Abstracts

Rationale: Ictal vocalizations, which are defined as production of sound without speech quality, are frequent in frontal lobe seizures, while verbalizations are less common. We report a case of right orbitofrontal seizures presenting with buccal pseudovoice (Donald Duck like speech). Our patient was successfully treated with resection of the right orbitofrontal epiletogenic focus. Clinicians should be aware that even bizarre and complex verbalizations may occur in frontal lobe seizures. Methods: A 40 year old male without significant past medical history started having paroxysmal episodes at the age of 18. The seizures included vocalization that contained obscene words and clearly understandable complex phrases produced with buccal pseudovoice. He failed multiple antiepileptic medications, and was deemed a candidate for epileptic surgery. Results: The initial evaluation in our Epilepsy Monitoring Unit (EMU), which included intracranial EEG (iEEG), ictal SPECT, and PET, localized the seizure foci to the right frontal operculum and the right superior temporal gyrus. Following resection of these areas in October 2005, the patient remained seizure-free for six months. Thereafter seizures of identical semiology reappeared. During his second EMU evaluation in 2007, both SPECT and MEG failed to localize a discrete seizure focus. Multiple clinical events were captured on iEEG with onset localized to the right orbitofrontal area that was resected in January 2008. Our patient remains seizure-free. Conclusions: Our patient exhibited very unusual ictal verbalizations that included clearly understandable curse words produced in buccal pseudovoice. The production of buccal pseudovoice is taught by speech therapists to patients who undergo laryngectomy. Perhaps the most famous example of a buccal pseudovoice is the distinctively angry voice of the cartoon character Donald Duck supplied by Clarence Nash. Our patient was able to produce buccal pseudovoice interictally. Ictal vocalizations occur in up to 50% of frontal lobe seizures, while ictal verbalizations are less frequent. In some frontal lobe series ictal vocalizations lateralized more often to the left. In our patient, however, the seizure onset zone was mapped to the right orbitofrontal region.