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PubMed1995

Increased technetium-99m-HMPAO uptake in grade II astrocytoma.

Most brain tumors show decreased uptake of blood flow tracers in brain SPECT imaging and in some cases meningiomas show increased uptake, mainly associated with high regional blood flow values. A reason for regionally increased tracer uptake is partial epilepsy when a tracer is injected during the ictal phase. We present a case of a histologically proven Grade II astrocytoma in the mesial part of the left temporal lobe that caused complex partial seizures. After tracer injection during a phase without signs of clinical seizure, markedly increased uptake of 99mTc-hexamethylpropyleneamine oxime (99mTc-HMPAO) occurred, although the tumor was partially calcified.

Adult↗
PubMed2000

[Status epilepticus with confusional symptomatology].

Non-convulsive confusional status epilepticus (NCSE) is classically separated into two forms on the basis of the ictal EEG, i.e., absence status (AS) and complex partial status epilepticus (CPSE). The diagnosis is difficult on the basis of clinical semiology alone, and requires emergency EEG investigation. Absence status, or 'petit mal' status, is a polymorphic condition that can complicate many epileptic syndromes, and is the most frequently encountered form of NCSE. It is characterized by confusion of varying intensity, associated in 50% of cases with bilateral periocular myoclonias. The EEG shows ictal generalized paroximal activity; normalization is obtained after benzodiazepine injection. In AS, there is a significant nosographic heterogeneity. Four groups can be distinguished: i) typical AS occurs in the context of a generalized idiopathic epilepsy; ii) atypical AS occurs in patients with symptomatic or cryptogenic generalized epilepsies; iii) 'de novo' AS (of late onset) is characterized by toxic or metabolic precipitating factors in middle-aged subjects with no previous history of epilepsy; iv) AS with focal characteristics occurs in subjects with a pre-existing or newly diagnosed partial epilepsy, mostly of extra-temporal origin. The majority of cases are in fact transitional forms between these four groups. CPSE is characterized by continuous or rapidly recurring complex partial seizures which may involve temporal and/or extratemporal regions. Cyclic disturbance of consciousness is characteristic of CPSE of temporal lobe origin, which requires vigorous treatment to prevent recurrence or cognitive sequelae. CPSE of frontal lobe origin is a diagnostic challenge: it is rare, the symptoms are unusual, and the patients should be documented extensively. A focal frontal lesion is revealed in one-third of cases.

Confusion↗
PubMed2005

Cognitive functioning in community dwelling older adults with chronic partial epilepsy.

PURPOSE: To examine cognitive functioning in community-dwelling older adults with chronic partial epilepsy and demographically matched healthy older adults. METHODS: Standardized measures of neurocognitive function were collected as part of an ongoing study investigating health-related quality-of-life issues in older adults with epilepsy. Cognitive tests consisted of the Mattis Dementia Rating Scale (subscales include attention, initiation/perseveration, construction, conceptualization, memory), Logical Memory subtest from the WMS-III (immediate and delayed recall scores), and word fluency. Mood was measured with the Geriatric Depression Scale. Older adults with epilepsy (n=25) and healthy older adults (n=27) completed testing. All participants were at least 60 years old, living independently in the community, and had no history of drug/alcohol abuse or life-threatening medical conditions. All older adults with epilepsy had been diagnosed as having medically intractable partial complex seizures, including those with histories of secondary generalization. RESULTS: Older adults with epilepsy demonstrated impairments across all cognitive measures compared with the healthy controls. Seizure onset (age) and seizure duration (years) were not statistically associated with neurocognitive function or self-reported mood. Older adults with epilepsy who were receiving antiepileptic drug (AED) polytherapy (n=11) displayed worse performance on the attention, initiation/perseveration, and memory subscales of the DRS and Logical Memory delayed recall score compared with those older adults with epilepsy receiving monotherapy (n=14). The number of AEDs taken was not associated with seizure frequency. CONCLUSIONS: Negative effects on cognitive function are experienced by older adults with chronic partial epilepsy. AED polytherapy may increase the risk for negative cognitive dysfunction.

Affect↗
PubMed1990

Use of intravenous immunoglobulins in drug-resistant epilepsy.

