Selected Papers: Case Reports
Independent Epileptogenic Multifoci in a Girl with Symptomatic Partial Epilepsy Mikio Haga, M.D., Takashi Soga, M.D., Morikazu Ohori, M.D.,* and Shiro Totsuka, M.D.**
National Epilepsy Centre, Yamagata * Nihonmatsukai Yamagata Hospital, Yamagata **Department of Neuropsychiatry, Yamagata University School of Medicine, Yamagata Not rarely independent plural partial seizures are recognized in the same patient with epilepsy. Such questions are raised to be clarified as the followings: relations between clinical manifestation and interictal EEG findings, actual epileptogenecity of each interictal focus, and capabilities of concerned EEG focus to produce plural seizures of different types in its clinical feature or its nature. We experienced a 2year-old girl with independent plural epileptogenic foci from the viewpoint of scalp EEG. The girl was born in March 1988, showing neonatal asphyxia due to the umbilical cord winding round her neck without any special family history nor specific problems during pregnancy. On the fourth day she showed a generalized convulsion. Under the diagnosis of neonatal seizure, a thorough examination and treatment were carried out without any control of the seizure. She was referred to our epilepsy ward in August 1990, at one and a half year of age. Her development was normal in body length and weight, but sitting and standing alone were delayed and she could not even utter a word. There were no gross neurological findings. Serial investigations of CT, MRI and SPECT showed no apparent abnormal findings. An interictal EEG showed a slow background activity at wakefulness, and frequent polyspike and polyspike-wave
activity synchronously/dependently localized bilateral posteriors during a light sleep. Seizure Types and Their Ictal EEGs
(A) Complex Partial Seizures Clinical manifestations Behavioral arrest was followed by head turning to the right or left with gradual tonicity of the whole body and then motor automatism of the extremities as pedaling terminated by momentary laughing and falling to sleep. Any definite laterality was not confirmed by the numerous numbers of video-EEG monitoring. Ictal EEG pattern A-1 (Fig. 1-1) Onset (a): Appearance of a high amplitude sharp activity following slow wave activity localized F7-T3. Middle stage of seizure (b): Periodicity and amplitude of the localized sharp activity decreased without propagating to the other areas nor generalization. Following this clinical stage with moderate tonicity there appeared automatism associated with an irregular movement of the extremities. Late stage of seizure (c): Activity of the localized sharp became less clear. End of seizure (d): Irregular slow wave activity followed after the disappearance of the localized sharp. Additionally there could be higher amplitude slow waves in the contralateral temporal lobe. Ictal EEG pattern A-2 (Fig. 1-2) Onset (a): In this ictal EEG case, a sharp activity appeared in F8-T4 and showed a waxing feature at a drowsy state. Middle stage of seizure (b): Similarly as the former, this sharp activity continued to be localized, not propagating nor generalizing. Late stage of seizure (c): Decrease of the localized sharp was shown. End of seizure (d): Disappearance of a sharp activity, not showing a postictal slow activity in the right temporal area or hemisphere.
The Japanese Journal of Psychiatry and Neurology, Vol. 46, No. 2, 1992
Dee. 5, '81 (1731)
Selected Papers: Case Reports
Apr. 3, '91
Fig. 2: Complex partial seizure evolving into hemilateraVgeneralized convulsion. Ictal EEG pattern A-3 (Fig. 1-3) This trace shows an ictal pattern that began to appear in the left temporal at first and then propagated to the right temporal lobe in the early seizure stage. We could also detect seizures in the reverse order.
(B) Complex Partial Seizure Evolving into Prolonged HemilateraVGeneralued Convulsion Clinical manifestations Sequentially she fell into an absentmindedness with head version to right, gradually hemilateral clonic convulsive state, and finally generalized clonic convusion lasting for a few hours. Ictal EEG pattern (B) (Fig. 2) Fortunately the concerned seizure was thoroughly tailored twice. Onset (a): Irregular but sustained seizure discharges localized 01-T5 recruited gradually. The patient showed turning of eyes and head to the right. Early clonic phase of the right arm (b): Waxing spike activity enfolded broadly to the left posterior areas and developed into 1.5 Hz polyspike activity. Generalized clonic phase with enrolled left side of the body (c): Seizure discharges
propagated to the whole left posterior parts and also to the right hemisphere. Late clinic phase of the right arm (d): EEG pattern was not the same as mentioned in (b). The periodicity slowed to about 1 Hz and the slowed activity of the right hemisphere and sharp-wave activity in the right posterior were characteristic on the contrary to the fact of (b). End of seizure (e): Showing remaining irregular slow wave activity with lowered amplitude in the left posterior, and seizure activity ceased abruptly. Conclusion 1) A girl showed plural partial seizures of independent epileptogenic EEG foci, namely of each bilateral temporal lobe and left occipital lobe. 2) Epileptogenic foci in bilateral temporal were not detected by interictal EEG recordings. 3) No clarification of any direct or indirect relationship between bilateral temporal and occipital. 4) Each of seizure discharges of bilateral temporal foci could stay in their own site or in same hemisphere. 5 ) Epileptogenic activities of bilateral temporal were connected to each other in one seizure.