Abstract
Painful Hand Seizures are a rarely reported form of secondary sensory seizures (SSS) characterized by painful, bilateral sensorimotor hand involvement and preserved consciousness. We report our case to aid neurologists in recognizing SSS as an atypical presentation of seizures.
Keywords: secondary sensory seizures, somatosensory cortex, SII, painful hand seizures
A 25-year-old woman with known history of parietal lobe oligodendroglioma underwent stereotactic tumor ablation. In the subsequent months, she developed stereotyped episodes of painful, bilateral hand “clenching” and paresthesias with preserved consciousness. These events occurred 2-3 times daily and self-resolved within minutes. She had been previously told by neurologists in various emergency departments that these were related to anxiety. Given the ongoing severity of these symptoms, she then presented to our emergency department. During our encounter, her inter-ictal neurologic exam was normal. Brain magnetic resonance imaging (MRI) revealed a T2-based hyperintensity in the left somatosensory cortex consistent with post-surgical scarring (Figures 1A-1D). Routine electroencephalogram showed rare epileptiform discharges over the corresponding left tempo-parietal region. Her episodes stopped with initiation of levetiracetam.
Figure 1.
(A) Axial Fluid attenuated inversion recovery (FLAIR) magnetic resonance image demonstrating T2-based hyperintensity in the left parietal lobe, consistent with post-surgical resection cavity. (B) Axial susceptibility-weighted image (SWI) demonstrating susceptibility artifact surrounding the resection cavity, consistent with residual blood products. (C) Contrasted coronal T1 image showing heterogeneous contrast enhancement of the resection cavity. (D) Sagittal view of the FLAIR hyperintensity, lying immediately superior to the lateral sulcus and caudal to the primary somatosensory cortex. (E) Somatotopic map of the secondary somatosensory cortex (SII; green region) in relation to the primary somatosensory cortex (SI; blue region), with bordering central sulcus (yellow margin), lateral sulcus (red margin), and superior parietal cortex (SPC; purple region).
Painful Hand Seizures are a rarely reported form of secondary sensory seizures (SSS) characterized by painful, bilateral sensorimotor hand involvement and preserved consciousness.1,2 Secondary sensory seizures are thought to originate from secondary somatosensory cortex (SII).3,4 The same area was involved on our patient’s MRI (Figures 1D-1E). Differential considerations for bilateral hand pain are broad, but the discrete, stereotyped nature of our patient’s episodes raised concern for epileptic seizures. 5
The bilateral semiology of a unilateral seizure focus with preserved consciousness contrasts with conventional teaching of the somatotopy of the sensory cortex.6,7 Stimulation experiments of SII, dating back to the 1950’s, have been shown to elicit bilateral sensorimotor hand symptoms. 8 More recent functional neuroimaging has shown that ipsilateral SII activation causes bilateral SII involvement without generalization, which may explain the preserved consciousness often seen in SSS. 9 We report our case to aid neurologists in recognizing SSS as an atypical presentation of seizures.
Footnotes
Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding: The author(s) received no financial support for the research, authorship, and/or publication of this article.
ORCID iD
Jordan Y. Amar, MD, MSc https://orcid.org/0000-0002-2455-6543
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