal SPECT in 2 patients showed increased temporal uptake. Treatment interventions included medical management in 2, radiotherapy in 2, subtotal resection of the hamartoma in 1 and selective amygdalo-hippocampectomy in 1 patient. Only this latter patient became seizure free on follow up. Conclusions: We present one of the largest series of dacrystic seizures to date. Dacrystic seizures are a rare semiological feature occurring in 0.1% of admissions to the V-EEG monitoring unit in tertiary epilepsy centers. All patients had focal epilepsy of childhood onset associated either with hypothalamic hamartomas or (mesial) temporal lobe lesions. Concomitant gelastic seizures were seen in the 4 patients with hypothalamic hamartomas. We speculate that dacrystic seizures are likely automatisms (analogous to gelastic seizures) or possibly a release phenomenon similar to that of pseudobulbar palsy seen in demyelinating, vascular, or degenerative conditions.