mystery of yawning
Le bâillement, du réflexe à la pathologie
Le bâillement : de l'éthologie à la médecine clinique
Le bâillement : phylogenèse, éthologie, nosogénie
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La parakinésie brachiale oscitante
Yawning: its cycle, its role
Warum gähnen wir ?
 
Fetal yawning assessed by 3D and 4D sonography
Le bâillement foetal
Le bâillement, du réflexe à la pathologie
Le bâillement : de l'éthologie à la médecine clinique
Le bâillement : phylogenèse, éthologie, nosogénie
 Le bâillement : un comportement universel
La parakinésie brachiale oscitante
Yawning: its cycle, its role
Warum gähnen wir ?
 
Fetal yawning assessed by 3D and 4D sonography
Le bâillement foetal
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25 septembre 20111
Epilepsy Behav
2011;22(3):602-605
Ictal yawning in a patient
with drug-resistant focal epilepsy:
Video/EEG documentation and
review of literature reports
 
Specchio N, Carotenuto A, Trivisano M,
Cappelletti S, Vigevano F, Fusco L.
Division of Neurology, Bambino Gesù Children's Hospital, Rome, Italy.

Chat-logomini

Abstract
 
Yawning is an involuntary sequence of mouth opening, deep inspiration, brief apnea, and slow expiration. Few cases of yawning as a clinical sign of epileptic seizures, ictally or postictally, have been reported. We report the video/EEG documentation of yawning as an ictal sign in a 31-year-old patient affected by drug-resistant focal epilepsy symptomatic of bilateral perisylvian polymicrogyria. Since the age of 10 she has had seizures characterized by yawning, staring, and eye blinking. Bilateral rhythmic frontotemporal spikes and waves characterized her EEG.
 
We reviewed all reported cases and compared clinical and EEG features. We believe that yawning as part of an epileptic seizure might be considered a rare automatic behavior, like other automatisms frequently reported in epileptic seizures. Automatisms are more frequently described in patients with temporal lobe epilepsy, and involvement of the temporal lobe in most of the published cases may have led to this explanation. It is possible that yawning within epileptic seizures could be considered activation of distinct symptomatogenic cortex rather than a release phenomenon. This rare ictal manifestation should be recognized as epileptic to avoid misdiagnosis and treatment failure.
 
 
(A) Ictal video/EEG recording during a typical episode of yawning (Video 1, Sequence 2&emdash;see Appendix). The EEG of the episode shows low- to medium-voltage fast activity over bilateral central areas lasting a few seconds, followed by rhythmic spikes and polyspikes involving bilateral central and frontal areas during which the patient yawns. Multiple artifacts related to mouth movement and tongue protrusion are also evident. A prolonged subclinical sequence of spike-and wave complexes is evident over frontal and central areas after the artifacts. Arrows indicate the correlation with the snapshot of the video.
 
(B) Snapshot of the video showing ictal yawning and eyelid myoclonia.
 
 
1. Introduction
 
Yawning is a physiological event that occurs in both animals and humans. In mammals it is an involuntary sequence of mouth opening, deep inspiration, brief apnea, and slow expiration . The physiological mechanism underlying yawning remains unknown, but various brain structures are related to this event.
 
Several physiological events can lead to yawning such as drowsiness, sleepiness, and emotional states; also, yawning may be induced by pathological conditions such as stroke, encephalitis, Parkinson's disease, migraine, frontal lobe and brainstem tumors, and amyotrophic lateral sclerosis. Numerous neurotransmitters, neuropeptides, and hormones are implicated in the control of yawning. Neuroendocrine substances such as dopamine, acetylcholine, serotonin, nitric oxide, noradrenaline, oxytocin, and steroid hormones have a facilitatory effect; opioid peptides and GABA have an inhibitory effect. There is evidence of contagious yawning, which occurs in 40-60% of adult humans and is probably related to mirror-neuron system activity. Despite this evidence, the role and physiology of yawning are not clear.
 
Few cases of yawning as a clinical sign of epileptic seizures have been reported: the majority of patients described had symptomatic temporal lobe epilepsy, and yawning was reported as an ictal or postictal sign.
 
Our aim was to contribute to the understanding of the clinical semiology and neurophysiological features of patients affected by symptomatic focal epilepsy with seizures characterized by yawning in association with staring and eye blinking. Moreover, we reviewed all reported cases and compared their clinical and EEG features.
 
