Asymmetric termination of secondarily generalized tonic-clonic seizures in temporal lobe epilepsy

Trinka, Eugen; Walser, Gerald; Unterberger, Iris; Luef, Gerhard; Benke, Thomas; Bartha, Lisa; Eibl, Günther; Ortler, Martin; Bauer, Gerhard

doi:10.1212/01.wnl.0000032105.00984.77

Cited by 25 publications

(27 citation statements)

References 9 publications

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“…Asymmetric motor signs in the semiology of sGTCS such as forced head version, figure 4 sign, and AST are highly lateralizing, with 74–100% correct prediction of the side of seizure origin in FE (Chee et al., 1993; Bleasel et al., 1997; Marks & Laxer, 1998; Kotagal et al., 2000; Jobst et al., 2001; Leutmezer et al., 2002a; Trinka et al., 2002). The present study supports the hypothesis that AST is useful for lateralizing seizure onset to the ipsilateral hemisphere in both TLE and FLE (PPV for seizures 74% and 75%, respectively).…”

Section: Discussionmentioning

confidence: 99%

“…Video recordings of seizures where both upper extremities were not clearly visible (e.g., covered by a blanket) or without superior quality were excluded from analysis (n = 21). AST was defined as at least one clonic jerk outlasting the contralateral side (Trinka et al., 2002). Version was defined as forced and involuntary head and eye deviation to one side, resulting in sustained and unnatural positioning of head and eyes (Bleasel et al., 1997).…”

Section: Methodsmentioning

confidence: 99%

“…Not only the clinical symptoms during the early phase of focal seizures, but also signs appearing at the beginning of the secondary generalization, like forced ictal head version (Bleasel et al., 1997; Janszky et al., 2001; Jobst et al., 2001; Bonelli & Baumgartner, 2002) or asymmetric tonic limb posturing (figure 4 sign) (Bleasel et al., 1997; Kotagal et al., 2000) or even at the end of secondary generalized tonic–clonic seizures (sGTCS) are highly informative for seizure lateralization. Asymmetric ending of the clonic phase of sGTCS, so‐called asymmetric seizure termination (AST), has been described as a lateralizing sign in temporal lobe epilepsy (TLE) (Leutmezer et al., 2002a; Trinka et al., 2002). Only one recent study analyzed AST in frontal lobe epilepsy (FLE) (Bonelli et al., 2007).…”

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confidence: 99%

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Asymmetric seizure termination in primary and secondary generalized tonic–clonic seizures

Walser¹,

Unterberger²,

Dobesberger³

et al. 2009

Epilepsia

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SUMMARYPurpose: In temporal lobe epilepsies an asymmetric termination (AST) of the clonic phase of secondary generalized tonic-clonic seizures (sGTCS) reliably lateralizes the side of seizure onset. The last clonic activity occurs ipsilateral to the side of the seizure onset zone. We compared the prevalence and lateralizing value of AST in sGTCS of frontal and temporal lobe origin as well as in primary generalized tonic-clonic seizures (pGTCS). Methods: We analyzed 177 seizures in 84 consecutive patients. Forty-one patients had temporal lobe epilepsy (TLE), 24 frontal lobe epilepsy (FLE), and 19 had nonfocal (primary) generalized epilepsies (GE). All patients underwent intensive video-EEG (electroencephalography) monitoring, high-resolution magnetic resonance imaging (MRI), neuropsychological testing, and single photon emission computed tomography/positron emission tomography (SPECT/PET) when feasible. Two investigators blinded for diagnosis, EEG, and imaging data assessed frequency and side of the last clonic jerk. Results: AST occurred in 63% of patients with TLE (47% of seizures), in 71% with FLE (60% of seizures), and in 42% with GE (21% of seizures). These results were not significant for patients, but significant for seizures in TLE versus GE and in FLE versus GE (p < 0.001). The positive predictive value (PPV) for the side of seizure onset was 74% (p = 0.003) in TLE and 75% (p = 0.008) in FLE. Discussion: AST in sGTCS lateralizes the side of seizure onset in TLE and in FLE to the ipsilateral hemisphere with a high PPV. However, AST was also observed in GE. Therefore, asymmetric clinical signs should not inevitably lead to the assumption of focal epilepsy syndromes.

