Lateralizing value of unilateral motor and somatosensory manifestations in frontal lobe seizures

PURPOSE: To evaluate the lateralizing value of unilateral somatosensory aura, unilateral tonic posturing, head version, non-forced head turning, ictal cloni, dystonic posturing, and postictal nose wiping in seizures originating in the frontal lobe. METHODS: We included patients who had consecutively undergone presurgical evaluation with ictal video-EEG monitoring at our institution, had had resective epilepsy surgery involving the frontal lobe, and had remained seizure-free >1 year after operation. Twenty-seven patients aged 1-42 years (mean 18) met the inclusion criteria. Fifteen patients had right-sided, 12 patients had left-sided epileptogenic regions. Seizures recorded during EEG-video monitoring were re-evaluated by two investigators in order to identify lateralization signs in frontal lobe seizures. One of the investigators was blind to patients' clinical data. RESULTS: We analyzed 153 seizures of 27 patients. The most common unilateral phenomenon was the unilateral tonic posturing occurring in 48% of all the patients and in 25% of all seizures. Somatosensory aura and head version appeared exclusively contralateral whereas clonus occurred in 92% and unilateral tonic posturing in 89% of seizures contralateral to the epileptogenic region. Ictal non-forced head turning and postictal nose wiping showed no lateralizing significance. Dystonic posturing did not occur. CONCLUSIONS: Somatosensory aura, head version, ictal cloni, and tonic posturing are reliable lateralizing signs in frontal seizures. These signs may help in identifying the epileptogenic region during presurgical evaluation of patients suffering from frontal lobe epilepsy.     

Ictal Contralateral Paresis in Complex Partial Seizures

Summary: Certain behaviors that occur during a complex partial seizure (CPS) are useful in lateralizing the side of seizure onset. In 5 (5.3%) of 94 consecutive patients with partial epilepsy, we observed ictal unilateral arm and hand paresis during 27 of 34 CPS. In all these seizures, this behavior occurred contralateral to an epileptogenic temporal lobe, as determined by video-EEG monitoring and surgical outcome. In 5 of the 27 seizures, an observer demonstrated that the paretic arm and hand were flaccid. None of these patients had postictal (Todd's) paralysis. In most of the seizures, the arm ipsilateral to seizure onset had simultaneous purposeful movements or automatisms, sometimes with awkward posturing. Ictal unilateral paresis is distinctly different from ictal dystonia or postictal paralysis and consistently lateralizes seizure onset to the contralateral temporal lobe. Recognition of this particular ictal behavior and comparison to other simultaneous behaviors can aid in the lateralization and possibly localization of the epileptogenic zone.     

Nonmanipulative proximal upper extremity automatisms lateralize contralaterally in temporal lobe epilepsy

Purpose : Upper extremity automatisms are considered to be an ipsilateral seizure lateralizing sign in temporal lobe epilepsy (TLE). Herein we describe different types of contralateral upper extremity automatisms (CUEAs). Methods : One hundred ninety‐three video–(electroencephalography) EEG recordings of 59 patients were reviewed. Other than two patients who refused surgery, all patients underwent standardized temporal lobectomy with favorable postoperative outcome. Fifty‐seven seizures of 21 patients were selected with CUEAs. We evaluated their electroclinical characteristics and their relation to other lateralizing motor symptoms. Results : Two types of CUEAs were observed. Nonmanipulative, proximal upper extremity automatisms were seen unilaterally and contralaterally to the operated side. These automatisms were rhythmic; repetitive; and often occurred with a circulatory component resembling waving, flaunting, circling, or stirring movements. They occurred in 29 seizures (15%) of 11 patients (19%), in most seizures in the first half of the seizure, and never postictally, in various time sequences and combined with dystonic/tonic posturing or limb immobility. Manipulative/distal type of CUEAs occurred in 11 seizures (6%) of 7 patients (12%) on the unexpected contralateral side. These CUEAs were seen in all phases of the seizures, including in the postictal state. Discussion : Nonmanipulative unilateral proximal upper extremity automatism is a reliable lateralizing sign to the contralateral hemisphere in TLE. This sign may be pathophysiologically related to dystonic/tonic posturing. Manipulative distal automatisms have less lateralizing value.     

