Orbitofrontal seizures presenting with ictal visual hallucinations and interictal psychosis

Hallucinations are commonly believed to reflect temporal lobe dysfunction. This report presents the clinical, electroencephalographic, and neuroimaging findings in an 8-year-old male who experienced the acute onset of ictal auditory and visual hallucinations associated with epileptic activation of the right orbitofrontal region. Right frontal lobe surgery resulted in seizure freedom and disappearance of his psychotic symptoms. Histologic tissue examination revealed non-balloon cell Taylor type cortical dysplasia.     

Case of Simple Partial Status Epilepticus in Occipital Lobe Epilepsy Misdiagnosed as Migraine: Clinical, Electrophysiological, and Magnetic Resonance Imaging Characteristics

Summary: A 31–year-old man had a unique form of occipital lobe epilepsy. Since age 13 years, he has had episodes of simple partial status epilepticus (SE) occurring twice a month. These typically consisted of elementary visual hallucinations of flashing lights obscuring his left visual field for a period of 2 days, associated with a severe frontal headache initially diagnosed as migraine. These episoaes of simple partial SE then evolved to a complex partial seizure (CPS) or secondarily eneralized seizure. There were unique EEG features, including: (a) the perception of a flash of light in the left visual field with a single sharpislow wave discharge over the right occipital lobe, (b) right occipital lobe epileptiform activity during the prolonged aura, and (c) an abnormal response to photic stimulation, with occipital lobe discharges during low rates of stimulation (3–5 Hz), time-locked to the stimzlus. High-resolution magnetic resonance imaging (MRI) with quantitative morphometry demonstrated that the right hemisphere and right caudate nucleus were smaller than those on the left. An abnormal gyral pattern was also noted over the right parietal region. Occasionally, distinguishing occipital lobe epilepsy from migraine may be difficult.     

An unusual case of epilepsy exhibiting gelastic seizure, simple visual hallucination, and transient swelling of the left parieto-occipital region]

We report a 74-year-old man with gelastic seizure, simple visual hallucination, and adversive seizure. The patient described his visual hallucinations as "rotating light like a firefly" and "mimicking a stream". Brain CT scan showed a transient swelling as well as low density of a left parieto-occipital region. Electroencephalographic study revealed spikes and fast waves beginning at left occipital region. Although temporal lobe and hypothalamic lesions (especially hypothalamic hamartomas) are well known as origins of gelastic seizures, we could not find any report that described a series of occurrence of gelastic seizure and simple visual hallucination. Usually, simple visual hallucination is thought to occur in occipital lesion. In our case, it is possible that gelastic seizure and simple visual hallucination are related to the epileptic discharge from occipital lesion directly or indirectly. The reversible brain swelling with low density seen in the present case might be caused by cytotoxic edema due to status epilepticus.     

A case of right mesial temporal lobe epilepsy accompanied with ictal polyopsia]

A 59-year-old, right-handed woman had a paroxysmal polyoptic visual illusion, in which multiple copies of the object she saw spread horizontally in the left hemi-visual field. Polyopsia appeared for a few seconds. Neurological examination was normal. Magnetic resonance imaging (MRI) showed a tumor-like lesion involving the cortical and subcortical matters in the right mesial temporal regions. An interictal EEG showed frequent spikes in the right mesial temporal area and intermittent theta waves in the right fronto-temporal area. Video-EEG monitoring using the sphenoidal electrodes showed the seizure discharges originating in the right sphenoidal lead accompanying the polyoptic visual illusion. The seizure discharges were restricted within the right mesial temporal lobe. Paroxysmal visual illusion disappeared after administration of anti-epileptic drugs. EEG showed rare spikes in the right mesial temporal area. Polyopsia in this patient presumed to be associated with right mesial temporal lobe epilepsy because polyopsia and seizure activities on the ictal EEG were coupled and polyopsia ceased after administration of anti-epileptic drugs. Polyopsia is recognized as visual perseveration in space and a rare visual illusion. The lesion causing polyopsia has been reported to be mostly within posterior cerebral areas including occipital, parietal and temporal regions. This patient whose ictal polyopsia associated with mesial temporal lobe epilepsy is a very rare case because most reported cases presenting ictal polyopsia are neocortical temporal lobe epilepsy. The precise mechanism of polyopsia remains unknown. The mesial temporal lobe includes the hippocampus and parahippocampal formation that have been reported to receive information from the diverse association cortex and work as memory controllers. Ictal polyopsia may result from dysfunction of the visual association cortex or visual memory systems induced by the epileptic activities in the mesial temporal lobe. Polyopsia is a rare ictal semeiology of mesial temporal lobe epilepsy and may be one of the important ictal symptoms.     

