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Neurology 2001;56:133-134
© 2001 American Academy of Neurology
Clinical/Scientific Notes

Postictal coughing and noserubbing coexist in temporal lobe epilepsy

Richard Wennberg, MD, FRCP(C)

From the Division of Neurology, University Health Network, Toronto Western Hospital, University of Toronto, Ontario, Canada.

Address correspondence and reprint requests to Dr. R. Wennberg, Toronto Western Hospital, EC8 - 022, 399 Bathurst Street, Toronto, Ontario, Canada M5T 2S8; e-mail: r.wennberg{at}utoronto.ca


   Introduction
Top.
 Introduction
Patients and methods.
 Discussion.
 References
 
Postictal coughing (PIC) has been described as a clinical localizing sign more common in temporal than extratemporal epilepsy.1,2 Postictal noserubbing (PIN) is another clinical sign indicative of temporal lobe seizure onset.3-6 PIN is thought to occur in response to increased nasal secretions caused by ictal activation of the central autonomic pathways.3,4,6 Because PIC could also be a reaction to increased respiratory secretions,3 this study sought to determine whether PIC and PIN co-occurred in the same patients. If so, it would define a subset of patients with temporal lobe epilepsy whose seizures preferentially induce secretions throughout the nasotracheobronchial tree.


   Patients and methods.
Top.
 Introduction
 Patients and methods.
Discussion.
 References
 
As part of a larger prospective study analyzing the electroclinical features of PIN,6 episodes of PIC were documented in a group of 75 consecutive patients with temporal lobe epilepsy investigated in an epilepsy monitoring unit between April 1997 and April 2000. Coughing that occurred simultaneously with electrographic ictal offset or within a few seconds (1 to 3) of offset was included along with PIC for the purposes of this study.

Patients were classified as mesial temporal or neocortical temporal based on the MRI or pathologic findings or, in four cases, based on the results of intracranial EEG recording. Thirteen patients were excluded from the analysis because all recorded seizures either secondarily generalized or were auras with no other clinical manifestations. Thirty-five of 40 mesial temporal patients had MRI evidence of mesial temporal atrophy or sclerosis, three were identified through depth electrode recordings, and the remaining two cases had structural lesions in the uncus (one neoplasm, one cavernoma). Seventeen of 19 neocortical temporal patients had MRI or pathologic evidence of a structural lesion, either neoplastic (four), hamartomatous (two), gliotic (nine), or vascular (two), and two had no identifiable structural lesion but scalp EEG findings incompatible with a mesial temporal localization. Two of the patients could not be classified with certainty as either mesial or neocortical.

Forty-nine patients with extratemporal epilepsy and 22 patients with nonepileptic events (pseudoseizures) were investigated during the same study period.

Results. PIC was observed in eight of 62 patients (12.9%) with temporal lobe epilepsy in 30 of 287 seizures (10.4%). Sixty seizures were recorded in the eight patients with PIC: five with right mesial, two with right neocortical, and one with left neocortical temporal epilepsy. PIC invariably occurred within 30 seconds of seizure termination, often at or just before ictal offset (17 of 30 seizures). PIN was seen in 28 of 62 patients (45.2%), in 61 of 287 seizures (21.2%). All eight patients with PIC also demonstrated PIN (p = 0.0034; Fisher’s exact test, two-tailed), either in the same (9 of 60) or different (13 of 60) seizures.

One patient with PIC was investigated with bilateral frontal and temporal depth electrodes. All 18 recorded clinical seizures, and all seizures with PIC (and PIN), showed onset localized to the right anterior hippocampus with subsequent spread to the amygdala and then right orbital frontal region ( figure). Seizures restricted to the hippocampus were always subclinical and did not evoke PIC or PIN.



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  		Figure. Intracranial depth electrode recording in patient with right mesial temporal epilepsy. Focal electrographic onset occurred at RH1,2 (right anterior hippocampus) 52 seconds earlier (not shown). The ictal activity remained confined to RH1,2 before clinical onset 25 seconds later, coinciding with spread to ipsilateral amygdala (RA2,3) and orbital frontal contacts (RF1,2). Coughing occurred at ictal offset (**); noserubbing occurred 54 seconds later. Average referential montage.

 
PIC was less common in patients with extratemporal epilepsy, seen in 2/49 patients (p < 0.05; {chi}2, one-tailed), one of whom also had PIN. PIC was not observed in patients with nonepileptic events.


   Discussion.
Top.
 Introduction
 Patients and methods.
 Discussion.
References
 
All patients with temporal lobe epilepsy and PIC also had PIN in the same or other seizures, a significant correlation indicating that the two phenomena may be markers for a subset of patients whose seizures induce autonomic activation of respiratory secretions to an extent greater than that seen in other patients with temporal lobe epilepsy.

PIC is less common than PIN, occurring in 13% of patients with temporal lobe epilepsy in this study. Previous reports have described the incidence of PIC in patients with temporal lobe epilepsy as 9%,7 10%,1 and 40%.2 PIC tends to occur earlier after ictal offset than PIN (100% within 30 seconds of offset with PIC, compared to 61% within 30 seconds of offset with PIN6). Also, as described previously,1 PIC frequently occurs at or just before ictal offset, which may indicate a need to regain partial awareness in the postictal period to initiate PIN3 which is not required for PIC.

PIC is more common in temporal than extratemporal epilepsy and is not seen with pseudoseizures. A trend toward right-sided lateralization and mesial temporal localization was seen in this and another study,7 however, no significant differences in lateralization or intratemporal localization of seizure onsets with PIC have been reported.1,2,7


   Acknowledgments
 
Dr. A. Lozano performed the intracranial depth and subdural electrode implantations.


   References
Top.
 Introduction
 Patients and methods.
 Discussion.
 References
 

  1. Van Ness PC, Marotta J, Kucera A, Klem G, Chee M. Postictal cough is a sign of temporal lobe epilepsy. Neurology 1993; 43: A273–A274. Abstract.
  2. Bogolioubov A, Walczak T, Bazil C. Postictal cough and temporal lobe epilepsy. Epilepsia 1994; 35 (suppl 8): 16. Abstract.
  3. Hirsch LJ, Lain AH, Walczak TS. Postictal nosewiping lateralizes and localizes to the ipsilateral temporal lobe. Epilepsia 1998; 39: 991–997.[Medline]
  4. Leutmezer F, Serles W, Lehrner J, Pataraia E, Zeiler K, Baumgartner C. Postictal nose wiping: a lateralizing sign in temporal lobe complex partial seizures. Neurology 1998; 51: 1175–1177.[Abstract/Free Full Text]
  5. Geyer JD, Payne TA, Faught E, Drury I. Postictal nose-rubbing in the diagnosis, lateralization, and localization of seizures. Neurology 1999; 52: 743–745.[Abstract/Free Full Text]
  6. Wennberg R. Electroclinical analysis of postictal noserubbing. Can J Neurol Sci 2000; 27: 131–136.[Medline]
  7. Gil–Nagel A, Risinger MW. Ictal semiology in hippocampal versus extrahippocampal temporal lobe epilepsy. Brain 1997; 120: 183–192.[Abstract/Free Full Text]
Received May 17, 2000. Accepted in final form August 2, 2000.




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