Evidence for reflex activation of experiential complex partial seizures Article abstract—Reflex activation of seizures by thoughts or mental im- ages is suggested by patients but has not been objectively demonstrated. The authors present a report of a man with experiential complex partial seizures reliably activated by thinking about his family home. During monitoring, such seizures were repeatedly induced in this way. Seizures were refractory to antiepileptic drugs, but ceased after left temporal resection. Pathologic examination showed cortical dysplasia. NEUROLOGY 2001;56:121–123 O. Martinez, MD; R. Reisin, MD; F. Andermann, MD, FRCPC; B.G. Zifkin, MD, CM, FRCPC; and G. Sevlever, MD, PhD Patients often say that they can bring about seizures by certain thoughts, and even more frequently imply that they can interrupt or prevent attacks by break- ing a train of thought. Such experiential reflex acti- vation, though suspected, has only rarely been studied and, to our knowledge, never documented. We present a case report of a man who could reliably induce temporal lobe seizures by thinking about his family home, and whose reflex attacks were recorded during video monitoring. Case report. This 36-year-old, right-handed man with no risk factors had intractable complex partial seizures that began at age 14. He had a rising epigastric sensation, an ill-defined feeling in his head, or a feeling of warmth followed by altered consciousness, lip smacking, and ges- tural automatisms. The seizures lasted about 1 to1.5 min- utes. Postictally, he was drowsy and confused. There were no precipitating factors in the first several years, but he noted later that seizures were reliably precipitated by the thought of his family home, where he lived from birth to age 18, and more specifically by thinking of his father looking at him. He reported that about 90% of all seizures were triggered by this thought, and that the thought would always trigger a seizure. Seizures would occur if he thought spontaneously about it, or if he was asked to de- scribe or recall it. He stated that he could also trigger seizures voluntarily by thinking about his family home. These were heralded by a feeling of fear. He noted that just after the triggering thought occurred, he would expe- rience seeing his father, the rooms in the home, and other members of his family. He avoided walking by or visiting his parents’ home because this would always trigger an attack. He described his childhood as happy, and recalling other childhood events or viewing photographs of his fa- ther, family, friends, or home did not precipitate seizures. Seeing or speaking to his father did not trigger attacks. He did not have seizures induced by mental stress without this thought. He found the seizures unpleasant and tried to avoid them by diverting his attention from the thought. He claimed to be able to abort some seizures in this way. Several seizures occurred during interviews during which he was questioned about the seizure trigger. Neuro- logic examination was unremarkable. He was treated with several antiepileptic drugs in various combinations with- out success. Routine EEG showed only sporadic left temporal slow activity. Neuropsychological evaluation showed mild ver- bal memory deficits, suggesting left temporal dysfunction. MRI with volumetric study of the temporal lobes showed no significant lateralized hippocampal atrophy. However, gray–white matter differentiation was indistinct in the left temporal lobe. Interictal SPECT showed mild left temporal lobe hypoperfusion. Ictal SPECT showed increased blood flow in the left temporal region. Four typical seizures were recorded during video–EEG monitoring with scalp and sphenoidal electrodes (figure). All were triggered during interviews in which he was being asked about the seizure trigger or when he was talking about it. He reported his aura, and the seizures then oc- curred with staring, lip smacking, altered consciousness, and automatisms. The EEG showed ictal epileptiform ac- tivity initially over the left sphenoidal electrode and left temporal convexity. Just after the aura of one of these seizures, elicited while he was explaining what could trig- ger an attack, he said that he would have a seizure if he continued to think about it and then immediately repeated “la casa, la casa.” He then said that the attack was coming, and then stared as the clinically evident seizure began. He had a left temporal resection extending 5 cm from the temporal pole, including the amygdala and hippocam- pus. Pathologic examination showed cortical laminar disor- ganization, irregular clustering of neurons, balloon cells, occasional binucleate cells, and neurons showing abnormal polarity with misdirected apical dendrites. The amygdala and hippocampus were removed by aspiration and could not be studied pathologically. Adjacent white matter showed non- specific astroglial changes. He has had no seizures since the operation in May 1998, and takes 300 mg oxcarbazepine three times a day. He has been able to visit the family home and think about it spontaneously and on command without ill effects. Discussion. The unusual feature of this patient’s attacks is that almost all of his seizures were of an experiential nature, and for many years prior to sur- gery were generated by an action of mind, a quite specific recollection of emotionally meaningful people From the Hospital Britanico de Buenos Aires (Drs. Martinez, Reisin, and Sevlever), Argentina; Faculty of Medicine (Dr. Andermann), McGill Univer- sity and Montréal Neurological Hospital and Institute, Montréal; and Epi- lepsy Clinic (Dr. Zifkin), Montréal Neurological Hospital; and Département des Sciences Neurologiques, Hôpital du Sacré-Coeur de Montréal and Fac- ulté de Médicine, Université de Montréal, Quebec, Canada. Received April 26, 2000. Accepted in final form August 24, 2000. Address correspondence to Dr. Frederick Andermann, Montréal Neurological Hospital and Institute, 3801 rue Université, Montréal, PQ, Canada H3A 2B4. Copyright © 2001 by AAN Enterprises, Inc. 121