 
2. Case report
 
This 31-year-old woman was born at term after an uneventful pregnancy. She was the first child of healthy nonconsanguineous parents. Perinatal moderate hypoxia and bilateral hip dislocation were reported. No family history of epilepsy or other neurological disorders was reported. Moderate psychomotor retardation was evident since the first year of life.
 
At the age of 16 months she started to have focal seizures characterized by psychomotor arrest and left- or right-sided head and eye deviation, sometimes followed by tonic posturing of the upper limbs. Several EEGs showed bilateral frontal and frontal and temporal epileptiform abnormalities. Seizure frequency was almost daily soon after onset. The patient was treated with carbamazepine (30 mg/kg/day), which was ineffective. Polytherapy with carbamazepine and clobazam (1 mg/kg/day) led to a reduction in seizure frequency. Brain MRI revealed bilateral perisylvian polymicrogyria. The karyotype was normal. Over the following years, seizure frequency varied from weekly to monthly.
 
At the age of 10 years, seizure semiology changed, and bilateral eye blinking, yawning, and staring were observed. During puberty she had started to experience atypical absences, which were successfully treated with valproate (30 mg/kg/day). At the age of 18, video/ EEG monitoring captured several seizures showing varied, intermingled bilateral eye blinking and yawning; yawning was usually the first sign after the onset of the electrical discharge. Loss of consciousness was difficult to ascertain because of the underlying cognitive impairment. Bilateral rhythmic central and frontal spikes and waves characterized the EEG, at times preceded by low-voltage rhythmic diffuse spike discharges. Lamotrigine (5 mg/kg/day) was added with a slight improvement in seizure frequency.
 
During follow-up she has continued to the present with almost monthly focal seizures, most of them characterized by psychomotor arrest and yawning of brief duration with an EEG similar to that already described.
 
3. Discussion
 
Yawning has rarely been reported in association with epilepsy. The anatomical network involved in yawning is not clear, but the reticular formation and brainstem seem to be involved. The paraventricular nucleus of hypothalamus, through projections to the hippocampus, pons, and medulla oblongata, may also be involved in the generation of yawning. Penfield and jasper were the first to describe yawning as part of an epileptic seizure in two patients affected by symptomatic temporal lobe epilepsy with autonomic seizures and cryptogenic epilepsy with mainly autonomic seizures; in both cases, yawning was reported to be strictly related to seizures.
 
Ten other cases have been published since those first two cases. Table 1 summarizes the main clinical findings in all cases reported. Most patients had temporal lobe epilepsy (9/12); for two patients, type of epilepsy was not specified, and the one patient remaining had infantile spasms symptomatic of a brain malformation. The seizure semiology of most of these patients was characterized by staring, sometimes preceded by aura and followed by oral or motor automatisms, but motor phenomena were also reported. Our case presented with episodes of staring associated with bilateral eye blinking. In 50% of reported patients, yawning occurred as the main part of the seizure, and in the other half, yawning occurred postictally but was strictly related to the seizure. In all seizures recorded for our patient, yawning was one of the first signs of the seizure. Etiology was symptomatic in 8 of 12 patients reported; tumor and malformations were the most frequently described lesions. All but two cases so far had a focal lesion, in contrast to our patient who had a bilateral malformation of cortical development. When reported, ictal EEG revealed a focal discharge or diffuse attenuation. It has also been postulated that in temporal lobe epilepsy, yawning may have lateralizing value (for the nondominant hemisphere); this should be kept in mind during presurgical evaluation of patients with drug-resistant focal epilepsy.
 
Outcome was good in most of cases, and either pharmacological treatment or surgery led to a complete remission. Our patient, however, had drug-resistant epilepsy, and seizures slightly decreased only on polytherapy.
 
 
 4. References
 
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[14] Yankovsky AE, Andermann F, Dubeau F. Post-ictal forceful yawning in a patient with nondominant hemisphere epilepsy. Epileptic Disord 2006;8:65&endash;9.
 
[15] Kuba R, Musilová K, Brázdil M, Rektor I. Peri-ictal yawning lateralizes the seizure onset zone to the nondominant hemisphere in patients with temporal lobe epilepsy. Epilepsy Behav 2010;19:311&endash;4.
 
-Specchio N, Carotenuto A et al. Ictal yawning in a patient with drug-resistant focal epilepsy: Video/EEG documentation and review of literature reports.Epilepsy Behav 2011