Somatosensory Aura Research Articles

Somatosensory migraine auras evoked by bihemispheric cortical spreading depression events in human parietal cortex.

Cortical spreading depression (CSD) is associated with pronounced alterations in cerebral blood flow. These alterations can be captured using high-field functional magnetic resonance imaging (fMRI). While compelling clinical and experimental data suggest that CSD is involved in the pathogenesis of migraine aura, the mechanistic intricacies remain poorly understood. Here, we use visual stimulus-induced blood oxygen level-dependent (BOLD) fMRI responses to characterize spatiotemporal alterations in cerebral blood flow during spontaneous attacks with migraine aura. Six adult participants diagnosed with migraine with aura underwent BOLD fMRI scans with a visual stimulation paradigm, consisting of flickering checkerboard stimulation. Our results revealed that auras with somatosensory symptoms corresponded with bilateral alterations of stimulus-induced BOLD responses in the somatosensory cortex, exhibiting anterior-to-posterior propagation and absence of antecedent occipital abnormalities. These altered stimulus-induced BOLD responses were bilateral, despite a unilateral manifestation of aura symptoms, and had no relationship with positive or negative aura symptoms. The bilateral abnormalities in stimulus-induced BOLD responses completes our current knowledge on migraine aura.

Bilateral Todd's paralysis in a patient with left fronto-opercular epilepsy.

Postictal paresis ("Todd's paralysis") is commonly observed as a unilateral, transient motor weakness, lasting minutes to hours, after focal or focal to bilateral tonic-clonic seizures, contralateral to the epileptogenic zone. Bilateral postictal paresis is exceedingly rare and could be misinterpreted, especially if the preceding convulsive phase was not witnessed. An 18-year-old right-handed male patient with refractory focal epilepsy with seizure onset at age 3 years, was admitted for presurgical video-EEG monitoring. His seizures were predominantly nocturnal, consisting of a laryngeal somatosensory aura, occasionally evolving to bilateral tonic or tonic-clonic seizures with occasional asymmetrical limb extension during the tonic phase (right arm extension). Postictally, consciousness recovery was fast, if ever lost. At that stage, we documented severe dysarthria and bilateral symmetrical arm paresis lasting several minutes. The ictal pattern and interictal epileptiform activity were projected on the fronto-central midline. Brain MRI was highly suggestive of a bottom-of-sulcus dysplasia with underlying transmantle sign on the left premotor, fronto-opercular region and an FDG-PET-CT showed a concordant left fronto-operculo-insular hypometabolism. A complete lesionectomy was performed, with the additional guidance of intraoperative electrocorticography, resulting in sustained seizure freedom. Anatomo-pathology confirmed a type 2b focal cortical dysplasia. We speculate that, in our patient, a left fronto-opercular ictal onset with an early spread to both primary motor cortices and relative sparing of consciousness networks allowed the emergence of a clinically detectable postictal bilateral paresis.

Clinical features of migraine with aura: a REFORM study

BackgroundAbout one-third of persons with migraine experience transient neurologic symptoms, referred to as aura. Despite its widespread prevalence, comprehensive clinical descriptions of migraine with aura remain sparse. Therefore, we aimed to provide an in-depth phenotypic analysis of aura symptoms and characteristics in a cross-sectional study of a large sample of adults diagnosed with migraine with aura.MethodsData were extracted from the baseline characteristics of participants in the Registry for Migraine (REFORM) study – a single-center, prospective, longitudinal cohort study. Participants were adults diagnosed with migraine aura, reporting ≥ 4 monthly migraine days in the preceding 3 months. Trained personnel conducted in-person semi-structured interviews, capturing details on the nature, duration, localization, and progression of individual aura symptoms.ResultsOf the 227 enrolled participants with migraine with aura, the mean age was 41.1 years, with a predominant female representation (n = 205 [90.3%]). Visual aura was present in 215 (94.7%) participants, somatosensory aura in 81 (35.7%), and speech and/or language aura in 31 (13.7%). A single type of aura was observed in 148 (65.2%) participants, whilst 79 (34.8%) reported multiple aura types. Most participants (n = 220 [96.9%]) described their aura symptoms as positive or gradually spreading. Headache in relation to aura was noted by 218 (96.0%) participants, with 177 (80.8%) stating that the onset of aura symptoms preceded the onset of headache.ConclusionsThis study offers a detailed clinical depiction of persons with migraine with aura, who were predominantly enrolled from a tertiary care unit. The findings highlight potential gaps in the available literature on migraine with aura and should bolster clinicians’ acumen in diagnosing migraine with aura in clinical settings.

