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Summary:Purpose: To determine the lateralizing value of ictal urinary urgency.Methods: A retrospective database search was performed for patients with ictal urinary urgency admitted to the Epilepsy Monitoring Unit at the Cleveland Clinic between 1994 and 2001.Results: Six patients were identified; intracarotid amytal test demonstrated left hemispheric speech dominance in five cases.The sixth patient continued to speak during right temporal seizures. EEG and imaging data supported right temporal or frontotemporal epilepsy in all six cases. Two patients were seizure free after focal right hemispheric resection.Conclusions: Ictal urinary urge appears to be a lateralizing sign for nondominant temporal lobe epilepsy. Key Words: Ictal urinary urge-Temporal-Lateralizing sign-Nondominant.Ictal "desire to void" was first described by Feindel and Penfield in 1954 (1). The frequency of this autonomic manifestation in temporal lobe epilepsy (TLE) ranges from 0.3 to 8% (1-3). Recently a series of six patients with an aura of ictal urinary urge was described (4). Four of these patients underwent intracarotid amytal testing (IAT) and were found to have seizures arising from the either right or left, but always nondominant temporal lobe. METHODSMedical records of 3,446 patients who underwent video-EEG monitoring at the Cleveland Clinic between 1994 and 2001 were reviewed for the presence of ictal urinary urge. The patient population consisted of 75% with focal epilepsy (temporal, 48%; extratemporal, 19%; nonclassifiable focal, 8%), 5% with generalized epilepsy, 1% with multifocal epilepsy, and 19% with nonepileptic seizures.Clinical history, interictal and ictal video-EEG recordings with scalp and sphenoidal electrodes, and imaging studies were reviewed. Trained EEG/epilepsy technologists and nurses tested the patients during and after seizures to determine level of consciousness and reactivity. Only patients with repeated seizures with ictal urinary urge were included. RESULTSSix patients were identified (0.4% of all patients with TLE). The results are summarized in Table 1. In all cases, patients reported an urge to void at the onset of clinical seizures, usually accompanied by other types of auras. None of these patients had urinary incontinence. In one patient (case 5), urinary urgency was the first symptom of impending seizures. The IAT revealed left hemispheric speech dominance in five patients studied. The sixth patient was right-handed and had ictal speech during right-hemispheric EEG seizures. In all cases, ictal and interictal EEG suggested localization of the seizure onset to the nondominant, right temporal region. In two patients, seizures originated independently from the left and right temporal regions; however, only the right temporal seizures were associated with ictal urinary urge. In all cases with documented left hemisphere speech dominance, neuroimaging revealed abnormalities involving the temporal lobe, often extending to the insula or inferior frontal regions. In two cases, right anterior temporal resectio...

Reliable lateralizing signs included focal clonic activity and predominantly unilateral spasms. Focal tonic activity, nystagmus and postictal hemiparesis were also consistently contralateral but were observed only in few patients. Tonic eye version was unreliable and could not be used to lateralize seizure onset. The sequence of eye and head version evolving to generalized tonic clonic convulsions was not seen in this age group.

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A patient with absence of the basal ganglia and refractory epilepsy without impairment of pyramidal or extrapyramidal motor function is reported. Imaging findings suggest a vascular insult as etiology. Preserved motor function could be explained by neuronal plasticity involving contralateral corticostriatal and pallidothalamic connections and points to a lesion received in early pregnancy.