Automatisms with preserved responsiveness and ictal aphasia: contradictory lateralising signs during a dominant temporal lobe seizure

Abstract

The 25-year-old right-handed woman suffering from temporal lobe epilepsy (TLE) was referred to our centre for presurgical evaluation. MRI showed a right-sided hippocampal sclerosis. During video-EEG-recorded seizures, abdominal aura was followed by oral automatisms, during which she was completely reactive to external stimuli, although she was unable to speak. Ictal EEG showed right temporal seizure pattern, without contralateral propagation. She had abnormal speech postictally. Speech-activated functional transcranial Doppler sonography revealed right-sided speech dominance. She has become seizure free after a right-sided amygdalo-hippocampectomy. In our patient, contradictory clinical ictal lateralising signs (automatisms with preserved responsiveness vs. ictal and postictal dysphasia) occurred during right-, speech-dominant-sided seizures. This is the first report when automatisms with preserved consciousness occurred during a seizure originating and involving the speech-dominant hemisphere.

Secondarily generalized seizures in temporal lobe epilepsy

“…In that study, we hypothesized that ARBS was associated with a more circumscribed region involved at seizure onset, since we found that ARBS was associated with a lateralized seizure onset and a better outcome after TLE surgery. APR is a well-known sign for nondominant TLE seizure (Ebner et al, 1995) but also indicates circumscribed seizure activity that strictly involves only one temporal lobe without seizure spread to the contralateral side (Park et al, 2001;Janszky et al, 2003). The present and previous studies suggest that if the seizure activity remains in a circumscribed region for a certain period, that is, long enough to produce ARBS or APR, then it rarely progresses to secondary generalization.…”

Why do Seizures Cause Loss of Consciousness?

“…Complex partial seizures most commonly arise from the temporal lobe, often accompanied by pathological changes referred to as mesial temporal sclerosis (Engel 1987;Williamson and others 1993). Temporal lobe seizures typically begin with focal phenomena such as fear, rising epigastric sensation, indescribable premonitions, or lip-smacking automatisms (Park and others 2001;Janszky and others 2003). Simple partial seizures terminate without impaired consciousness, whereas complex partial seizures progress to impaired consciousness.…”