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semiological classification of seizure, localisation and lateralisation


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Semiologial classification plays an important role in proper diagnosis and treatment of epilepsy .it also has localizing and lateralizing value which helps in epileptic surgical interventions .

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semiological classification of seizure, localisation and lateralisation

  1. 1. Seizure Semiology localisation and lateralisation Dr. Vinayak Rodge DM Neurology
  2. 2. Semiology  That branches of linguistics concerned with signs and symptoms Ictus  A sudden neurologic occurrence such as a stroke or an epileptic seizure Glossary of 2001 ILAE report Epilepsia 42(9):1212-8, 2001
  3. 3. Detailed Analysis of Seizure Semiology  Seizure - main symptom of epilepsy  Seizure control - target of treatment  Presurgical workup  Differentiate between epileptic and nonepileptic seizures
  4. 4. Seizure Semiology  1998, Lüders et al. Semiological seizure classification  2001, ILAE Commission Report Glossary of descriptive terminology for ictal semiology
  5. 5.  Motor seizure Epileptic Seizure  Motor sphere Prominent Features Semiological Seizure Classification Lüders et al. (1998)  Aura  Dialeptic seizure  (Autonomic aura) Autonomic seizure  Sensorial sphere  Consciousness  Autonomic sphere
  6. 6. Auras  Somatosensory  Auditory  Olfactory  Abdominal  Visual  Gustatory  Autonomic  Psychic  Unclassifiable
  7. 7. Aura features Lateralising and localising value Visual Flashing light of different colour ,circular, crossing midline Contalateral to area 17 and 18, v illusion- v. association cortex parito- temporal Auditory Positive-“buzz”, noise : Negative-loss hearing. Heschells gurus in STG, LTLE Olfactory Unpleasant smells Mesial temporal lobe epilepsy (high % have amygdala neoplasm) Gustatory Unpleasant taste insula Somato- sensory Tingling, numbness, unpleasant heat and pain If u/l –c/l prim. Sensory cortex If b/l-supplementary sensory motor area, second sensory-motor area(superior sylvian or posterior to insula) Autonomic aura Subjective sensation of palpitation, sweating, goose bumps insula Abdominal Nausea, tenseness, knot rolling, butterfly . Mainly localise to epigastriam . Sensation of increase peristalsis (van buren assesed same with gastric balloon during aura ) Temporal (mc) frontal ,insula Psychic Fear, elation ,déjà vu (inappropriate feeling of familiarity ) ,jamais vu . No lateralising value , localise to mesial temporal lobe (right )
  8. 8. Dialeptic Seizures “Dialeptic”, old Greek, means “to interrupt, stand still, or pass out” Alteration of consciousness Episodes of unresponsiveness or decreased responsiveness.  Associated with complete or at least partial amnesia for the episode • it can be absence seizures (dialeptic seizures with a generalized ictal EEG) and complex partial seizures (dialeptic seizures with a focal ictal EEG).
  9. 9. Generalized absence seizures seizuresuspension of awareness and arrest of activity Typical absence- •sudden onset without any aura , •brief duration, typically less than 15 seconds, •sudden termination without any postictal state. •Generalized 2.5 to 4 hz spike and wave activity. Atypical absence- •Slower loss of awareness and more gradual recovery as well as more prominent motor manifestations. •Slower frequency less than 2.5 hz
  10. 10. Dialeptic seizures features Absence Complex partial Frequency Frequent many per day Less frequent Onset and progression Abrupt and minimal slow Aura ,automatism None or rare common Motor signs Rare or minimal common duration Brief ,<15 sec minutes Postical confusion None common Postictal dysphasia none Common if originating from dominant lobe Hyperventilation Induce the seizure No effect Sleep activation none common
  11. 11. Autonomic Seizures  Objective proof of the autonomic alteration (i.e., tachycardia documented by EKG monitoring) vs Autonomic Aura
