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The Value of Seizure Semiology in Lateralizing and Localizing Partially Originating Seizures

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The Value of Seizure Semiology in Lateralizing and Localizing Partially Originating Seizures Review Article The value of seizure semiology in lateralizing and localizing partially originating seizures Mohammed M. Jan, MBChB, FRCP(C). observations help in lateralizing (left versus right) and ABSTRACT localizing (involved brain region) the seizure onset. Therefore, this information is vital not only for seizure Diagnosing epilepsy depends heavily on a detailed, and accurate description of the abnormal transient classification, but more so for identification of surgical neurological manifestations. Observing the candidates. The EEG and neuroimaging, particularly seizures yields important semiologic features that MRI, are needed to identify focal physiological and characterize epilepsy. Video-EEG monitoring allows pathological brain abnormalities.3-5 The development of the identification of important lateralizing (left video-EEG monitoring has allowed careful correlation of versus right), and localizing (involved brain region) semiologic features with simultaneous EEG recordings.6 semiologic features. This information is vital for As a result, clinical semiology gained greater reliability identifying the seizure origin for possible surgical in diagnosing specific seizure types and localizing their interventions. The aim of this review is to present a onset.7 The aim of this review is to present a summary summary of important semiologic characteristics of various seizures that are important for accurate seizure of important semiologic characteristics of various lateralization and localization. This would most seizures that are needed for accurate lateralization likely help during reviewing video-EEG recorded and localization. This would most likely help during seizures of intractable patients for possible epilepsy reviewing video-EEG recorded seizures of intractable surgery. Semiologic features of partial and secondarily patients for possible epilepsy surgery. generalized seizures can be grouped into one of 4 History taking. Careful and detailed history is categories including; automatism, speech, motor, and the cornerstone of an accurate epilepsy diagnosis. A autonomic features. These features will be discussed previous diagnosis of epilepsy should not be accepted in detail in this review. However, seizure semiology without a confirmatory history. A timed description should be correlated with EEG and MRI findings. of the patient’s behavior during the event is needed Accurate identification of the seizure origin is more 1 likely if focal EEG onset and MRI findings were for accurate classification and localization. The first concordant with the clinical semiology. encounter may require a follow-up visit or phone call to other witnesses, such as a family member or a friend. Neurosciences 2007; Vol. 12 (3): 185-190 The physician should remember to include the younger patient in the conversation, who may provide valuable From the Department of Pediatrics, King Abdul-Aziz University Hospital, and Department of Neurosciences, King Faisal Specialist additional information. If the description is not clear, Hospital & Research Center, Jeddah, Kingdom of Saudi Arabia. the physician can ask the witness to mimic the event, or the physician may mimic different seizures to find Address correspondence and reprint request to: Dr. Mohammed M. S. Jan, Professor and Consultant of Pediatric Neurology, Department a match for the patient’s events. Asking the parents or of Pediatrics (Neurology), King Abdul-Aziz University Hospital, relatives to videotape the events, whenever possible, PO Box 80215, Jeddah 21589, Kingdom of Saudi Arabia. Tel. +996 (2) 6401000 Ext. 20208. Fax. +996 (2) 6403975. E-mail: can be diagnostic. The history of each event should be [email protected] divided in 4 stages including pre-ictal, seizure onset, ictal, and postictal phase (Table 1). In the pre-ictal iagnosing epilepsy depends heavily on detailed phase, provoking or precipitating factors should be Dand accurate history of the abnormal transient sought, such as fever, illness, ingestion, compliance, neurological signs and symptoms.1 In other words, and head injury. The time of the seizure is important epilepsy is a clinical diagnosis. There is no single test that as some occur predominantly in sleep (benign rolandic can accurately exclude or diagnose epilepsy.2 Observing seizures, tonic seizures in Lennox Gastaut syndrome, the seizures would yield important semiologic features and frontal lobe seizures). History of any brief focal that characterize partially originating seizures. These signs or symptoms (aura) at the beginning of the 185 The value - 20070416.indd 185 6/25/07 8:25:25 AM Value of seizure semiology ... Jan more dramatic