INTERPRETING THE LANGUAGE OF INFERENTIAL EPILEPSY IN EMILY DICKINSON’S POETRY

<p>This paper explores the possibility that Emily Dickinson was living with a form of epilepsy. It uses research by contemporary neurologists, who have differentiated how patients with epileptic seizures, and patients with non-epileptic seizures, use language features to describe their subjective seizure experiences. The features of language used by patients with epilepsy have been applied to the reinterpretation of a series of Emily Dickinson’s poems that appear to be related to neurological experiences, especially ‘inner’ poems focusing on the operations of the “Brain”, “Thought”, “Mind”, and “Consciousness”. Further contemporary research into the auras of seizures, identified four signs that could stay in a person’s memory if they remained conscious during a simple partial seizure (SPC). These are “suddenness, passivity or automatism, great intensity, and strangeness”, which provided insights into Dickinson’s ‘inner’ poem, Fr340, “I felt a Funeral, in my Brain,”. The identification of the sensory manifestations of auras, such as, Somatosensory, Visual, Auditory, Vertiginous, Olfactory, and Psychic auras, has also helped to clarify aspects of Dickinson’s ‘inner’ poems, especially Fr355, “It was not Death, for I stood up,”. The autobiography of the Welsh writer, Margiad Evans, identified language use arising from epileptic episodes, including the response of ‘giggling’, and the appearance of a ‘double self’, which revealed a close association to Dickinson’s language use in a range of poems. The application of research into autoscopy and “Déjà” experiences, and their appearance in poems, strengthened critical reading interpretations as expressions of inferential epileptic experiences. Finally, the poems featuring neurological experiences are seen to possess empirical dimensions that might help to explain Dickinson’s consultations with Dr Williams in Boston during 1864 and 1865, as a quest for a diagnosis and remedy for the disruptions to her consciousness.</p>

Somatosensory Auras in Epilepsy: A Narrative Review of the Literature.

An aura is a subjective experience felt in the initial phase of a seizure. Studying auras is relevant as they can be warning signs for people with epilepsy. The incidence of aura tends to be underestimated due to misdiagnosis or underrecognition by patients unless it progresses to motor features. Also, auras are associated with seizure remission after epilepsy surgery and are an important prognostic factor, guiding the resection site and improving surgical outcomes. Somatosensory auras (SSAs) are characterized by abnormal sensations on one or more body parts that may spread to other parts following a somatotopic pattern. The occurrence of SSAs among individuals with epilepsy can range from 1.42% to 80%. The upper extremities are more commonly affected in SSAs, followed by the lower extremities and the face. The most common type of somatosensory aura is paresthetic, followed by painful and thermal auras. In the primary somatosensory auras, sensations occur more commonly contralaterally, while the secondary somatosensory auras can be ipsilateral or bilateral. Despite the high localizing features of somatosensory areas, cortical stimulation studies have shown overlapping sensations originating in the insula and the supplementary sensorimotor area.

