Epileptogenesis due to Peripheral Injury as a Cause of Focal Epilepsy

Abstract

Summary: Purpose:To report three patients in whom focal epilepsy developed shortly after painful soft tissue injuries to their hands.Methods: Case reports.Results: The attacks started in the injured hand. No evidence was found of an underlying brain lesion by history or from imaging studies.Conclusions: These cases suggest the possibility that the injuries led to a plastic change in the sensory/motor cortex, leading to increased excitability and ultimately to seizures. This suggests that epileptogenesis can occur in response to painful peripheral stimuli in some individuals. Key Words: EpileptogenesisPeripheral injury-Focal seizures-Focal epilepsy-Cortical reorganization.We present three patients in whom focal epilepsy developed shortly after injuries to one hand. Presumably, the injuries led to a plastic change in the sensory/motor cortex, leading to increased excitability and ultimately to seizures. Whether this can occur de novo or requires activation of an underlying lesion remains to be seen. This association de novo has not been reported previously in the literature. CASE REPORTS Patient 1A 23-year-old right-handed man with no significant medical or family history was admitted for assessment of abnormal movements and epilepsy. Five years earlier, he accidentally caught his right hand between the rollers of a machine, sustaining soft tissue injuries. Approximately 24 h later, jerking movements developed, initially involving only his right hand, that lasted ∼2-3 s and recurred >20 times a day. Three months later, he started having nocturnal generalized seizures. Valproate (VPA) and carbamazepine (CBZ) resulted in seizure control but no improvement in the myoclonic jerks. These occurred withAccepted January 23, 2005. Address correspondence and reprint requests to Dr. F. Andermann at Montreal Neurological Institute, 3801 University St., Montreal, PQ, Canada H3A 2B4. E-mail: Frederick.Andermann@mcgill.ca out warning, at rest or during purposeful movement. They were sometimes triggered by startle, causing him to fall and injure himself, but this was not consistent.At the time of admission, his general, neurologic, ophthalmologic, and skin examinations were normal. Initially, it was thought that these events were not epileptic, and anticonvulsant medications (AEDs) were rapidly discontinued during continuous video telemetry. He then had nine stereotyped seizures with stiffening of the whole body, elevation of the right arm, slight head and eye deviation to the right, and secondary generalization. Typically, the movement stopped on the right side before the left. Postictally, he had no focal deficits. EEG seizure onset was obscured by muscle artifact but was followed by rhythmic activity over both hemispheres with parasagittal predominance. During one seizure, these changes were clearly lateralized to the left parasagittal region. Only one generalized myoclonic jerk was recorded during wakefulness and was not associated with any EEG change. No interictal epileptiform activity was found.Brain magnetic resonance ima...

Electrophysiology of the focal cortical dysplasias

“…The emergence of continuous epileptic myoclonus originating from the cortical sensory regions receiving afferent volleys from the injured left hand suggests disruption of an inhibitory equilibrium in a cortical dysplastic network. The abrupt onset of continuous seizures following the injury set this patient apart from others in whom epilepsy with occasional seizures began after different types of peripheral injury (Spiller et al., 2005). Although the mechanisms involved in the disinhibition of dysplastic networks by intense afferent stimuli are unknown, they are probably related to those operant in patients of malformations of cortical development who present reflex seizures (Palmini et al., 2005).…”

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“…Furthermore, ~30% of patients with epilepsy are refractory to conventional antiepileptic drugs, representing an unmet need for epilepsy research from many possible points of view such as new treatments, biomarkers and so on (Chen et al, 2017). Recently, there has been increasing focus on the role of peripheral inputs (stimuli) that can interfere with neurodevelopment (De Vadder et al, 2014;den Heijer et al, 2018;Riazi et al, 2010;Spiller et al, 2005;Vieira et al, 2016) and be thus possibly involved in epileptogenesis and epilepsy.…”

Misdiagnoses of Epilepsy as Ekbom Syndrome, Mood Instability, and Nocturnal Visual Hallucinations

“…We found some rare case reports describing focal epilepsy developed after soft tissue lesions of hands, with start of seizures in the injured hand. It is presumed that the peripheral injuries can result in plastic changes in cortex causing hyperexcitability and seizures [3]. …”