Among the 257 pediatric patients examined, 104 were classified as having drug-resistant epilepsy (DRE). In all of them genetic, metabolic, chromosomal and infectious causes were investigated, and brain imaging with computed tomography scans and nuclear magnetic resonance were obtained. Since treatment with gammaglobulins (GGs) has been reported to be useful in pediatric cases of epilepsy, informed consent for GGs treatment was obtained in 43 patients with DRE. The etiology or evidence of brain lesions was identified in 16 of them. In 31 of these patients, neither conventional drug treatment, nor a trial with adrenocorticotropic hormone was successful. Intact monomeric GGs, 400 mg/kg, were given intravenously. A second dose was given after 15 days and, thereafter, every 21 days for a maximum of ten injections (protocol A), or every 2nd day for a maximum of five doses (protocol B). In every patient, the type of epilepsy was identified according to the classification of the International League Against Epilepsy. The frequency of seizures was recorded for a period beginning at least 6 months before the administration of GGs. Immunological evaluation was also performed before and after the treatment with GGs. A transient decrease of the seizure frequency was noted in 12 subjects. In another patient with infantile idiopathic myoclonic epilepsy, seizures disappeared for 30 months. In 1 case a persistent 80% reduction in the number of seizures was observed. A persistent disappearance of seizures was noted in a subject with complex partial seizures (CPS) that followed an idiopathic infantile spasm syndrome.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMed1996

[The mechanism of controlling regional cerebral blood flow in patients with localization-related epilepsy].

INTRODUCTION: Hypoperfusion around the seizure foci has been reported in interictal CBF studies of partial epilepsy. Hypoperfusion may reflect some interictal pathophysiology characteristic of epilepsy, but the mechanism remains to be elucidated. In order to elucidate the controlling system of rCBF in patients with CPS (complex partial seizure), we measured by positron emission tomography rCBF and CO2 vasoreactivity performing a hyperventilatory task, and made comparisons between the affected and contralateral sides of the temporal lobes in CPS patients and the temporal lobe of normal volunteers. We also measured PaCO2, pH, PaO2 and respiratory rate at rest to elucidate the CBF maintaining system. SUBJECTS: 15 volunteers and 12 medically controlled patients with CPS were examined. The affected side of the brain of the patients was determined by dominance of EEG paroxysm. METHOD: For measuring rCBF, the Shimadzu HEADTOME-IV system (8mm FWHM) and H2(15)O (740-1480 [MBq]/scan) bolus injection method were employed. First a rest scan, then a hyperventilatory task scan was performed, at 20 min. intervals between each scan. During the rest scans, the subjects were required to close their eyes, which were covered through the transmission scan and all the other scans. They were monitered with EEG to insure that they were not asleep. Room lights were dimmed, room sounds were kept to a minimum and noises were damped with earplugs. During the hyperventilatory tasks, the subjects were asked to inspire deeply at a rate of 15/min. for 4.5 min. from 3 min. before the scan up to the end of the 1.5 min. scan, and monitored with a respiratory band around the abdomen. Arterial blood gas pressures (PaCO2, pH and PaO2) were also measured with a blood gas analyzer (Radio Meter ABL 330) at the beginning and at the end of the scans. [HCO3-] was calculated on the formula of Henderson-Hasselbalch. Vascular response to PaCO2 change: VrCO2 was defined as follows: VrCO2 = 100 x (CBFh-CBFr)/CBFr/(PaCO2h-PaCO2r) the subscripts h: hyperventilatory r: resting conditions. RESULTS: Blood gasses, rCBF and corrected-rCBF at rest: In the patients, PaCO2 (mmHg) = 46.11 +/- 2.32, pH = 7.374 +/- 0.020, [HCO3-] (mEq/ml) = 25.98 +/- 1.15, CBF (ml/100g/min) = 45.51 +/- 9.33, corrected-CBF (ml/100g/min) = 40.06 +/- 7.27. In the volunteers, PaCO2 = 40. 67 +/- 2.37, pH = 7.400 +/- 0.021, [HCO3-] = 24.36 +/- 1.66, CBF = 48.76 +/- 8.54, corrected-CBF = 48.02 +/- 9.04. PaCO2 and [HCO3-] in the patients were significantly higher than those in the volunteers. pH and corrected-CBF were significantly lower than those in the volunteers. CBF showed no difference. VrCO2 in the temporal lobe: In the affected side of the patients, VrCO2 = 1.976 +/- 0.54. In the contralateral side of the patients, VrCO2 = 2.145 +/- 0.667. In the temporal lobe of the volunteers, VrCO2 = 2.557 +/- 0.898. In both sides of the temporal lobe of the patients, VrCO2 was significantly lower than those in the volunteers. COMMENTS: The effect of anticonvulsant drugs and the suppressive mechanism around the foci are supposed to reduce CBF of CPS patients. We suppose another mechanism, which is vasoconstriction. A significant difference was noted in CO2-vasoreactivity in the temporal lobe between patients and volunteers. Also no difference was noted in rCBF in the temporal lobe between the volunteers and the patients, when the arteries were maximally constricted with the HIV-task. These two results suggest that vasoconstrictive mechanism may be among the factors for the hypoperfusion seen in the temporal lobe of the patients. In patients, PaCO2, [H+], [HCO3-] were significantly higher compared with the volunteers, which suggests the mechanism of respiratory acidosis. Owing to this hypercapnia, global CBF in the patients is maintained in compensation for the hyperfusion and vasoconstriction seen around the foci. CO2 acts as an anticonvulsant and also reduces glucose metabolites which accumulate around the foci.

