Amid seizures, man sketched his ‘beautiful’ hallucinations

At first, he would see a colorful circle. It would grow a shimmering, flashing tail “dripping” down, which he compared to fireworks. “It’s beautiful!” he said of one of these episodes — but they gave him headaches, blinded him when they occurred and left a visual deficit in the right field of his vision for minutes after they subsided.

Five days went by, and the 71-year-old experienced episodes more and more frequently until they were occurring several times an hour. That’s when he decided to drive himself from western Washington to the Seattle division of the VA Puget Sound Health Care System, according to Dr. Christopher Ransom, a staff neurologist at the hospital and first author of a report that accompanied an image the man drew of his hallucinations. The image was published Monday in the journal JAMA Neurology.

Initially, the man was treated in the hospital’s emergency department for a migraine, but his symptoms did not subside.

At that point, “he kind of refused to leave the hospital until he was seen by neurology,” Ransom said.

A neurology consultation resulted in a recommendation for the main diagnostic test available for epilepsy: an electroencephalogram, or EEG, in which electrodes attached to the scalp record brain waves.

The results made a diagnosis abundantly clear to Ransom and his colleagues: occipital lobe epilepsy.

Over the course of the 52-minute EEG, the man experienced three seizures, which Ransom said was uncommon. He added that neurologists will often have to monitor suspected epilepsy patients for days in order to get an EEG of even one seizure.

The test, in combination with the symptoms, also revealed that the seizures originated in the left occipital lobe, a region in the brain that controls vision, color and motion.

Ransom said he and co-authors submitted the man’s drawing with the hope that other physicians may better recognize this type of epilepsy, which is often misdiagnosed as migraine with aura.

Dr. Kathryn Davis, medical director of the Epilepsy Monitoring Unit at the Hospital of the University of Pennsylvania and a member of the American Neurological Association, said this misdiagnosis is often made because migraines are much more common than occipital lobe epilepsy. Davis, who was not involved in the man’s treatment, said the case highlights how important it is to not always assume that the more common diagnosis is the correct one.

The authors wrote that the man’s case was uncommon, since occipital lobe epilepsies typically present early in life and are associated with a presence of abnormal brain structures, but an MRI scan revealed that the man did not have them.

Once they made the diagnosis of occipital lobe epilepsy, doctors immediately started the man on antiseizure medications, and he has been seizure-free for nearly two years, Ransom said.

The pièce de resistance of the submission is the drawing the man created while at the hospital, depicting the colorful blob and shimmering tail he saw during his episodes.

“We happened to have a big box of colored pencils, and he was having his seizures so frequently that we decided to ask him if he could illustrate what exactly he was seeing, and this was really intriguing to us, the drawing he produced,” Ransom said. The drawing, he added, is unique because it was sketched contemporaneously with the man’s seizures, as opposed to an after-the-fact recreation.

These kinds of visual hallucinations can give us a window into the functions of each of the brain’s regions, Davis said.

“The fact that just a small area of abnormal electrical activity can recapitulate such a fascinating and beautiful picture shows the brain working,” she said.

Davis added that she once had a patient with similar symptoms who reported optical hallucinations that looked like colorful pinwheels during his seizures.

The hallucinations might also hint at the origins and progression of each seizure, Ransom said. The primary visual cortex controls perception of static images, so the fact the man first saw a nonmoving circle may indicate that the seizure began there. As he saw a moving tail after, this could mean the seizure then traveled to parts of the occipital lobe that control perception of motion.

Approximately 5% to 10% of epilepsies are occipital lobe epilepsies, according to the Epilepsy Foundation.