Electro-clinical correlation of rinch and peri-ictal vegetative symptoms

TL;DR

This paper reports a rare case linking rhythmic hand movements and vegetative symptoms in temporal lobe epilepsy with brain activity patterns and surgical outcomes.

Contribution

The study provides a unique anatomo-electro-clinical correlation of RINCH and PIVS in dominant TLE using SEEG.

Findings

RINCH lateralized to the hemisphere contralateral to seizure onset and occurred with spread to STG and STS.

PIVS like spitting and coughing lacked lateralizing value but were linked to spread to entorhinal and parahippocampal regions.

Invasive EEG helped confirm seizure localization and led to successful surgical treatment.

Abstract

•RINCH and PIVS co-occurred in dominant temporal lobe epilepsy (TLE).•RINCH lateralized to the hemisphere contralateral to seizure onset.•RINCH appeared only with spread to STG and STS on SEEG.•PIVS like spitting and coughing lacked lateralizing value.•Invasive EEG helped refine seizure localization for surgical planning.

RINCH and PIVS co-occurred in dominant temporal lobe epilepsy (TLE).

RINCH lateralized to the hemisphere contralateral to seizure onset.

RINCH appeared only with spread to STG and STS on SEEG.

PIVS like spitting and coughing lacked lateralizing value.

Invasive EEG helped refine seizure localization for surgical planning.

Rhythmic ictal non-clonic hand (RINCH) movements and peri-ictal vegetative symptoms (PIVS) are rare semiological signs in temporal lobe epilepsy (TLE). RINCH refers to rhythmic, low-amplitude, complex hand movements that typically lateralize to the contralateral hemisphere, while PIVS includes manifestations such as ictal spitting and post-ictal coughing, more frequently associated with non-dominant TLE. We report a unique case of a 40-year-old woman with drug-resistant dominant TLE who exhibited both RINCH and PIVS as part of her habitual seizures. Non-invasive EEG and imaging localized the seizure onset to the left anterior temporal region. Stereoelectroencephalography (SEEG) confirmed seizure onset in the left mesial temporal pole with rapid propagation to the hippocampus, amygdala, and other limbic structures. Notably, RINCH was observed only in seizures that showed ictal spread to the superior temporal gyrus (STG) and superior temporal sulcus (STS), suggesting their role in mediating semi-automatic motor behaviors. Ictal spitting and other PIVS were linked to the spread to the entorhinal and parahippocampal regions. The patient underwent left anterior temporal lobectomy with histopathological confirmation of hippocampal sclerosis and has remained seizure-free at one-year follow-up. This case provides a rare anatomo-electro-clinical correlation of RINCH and PIVS using SEEG and emphasizes that while RINCH retains lateralizing value, PIVS may not. Our findings underscore the importance of invasive EEG in characterizing complex semiology and refining the epileptogenic zone in dominant TLE.

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