Lateralizing Value and Semiology of Ictal Limb Posturing and Version in Temporal Lobe and Extratemporal Epilepsy

Summary: Purpose : Unilateral dystonic limb posturing in partial seizures has been shown to be an accurate lateralizing sign indicating seizure onset in the contralateral hemisphere. However, its clinical utility may be reduced by confusion with other lateralized ictal motor phenomena. In this study, the ictal phenomena of dystonic limb posturing, tonic limb posturing, unilateral immobile limb, and version were distinguished and examined in patients with temporal and extratemporal seizures.
Methods : Partial seizures in 54 patients, successfully treated by surgery (34 temporal, 20 extratemporal; 14 frontal, 3 parietal, and 3 occipital), were analyzed blindly by 3 reviewers. Interobserver agreement was tested with kappa indexes and positive predictive value (PPV) was determined for each sign.
Results : In patients with temporal lobe epilepsy (TLE), dystonic posturing occurred in 35.3% (kappa 0.78, positive predictive value (PPV) for the sign being contralateral to seizure onset 92%); tonic limb posturing occurred in 17.7% (kappa 0.36, PPV 40%); unilateral immobile limb occurred in 11.8% (kappa 0.23, PPV 100%); and version occurred in 35.3% (kappa 0.77, PPV 100%). In patients with extratemporal epilepsy, dystonic posturing occurred in 20.0% (kappa 0.31, PPV 100%); tonic limb posturing occurred in 15.0% (kappa 0.08, PPV 67%); and version occurred in 40.0% (kappa 0.54, PPV 100%). The higher kappa indexes were significant for dystonic posturing (p < 0.001) and tonic limb posturing (p = 0.032) in TLE. Dystonic posturing (p = 0.034), tonic posturing (p = 0.07), and version (p = 0.0038) occurred earlier in extratemporal seizures than in temporal seizures.
Conclusions : Of the limb ictal motor phenomena, only dystonic posturing was accurate and had good interobserver agreement.     

Association of ipsilateral motor automatisms and contralateral dystonic posturing: a clinical feature differentiating medial from neocortical temporal lobe epilepsy.

BACKGROUND: Clinical features that may help to differentiate medial temporal lobe epilepsy (MTLE) from neocortical temporal lobe epilepsy (NTLE) are lacking. OBJECTIVE: To investigate the localizing and lateralizing value of the association of ipsilateral motor automatisms and contralateral dystonic posturing in patients with medically refractory temporal lobe epilepsy. PATIENTS AND METHODS: Videotapes of 60 patients with well-defined MTLE, NTLE, or both were reviewed to assess the presence and the localizing value of unilateral dystonic posturing associated with motor automatisms. RESULTS: Twenty-eight of the 60 patients exhibited unilateral dystonic posturing. This sign was observed in patients with MTLE and NTLE. It was mostly contralateral to the seizure focus in patients with MTLE and exclusively ipsilateral in patients with NTLE. Unilateral motor automatisms occurred in 26 of the 60 patients with MTLE or NTLE. It was predominantly ipsilateral to the seizure focus in patients with MTLE and exclusively contralateral in patients with NTLE. The association of ipsilateral motor automatisms and contralateral dystonic posturing was found in 14 patients with MTLE but in none of the patients with NTLE. Two patients who had medial and neocortical seizure onset also exhibited this clinical feature. This association was not significantly correlated with the postoperative outcome in patients with MTLE. CONCLUSIONS: The association of ipsilateral motor automatisms and contralateral dystonic posturing may help to differentiate MTLE from NTLE with a reliable lateralizing value. This clinical association may reflect a specific pattern in the spread of the ictal discharge.     

Electrode manipulation automatism during temporal lobe seizures.

