“Seizure semiology according to anatomical origin” Korean Epilepsy

“Seizure semiology according to anatomical
origin”
Korean Epilepsy Congress 9 June 2012
Dr Chak wai kwong
Associate consultant
Department of Paediatrics and Adolescent Medicine
Tuen Mun Hospital NT West Cluster
Horonary Clinical Associate Professor
The University of Hong Kong
Why Seizure Semiology important ?
• By studying the clinical features of seizure alone,
in around 78% of patients, the area responsible
for seizures can be lateralized to a hemisphere
Seizure Semiology is an essential tool for
• diagnosing epileptic patients
• provide information about the localization and
lateralization of the symptomatic zone
• offer valuable information in pre-surgical
evaluation
Gonzalo Alarcon et al. Oxford Specialist Handbooks in Neurology Epilepsy p. 417
Roadmap
• Video EEG monitoring and Epilepsy Surgery
Case series illustration
• Literature review of different seizure
semiology with lateralizing and localization
significance
Types of Seizure Semiology
• Aura
• Ictal positive motor phenomena and negative
motor phenomena
• Ictal automatism
• Ictal Language phenomena
• Ictal autonomic symptoms
• Postictal features
Aura of vertigo and visual hallucination
Ictal nystagmus
• Is associated with ictal EEG onset,
contralateral to the fast phase of the
nystagmus.
• This lateralising sign often occurs in epilepsies
originating from posterior brain regions
(Kaplan and TUSA, 1993; Stolz,1991; Tusa
,1990) and has been observed in 10% of
patients with occipital lobe epilepsy (Salanova
,1992)
Cordula Stoyke et al. Video atlas of lateralising and localising seizure phenomena. Epileptic Disord Vol 2011;13(2):113-24
Aura (Simple Partial Seizure)
Gonzalo Alarcon et al. Oxford Specialist Handbooks in Neurology Epilepsy p. 417
Lateralizing sign
Lateralization/Localization
Déjà vu
(feeling that what is happening has
already happened)
Mesial temporal onset
Hearing sounds or melodies
Lateral temporal onset
Unilateral tingling
Contralateral onset near somatosensory
area
Unilateral elementary visual symptoms
(flashing lights, circles, colours)
Contralateral occipital onset
Complex visual hallucination
Occipital, parieto-occipital or frontal onset
Thought disorder (thought implanted on
someone’s head)
Frontal onset
Lateralizing sign
Frequency
Lateralizing Value
Symptomatic zone
Unilateral sensory
aura
6.1 % epilepsy
patients
89% contralateral
Brodmann areas
1,2,3
Hemifield visual
aura
28.6% OLE
100%
contralateral
Brodmann areas
17-19 and
adjacent areas
Aura
F/9 year Occipital Epilepsy
• Seizure onset at 2 year of age
• Complex partial seizure: eye blinking, eye deviate to
right, impair consciousness, vomiting, twitching of
right upper limbs for few minutes
• 5-6 times per day
• put on Carbamazepine with good response
• Seizure free for four years
• Carbamazepine stopped at 2006
• Seizure relapse one month later
• add Phenobarbitone and Sodium Valproate, still
frequent seizure
Interictal left occipital spike wave
Ictal fast rhythm over left occipital region
Left occipital focal cortical dysplasia
Progress
• added Phenobarbitone and Clobazam
• Seizure frequency: daily seizure to once every 3 to 4
days
• changed Clobazam to Valproate, better seizure control
• Current Medication: Epilim Chrono 200mg bd,
Phenobaritone 60 mg bd
• Sufferred from sedative side effect
• High serum Phenobarbitone level
• Study in mainstream school
• Poor concentration and memory
6 year old girl with Tuberous Sclerosis
• Left upper and lower
limb spasticity
• Hx of infantile spasm
• Start Carbamazepine
and Vigabatrin
• Episodic dystonic
twitching of left hand
and fingers
Left hand focal motor seizure
Cortical tubers resection at Primary motor area
Unilateral clonic seizure
• The significance of localisation and lateralizsation was first
recognized, (Jackson, 1890) which consist of regular,
repeated, short contractions of various muscle groups(0.25Hz).