Adult↗
PubMed1991

Sleep spindles in epilepsy.

Spindles are a ubiquitous phenomenon in sleep, but their physiology and the effects of neurologic disorder on their frequency and amplitude are incompletely understood. We compared the incidence of three commonly defined spindle types (14-15 Hz, 12-13 Hz, and 10 Hz) and the frequency and amplitude of spindles during Stage II sleep in 50 patients with complex partial, partial and secondarily generalized, and primary generalized seizures, with and without interictal behavioral symptoms. All patients had 12-13 Hz and 14-15 Hz spindles of symmetric character in C3-A1 and C4-A2 derivations during prolonged sleep-deprived EEG recordings, which were normal except for partial or generalized epileptiform activity. Seventy-one per cent of complex partial seizure patients had 10 Hz spindles, and they occurred in 50% of the other two groups, predominating among those with interictal behavioral symptoms in all groups. Spindle frequency was significantly less in patients with generalized epilepsy than with partial seizures, and patients with complex partial seizures and partial seizures with secondary generalization differed significantly in spindle frequency. Spindle frequency was significantly lower with polypharmacy than with monotherapy. Patients whose regimens included phenobarbital had significantly lower spindle frequencies and spindle frequencies differed significantly between phenytoin and carbamazepine. Differences in spindle frequency may be due to residual medication effects, underlying encephalopathy or physiological differences between partial and generalized epilepsy.

Adolescent↗
PubMed2006

Correlations of interictal FDG-PET metabolism and ictal SPECT perfusion changes in human temporal lobe epilepsy with hippocampal sclerosis.

BACKGROUND: The pathophysiological role of the extensive interictal cerebral hypometabolism in complex partial seizures (CPS) in refractory mesial temporal lobe epilepsy with hippocampal sclerosis (mTLE-HS) is poorly understood. Our aim was to study ictal-interictal SPECT perfusion versus interictal fluorodeoxyglucose (FDG)-PET metabolic patterns. METHODS: Eleven adults with refractory unilateral mTLE-HS, who were rendered seizure free after epilepsy surgery, were included. All had an interictal FDG-PET and an interictal and ictal perfusion SPECT scan. FDG-PET data were reconstructed using an anatomy-based reconstruction algorithm, which corrected for partial volume effects, and analyzed semi-quantitatively after normalization to white matter activity. Using Statistical Parametric Mapping (SPM), we compared interictal metabolism of the patient group with a control group. We correlated metabolic with ictal perfusion changes in the patient group. RESULTS: Global cerebral grey matter glucose metabolism in patients was decreased 10-25% compared with control subjects. Interictal PET hypometabolism and ictal SPECT hypoperfusion were maximal in the ipsilateral frontal lobe. Ictal frontal lobe hypoperfusion was associated with crossed cerebellar diaschisis. The ipsilateral temporal lobe showed maximal ictal hyperperfusion and interictal hypometabolism, which was relatively mild compared with the degree of hypometabolism affecting the frontal lobes. CONCLUSION: Interictal hypometabolism in mTLE-HS was greatest in the ipsilateral frontal lobe and represented a seizure-related dynamic process in view of further ictal decreases. Crossed cerebellar diaschisis suggested that there is a strong ipsilateral frontal lobe inhibition during CPS. We speculate that surround inhibition in the frontal lobe is a dynamic defense mechanism against seizure propagation, and may be responsible for functional deficits observed in mTLE.

Adult↗
PubMed2005

Regional cerebral blood flow in children with ADHD: changes with age.