OBJECTIVE: To describe clinical characteristics and lateralizing value of peri-ictal electrode manipulation automatism (EMA) in patients with temporal lobe epilepsy (TLE) and compare our data with ictal manual automatisms described in the literature. METHODS: Two-hundred and five videotaped seizures of 55 consecutive patients with refractory TLE and postoperatively seizure-free outcome were analyzed and EMA (tugging, scratching or adjusting the electrodes and cables) were monitored. RESULTS: Twenty-eight (51%) patients showed EMA during 47 (23%) seizures. Ictal start was noted in 22 seizures and in 19/22 cases EMA finished before the end of seizure. Ictal EMAs were always associated with automotor seizure components. During 25 seizures, exclusively postictal EMAs were observed. Electrode manipulation was presented during 24/112 left-sided and 23/93 right-sided seizures (p = 0.742). Peri-ictal EMA was unilateral (completed by one hand) in 24/47 seizures (10 ictal, 14 postictal); it was done by the hand ipsilateral to the seizure onset zone in 17/24 and by contralateral hand in 7/24 cases (p = 0.064). We observed concomitant contralateral dystonic posturing during 3/10 seizures with unilateral ictal EMA. Unilateral hand automatism, temporally independent from the EMA appeared in 30 (64%) of the 47 seizures. CONCLUSION: Peri-ictal EMA is a frequent phenomenon but shows no lateralizing value in TLE. The mechanism of EMA is in many ways dissimilar from that of earlier described manual automatisms.     

Electroclinical analysis of postictal noserubbing

BACKGROUND: Postictal noserubbing (PIN) has been identified as a good, albeit imperfect, lateralizing and localizing sign in human partial epilepsy, possibly related to ictal autonomic activation. METHODS: PIN was studied prospectively in a group of consecutive patients admitted for video-EEG monitoring, with the laterality of noserubbing correlated with electrographic sites of seizure onset, intra- and interhemispheric spread, and sites of seizure termination. RESULTS: PIN was significantly more frequent in temporal than extratemporal epilepsy (p<0.001; 23/41 (56%) patients and 41/197 (21%) seizures in temporal lobe epilepsy compared with 4/34 (12%) patients and 12/167 (7%) seizures in extratemporal epilepsy). The hand used to rub the nose was ipsilateral to the side of seizure onset in 83% of both temporal and extratemporal seizures. Seizures with contralateral PIN correlated with spread to the contralateral temporal lobe on scalp EEG (p<0.04). All extratemporal seizures with PIN showed spread to temporal lobe structures. One patient investigated with intracranial electrodes showed PIN only when ictal activity spread to involve the amygdala: seizures confined to the hippocampus were not associated with PIN. PIN was not observed in 63 nonepileptic events in 17 patients. Unexpectedly, one patient with primary generalized epilepsy showed typical PIN after 1/3 recorded absence seizures. CONCLUSIONS: This study confirms PIN as a good indicator of ipsilateral temporal lobe seizure onset. Instances of false lateralization and localization appear to reflect seizure spread to contralateral or ipsilateral temporal lobe structures, respectively. Involvement of the amygdala appears to be of prime importance for induction of PIN.     

Lateralized ictal immobility of the upper limb in patients with temporal lobe epilepsy

The primary aim of this study was to establish the incidence and the lateralizing value of 'lateralized ictal immobility of the upper limb' (LIL) in patients suffering from temporal lobe epilepsy (TLE), and to describe the connection between LIL and other clinical ictal signs. We retrospectively reviewed video records of 87 patients with TLE. We reviewed a total of 276 focal epileptic seizures with or without secondary generalization. We studied the incidence of LIL, its lateralizing value, and its relationship to other ictal clinical signs. Of the 87 patients, 49 had undergone a successful resective surgery at least 1 year prior to the study. LIL is a late sign in the course of partial seizure. It occurred in 25 of our 87 patients (28.7%), and in 47 of 276 seizures (17.1%). In all of the evaluated seizures, LIL occurred contralateral to the side of seizure onset (P < 0.001). LIL was always associated with ipsilateral upper limb automatisms, and in 63.1% of the occurrences, it was immediately followed by ictal dystonia. LIL is a more accurate term to describe what has previously been called 'ictal paresis' in the literature. Due to the inability to execute proper testing during a partial seizure, it is better to use the term LIL when making a visual analysis of a seizure. LIL is a more suitable term to describe the studied ictal sign. It is a relatively frequent sign in patients with TLE. LIL has an excellent lateralizing value for the contralateral hemisphere. It is a negative motor sign, and its genesis is probably associated with the epileptic involvement of the contralateral frontal lobe.     