Complex visual hallucination in the quadrantanopsic field in a patient with a medial temporal hematoma following left putaminal hemorrhage]

A 56-year-old man with a left medial temporal lobe hematoma from the left putaminal hemorrhage presented with complex visual hallucinations in the right quadrantanopsic field. In the right superior quadrantanopsic field, he saw colored and formed hallucinations of plants, bamboo thickets and a stature of bodhisattva. Most of these hallucinations were what he had actually seen before. The visual hallucinations disappeared when he gazed them with saccadic eye movements. EEG showed no epileptic discharges. MRI revealed hematoma from the lower putamen to the medial temporal lobe including amygdala on the left. 123I-IMP SPECT showed hypoperfusion in the left temporal lobe and in the left occipital and parietal lobes. We speculate that the hallucinations of the present case were produced by the dysfunctions not only of the temporooccipital and temporoparietal regions but also of the posterior inferotemporal cortex which has strong interactions with amygdala and works as the visual memory center.     

A child with ictal fear as the primary epileptic manifestation

We report a 4-year-old boy with ictal fear as his primary epileptic manifestation. Following an arrest of motion, the boy started to scream and struggle with an expression of horror on his face. Oral automatisms appeared around the end of the seizure. Complex visual and gustatory hallucinations and pain in the left leg were also observed. Ictal and interictal scalp EEGs revealed epileptic discharges in bilateral frontal regions. Ictal SPECT (99 mTc-HMPAO) showed hyperperfusion in right medial temporal area. These findings suggest that ictal fear associated with other ictal manifestations such as various hallucinations and oral automatisms resulted from rapid spread of epileptic discharges from frontal lobes to the right anterior temporal region.     

Complex visual hallucinations in the hemianopic field.

From 120 patients with an homonymous hemianopia 16 experienced complex visual hallucinations in the hemianopic field. The brain lesion was located in the occipital lobe, though damage was not limited to this area. Complex hallucinations appeared after a latent period. They were weak in colour and stereotypical in appearance, which allowed differentiation from visual hallucinations of other causes. Different behaviour after saccadic eye movement differentiated between complex visual hallucinations in the hemianopic field and visual auras of an epileptic origin.     

Complex visual hallucinations after occipital cortical resection in a patient with epilepsy due to cortical dysplasia

BACKGROUND: Charles Bonnet syndrome is a rare disorder characterized by complex and recurrent visual hallucinations in elderly patients with visual pathway pathologic defects. To date, to our knowledge, it has not been described in patients undergoing surgical resection for occipital lobe epilepsy due to cortical dysplasia. OBJECTIVE: To describe a patient who experienced complex visual hallucinations following resection of cortical dysplasia on the right occipital lobe and who was diagnosed as having Charles Bonnet syndrome. PATIENT: A 35-year-old woman underwent surgical resection for medically intractable epilepsy caused by cortical dysplasia involving the right occipital lobe. RESULTS: Two months after resection of the epileptogenic zone, complex visual hallucinations in the left visual field not associated with loss of consciousness or delusion developed in the patient. Hallucinations persisted for more than 12 months despite treatment with antiepileptic medications. During hallucination, no electrographic seizures were recorded through long-term video-electroencephalographic monitoring. CONCLUSIONS: Charles Bonnet syndrome may occur in a patient with occipital lobe epilepsy following resection of the diseased brain with a developmental malformation. Charles Bonnet syndrome associated with surgical treatment of occipital lobe epilepsy may have been overlooked.     

Occipital lobe epilepsy with fear as leading ictal symptom

Ictal fear is a semiological feature which is commonly associated with mesial temporal lobe epilepsy. Here, we describe fear as a leading symptom in cryptogenic occipital lobe epilepsy. In a patient with negative MRI findings, intracranial EEG recordings documented a strict correlation between habitual ictal anxiety attacks and both spontaneous and stimulation-induced epileptic activity in a right occipital epileptogenic area with subsequent spreading to the symptomatogenic zone in the amygdala. Circumscribed occipital topectomy led to seizure freedom. Episodes of non-epileptic fear ceased shortly afterwards. This report provides insight into pathways of propagation of epileptic activity, illustrates different etiologies of pathologic fear and underlines the importance of ictal EEG recordings.     

Occipital lobe epilepsy: clinical characteristics, seizure spread patterns, and results of surgery.

