Seizure semiology

Moahmed HamdyAssistant Professor of neurology

Alexandria university

• Diagnostic protocols rely on – clinical semiology,– optimized MRI sequences, – video-telemetry, – Functional neuroimaging, – neuropsychology and neuropsychiatry

assessments and, at times, – invasive EEG monitoring.

Pitfalls of neuroimaging alone

• In adults, 25% of pathologically confirmed cases of focal cortical dysplasia are reported to be MRI-negative prior to surgery (high resolution 3 tesla)

Pitfalls of neuroimaging alone

• Increased signal on FLAIR indicative of HS is not always accompanied by hippocampal atrophy,

• Neoplasms are the structural substrate in 3-4% of patients with epilepsy in the general population

• Although MRI-defined structural lesions are a strong predictor of the seizure onset zone, there are reports of well-documented cases in which resections of EEG-defined seizure onset regions that spared structural lesions have resulted in seizure freedom

• Diagnostic protocols rely on – clinical semiology,– optimized MRI sequences, – video-telemetry, – Functional neuroimaging, – neuropsychology and neuropsychiatry

assessments and, at times, – invasive EEG monitoring.

Semiology is the 1st and the most important step

• Questioning the patient and family• Direct observation while hospitalization• Video-EEG monitoring

• The overall pattern of ictal semiology• The initial subjective phenomenon (aura)

and/or objective phenomenon which sometimes make it possible to confirm specific topographic origin

• the spatial and temporal articulation of the different ictal phenomenae.

• The post-ictal phase (focal deficit)• Conciousness during the attack

From symptom to localization or lateralization

• Sensory Phenomena• Psychic Manifestations• Head and Limb Movements• Eye and Eyelid Movements• Dystonic Posturing• Automatisms• Behavioral and Phasic Manifestations• Autonomic Manifestations

From symptom to localization or lateralization

• Sensory Phenomena• Psychic Manifestations• Head and Limb Movements• Eye and Eyelid Movements• Dystonic Posturing• Automatisms• Behavioral and Phasic Manifestations• Autonomic Manifestations

Somatosensory phenomena

well localized, discriminatory, and spread relatively slowly (like a sort of ‘jacksonian march’)

• parietal lobe (primary somatosensory cortex, S1)

ill-defined, often accompanied by pain, spread within seconds,

• posterior insula-parietal operculum (supplementary somatosensory area, S2) and may be contra- or ipsilateral

Lateralized ictal headache

• Ipsilateral temporal or occipital

Post ictal headache

• Non localizing

Special senses

Gustarory aura

• Insular region

Visual aura

• Contralateral occipital cortex

Elementary auditory

• Primary auditory cortex

Complex auditory

• Temproparietal junction

Olfactory aura

• Anterior mesiotemporal (uncinate)

From symptom to localization or lateralization

• Sensory Phenomena• Psychic Manifestations• Head and Limb Movements• Eye and Eyelid Movements• Dystonic Posturing• Automatisms• Behavioral and Phasic Manifestations• Autonomic Manifestations

Psychic manifestations

Deja vu

• Mestiotemporal without lateralization

Forced thinking

• Frontal or mesiotemporal of the dominant hemisphere

Ictal fear

• Amygdala

Ictal autoscopy

• Non dominant parietal lobe

From symptom to localization or lateralization

• Sensory Phenomena• Psychic Manifestations• Head and Limb Movements• Eye and Eyelid Movements• Dystonic Posturing• Automatisms• Behavioral and Phasic Manifestations• Autonomic Manifestations

Head and limb movement

Nonversive head turning

• Ipsilateral temporal lobe

Forced (versive) head turning

• Contralateral frontal lobe

Focal clonic movement

• Contralateral frontal lobe

Hyperkinetic seizures

• frontal lobe

Gyratory seizures

• Contralateral frontotemporal

Todd’s paresis

• contralateral

From symptom to localization or lateralization

• Sensory Phenomena• Psychic Manifestations• Head and Limb Movements• Eye and Eyelid Movements• Dystonic Posturing• Automatisms• Behavioral and Phasic Manifestations• Autonomic Manifestations

Eye and eyelid movements

Unilateral blinking

• Ipsilateral temporal or frontal

Ictal nystagmus

• Contralateral frontal or occipital

From symptom to localization or lateralization

• Sensory Phenomena• Psychic Manifestations• Head and Limb Movements• Eye and Eyelid Movements• Dystonic Posturing• Automatisms• Behavioral and Phasic Manifestations• Autonomic Manifestations

Dystonic posturing

Unilateral limb dystonia

• Contralateral temporal or frontal

From symptom to localization or lateralization

• Sensory Phenomena• Psychic Manifestations• Head and Limb Movements• Eye and Eyelid Movements• Dystonic Posturing• Automatisms• Behavioral and Phasic Manifestations• Autonomic Manifestations

Automatism

Unilateral automatism

• Ipsilateral temporal or orbitofrontal

Postictal nose wiping

• Ipsilateral temporal

Rhythmic ictal non clonic hand movement

• Contralateral temporal lobe

From symptom to localization or lateralization

• Sensory Phenomena• Psychic Manifestations• Head and Limb Movements• Eye and Eyelid Movements• Dystonic Posturing• Automatisms• Behavioral and Phasic Manifestations• Autonomic Manifestations

Behavioral and phasic manifestations

Post ictal dysnomia

• Dominant hemisphere

Behavioral arrest

• Temporal, or orbitofrontal region

From symptom to localization or lateralization

• Sensory Phenomena• Psychic Manifestations• Head and Limb Movements• Eye and Eyelid Movements• Dystonic Posturing• Automatisms• Behavioral and Phasic Manifestations• Autonomic Manifestations

Autonomic manifestations

Ictal spitting

• Non dominant temporal lobe

Ictal nausea and vomiting

• Anterior insula

Ictal laughing

• Hypothalamic hamartoma in children and frontal cingulus in adults (non lateralizing)

Ictal weeping

• Non lateralizing mesiotemporal

Vertigo

• Insular-tempro-parietal junction

viscerosensory

• mesiotemporal

Thank You