Ictal spitting in left temporal lobe epilepsy: report of three cases.

PURPOSE: Ictal spitting is rarely reported in patients with epilepsy. More often it is observed in patients with temporal lobe epilepsy (TLE) and is presumed to be a lateralizing sign to language nondominant hemisphere. We report three patients with left TLE who had ictal spitting registered during prolonged video-EEG monitoring. METHODS: Medical charts of all patients with medically refractory partial epilepsy submitted to prolonged video-EEG monitoring in the Epilepsy Unit at UNIFESP during a 3-year period were reviewed, in search of reports of ictal spitting. The clinical, neurophysiological and neuroimaging data of the identified patients were reviewed. RESULTS: Among 136 patients evaluated with prolonged video-EEG monitoring, three (2.2%) presented spitting automatisms during complex partial seizures. All of them were right-handed, and had clear signs of left hippocampal sclerosis on MRI. In two patients, in all seizures in which ictal spitting was observed, EEG seizure onset was seen in the left temporal lobe. In the third patient, ictal onset with scalp electrodes was observed in the right temporal lobe, but semi-invasive monitoring with foramen ovale electrodes revealed ictal onset in the left temporal lobe, confirming false lateralization in surface records. The three patients became seizure-free following left anterior temporal lobectomy. CONCLUSIONS: Ictal spitting is a rare finding in patients with epilepsy, and may be considered a localizing sign of seizure onset in the temporal lobe. It may be observed in seizures originating from the left temporal lobe, and thus should not be considered a lateralizing sign of nondominant TLE.     

Ictal semiology in patients with medial temporal lobe epilepsy: value in lateralizing the seizure focus]

We have evaluated useful lateralizing signs in 28 patients with medial temporal lobe epilepsy who were seizure-free after anterior temporal lobectomy by reviewing videotapes during video-EEG monitoring. The most frequent types of aura were epigastric sensation and psychic symptom in 8, respectively, both of which did not predict lateralization of the focus. Of the motor signs, early head deviation and unilateral upper extremity automatism predicted an ipsilateral focus in 72 and 80%, respectively. On the other hand, late head deviation(< 15 seconds before secondarily generalized seizure) and unilateral upper extremity dystonic posturing predicted a contralateral focus in 80 and 100%, respectively. Twelve of the patients displayed oroalimentary automatism which did not predict focus lateralization. Three patients with ictal speech demonstrated a seizure focus contralateral to their language-dominant hemisphere. In medial temporal lobe epilepsy, several clinical seizure manifestations such as: early and late head deviation, unilateral upper extremity automatism and dystonic posturing were not a little noted and provided additional information as to the side of seizure origin.     

Contralateral motor automatisms in neocortical temporal lobe epilepsy

BACKGROUND: The lateralizing value of the motor automatisms is generally doubted in most patients with temporal lobe epilepsy. However, subgroup analysis of the seizures of temporal lobe origin suggests a role for motor automatisms in discriminating seizures of neocortical versus mesial temporal lobe origin. METHODS: Video-EEG of a patient with well-defined neocortical temporal lobe epilepsy was reviewed to assess the localizing value of motor automatisms. RESULTS: We report a patient with left upper extremity motor automatisms and clonic movements of the proximal left lower extremity with altered awareness as the sole manifestations of right temporal neocortical seizures. CONCLUSION: Early onset unilateral motor automatisms without dystonic posturing can localize the seizure origin to the contralateral temporal lobe neocortex.     

Localizing Value of Seizure Manifestations of Temporal Lobe Epilepsies and the Consequence of Analyzing Their Sequential Appearance

We investigated the localizing and lateralizing value of principal seizure manifestations in temporal lobe epilepsies (signal symptoms, oroalimentary automatisms, somatomotor manifestations, unilateral dystonic posturing, ictal speech, motionless stare) of 223 complex partial seizures in 50 patients. All the patients had invasive long-term monitoring with the combined implantation of intracerebral electrodes in and subdural electrodes on the bilateral temporal lobes. Postoperative freedom from seizures was ascertained for longer than one year. We found that 35 patients had amygdalohippocampal seizures and 15 had lateral temporal seizures. The value of the manifestations was established in relation to the site and side of seizure origin and to the progression of seizure discharges within the unilateral temporal lobe or to the contralateral cerebral hemisphere. Several signs among the manifestations were found to be reliable in predicting the site or side of the temporal lobe seizure focus. We emphasized the importance of investigating sequential changes of seizure manifestations in relation to ictal EEG findings by means of simultaneous recording.     

