Epileptic nystagmus: A case report and systematic review

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Abstract

Purpose

We aimed to define the characteristics of epileptic nystagmus and correlate those with other clinical findings in a large number of patients.

Methods

We report a patient with epileptic nystagmus and additionally reviewed the reported clinical features of 36 more patients through a systematic literature search. We analyzed the characteristics of epileptic nystagmus and attempted correlations of those with alertness of the patients and epileptic foci on EEG.

Results

All 33 patients with unilateral horizontal nystagmus showed nystagmus beating away from the side of ictal discharges. Epileptic nystagmus was preceded by gaze deviation in 21 patients, with contraversive in 19 and ipsiversive in 2. Seizures associated with epileptic nystagmus were mostly focal (25/29, 86.2%) with or without loss of awareness. Ictal discharges originated from the occipital (n = 16), parietal (n = 9), temporo-occipital (n = 6), frontal (n = 4), and temporal (n = 3) areas, and two patients had multiple epileptic foci. Seizures were usually symptomatic (24/37, 64.9%). The presence of preceding gaze deviation and midline crossing of the nystagmus did not correlate with the ictal onset zone or alertness of the patients. Recording of epileptic nystagmus was available only in 6 patients, and the epileptic nystagmus could be localized to the saccadic areas in two and to the smooth pursuit areas in another two. Two patients showed the features of epileptic nystagmus from both areas.

Conclusion

Even though the localizing value of epileptic nystagmus seems limited in previous reports, the fast phase of epileptic nystagmus was almost always directed away from the epileptic focus that mostly arose from the posterior part of the cerebral hemisphere.

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Most cited references 34

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The role of the human dorsolateral prefrontal cortex in ocular motor behavior.

René Müri, Dan Milea, T. Nyffeler … (2005)

The dorsolateral prefrontal cortex (DLPFC) is involved in the preparation of saccadic eye movements. Lesion studies and functional magnetic resonance imaging (fMRI) studies suggest that the human DLPFC is located in area 46 of Brodmann. The DLPFC has direct connections with the main cortical ocular motor areas, that is with the frontal eye field (FEF) and the supplementary eye field (SEF) in the frontal lobe; with several (associative, attentional, and motor) areas in the posterior parietal cortex (PPC), including the parietal eye field (PEF); with the cingulate eye field in the anterior cingulate cortex; and directly downstream with the superior colliculus in the brainstem. Lesion and fMRI studies using the antisaccade paradigm have shown that the DLPFC is involved in the inhibition of unwanted reflexive saccades (triggered toward the target by the PEF), whereas the triggering of correct intentional antisaccades (made in the direction opposite to the target) may depend mainly upon the FEF. The DLPFC also controls short-term spatial working memory involved in memory-guided saccades, as shown by lesion and transcranial magnetic stimulation (TMS) studies. By contrast, medium-term spatial memory (after 25 s) may be controlled by the medial temporal cortex (MTC). Recently, TMS studies have suggested that the transmission of memorized information from the integrative parietal areas (PPC) to the MTC is performed via both an indirect pathway comprising the DLPFC (i.e., transmission in series) and a direct pathway bypassing the DLPFC (i.e., transmission in parallel). Furthermore, the DLPFC is involved in the preparation of predictive saccades (i.e., saccades made before the appearance of an expected target) and saccade sequences, and, therefore, also controls some aspects of temporal working memory. Lastly, the involvement of the DLPFC has recently been reported in tasks comprising a target selection or a directional decision to make for the forthcoming saccade. These different functions suggest that the DLPFC plays a major role in the decisional processes governing ocular motor behavior.

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Occipital lobe epilepsy: electroclinical manifestations, electrocorticography, cortical stimulation and outcome in 42 patients treated between 1930 and 1991. Surgery of occipital lobe epilepsy.