• involve the distal part of the extremities or face and most
probably orginate from the primary motor or premotor area.
(Noachtar and Arnold, 2000).
• have a positive predictive value of 92% for seizure onset in
the contralateral hemisphere (Janszky, 2001)
• In FLE, clonic seizures occur early in seizure evolution and
consciousness remains unclouded at the beginning of
the clonic activity (Manford,1996).
• In TLE, clonic seizures typically occur later, after
automatisms and consciousness is disturbed.(Noachter
and Arnold, 2000)
Cordula Stoyke et al. Video atlas of lateralising and localising seizure phenomena. Epileptic Disord Vol 2011;13(2):113-24
Unilateral tonic seizure
Tonic seizures
• consist of a unilateral or bilateral contraction of one or more
muscle groups, usually lasting for more than three seconds,
leading to tonic posturing (Noachtar and Arnold, 2000).
• If clearly unilateral, they have a high lateralising value for
seizure onset in contralateral hemisphere.
• Tonic seizures occur more often in extratemporal lobe
epilepsies (79%) than in temporal lobe epilepsies (1.7%)
(Werhahn et al., 2000)
• Generally, tonic activity is generated by epileptic activation of
the cortical motor areas i.e. the primary motor and
supplementary sensorimotor areas (Bleasel et al.,1997;
Luders and Noachtar, 2000; Penfield and Jasper, 1954)
Cordula Stoyke et al. Video atlas of lateralising and localising seizure phenomena. Epileptic Disord Vol 2011;13(2):113-24
Head and eye deviation
Versive seizure
consist of a lateral eye deviation, which is followed by a head
and trunk deviation in the same direction.
defined as a forced and involuntary head movement resulting
in sustained unnatural positioning (Wyllie 1986a),
have a high specificity(>90%) of lateralisation for a
contralateral seizure onset zone (Chee 1993; Steinhoff 1998),
particularly when occurring immediately prior to
generalisation (Kernan 1993).
is highly probable due to epileptic activation of the frontal
eye field which is contralateral to the side to which the eyes or
head turn (Penfield and Jasper 1954).
Non-forced head deviation
is not a lateralising sign unless it ends before generalisation or
is followed by contralateral forced head deviation
(Kernan,1993)
Cordula Stoyke et al. Video atlas of lateralising and localising seizure phenomena. Epileptic Disord
Vol 2011;13(2):113-24
Head and eye deviation
In FLE, it occur significantly earlier
In TLE, it occur later following a
disturbance of consciousness, reflecting the
spread of epileptic activity to the frontal
lobe.
In TLE, initially head turns ipsilaterally then
contralaterally before secondary generalisation
(O’Dwyer 2007)
Cordula Stoyke et al. Video atlas of lateralising and localising seizure phenomena.
Epileptic Disord Vol 2011;13(2):113-24
The figure 4 sign
• Asymmetric tonic limb posturing (e.g. Figure
of Four: one elbow extended while the other
arm flexed) at the onset of secondary GTCS, is
a valuable lateralising sign.
• In 35 of 39 patients with secondary GTCS, the
extended elbow was found to be
contralateral to the side of ictal EEG on onset
(Kotagal et al., 2000)
Cordula Stoyke et al. Video atlas of lateralising and localising seizure phenomena. Epileptic Disord Vol 2011;13(2):113-24
Asymmetric termination of
generalised tonic clonic seziures
• The clonic phase of a generalised tonic clonic
seizures may end asymmetrically with clonic
jerks persisting in the limbs ipsilateral to
hemisphere of seizure onset
• Based on two series of patients with temporal
lobe epilepsy (Leutmezer 2002; Trinka 2002), it
was shown to be a frequent lateralising sign
(43% and 66%), occurred 80% ipsilaterally to the
seizure onset zone with excellent interoberserver reliability.