Aura Type and Outcome After Anterior Temporal Lobectomy

Temporal lobe epilepsy (TLE) is one of the most common causes of medically refractory focal epilepsy. Anterior temporal lobectomy (ATL) leads to improved seizure control in patients with medically refractory TLE. Various auras are associated with TLE; however, the relationships between aura type and outcome after ATL are poorly understood. Our objective was to investigate the associations among clinical features, aura type, and seizure outcome after ATL. The records of patients who underwent ATL between 1993 and 2016 at a single institution (N= 174) were retrospectively reviewed. Demographic and clinical variables were compared among aura types using analysis of variance and logistic regression analysis. A multiple regression analysis was conducted to determine whether aura type predicted seizure outcome after ATL. Mesial temporal sclerosis (MTS) on magnetic resonance imaging inversely correlated with cephalic auras (P= 0.0090). Affective auras (P= 0.014) and somatosensory auras (P= 0.021) were correlated with findings of MTS on pathology, whereas this finding was inversely correlated with the presence of auditory auras (P= 0.0056). On multiple regression analysis, predictors of worse seizure outcome after ATL were cephalic auras (P= 0.0048), gustatory auras (P= 0.029), visual auras (P= 0.049), and tonic-clonic seizures (P= 0.047). Fewer preoperative antiepileptic medications (P= 0.0032), and presence of multiple auras (P= 0.011) were associated with better outcome. Cephalic auras, gustatory auras, and visual auras were associated with worse seizure outcome after ATL.

Aura Mapping: Where Vision and Somatosensation Meet.

While migraine auras are most frequently visual, somatosensory auras are also relatively common. Both are characterized by the spread of activation across a cortical region containing a spatial mapping of the sensory (retinal or skin) surface. When both aura types occur within a single migraine episode, they may offer an insight into the neural mechanism which underlies them. Could they both be initiated by a single neural event, or do the timing and laterality relationships between them demand multiple triggers? The observations reported here were carried out 25 years ago by a group of six individuals with migraine with aura. They timed, described and mapped their visual and somatosensory auras as they were in progress. Twenty-nine episode reports are summarized here. The temporal relationship between the onset of the two auras was quite variable within and across participants. Various forms of the cortical spreading depression hypothesis of migraine aura are evaluated in terms of whether they can account for the timing, pattern of symptom spread and laterality of the recorded auras.

Sleep-related hypermotor seizures of insulo-opercular origin: A review of 27 cases

Introduction . Insular epilepsy is known to be a “great mimicker” of various types of focal epilepsy, including sleep-related hypermotor epilepsy (SHE) in about 15% of cases. Because SHE tends to have a frontal origin, misdiagnosis can result in a poor surgical outcome when epilepsy surgery is considered. In this study, we reviewed the existing literature to identify electro-clinical features suggestive of an insulo-opercular (IO) origin in SHE. Methodology . We found 11 case series of SHE or insular epilepsy with sufficiently detailed patient data. We identified 27 patients with IO SHE from 6 studies. When available, the semiology patterns (SP), early nonmotor manifestations, alteration of consciousness (AOC), EEG and MRI features and histopathology were collected. Results . SP analysis of the 27 identified patients showed a wide variety of indiscriminate SP, including hyperkinetic and/or dystonic features. Early nonmotor manifestations were observed in 80%, most commonly somatosensory auras (44%). Laryngeal constriction, pain, oral and widespread paresthesia were observed in IO SHE but not in frontal SHE. AOC was uncommon (20%). EEG was rarely suggestive of an IO origin (17%) and MRI was diagnostic in 48%. Focal cortical dysplasia was the most common diagnosis (78%). Following surgery, 83% were seizure-free (follow-up: 12–60 months). Conclusions . Few electro-clinical features, except early non-motor manifestations, are suggestive of an IO onset in SHE. Therefore, in MRI-negative patients, a heightened vigilance for subtle subjective or behavioral signs is warranted to avoid misdiagnosis and poor surgical outcome.

Auras in intractable frontal lobe epilepsy: Clinical characteristics, values, and limitations

Auras are essential in preoperative evaluation and can provide valuable information for delineating seizure onset zones. Frontal lobe epilepsy (FLE) is the second most common focal epilepsy, while a few studies have focused on auras in FLE. To better understand FLE, we analyzed the clinical characteristics, values, and limitations of auras in FLE. The incidence rate of aura in FLE was 37.9% in our study. We included 54 patients and 76 auras in 11 categories were reported. The rate of auras in the decreasing order are as follows: autonomic aura; emotional aura; somatosensory aura; psychic aura; cephalic aura; abdominal aura; whole-body sensory aura, visual aura; auditory aura; and vestibular and unclassified aura. A significant number of aura types can be reported by FLE patients; autonomic aura was the most frequent category and somatosensory auras are most likely associated with the contralateral motor areas.