Twenty-five patients with occipital lobe seizure origin were retrospectively evaluated to determine clinical seizure characteristics and electroencephalographic manifestations. Certain symptoms and signs served to identify occipital lobe origin in 22 (88%). These included elementary visual hallucinations, ictal amaurosis, eye movement sensations, early forced blinking or eyelid flutter, and visual field deficits. Eye or head deviation, or both, was observed frequently and was contralateral to the side of seizure origin in 13, but 3 patients exhibited ipsilateral deviation in some or all their seizures. After the initial signs and symptoms, clinical seizure characteristics resembled those of seizures originating elsewhere. Seizures typical of temporal lobe origin with loss of contact and various types of automatic, semipurposeful activity occurred in 11 patients. Seizures in 3 patients exhibited asymmetrical tonic or focal clonic motor patterns characteristic of frontal lobe seizures. Eleven of the 25 patients had, on two occasions, two or more distinctly different seizure types. Scalp electroencephalographic findings were seldom helpful for occipital lobe localization and were frequently misleading. Intracranial electroencephalographic recording correctly identified occipital lobe seizure origin in most, but not all, patients who had such studies. Intracranial electroencephalic recording also proved the variability in clinical seizure characteristics was related to different seizure spread patterns, medially or laterally above and below the sylvian fissure, both ipsilateral and contralateral to the occipital lobe of seizure origin. Eighteen patients had occipital lobe lesions detected with computed tomographic or magnetic resonance imaging scans or both. Resection of the lesions in 16 patients produced excellent results in 14 (88%). Five patients had temporal lobectomies, with good results in 3, but poor results in 2. Two patients with unlocalized seizures had complete section of the corpus callosum, 1 with a good result and the other with a poor result.     

Epileptic activity of the occipital lobe. Clinico-electroencephalographic contribution

Our analysis of the course of illness in 14 patients, whose common electroencephalographic characteristic was epileptogenic activity in the occipital area, showed very different clinical symptoms. The first group comprised patients who presented bilateral amaurosis. In four of these cases, the occipital hypersynchronous EEG activity was merely a secondary symptom of either ischaemic hypoxia or of a degenerative process in the occipital visual cortex and was not responsible for the genesis of the actual blindness. In two further cases of monosymptomatic temporary loss of vision, it was difficult to make a differential diagnosis between ictal blindness, respectively status epilepticus amauroticus occurring in a occipital lobe epilepsy and a migraine attack involving the basilar territory. The second group comprised five patients with paroxysmal visual hallucinations respectively illusions. Three of them suffered from hallucinations of the elementary type, respectively flickering fits in the hemianopic field, symptoms which are based on discharges in the visual cortex of the occipital lobe. In a case of one patient with complex visual hallucinations as well as in a further case with visual illusions, it was not possible to find out with certainty their place of origin. A study of these cases shows that the cortical or sub-cortical functional disturbance within the visual system causing the various optical deformations and visual hallucinations, form an inhomogeneous group with different etiology. In the only patient belonging to the third group, whose seizures were i.a. characterized through motor phenomena in the field of the ocular organs and the tonic lateral turning movement of the bulbi of the eyes and of the head, an occipital epileptic crisis with spread of discharges from the occipital pole to the frontomesial surface should be assumed. The occurrence of complex partial seizures, respectively generalized tonic-clonic attacks in two patients of the fourth group who have definite epileptogenic EEG-activity in the occipital area, can be explained by a propagation of paroxysmal activity to the temporal lobe or to the motor cortex. Because of the marked tendency to propagation of the hypersynchronous activity originating in the occipital lobe, many combinations of sensory and/or motor symptoms can occur within the frame-work of occipital epileptic seizures. On the basis of one scalp EEG finding, no final localizing conclusions may be drawn here.     

Epileptic ictal strabismus: a case report and review of the literature

Ictal strabismus, sometimes associated with epileptic nystagmus, is an extremely rare epileptic phenomenon, suggestive of cortical involvement in monocular eye movement control. We describe a patient with ictal disconjugate contraversive horizontal eye deviation of cortical origin as the main clinical feature of a focal seizure. A 17‐year‐old, previously healthy woman had a seizure characterized by initial rightward conjugate eye deviation, followed by convergent strabismus due to adduction of the right eye towards the nose without conjugate left eye abduction (esotropia), forced leftward head deviation with impaired awareness, and subsequent evolution into a bilateral tonic‐clonic seizure. Postictal and interictal neurological status were unremarkable; more specifically, neuro‐ophthalmological examination revealed no nystagmus or altered eye motility. Ictal EEG showed a rhythmic theta activity over the right posterior temporal region, involving fronto‐central regions when strabismus appeared. MRI showed cortical dysplasia in the right temporal lobe. Due to the low spatial resolution of scalp EEG, we could not identify with precision the symptomatogenic zone underlying ictal strabismus. However, the concomitant appearance of rhythmic theta activity over the right fronto‐central region and the leftward head version with MRI perfusion sequences, showing cerebral blood flow increase in the right frontal eye field area, suggest involvement of the right frontal lobe. [Published with video sequence on www.epilepticdisorders.com ].     

