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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
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

mise à jour du
12 septembre 2010
Epilepsy Behav
Peri-ictal yawning lateralizes the seizure onset zone to the nondominant hemisphere in patients with temporal lobe epilepsy
Kuba R, Musilová K, Brázdil M, Rektor I.
Brno Epilepsy Center, First Department of Neurology, St. Anne's University Hospital and Faculty of Medicine
Masaryk University, Brno Czech Republic


Bâillements et épilepsie
Yawning and seizure
The main aim of this retrospective study was to investigate the incidence and lateralizing value of peri-ictal yawning in patients with temporal lobe epilepsy (TLE) who underwent successful surgery for epilepsy (Engel class I outcome at the 2-year follow-up visit). We reviewed a total of 97 patients (59 men and 38 women). Fifty-three patients had TLE arising from the nondominant temporal lobe, and 44 had TLE arising from the dominant temporal lobe. In total, we reviewed 380 seizures. Of those, 202 seizures arose from the nondominant temporal lobe and 178 from the dominant one. Peri-ictal yawning was observed in 4 of 97 patients (4.1%) and in 7 of 380 seizures (1.8%), in the postictal period in all cases. Peri-ictal yawning occurred only in patients with right-sided, nondominant TLE. It may have a lateralizing value.
1. Introduction
Yawning is a phylogenetically old, stereotyped phenomenon that occurs in humans and many animals. It is characterized by a standard cascade of movements including wide opening of the mouth and retraction of the tongue. This movement pattern is often repetitive. Yawning is associated with generalized stretching of the muscles of the respiratory tract (diaphragm, intercostal), face, and neck [1,21. Pathological or excessive yawning has been described in various medical conditions [31. The occurrence of yawning associated with epilepsy or epileptic seizures has been repeatedly described, mostly in case reports. Yawning has been noted in individuals with both generalized and focal epilepsies [4-81. However, there has not been a systematic review of yawning as a part of peri-ictal semiology in focal epilepsies.
The main aim of this retrospective study was to investigate the incidence and lateralizing value of peri-ictal yawning (PY) in a selected population of patients with temporal lobe epilepsy (TLE) who had undergone successful surgery for epilepsy.
2. Methods
We reviewed 97 patients (59 men and 38 women) with intractable TLE, ranging from 14 to 58 years of age (mean ±SD=36.6±9.2), with an average duration of epilepsy of 17.2 ± 10.9 years. All patients underwent a successful epilepsy surgery procedure and were classified as Engel class I at the 2-year follow-up visit. Histopathological examination revealed hippocampal sclerosis (HS) in 60 patients and other lesions in 34 patients; 4 patients had no lesions. Histopathological investigations revealed benign brain tumors in 12 patients, dysembryonic neuroepithelial tumors in 8, vascular malformations in 7, both focal cortical dysplasia and gliosis in 2, and posttraumatic changes in 1 patient.
Fifty-three patients had TLE arising from the nondominant temporal lobe and 44 had TLE arising from the dominant temporal lobe. We reviewed 380 seizures (234 seizures in patients with HS and 146 seizures in patients with other lesions). Of those, 202 seizures arose from the nondominant temporal lobe and 178 from the dominant lobe.
Ictal semiology was assessed from the first clear-cut clinical ictal symptom to 3 minutes after the seizure ended. The end of a seizure was evaluated on an individual basis due to clinical semiology and electroencephalographic seizure offset.
All of the patients underwent the standardized presurgical investigation, including magnetic resonance imaging (MRI), interictal and! or ictal HMPAO single-photon emission tomography, fluorodeoxyglucose positron emission tomography (FDG-PET), neuropsychological assessment, and evaluation of interictal and ictal scalp recordings. Of the 97 patients, 28 patients (78 of 380 seizures) were recorded with invasive EEGs using either depth or subdural electrodes. A Wada test was performed individually to assess memory lateralization.
3. Results
Postictal yawning was observed in 4 of 97 patients (4.1%) and 7 of 380 seizures (1.8%). In the 4 patients in whom PY was observed, a total of 11 seizures were recorded, of which 7 featured yawning (64%). All of these patients had been evaluated with noninvasive video/EEG (scalp and sphenoidal) monitoring; none of them underwent invasive monitoring. In all of the seizures, the yawning was postictal; the yawning was repetitive (at least two times) in all but one seizure.
In two seizures, PY occurred in the first minute after the end of the seizure; in three seizures, between the first and second minutes; and in two seizures, between the second and third minutes.
Postictal yawning was not forceful in any seizure. Postictal testing showed that three patients (five seizures) were not aware of the yawning. The last patient was not asked.
3.1. Cases with PY
Case 1 was a 19-year-old right-handed woman who underwent surgery for epilepsy in 1999. An anteromedial temporal lobe resection on the right side was performed; histopathological investigation revealed HS. The ictal semiology of her habitual seizures comprised epigastric aura followed by complex partial seizure with limb automatisms, oroalimentary automatisms, left-sided hemidystonia, and postictal nose wiping with the right upper limb. PY was noted in two of two recorded seizures.
Case 2 was a 17-year-old right-handed man with suspected low-grade glioma in the right temporal lobe. He underwent a tailored lesionectomy in 2006; histopathological investigation revealed ganglioglioma (see Fig. 2). His seizures started with a nonspecified aura (strange feeling"), followed by complex partial seizure with automatisms, ictal speech, right-sided goose bumps, and occasionally secondary generalization. We observed postictal yawning in one of four seizures.
