Abstracts

Rationale: Complex stereotypic hyperkinetic movements presenting as a seizure semiology has been described in the literature. Seizures involving various brain regions such as temporal, frontal, SMA and parietal were thought to produce these ictal motor manifestations.Methods: We report a case of 67 year old male with recurrent right parietal anaplastic meningioma admitted with left epilepsia partialis continua (EPC). Multiple AEDs (LEV, LCM, VPA, PB and PHT) were employed with control of clinical seizures, although patient had significant sedation. Patient was also noted to have intermittent choreiform-like movements of the right arm; significantly evident after control of left EPC and was initially thought to be non epileptic in nature. A repeat VEEG was performed to identify NCSE as a possible etiology for coma. Many stereotypic choreiform-like movements such as “raising arm in air, rotational movements of right upper extremity” were captured. EEG revealed evolving rhythmic theta-delta pattern intermixed with sharp waves suggestive of seizures over the right parietal region time locked with these movements. Few electrographic seizures were also captured over the right parietal region without any clinical manifestation. No contralateral movements were observed prior to the beginning of these ipsilateral movements. Patient was treated with Midazolam and Pentobarbital with better control of EEG and clinical seizures. At present, patient is being evaluated for possible neurosurgical resection of the right parietal lesion.Results: Ipsilateral automatism and contralateral dystonia is a well known localizing sign for mesial temporal lobe epilepsy. Hypermotor seizure is known to be associated with orbitofrontal/mesial frontal lobe. Ictal ipsilateral stereotype movements of upper extremity as a manifestation of SMA seizures were described in literature (Barba et al, 2005). Hyperkinetic automatism and hemiballism-like movements of ipsilateral upper and lower extremities were previously described as seizure semiology. Ictal onset was localized to the inferior parietal lobule, the parietal operculum and SMA regions confirmed with intracranial monitoring (Fluche`re et al, 2011, Teotónio et al 2013). We report ipsilateral choreiform-like movements of the arm correlated with the parietal electrographic seizures in a patient with a known parietal lesion. These movements were observed in a time locked pattern with ictal EEG seizures and were rarely associated with other lateralizing signs. Patient was treated aggressively and surgical options were reconsidered after recognizing the epileptic nature of these choreiform-like movements.Conclusions: Repetitive ictal ipsilateral hyperkinetic upper limb movements can be a useful localizing sign for parietal lobe seizures. This type of seizure semiology is rare in clinical practice and may be underdiagnosed. Our case highlights not only the importance of recognizing the epileptic nature of these choreiform-like movements, but also the concept of ""subtle status epilepticus"" in a patient with coma and a known focal lesion.