Dystonia, clinical lateralization, and regional blood flow changes in temporal lobe seizures.

We analyzed the lateralizing value of ictal dystonia and head-turning in temporal lobe epilepsy, and sought the biologic basis of these clinical signs by studying the regional changes in perfusion with ictal single-photon emission computed tomography (SPECT). We identified unilateral temporal lobe epilepsy in 40 of 42 patients undergoing evaluation for temporal lobe surgery, and with ictal SPECT all 40 showed striking hyperperfusion of the epileptogenic temporal lobe. Twenty-five of the 40 patients showed unilateral or predominantly unilateral upper limb dystonia, which was opposite the epileptic temporal lobe in all cases. Analysis of regional count ratios in cases with ictal dystonia, compared with those without, showed significant changes only in the basal ganglia. Specifically, we found that ictal dystonia was associated with a relative increase in perfusion of the basal ganglia opposite the dystonic limb. Although we found 26 cases with head-turning, the sign was of no lateralizing value, even when only those with major or "tonic" versions (n = 11) were analyzed. Slight increases in cortical blood flow on the side opposite the direction of version were associated with head-turning, irrespective of the side of seizure focus. In clinical practice, ictal SPECT is a highly accurate aid in the lateralization of temporal lobe foci, in addition to providing a new method to investigate the pathophysiology of clinical signs in focal seizures.     

Semiology of Temporal Lobe Seizures: Value in Lateralizing the Seizure Focus

Summary: Purpose: To determine the lateralizing value of the clinical manifestations of seizures in patients with temporal lobe epilepsy (TLE), we made a retrospective videotape analysis of complex partial seizures (CPS) in 55 patients who underwent temporal lobectomy and were seizure-free postopera-tively for >2 years. Methods: Blinded to clinical details, we reviewed videotapes from video-EEG telemetry monitoring with attention paid to seizure semiology. Results: Useful lateralizing features included unilateral clonic activity (with the seizure focus contralateral in all patients), unilateral dystonic or tonic posturing (with the seizure focus contralateral in 90 and 86%, respectively), unilateral automatisms (with the seizure focus ipsilateral in 80%), and ictal speech preservation (with the seizure focus contralateral to the language-dominant hemisphere in 80%). Versive head rotation occurring ≤10 s before seizures secondarily generalized consistently predicted a contralateral focus. Seizure manifestations less predictive but suggestive of lateralization included ictal speech arrest and postictal speech status, with predictive values of 67%. Seizure manifestations not providing reliable lateralizing information included eye deviation, type of aura, and versive head movements occurring at times other than immediately before seizures secondarily generalized. Conclusions: In TLE, several clinical seizure manifestations are useful in lateralizing the seizure focus, although some provide no reliable information. Therefore, ictal semiology can assist in the evaluation of patients for seizure surgery, providing additional information in the lateralization of TLE.     

Peri‐ictal water drinking: a rare automatic behaviour in temporal lobe epilepsy

Peri‐ictal water drinking (PIWD) has been reported as the action of drinking during or within two minutes of an electroclinical seizure. It is considered a peri‐ictal vegetative symptom, evident both during childhood and adulthood epilepsy. The aim of this paper was to describe the clinical and electroencephalographic features of two new adult subjects suffering from symptomatic temporal lobe epilepsy with episodes of PIWD recorded by VIDEO‐EEG and to review literature data in order to better define this peculiar event during seizures, a rare and probably underestimated semiological sign. To date, 51 cases with focal epilepsy and seizures associated with PIWD have been reported. All patients presented with temporal lobe epilepsy. All cases but one had symptomatic epilepsy. Most of the patients had an involvement of the right hemisphere. Water drinking was reported as an ictal sign in the majority of patients, and less frequently was reported as postictal. We believe that PIWD might be considered a rare automatic behaviour, like other automatisms. Automatisms are more frequently described in patients with temporal lobe epilepsy. PIWD was reported also to have lateralizing significance in the non‐dominant temporal lobe, however, because of its rarity, this finding remains unclear.     

