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Seizure semiology

       Moahmed Hamdy
Assistant Professor of neurology
      Alexandria university
Semiology of seizures
Semiology of seizures
Semiology of seizures
Semiology of seizures
Semiology of seizures
• 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
Semiology of seizures
Semiology of seizures
• 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
Semiology of seizures
Thank You

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Semiology of seizures

  • 1. Seizure semiology Moahmed Hamdy Assistant Professor of neurology Alexandria university
  • 7. • Diagnostic protocols rely on – clinical semiology, – optimized MRI sequences, – video-telemetry, – Functional neuroimaging, – neuropsychology and neuropsychiatry assessments and, at times, – invasive EEG monitoring.
  • 8. 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)
  • 9. 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
  • 10. • 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
  • 13. • Diagnostic protocols rely on – clinical semiology, – optimized MRI sequences, – video-telemetry, – Functional neuroimaging, – neuropsychology and neuropsychiatry assessments and, at times, – invasive EEG monitoring.
  • 14. Semiology is the 1st and the most important step • Questioning the patient and family • Direct observation while hospitalization • Video-EEG monitoring
  • 15. • 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
  • 16. 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
  • 17. 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
  • 18. 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
  • 19. Lateralized ictal headache • Ipsilateral temporal or occipital Post ictal headache • Non localizing
  • 20. 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)
  • 21. 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
  • 22. 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
  • 23. 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
  • 24. Head and limb movement Nonversive head turning • Ipsilateral temporal lobe Forced (versive) head turning • Contralateral frontal lobe Focal clonic movement • Contralateral frontal lobe
  • 25. Hyperkinetic seizures • frontal lobe Gyratory seizures • Contralateral frontotemporal Todd’s paresis • contralateral
  • 26. 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
  • 27. Eye and eyelid movements Unilateral blinking • Ipsilateral temporal or frontal Ictal nystagmus • Contralateral frontal or occipital
  • 28. 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
  • 30. 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
  • 31. Automatism Unilateral automatism • Ipsilateral temporal or orbitofrontal Postictal nose wiping • Ipsilateral temporal Rhythmic ictal non clonic hand movement • Contralateral temporal lobe
  • 32. 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
  • 33. Behavioral and phasic manifestations Post ictal dysnomia •Dominant hemisphere Behavioral arrest •Temporal, or orbitofrontal region
  • 34. 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
  • 35. 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