Early prediction of encephalopathic transformation in children with benign epilepsy with centro-temporal spikes

BackgroundMost children with Benign epilepsy with centro-temporal spikes (BECTS) undergo remission during late adolescence and do not require treatment. In a small group of patients, the condition may evolve to encephalopathic syndromes including epileptic encephalopathy with continuous spike-and-wave during sleep (ECSWS), or Landau-Kleffner Syndrome (LKS). Development of prediction models for early identification of at-risk children is of utmost importance. AimTo develop a predictive model of encephalopathic transformation using data-driven approaches, reveal complex interactions to identify potential risk factors. MethodsData were collected from a cohort of 91 patients diagnosed with BECTS treated between the years 2005–2017 at a pediatric neurology institute. Data on the initial presentation was collected based on a novel BECTS ontology and used to discover potential risk factors and to build a predictive model. Statistical and machine learning methods were compared. ResultsA subgroup of 18 children had encephalopathic transformation. The least absolute shrinkage and selection operator (LASSO) regression Model with Elastic Net was able to successfully detect children with ECSWS or LKS. Sensitivity and specificity were 0.83 and 0.44. The most notable risk factors were fronto-temporal and temporo-parietal localization of epileptic foci, semiology of seizure involving dysarthria or somatosensory auras. ConclusionNovel prediction model for early identification of patients with BECTS at risk for ECSWS or LKS. This model can be used as a screening tool and assist physicians to consider special management for children predicted at high-risk. Clinical application of machine learning methods opens new frontiers of personalized patient care and treatment.

Application of the Migraine Aura Complexity Score (MACS): Clinical and Neuroimaging Study.

Background: Manifestations of typical migraine aura can be numerous. Investigation of its pathophysiological mechanisms can be challenging if a stratification of phenotypes is not performed. In this context, the Migraine Aura Complexity Score (MACS), recently developed, may help. Here we aimed to categorize migraine patients into homogenous groups using MACS and to compare those groups with respect to patients' characteristics and neuroimaging findings.Methods: Participants who have a migraine with aura (MwA) were interviewed after each attack in order to obtain the characteristics of migraine aura. Thereafter, we scored the complexity of their auras by MACS. The MACS was used to categorize patients into three groups: MwA-S (with simple aura), MwA-MC (with moderately complex aura), and MwA-C (with complex aura). The patient characteristics and estimated cortical thickness of regions of interest, which are potentially linked to the symptoms that develop during the aura, were used to compare these groups.Results: In total, 338 MwA attacks were recorded in analyzed groups. Scotoma was the most frequently reported symptom in the groups, followed by somatosensory aura in the MwA-C group and zig-zag lines in the MwA-MC and MwA-S groups. Patients in the MwA-C and MwA-MC groups had a thicker cortex in the left primary visual cortex with respect to MwA-S group. In addition, patients in the MwA-C group had a thicker cortex in several visual and somatosensory cortical regions relative to the MwA-S group.Conclusions: Our results show that the newly developed MACS can be used for the stratification of MwA patients, herewith allowing the better investigation of changes in migraineurs' brains.

P54-S Somatosensory and motor phenomena elicited by electrical stimulation of hippocampus: insight into the ictal network

Background Direct electrical stimulation of the cortex elicits responses according to the physiology of the stimulated area. In patients with drug resistant epilepsy evaluated for surgical therapy, this method is used for mapping the eloquent cortex and for triggering the patients’ habitual seizures, using intracerebral electrodes. Up to 11% of patients with mesial temporal lobe epilepsy have somatosensory aura, although these structures do not have any somatosensory physiological representation. Material and methods We present the case of a patient with left mesial temporal lobe epilepsy who had somatosensory auras on the right side. Direct electrical stimulation of the left hippocampus, at 50 Hz, elicited the somatosensory auras, while stimulation at 1 Hz elicited myoclonic jerks time-locked to the stimulus. Results and conclusions These unusual responses to cortical stimulation suggest that in patients with epilepsy aberrant neural networks are established, which have an essential role in ictogenesis.

