In a recent article, Ozkara et al. have suggested that spitting
automatism could be a localizing sign to the nondominant temporal lobe
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  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
Based on this observation, we would like to emphasize the following
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 ; 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 , 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 , 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 . Failure of temporal lobe surgery in two of the
five patients reported by Voss et al.  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.
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:
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.
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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:
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diagnosis between temporal and "perisylvian" epilepsy in a surgical perspective.
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6. Fakhoury T, Abou-Khalil B, Peguero E. Differentiating clinical
features of right and left temporal lobe seizures. Epilepsia 1994;
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lobe seizures with a brief review of etiological and phylogenetic aspects
of spitting. Epilepsia 1972; 13: 767-72.