© 1986 S, Karger ACi. Basel 0014-3022 86 0254-029952.75 0 Eur. Neurol. 25: 299-303 (1986) Neuropsychological Findings in Epileptic Amnesic Attacks Roberto (¡aliassi. Paolo PazzagUa. Sebastiano Lorusso, Angela Morreale Ismuio di Clínica Neurologica dell'Universitá di Bologna. Italia Key Words. Epilepsy • Memory • Transient global amnesia Introduction Complex partial seizures may produce ietal memory disturbances, especially amnesia concerning the seizure itself, but amnesia as the sole epileptic manifestation is rare |l |. We report a case of a man affected by epilep­ tic seizures causing ictal memory distur­ bances resembling transient global amnesia (TGA) attacks. Case Report B.A. is a 67-year-old right-handed man with 13 years of formal education: he was a bank clerk before retiring 10 years ago. His medical history was un­ eventful up to the age of 64 when his wife one day noted a sudden loss of contact, repetitive movements of swallowing and pallor; a few seconds later con­ sciousness returned to normal but memory distur­ bances started. He became unable to retain new infor­ mation and he repeated the same questions; amnesia for recent events and slight time disorientation were also present. This memory impairment continued for about 15 min. during which time the patient was quiet and rather indifferent but was able to perform com­ plex operations such as reading or speaking. He fully recovered but a complete amnesia concerning the epi­ sode persisted. The patient remained in good health until 6 months later when an identical episode oc­ curred; alter 4 months he presented the third attack and from that time these events increased to 1-2 a month. They frequently begin during sleep: the patient presents automatisms of noisy swallowing and once awake the memory disability appears; the attacks also occur during the day and last from 10 to 60 min. The patient came under our observation at the age of 66 when he had had 25 attacks (20 in the last year). Apart from the episodes of amnesia, he also complained of memory difficulties which had begun at about the same lime as the onset of seizures. Careful investiga- Downloaded by: Univ. of Michigan, Taubman Med.Lib. 141.216.78.40 - 3/18/2018 4:48:45 PM Abstract. A elinical observation and a neuropsychological study in a patient with amnesic attacks due to epileptic seizures were performed. Gallassi/Pazzaglia/Lorusso/Morrcalc 300 Fig. 1. EEG showing an excess of theta activity in the right temporal region. Neuropsychological Testing A neuropsychological examination was performed to evaluate the intercritical mem­ ory deficits and to establish whether such dis­ turbances arc primary or secondary to a men­ tal deterioration. The tests administered arc listed in table I. We report their main charac­ teristics. Our ‘brief mental deterioration battery' (BMDB). described in a previous study [sub- Downloaded by: Univ. of Michigan, Taubman Med.Lib. 141.216.78.40 - 3/18/2018 4:48:45 PM tion of the patient’s history revealed another rare type of seizures characterized by epigastric 'aura' and a gen­ eral feeling of well-being for a few seconds; sometimes the amnesic attack followed after a brief time inter­ val. General and neurological examinations were nor­ mal. EEG showed (fig. I) an excess of theta activity in the right temporal region; CT scan showed a moderate and diffuse cortical atrophy. Considering an epileptic origin of the attacks the most likely hypothesis, we prescribed phenytoin (250 mg/day) and the attacks decreased to 8 (2 diurnal and 6 nocturnal) during I year of follow-up. Epileptic Amnesic Attacks 301 Brief menial deterioration battery Rcy's 15 words - long-term Immediate visual memory Simple analogies lest Barrage - lime, s Discriminant score Other memory tests Rcy’s 15 words - short-term Verbal digits span Spatial span Spatial learning Logical memory Immediate recall Delayed recall Total score Associate learning of words 4/15 20/22 19/20 46 1.87 29/75 4 5 8/20 12/26 8/26 20/52 7.5/22. mined], is derived by means of a discrimi­ nant analysis from the ‘mental deterioration battery' [2] and includes the long-term mem­ ory item of Rev's [3] ‘15 words test’ (I5WLT), ‘immediate visual memory’ (IVM), ‘simple analogies test (SAT) and the time of performance at the Barrage test. In addition to these four neuropsychological items, age and educational level arc also included in the calculation of the discriminant score (DSC) that summarizes all variables of BMDB. The threshold value of DSC is 0 and lower scores are considered pathological. Rev's [3] 15 words test is a free recall task of 15 common words read by the examiner; this task is repeated 5 times and the sum of all words recalled is the score of short-term memory (15W-ST). After 15 min employed in non­ verbal tasks the patient must recall the words and this is the score of 15W-LT. In the IVM test 22 abstract stimuli are presented one at a time for a few seconds; then the stimulus is removed and the patient is asked to point it out among four different options. SAT is a logic item in which the patient must cor­ rectly complete 20 analogies of the type: sheepdamb = cow:(calf). Barrage is a test of visual attention similar to the Toulouse-Pierron test of which the time of performance enters as a variable in BMDB. Verbal digits span and spatial span assessed by Corsi’s blocks are employed as tests of immediate memory. Spatial learning was investigated by means of blocks ‘supra-span +2’ in 20 presen­ tations. Logical memory was explored with a ‘brief story’ similar to those of the Wechsler memory scale (WMS), proposed by De Renzi [4], which includes immediate recall and de­ layed recall after 10 min; total score is the sum of the above-mentioned scores. Asso­ ciate learning of paired words (AL) is a test similar to that of WMS used by De Renzi [4], Finally, in the ‘serial position curve' (SPC) test, the subject is asked to give an immediate free recall of ten lists of 12 bisyllabic words. The first items of the list represent the long­ term storage component while words at the end arc present in the short-term store [5]. Results Table I lists the testing score. It can be seen that the DSC of BMDB is normal but the patient presents a deficit of verbal mem­ ory which is more evident in the long-term component (15W-LT, AL). In the logical memory, total score corrected for age and educational level is not pathological but de­ layed recall is poor. There is also a deficit of the long-term component in SPC and the curve docs not have a normal U-shaped as­ pect (fig. 2) [12], Downloaded by: Univ. of Michigan, Taubman Med.Lib. 141.216.78.40 - 3/18/2018 4:48:45 PM Table I. Test results 302 Gallassi/Pazzaglia/Lorusso/Morrcale Discussion Our patient presents multiple attacks of anterograde amnesia associated with short retrograde amnesia and a persistent deficit of long-term verbal memory without mental de­ terioration. It is likely that the attacks are due to epileptic seizures because they always fol­ low a brief alteration of consciousness associ­ ated with oral automatisms, although it is difficult to ascertain whether they are ictal or postictal phenomena. The 2 patients pre­ viously reported by Pritchard et al. [1] showed transient anterograde amnesia as the sole manifestation of epileptic seizures. In our case the acute memory failure ap­ pears similar to that of TGA attacks. Also the persistence of memory impairment cannot be considered a differential element against TGA. In fact some authors [6, 7] have dem­ onstrated a permanent deficit of long-term verbal memory after TGA. References 1 Pritchard. P.B., III; Holnstrom, V.L.; Roitzsch. J.C.; Epileptic amnesic attacks: dilTercntation from transient global amnesia and benefit from antiepilcptic drugs. Neurology 34: suppl. 1. p. 161 (1984). 2 Callagirone, CV, Gainotti, G.; Masullo, C.; Miceli. G.: Validity of some neuropsychological tests in the assessment of mental deterioration. Acta psychiat. scand. 60: 50-56 (1979). 3 Rey. A.: Memorisation d'une serie dc 15 mots en 5 repetitions. L’cxamen cliniquc en psychologic (PIJF, Paris 1958). 4 Dc Renzi. E.: Le amnesic. Ncuropsicologia clinica. pp. 137-148 (Angeli. Milano 1977). 5 Miller. E.: On the nature of the memory disorder in presenile dementia. Neuropsychologia 9; 75-81 (1971). 6 Mazzucchi. A.; Moretti. G.; CalTarra, P.; Parma. M.: Neuropsychological functions in follow-up of transient global anmesia. Brain 103: 161-178 (1980). Downloaded by: Univ. of Michigan, Taubman Med.Lib. 141.216.78.40 - 3/18/2018 4:48:45 PM Fig. 2. Performance at the ‘serial position curve’. W = Words position; N = number of words recalled. The EEG aspects too in our case are not typical of epilepsy and similar abnormalities are found in TGA patients [8-11]. However, we believe that the episodes of the case must be considered as ‘epileptic amnesic attacks’ because they are of short duration, recurrent and frequent and respond favorably to antiepileptic therapy. The residual memory dis­ turbances noticed by the patient himself arc similar to the complaints of other epileptic patients, especially those with temporal lobe seizures [12, 13]. These very rare amnestic attacks due to epileptic mechanism arc there­ fore well characterized. In fact, albeit the acute and chronic memory impairment is similar to TGA phenomena, several clinical features are distinct. This observation can be in agreement with those authors [9. 14] who deny the epileptic origin of TGA previously emphasized byothers [8, 15-17], 303 Epileptic Amnesic Attacks 14 Kaplan, L.B.: Transient global amnesia. Hand­ book of clinical neurology, vol. 1. pp. 205-218 (Elselvicr, Amsterdam 1985). 15 Fisher. C.M.; Adams, R.D.: Transient global am­ nesia. Acta ncur. scand. 40: suppl. 9, pp. 1-83 (1964). 16 Cantor, F.: Transient global amnesia and temporal lobe epilepsy. Neurology 21: 430-431 (1971). 17 Green, H.; Bcnnet, D.: Transient global amnesia with a previously unreported EEG abnormality. Electrocnccph. clin. Ncurophysiol. 36: 409-413 (1974). Received: May 2, 1985 Accepted: October 2. 1985 Dr. Roberto Gallassi. MD, Istituto Clinica Ncurologica, Via Ugo Foscolo 7, 1-41023 Bologna (Italy) Downloaded by: Univ. of Michigan, Taubman Med.Lib. 141.216.78.40 - 3/18/2018 4:48:45 PM 7 Caffarra, P.; Morcui, G.; Mazzucchi, A.: Parma, M.: Neuropsychological testing during a transient global amnesia and its follow-up. Acta ncur. scand. 63: 44-50 (1981). 8 Tharp, B.: The electroencephalogram in transient global amnesia. Electrocnccph. clin. Ncurophysiol. 26:96-99 (1969). 9 Mathew. N.; Meyer, J.: Pathogenesis and natural history of transient global amnesia. Stroke 5: 303311 (1974). 10 Jaffc. R.; Bender. M.: EEG studies in the syndrome of isolated episodes of confusion with amnesia ‘transient global amnesia'. J. Neurol. Neurosurg. Psychiat. 29: 412-414 (1966). 11 Nausicda, P.: Transient global amnesia. J. Am. mcd. Ass. 241: 2703 (1979). 12 Mayeux, R.; Brandt, J.; Rosen. J.; Benson. F.: Intcrcritical memory and language impairment in temporal lobe epilepsy. Neurology 30 120-125 (1980). 13 Loiscau, P.; Strubc, E.; Broustct. D.; Battellocchi. S.; Gomeni, C ; Morselli, P.L.: Learning impair­ ment in epileptic patients. Epilepsia 24: 183-192 (1983).