Ictal urinary urge indicates seizure onset in the nondominant temporal lobe

ARTICLE ABSTRACT: The authors describe six patients with medically refractory temporal lobe epilepsy whose seizures were characterized by an aura of ictal urinary urge. All seizures originated in the nondominant temporal lobe as evidenced from interictal spikes, ictal EEG, and MRI. Ictal SPECT, which was obtained in two patients, showed a hyperperfusion of the insular cortex, indicating a critical role of the insula for the generation of this symptom. Ictal urinary urge represents a new lateralizing sign indicating a seizure onset in the nondominant temporal lobe.     

Ictal urinary urge: further evidence for lateralization to the nondominant hemisphere

PURPOSE: To determine the lateralizing value of ictal urinary urgency. METHODS: A retrospective database search was performed for patients with ictal urinary urgency admitted to the Epilepsy Monitoring Unit at the Cleveland Clinic between 1994 and 2001. RESULTS: Six patients were identified; intracarotid amytal test demonstrated left hemispheric speech dominance in five cases. The sixth patient continued to speak during right temporal seizures. EEG and imaging data supported right temporal or frontotemporal epilepsy in all six cases. Two patients were seizure free after focal right hemispheric resection. CONCLUSIONS: Ictal urinary urge appears to be a lateralizing sign for nondominant temporal lobe epilepsy.     

Spitting Automatism in Complex Partial Seizures: A Nondominant Temporal Localizing Sign?

Summary: Purpose: Spitting as an ictal automatism has been rarely reported. We aimed to establish its potential lateralizing and localizing significance.
Methods: Review of patients undergoing surgery for intractable epilepsy at two comprehensive epilepsy centers.
Results: Five patients were found who had spitting as a stereotyped automatism of their complex partial seizures. All had evidence of right temporal ictal onset and underwent resective surgery. Two had tumors; one, a cavernous angioma; one, hippocampal gliosis, and one, hippocampal sclerosis. We found no instances of ictal spitting in patients with left hemisphere onset.
Conclusions: Spitting as an automatism in complex partial seizures, although uncommon, may be a localizing sign to the nondominant temporal lobe.     

Intractable seizures of frontal lobe origin: clinical characteristics, localizing signs, and results of surgery

PURPOSE: We analyzed the clinical characteristics of seizures of frontal lobe (FL) origin with particular emphasis on establishing different categories and determining if these categories had any localizing or lateralizing value. In addition, results of surgery are reported. METHODS: Seizure characteristics were established by historical review and electroencephalographic/videotape analysis of 449 seizures in 26 adult patients with refractory seizures of FL origin. RESULTS: No outstanding risk factor was identified for seizures of FL origin. Seizures were frequent (7.1 per week), brief (mean duration, 48.3 seconds), and had a nocturnal preponderance in 58% of the patients. Status epilepticus was reported in 54%, and generalized convulsions as a prominent seizure type were reported in 26% of patients. The most common reported aura was a nonspecific sensation, often localized to the head (35%). Early forced head and eye deviation was not a consistent lateralizing sign, whereas late head and eye deviation always occurred contralateral to the site of seizure origin. Early asymmetric tonic posturing occurred consistently contralateral to the side of seizure origin. Clinical seizure patterns did not consistently localize to specific regions of the frontal lobe, although there were some noticeable trends: focal clonic seizures were associated with seizure origin in the frontal convexity; tonic seizures were most often associated with origin in the supplementary motor area but also occurred with origin in other parts of the frontal lobe; seizures resembling typical temporal lobe seizures with oroalimentary automatisms were observed with seizure origin in the orbitofrontal region; and seizures with hyperactive, frenetic automatisms were not associated with any specific region within the frontal lobes. Eighty percent of patients had favorable seizure outcome after surgery (class I/II). CONCLUSION: Although certain clinical features are characteristic for seizures of frontal lobe origin and some have lateralizing value, they do not localize to specific areas within the FL. After careful presurgical evaluation, both lesional and nonlesional patients benefit from epilepsy surgery.