Cordula Stoyke et al. Video atlas of lateralising and localising seizure phenomena. Epileptic Disord Vol 2011;13(2):113-24
Right upper limb dystonic posturing
Left TLE
Andrew Bleasel et al. Lateralizing Value
and Semiology of Ictal Limb Posturig and Version in Temporal Lobe and Extratemporal Epilepsy Epilepsia, 38(2):168-174, 1997
Unilateral Dystonic Hand Posturing
defined as unnatural tonic posturing with a rotatory
component, reliably indicates seizure onset in the
contralateral hemisphere (Bleasel 1997; Chee 1993; Kotagal
1989).
In these studies, positive predictive value of seizure onset in
the contralateral hemisphere was between 92-100%.
occurs more often in patients with mesial temporal lobe
epilepsy than in patients with neocortical temporal lobe
epilepsy (Pfander 2002)
occurs later in seizure evolution in TLE than in extraTLE (Lieb
1991, Lieb 1986)
Often associated with simultaneous manual automatisms in
the contralateral hand.
Cordula Stoyke et al. Video atlas of lateralising and localising seizure phenomena. Epileptic Disord Vol 2011;13(2):113-24
• Dystonic posturing
• Tonic limb posturing
• Version
Occurred earlier in
extratemporal seizures
than in temporal seizures
Postictal paresis
• Is the oldest known lateralising signs, first published by
Bravais in 1827
• Is a relatively frequent lateralising sign and incidence of
ranges in different studies from 6.1-40% ( Adam et al.,
2000; Gallmetzer et al.,2004; Leutmezer et al.,1988; Rolak
et al.,1992)
• It appears regularly contralateral to the seizure onset zone
(Adam et al., 2000; Gallmetzer et al., 2004; Kellinghaus and
Kotagal, 2004; Leutmezer et al., 1998)
• Seems to be more frequent in patients with underlying
focal brain lesion (Adam et al.,2000; Rolak et al., 1992), as
well as in seizures with tonic or clonic phenomena
(Gallmetzer et al.,2004, kellinghau and Kotagal, 2004).
Cordula Stoyke et al. Video atlas of lateralising and localising seizure phenomena. Epileptic Disord Vol 2011;13(2):113-24
Ictal unilateral akinesia
/immobile limb
• observed in 5.8% of patients with focal epilepsy
(Oestreich 1995) and 11.8% of patients with TLE
(Bleasel 1997) and points to the contralateral
hemisphere as the site of seizure onset(Bleasel 1997;
Noachtar and Luder 1999; Oestreich 1995)
• Need to rule out increased muscle tone or dystonic
posturing
• caused by epileptic activation of one of negative
motor areas in the frontal lobe, immediately anterior
to the motor face area, close to Boca's speech area and
anterior to the face region of the supplementary
sensoriomotor area (Luder,1995)
Cordula Stoyke et al. Video atlas of lateralising and localising seizure phenomena. Epileptic Disord Vol 2011;13(2):113-24
Lateralising sign
• Left limbs, facial clonic and
tonic convulsion
• Both eyes deviate to left
• Versive seizure to left
• Left arm extension, right
arm flexion (Figure of four)
• Asymmetrical tonic
posturing preceding
secondary generalised
seizure
• Asymmetrical termination
of GTCS
Right hemispheric ED,
unilateral PLEDs
MRI BRAIN
•
•
CLINICAL HISTORY:
intractable epilepsy with history of prolonged febrile convulsion, one of twin baby. PET scan
showed right hemispheric hypometabolism, PE no focal neurological deficit; previous MRI
NAD, please book 3T MRI scan for progress
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•
•
•
TECHNIQUE:
AXIAL T1W, T2W, DWI, T1W+C
CORONAL 3D T2 FLAIR, T1W+C, 3D T1W TFE
SAGITTAL T1W IR
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•
•
•
•
FINDINGS:
Volume loss is noted at right hippocampus associated with FLAIR hyperintensities. Volume
loss of adjacent white matter is also evident.
