Auditory verbal hallucinations as ictal phenomena in a patient with drug-resistant epilepsy

Juan Toro Perez; Jorge G Burneo; Keith Macdougall; Richard McLachlan; Seyed M Mirsattari; David C Diosy; Brent Hayman-Abello; Mubarak Aluwari; Manuel Herrera; Miguel Arevalo; Ana Suller Marti

doi:10.1016/j.clineuro.2022.107223

Auditory verbal hallucinations as ictal phenomena in a patient with drug-resistant epilepsy

Clin Neurol Neurosurg. 2022 May:216:107223. doi: 10.1016/j.clineuro.2022.107223. Epub 2022 Mar 26.

Affiliations

¹ Clinical Neurological Science Department, University Hospital - Western University, London, Ontario, Canada; Division of Neurology, Department of Pediatrics, Children's Hospital of Eastern Ontario-University of Ottawa, Ottawa, Ontario, Canada.
² Clinical Neurological Science Department, University Hospital - Western University, London, Ontario, Canada; Neuroepidemiology Unit, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada.
³ Clinical Neurological Science Department, University Hospital - Western University, London, Ontario, Canada.
⁴ Clinical Neurological Science Department, University Hospital - Western University, London, Ontario, Canada; Paediatrics Department, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada. Electronic address: ana.sullermarti@lhsc.on.ca.

PMID: 35413637
DOI: 10.1016/j.clineuro.2022.107223

Abstract

Purpose: The presence of verbal auditory hallucinations is often associated with psychotic disorders and rarely is considered as an ictal phenomena. The aim of this paper is to describe the anatomical structures involved in the genesis of this ictal symptom during epileptic seizures and direct cortical stimulation using stereo encephalography (SEEG).

Method: The case is of a 31-year-old right-handed female, bilateral speech representation, schizophrenia and with drug-resistant epilepsy and focal aware sensory seizures characterized by ictal verbal auditory hallucinations. She was implanted with depth electrodes, and she was monitored using SEEG recordings.

Results: She had focal aware sensory seizures characterized by verbal auditory hallucinations, with the following features: hearing numerous voices (both male and/or female), talking at the same time (not able to distinguish how many). The voices were inside her head, consisted of negative content, and lasted up to two minutes. Some of her focal aware sensory seizures evolved to focal motor seizures and rarely progressed to bilateral tonic clonic seizures. Her neurological examination, her brain MRI and her interictal SPECT were unremarkable. Her PET scan identified mild hypo metabolism over the right temporal and right frontal lobes. Her neuropsychological evaluation showed language laterality undetermined but her functional MRI showed bilateral language representation. On her video-EEG, three seizures were captured with a right posterior temporal onset. A subsequent SEEG showed thirteen typical seizures originating from the posterior temporal neocortical region. The cortical stimulation of the right posterior temporo-parietal neocortical region and right amygdala triggered her typical phenomena, which was multiple voices, inside her head, speaking in the second person, negative content, unable to identify gender, in English, and no side lateralization.

Conclusion: Verbal auditory hallucinations should be analyzed carefully because they can be part of the seizure presentation. Our case supports the localization of these hallucinations in the right posterior neocortical temporal regions.

Keywords: Cortical stimulation; Epilepsy; Hallucination; Seizure; Stereoencephalography.