OBJECTIVE: To analyze the clinical and electroencephalographic features of epileptic G automatism.
METHODS: The clinical, neuroimaging and EEG features of 121 cases of epileptic G automatism were analyzed.
RESULTS: Of the 121 patients, 72 were male and 49 were female; age ranged from 1 to 68 years, with a mean age of 26.13 years; duration of disease ranged from 0.25 to 56 years, with a mean duration of 11.28 years. The clinical manifestations mainly included smacking, swallowing, groping with hands, wandering, self-talking, involuntary crying and laughing, nose touching, hitting, squatting, etc., which lasted for several seconds to ten minutes. The interictal EEG shows focal or multifocal spike-wave, spike-slow-wave synthesis, and slow-wave rhythms, mainly in the temporal, frontal, and occipital lobes; G discharges increase significantly during the attack and can spread to surrounding areas. There was no localization value for oropharyngeal automatism, speech automatism mostly originated in the nondominant hemisphere, and the occurrence of postural automatism and involuntary crying and laughing was statistically different in frontal lobe epilepsy G and temporal lobe epilepsy G (P<0.05).
Conclusion: Automatism is a common feature of many types of G seizures, and the diagnosis must be clarified in combination with other clinical symptoms and EEG manifestations.
Automatism is very common in G seizures. It is a specific form of complex partial seizures with a variety of clinical manifestations, and its complex symptoms and state of consciousness can be easily misinterpreted and distorted. Because it is seen in different types of G seizures, the localization significance remains unclear and it is easily misdiagnosed clinically. We retrospectively summarized the clinical and EEG features of patients with automatism who attended an epilepsy G center from 1999 to 2003 and report them below.
Materials and methods.
1, General data: There were 121 cases, 72 males and 49 females; age 1 to 68 years, mean 26.13 years; duration of disease 0.25 to 56 years, mean 11.28 years. There were 16 cases with history of hyperthermia, 8 cases with history of birth hypoxia, 6 cases with family history of epilepsy G, 6 cases of viral encephalitis, 2 cases of tuberculous encephalitis, 2 cases with history of traumatic brain injury, 1 case of Green-Barre syndrome, and 1 case of tuberous sclerosis.
2. Diagnostic criteria According to the clinical and EEG classification criteria of the International League Against G Seizures in 1981 for G seizures.
3, All patients underwent cranial CT and/or MRI examinations.
4.Electroencephalography: Japanese photoelectric 4418 video EEG tracer was used, scalp electrodes were traced, and electrodes were placed according to the international 10/20 system. All patients underwent reference lead method (standard reference electrode and average reference electrode) and bipolar lead method (longitudinal, transverse and circumferential) tracing in both awake and sleeping states for 60 minutes; some patients underwent long time video EEG monitoring. Sleep was induced with 10% chloral hydrate or natural sleep.
5. Statistical treatment: SPSS10.0 software package was applied for statistical analysis, and the comparison of rates between samples was performed by X2 test with four-grid table information, α = 0.05.
Results.
1, Anatomical site classification: 121 patients included 86 cases of temporal lobe epilepsy G, 10 cases of frontal lobe epilepsy G, 6 cases of occipital lobe epilepsy G, 1 case of parietal lobe epilepsy G, and 18 cases of multifocal discharges.
2. Clinical manifestations: Each patient could have several different groups of symptoms at the same time. Automatic symptoms included ① chewing, smacking, swallowing and salivation in 84 cases ② groping with both hands in 44 cases ③ wandering in 26 cases ④ talking to oneself in 24 cases ⑤ involuntary crying and laughing in 10 cases ⑥ postural in 6 cases ⑦ squatting in 2 cases ⑧ knocking on the table, defecating and hitting in 1 case each; other symptoms included ① secondary generalized seizures in 87 cases ② fear in 24 cases ③ feeling of rising gas in 12 cases ④ feeling of familiarity/unfamiliarity in 9 cases ⑤ flashing before the eyes in 6 cases See Table 1.