The right cerebral sulci including the right collateral sulcus are also prominent compared to
left side.
Contralateral hippocampus appears normal.
Ventricular system and sulcal spaces are normal.
No midline shift nor extraaxial fluid collection is noted.
•
•
OPINION:
Features probably represent right mesial temporal sclerosis.
•
Unilateral ictal eye blinking
• As lateralising sign in seizures originating from
the temporal lobe was first reported by Wada
(Wada, 1980)
• Ictal eye blinking is a rare motor phenomenon
(0.8-1.5%) which is observed in temporal and
extratemporal epilepsies and is highly suggestive
of ipsilateral seizure onset (Benbadis, 1996;
Henkel,1999).
• The symptomatic zone generating ipsilateral
blinking is still unclear.
Cordula Stoyke et al. Video atlas of lateralising and localising seizure phenomena. Epileptic Disord Vol 2011;13(2):113-24
Unilateral manual automatisms
• Were reported to be associated with
ipsilateral seizures onset (Wada, 1982). This
observation is frequently associated with
more or less obvious dystonia of the
contralateral hand or arm.
• The lateralising significance of dystonic hand
posturing alone is greater than that of
ipsilateral automatisms alone (Kotagal,1991;
Mirzadjanova,2010)
Cordula Stoyke et al. Video atlas of lateralising and localising seizure phenomena. Epileptic Disord Vol 2011;13(2):113-24
Seizure Semiology
• Right eye blinking
• Right manual
automatism
• Oral automatism
• Ictal Speech
11year MTLE Right Mesial Temporal FCD
Right temporal lobectomy
11year old boy with Mesial Temporal Lobe
Epilepsy
• Seizure since 6 year old
• Change in consciousness,
behavioural arrest, eye staring,
bilateral hand movement, right more
prominent, mouthing
• Medication: Carbamazepine,
Valproate, Clobazam
• Daily seizure
• MRI: Right sided anterio-inferior
temporal lesion ? Cortical dysplasia
• Deteriorated school result with poor
memory since seizure onset
12 year old girl
Video of Versive Seizure
Perictal water drinking
• As a localising sign was first reported in a large
series of patients in 1981 by Remilard; it was
proposed that ictal drinking is caused by
epileptic discharges arising from the
temporal lobe (Remilard 1981).
• In seven patients with temporal lobe
epilepsies of the non-dominant hemisphere
and the incidence was reported to be 15.3 %
(Trinka et al.,2003)
Automatism with preserved
responsiveness
• observed in 10% of patients with right
temporal lobe epilepsy (Ebner 1995; Noachtar
1992)
• So far, one patient with left mesial temporal
lobe epilepsy and right hemisphere speech
dominance has been reported (Park 2001)
Cordula Stoyke et al. Video atlas of lateralising and localising seizure phenomena. Epileptic Disord Vol 2011;13(2):113-24
Postictal aphasia
• Is a common features in seizures orginated from the
temporal lobe and is suggestive of a seizure onset in the
speech dominant hemisphere (Fakhoury 1994; Gaber 1989).
• It can be difficult to clarify the type of aphasia or sensorial
(Wernicke) aphasia or distinguish between aphasia and
impaired consciousness with motor dysfunction.
