Abstracts

Rationale: Focal findings during postictal period are related with the epileptogenic zone providing them a localizing value. Sneeze is defined as an involuntary, violent and thunderous body reflex in response to nonspecific nasal irritation. Its aetiology corresponds either to a symptom of nasal affection (blow, allergenic, heat or pressure changes) or to an autonomic reaction (photic reflex). Other less common causes are of psychogenic or epileptic origin. Only a few cases are previously reported. Kofman (1964) presented sneezing as a form of epileptic seizure with good response to phenobarbital. Gowers had referred to them with two other cases in his book Epilepsy (1901). Jasper and Peinfield (1954) evoked sneezing during stimulation of the right temporal lobe. No cases of sneezing as postictal manifestation were previously reported to our awareness. Its pathophysiology could be similar to nose-wiping or coughing, in relation with nasal or bronchial hypersecretion secondary to the activation of the amigdala.Methods: We show the case of a 70 years-old patient who had suffered a traumatic brain injury (TBI) with loss of consciousness when he was 40 years old. Twelve years ago, after another TBI, he presented with a secondary tonic-clonic generalized seizure and started suffering episodes in which he stared for several seconds, with a frequency of 1-2 per year. After his treatment with lamotrigine was substituted by the generic formulation, the frequency of seizures worsened despite of restoring the original antiepileptic drug or adding new treatments. A CT scan previously performed had shown a hypodense porencephalic lesion in the left temporal lobe. In relation with refractory epilepsy according to ILAE new definition, a complete evaluation was performed, with magnetic resonance imaging (MRI) and videoEEG monitoring.Results: Brain MRI with epilepsy protocol showed a hypointensity in the lateral left temporal lobe in T1-weighted sequences which appeared as hyperintensity in T2-weighted sequences. During the videoEEG monitoring two seizures were recorded during wakefulness, characterized by oral automatisms and partial disconnection for a few seconds, associating a right arm dystonia in the second episode. Both conclude with clusters of postictal sneezing. Rapid rhythms were followed by a spike and spike and wave discharge arising from the left temporal lobe. After being pointed out, his family realized than he had previously suffered this symptom at home after the seizures but they had not established a connection between both manifestations.Conclusions: Sneezing as an ictal symptom is a very rare phenomena still to be further characterized. We present the first case as a postictal finding and hypothesize its value as a lateralizing sign from the left temporal lobe.