The aim of this study was to investigate the changes in regional cerebral blood flow (rCBF) with age in patients with attention deficit hyperactivity disorder (ADHD). Twenty-nine drug-naive ADHD subjects (24 boys, 5 girls; age 7-13; mean+/-SD=age 9.2+/-2.1) and 12 subjects with epilepsy (all diagnosed as having complex partial seizure, 6 boys, 6 girls; age 7-14; mean+/-SD=8.5+/-2.1) were included in the study. All cases of ADHD were diagnosed according to DSM-IV criteria. Cerebral blood flow was evaluated with Tc-99m-hexamethylpropyleneamine oxime (Tc99m HMPAO) brain single photon emission tomography (SPECT) during standard resting condition in all of the cases. Asymmetry indices for each region of interest were calculated. Absolute rCBF values were normalized as the absolute rCBF values divided by the whole brain absolute value. The prefrontal lobe asymmetry indices were significantly negatively correlated with age in ADHD cases (r=-0.408, P=0.025), which indicated the increased prefrontal rCBF lateralization from the right to the left side with age. When ADHD cases older than 7 years of age were compared with those with epilepsy, the ADHD cases had lower right prefrontal and frontal rCBF and higher left parietal rCBF. The epilepsy group showed no significant correlations between age and asymmetry indices and showed a different developmental trajectory for prefrontal asymmetry and right prefrontal rCBF values. The results indicated that the left hemisphere dominance in the prefrontal cortex significantly increases with age in ADHD cases.

Adolescent↗
PubMed1993

[Gamma-vinyl-GABA: the first trials in Italy].

Vigabatrin (gamma-vinyl-GABA), a structural analogue of GABA, is a selective inhibitor of GABA transaminase. Vigabatrin has been effective in patients with refractory epilepsy. We treated patients with complex partial seizures and some of them also with secondary generalized seizures. Vigabatrin was administered as "add on therapy" (Table 1) and monotherapy (Table 2). As to table 1, concerning a variety of treatments and too few patients we could not reach any definitive statistical conclusion (paired Student's t test not significant). In table 2 the paired Student's t test was significant with p < 0.01. Longer follow-up is needed to determine whether the clinical effect is maintained and no severe side effects appear.

Adolescent↗
PubMed1981

Symptomatology of temporal lobe epilepsy.

The numerous and varied symptoms of temporal lobe epilepsy are reviewed in detail. Partial elementary, partial complex, secondary generalized, post-ictal and predisposing aetiological symptoms are examined.

Affective Symptoms↗
PubMedDate not supplied

[Clinical pattern of epilepsy with abortive temporal lobe attacks].

The purpose of the present work was to evaluate the clinical course of epilepsy with infrequent partial attacks with complex manifestations derived from the temporal lobe. Thirty patients aged 14 to 64 years treated on an outpatient basis and discovered during epidemiological investigations were followed-up. In half the cases only attacks without generalization occurred, in the remaining cases isolated generalized seizures appeared during many years of disease duration. In both groups a decrease was observed in the frequency of seizures in patients treated systematically or irregularly, as well as in those who had never been treated. Despite a long duration of the disease (above 6 years in 24 cases) the patients had normal mental level and good social adaptation.

Adolescent↗
PubMed2001

Reexamination of interictal psychoses based on DSM IV psychosis classification and international epilepsy classification.

We sought to examine interictal psychoses based on the international epilepsy classification and DSM IV criteria, with special attention paid to epilepsy types as well as to subcategories of psychoses. One hundred thirty-two outpatients were studied, each with definite evidence of both epilepsy and interictal psychosis clearly demarcated from postictal psychosis. We compared them with 2,773 other epilepsy outpatients as a control. Risk factors for psychosis were examined within the temporal lobe epilepsy (TLE) group and the more extended group of symptomatic localization-related epilepsy. Further, nuclear schizophrenia and other nonschizophrenic psychotic disorders were compared. We confirmed a close correlation between TLE and interictal psychoses. Within the TLE group, only early epilepsy onset and a history of prolonged febrile convulsions were revealed to be significantly associated with interictal psychosis. Within the symptomatic localization-related epilepsy group, such parameters as complex partial seizures, autonomic aura, and temporal EEG foci were closely associated with psychoses. There was also a significant difference between groups as to ictal fear and secondary generalization. Whereas patients with early psychosis onset and a low intelligence quotient were overrepresented in the nuclear schizophrenia group, drug-induced psychosis and alternative psychosis were underrepresented. TLE proved to be preferentially associated with interictal psychoses. Within the TLE group, medial TLE in particular was found to be more closely associated with psychosis. Our data support the original postulation of Landolt, stating that alternative or drug-induced psychoses constitute a definite subgroup of interictal psychoses, which are different from chronic epileptic psychoses that simulate schizophrenia.