• Required a specialised testing during and after the seizure in
video-EEG monitoring units
• Postictal aphasia can be observed more frequently than ictal
aphasia. It may due to frequently altered consciousness
during seizures originated from non-dominant temporal lobe
which makes it difficult to reliably test ictal speech (Gabr
1989)
Cordula Stoyke et al. Video atlas of lateralising and localising seizure phenomena. Epileptic Disord Vol 2011;13(2):113-24
Ictal speech
• Defined as “intact speech mechanisms consisting
of identifiable (clearly understandable) words or
phases well articulated and linguistically correct”
(Gabr et al., 1989) usually indicates the nondominant hemisphere as the site of seizure onset
• In 83-100% of the investigated patients with ictal
speech, seizure arose from the non-dominant
temporal lobe (Chee 1993; Fakhoury 1994;
Koerner and Laxer 1998; Steinhoff 1998)
•
•
•
•
•
•
Versive seizure to left
Ictal drinking
Ictal speech
Right temporal onset
Ictal fear
Right amydala onset
Seizure semiology: Overview of some ictal or postictal clinical
features with regard to anatomical origin and their reliability
Andrea O. Rossetti et al. Seizure Semiology: An overview of the “Inverse Problem” Eur Neurol 2010;63:3-10
Clinical features
Anatomical origin
Lateralization
Reliability
Ictal fear
Amygdala,
hippocampus
None
High
Forced head version Frontal, Temporal
(Slow, gradual,
sustained and
extreme rotation of
head)
Contralateral to the
side towards which
the head rotates
(patient looks away
from focus)
High
Nonversive head
turning
Temporal
ipsilateral
Moderate
Nystagmus
Frontal eye field or
parieto-temporal
junction
Contralateral to fast
component
High
Ictal laughing
Hypothalamus,
temporal,
mesiofrontal
None
Moderate
Aug 2009
Apr 2009
• Versive seizure to left
• Right hemispheric
seizure onset
• Ictal drinking
• Ictal speech
• Right temporal lobe
onset
• Ictal fear
• Right amydala onset
Ictal body turning along horizontal axis gave a
55.2% positive predictive value, which improved
to 85.7% when clustered with restlessness, facial
expressions of anxiety and fear, and barking.
Ictal body turning along the horizontal body axia
and semiology with physiological movements are
not only prevalent semiology items of mesial
frontal lobe epilepsy but they distinguish mesial
frontal from lateral frontal and orbitofrontal
seizures.
Seizure Semiology: Overview of some ictal or postictal clinical
features with regard to anatomical origin and their reliability
Andrea O. Rossetti et al. Seizure Semiology: An overview of the “Inverse Problem” Eur Neurol 2010;63:3-10
Clinical features
Anatomical origin
Lateralization
Reliability
Ictal eye closure
Nonepileptic seizure None
High
Asymmetric
termination of cloni
Temporal, Frontal
Ipsilateral ( to last
cloni)
High
Postictal unilateral
paralysis or
weakness
Frontal, Temporal
Contralateral
High
Postictal
aphasia/dysnomia
Frontal, temporal,
parietal
Dominant
hemisphere
High
Ictal Vomiting
• is rare lateralising sign
• observed in 2.8% of 178 patients with medically
refractory temporal lobe epilepsy (Baungartner
1999).
• In a series of 31 patients with TLE, 10% showed
ictal vomiting or retching and an epigastric aura
was strongly correlated with the occurrence of
ictal vomiting (Kotagal 1995)
• predicts an ictal onset in non-dominant temporal
lobe epilepsy (Devinsky 1995; Kotagal 1995;
Kramer 1988)
Ictal vomiting
• Three patients with ictal emesis during dominant
temporal lobe onset seizures have been
described (Chenet al.,1999; Schauble et al.,2002).
• Former studies suggest that insular cortex and
medial and lateral temporal structures are
associated with nauseas and vomiting in epileptic
seizures (Baumgartner et al.,1999; Fiol et
al.,1988; Kramer eta l.,1988; Pendfield and
Jaspeer,1954)
Hypomotor seizure
Luders et al. Semiological seizure classification Epilepsia 1998.39(9):1006-13.
