Abstracts

Rationale: Injury from falls due to seizures is a very worrisome complication of uncontrolled epilepsy. Epileptic falls are usually attributed to GTCS, tonic, or atonic seizures. We describe here 5 adult patients with epileptic falls due to reflex focal seizures that had been variably suspected to be psychogenic, cardiac or cataplectic attacks.Methods: We reviewed the medical records of 3 patients from Mayo Clinic Minnesota and 2 patients from Mayo Clinic Arizona. All patients had spells recorded during video-EEG monitoring. The patients were compared to determine whether there are common features that underlie the condition, and what treatment was effective to stop their spells and falls.Results: Three were females. Onset of spells was at age 9, 14, 69, 10, & 17 years. None had epilepsy risk factors, febrile seizures, or family history of epilepsy. All had propensity for multiple spells on some days, all having experienced serious injuries. Spells were unilateral positive motor movements in Pt. #1 (leg contraction/jerk), #3 (kick/shudder), & #5 (stiffening); whereas, Pts#2 & 4 had unusual sensation of one leg and loss of control without abnormal movements. No patient had loss of awareness with the spells. Consistent trigger of spells was startling loud noise in Pts.#1, 2, 3 & 5; uneven ground in Pt#1 & 2; gait obstruction in Pt#2, and voluntary left ankle movement in a particular direction in Pt#4. Neurological examination shows left foot drop in Pt#4, and slightly abnormal bilateral heel-to-shin and tandem walk in Pt#3. Spells in all patients were medically intractable, and VNS also failed in Pt#1. Only patient #1 had interictal multifocal EEG discharges, which were at the left frontal, bifrontal (maximal left) and midline central regions. Only Pt#3 had abnormal MRI with bilateral hippocampal atrophy. Ictal scalp EEG shows: bifrontal discharge in Pt#1; midline discharge in Pt#2; no EEG discharge in Pt#3 & 5. Ictal EEG not captured in Pt4, but ictal SPECT (SISCOM) showed bifrontal hyperperfusion, maximal right. Intracranial recording localized seizure onset at the contralateral motor region in Pt#1, and at the superior parietal cortical sensory area in Pt#2. Further recordings in Pt#2 proved ictal asomatognosia (as previously reported in Neurology 2004; 63:2153-2154). Video of spells will be shown. Pt#1 continued to fail AED therapy. Pt#2 failed multiple subpial transection surgery at another institution. Pt#3 had seizure remission for 8 years but seizures recur without triggers. Pt#4 was lost to follow-up after intracranial electrode implantation was offered. Pt#5 had satisfactory but incomplete seizure control with valproate. Conclusions: Reflex focal seizures can cause falls and injuries, and often involve the motor cortex. Consistent triggers of these seizures are startling loud noise, and less frequently gait impediment or specific limb posture/movement. The retention of awareness, unilateral limb involvement, high seizure frequency, and mostly negative EEG and MRI are all compatible with a form of cryptogenic extratemporal epilepsy. Despite the reflex component, family history is negative.