Video-EEG has familiarized most neurologists with the fencing or "M2e" postures of supplementary motor
The figure demonstrates a young girl who loses motor control of her right hand during seizures (reproduced from video). The EEG of the event (indicated at vertical line) did not show a clear ictal build-up but demonstrated epileptiform potentials at Cz-Pz (arrow) during the event. On this and subsequent EEG figures, the calibration bar indicates 50 |V, the green vertical line corresponds to the time of the video picture, the dashed vertical lines are 200 msec, and the solid vertical lines are 1 sec. LFF = 0.1 Hz; HFF = 50 Hz.
seizures (head and eyes looking at the elevated arm on an abducted shoulder (11). We also appreciate the frenetic automatisms of the hyperkinetic seizure (1.2.5), which can be pedal, manual, or bimanual/bipedal (12-15). These seizures typically begin with wild automatisms such as rocking, bicycling, kicking, thrashing, pelvic thrusting, and arm waving. These are sometimes semipurposeful, accompanied by grunts, groans, screams, or animal noises. The subject may appear to do karate, direct an orchestra, or cast for a fish. They typically originate from ventral prefrontal lobe and/or orbital frontal complex, or deep mesial frontal [supple mentary motor area (SMA) and cingulate; 12-17)], although they can emit from the parietal operculum with anterior propagation (12).
Case Study #3. A 23-year-old male with seizures since age 12 years was studied. His seizures began with an angry stare and deep inspiration followed by a barking noise and then by rocking, grunting, and banging his legs on the bed rails. His movements were so violent that he broke out of a posey, and at home, his mother reported he once tore down the curtains in his room. On depth record-
This female is demonstrating an angry facial expression and rotatory movements of the right arm with that hand in a fist while the left arm extends beside her as she looks to the left. The semeiology is consistent with a right-sided seizure, possibly temporoparietal (reproduced from video). The EEG at the time of the picture (green vertical line) shows a clear ictal pattern without clear localization, maximal in the temporal regions (arrows). LFF = 0.1 Hz; HFF = 15 Hz.
ings, ictal onsets were located at the left ventral premotor and prefrontal region (12).
Although the automatisms may appear "violent," directed violence occurs rarely—5% in a large series of video-EEG-documented seizures (18). Violent behavior typically is resistive, at the end of a seizure, can include throwing things or self-pugilism (19), but never occurs as part of a coherent plan of action against an individual (18). Therefore, no seizures are classified or described as "violent." Other automatisms of the arms may arise from the posterior temporal cortex or temporoparietal junction.
Case Study #4. A 13-year-old female had complex partial seizures beginning with eye blinking and a threatening facial expression. Subsequently, fast and repetitive rotatory right arm movements occurred with a clenched fist. EEG showed widespread rhythmicity, maximal in the temporal regions (Figure 3.2a and b).
Ambulatory epileptic seizures, also called Wandertrieb or poriomania (compulsive, aimless wandering) can be mistaken for psychic fugue states as they can be accompanied by depression, irritability, and dizziness (20-22). These may represent a special case of the hyper-
kinetic seizure, although it is not known if this behavior is truly ictal or is postictal. Bitemporal discharges have been associated most frequently with this semiology.
Opisthotonic posturing may occur in the context of a hyperkinetic epileptic seizure or as an isolated seizure. It has been ascribed to deep mesial frontal structures and may occur with or without loss of consciousness (12,17). Odd postures can resemble certain types of catatonia, as is illustrated in the upcoming psychiatric manifestations section.
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