Unilateral Eyelid Blinking and Intermittent Gagging as Manifestation of Focal Motor Status Epilepticus with Atypical Frontal Ictal Discharges on EEG
Abstract number :
3.117
Submission category :
3. Neurophysiology / 3A. Video EEG Epilepsy-Monitoring
Year :
2023
Submission ID :
1151
Source :
www.aesnet.org
Presentation date :
12/4/2023 12:00:00 AM
Published date :
Authors :
Presenting Author: Jian Xu, MD PhD – Henry Ford Health, Detroit, MI, United States
Vibhangini Wasade, MD – Senior Staff Neurologist/Clinical Associate Professor, Comprehensive Epilepsy Program, Department of Neurosciences, Henry Ford Health, Detroit, MI, United States; Jules Constantinou, MD, FRCAP – Senior Staff Neurologist/Clinical Associate Professor, Comprehensive Epilepsy Program, Department of Neurosciences, Henry Ford Health, Detroit, MI, United States
Rationale:
Unilateral eyelid blinking and intermittent gagging are rare seizure semiologies in people with focal epilepsy. We report a case who presented because of prolonged episodes of eyelid twitching associated with facial twitching, initially considered to be non-epileptic. A diagnosis of focal motor status was established on EMU admission. We draw attention to an under recognized ictal manifestation.
Methods:
A 24-year-old woman with a background of anxiety, bipolar disorder, fetal alcohol syndrome and generalized seizures in childhood was admitted to the EMU for characterization of prolonged episodes of eyelid twitching associated with facial twitching. She had a history of generalized seizures diagnosed in infancy well controlled in childhood with anti-seizure medications (ASMs) and then staring episodes in childhood for which she was taking lamotrigine prior to EMU admission. The episodes of right eyelid and right facial twitching presented only at age 18 years and were thought to be non-epileptic when she experienced intermittent gagging as well. Her neurological examination was normal as were other prior diagnostic tests including EEGs, MRI brain and Magnetoencephalography (MEG) scan.
Results:
During EMU evaluation, interictally, there were occasional sleep activated spike and slow wave discharges over the left fronto-central derivations (C3/F3 max) as her ASM was tapered. Intermittent right eyelid and right facial twitching consistent with focal motor seizures were noted that became more prominent and prolonged after weaning off ASM. Intermittent gagging was also noted. These subsided in sleep but recurred with brief periods of arousal. On EEG, time-locked atypical irregular needle like transients, over bifrontal derivations, sometimes with a squared off appearance, often showed emphasis across the right frontal electrodes (Fp2 >F4/F8) were recorded at a variable frequency of 4-8 Hz to 1-2 Hz, lasting for 8-10 hours. A first-time focal to generalized tonic-clonic seizure was also recorded with EEG onset from bifrontal electrodes (Fp2/Fp1 max) that quickly spread to the neighboring chains lasting for 21 seconds followed by background suppression. Clinically the patient had sudden behavioral arrest, ictal gagging, tonic facial gesture followed by generalized tonic-clonic jerking. She was restarted on lamotrigine, and to further control her seizures, lacosamide and clobazam therapy was also initiated before discharge.
Conclusions:
Unilateral/asymmetric eye blinking is a rare lateralizing sign. To our knowledge, ictal gagging has not been reported in people in unilateral eye blinking seizures and could suggest insular involvement. Interictal and ictal data in our patient were discordant and this highlights the challenges of lateralization because of the bifrontal nature of ictal EEG discharges and the anticipated eyelid movement artifacts. Careful observation of clinical symptoms and analysis of the EEG data can aid in formulating the final diagnosis and guiding the treatment plan.
Funding: None.
Neurophysiology