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Section: Discussionmentioning

confidence: 99%

Section: Methodsmentioning

confidence: 99%

mentioning

confidence: 99%

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Asymmetric seizure termination in primary and secondary generalized tonic–clonic seizures

Walser¹,

Unterberger²,

Dobesberger³

et al. 2009

Epilepsia

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“…In localization-related epilepsies, it has been seen that clonic jerking often ends asynchronously, ipsilateral to the hemisphere of seizure origin, in up to 80% of the patients with temporal lobe epilepsy. [5657] The mean durations of these phases were: Phase 3, 9.5 s; Phase 4, 8.5 s; Phase 5, 18.5 s; and Phase 6 and 7 together, 43.5 s. No GTCs lasted longer than 2 min. Only 27% of the seizures had all five phases of the main seizure, but tonic Phase 5 and clonic Phases 6–7 were present in 95 and 98%, respectively.…”

Section: Video-eeg Telemetrymentioning

confidence: 99%

The adolescent or adult with generalized tonic-clonic seizures

Gursahani

Gupta

2012

Ann Indian Acad Neurol

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Primary and secondary generalized tonic–clonic seizures (GTCs) together constitute up to 50% of adolescent and adult patients with epilepsy as diagnosed by history and EEG. Syncope and psychogenic nonepileptic seizures are major differential diagnoses and must be carefully excluded in therapy-resistant cases. Individual episodes can have up to seven phases in secondarily generalized GTCs. The distinction between primary and secondary GTCs depends mainly on history and EEG, and yield can be improved with sleep deprivation or overnight recording. Epilepsies with primary or unclassified GTCs can respond to any one of the five broad-spectrum antiepileptic drugs (AEDs): valproate, lamotrigine, levetiracetam, topiramate and zonisamide. Unless a focal onset is clearly confirmed, a sodium-channel blocking AED should not be used in the initial treatment of these conditions.

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“…Versive head movements (Wyllie et al, 1986) and the "sign of four" (Bleasel et al, 1997;Kotagal et al, 2000) occur at the onset of GTCS and are of major importance for diagnosis as well as presurgical assessments of patients in the epilepsy monitoring unit. The terminal phase of GTCS also has apparent semiological value due to the sign of asymmetric seizure termination in SGTCS, whereby the terminal limb jerks are ipsilateral to the hemisphere of seizure onset (Trinka et al, 2002;Leutmezer et al, 2002;Walser et al, 2009). However, the period in between, after onset and before the termination of GTCS, has not attracted much attention.…”

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confidence: 99%

Side‐to‐side axial movements

França

Rao

et al. 2014

Epileptic Disorders

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Aim. To study new semiological signs which help distinguish between primary and secondarily generalised tonic-clonic seizures (GTCS). Methods. We retrospectively studied 86 GTCS, 13 primary and 73 secondary, in 58 patients who underwent video-EEG (vEEG) evaluation in our epilepsy monitoring unit. Eleven patients had generalised epilepsy and 47 focal epilepsy. Two expert epileptologists, blinded to diagnosis, examined the vEEGs independently for the presence of five semiological signs. Results. Asymmetry of limb movements in clonic phase, side-to-side axial movements, and asymmetric seizure termination occurred more frequently (p<0.05) in secondary GTCS compared to primary GTCS. Combining asymmetry of limb movements in clonic phase and side-to-side axial movements provided the greatest value in differentiating secondary GTCS from primary GTCS. Conclusion. Careful examination of GTCS seizure semiology can help differentiate primary from secondary GTCS. The semiological sign of side-to-side axial movements, which has not previously been studied in this context, may add to existing literature of semiological signs and be of value for the evaluation of surgical patients in the epilepsy monitoring unit. In the out-patient setting, a clear history of these signs may help guide drug treatment choices. [Published with video sequences].

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Asymmetric termination of secondarily generalized tonic-clonic seizures in temporal lobe epilepsy

Cited by 25 publications

References 9 publications

Asymmetric seizure termination in primary and secondary generalized tonic–clonic seizures

Asymmetric seizure termination in primary and secondary generalized tonic–clonic seizures

The adolescent or adult with generalized tonic-clonic seizures

Side‐to‐side axial movements

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