Case Report Writing epilepsy: A neurophysiological, neuropsychological and neuroimaging study Pedro Abreu a, * , Mendes Ribeiro b , Alessandra Forni b , Isabel Pires b , Georgina Sousa b a Department of Neurology, Hospital S. Joa ˜o, Porto, Portugal b Neurophysiology Unity, Hospital S. Joa ˜o, Porto, Portugal Received 1 December 2004; revised 6 February 2005; accepted 8 February 2005 Abstract Writing epilepsy is a rare reflex syndrome in which seizures are triggered by writing. We describe a 33-year-old, right-handed man, with a history of juvenile absence epilepsy in remission and a family history of epilepsy, in whom myoclonic jerks precipitated exclusively by writing started at the age of 30. Intensive video/EEG monitoring during neuropsychological tests revealed, at about 1 minute after starting to write, a dystonic posture, followed by myoclonic jerks involving the right hand that shortly after became generalized. Concomitantly, the ictal EEG documented generalized hypersynchronous polyspike–wave discharges, maximal over the right parietocentral area. SPECT revealed an ictal hyperperfusion and interictal hypoperfusion over right parietofrontal regions, and fMRI showed extensive and intense left frontal, supplementary motor area activation, induced by writing. This case study pro- vides some evidence supporting the hypothesis that the mechanism underlying writing-triggered seizures may be a generalized sei- zure process, with a focal cortical trigger zone, presumed to be the left frontal lobe as suggested by clinical and fMRI data. A relevant role played by the right hemisphere (right parietofrontal region) is postulated in the full-blown expression of reflex epilep- togenesis, as supported by EEG and SPECT findings. Ó 2005 Elsevier Inc. All rights reserved. Keywords: Writing-induced epilepsy; Graphogenic epilepsy; Language epilepsy; Reflex epilepsy 1. Introduction In language-induced epilepsy, a well-known syn- drome proposed by Geschwind and Sherwin [1], differ- ent aspects of language function, namely, reading, writing, and speaking, may precipitate seizures. In the majority of the reported cases [2–4] reading is the major triggering factor and writing is only an additional pre- cipitating stimulus. Furthermore, seizures induced exclusively by writing are very rarely described in the lit- erature [5], and in the reported cases of graphogenic epi- lepsy, the reflex seizures were related to juvenile myoclonic epilepsy [4–8]. To our knowledge, a pure graphogenic epilepsy syndrome associated with a past history of juvenile absence epilepsy has not yet been described. This case is a good experimental paradigm for study- ing writing-induced epilepsy with neuropsychological tests under video/EEG monitoring and functional neu- roimaging (SPECT and fMRI). 2. Case report The 33-year-old, right-handed man has been attend- ing our epilepsy clinic in S. Joa ˜o Hospital in northern 1525-5050/$ - see front matter Ó 2005 Elsevier Inc. All rights reserved. doi:10.1016/j.yebeh.2005.02.004 * Corresponding author. Present address: Servic ¸o de Neurologia, Hospital S. Joa ˜o, Alameda Prof. Herna ˆni Monteiro, 4200-319, Porto, Portugal. E-mail addresses: pmabreu@portugalmail.pt, pmabreu@netcabo. pt (P. Abreu). www.elsevier.com/locate/yebeh Epilepsy & Behavior 6 (2005) 463–466