seizure should be obtained. Anxious Table 2 - Differentiating staring due to absence from that of complex relatives tend to describe the most dramatic part of partial seizures. the seizure and ignore the more subtle initial focal signs. Rising abdominal (epigastric) sensation suggests Features Absence Complex partial mesial temporal lobe localization. Psychic symptoms, Sleep activation None Common particularly fear, suggest seizures originating from the Hyperventilation Results in seizure No activating effect amygdala of the temporal lobe. Visual aura can be induction positive (for example flickering lights, spots, lines) or negative (field defects) and localizes to the occipital Seizure frequency Frequent, many per day Less frequent lobe. However, more complex visual hallucinations (for Seizure onset Abrupt Slow example, person, animal, or object) suggest involvement of the visual association cortex in the posterior temporal Aura None If preceded by a simple partial seizure lobe. Epileptic visual aura should be distinguished from migraine aura, which develops gradually over 5 minutes Automatism Rare Common and lasts for a longer period of time with no disruption Progression Minimal Evolution of features in the level of consciousness. In this situation, headache usually occurs during or within 60 minutes of the visual Cyanosis None Common aura. Olfactory aura usually involves smelling foul Motor signs Rare, or minimal Common odors (uncal fits) and is localizable to the uncus of the Seizure duration Brief Minutes temporal lobe, while auditory aura, usually originates (usually <30 seconds) from the temporal neocortex.8 Sensory features can be positive (for example, pins and needles) or negative Postictal None Common confusion or (numbness), and suggests parietal lobe origin. Aura sleep symptoms should not be confused with prodromal Postictal None Common in seizures symptoms, which may precede generalized tonic clonic dysphasia originating from the dominant hemisphere Table 1 - Important aspects of seizure history and their significance. Features Significance seizures by several hours to a day. Prodromal symptoms include headache, irritability, and personality changes; 1. Preictal phase Prodrome Precedes generalized tonic clonic all are rare in children and are not part of the ictus. seizures During the seizure, the exact description of the clinical Environment of occurrence To exclude syncope or manifestations, their evolution and duration is termed pseudoseizures Time of the day Myoclonic epilepsy or primary “seizure semiology” (Tables 2-4). These features will be (for example upon awakening) generalized discussed in detail in the next sections. Precipitants or triggers Reflex or photosensitive epilepsy Semiology. Seizures are stereotyped and random Association with sleep Rolandic or frontal lobe epilepsy events. Semiologic features are needed in order to 2. Ictal onset accurately lateralize and localize the seizure origin. These Aura Lobe of origin (for example occipital if visual) features may only be identified accurately by using Focal onset Lateralization and localization video-EEG recording. In addition to MRI and EEG, (Table 4) the semiologic characteristics play an important role in 3. Ictal phase the decision for possible epilepsy surgery in intractable Progression Identify involved brain regions patients. Concordance between the semiologic, MRI, Aphasia Dominant hemisphere and EEG findings are usually necessary for successful Awareness and consciousness Simple versus complex partial or 5,9 generalized epilepsy surgery. However, some patients have several Duration Status epilepticus seizure types with different semiology. Different seizures 4. Postictal phase may be due to varying cortical involvement or propagation Confusion/amnesia Suggests complex partial or to neighboring cortex. A seizure may be characterized generalized by flashing lights in one visual field (occipital), followed Unilateral headache Ipsilateral seizure origin Weakness (Todd’s paresis) Contralateral hemispheric origin by eye deviation away from the side of onset (spread to Visual field defect Occipital lobe involvement association cortex), followed by loss of awareness and Dysphasia Dominant hemispheric automatic behavior (spread to the temporal lobe), and involvement then culminates in a generalized tonic-clonic seizure 186 Neurosciences 2007; Vol. 12 (3) The value - 20070416.indd 186 6/25/07 8:25:26 AM Value of seizure semiology ... Jan (secondarily generalized). Facial twitching followed Table 4 - Value of various semiologic characteristics in lateralizing or by speech arrest supports the diagnosis of a partial localizing the onset of partial seizures. seizure originating from the dominant hemisphere.10 During complex partial seizures, the patient may have Semiologic characteristic Lateralization or localization simple oral-buccal automatisms
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