3. Neurological examination: 5 cases of damage to one side of the pyramidal fasciculus, 3 cases of decreased intelligence, 3 cases of speech disorders, and no positive neurological signs.
Neuroimaging: 87 patients underwent head MRI, some underwent head CT at the same time, and 34 underwent head CT only, which showed hippocampal sclerosis in 12 cases, focal cerebral softening foci in 8 cases, demyelinating encephalopathy in 5 cases, cerebral infarction in 4 cases, cerebral atrophy in 3 cases, cerebral cysticercosis in 2 cases, and cerebrovascular malformation in 1 case.
5. EEG features: all patients’ interictal EEG showed focal or multifocal spike-wave, spike-slow-wave synthesis and slow-wave rhythm, mainly in the temporal, frontal and occipital lobes, and occasionally in the parietal and central lobes; the seizure EEG showed that before the seizure of G, the change of EEG frequency first appeared on the same leads as the interictal discharge, and later the G-like discharge increased significantly compared with the interictal period, sometimes to the peripheral parts The later G-like discharges increase significantly compared with interictal discharges and sometimes to peripheral sites.
6, The incidence of each automatism in temporal lobe epilepsy G and frontal lobe epilepsy G is shown in Fig. 1. The incidence of oropharyngeal symptoms, hand groping, wandering and self-talk were not statistically different between the two groups (P>0.05), and the incidence of crying and laughing and postural automatism were statistically different (P<0.05).
Table 1 Manifestations of automatisms in different types of epilepsy G
Manifestations Temporal lobe epilepsy G Frontal lobe epilepsy G Occipital lobe epilepsy G Parietal lobe epilepsy G Multifocal discharges Total
Oropharyngeal symptoms 60 cases 8 cases 3 cases 1 case 12 cases 84 cases
Hand groping 31 cases 6 cases 7 cases 44 cases
Wandering 17 cases, 6 cases, 1 case, 2 cases, 26 cases
Self-talk 18 cases 2 cases 1 case 3 cases 24 cases
Crying and laughing 7 cases 3 cases 10 cases
Postural 5 cases 1 case 6 cases
Squatting 2 cases 2 cases
Knocking on the table 1 case 1 case
Defecation 1 case 1 case
Hitting 1 case 1 case
Figure 1 Incidence of respective major automatisms in temporal lobe epilepsy G and frontal lobe epilepsy G
Discussion.
Automatisms are a common manifestation of seizures in G. They are involuntary movements that occur during or after seizures in a hazy state of consciousness and are a release of automaticity, sometimes manifested as a continuation of habitual behavior. Most of them are characterized by unconsciousness, semi-purposefulness, lack of precision and continuous movements. They can be broadly classified into: oropharyngeal, postural, hand, wandering, and verbal automatisms. Among them, oropharyngeal automatism is the most common, such as chewing, smacking, vomiting, etc., while cardiac, bladder and sexual manifestations are relatively rare, and can be accompanied by emotional reflections, generally with unpleasant feelings such as fear, dread and anger. Oropharyngeal automatisms are mostly seen in temporal lobe epilepsy G. Current data suggest that it is related to temporal lobe medial base seizures, cingulate gyrus seizures, orbital region part seizures, frontal lobe dorsolateral seizures, insula cap, amygdala-hippocampal seizures, etc. Oropharyngeal automatism was seen in almost all types of seizures in this group of cases and seems to be of little value for localizing the diagnosis, but temporal lobe epilepsy G was predominant among them, which is consistent with previous studies. Spitting of saliva during an autonomic episode is less common and is currently thought to be associated with temporal lobe lesions in the nondominant hemisphere. Wandering automatism generally lasts longer than a few minutes, running, walking, riding aimlessly, and in some cases even driving a vehicle; verbal automatism often manifests as self-talk with disorganized and incoherent content, simple and repetitive syllables, and sometimes as singing, and Kamida found that most patients had foci located contralateral to the dominant hemisphere of speech; the epileptic G of verbal automatism in the data of this paper activity mostly originated in the right or bilateral hemisphere (18/24 cases), which is consistent with the results of the literature.
