Ictal spitting: clinical and electroencephalographic features.

PURPOSE

To identify clinical and EEG correlates of ictal spitting automatisms and to assess their reliability in indicating the hemisphere of seizure onset.

METHODS

The epilepsy-monitoring database (1994-2002) of the Cleveland Clinic Foundation (CCF) was searched for patients with a definite history of ictal spitting. All available documents of the patients, particularly their original video and EEG data, were reviewed.

RESULTS

Twelve (0.3%) of the approximately 4000 patients had a documented history of ictal spitting. In seven of them, 15 seizures with spitting automatisms were recorded. All of them started with an aura or arousal out of sleep. In six of the seven patients (12 of 15 seizures), EEG onset was clearly lateralized to the right, nondominant hemisphere. Spitting occurred at a median time of 21 s after EEG seizure onset. At that time, predominantly fast, high-amplitude theta (5-7 Hz) was seen in the hemisphere of seizure onset, maximum temporal. In all but one of the total 12 patients, the epileptogenic zone was in the temporal lobe. In nine of the 12 patients, seizure onset was in the non-language-dominant hemisphere. Two patients had seizures arising from the language-dominant hemisphere; in another patient, the side of the seizure onset could not be determined.

CONCLUSIONS

Ictal spitting is an uncommon feature of epileptic seizures. Although the symptomatogenic area is probably outside the temporal lobe, it is most frequently seen in temporal lobe epilepsy of the right, nondominant hemisphere.