Dacrystic seizures
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PMID: 34874270
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PMID: 27084975
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Dacrystic Seizures
Definition
Dacrystic seizures (also called dacrystic epilepsy or ictal crying) are a rare form of focal seizure in which unprovoked, involuntary crying - with or without actual tears - is the predominant ictal manifestation. The term comes from the Greek "dakryon" (tear). They are the crying counterpart of gelastic seizures (ictal laughing), and the two can co-exist in the same patient.
- Bradley and Daroff's Neurology in Clinical Practice, Chapter 100: "Gelastic refers to abrupt laughter or giggling, while dacrystic refers to abrupt crying, both inappropriate."
Pathophysiology and Etiology
Dacrystic seizures arise from ictal discharge in structures that subserve emotional expression, particularly those with connections to the limbic system and hypothalamus.
Common causes:
| Cause | Notes |
|---|---|
| Hypothalamic hamartoma | The classic and best-known cause; same lesion that produces gelastic seizures |
| Temporal lobe epilepsy | Mesial temporal structures involved in emotional processing |
| Frontal lobe epilepsy | Supplementary motor area and cingulate involvement |
| Lennox-Gastaut syndrome | Rare association |
| Psychogenic non-epileptic seizures (PNES) | The most common cause of ictal crying in EMU series (see below) |
Hypothalamic hamartomas generate ectopic electrical discharges that propagate through the limbic system (hippocampus, amygdala, cingulate), which modulates both laughing and crying. The same hamartoma can trigger gelastic or dacrystic events depending on the direction of spread. - Neuroanatomy through Clinical Cases, 3rd Ed.
Clinical Features
- Sudden onset of crying, often without subjective emotional distress (the patient does not feel sad); this emotionless quality is a clue to an epileptic origin
- Some patients do report a vague feeling of sadness or distress during the episode
- Episodes are brief (seconds to 1-2 minutes), stereotyped, and unprovoked
- May be followed by post-ictal confusion (if evolution to impaired awareness occurs)
- Can precede, accompany, or follow gelastic manifestations in the same patient
- In children especially, frequently associated with precocious puberty when linked to hypothalamic hamartoma
As Adams and Victor's Principles of Neurology (12th Ed.) states: "Crying, or dacrystic epilepsy, while demonstrated in children, is very infrequent and more often indicates a psychogenically induced episode" - an important diagnostic caveat.
Important Diagnostic Pearl: PNES vs. Epileptic Dacrystic Seizures
A key finding from the largest case series (Asadi-Pooya et al., Epilepsy & Behavior 2016, PMID 27084975) reviewing 12 years of video-EEG data at a major epilepsy center:
- Among 5,133 patients monitored, only 0.6% had ictal crying
- Of these, 27/32 (84%) had PNES - making PNES the dominant cause
- Only 5/32 (0.1% of all monitored patients) had truly epileptic dacrystic seizures
- Epileptic cases: 4 had focal epilepsy (frontal lobe predominant), 1 had Lennox-Gastaut
- Dacrystic seizures do not reliably predict localization of the epileptogenic zone
Localization
Ictal onset zone in epileptic dacrystic seizures has been reported from:
- Hypothalamus (hamartoma cases)
- Frontal lobe (cingulate, supplementary motor area) - most common in adult focal epilepsy
- Temporal lobe (mesial structures)
- Scalp EEG is often non-localizing; intracranial EEG (stereo-EEG or subdural grids) may be needed
A 2022 report (Espino & Burneo, Epileptic Disorders 2022, PMID 34874270) specifically documented dacrystic seizures in MRI-negative patients, confirming that no structural lesion is always identifiable and that these can occur in the setting of non-lesional focal epilepsy.
Investigations
- Prolonged video-EEG monitoring - captures the episode and correlates with EEG
- High-resolution MRI brain - specifically protocol for hypothalamic hamartoma (thin coronal cuts through the hypothalamus)
- Depth EEG / stereo-EEG - if scalp EEG is unrevealing and surgical evaluation is being considered
- Endocrinological workup - LH, FSH, testosterone/estradiol (for precocious puberty in hamartoma cases)
Management
- Medical: Standard antiepileptic drugs (AEDs); hypothalamic hamartoma-related seizures are notoriously drug-resistant
- Surgical: Resection, stereotactic radiosurgery (Gamma Knife), or laser interstitial thermal therapy (LITT) for hypothalamic hamartomas (Bourdillon et al., Neurosurg Rev 2021, PMID 32318922)
- For PNES: Cognitive-behavioral therapy; antiepileptics are not indicated and may be harmful
Summary Table
| Feature | Detail |
|---|---|
| Ictal behavior | Involuntary crying (with or without tears) |
| Emotional content | Often absent (emotionless crying) |
| Classic cause | Hypothalamic hamartoma |
| Most common cause in EMU series | PNES |
| Counterpart | Gelastic seizures (ictal laughing) |
| EEG | Often non-localizing on scalp; may need intracranial EEG |
| Localization value | Poor - does not predict seizure onset zone |
| Pediatric association | Hypothalamic hamartoma + precocious puberty |
| Drug resistance | High when due to hypothalamic hamartoma |
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