Introduction:

Déjà vu and jamais vu are phenomena consistent with normalcy. Pathological déjà vu is seen in temporal lobe epilepsy, several psychiatric disorders, or migraine and its genesis involve the lateral temporal cortex, hippocampus, and the amygdala [1]. We present clinical findings in a patient with an uncommon semiology of recurrent aura along with Déjà vu and Jamais vu with no history of seizure or migraine.

Case 

The patient is a 15-year-old adolescent girl with a past medical history significant for depression and anxiety who presented with increased frequency of episodes of aura. She reports experiencing episodes of déjà vu and jamais vu since childhood in which a typical story plays over in her head, and she experiences a sense of familiarity or unfamiliarity to her surroundings. Two and a half years ago she had another of these episodes except this instance she experienced severe and overwhelming gustatory and olfactory hallucination described as a disgusting smell and taste that gave her a stomach pain due to the intense nausea from the putrid sensations. She began experiencing these episodes once every few months, but they progressed, and she was experiencing approximately six per day for the two weeks leading up to her presentation. Her mother videotaped the episodes and brought her to the hospital for evaluation.

During these episodes she does not lose awareness. She is fully responsive and communicative and has no motor or autonomic manifestations. The episodes are unprovoked and occur without relation to sleep, food, stress, time of day, or any significant life changes or stressors. Episodes last approximately five minutes with the gustatory and olfactory sensations occurring first, then nausea, then the sensations disappear, and she has a mild headache and mild tiredness for the following 20 minutes and then returns fully to baseline. Of note, in the past few months, she has had two instances where she forgot a specific life event. She fell on a foot that had been previously injured and surgically repaired and was said to have forgotten this fall in its entirety. Her anxiety and depression have been mildly exacerbated during COVID but are well controlled on Bupropion extended release 150mg and Sertraline 100mg daily. The patient’s family, birth, developmental, and social history are non-contributory.

During her hospitalization, her basic blood workup including CBC, CMP were normal. 72-hour continuous video EEG was unremarkable. During the monitoring, one of the patient's events was recorded without electrographic correlation (Figures 1 & 2). Due to patient dental hardware, MRI was postponed.

DISCUSSION

Aura is a transient focal neurological symptom than can include auditory, gustatory, motor, olfactory, psychic, sensory, vestibular, or visual disturbances. In clinical practice, auras are typically encountered in the setting of migraine or epilepsy [2]. Auras are of diagnostic value as they can predict a focal site of CNS involvement.

In migraine, aura is defined as an early symptom, manifesting as a focal cerebral dysfunction [3]. Migraine auras frequently manifest as paresthesia, numbness, scintillations, and scotomas [4]. While migraine auras may come in various forms, they typically have a progressive onset taking a few minutes (differentiates from ischemia), commonly resolve within 30 minutes, and may possess both positive and negative symptomology [4].

Epileptic auras, described as a subjective experience of a focal seizure are usually short, have a rapid progression, and mainly involved the temporal or occipital lobe [5]. The most common clinical findings consist of feeling of fear, visual disturbance, déjà vu, or jamais vu [6]. Gustatory and olfactory hallucinations are rare in epilepsy, with incidences of 1.3 – 3 % and 5.5% respectively in all types of epilepsies [7]. Gustatory hallucinations are localized to anterior insular–opercular areas spreading to frontal operculum face motor area, while olfactory hallucinations are localized to orbitofrontal cortex medial and lateral spreading to cingulate gyrus [8].

Pathological déjà vu is seen in temporal lobe epilepsy, several psychiatric disorders, or migraine and its genesis involve the lateral temporal cortex, hippocampus, and the amygdala. Localization of déjà vu in epilepsy is to the amygdala and/or ento-peri-rhinal cortex spreading to orbito-frontal cortex and anterior peri-sylvian region [8]. If the déjà vu is frequent and/or associated with other sensory or automatism symptoms, temporal lobe seizure is the most likely explanation [9].

Recurrent auras alone is reported in patient who previously had migraine headaches or seizures with aura and then began experiencing only aura [10]. This patient has neither history of migraine nor seizures. Her one push-button event had no EEG correlate. However, approximately only 20% of events without observable features are associated with notable findings on scalp EEG. The differential includes deja-vu seizures, temporal lobe seizures, migraine, and psychogenic non-epileptic seizures. She was started on a three-day 0.25mg BID Clonazepam bridge to Zonisamide 50mg BID. Before starting the medication, she was experiencing up to six episodes per day. During her second day of Clonazepam bridge, she experienced two episodes and has been episode-free for the subsequent 9 days. To further assess, we will obtain MRI once she has her braces removed and will consider prolonged EEG monitoring.

REFERENCES

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3. Headache Classification Committee of the International Headache Society (IHS) The International Classification of Headache Disorders, 3rd edition. Cephalalgia. 2018;38(1):1-211.

4. Viana M, Tronvik EA, Do TP, Zecca C, Hougaard A. Clinical features of visual migraine aura: a systematic review. J Headache Pain. 2019;20(1):64.

5. Dugan P, Carlson C, Bluvstein J, et al. Auras in generalized epilepsy. Neurology. 2014;83(16):1444-1449.

6. Diener HC, Johansson U, Dodick DW. Headache attributed to non-vascular intracranial disorder. Handb Clin Neurol. 2010;97:547-587.

7. Elliott B, Joyce E, Shorvon S. Delusions, illusions and hallucinations in epilepsy: 1. Elementary phenomena. Epilepsy Res. 2009;85(2-3):162-171.

8. Chauvel P, Gonzalez-Martinez J, Bulacio J. Presurgical intracranial investigations in epilepsy surgery. Handb Clin Neurol. 2019;161:45-71.

9. Wild E. Deja vu in neurology. J Neurol. 2005;252(1):1-7.

10. Kunkel RS. Migraine aura without headache: benign, but a diagnosis of exclusion. Cleve Clin J Med. 2005;72(6):529-534.

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Supplementary Video