Epilepsia, 47(12):2189–2192, 2006
Blackwell Publishing, Inc.
C 2006 International League Against Epilepsy
Rhythmic Ictal Nonclonic Hand (RINCH) Motions: A Distinct
Contralateral Sign in Temporal Lobe Epilepsy
George R. Lee, Amir Arain, Noel Lim, Andre Lagrange, Pradumna Singh,
and Bassel Abou-Khalil
Department of Neurology, Vanderbilt University, Nashville, Tennessee, USA
Summary: Purpose: To describe a new ictal sign in temporal
lobe seizures—rhythmic ictal nonclonic hand (RINCH) motions
and to determine its lateralizing significance and other ictal manifestations associated with it.
Methods: We identified 15 patients with temporal lobe
epilepsy who demonstrated RINCH motions and reviewed
video-EEG recordings of all their seizures. We analyzed the
epilepsy characteristics and all clinical features of recorded
seizures, with particular attention to RINCH motions.
Results: RINCH motions were unilateral, rhythmic, nonclonic, nontremor hand motions. RINCH motions were usually
followed by posturing, sometimes with some overlap. They involved the hand contralateral to the temporal lobe of seizure
onset in 14 of 15 patients.
Conclusions: RINCH motions are a distinct ictal sign that
could be considered a specific type of automatism. They
appear to be a lateralizing contralateral sign and are associated with dystonic posturing in temporal lobe epilepsy.
Key Words: Seizure semiology—Automatisms—Dystonic
posturing—Temporal lobe epilepsy.
Accurate localization of the epileptogenic zone is essential for successful epilepsy surgery. Although many
tests contribute to the final localization, seizure semiology plays an important role in localization and lateralization (Kotagal et al., 1995; Kramer et al., 1997). The
majority of patients seen for epilepsy surgery have temporal lobe epilepsy (TLE). In many patients with TLE,
lateralization of the seizure focus is the major challenge,
particularly when bilateral EEG abnormalities are in evidence. Dystonic posturing is one of the most reliable lateralizing signs in TLE, being contralateral to the hemisphere involved in the seizure activity. Manual automatisms have generally been regarded as lacking lateralizing significance, except when associated with dystonic
posturing, which tends to inhibit or mask automatisms
in the affected extremity (Serles et al., 1998; Kotagal,
1999). It is possible that the classification of automatisms so far has been too broad and that some movements classified as automatisms may be distinct in their
characteristics.
We observed distinctive nonclonic unilateral rhythmic
hand (RINCH) motions during seizures in several patients
with TLE undergoing seizure monitoring. We initially
considered these rhythmic hand movements to be automatisms, but noted they were contralateral to the seizure focus. We studied these RINCH motions systematically in
a consecutive series of patients.
METHODS
After our initial observation of RINCH motions, we
identified 15 patients with epilepsy who demonstrated
these motions and reviewed the video recordings of all
their seizures. We recorded time of clinical and EEG onset,
time and duration of the rhythmic motions, specific character and laterality of these motions, and association with
other ictal signs. We recorded the proportion of seizures
that involved RINCH activity. We reviewed the results of
the presurgical evaluation and in particular recorded the
localization and laterality of the seizure focus. All patients
had video-EEG monitoring with antiepileptic drug (AED)
discontinuation.
Based on the total number of seizures recorded, we estimated the incidence of RINCH in seizures of affected
patients. We also surveyed the population of patients
with TLE evaluated during the period that the patients
with RINCH were identified, to estimate the incidence of
RINCH in TLE.
Accepted May 26, 2006.
Address correspondence and reprint requests to Dr. B. Abou-Khalil
at 2311 Pierce Ave, Room 2224, Nashville, TN 37232, USA. E-mail:
bassel.abou-khalil@vanderbilt.edu
doi: 10.1111/j.1528-1167.2006.00858.x
2189
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G. R. LEE ET AL.
The study was approved by the Vanderbilt Institutional
Review Board.
RESULTS
The RINCH motions varied between patients but were
consistent in each patient. They were low-amplitude milking, grasping, fist clenching, or pill rolling, or largeramplitude opening–closing motions (Table 1). A description common to all patients would be that RINCH motions
were unilateral, rhythmic, nonclonic motions. They were
different from tremor, in that they were slower and more
complex than most tremors. In addition, they were often
associated with a more forceful contraction than is seen
with tremor.
The mean duration of the motions was 24 s, with a
range of 6–128 s. RINCH motions occurred 0–79 s (mean,
24.7 s) after the onset of the electrographic seizure and
0–58 s (mean, 16.5 s) after the onset of the clinical seizure.
RINCH motions were seen within 5 s of clinical seizure
onset in eight (24%) of 34 involved seizures and within
10 s in 15 (44%) of 34 seizures (in six and seven patients,
respectively).
RINCH motions were followed by posturing (dystonic
or tonic) in every patient (although not in every seizure).