Adolescent↗
PubMed1990

Factors that preclude the successful use of monopharmacy in the medical treatment of patients with epilepsy.

A neurologist conducted research efforts for more than 12 years as a step toward the establishment of monotherapy for epilepsy. Of 406 patients with epilepsy, seizures could be controlled for more than one year in 72% and for more than 3 years in 54%. Monotherapy was given to 57% of all the patients with a success rate of 54%. Factors that were found likely to interfere with a reduction in antiepileptic drug therapy to one drug modality included: symptomatic etiology, prolonged duration of illness, low age at onset and secondary generalized epilepsy with a large number of seizures in combination, for generalized epilepsies; symptomatic etiology, prolonged duration of illness, low age at onset, other than occipital lobe origin, complex partial seizure with secondary generalization, temporal lobe epilepsy with associated automatisms, elementary sensorimotor seizure and high frequency of seizures, for partial epilepsies. In addition to these factors relevant to the nature of epilepsies, other factors apparently unrelated to the disease process, e.g., liability of polypharmacy to produce side effects precluding dosage elevation, patient's rejection to reduce drug and the inability of a physician to treat the patient properly for want of information, were also recognized to exist.

Adult↗
PubMed2006

Evidence for a rapid action of levetiracetam compared to topiramate in refractory partial epilepsy.

The objective of this observational study was to compare the efficacy of levetiracetam and topiramate during the first 15 days of add-on treatment in adults with refractory partial epilepsy. Two cohorts of patients with > or =3 simple or complex partial seizures with or without secondary generalisation per month over an 8-week baseline period received levetiracetam or topiramate in two distinct phases, in addition to standard antiepileptic treatment. During the first 15 days of the therapy, levetiracetam was added at the dosage of 250 mg b.i.d. or topiramate at 25mg o.i.d. Efficacy parameters included number of seizure-free days (SFDs), mean and percent reduction in seizure frequency (in general and by type), and number of seizure-free patients in the first 15 days of treatment compared to last 15 days of the baseline period. Sixty-one patients received levetiracetam and 61 topiramate. The general characteristics of the two treatment groups were similar. The total number of SFDs during 15 days before treatment was 637 with levetiracetam and 621 with topiramate; in the 15-day evaluation period the SFDs increased to 748 (17.4%) and 668 (7.6%), respectively (ANOVA, p<0.05). Twenty-six patients (42.6%) taking levetiracetam were seizure free compared to 10 (16.4%) receiving topiramate (chi-square, p=0.003). This open-label non-controlled study suggests an early efficacy of levetiracetam as add-on therapy in patients with refractory partial epilepsy: these results appear to confirm previous indications of a rapid onset of action and seem to suggest first evaluation of the patient at the dose of 500 mg/day before increasing to the considered minimum standard dose of 1000 mg/day, as some patients could respond to the starting dose.

Adolescent↗
PubMed2000

Acute effects of gamma-vinyl-GABA on low-magnesium evoked epileptiform activity in vitro.

Vigabatrin (gamma-vinyl-GABA, VGB) is a gamma-aminobutyric acid (GABA) derivative designed to boost synaptic inhibition by inhibiting the degradation of GABA in brain tissue. Indeed, VGB shows potent anti-convulsant activity in animal models of epilepsy and in humans with complex partial seizures. However, details of the mechanism of action of VGB are not well understood and the systemic effects include possible pro-convulsant actions. We therefore analysed the effects of VGB in rat brain slices in the low-Mg(2+) model in vitro. VGB at 100 microM-5 mM showed a concentration- and time-dependent reduction of interictal-like events in the hippocampal CA1 region. Likewise, VGB suppressed epileptiform discharges in the medial entorhinal cortex (mEC), which are known to resist conventional anti-convulsants. In contrast, evoked population spikes in CA1 (which became repetitive after washout Mg(2+)) were not altered by VGB. Our data show that VGB is efficient against epileptiform discharges in temporal structures including pharmacoresistant patterns of activity. The waveform of evoked population spikes in this in vitro model is no indicator for the anti-convulsant properties of drugs.

Animals↗
PubMedDate not supplied

Factors relating to dramatic response to clobazam therapy in refractory epilepsy.