Neurophysiology of a double aura in migraine and Alice in wonderland syndrome: Is there a link?

ObjectivesAlice in Wonderland syndrome (AIWS) is a pathological condition characterized by distortions of visual representation, with symptoms deforming images, figures, bodies, objects, which are seen larger or smaller than normal. Causes are sought in infectious diseases, psychiatric illness, migraines. It may be associated with alterations in the body schema such as non-recognition of own body in space. It's a rare form of visual aura. Unlike it, migraine with aura is a very frequent disorder, in which the phenomenon of visual aura is considered a consequence of cortical spreading depression(CSD), a wave of depolarization that propagates from the occipital cortex, creating a vasoconstriction and visual disturbances. MethodsRecent studies have found an anatomical correlation between visual and somatosensory disorders such as those found in AIWS, located in the temporo- parieto-occipital junction.Neuroimaging studies allowed to identify the CSD and the occipital cortex responsible for the mechanism of the visual aura and the involvement of the parietal cortex in the genesis of the somatosensory aura. ResultsThe mechanism of the initiation of the stage of visual and somatosensory aura could be a combination of two events. ConclusionsLiterature data now offer agreed confirmations on the role of the CSD associated to somatosensory aura.

Noninvasive peripheral vagal nerve stimulation prevents migraine aura: A case report

We describe a patient affected by migraine with visual and somatosensory aura, whose symptoms were consistently attenuated by noninvasive peripheral vagal nerve stimulation (nVNS) in multiple prospectively recorded attacks. When compared with the current standard of care, nVNS significantly reduced the duration of visual aura in all the attacks ( n = 5) and prevented the somatosensory aura in three of the five attacks. The overall duration of nVNS-treated auras was 19.0 ± 4.2 min, significantly shorter than the duration of aura in attacks treated with standard of care (103.8 ± 10.3 min). This single-case study requires confirmation in a larger sample size, but we believe that this first report is suggestive of likely efficacy given the relatively high number of treated attacks and the consistent effect of nVNS.

Volume alterations of brainstem subregions in migraine with aura.

BackgroundThe brainstem plays a significant role in migraine pathogenesis, but a relationship between volume alterations of brainstem subregions and migraine aura characteristics has not been sufficiently investigated. The aim of this study is to compare the volume of the brainstem, and its subregions, between patients with a migraine with aura (MwA) and healthy controls (HC), and also to correlate characteristics of MwA and the volume of the brainstem subregions.MethodsForty-two MwA and 42 HCs, balanced by sex and age, were selected for this study. Total brainstem volume changes as well as volume changes in the pons, medulla, midbrain and the superior cerebellar peduncles were investigated in MwA relative to HCs. In addition, the relationships between brainstem subregions and aura characteristics (aura duration, the frequency of the aura, occurrence of somatosensory and dysphasic aura, duration of a headache, intensity of headache pain and disease duration) were explored in MwA.ResultsMwA patients had a larger brainstem volume relative to HCs (25,941.35 ± 2559.2 mm3 vs. 25,179.32 ± 2019.1 mm3; p = .008), as well as the midbrain and pons (6155.98 ± 565.7 mm3 vs. 5964.22 ± 457.0 mm3, p = .002; 15,105.13 ± 1765.5 mm3 vs. 14,539.89 ± 1408.4 mm3, p = .007, respectively). Total brainstem volume, as well as volumes of brainstem subregions, were not significantly correlated to the MwA characteristics.ConclusionThe results of this study reveal that a migraine with aura is associated with a larger volume of the brainstem with a particular involvement of the midbrain and pons.

Proposal for a Migraine Aura Complexity Score.