The posturing usually started after the RINCH motions
ended, but occasionally started before they ended. RINCH
motions involved the hand contralateral to the temporal
lobe of seizure onset in 14 of 15 patients. In the single
patient who demonstrated rhythmic hand movements ipsilateral to the seizure onset (Table 1, patient 4), dystonic
posturing became bilateral, consistent with contralateral
seizure spread. In one patient with bilateral independent
seizure onsets, RINCH motions were usually contralateral
to the seizure onset (Table 1, patient 14). Posturing did not
follow RINCH motions in six of the 34 seizures, and in
one seizure, the affected hand went out of camera range
right after the RINCH motions.
Interestingly, RINCH motions affected the right hand in
28 (82%) of 34 seizures and 11 of 14 patients (one patient
demonstrated independent right- and left-hand involvement) and were most often associated with left mesial
temporal sclerosis. Whereas we did not specifically review
and record automatisms in general, we did observe that
picking and fumbling automatisms sometimes occurred
simultaneously with RINCH motions, but tended to affect
the opposite extremity.
All patients with RINCH motions had TLE (Table 2).
In the 15 patients studied, RINCH motions were noted in
34 of 120 seizures analyzed. For each individual, the proportion of seizures with these rhythmic hand movements
ranged from 7 to 100%. Based on a survey of patients
admitted with TLE around the time that RINCH motions
were identified, we estimated that RINCH motions occur
in about 10% of patients with TLE.
Epilepsia, Vol. 47, No. 12, 2006
DISCUSSION
We have identified a distinct ictal motor sign in TLE
that is contralateral to the side of seizure activity. RINCH
movements typically precede dystonic or tonic posturing
and involve the posturing extremity. RINCH motions may
be a useful lateralizing sign, particularly in that they are an
early sign and tend to precede dystonic posturing. They
were usually the first lateralizing sign when they were
present. Early signs are more reliable because they are
more likely to precede contralateral seizure spread. In the
population that we studied, RINCH motions were consistently contralateral to the focus, except in one patient who
also had bilateral dystonic posturing. This suggested that
seizure activity had spread to the contralateral hemisphere
in that patient. In the presence of bilateral dystonic posturing, or other signs of rapid contralateral seizure spread,
RINCH motions may not be totally reliable in their lateralizing value. In the absence of bilateral dystonic posturing,
RINCH motions were a lateralizing sign in the patients that
we evaluated. However, this finding has to be confirmed
in patients who became seizure free with epilepsy surgery.
Additionally, as with any other seizure sign, RINCH motions should not be used in isolation, but rather in concert
with other signs.
No evidence was found in a literature review that
RINCH motions were recognized in studies of TLE
seizure semiology. If they were noted in these studies, they
were likely to have been classified as plain automatisms.
In TLE, extremity automatisms seem to be of lateralizing
value only in the presence of dystonic posturing (Kotagal
et al., 1995; Serles et al., 1998; Williamson et al., 1998;
Kotagal, 1999). In that setting, the automatisms are ipsilateral, whereas the contralateral extremity is affected with
dystonic posturing (Fakhoury et al., 1994). Before the onset of posturing, automatisms are often bilateral (Fakhoury
et al., 1994; Kotagal, 1999). The presence of unilateral automatisms will therefore suggest that the focus is ipsilateral. This is where the recognition of RINCH motions will
be extremely valuable, as these are typically contralateral.
Recognizing RINCH motions will make their contralateral localization supportive rather than problematic for
presumed focus lateralization. Based on the example of
RINCH motions, further subclassification of automatisms
in general may improve their value in seizure localization
and lateralization.
The mechanism underlying RINCH motions is unclear.
Patients occasionally look at their extremity as they are
engaging in RINCH motions. One speculation could be
that RINCH motions are triggered by a sensory experience in the affected hand. However, no patients reported
any sensation in the hand as a component of the seizure.
If RINCH motions are a response to a sensory experience,
they must occur in the presence of altered awareness or amnesia. The association of RINCH motions with dystonic
RINCH MOTIONS IN TLE
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TABLE 1. Demographics, epilepsy/seizure data, and characteristics of RINCH motions in affected patients
Patient
no.
Gender Age (yr)
RINCH description
RINCH
side
RINCH duration (s)
1
F
45
Repetitive grasping motions with fingers
R
rubbing palm, starting with the 5th digit
and followed immediately in succession
by the fourth, third, and second digits
Repetitive grasping (fingers repetitively
L
flex into a fist, then extend)
Repetitive grasping (fingers repetitively
R
flex into a fist, then extend)
Repetitive pill rolling of thumb and fingers
R
Repetitive grasping (fingers repetitively
R
flex into a fist, then extend)
Repetitive grasping motions with fingers
R
rubbing palm, starting with the 5th digit
and followed immediately in succession
by the fourth, third, and second digits
Repetitive grasping (fingers repetitively
R
flex into a fist, then extend)
Repetitive pill rolling of thumb and fingers
R
Repetitive flexion and extension of fingers
R
Repetitive flexion and extension of the
R
index finger followed by repetitive
flexion and extension of all fingers
Repetitive opening and closing of the
L
hand, starting with the fifth digit and
followed by rhythmic succession of the
fourth through the first digit in a
fanning motion
Repetitive rubbing of fingers on palm,
R
followed by fist squeezing
Repetitive flexion and extension of fingers
L
Repetitive squeezing of fist and repetitive L3/R1a
pill rolling of thumb and fingers
Repetitive rubbing of fingers on palm,
R
followed by fist squeezing
2
M
22
3
M
26
4
5
F
F
9
36
6
F
44
7
F
51
8
9
10
M
F
F
30
28
38
11
M
41
12
M
34
13
14
M
M
24
33
15
M
30
Patient
no.
