Tuesday, October 20, 2015

Seizures and sudoku

Dominik Erich, a 25-year-old physical education student from Germany, endured 15 minutes of hypoxia while being buried under the snow during a ski trip, leaving him with posthypoxic intention myoclonus with involuntary myoclonic jerks of the mouth and legs when he was talking and walking.
A few weeks later, he was still in the hospital recovering from his injuries and trying to solve a sudoku puzzle when he developed clonic seizures of the left arm that, well, snowballed, Berend Feddersen, MD, PhD, of the University of Munich, and colleagues reported in a brief in JAMA Neurology.
"I fell out of my wheelchair," Erich told MedPage Today. "I couldn't move, I couldn't talk or shout for help, so I was on the floor for some time."

Erich said he imagined the puzzles in a 3-dimensional manner -- and Feddersen and colleagues pointed to reports in the literature that similar seizures could be elicited by other visual-spatial tasks. Similarly, "reflexive epilepsy" is characterized by seizures prompted by external stimuli like reading, calculating, touching, warm bathing, game playing, or noise.

"When I do a sudoku or a crossword puzzle and concentrate on a spot, while still scanning the horizontal and vertical options, my left hand freaks out," Erich said. "Freaks out means: a tremor begins. My hand cramps and moves without control. This will grow, unless I close my eyes. So my left hand is like the epicenter of a seizure."

Erich did have evidence of seizure on electroencephalography, which ceased as soon as he stopped trying to solve the puzzle, Feddersen and colleagues found.
To further assess what might be going on in his brain, the researchers conducted a CT while the patient did a sudoku puzzle, which showed hyperperfusion of the posterior cingulate gyrus.
A functional MRI also revealed maximal activation in the right central region on fMRI, as well as increases in somatosensory evoked potentials, which indicated a loss of U-fibers -- inhibitory fibers in the brain arranged in small loops under the brain cortex.

"Due to the loss of U-fibers, inhibition is diminished and a 'physiological' activation results in a hyperexcitability," Feddersen told MedPage Today. "As this was exactly in the region were 3D visualisation takes part, the seizures were induced by 3D-imagination of sudoku puzzles."

Luckily, the cure was simple -- Erich stopped solving sudoku puzzles and has been seizure-free for more than 5 years, Feddersen said.


Berend Feddersen, MD, PhD, Christian Vollmar, Jan RĂ©mi, Thomas Stephan, PhD3; Virginia L. Flanagin,  Soheyl Noachtar, MD.  Seizures From Solving Sudoku Puzzles.  JAMA Neurol. Published online October 19, 2015.


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