title: Pathological laughter as prodromal manifestation of transient ischemic attacks--case report and brief review.
abstract: BACKGROUND
  Based on a case report, the authors reviewed the data about involuntary emotional expression disorder (IEED). IEED includes the syndromes of pathological laughing and crying (PLC) and emotional lability (EL). PLC is a rare disorder of emotional expression characterized by relatively uncontrollable episodes of laughter and crying or both that do not have an apparent motivating stimulus.
  
  
  METHODS
  Authors report the case of a 59-year-old man who presented with recurrent episodes of PLC of approximately 2 min duration, consisting of accelerated breathing, emission of guttural, snoring sounds, frowning of the eyebrows, followed by laughter accompanied by motor restlessness of all four limbs. PLC episodes preceded left carotid transient ischemic attacks (TIA's) manifested by reversible aphasia and right hemiparesis. Electroencephalography performed during PLC episodes revealed no spike-wave activity. Brain magnetic resonance imaging showed lacunar infarcts in the left lenticulo-capsulo-thalamic area and multiple round lesions in the cortical-subcortical and in the deep white matter of frontal-parietal-occipital lobes bilaterally, with T2 hyperintensity, T1 isointensity and no diffusion changes. The episodes were interpreted as transient ischemic attacks although gelastic seizures could not be excluded. The etiological investigations revealed unstable plaques on the left carotid artery bulb and the aortic arch and a degenerative mitral valve stenosis. The patient was treated first with antiplatelet therapy and antiepileptic drugs but PLC stopped only after anticoagulation was started. During follow-up the patient continued to have left carotid and vertebrobasilar TIA's being on oral anticoagulation. The patient became asymptomatic only after mitral valve replacement was performed.
  
  
  CONCLUSIONS
  This case illustrates the difficulty distinguishing between gelastic epilepsy and TIA's in cases of PLC episodes and discuss the neuroanatomic bases and pathophysiology of this rare condition.
authors.affiliation: University of Medicine and Pharmacy "Carol Davila", Bucharest, Romania. adrianadulamea@gmail.com.|Neurology Department Fundeni Clinical Institute, Sos Fundeni nr 258, sector 2, Bucharest, 022328, Romania. adrianadulamea@gmail.com.
authors.forename: Adriana O
authors.initials: AO
authors.lastname: Dulamea
authors.affiliation: University of Medicine and Pharmacy "Carol Davila", Bucharest, Romania. cmatei2002@yahoo.co.uk.|Cardiology Department Emergency Institute for Cardiovascular Diseases "Prof. Dr. C. C. Iliescu", Bucharest, Romania. cmatei2002@yahoo.co.uk.
authors.forename: Costel
authors.initials: C
authors.lastname: Matei
authors.affiliation: University of Medicine and Pharmacy "Carol Davila", Bucharest, Romania. ioanamindruta@me.com.|Neurology Department University Emergency Hospital, Bucharest, Romania. ioanamindruta@me.com.
authors.forename: Ioana
authors.initials: I
authors.lastname: Mindruta
authors.affiliation: Radiology Department Sanador Hospital, Bucharest, Romania. virgilion65@gmail.com.
authors.forename: Virgil
authors.initials: V
authors.lastname: Ionescu
mesh_terms: D006801:Humans; D002546:Ischemic Attack, Transient / Q000503:physiopathology*; D007845:Laughter / Q000502:physiology*; D008297:Male; D008875:Middle Aged; D062706:Prodromal Symptoms; D000068356:Self-Control