Focus localization/ laterality
MRI findings/ pathology
1
L
L MTS
2
B (R for RINCH seizures)
L MTS
3
4
5
L
R
L
L temporal cortical dysplasia
Normal
L MTS
6
L
L MTS
7
L
L MTS
8
L
L MTS
9
L
10
L
Left midposterior temporal
encephalomalacia
L MTS
11
12
B (R for RINCH seizures)
L
Normal
L MTS
13
14
15
B (R for RINCH seizures)
B (R for RINCH seizures)
B (L for RINCH seizures)
Normal
L MTS
L MTS
Associated signs
(after RINCH)
No. seizures
with RINCH/
total seizures
9–16 (mean, 11.5)
Fist clenching/wrist posturing
4/4
7
Dystonic posturing
1/13
15
1/4
18–35 (mean, 23)
28
Fist clenching (likely subtle
posturing)
Tonic posturing
Dystonic posturing
3/4
1/14
37–38 (mean, 37.5)
Tonic posturing
2/8
6–36 (mean, 11)
Dystonic or tonic posturing
8/12
9
57–128 (mean, 92.5)
37
Tonic posturing
Tonic posturing
Tonic posturing
1/5
2/3
1/8
19
Dystonic posturing
1/2
27–29 (mean, 28)
Tonic posturing
2/6
8
7–43 (mean, 24.5)
Dystonic posturing
Dystonic or tonic posturing
1/3
4/21
8–32 (mean, 20)
Dystonic posturing
2/13
Surgery: surgical outcome (FU duration)
No surgery because of failed Wada memory
testing
L temporal lobectomy despite bilateral foci:
no worthwhile improvement (4 yr)
L temporal lobectomy: seizure free (3 mo)
R temporal lobectomy: seizure free (5 mo)
L selective amygdalohippocampectomy:
seizure free (3 yr)
L selective amygdalohippocampectomy:
seizure free (1 yr)
L selective amygdalohippocampectomy:
seizure free (1.5 yr)
L selective amygdalohippocampectomy:
seizure free (1 yr)
No surgery
L selective amygdalohippocampectomy:
seizure free for 7 mo, then recurrence with
no worthwhile improvement now (2 yr)
No surgery
L selective amygdalohippocampectomy:
seizure free (1 yr)
No surgery
No surgery
No surgery
B, bilateral; R, right; L, left; MTS, mesial temporal sclerosis.
a RINCH was on the left in three seizures, on the right in one.
Epilepsia, Vol. 47, No. 12, 2006
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TABLE 2.
Features that discriminate RINCH motions from other extremity automatisms
Features
RINCH
Other extremity automatisms
Body part involved
Fingers and hand
Repetition
Amplitude
Pattern
Rhythmic
Low
Rhythmic milking, grasping, fist clenching, pill
rolling, or opening–closing
Contralateral to seizure focus
Often precedes or is associated with dystonic
posturing
Lateralization
Association with other signs
posturing raises the possibility of a common pathophysiology. Ictal dystonia is most probably related to involvement
of the basal ganglia in the seizure discharge, particularly
the putamen (Newton et al., 1992; Dupont et al., 1998; Joo
et al., 2004; Mizobuchi et al., 2004). RINCH motions preceded dystonic posturing, and therefore may be an early
sign of basal ganglia involvement, but such a conclusion
would require further investigation. Evidence exists of a
sensory role for the basal ganglia, particularly the putamen
(Kaji, 2001).
The findings of the current study should be confirmed
with a prospective investigation of patients undergoing
epilepsy presurgical evaluation. Understanding of the
mechanism underlying RINCH motions may be advanced
with ictal SPECT, which has been helpful in the physiology of dystonic posturing (Newton et al., 1992; Joo et al.,
2004; Mizobuchi et al., 2004). Studying RINCH motions
in patients with implanted electrodes may also be helpful
in evaluating associated cortical ictal activity.
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Epilepsia, Vol. 47, No. 12, 2006
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Often arrhythmic (but may be rhythmic)
Often large amplitude
Variable, but often picking, fumbling, or large-amplitude
motions
Bilateral or ipsilateral
Inhibited by dystonic posturing; will persist contralateral
to the side of posturing
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