• Characterized by “ negative features” (atonic;
astatic; hypomotor; akinetic and aphasic seizure)
• Characterized by arrest or significant decrease of
behavoural motor activity with indeterminate
level of consciousness.
• common in Paediatric epilepsy
• Children with exclusively hypomotor seizure have
most frequently temporal lobe epilepsy
• Hypermotor seizures associated with other
semiology, can arises from any lobe
Ictal vomiting, behavioural arrest/hypomotor seizure, eye
staring, head nodding
developmental regression
right temporal ganglioglioma
58
Seizure semiology –transitions with
age
• Ictal automatisms,
number of different
lateralizing signs
increased with age
• Aura, emotional
symptoms and
autonomic signs
occurred independently
of patient’s ages.
Predictive Clinical Factors for Differential Diagnosis of
Children Extratemporal epilepsy (FLE vs PCE)
(aged 11months to 12 years)
Forgarasi A, Tuxhorn I et al. Epilepsia 2005
Frontal Lobe Epilepsy
Posterior Cortex Epilepsy
• Somatosensory aura
• Hypermotor seizure
• Tonic seizure
• Visual aura
• Nytagmus
• Versive seizure
Myclonic seizures, epileptic spasms, psychomotor seizures, atonic seizures,
oral and manual automatism, vocalization and eye deviation appeared in both
groups without significant differences in their frequency
Characteristic features described in adults’ extratemporal epilepsies were
frequently missing during childhood seizures, especially in infants and
preschool children.
Ictal features help only a little in differentiating childhood FLE from PCE
Nocturnal appearance and the type of aura have high localizing value;
therefore an accurate history taking is still an essential element of paediatric
presurgical evaluation
Video of ictal laughing
Hypothalamic harmatoma
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•
•
•
Ictal laughing
Gelastic seizure
Complex partial seizure
GTCS
Take home message
• A variety of signs and symptoms may occur during epileptic
seizures have a lateralising or localising significance with
high reliability and positive predictive value, they provide
valuable information in seizure localization and propagation
• But there is still some exceptional cases reported
• Brain maturation have the effect on seizure semiology
which should be aware, while analyzing paediatric seizure
pattern especially in early age
• Temporal lobe seizure semiology undergoes transition
from the paediatric to more adult type clinical pattern
• Characteristic features described in adult’s extratempral
epilepsies were frequently missing in childhood seizure
References
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•
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•
•
•
•
•
Aileen McGonigal et al. Practical Neurology, 2004, 4, 260-273
Andras Fogarasi, Ingrid Tuxhorn et al. Age-dependnet seizure semiology in
Temporal Lobe Epilepsy Epilepsia, 48(9):1697-1702,2007
Andras Forgarasi, Tuxhorn I et al. Predictive Clinical Factors for Differential
Diagnosis of Children Extratemporal epilepsy Epilepsia 2005
Andrea O. Rossetti et al. Seizure Semiology: An overview of the “Inverse Problem”
Eur Neurol, 2010;63:3-10
Andrew Bleasel et al. Lateralizing Value and Semiology of Ictal Limb Posturig and
Version in Temporal Lobe and Extratemporal Epilepsy Epilepsia, 38(2):168-174,
1997
Gonzalo Alarcon et al. Oxford Specialist Handbooks in Neurology Epilepsy p. 417
Tobias Loddenkemper et al. Lateralizing signs during seizures in focal epilepsy
Epilepsy & behavior 7 (2005) 1-17
Cordula Stoyke et al. Video atlas of lateralising and localising seizure phenomena.
Epileptic Disord Vol 2011;13(2):113-24
V Nagaraddi , HO Luders Autonomic seizures: localizing and lateralizing value,
Textbook of epilepsy surgery p443-p447
Thank you
Video of CPZ
Ictal body turning along horizontal axis gave a
55.2% positive predictive value, which improved
to 85.7% when clustered with restlessness, facial
expressions of anxiety and fear, and barking.