Currently, there is no scoring system for assessing the complexity of migraine aura. Our goal was to develop a Migraine Aura Complexity Score that synthesizes the quantity and quality of aura symptoms and to test its applicability in neuroimaging studies. Patients with migraine aura were interviewed in order to obtain characteristics of migraine aura. Explorative and confirmatory analyses were used to develop the Migraine Aura Complexity Score. Median values were derived from 10 consecutive migraine auras in each patient. The Migraine Aura Complexity Score was correlated with an average cortical thickness of different brain areas in studied patients. The Surface-based Morphometric Analysis approach was used to estimate cortical thickness. This study included 23 (16 females and seven males) migraineurs with aura. Confirmatory factor analysis suggested the second-order model with three-factor measurement for grading migraine aura. The first factor is linked to higher cortical dysfunction during migraine aura, while the second is associated with the degree of involvement of primary visual and somatosensory cortices; the third linked symptoms of somatosensory aura and hand and head involvement. Positive correlation of Migraine Aura Complexity Score and averaged cortical thickness were found in the left and right hemispheres overall (r = 0.568, p = 0.007; r = 0.617, p = 0.003) and in some of their regions. This study demonstrates that the Migraine Aura Complexity Score could be a valuable tool for assessing migraine aura. The score could be used in neuroradiological studies in order to achieve a stratification of patients with migraine aura.

Electroclinical characteristics of seizures arising from the precuneus based on stereoelectroencephalography (SEEG)

BackgroundSeizures arising from the precuneus are rare, and few studies have aimed at characterizing the clinical presentation of such seizures within the anatomic context of the frontoparietal circuits. We aimed to characterize the electrophysiological properties and clinical features of seizures arising from the precuneus based on data from stereoelectroencephalography (SEEG).MethodsThe present retrospective study included 10 patients with medically intractable epilepsy, all of whom were diagnosed with precuneal epilepsy via stereoelectroencephalography (SEEG) at Yuquan Hospital and Xuan Wu Hospital between 2014 and 2016. Clinical semiology, scalp electroencephalography (EEG) findings, magnetic resonance images (MRI), and positron emission tomography (PET) images were analyzed during phase I preoperative evaluations. Following electrode implantation, the semiological sequence, ictal SEEG evolution, and anatomy of the relevant brain structures were analyzed for each seizure.ResultsSeven of ten patients reported auras, including body image disturbance (2/7), vestibular responses (2/7), somatosensory auras (1/7), visual auras (1/7), and non-specific auras (1/7). Primary motor manifestations included bilateral asymmetric tonic seizures (BATS) (7/10) and hypermotor seizures (HMS) (3/10). In one patient, epileptiform discharge on interictal EEG occurred ipsilateral to the side of the epileptogenic zone (EZ). Discharge was non-lateralized in the remaining nine patients. In six patients, interictal EEG signals were primarily localized in the temporal–parietal–occipital area. In two patients, ictal onset occurred ipsilateral to the EZ, which was mainly located in the temporal–parietal–occipital area. Two patterns of seizure spread were observed. The first pattern was characterized by BATS activity with ictal spread to the supplementary motor area (SMA), paracentral lobule (PCL), precentral gyrus (PrCG), or postcentral gyrus (PoCG). The second pattern was characterized by HMS activity with ictal spread to middle cingulate cortex (MCC) and posterior cingulate cortex (PCC).ConclusionAura type (e.g., body image disturbance and vestibular response), BATS, and HMS are the main indicators of precuneal epilepsy. Scalp EEG is of little use when attempting to localize precuneal seizures. Our findings indicate that the clinical characteristics of precuneal epilepsy vary among patients, and that the final electro–clinical phenotype depends on the pattern of seizure spread.

Migraine with aura and white matter tract changes.