Respiratory arrest at the onset of idiopathic childhood occipital epilepsy of Gastaut

Occipital lobe epilepsy of childhood includes two entities: Panayiotopoulos syndrome in pre-school children, and idiopathic childhood occipital epilepsy of Gastaut (ICOEG) in school-age children. The typical initial manifestation of the former is vomiting, and that of the latter is visual hallucinations. Ictal cardiopulmonary arrest at initial presentation has been reported for Panayiotopoulos syndrome, but not for ICOEG. We document a 7-year-old previously healthy girl who experienced an acute elemental visual hallucination of seeing insects, followed by a new-onset generalized seizure. Upon arrival at the local hospital, she was unconscious and soon thereafter, developed respiratory arrest. She was resuscitated and initiated on mechanical ventilation. An electroencephalogram taken three days after seizure cessation showed frequent occipital spikes, consistent with the diagnosis of ICOEG. The sequence of acute elementary visual hallucination followed by a motor seizure, and then witnessed respiratory arrest illustrated occurrence of life-threatening autonomic involvement at initial onset in ICOEG. We speculate that the epileptic propagation from the occipital lobes eventually compromised the respiratory center in the brainstem. The possibility of occipital lobe epilepsy should be considered in school-age children presenting with acute visual hallucination followed by respiratory arrest. Such a presentation should prompt an urgent electroencephalogram and initiation of antiepileptic treatment if indicated.     

Partial Seizure with Aphasic Speech Arrest Caused by Watching a Popular Animated TV Program

On the evening of December 16, 1997, about 700 children across Japan were hospitalized because of convulsive seizures or vomiting experienced while watching a popular animated TV program that included blue and red stimuli that alternated at 12 flashes per second. In one case, an 11-year-old girl developed a hallucination in the right visual field and a subsequent cramp on the right side of her face, with aphasic speech arrest. She had no history of seizures. Her electroencephalogram (EEG) showed normal background activity and no epileptiform discharges. Intermittent photic stimulation provoked a photoparoxysmal response. Her main clinical manifestation was a TV-induced left occipital lobe seizure spreading toward the left inferior frontal lobe. This suggested a functional link from the occipital lobe to the frontal operculum.     

Visual disturbances representing occipital lobe epilepsy in patients with cerebral calcifications and coeliac disease: a case series

Paroxysmal visual manifestations may represent epileptic seizures arising from the occipital lobe. In coeliac disease (CD) bilateral occipital calcifications and seizure semiology consistent with an occipital origin have been described, primarily in Mediterranean countries. By reporting three adult patients from an Australian outpatient clinic with visual disturbances, occipital cerebral calcifications, and CD, this study seeks to emphasise that CD should be considered even when patients of non-Mediterranean origin present with these symptoms. Seizure types included simple partial, complex-partial, and secondarily generalised seizures. The seizure semiology consisted of visual disturbances such as: blurred vision, loss of focus, seeing coloured dots, and brief stereotyped complex visual hallucinations like seeing unfamiliar faces or scenes. Symptoms of malabsorption were not always present. Neurological examination was unremarkable in two patients, impaired dexterity and mild hemiatrophy on the left was noted in one. Routine electroencephalography was unremarkable. In all cases, computed tomography demonstrated bilateral cortical calcification of the occipital-parietal regions. Magnetic resonance imaging showed no additional lesion. All patients had biopsy confirmed CD. Seizure control improved after treatment with gluten free diet and anticonvulsants. This report illustrates the association between seizures of occipital origin, cerebral calcifications, and CD even in patients not of Mediterranean origin.     

Epileptic polyopia with right temporal lobe epilepsy as studied by FDG-PET and MRI: a case report

Polyopia is one of rare, visual hallucinations. A 61-year-old man suffered from daily episodes of polyopia and generalized convulsions, and he was diagnosed as right temporal lobe epilepsy. MRI revealed right amygdalar swelling. FDG-PET showed hypometabolism in the right anterior temporal and the mesial occipital areas. Polyopia is thought to be caused by dysfunction of updating process of visual information in the visual association cortices. It was most likely that, in this patient, both mesial temporal and ipsilateral occipital areas were responsible for manifesting epileptic polyopia, as ictal onset zone and symptomatogenic zone, respectively.     

