Abstracts

Rationale: Despite ictal tremor being reported for the first time over forty years ago, it remains a very rarely documented phenomenon. We can find some papers on familial cortical myoclonic tremor with epilepsy, but we were able to find just one paper on ictal tremors from 1966 (Harrington, Karnes, Klass, 1966). The authors reported involuntary movements in three patients which were clearly non-clonic in character. We would like to present the case of one of our patients with suspected ictal tremor. Three possible alternatives to tremor will be discussed: automatism, RINCH and myoclonus. Methods: The case study Woman, 19 years old; epilepsy since 13 years. No epilepsy reported in her family. Febrile seizures did not appear. Pharmacoresistant, average number of seizures 20 / 30 per month. The MRI examination: right-sided mesiotemporal sclerosis (MTS), PET FDG: considerable hypometabolism on the temporal-right region. Right-hander Wada test proved supposed speech dominance of left hemisphere. Electrophysiology: Inter-ictal as well as ictal semiinvasive video EEG finding is lateralized on right anteromedial area only. Aura (palpitation, deja vu, deja vecu, gastric aura), complex partial seizure with perioral automatisms, extremity automatisms, ictal tremor of right upper extremity, dystonia of left upper extremity, ictal and post-ictal drinking water. She had the AMTR epilepsy surgery 3 months ago and is seizure-free now. Results: Clinical and neurophysiological findings Ictal semi-invasive EEG proved that a seizure onset zone is located in the right temporal lobe. Clinical semiology proved right-side localization of seizures onset zone; the right side is speech non-dominant. There is no clinical finding of the ictal activity spreading to the left side. Back averaging was negative. EMG polygraphy results support the tremor diagnosis. Discussion In a temporal lobe epilepsy, a finding ipsilateral to seizure onset zone usually counts for automatism; however, our finding is of a rhythmic character, contrary to automatism. The RINCH is rhytmic, contralateral, non-clonic, non-tremor hand-motion. However, our case is ipsilateral to the seizure onset zone and the recorded tremor is of a higher frequency than we can usually find in RINCH-movement cases. Cortical myoclonus is indicated by rhythmic muscle activity. However, we did not find cortical potential preceding the followed phenomena in the course of back-averaging examination. Conclusions: The findings point to a rhytmic, non-clonic character of movements and a relatively high frequency of the movement, which support the tremor conclusions. However, the ipsilateral seizure onset zone should be further explained. We suppose that our finding is a case of ictal activity which has spread to deep subcortical cerebral structures. On the other hand, we cannot rule out a possible spread of ictal activity to the left side.