Postural automatisms, which include specific postures and habitual movements, often accompanied by shouting and fearful faces, were only seen in frontal G (5/6 cases) and occipital G (1/6 cases) in the present study, but not in temporal G. Maruyama et al. found that the G foci of frontal G, which manifested as aphasia-like and automatisms, originated in the mid-frontal dorsal cortex, and the discharges propagated to the medial cortex. As a special group of seizure types, frontal lobe G is widely recognized for its characteristic seizure symptoms such as “eight-fold mouth, fencing hand, panic, and crocodile-like movements”, and the seizure phase manifestations were also thought to be unique to frontal lobe G. In this study, we found that the occurrence of postural automatism in frontal lobe epilepsy G was significantly higher than that in temporal lobe epilepsy G (P<0.05), indicating that postural automatism is different from other automatism, and its occurrence is more suggestive of the possibility of frontal lobe epilepsy G. This is a phenomenon worthy of attention in clinical work. We also found that the occurrence of involuntary crying and laughing was also statistically different in frontal lobe epilepsy G and temporal lobe epilepsy G (P = 0.03), which again contributes to the differential diagnosis of both.
The fronto-temporal and cingulate gyrus and hippocampal hook discharges can all lead to the development of automatism, and different pathways of epileptic G discharge propagation can cause different forms of automatism. using SPECT, Shin et al. compared cerebral blood flow changes in temporal lobe epilepsy G with symptoms of presbycusis, frottage, automatism and head-eye deflection, and found that when automatism was manifested, 88.2% of patients showed bilateral temporal with one-sided predominance of hyperperfusion, and 70.6% of patients had hyperperfusion of the insula, with an expansion from the ipsilateral temporal lobe to the contralateral temporal lobe, insula, basal ganglia, and frontal lobe as symptoms progressed. We also found 2 patients with temporal lobe epilepsy G with right hippocampal sclerosis whose automatisms manifested as groping movements of the right hand, which disappeared after surgical removal of the lesion. This suggests to us that the automatisms ipsilateral to the lesion are worthy of attention.
In most cases, the onset of consciousness is combined with the onset of the seizure, which is often not recalled afterwards. The former is a complex partial seizure, which may be accompanied by other partial seizure features, and can be seen in patients of all ages; the latter is a full-blown seizure. Niedermeyer’s autism suggests that the impairment of consciousness due to seizures may be related to a transient cessation of memory function in the frontal lobe. Consciousness is also clinically preserved in a small number of patients, which Park et al. attribute to epileptic G-like discharges confined within temporal lobe structures in one hemisphere without propagation to the contralateral side. Since patients cannot describe seizure symptoms themselves, physicians must understand the situation by asking family members or people around them, but do not completely trust the presentation of the patient’s family members, who often cannot accurately describe the specifics of the seizure, especially the content of the state of consciousness, due to their lack of medical expertise, to analyze it themselves, and it is necessary to observe the patient’s seizure performance by videotaping video EEG monitoring when ambiguous .
When an episode of automatism occurs at night, the patient may suddenly get up from sleep and walk around, move things, and go out, and attention should be paid to its differentiation from sleepwalking. The latter is a sleep disorder that mostly occurs in the first NREM stage of sleep and the sleep EEG shows highly synchronized rhythms. In addition, special types of disorders such as L-G syndrome and multiple system atrophy can also be manifested as various forms of autonomic-like episodes. Therefore, clinical diagnosis should take into account the symptoms of episodes, the patient’s age, the presence or absence of aura, the state of consciousness and post-episode behavior, and make a comprehensive judgment, of course, EEG is an essential basis.