Lucas T Rasmussen, L F Quesney, V Salanova … (1992)

Our study documents the clinical and electrographic findings in 42 patients with medically refractory occipital lobe epilepsy, who underwent surgery at the Montreal Neurological Institute between 1930 and 1991, and the evolving manner in which those patients were studied by successive generations of investigators. In more than two-thirds of the patients the clinical manifestations indicated the occipital onset of the seizures. Seventy-three percent experienced visual aurae, of which elementary hallucinations were the most common and 12 also had ictal blindness. Other occipital manifestations included: contralateral eye deviation, blinking, a sensation of eye movement and nystagmoid eye movements. Intra-operative cortical stimulation elicited a habitual aura in 37% of 29 patients. Lateralizing clinical features were seen in almost two-thirds of patients: contralateral head deviation occurred in half, 59% had visual field defects contralateral to the epileptogenic area and 64% had abnormal imaging studies ipsilateral to the side of surgery. More than one-third of patients exhibited more than one seizure type, suggesting ictal spread to temporal or frontal lobe: 50% had typical temporal lobe automatisms, and 38% exhibited focal motor seizure activity. Surface electroencephalogram (EEG) recordings showed posterior temporal-occipital epileptiform discharges in 46% of patients. Only 18% had electronegative spiking limited to 01 or 02. Large epileptogenic areas were often found on intracranial recording with depth electrodes and on electrocorticography. Pre-excision electrocorticography spiking was restricted to the occipital lobe in only 13 out of 34 patients. More often spiking also involved the posterior temporal and posterior parietal regions. Twenty-three patients underwent only occipital resections; five had only temporal resections, so as to preserve the visual fields, and the remaining 14 patients had extensive resections, which included the posterior temporal or posterior parietal regions. A follow-up period of 1 to 46 yrs (mean 17 yrs) was available for 37 patients. Forty-six percent became seizure free and 21% had a significant reduction in seizure frequency. A better outcome was observed in those patients in whom there was no post-resection electrocorticographic or surface EEG epileptiform discharge, or who exhibited an occipital lobe lesion.

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The cerebral cortex of man: A clinical study of localization of function

W. Penfield, T Rasmussen, T RASMUSSEN (1950)

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Author and article information

Contributors

Ji-Soo Kim

Journal

Journal ID (nlm-ta): Epilepsy Behav Case Rep

Journal ID (iso-abbrev): Epilepsy Behav Case Rep

Title: Epilepsy & Behavior Case Reports

Publisher: Elsevier

ISSN (Electronic): 2213-3232

Publication date PMC-release: 18 September 2014

Publication date Collection: 2014

Publication date (Electronic): 18 September 2014

Volume: 2

Pages: 156-160

Affiliations

[a ]Department of Neurology, Ajou University School of Medicine, Ajou University Hospital, Suwon, South Korea

[b ]Department of Brain Sciences, Ajou University School of Medicine, Suwon, South Korea

[c ]Department of Biomedical Laboratory Science, Kyungdong University, Goseong, South Korea

[d ]Department of Neurology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea

Author notes

[* ]Corresponding author at: Department of Neurology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, 173-82 Gumi-ro, Bundang-gu, Seongnam-si, Gyeonggi-do 463-707, South Korea. Tel.: + 82 31 787 7463; fax: + 82 31 719 6828. jisookim@ 123456snu.ac.kr

Article

Publisher ID: S2213-3232(14)00039-5

DOI: 10.1016/j.ebcr.2014.08.004

PMC ID: 4308050

PubMed ID: 25667896

SO-VID: a6302e11-bb5f-4af0-b7e5-4fea50354286

License:

This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/3.0/).

History

Date received : 28 July 2014

Date accepted : 23 August 2014

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Epileptic nystagmus: A case report and systematic review

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Abstract

Purpose

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Most cited references 34

The role of the human dorsolateral prefrontal cortex in ocular motor behavior.

Occipital lobe epilepsy: electroclinical manifestations, electrocorticography, cortical stimulation and outcome in 42 patients treated between 1930 and 1991. Surgery of occipital lobe epilepsy.

The cerebral cortex of man: A clinical study of localization of function

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