Cingulate gyrus epilepsy: Clinical and behavioral aspects, with surgical outcomes

Background: Cingulate gyrus epilepsy is controversial because it may overlap with other frontal lobe epilepsy syndromes. Reported cases are rare in the pre-magnetic resonance imaging literature but are more common thereafter. Information about peri-ictal and ictal behaviors is scarce. Objectives: To characterize epilepsy originating from the cingulate gyrus and to report surgical outcomes. Design: Case studies. Setting: Academic research. Patients: We report 3 surgically treated cases of cingulate gyrus epilepsy, with seizure-free or almost seizure-free outcomes. The cases were identified from a database of 4201 consecutive epilepsy monitoring unit admissions since October 1998 through September 2008. All 3 cases involved cingulate lesions. Main Outcome Measures: Neuroimaging, video electroencephalographic, pathologic, and surgical outcome data were reviewed. Results: All 3 patients had lesional left anterocingulate seizures confirmed by magnetic resonance imaging and experienced cessation of seizures after lesionectomy. Two patients had auras (fear and laughter) previously associated with cingulate gyrus epilepsy. All patients had clinical features consistent with frontal lobe epilepsy, including hyperkinetic behavior and ictal vocalization. Two patients had behavioral changes with aggression, personality disorder, and poor judgment; some behavioral episodes lasted for days and were socially devastating. One patient, a commercial pilot, showed behavior as a passenger that resulted in a diversionary landing. The other patient demonstrated behavior that led to his arrest, and he was almost arrested again in the hospital for threatening security officers. Aberrant behaviors in all 3 patients completely resolved after lesionectomy. Conclusions: Lesional cingulate gyrus epilepsy is uncommon. Our 3 confirmed cases included 2 patients with unique and severe behavioral changes that resolved with lesionectomy.