Abstracts

RATIONALE: Semiological features of seizures are helpful in lateralizing the epileptogenic zone. Ictal spitting is a rare event during focal seizures. The goal of our study was to identify clinical and electroencephalographic (EEG) correlates of ictal spitting and assess their lateralizing value.
METHODS: The epilepsy monitoring database of The Cleveland Clinic Foundation (CCF) was searched for patients with history of ictal spitting. The charts of the patients and their original video- and EEG data were reviewed.
RESULTS: Nine of approximately 5000 patients who underwent long-term video-EEG-monitoring at the CCF between 1990 and 2001 had a clear history of ictal spitting. In five of them, a total of 13 seizures with ictal spitting automatisms could be recorded. All seizures started with an aura or arousal out of sleep. In two seizures, the aura consisted of intense fear. In five seizures, ictal spitting was not preceded by any motor features. Before the spitting, oral automatisms were seen in three seizures, staring in two seizures, and hole body automatisms in four seizures. Ictal spitting was followed by retching and nausea in two seizures, by oral automatisms in two seizures, by hand or hole body automatisms in five seizures, and by dystonic posturing of the right hand in one seizure. In five seizures, there were no other clinical features following the spitting. In four of the five patients (10 of 13 seizures), EEG onset was clearly lateralized to the right, non-dominant hemisphere. Spitting occurred 21 seconds (median) after EEG seizure onset. At that time high-amplitude theta was seen in the hemisphere of seizure onset, maximum temporal. In seven seizures, there was no significant ictal EEG activity in the hemisphere contralateral to seizure onset at that time. Total duration of the EEG seizures was 61 seconds (median). In one patient (three seizures), left temporal and parietal depth electrodes were implanted. His seizures started in the left posterior hippocampus. At the time the spitting occurred, discharges had spread to the amygdala and anterior hippocampus, without change in surface EEG in two of the three seizures. He became seizure-free after left anterior temporal lobectomy. Six of the total of nine patients had the seizure onset in the right, non-dominant hemisphere. In two patients, seizure onset was bilateral independent, and not spitting automatism could be recorded during the stay. One patient had seizure onset in the left, language dominant hemisphere.
CONCLUSIONS: Ictal spitting occurs predominantly in the first half of a seizure, usually preceded by an aura. Oral, manual or hole body automatisms may occur before or after the spitting. Seizure onset is from the non-dominant hemisphere in the majority of the cases, and ictal EEG activity often is confined to this hemisphere at the time of the spitting automatisms. However, there was one carefully documented case with the seizures arising from the left, dominant hemisphere. Therefore, this clinical sign should be interpreted with caution.