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Proceedings SNO “Percorsi clinici in Neuroscienze”

Case report V SESSIONE
“PERCORSI CLINICI COMPLESSI”

“Ictal rage”: a case report

M.G. PASCARELLA, V. BADIONI, S. SPERBER, E.DOMINA, V. BELCASTRO

Neurology Unit, “Maggiore” Hospital, Lodi, Italy

CASE REPORT (Figure 1). A diagnosis of epileptic seizures arising
from the right frontal lobe was made. Antiepileptic
A 32-year-old right-handed woman was seen in the drugs, including topiramate, levetiracetam, la-
Emergency Room because of suspected psychogenic cosamide and clonazepam, were periodically adjust-
non-epileptic seizures. Two months before she had ed without a clinically significant effect. Surgical
begun experiencing daily episodes of “intense feeling treatment was proposed, given medical intractability
of anger’’, which made her curse, as well as suffer of disabling seizures. The histological examination of
from violent and bizarre head and limb movements. the surgically excised lesion revealed an FCD type
Her parents reported these episodes as socially dev- IIA. After six years of follow-up, the patient is
astating. For this reason she had a number of visits at seizure-free (Engel Class Ia).
emergency room and lorazepam 4 mg e.v. was ad-
ministered in several different clinical setting.
The patient was born spontaneously after an unevent- DISCUSSION
ful pregnancy at term, and family history for epilep-
sy was negative. At age of six, she experienced sev- Ictal emotional changes are frequently observed dur-
eral nocturnal focal to bilateral tonic-clonic seizures. ing focal seizures however, these symptoms can be
An MRI study of the brain showed a right frontal cor- misdiagnosed as paroxysmal psychiatric distur-
tical dysplasia. Psychiatric personal history was neg- bances, resulting in therapeutic failures and persist-
ative. The patient started carbamazepine and pheno- ence of disability . Frontal lobe seizures can be mis-
(1)
barbital, after which tonic-clonic seizures were par- diagnosed as PNES due to hypermotor and “emotional”
tially controlled (less than one nocturnal focal to bi- semiology, which often results in a “failure treat-
lateral tonic-clonic seizure per year). ment” and in a socially disabling condition. Since ic-
(2)
On admission in the neurologic clinic, EEG monitor- tal EEG shows a number of muscle artifacts , the
ing captured several of these stereotyped self-limited analysis of ictal semiology is crucial for the differ-
events, characterized by paroxysmal rage and aggres- ential diagnosis between FLS and PNES. Features
sive behaviour, all of which were reported by the pa- commonly associated with PNES are: i) gradual on-
tient. On this ground, phenytoine 18 mg/kg ev was set or termination; ii) pseudo sleep; iii) discontinuous
administered with full clinical recovery. (stop and go) and irregular activity; iv) side-to-side
MRI confirmed a focal cortical dysplasia in the right head shaking, opisthotonic posturing, stuttering and
(3)
dorso-lateral prefrontal cortex, at the bottom of the weeping .
sulcus between the superior and middle frontal gyri Hypermotor seizures and ictal behavioural alterations

Corrispondenza: Dr.ssa Maria Grazia Pascarella, UO di Neurologia, Ospedale Maggiore, largo Donatori del Sangue 1, 26900 Lodi
(LO), e-mail: mariagrazia.pascarella@asst-lodi.it
Percorsi clinici in Neuroscienze. Clinical Round SIN e SNO Lombardia, 21 gennaio 2022, Desio (Monza e Brianza)
Atti a cura di Paolo Ferroli, Alessandra Protti, Andrea Salmaggi, Ignazio Michele Santilli, Luca Valvassori
Copyright © 2022 by new Magazine edizioni s.r.l., Trento, Italia. www.newmagazine.it ISBN: 978-88-8041-135-2

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