John Libbey Eurotext

Spitting automatism Volume 2, numéro 4, Décembre 2000

In a recent article, Ozkara et al. have suggested that spitting automatism could be a localizing sign to the nondominant temporal lobe [1].

In our experience, only one out of 351 patients with partial epilepsy, who underwent surgery at Grenoble Hospital presented such a phenomenon. This patient was reported in our series of multilobar epilepsies [2] as an illustrative case of temporo-perisylvian epilepsy in the left hemisphere dominant for language, as assessed by intracerebral stereo-EEG recordings (case D.91.04, p. 1327). The recordings demonstrated that ictal discharges, although originating in the hippocampo-amygdaloid complex, quickly involved the temporal pole and the anterior cingulate gyrus, with rapid spread to the temporal neocortex, the orbito-frontal cortex and the suprasylvian opercular cortex (figure 1). Spitting occurred only at that time, and there was no contralateral propagation of seizure activity, as assessed on scalp-EEG which was conducted simultaneously. Spitting was preceded by a distressing, epigastric sensation with swallowing and sourness in the mouth, and was followed by lip smacking, chewing, and impairment of consciousness with aggressive behaviour. There was a prolonged post-ictal aphasia, and occasional amnesia of the initial symptoms. Because of anatomical constraints, resective surgery was restricted to mesial and lateral temporal lobe structures, leading however, to significant improvement of seizure frequency. Importantly, spitting persisted during residual seizures. Pathological analysis of resected tissue revealed hippocampal sclerosis.

Based on this observation, we would like to emphasize the following points:

i) ictal spitting is not always a "motor automatism", but may appear as a response to unpleasant gustatory sensations, which are related to the ictal involvement of the operculo-insular cortex [3]; such sensations can be forgotten after the seizures, as was observed in some episodes in our patient;

ii) the localizing value of ictal symptomatology must be assessed by taking into account the spatial evolution of seizure activity at the time of the symptoms; Ozkara et al., as well as other authors [4], did not provide this information; our observation showed that spitting occurred when ictal discharges spread over temporal, frontobasal, and opercular cortices, and it seems likely, as suggested by the authors, that the insula was also involved;

iii) consequently, we assumed that our patient was suffering from "temporo-perisylvian" seizures [5], rather than temporal lobe seizures; as a matter of fact, complete cessation of seizures could not be achieved after temporal lobectomy, and ictal spitting behaviour persisted; this confirms that an epileptogenic area is not necessarily limited by the anatomical boundaries which define the cerebral lobes [2]. Failure of temporal lobe surgery in two of the five patients reported by Voss et al. [4] might provide a similar explanation, and it would be interesting to have the post-operative follow-up of the patient reported by Ozkara and colleagues;

iv) finally, among 13 reported cases of ictal spitting [1, 4, 6, 7], seizures had a non-dominant hemisphere onset in 10, and lateralization was not known in 3; our observation shows that spitting can unequivocally occur during discharges lateralized to the left, and dominant - for - langage hemisphere. Thus, due to the small number of reported cases, the lateralizing value of ictal spitting remains a debatable issue.

References

1. Ozkara C, Hanoglu L, Eskazan E, Kulaksyzoglu IB, Ozyurt E. Ictal spitting during a left temporal lobe-originated complex partial seizure: a case report. Epileptic Disord 2000; 2:
169-71.

2. Munari C, Francione S, Kahane P, et al. Multilobar resections for the control of epilepsy. In: Schmidek HH, Sweet WJ, eds. Operative neurosurgical techniques, 3rd edition, vol. 2. Philadelphia: WB Saunders Company, 1995: 1323-39.

3. Hausser-Hauw C, Bancaud J. Gustatory hallucinations in epileptic seizures. Electrophysiological, clinical and anatomical correlates. Brain 1987; 110: 339-59.

4. Voss NF, Davies KG, Boop FA, Montouris GD, Hermann BP. Spitting automatism in complex partial seizures: a non-dominant temporal localizing sign? Epilepsia 1999; 40:
114-6.

5. Munari C, Talairach J, Bonis A, Szikla G, Bancaud J. Differential diagnosis between temporal and "perisylvian" epilepsy in a surgical perspective. Acta Neurochir 1980; (Suppl 30): 97-101.

6. Fakhoury T, Abou-Khalil B, Peguero E. Differentiating clinical features of right and left temporal lobe seizures. Epilepsia 1994; 35: 1038-44.

7. Hecker A, Andermann F, Rodin EA. Spitting automatism in temporal lobe seizures with a brief review of etiological and phylogenetic aspects of spitting. Epilepsia 1972; 13: 767-72.