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Table of Contents    
CASE REPORT
Year : 2018  |  Volume : 66  |  Issue : 7  |  Page : 131-134

Lateralized hyperkinetic motor behavior


Department of Neurology, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA

Date of Web Publication1-Mar-2018

Correspondence Address:
Dr. Balaji Krishnaiah
Department of Neurology, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.226448

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 » Abstract 


Seizures are followed by a post-ictal period, which is characterized by usual slowing of brain activity. This case report describes a 68-year old woman who presented with right-sided rhythmic, non-voluntary, semi-purposeful motor behavior that started 2 days after an episode of generalized seizure. Her initial electroencephalogram (EEG) showed beta activity with no evidence of epileptiform discharges. Computed tomography scan showed hypodensity in the left parieto-occipital region. Magnetic resonance imaging (MRI) showed restricted diffusion/fluid-attenuated inversion recovery hyperintensities in the left precentral and post-central gyrus. Unilateral compulsive motor behavior during the post-ictal state should be considered, and not confused with partial status epilepticus to avoid unnecessary treatment. Abnormal magnetic resonance imaging (MRI) findings, which are reversible, can help with the diagnostic and therapeutic approach.


Keywords: Electroencephalogram, epilepsy, post-ictal state, seizures
Key Message: One must be aware of unilateral compulsive motor behavior during the post-ictal state and should not confuse it with partial status epilepticus. Recognition of the reversible MRI lesions helps in modulating the diagnostic and therapeutic approaches and in avoiding an unnecessary, and occasionally, harmful intervention.


How to cite this article:
Krishnaiah B, Acharya J, Ahmed A. Lateralized hyperkinetic motor behavior. Neurol India 2018;66, Suppl S1:131-4

How to cite this URL:
Krishnaiah B, Acharya J, Ahmed A. Lateralized hyperkinetic motor behavior. Neurol India [serial online] 2018 [cited 2018 Dec 16];66, Suppl S1:131-4. Available from: http://www.neurologyindia.com/text.asp?2018/66/7/131/226448




Post-ictal state is an altered state of consciousness after a seizure event. A patient who suffered a rare post-ictal phenomenon called 'lateralized hyperkinetic motor behavior' characterized by continuous, nonvoluntary, semi-purposeful motor behavior has been described.


 » Case Report Top


A 68-year old woman with a history of rectal and bladder cancer who, following the resection of the primary tumor and chemotherapy, developed seizure disorder, was brought to the emergency department with rhythmic movements of her right upper and lower extremities for 2 days [Video 1]. She had an episode of generalized body shaking which appeared to be a part of the seizure phenomenon, 2 days before her presentation. Following the event, she suffered from twitching of her right-sided extremities, which increased in frequency over the span of 2 days, which prompted her to get medical attention. In the emergency department, she was given 2 doses of lorazepam, which decreased the intensity of twitching, although upper extremity twitching continued at a lower intensity. Assessing her strength of the right upper extremity was difficult as a result of its continuous rhythmic jerking. She was also not following simple commands and was not oriented to time, place or person. Magnetic resonance imaging (MRI) showed cortically-based restricted diffusion [Figure 1]a and [Figure 1]b and fluid-attenuated inversion recovery (FLAIR) hyperintense signals [Figure 1]c in the precentral and postcentral gyri as well as the left parietal lobe. Electroencephalogram (EEG) on the day of the admission showed excessive beta activity [Figure 2] (which was probably related to benzodiazepine use), without any epileptiform activity. The rhythmic movements were present even while the patient was asleep, making it difficult for her to have a sound sleep. She was treated with levetiracetam, and a repeat EEG showed left hemispheric slowing with no ictal activity [Figure 3]. Over the course of 4 days, her neurological status improved significantly. On the second day, her mental status improved and she became oriented to place, person, and time; and, the intensity of the rhythmic movements decreased. EEG at this time showed sharp waves in the left hemisphere [Figure 4] consistent with her MRI findings, but there were no electrographic seizures documented. On the third day, her strength improved to the baseline level. On the fourth day, her lateralized hyperkinetic motor behavior completely resolved. Repeat MRI showed resolution of diffusion weighted imaging (DWI)/apparent diffusion coefficient (ADC) changes. MRI with contrast did not show any enhancement in the region that exhibited the DWI changes. Repeat EEG showed improvement in the sharp waves with no evidence of any seizure focus.
Figure 1: (a and b) Cortically based restricted diffusion in the precentral and the postcentral gyri. (c) Fluid-attenuated inversion recovery hyperintensity in the precentral and the postcentral gyri. (d) Magnetic resonance imaging with contrast shows no abnormal enhancement in the areas in which restricted diffusion was present