Right hemispheric dominance of visual phenomena evoked by intracerebral stimulation of the human visual cortex

Electrical brain stimulation can provide important information about the functional organization of the human visual cortex. Here, we report the visual phenomena evoked by a large number (562) of intracerebral electrical stimulations performed at low‐intensity with depth electrodes implanted in the occipito‐parieto‐temporal cortex of 22 epileptic patients. Focal electrical stimulation evoked primarily visual hallucinations with various complexities: simple (spot or blob), intermediary (geometric forms), or complex meaningful shapes (faces); visual illusions and impairments of visual recognition were more rarely observed. With the exception of the most posterior cortical sites, the probability of evoking a visual phenomenon was significantly higher in the right than the left hemisphere. Intermediary and complex hallucinations, illusions, and visual recognition impairments were almost exclusively evoked by stimulation in the right hemisphere. The probability of evoking a visual phenomenon decreased substantially from the occipital pole to the most anterior sites of the temporal lobe, and this decrease was more pronounced in the left hemisphere. The greater sensitivity of the right occipito‐parieto‐temporal regions to intracerebral electrical stimulation to evoke visual phenomena supports a predominant role of right hemispheric visual areas from perception to recognition of visual forms, regardless of visuospatial and attentional factors. Hum Brain Mapp 35:3360–3371, 2014. © 2013 Wiley Periodicals, Inc .     

Memory function in focal epilepsy: a comparison of non-surgical, unilateral temporal lobe and frontal lobe samples

Three well-matched groups of non-surgical, pharmacologically controlled epileptic patients with unilateral seizure foci in either the left temporal lobe, the right temporal lobe or a frontal lobe, and a normal control group were compared on several verbal and non-verbal memory tasks. Results revealed significant impairment of verbal memory in left temporal epileptic subjects, and significant impairment of non-verbal, visual memory in right temporal epileptic subjects. Seizure patients with unilateral frontal lobe foci did not differ from the control sample on any measure. Results support previous research which emphasizes the importance of temporal lobe systems in memory function. The findings are discussed with regard to the nature and specificity of the observed deficits.     

Palliative temporal resection for the treatment of intractable bioccipital epilepsy.

RATIONALE: Temporal resection is usually ineffective in patients with occipital seizures. However, when seizures are unilateral occipital resections are now, occasionally, considered. When bilateral seizures and visual field defects exist, occipital resection can not be carried out. When predominantly lateralized, temporal seizure onset can be shown in such patients, palliative temporal resection may be justified. METHODS: We report two patients with medically refractory, bilateral occipital lobe seizures. Clinical and electrophysiological patterns suggested consistent spread of the ictal discharge to temporal lobe structures. Long-term EEG video monitoring was followed by stereoelectroencephalography (SEEG) to assess involvement of temporal and occipital regions symmetrically. RESULTS: Both patients had non-lateralized, elementary visual aura followed by loss of contact, automatisms, frequent falls and occasionally secondary generalization. Brain MR imaging revealed bilateral parieto-occipital ischemic lesions without concomitant temporal volumetric abnormalities. They had bilateral or unilateral visual field defects. Scalp EEGs showed bilateral temporal or temporo-parieto-occipital interictal and ictal epileptic abnormalities. Intracranial SEEG recordings confirmed the presence of multifocal, temporo-occipital epileptic abnormalities. In both however, disabling seizures originated in, or rapidly spread to the right hippocampus. Since occipital resections were inadvisable, both patients underwent selective, right amygdalohippocampectomy. Seizures continued in both (two-year follow-up), but were much less severe, not associated with falling or secondary generalization, not followed by fatigue or headache and with faster recovery. CONCLUSION: When occipital resection is inadvisable because of bilateral or diffuse visual problems, palliative temporal resection may be considered in patients with lesional, bilateral occipital lobe epilepsy, and rapid seizure spread to mesial temporal structures. (Published with videosequences).     

The physiological basis of visual hallucinations after damage to the primary visual cortex

We used functional magnetic resonance imaging to examine the neuroanatomical correlates of visual hallucinations in a patient with a left visual field defect who had suffered bilateral occipital infarction. By cross-correlating the functional magnetic resonance imaging data with the hallucination events, we were able to identify the cerebral activity underlying the hallucinations. Bilateral activation was observed during visual stimulation in the calcarine fissure and the same activation was found medially in the left and right occipital cortex adjacent to the infarcted areas. This pattern of perilesional visual cortex activation is consistent with the suggestion that primary sensory areas may be involved in visual hallucinations after stroke.