Ictal motor sequences: Lateralization and localization values

Abstract

SUMMARYObjective: To determine the lateralization and localization values of ictal motor sequences in the setting of focal epilepsy ending with a secondarily generalized motor seizure. Methods: Retrospectively, the ictal motor sequences were analyzed in patients with focal epilepsy ending with a secondarily generalized motor seizure by three readers blinded to all clinical and electrographic data. One representative seizure per patient was selected. Prevalence, positive predictive value (PPV), and Fleiss Kappa for the following motor signs were calculated: version, unilateral limb tonic posturing, unilateral limb clonic seizure, figure-of-4, M2e, hand dystonia, clonic asymmetric ending, and Todd's paralysis. Sequences of signs with a PPV ≥ 80% were then analyzed to determine their lateralization and localization values. Results: A total of 47 seizures were studied. The "reliable" motor signs with a robust lateralizing value (PPV > 80%) were version, unilateral tonic posturing, M2e, unilateral clonic seizure, asymmetric clonic ending, and Todd's paralysis. Figure-of-4 and hand dystonia had a relatively low PPV, and therefore were not included in the following sequence analysis, which included only 38 patients with two or more motor signs of high PPV. Multiple combinations of temporal progression of motor signs were seen in these 38 patients, with version being the most common initial motor sign (29 of 38 patients) usually followed by M2e (15 of 29 patients), and/or a focal tonic seizure (7 of 29 patients). Accurate lateralization of the epileptogenic zone (EZ) with a PPV of 100% can be predicted when two or more reliable motor signs point to the same side. However, the various sequences of reliable motor signs did not differentiate between temporal and extratemporal epilepsy. Significance: The presence of reliable ictal motor signs in focal epilepsy is extremely valuable in lateralizing the EZ, but not in determining the localization of the EZ. This is especially useful when epilepsy surgery is indicated. KEY WORDS: Focal epilepsy, Semiology, Lateralization, Epileptogenic zone.Analysis of seizure semiology is the first step in evaluating patients with epilepsy. Despite all the advances in clinical epilepsy, it remains the only tool to study and predict the symptomatogenic zone.There is a rich ictal semiology literature, going back to the times of Tissot, Esquirol, Todd, Jackson, and many others in the 18th and 19th centuries.1-4 Many seizure components including auras and motor signs were studied extensively, and their values in lateralization and localization of the symptomatogenic zone and the epileptogenic zone (EZ) have been well described. [5][6][7][8][9][10] However, to our knowledge, no attempt has been made to put together two or more motor signs in a sequence and

Focal EEG abnormalities and focal ictal semiology in generalized epilepsy

“…The presence of ictal motor signs in focal epilepsy is important for lateralizing the epileptogenic zone [24]. However, relying solely on a report of an ictal focal symptom may lead to an incorrect diagnosis of focal epilepsy in a patient with generalized epilepsy.…”

Temporal lob epilepsisinde semiyolojinin lateralizasyon değeri

“…Kontrlaterali işaret eden klasik motor bulgular daha önce de birçok yayında ifade edilmişti. [2][3][4][5][6][7]34,45] Klasik ve güvenilir motor işaretlerden iki veya daha fazlasının kombinasyonu, epileptojenik zonu yaklaşık %100 doğruluk ile lateralize eder. [45] İlginç bir bulgu olan sekonder jeneralizas-yondan sonra son klonik atma 13 nöbette izlendi.…”

“…Az sayıda literatürde yayınlanan bu bulgu anlamlı ölçüde ipsilaterali işaret etti. [45][46][47] Bizim hasta çalışmamızda literatürle uyumlu olarak versiyonel baş rotasyonu, tek taraflı distonik postür, asimetrik tonik postür ve tek taraflı el otomatizmaları ve distonik pozisyonun kombinasyonu en yüksek lateralizasyon değerlerine sahip semiyolojik işaretler olarak belirlendi (%90-100). [2][3][4][5][6][7] Bizim hasta grubumuzda da lateralizasyon değeri yüksek bulguların literatür ile uyumlu bulunması daha nadir gözlenen belirtilerin güvenilirliğine katkı sağlamıştır.…”

Calibration of the Epilepsy Questionnaire for Use in a Low-Resource Setting

“…To this end, there may be a need for establishing a widespread use of epilepsy questionnaires in the primary and secondary healthcare setting to obtain key semiology details for patient management. This is based on the premise that increased patient to doctor ratio reduces time for detailed interview, and eye-witness descriptions may also not be accurate [ 23 – 25 ], as key signs during seizure, especially at its onset and resolution, can help to identify epileptogenic focus in the brain [ 26 – 28 ] and possibly diagnosis [ 29 ]. This study aimed to determine if the use of an epilepsy questionnaire in a traditional sub-Saharan African clinical setting would improve acquisition of semiology details and diagnostic accuracy compared to routine seizure history.…”