Ictal body turning along the horizontal body axia
and semiology with physiological movements are
not only prevalent semiology items of mesial
frontal lobe epilepsy but they distinguish mesial
frontal from lateral frontal and orbitofrontal
seizures.
Andrew Bleasel et al. Lateralizing Value
and Semiology of Ictal Limb Posturing and Version in Temporal Lobe and Extratemporal Epilepsy Epilepsia, 38(2):168-174,
Andrew Bleasel et al. Lateralizing Value
and Semiology of Ictal Limb Posturing and Version in Temporal Lobe and Extratemporal Epilepsy Epilepsia, 38(2):168-174,
Andrew Bleasel et al. Lateralizing Value
and Semiology of Ictal Limb Posturing and Version in Temporal Lobe and Extratemporal Epilepsy Epilepsia, 38(2):168-174,
Frontal seizure semiology in
dorsolateral view
Dr Aileen McGonigal et al. Practical Neurology, 2004, 4, 260-273
Frontal seizure semiology in medial view
Dr Aileen McGonigal et al Practical Neurology, 2004, 4, 260-273
Negative motor phenomena
Epileptic negative mycolonus
• Consists of short phases of muscle atonia and is
clinically observed only during muscle contraction, i.e.,
it doses not occur when the patient is at rest (Tassinari
and Gastaut, 1969)
• focal negative motor phenomena are frequently
preceded by epileptiform discharges in the
contralateral central region (20-30ms before atonia).
• The primary somatosenory motor cortex (Ikeda
etal.,2000), the premotor cortex (Baumgartner,1996,
Meletti, 2000) and the postcentral cortex
(Noachtar,1997) have been identified as possible
generators
Cordula Stoyke et al. Video atlas of lateralising and localising seizure phenomena. Epileptic Disord Vol 2011;13(2):113-24
Motor
Tobias Loddenkemper et al. Lateralizing signs during seizures in focal epilepsy Epilepsy & behavior 7 (2005) 1-17
Lateralizing sign
Frequency
Lateralizing Value
Symptomatic zone
Version
22.2% FLE
100% contralateral
Brodmann areas 6,8
Clonic activity
44.4% FLE
83% contralateral
Brodmann areas 4,6
Tonic activity
48.1% FLE
89% contralateral
SMA, Brodmann area 6,
Anterior Cingular Gyrus
Figure of-4-sign
17.7% TLE;
15% ETLE
89% contralateral
SMA or Prefrontal Areas
Unilateral dystonic
posturing
43.9% TLE
100% contralateral;
Activation of Basal Ganglia
Unilateral automatism
Ipsilateral
Automatisms and
preserved
consciousness
5.7% TLE
100% non-dominant
Unilateral ictal
eyeblinking
1.5% EMU patients 83% ipsilateral
Unknown, possible impairment of
consciousness with left or bilateral
hippocampal impairment
Unknown
Ictal urinary urge
• Is typically expressed ictally or postictally
• This symptom was associated with non-dominant
temporal lobe seizure onset in a series of six
patients, whose seizures where characterised by
an aura of ictal urinary urge (Baumgartner 2000)
• These result were confirmed by an additional six
patients (0.4% of all patients with TLE) in a series
of 3446 patients who underwent video-EEG
monitoring (Loddenkemper 2003)
Ictal spitting
• Is a rare epileptic phenomenon in focal epilepsy and indicate a
seizure onset in the non-dominant Temporal lobe
• Of the patient studies in monitoring units, 0.3% presents with ictal
spitting. EEG onset was lateralised to the right non-dominant
hemisphere in all 12 patients evaluated recently(Kellinghaus et
al.,2003)
• In another study(Voss et al.,1999), ictal spitting was present in five
of 2500 patients; all five patients had righty temporal lobe epilepsy
as determined by seziure freedom or greater than 90% seizure
reduction after epilepsy surgery (Voss et al., 1999)
• A case with ictal spitting in a patient with a left mesial temporal
lobe epilepsy was reported (Ozkara et al.,2000). Interestingly, the
intracartid amobarbital test demonstrated a right hemispheric
speech dominance.