Twenty-five out of 41 (61%) patients with drug-resistant complex partial seizures showed an initial dramatic response to clobazam. Sixteen of these responders developed tolerance to the effects of clobazam so that only 9 (22%) maintained a dramatic response for 1 year. Factors which appeared important in predicting a dramatic response to treatment were a known aetiology for the epilepsy, the occurrence of complex partial seizures alone (i.e., without secondary generalisation) and the absence of mental retardation.

Adolescent↗
PubMed1993

Differential regulation of N-methyl-D-aspartate receptor subunit messenger RNAs in kindling-induced epileptogenesis.

N-methyl-D-aspartate-receptors are implicated in several neuropathological conditions including epilepsy. As a model of complex partial seizures, rapid hippocampal kindling was chosen to investigate changes in the expression of messenger RNAs encoding the N-methyl-D-aspartate-receptor subunits NR1, NR2A and NR2B both during and in the period immediately following the induction of the kindled state. The study demonstrates a cell-specific, time-dependent modulation of the N-methyl-D-aspartate-receptor subunit messenger RNAs almost entirely restricted to the granule cells of the dentate gyrus. In partially kindled animals (10 stimulations), while the NR1 subunit messenger RNA remained unaltered after a period of 2 h, the NR2A and NR2B subunit messenger RNAs were bilaterally reduced in dentate gyrus granule cells by around 50% below control values. In fully kindled animals (40 stimulations), a progressive reduction in NR1 subunit messenger RNA levels in the dentate gyrus was observed, being maximal after 4 h (-67%). At the same time point, NR2A and NR2B transcript levels were transiently increased by 102% and 46% above control values, respectively. These data point to a differential regulation of N-methyl-D-aspartate-receptor subunit messenger RNAs. No alterations were detected in pyramidal cells. Long-term maintenance of the kindled state was not associated with alterations in N-methyl-D-aspartate-receptor subunit messenger RNAs since control levels of messenger RNA were attained by 12 h and persisted for at least five days. The early changes in messenger RNAs described in this study indicate that the expression of N-methyl-D-aspartate-receptor subunits is under independent regulatory control. This phenomenon may contribute to epileptogenesis and to kindling-associated plasticity by mediating a structural reorganization of N-methyl-D-aspartate-receptors, leading to an altered excitability of dentate gyrus granule cells.

Animals↗
PubMed1998

Postictal nosewiping lateralizes and localizes to the ipsilateral temporal lobe.

PURPOSE: We observed many patients with temporal lobe epilepsy (TLE) wiping their nose postictally, usually with the hand ipsilateral to their seizure focus. We wished to determine if this had lateralizing or localizing significance. METHODS: We retrospectively studied 87 patients: 47 with unilateral TLE defined by successful surgical outcome [30 with medial TLE (MTLE) and 17 with neocortical TLE (neoTLE)]; and 40 with extratemporal epilepsy (ExTLE). Videotapes of 319 complex partial seizures (CPS) without generalization were reviewed by 1 neurologist, blinded to patient identity, who recorded each episode of nosewiping and the hand with which it was performed. RESULTS: With regard to localizing potential, postictal nosewiping (PINW) was significantly more common in patients with unilateral TLE than in those with ExTLE. In the TLE group, PINW within 60 s of electrographic seizure offset occurred in 60% of patients (28 of 47) and 43% of seizures (74 of 171). In the ExTLE group, PINW was noted in 33% of patients (13 of 40; p < 0.05 as compared with TLE) and 15% of seizures (22 of 148; p < 0.001). Similar results were obtained with PINW within 30 s of seizure offset. Although PINW was more frequent in MTLE than in neoTLE (67% of patients vs. 47%), this finding did not reach significance. With regard to lateralizing potential, in the TLE group, unilateral PINW (performed with a single hand only) within 60 s of seizure offset was observed in 53% of patients (25 of 47) and was performed with the hand ipsilateral to the seizure focus in 92% (23 of 25). Thirteen patients (9 with TLE) wiped their nose more than once with the same hand in a single seizure within 60 s of offset in 18 seizures; this was done with the hand ipsilateral to the seizure focus in all 18 instances (predictive value = 100%). CONCLUSIONS: PINW is more common in unilateral TLE, particularly MTLE, than in ExTLE. PINW performed exclusively with one hand occurs in approximately 50% of patients with TLE and is highly predictive (92%) of seizure onset ipsilateral to the hand used, especially when it occurs repetitively. We hypothesize that ictal activation of the central autonomic nervous system, particularly the amygdala, results in ictal nasal secretions and causes nosewiping as the patient regains awareness postictally. The ipsilateral hand is used due to contralateral neglect or weakness.

Amygdala↗