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Images in Neurology |

Seizures From Solving Sudoku Puzzles

Berend Feddersen, MD, PhD1,2; Christian Vollmar, MD2; Jan Rémi, MD2; Thomas Stephan, PhD3; Virginia L. Flanagin, PhD3; Soheyl Noachtar, MD2
[+] Author Affiliations
1Department of Palliative Medicine, Klinikum Innenstadt, University of Munich, Munich, Germany
2Epilepsy Center, Department of Neurology, Klinikum Großhadern, University of Munich, Munich, Germany
3Graduate School of Systemic Neuroscience, University of Munich, Planegg-Martinsried, Germany
JAMA Neurol. 2015;72(12):1524-1526. doi:10.1001/jamaneurol.2015.2828.
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This case report describes a patient who had hypoxia and posthypoxic intention myoclonus and subsequently developed clonic seizures while solving sudoku puzzles.

A 25-year-old right-handed physical education student was buried by an avalanche during a ski tour, resulting in 15 minutes of hypoxia. He developed posthypoxic intention myoclonus with involuntary myoclonic jerks of the mouth induced by talking and of both legs by walking. Both arms were unaffected. Weeks later when the patient was trying to solve sudoku puzzles, which he imagined in a 3-dimensional manner, he developed clonic seizures of the left arm associated with a right centroparietal seizure pattern on electroencephalography (Figure 1; eFigure in the Supplement). The unilateral clonic seizures stopped immediately when the sudoku puzzle was discontinued. To solve a sudoku puzzle, every digit from 1 to 9 must appear in each of the 9 vertical columns, in each of the 9 horizontal rows, and in each of the 9 boxes.

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Figure 1.
Electroencephalographic Findings

Electroencephalography during single-photon emission computed tomography tracer injection (black arrowhead) shows a right centroparietal seizure pattern (beginning at blue arrowhead). C indicates central; Cz, central midline; F, frontal; FP, frontopolar; Fz, frontal midline; O, occipital; P, parietal; Pz, parietal midline; T, temporal; and TP, temporoparietal.

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Figure 2.
Right Centroparietal Hyperexcitability Caused by Hypoxia

A, Functional magnetic resonance imaging during a task of solving sudoku puzzles using visual-spatial imagination shows widespread activation, especially of the right centroparietal cortex. B, Diffusion tensor imaging shows loss of right centroparietal inhibitory U fibers. C, Loss of right centroparietal inhibitory U fibers resulted in 3-fold increased evoked potentials at the right postcentral gyrus after somatosensory stimulation of the left median nerve (stimulation parameters for both arms were the following: monophasic square pulse, pulse width 200 microseconds, frequency 3 Hz, 300 trains, and intensity 20 mA; electrode localizations were Erb point [Erb], proximal of sternum [S], cervical vertebra 7 [CV7], cervical vertebra 2 [CV2], frontal midline [FZ], centroparietal left [CP3], and centroparietal right [CP4] in the 10-10 electrode position system).

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Clonic Seizures of the Left Arm Induced by Solving Sudoku Puzzles

Clonic seizures of the left arm induced by solving sudoku puzzles during single-photon emission computed tomography tracer injection.

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