Researchers at Children’s Hospital, Boston; Boston University; Mayo Clinic, Jacksonville, FL; Northwestern University, Chicago; and the Cleveland Clinic in the USA; and centers in Germany and Spain studied the frequency of dacrystic seizures (DS) identified in video-EEG long-term monitoring units and the relationship of their clinical presentation to the underlying pathophysiology and etiology. Nine patients (5 male, 4 female) with DS were identified and included 1) stereotyped lacrimation, sobbing, grimacing, yelling, or sad facial expression; 2) long-term video-EEG recordings (at least 12 hrs.); and 3) at least one brain MRI study. Age at onset of seizures ranged from 0.08 – 70 years (mean 14.9 years). DS were identified in 0.06-0.53% of patients admitted for long-term video-EEG. DS occurred alone in only 1 patient; they were accompanied by gelastic seizures in 5 cases, and generalized tonic-clonic seizures in 5. Hypothalamic hamartoma was diagnosed in the 5 patients with DC and gelastic seizures. Left mesial temporal sclerosis was the etiology for 3 of the 4 patients with DC without gelastic seizures; and frontal glioblastoma was the underlying pathology in 1 patient.

Seizures were generally refractory to medication; at least 3 different AEDs were tried and only 2 of 9 patients responded. Six patients were considered for surgery and 3 underwent a surgical/radiosurgical or radioablative procedure that was successful in 1 who remains seizure-free after 3 years. [1]

COMMENT. The term “dacrystic epilepsy,” from the Greek dakryon, tear, was proposed in 1976 [2]. Hypothalamic hamartoma is the most likely cause when dacrystic seizures (DC) are accompanied by gelastic epilepsy. When DS occur alone, the lesion is commonly in the temporal lobe cortex. DS are refractory to treatment with AEDs and frequently require surgery for removal of a structural lesion. Whereas involuntary laughter is an accepted expression of epilepsy, especially as a symptom of hypothalamic hamartoma, involuntary crying is a relatively rare form of epilepsy. The current article adds to the sparse literature suggesting that DS are symptomatic of structural brain lesions, and demonstrates that patients with DS without gelastic epilepsy frequently present with mesial temporal sclerosis. Symptoms leading to the diagnosis of a hypothalamic-pituitary or temporal lobe lesion are usually neurological, including increased intracranial pressure and seizures. Endocrine symptoms (changes in weight, height, puberty, or diabetes insipidus) and their occurrence prior to the onset of neurologic symptoms may help to diagnose the hypothalamic-pituitary lesions earlier than the appearance of gelastic seizures see Pediatr Neurol Briefs 2012 Dec;26(12):95-96. [3]