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Figure 2: Electroencephalogram shows excessive beta activity probability due to the side effect of medication; there is no detectable epileptiform activity

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Figure 3: An awake EEG showing left hemispheric slowing but with no ictal activity during repetitive right arm movements

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Figure 4: An awake EEG showing left hemispheric sharp waves but with no ictal activity during repetitive right arm movements

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 » Discussion Top


The post-ictal phenomenon is well-studied in literature. Conventionally, the post-ictal state connotes the recovery period for the brain, and is characterized by, but not limited to, poor concentration, attention, short-term memory loss, presence of a variety of cognitive deficits, and temporary regional loss of function (Todd's paresis). The post-ictal state may last from seconds to hours.[1] Lateralized hyperknetic motor behavior (LHMB) is described as a continuous, nonvoluntary, semi-purposeful motor behavior. This hyperkinetic motor behavior was frequently seen after acute strokes, ipsilateral to the hemispheric lesions.[2] This phenomenon is rationalized as an active process, induced by disinhibition, in order to establish new compensatory pathways after a large ischemic stroke. LHMB, as as a post-ictal phenomenon, has not been studied systematically. To the best of our knowledge, post-ictal LHMB has only been reported by Beck et al.[3] In our patient, an episode of generalized seizure preceded this motor behavior. LHMB can be easily confused with partial seizures. However, in our case, EEG did not show any epileptiform activity, even though she continued to have these movements during the EEG recording. The recordings of multiple normal EEGs during her course in the hospital makes the possibility of seizures unlikely.

Our patient had impaired consciousness during the initial presentation, which eventually improved, supporting the theory that it was a post-ictal phenomenon. Many studies have reported transient MR changes after a seizure event. Most of these changes are thought to be secondary to changes in cerebral autoregulation and blood–brain permeability.[4] The radiologic characteristics of status epilepticus resemble those of ischemic stroke but can be differentiated based on the lesion location and findings on MR angiography and post-contrast MRI. The importance of differentiating these findings is important because these findings are easily confused with other pathologies, including encephalitis, ischemic stroke, or a tumor, leading to unnecessary diagnostic modalities or therapeutic interventions, which might even be harmful. Therefore, these findings should be approached with caution.[5] In our patient, the contrast MRI [Figure 1]d was showing no enhancement making ictal activity less likely, which is also reinforced by normalization of DWI changes in the repeat MRI. Further, there were no hippocampal changes, evidence of blood–brain barrier breakdown, or changes in the vessel caliber, which are common MRI changes during the ictal period.

Unilateral compulsive motor behavior during the post-ictal state should be considered, and not confused with partial status epilepticus to avoid unnecessary diagnostic and therapeutic interventions.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
 » References Top

1.
Fisher RS, Engel JJ, Jr. Definition of the postictal state: When does it start and end? Epilepsy Behav 2010;19:100-4.  Back to cited text no. 1
    
2.
Ghika J, Bogousslavsky J, van Melle G, Regli F. Hyperkinetic motor behaviors contralateral to hemiplegia in acute stroke. Eur Neurol 1995;35:27-32.  Back to cited text no. 2
    
3.
Beck B, Chang GY. Post-ictal, lateralized hyperkinetic motor behavior. Epilepsy Behav Case Rep 2013;1:20-1.  Back to cited text no. 3
    
4.
Aykut-Bingol C, Tekin S, Ince D, Aktan S. Reversible MRI lesions after seizures. Seizure. Case Rep 1997;6:237-9.  Back to cited text no. 4
    
5.
Lansberg MG, O'Brien MW, Norbash AM, Moseley ME, Morrell M, Albers GW. MRI abnormalities associated with partial status epilepticus. Neurology 1999;52:1021-7.  Back to cited text no. 5
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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