Abstracts

Analysis of seizure semiology is an important element of the presurgical evaluation. Hypermotor pattern at seizure onset is traditionally considered characteristic of frontal lobe seizure origin, with only rare reports in temporal lobe epilepsy. After observing several patients with hypermotor seizures and temporal tip lesions, we analyzed seizure manifestations in consecutive patients who had epilepsy surgery and MRI evidence of temporal tip lesions, to evaluate the frequency of hypermotor manifestations in epilepsy with temporal tip lesions. We systematically reviewed seizure history, imaging findings, EEG-video monitoring data, operative reports, pathology findings, and postoperative outcome in consecutive patients with temporal tip lesions evaluated over the preceding 10 years. We also reviewed recorded seizures for analysis of seizure semiology. Eight patients were found having temporal tip lesions. The age of seizure onset varied from 2 to 35 years (average 18). All patients had intractable complex seizures ranging in frequency from 1-2/day to 1-2/month. In all patients, brain MRI showed anterior temporal tip lesions. These included cavernoma in 2 patients, focal cortical dysplasia in 1 patient, cortical and subcortical white matter gliosis in 3 patients, ganglioglioma in 1 patient, and astrocystic proliferation in 1 patient. Four patients manifested hypermotor seizure semiology. The main features were rapid onset with moaning, barking or squealing vocal sound (2 patients) and vocal expletives (1 patient), followed by repetitive leg movement (bicycling, kicking, flexion-extension or sideway motion) in all 4 patients, repetitive body rocking motion (3 patients), pelvic thrusting (1 patient) and thrashing or flexion and extension of upper extremities (3 patients). The patients with hypermotor seizures also showed automatisms, head turning and unresponsiveness. The other 4 patients had typical manifestations of temporal complex partial seizures: gradual onset with staring, unresponsiveness, oralimentary or limb automatisms, hand posturing and head turning.
In the four patients with hypermotor seizures, ictal EEG demonstrated 4-5 Hz theta activity in the anterior temporal region then spread to the inferomesial temporal region, while the other 4 patients had initial rhythmic theta in the inferomesial temporal region.
All eight patients underwent epilepsy surgery. Six patients underwent anterior temporal lobectomy with hippocampectomy. One patient received lateral anterior temporal resection. One patient had a resection of cavernous angioma. Six patients remained seizure free since surgery (follow up range 12-36 months). Hypermotor seizures occur frequently in patients with temporal tip lesions. It is not clear if the hypermotor manifestations reflect temporal tip involvement or spread to the frontal lobe through the uncinate fasciculus. A search for temporal tip pathology is recommended for patients with hypermotor seizures and temporal epileptiform discharges.