Cordula Stoyke et al. Video atlas of lateralising and localising seizure phenomena. Epileptic Disord Vol 2011;13(2):113-24
Ictal unilateral piloerection
• Occur unilaterally or bilaterally and are
classified as a subtype of autonomic seizures
• Is a rare phenomenon in epileptic seizures
(0.14%), predominantly occurring in patients
with TLE (Loddenkemper 2004) and usually
associated with a seizure onset in ipsilateral
hemisphere (Scoppetta 1989, Yu 1998)
V Nagaraddi , HO Luders Autonomic seizures: localizing and lateralizing value, Textbook of epilepsy surgery
p443-p447
Sign
Lateralization
Location
Epigastric aura
Moderate
reliability
None
Mesiotemporal, Insula,
SMA
Ictal spitting
0.3% EMU
patients
75% nondominant
Temporal lobe and Insular
cortex
Possible asymmetry of
Central Autonomic Network
Ictal vomiting/retching
2% EMU
patients
81% nondominant
Medial, lateral superior,
inferior nondominant
Temporal Lobe and Papez
circuit
Insular cortex
Early childhood OLE
Ictal piloerection
occur unilaterally
had a “Jacksonian march”
0.04% of
EMU
patients
Ipsilateral to
onset of focal
epilepsy
Temporal lobe
Non-dominant
Temporal lobe
Ictal
Urinary urge
Postictal nose rubbing
• Is a frequent and easy to assess lateralising sign in
patients with TLE (Geyer et al.,1999; Leutmezer et al.,
1988; Wennberg,2001)
• The hand used for nose rubbing was ipsilateral to
hemisphere of seizure onset in 45.2-97.3 % of all
patients with TLE (Hirsh et al.,1998; Leutmezer et al.,
1998; Wennberg, 2001) with no statistically significant
difference between right and left temporal lobe
epilepsy.
• The ipsilateral hand is most probably due to mild
paresis or neglect of the contralateral arm (Leutmezer
et al.,1998).
Cordula Stoyke et al. Video atlas of lateralising and localising seizure phenomena. Epileptic Disord Vol 2011;13(2):113-24
Postictal coughing
• Can be observed in patients with TLE in 9-13% and seems
to be associated with postictal nose rubbing (Gil-Nagel and
Risinger, 1997; Wennberg,2001)
• It is less common in patients with extratemporal epilepsy
(Fauser 2004; Wennberg 2001)
• Was considered as right mesiotemporal seizure sign
without statistical significance (Gil-Nagel and Risiniger,
1997; Wennberg, 2001)
• a statistically signifant predominace of left temporal seizure
onset in seizures with postictal coughing (Fuser et al)
• The lateralising value remain unclear
Cordula Stoyke et al. Video atlas of lateralising and localising seizure phenomena. Epileptic Disord Vol 2011;13(2):113-24
Tobias Loddenkemper et al. Lateralizing signs during seizures in focal epilepsy Epilepsy & behavior 7 (2005) 1-17
Lateralizing sign
Frequency
Lateralizing Value
Symptomatic zone
Ictal speech
34.2% EMU patients
83% non-dominant
Impairment of areas
other than those
involved in language
production
Ictal dysphasia and
aphasia
34.2 % EMU patients
100% dominant
Impairment of language
areas
Postictal palsy
0.6% EMU patients
93% contralateral
Possible exhaustion or
inhibition of Brodmann
areas 4,6
Postictal nosewiping
/postictal cough
53.2% TLE
92% ipsilateral to hand
used in postictal nose
wiping
Unknown
increased
parasympathetic activity
cause increase nasal/
bronchial secretions
Language
Postictal features