We aimed to explore whether a migraine with aura (MA) is associated with structural changes in tracts of a white matter and to compare parameters of diffusivity between subgroups in migraineurs. Forty-three MA and 20 healthy subjects (HS), balanced by sex and age, were selected for this study. Analysis of diffusion tensor parameters was used to identify differences between MA patients and HS, and then between MA subgroups. A diffusion tensor probabilistic tractography analysis showed that there is no difference between MA patients and HS. However, using more-liberal uncorrected statistical threshold, we noted a trend in MA patients toward lower diffusivity indices of selected white matter tracts located in the forceps minor and right anterior thalamic radiation (ATR), superior longitudinal fasciculus (temporal part) (SLFT), cingulum-cingulate tract, and left uncinate fasciculus. Migraineurs who experienced somatosensory and dysphasic aura, besides visual symptoms, had tendency toward lower diffusivity indices, relative to migraineurs who experienced only visual symptoms, in the right inferior longitudinal fasciculus, forceps minor, and right superior longitudinal fasciculus (parietal part), SLFT, and cingulum-angular bundle. Aura frequency were negatively correlated with axial diffusivity and mean diffusivity of the right ATR (partial correlation = - 0.474; p = 0.002; partial correlation = - 0.460; p = 0.002), respectively. There were no significant differences between MA patients and HS, neither between MA subgroups. Migraineurs with abundant symptoms during the aura possibly have more myelinated fibers relative to those who experience only visual symptoms. Lower diffusivity indices of the right ATR are linked to more frequent migraine with aura attacks.

Clinical symptom analysis of hypermotor seizures originated from the insular-opercular epilepsy

Objective To investigate the value of the characteristics of hypermotor seizures in the localization of epileptogenic zone by studying the clinical symptom characteristics originated from the insular-opercular epilepsy. Methods From June 2006 to March 2014, the clinical data of 5 patients with intractable epilepsy of hypermotor seizures including history, imaging, scalp electroencephalogram, and intracranial electrode electroencephalography admitted to the Department of Neurosurgery, Tsinghua University Yuquan Hospital were studied retrospectively. Results In 5 patients, there was 1 with hypermotor seizures type Ⅰ, 2 with hypermotor type Ⅱ, and 2 with mixed type. Three patients accompanied with bilateral asymmetric rigidity. They were located in the contralateral epileptic foci. Five patients had an aura before seizures, 2 of them had a somatosensory aura on the contralateral side, 1 had palpitations, and 2 had a non-specific aura. The seizures of 2 patients originated from the left hemisphere and 3 from the right hemisphere. Four patients had brain area discharge in the intermittent period. They were located on the ipsilateral epileptic zones. No epileptiform discharges were observed in 1 case. Two patients had generalized ictal onset on the ictal electroencephalogram, the other 3 had unilateral hemisphere or unilateral ictal onset. Conclusions Seizures initiated from insular-opercular cortex can show any type in hypermotor seizures. The asymmetric rigidity of specific aura before onset and in hypermotor seizures has the lateralization value. The special facial expression in seizers is more common in hypermotor seizures originated from the insular-opercular cortex. Key words: Epilepsy; Hypermotor seizures; Insular-opercular; Electroencephalography

Understanding Hyper Motor Seizures

Introduction: Hyper Motor Seizures [HMS] are characterized by complex high amplitude movements involving proximal segments of the body resulting violent and inappropriate to the context. Objective: To review the possible ictal onset zones related to HMS and the cortical areas that would be covered if invasive recording are needed. Development: Semiology can predict the localization of ictal onset zone. Two subtypes of HMS [type 1 and 2] have been described. HMS1 is associated with an epileptogenic zone on the ventromedial frontal cortex and HMS2 has been associated with a more dorsal epileptogenic zone than those resulting in HSM1. However, HMS can also be originated in temporal lobe [mesial, neocortical or in the pole], in insular cortex or even in parietal lobe. The origin of HMS can be suspected by the associated signs. Thus, HMS originating in the insula–operculum regions can be associated with various somatosensory auras; in parietal seizures, propioceptive sensations may precede hyper motor behavior [HM], whereas autonomic and emotional auras prompt to think in the temporal lobe origin. Conclusion: Except in cases of lesional temporal lobe epilepsy with concordant prersurgical results, all patients with HMS should be evaluated through intracranial recordings. The auras, the HMS subtype, the hypometabolic areas showed by PET study, and the localization and lesion type seeing on MRI can help to decide what structures should be covered with depth electrodes during invasive recordings.