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\begin{document}

\title{Mirror writing in a patient with frontal-lobe epilepsy}



\author[1]{Vityala Yethindra}%
\author[2]{Elmira  Mamytova}%
\author[3]{Tugolbai Tagaev}%
\author[2]{Sagynali Mamatov}%
\affil[1]{International Higher School of Medicine, International University of Kyrgyzstan}%
\affil[2]{I K Akhunbaev Kyrgyz State Medical Academy}%
\affil[3]{International School of Medicine}%


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  \date{May 25, 2024}


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\begin{abstract}
A 36-year-old male with non-lesional refractory frontal-lobe epilepsy,
diagnosed at 16 years of age, and with a history of four
hospitalizations for refractory status epilepticus and admitted to the
intensive care unit with focal seizures in the right upper limb,
impaired consciousness, and recurrent progression to bilateral
tonic-clonic seizures.%
\end{abstract}%



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\textbf{Mirror writing in a patient with frontal-lobe epilepsy}

Vityala Yethindra\textsuperscript{1*}, Elmira
Mamytova\textsuperscript{2}, Tugolbai Tagaev\textsuperscript{3},
Sagynali Mamatov\textsuperscript{4}

\textsuperscript{1}Department of Pathology, International Higher School
of Medicine, International University of Kyrgyzstan, Bishkek, Kyrgyzstan

\textsuperscript{2}A.N. Murzaliev Department of Neurology and Clinical
Genetics, I.K. Akhunbaev Kyrgyz State Medical Academy, Bishkek,
Kyrgyzstan

\textsuperscript{3}Department of Public Health and Healthcare, I.K.
Akhunbaev Kyrgyz State Medical Academy, Bishkek, Kyrgyzstan

\textsuperscript{4}Department of Hospital Internal Medicine,
Occupational Pathology with a Course of Hematology, I.K. Akhunbaev
Kyrgyz State Medical Academy, Bishkek, Kyrgyzstan

\textbf{Running title:} Mirror writing in frontal-lobe epilepsy

*Corresponding author: Vityala Yethindra, Department of Pathology,
International Higher School of Medicine, International University of
Kyrgyzstan, Bishkek, Kyrgyzstan,
Email:\emph{yethindravityala10@gmail.com}, Contact: +91 9121925658

\textbf{ABSTRACT}

A 36-year-old male with non-lesional refractory frontal-lobe epilepsy,
diagnosed at 16 years of age, and with a history of four
hospitalizations for refractory status epilepticus and admitted to the
intensive care unit with focal seizures in the right upper limb,
impaired consciousness, and recurrent progression to bilateral
tonic-clonic seizures.

\textbf{Keywords:} Neurology, Mirror writing, Frontal-lobe epilepsy

\textbf{Key clinical message}

During the postictal period, the left cerebral hemisphere was affected
by the seizures, and consecutive epileptiform discharges and
disinhibition of the right cerebral hemisphere could have occurred,
which may explain the observed behavior.

\textbf{INTRODUCTION}

Mirror writing is defined as the writing of letters, words, and
sentences in the direction opposite to that of normal writing and with
the letters reversed. It is observed in children learning to write and
in individuals writing with their non-dominant
hand.\textsuperscript{1}Left-handers and adults using language that is
written from right to left may have the uncommon ability for mirror
writing. Pathologically, this alteration may be observed after a focal
brain injury, such as a stroke involving the dominant cerebral
hemisphere,\textsuperscript{2}traumatic brain injuries, and Parkinson's
disease.\textsuperscript{1}However, mirror writing in patients with
epilepsy has not been reported previously. Herein, we report a case of
mirror writing in a patient with epilepsy.

\textbf{CASE PRESENTATION}

A 36-year-old, right-handed male, as confirmed by the Edinburgh
Handedness Inventory,\textsuperscript{{[}4{]}} presented with
non-lesional refractory frontal-lobe epilepsy, diagnosed at 16 years of
age, and with a history of four hospitalizations for refractory status
epilepticus (SE); medically induced coma was required. The patient was
admitted to the intensive care unit with focal seizures in the right
upper limb, impaired consciousness, and recurrent progression to
bilateral tonic-clonic seizures, with mirror-writing episodes at a
frequency of one every 1--6 months; the electroencephalogram (EEG)
showed no signs of ongoing SE (Figure 1). After infectious and metabolic
etiologies were excluded and convulsive SE was diagnosed, the patient
was treated with intravenous lacosamide (200 mg), levetiracetam (1.5 g),
diazepam (40 mg), and phenytoin (1 g). However, the episodic seizures
continued. After regaining consciousness following a seizure, the
patient had a spontaneous 4-min-long episode of mirror writing with his
left hand (Figure 2), lasting until the onset of another seizure (Figure
3). The patient did not speak or respond to verbal commands during the
episode. As the patient was unresponsive to treatment, anesthetic
induction and deep sedation were required to manage the SE; bispectral
index monitoring was used. Under deep sedation with propofol infusion,
the EEG did not reveal any paroxysmal activity, and the patient
recovered with a good neurological outcome and no sequelae. The
patient's family members reported eight mirror-writing episodes
following seizures in the previous 4 years; the patient did not remember
these events.

\textbf{DISCUSSION}

Patients with dominant-sided paresis due to a stroke to the
corresponding hemisphere may rarely show spontaneous and unconscious
mirror writing during the initial attempts to write with their
non-dominant hand. The non-dominant cerebral hemisphere attempts to
imitate the necessary arm movements based on the motor memory forged
during the writing-learning process, and these movements are reversed.
The literature on the pathophysiology of mirror writing reveals a lack
of knowledge of the process. Various hypotheses have been proposed,
including alterations of the motor cortex, spatial orientation, and
visual and thalamocortical circuits.\textsuperscript{3} In this case,
during the postictal period, the left cerebral hemisphere was affected
by the seizures, and consecutive epileptiform discharges and
disinhibition of the right cerebral hemisphere could have occurred,
which may explain the observed behavior.

\textbf{ACKNOWLEDGMENTS}

The authors acknowledge their patient for kind cooperation and for
providing consent.

\textbf{FINANCIAL SUPPORT}

No financial support was received for the study.

\textbf{CONFLICT OF INTEREST}

The authors declare no conflicts of interest.

\textbf{AUTHOR CONTRIBUTIONS}

Conception, design of the work, manuscript preparation, and data
acquisition: Vityala Yethindra, Elmira Mamytova, Tugolbai Tagaev,
Sagynali Mamatov, Clinical management: Vityala Yethindra, Elmira
Mamytova, and Manuscript preparation and data acquisition: Vityala
Yethindra, Tugolbai Tagaev.

\textbf{REFERENCES}

\begin{enumerate}
\tightlist
\item
  Schott GD. Mirror writing: neurological reflections on an unusual
  phenomenon. \emph{J Neurol Neurosurg Psychiatry} . 2007; 78(1): 5-13.
\item
  Paradowski W, Ginzburg M. Mirror writing and hemiplegia. \emph{Percept
  Mot Skills.} 1971; 32(2): 617-618.
\item
  Fleming B, Adamides AA. Mirror writing after peri-mesencephalic
  subarachnoid haemorrhage. \emph{J Clin Neurosci.} 2019; 64: 29-32.
\item
  Oldfield RC. The assessment and analysis of handedness: the Edinburgh
  inventory. \emph{Neuropsychologia.} 1971; 9(1): 97-113.
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