Case 3 was a 45-year-old right-handed woman with a cavernoma in the right temporal lobe who underwent surgery for epilepsy in 1999; histopathological investigation proved, in correlation with MRI findings, a cavernous angioma. The seizure semiology comprised psychic aura (anxiety), oroalimentary and repetitive limb automatisms, and vocalization. We noticed PY in one of two seizures.
Case 4 was a 27-year-old right-handed man who underwent surgery for epilepsy caused by a dysembryonic neuroepithelial tumor in the temporal pole on the right side in 1999; histopathological investigation findings correlated with MRI. The seizure semiology included motionless staring without previous aura, nontonic head turning to the right, and slight oroalimentary automatisms. PY occurred in all three seizures recorded in this patient.
All four patients underwent the Wada test, confirming left-sided speech dominance.
4. Discussion
To our knowledge, this is the first study to systematically analyze the frequency of PY in patients with TLE. We chose a pure series of patients with TLE who underwent successful epilepsy surgery and were classified as Engel class I at the 2-year follow-up visit. We observed PY in 4 patients (4.1%), in 11 seizures (1.8%). In all cases, the yawning was postictal. All patients with PY had right-sided, nondominant TLE, which was confirmed with the Wada test.
Although not systematically studied with any particular type of epilepsy, yawning associated with epileptic seizures has been previously described in case reports of both focal and generalized epilepsies. Penfield and jasper [4J mentioned peri-ictal yawning in two patients. The first had TLE caused by a tumor in the left temporal lobe, and the second had focal seizures with autonomic and sensory symptoms associated with yawning. No other information was provided. Goldie and Green [5J described young patients who probably had idiopathic generalized epilepsy, and in whom yawning was associated with generalized 3-Hz spike-wave episodes. Donat and Wright [6] identified 11 children with atypical variants of infantile spasms. In one of these patients, who had an unspecified brain malformation, they noted atypical spasms associated with yawning. Muchnik et al. [7J described two patients with TLE in whom the yawning occurred in association with epileptic seizures. The first patient was a 95-year-old man for whom yawning was followed by a complex partial seizure during a state of drowsiness. An EEG of this patient revealed bilateral independent temporal sharp waves. A CT scan of the patient showed diffuse cortical atrophy; no lesion was seen within the temporal lobe. The second patient was a 17-year-old woman with complex partial seizures and secondary generalized seizures followed by yawning in the postictal period. The interictal EEG of this patient also showed bitemporal epileptic findings. Brain MRI was negative, but the patient had had insulin-dependent diabetes mellitus since the age of 14. The authors stressed that her seizures did not occur in any temporal relationship with hypoglycemia. Most recently, Yankovsky et al. [8] reported a 48-year-old woman with multiple seizure types, including simple sensorimotor partial seizures of the left upper limb, complex partial seizures with dystonic posturing of the left upper limb, non-forceful deviation of the head to the left side associated with unresponsiveness, sudden falls, and secondarily generalized tonic-clonic seizures. In the postictal period of several simple and complex partial seizures, the patient had repetitive and forceful yawning. Interictal EEG revealed interictal epileptic activity over the wide centro-parieto-temporal regions on the right side (speech/nondominant side). The MRI results were normal, and two previous epilepsy surgery procedures did not lead to improvement.
Yawning is a common behavioral act in a wide variety of vertebrate species, but its functions are not well understood. Despite the widely held beliefs that it serves as a signal of boredom, that it results from a lack of oxygen, and that it is a socially contagious act, we lack a comprehensive, satisfactory explanation of its mechanisms [9J. Yawning is usually associated with transitions between wakefulness and sleep or with satiety. This complex motor behavior requires the coordination of the motor nuclei of the brainstem (V, VII, IX, X, XI, XII cranial nerves) and of the spinal cord. Yawning is controlled by the hypothalamic paraventricular nucleus (PVN). This hypothalamic structure is the site of coordination between the central and peripheral autonomic systems. The PVN plays an important role in other functions, such as metabolic balance, blood pressure, heart rate, and erection [3J. Electrical lesioning of parvocellular neurons in the PVN inhibits yawning [3J. A group of oxytocin neurons situated in the PVN zone project to the hippocampus, the brainstem, and the spinal cord. Stimulation of these neurons with dopamine or its agonists histamine and oxytocin triggers yawning, whereas GABA and opioids have an inhibitory effect [10,111. Focal epileptic seizures are often associated with heart rate changes, which are probably triggered by the influence of the hypothalamus during epileptic seizures [12,131. Although largely hypothetical, hypothalamic impairment is the most probable explanation for yawning in the peri-ictal period.
Direct activation of the brainstem structures involved in yawning may be another explanation of PY. Yet another possible explanation is impairment of the brainstem structures involved in alertness. In this case, yawning should be associated with the change in alertness or drowsiness. None of our patients associated their yawning with changed alertness, although this association was described by both patients in one case report [71.
Postictal yawning may be one of the rare vegetative ictal signs in patients with TLE that lateralizes the ictal onset to the temporal lobe of the speech/nondominant hemisphere. Although there are some controversies in the literature, other vegetative signs that have some lateralizing value in TLE are peri-ictal water drinking [14], vomiting [15,16], spitting [17,18], and peri-ictal urinary urge [191.
Our study is the first to systematically analyze postictal yawning in patients with temporal lobe epilepsy. Further studies are needed to confirm the possible lateralizing value of postictal yawning.
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-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