Piloerection in epilepsy

PILOERECTION AS A RARE MANIFESTATION IN EPILEPSY PATIENTSJulio Cesar Hernandez M.D.

Introduction Subjective: Rare ictal manifestation

overlooked in epilepsy patients Objective: Evidence of piloerection is

seldom available due to limitations of video resolution and the impracticality of continuous exposure of involved body areas in the EMU

Ayman M and Abou-Khalil B. Epileptic Disord 2012; 14 (1): 76-9

Reported in patients with temporal lobe epilepsy

420 patients with temporal lobe farmacorresistant epilepsy, 1.2% had piloerection (Stefan et al., 2002)

12 of 14 patients had temporal lobe epilepsy (Loddenkemper et al., 2004)

Loddenkemper et al. J Neurol Neurosurg Psychiatry 2004;75:879–883

Ayman M and Abou-Khalil B. Epileptic Disord 2012; 14 (1): 76-9

Rarely associated with frontal lobe epilepsy (Seo et al ., 2003)

Classified as a subtype of autonomic seizure and rarely as primarily ictal manifestation


3500 patients who underwent vEEG monitoring at CCF between 1994 and 2001

The patient population: 75% with focal epilepsy (temporal: 48%; extratemporal: 19%; non-classifiable focal: 8%), 5% with generalised epilepsy, 1% with multifocal epilepsy, and 19% with non-epileptic seizures

Results 14 right-handed patients with ictal piloerection Ictal piloerection was documented in 9 cases

by observation and video recordings and 5 cases by history

12 cases (85%), the EZ was located in the temporal lobe either by EEG, neuroimaging or by seizure freedom after temporal lobectomy


7 patients (50%), the ictal EEG onset was located in the RH and one patient independently from LH and RH

9 patients (64%) experienced bilateral ictal piloerection and 5 patients had unilateral (or initially unilateral) ictal piloerection

5/9 patients (56%) with bilateral piloerection had right TLE. 4/5patients (80%) with unilateral (or initially unilateral) ictal piloerection had the ictal onset in the hemisphere ipsilateral to the side of piloerection


Associated clinical findingsPreceeding symptoms

Following symptoms

Autonomic findings

Fear (3 patients), nausea (3 patients), loss of consciousness (3 patients), olfactory auras, gustatoryauras, cephalic auras, loneliness, and automatisms

Automatisms (5 patients),loss of consciousness (2 patients), nausea,unilateral tonic seizures, cephalic auras, bilateral somatosensory aura, andperioral or nasal paresthesias

Shortness of breathand hyperventilation (6 patients), tachycardia (4patients), ictal cold (3 patients), diaphoresis (3), urinary urge (3 patients), pallor,Salivation, and hyperlacrimationn=14

9 patients were aware of the piloerection during and after the seizure, whereas 5 patients did not notice the ‘‘goosebumps’’Loddenkemper et al. J Neurol Neurosurg Psychiatry

2004;75:879–883

Literature review of 18 patients with documented unilateral (or unilateral onset of) ictal piloerection


Left hemispheric predominance(?)

MRI Lesion in 11/14 cases: 4 patients hippocampal atrophy 2 had hippocampal atrophy associated

with FP encephalomalacya in one and multiple bilateral tubers due to tuberous sclerosis in another

8 had other lesionsLoddenkemper et al. J Neurol Neurosurg Psychiatry

2004;75:879–883

Generator Insula and medial prefrontal cortex, central nucleus of the

amygdala, preoptic region, hypothalamus, midbrain periaquaeductal grey matter, the pontine parabrachial region, the nucleus of the solitary tract, and the intermediate reticular zone of the medulla

Electrical or pharmacological stimulation in humans and animals at multiple sites: insula, hippocampus, amygdala, hypothalamus, midbrain reticular core, and medial prefrontal cortices

Others: parahypocampal formation and anterior cingulateLoddenkemper et al. J Neurol Neurosurg Psychiatry

2004;75:879–883

A. Interictal B. Ictal

Masnou et al. Epileptic Disorders. Volume 8, Number 3, 232-7, September 2006

F7, T1, Sp1 F7, T1, Sp1

Conclusions: Piloerection as ictal phenomena

Rare ictal manifestation Rare independently, frequently associated to

other ictal manifestations Predominantly in TLE (specially insula) Bilateral piloerection localize EZ in RH (?), LH

predominance (?), unilateral piloerection localize EZ ipsilateral to the side of the piloerection (84% of cases)

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Piloerection in epilepsy