Significance of New Postresection Spikes

Abstract

We read with interest the article by Lombroso (1), who reported on the case of a 6-year-old boy with pavor nocturnus of proven epileptic origin. The important message of this article is that similarities in the clinical presentation of sleep terrors and certain partial seizures can lead to difficulties in their classification and to false treatment. However, the patient described by Lombroso suffered from epileptic seizures of frontal lobe origin. The table of differential features between sleep terrors and socalled "epileptic sleep terrors" presented in the same article is derived from this case. We would like to stress that not all epileptic nocturnal episodes with fear can be distinguished from sleep terrors by features like preserved responsiveness, occurrence in clusters, or absence of hallucinations and amnesia.We have recently seen a 7-year-old boy suffering from recurrent attacks of intense fear, which initially occurred only at night, usually only once and mostly in early morning hours, but later occasionally also during daytime. The attacks started with a fearful scream for help, followed by disorientation and impaired responsiveness. Afterwards, he regularly reported that he had seen snakes and crocodiles on the floor, but was amnesic for the rest of the attack. Among other differential diagnoses, like pavor nocturnus and nightmares, an adjustment disorder was suspected due to misleading psychosocial circumstances (divorce of the parents). The child received psychotherapy for more than 2 years without any effect on the attacks. Only when two typical attacks with left temporal ictal activity were recorded by long-term video-EEG was focal epilepsy diagnosed. A subsequent MRI revealed abnormalities suggesting diffuse cortical dysplasia of the left anteromedial temporal lobe extending to the amygdala. The semiology of the attacks and the EEG results were regarded as congruent with an epileptic seizure onset in this region. The patient was treated successfully using antiepileptic drugs.Thus, clinical features accompanying epileptic sleep terrors mostly depend on the site of the epileptogenic zone. As our case demonstrates, disturbed responsiveness and complex visual hallucinations are not contradictory to epileptic sleep terrors, but can result from involvement of temporal lobe structures.H. Reply To the Editor:There is no disagreement with these writers' observations, but I need to apologize for evidently failing to be sufficiently clear in my short paper.The table describes only differences between confusional arousals with the common night terrors and with those observed, as stated, in four children with sleep events proven to be of epileptic orgin within the frontal lobe. I provisionally termed these "epileptic night terrors." Neither the table nor the Discussion section were meant to include all nocturnal paroxysmal events that begin with feelings of fear. The latter of course are not uncommon, as, for instance, in complex partial seizures such as those manifested by the child they describe, and whic...