Telephone Induced Seizures: A new Type of Reflex Epilepsy
Robert Muchelucci, Elena Gardella, Gerrit-Jan de Hann, Francesca Bisulli, Anna Zaniboni, gaetano Cantalopue, Carlo Alberto Tassinari, Paolo Tinuper, Carlo Nobile, Paolo Nichelli, and Dorothee G.A. Kasteleijn-Nolst Trenite
From Epilepsia 45(3) 280-283
Hearing-induced seizures represent a rare and heterogeneous group of reflex epilepsies in which the attacks are almost constantly triggered by elaborate and complex stimuli such as music, voices and other sounds. In most reported cases, the seizures denote a temporal lobe involvement, but EEG documentation is available in only a few patients. Moreover, pathophysiology is largely unknown.
We present three patients with a previously unrecognized form of reflex epilepsy, in which seizures are exclusively induced by answering the telephone.
Case Reports
Case 1
A 21-year-old, left-handed woman was admitted to the Epilepsy Centre (Bologna) with a 2 year history of recurrent complex partial and secondary generalized seizures occurring only when she answered the telephone (both fixed and mobile).
The seizures were characterized by a subjective feeling of dizziness, distortion and attenuation of sound, inability to understand language, slowing or arrest of speech, and loss of contact, with motionless appearance. These seizures occurred on a monthly basis and evolved rarely into a tonic-clonic attack. A prolonged postictal dysphasia could ensue.
The seizures were usually triggered by a specific calling voice, belonging to her best friend. Because of this specific and unusual modality of induction, the seizures had been misdiagnosed as psychogenic by psychiatrists and psychologists, who had seen the patient for almost 2 years. She was frightened by the possibility of falling when answering the telephone and did not answer the phone in the last months before admission.
Her history was unremarkable except for migraine. Neurologic examination, MRI of the head, interictal SPECT, and auditory evoked potentials were normal. The routine EEG was normal whereas the tracing obtained after sleep deprivation disclosed mild, slow, sharp waves over the right temporal regions.
The patient underwent prolonged video-EEG monitoring after sleep deprivation and during the presentation of the triggering stimuli to capture seizures. The patient was seated comfortably on the bed in the laboratory next to a fixed telephone. The patient's friend whose voice usually triggered the seizures was instructed to phone the patient. Seven telephone calls were ineffective in inducing the seizures. At the eighth telephone call (perfomed by chance by a hospital nurse) the patient had one of her typical seizures immediately after picking up the receiver and hearing the voice. The patient appeared "absent", motionless and continued to hold the receiver in the left hand. Three minutes later, the patient regained normal contact with the environment and showed language disturbances for approximately 15 minutes.
Case 2
A 30-year-old, right-handed man was admitted to the Epilepsy Centre (the Netherlands) with a 2 year history of simple, complex and secondarily generalized seizures occurring only when he answered the telephone, including his mobile phone. At the beginning of each seizure, he could hear and recognize the voice through the receiver, but he could not understand the meaning of the spoken words (as if a "strange language is spoken"). Subsequently, when he tried to answer, his words did not make sense; then he would experience dizziness and show further loss of contact with the surroundings after trying to stand to get some water; sometimes a secondarily generalized tonic-clonic seizure could ensue.
His general history was uneventful, with no family history of epilepsy. Neurologic examination and brain MRI were normal. Repeated long-term EEG monitoring showed spontaneous, isolated epileptiform activity over the right frontotemporal region during both wakefulness and drowsiness. No seizures could be evoked by telephone calls including emotional content by different known and unknown people.
Case 3
A 28-year-old, right-handed man had an 8 year history of seizures, evoked predominantly by answering the fixed telephone, when he was first admitted to the Epilepsy Centre (Bologna).
The seizures were characterized only by auditory symptoms (high-pitched noise followed by familial and indistinct voices) and occurred on a monthly basis. Rarely the seizures evolved into a secondary generalization.
His history was unremarkable. His sister had rare tonic-clonic seizures preceded by auditory and psychic symptoms, and a paternal uncle had recurrent tonic-clonic seizures during early adulthood.
The EEG showed mild left temporal abnormalities. CT scan was normal. The molecular genetic study to detect mutation of the Epitempin gene gave normal findings. The attempt to record telephone-induced seizures in the laboratory by means of video-EEG monitoring was unsuccessful.
Discussion
To our knowledge, this is the first report with appropriate EEG documentation of a true form of reflex epilepsy evoked by a specific mode of activation. "Answering the telephone" may be regarded as a complex, elaborate auditory stimulus because hearing the "calling voice" seems to be the ultimate effective proactive factor.
Surprise and some emotional element may play a role, as mentioned in the clinical history of our patients and clearly demonstrated by the video-EEG recording of one attack.
