Abstracts

Rationale: Throughout time, epilepsy and spirituality have been closely linked. Religious and literary figures such as Ezekiel, Saint Paul, and Dostoyevsky, have been alleged to have seizures or epilepsy. The scientific literature commonly implicates temporal lobe foci in spiritually-linked seizures. We report a case of an ictal spiritual visual hallucination of a guardian angel that arises from the right parietal region. Methods: The patient is a 59-year-old woman with epilepsy onset in childhood, admitted to the epilepsy monitoring unit (EMU) for diagnostic video EEG monitoring of frequent brief episodes of dizziness, blurred vision, and a stereotyped visual hallucination of a "guardian angel." She experienced this recurrent stereotyped vision of a guardian angel since childhood. It is typically a nocturnal occurrence but rarely, she sees her guardian angel during the day also, "usually when I was having a serious seizure (like when I lost consciousness and drove my car into a tree)." She realizes it is a hallucination or dream and typically does not share her vision with acquaintances for fear that "they would think I'm crazy." MRI brain (Figure 1) revealed a right parieto-occipital FLAIR/T2 hyperintensity in the subcortical white matter measuring approximately 15 x 10 x 8 mm. Results: 4-day video EEG monitoring confirmed a diagnosis of right parietal lobe epilepsy, with frequent brief (20 to 40 seconds) seizures arising from P4 with a field to T6, about 90% occurring in stage II sleep. Her diurnal seizures are all associated with a subjective feeling of "dizziness" or "blurred vision" of her entire visual field whereas most of her nocturnal seizures are subclinical or associated with the same subjective feeling. We recorded one episode of the patient's typical "guardian angel" event during video EEG monitoring that had an electrographic correlate. One morning at about 5:30 AM, the patient aroused from stage II sleep and immediately pushed the event button. When the nurse entered the room, the patient reported a "vision" of "my guardian angel" standing above her. This event was associated with an electrically stereotyped 28-second seizure, identical to the rest, with desynchronization, low amplitude fast beta maximal at P4, then evolution and spread into rhythmic theta activity in the right posterior quadrant, maximal at P4-T6 (Figure 2). On obtaining further history, the patient described the guardian angel as an undulating "jelly-fish-like" vision, usually of light but sometimes dark, occasionally with wing-like structures, but without a face or sound, that gives her "a sense of peace." Conclusions: In the literature, religious premonitory symptoms or auras have been reported by up to 4% of epilepsy patients, most commonly seen in right temporal lobe epilepsy. We report a case of an ictal religious aura recorded in the EMU, arising from the right parieto-occipital area with predominantly visual symptoms, with spread to involve the right posterior temporal area which could explain the patient's subsequent feelings of serenity.