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
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
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