# Ictal fear of death with preserved context dependent speech and postictal amnesia in focal epilepsy

## TL;DR

A man with epilepsy experiences intense fear of death during seizures but retains coherent speech and later has no memory of the event.

## Contribution

This case demonstrates unique seizure features including multilingual speech and preserved awareness with complete postictal amnesia.

## Key findings

- The patient exhibited intense fear of death during seizures with coherent, context-dependent bilingual speech.
- He had accurate autobiographical references and preserved responsiveness despite complete postictal amnesia.
- Neuroimaging showed a brain cyst near the medial temporal lobe with seizure onset in the right anterior temporal region.

## Abstract

Seizure semiology reflects dynamic interactions among ictal activity, internal state, and environmental context, and often involves distributed neural networks beyond the epileptogenic focus.

We report a 27-year-old right-handed, blind, bilingual man with focal epilepsy whose seizures were characterized by intense fear of imminent death, loud and coherent vocalizations, context-dependent bilingual language use, accurate autobiographical references, preserved responsiveness, and complete postictal amnesia.

During seizures, the patient consistently addressed his mother in Urdu or English while speaking exclusively in English to medical staff, demonstrating preserved pragmatic awareness; nevertheless, he had no recollection of events afterward and expressed surprise when he heard his ictal vocalizations on the recorded video. Brain MRI revealed a left middle cranial fossa arachnoid cyst abutting the medial temporal lobe and ictal onset was in the right anterior temporal region.

This case expands the spectrum of ictal fear and ictal speech by illustrating the convergence of multilingual communication, autobiographical integration, and pure postictal amnesia, highlighting the engagement of distributed limbic, interoceptive, and medial frontal networks.