  12. 12. Autonimic seizures Lateralising and localising value Pilomotor seizure- May spread in jacksonian march (spread unilaterally to adjacent body part ) Ipsilateral to seizure onset zone. Localisation poor Ictal vomiting /retching Temporal (mainly) ,insula Ictal spitting Right temporal lobe Ictal hyper salivation Mesial temporal , lateralise to non dominant hemisphere Autonomic seizure (must have objective evidence ) Must be documented , for example – ictal tachycardia must be documented with ECG
  13. 13. Motor Seizures  2 major subgroups Simple : “Simple”, unnatural Reproducible by direct stimulation of the primary motor cortex Complex : Complexity of movement Generated by widespread neuronal matrices, natural but Inappropriate for the situation
  14. 14. Simple Complex Myoclonic Tonic Epilepticspasm Clonic Tonic-clonic Versive Hypermotor Automotor Gelastic Subtypes - duration of the muscle contraction - rhythmicity of movement repetition - muscles involved
  15. 15. Simple motor seizure features Lateralising and localising value Clonic Series of recurrent regular myoclonic contractions at rate of 0.2-5/sec Contralateral to primary motor cortex. In- frontal involve earlier . Secondary generalisation started on contralateral side and ends on ipsilateral (“end of seizure paradoxical clonus” ). Asymmetric seizure termination rare in prim. GTCS Myoclonic Short muscle contractions lasting <400ms Generalized epilepsy Epileptic spasm ( few sec. to min ) Symmetric Muscle contraction either tonic or myoclonic predominantly affect trunk and proximal axial muscles followed by extension and abduction of the arms in a “salaam position”. , usually appear in clusters . ,variable duration . Generalized . focal –parieto-occipital Mechanism -not been clearly determined but involvement of the brainstem raphe nuclei and spinal pathways has been suggested Versive seizure forced and involuntary turning of the head and eyes in one direction with neck extension resulting in a sustained unnatural position . Symptomatic zone- frontal eye field. Versive seizures appear earlier in- frontal lobe origin than TLE (can be the first sign in FLE ). Versive seizures – lateralized to contralateral hemisphere, specially when within 10 seconds before secondary generalization.
  16. 16. Simple motor seizures Features Lateralizing and localizing value Tonic •Sustained muscle contractions >3 s that leads to  tonic posturing •Tonic contraction of chest and abdominal muscle- “tonic epileptic cry” Secondarily generaliztion - have a typical “motor sequence- 1. The tonic face seizure and the versive seizure lateralize contralateral side. 2. The fencing position lateralizes contralateral to the raised arm . 3. The asymmetric tonic limb posturing “sign of four” lateralizescontralateral to the extended arm Most commonly- frontal lobe epilepsy (62.2%) mainly bilateral and rarely temporal lobe epilepsy (1.7%) (only unilateral tonic seizures ). if clearly unilateral lateralize to contralateral Tonic clonic •Generalized epilepsy - start with symmetrical tonic posturing of all the limbs followed by a “jittery” phase  clonic activity of all four extremities. • Focal epilepsies – seconadary generalization almost always preceded by other seizure types and the tonic phase is usually asymmetric.
  17. 17. Complex motor seizure Features Localising and lateralizing value Hypermotor movements involve more than one articulation and resemble normal movements mainly the trunk and proximal segments of the limbs. Ex. peddling movements, running, etc. May resembles sexual activity, like violent writhing, thrusting and rhythmic movements of the pelvis, arms and legs, picking and rhythmic manipulation of the groin or genitalia. Consciousness may be preserved. Mostly during sleep Most originate from the orbital or mesial frontal regions. may be from temporal lobe and insula. Automotor Mainly involves distal segments of the hands, feet, mouth and tongue. Automotors can be unilateral or bilateral . Unilateral automotors is likely a manifestation of limb dystonia in the contralateral limb. 95% are associated with altered consciousness. Typical of TLE but occasionally with FLE. Frontal automotor are shorter . Unilateral automatisms are more frequently lateralize to ipsilateral . Gelastic main motor manifestation is “laughing” . In 50% of the cases hypothalamic hamartomas were detected by MRI. However extrahypothalamic structures are anterior cingulate region- frontal, parietal and temporal lobes
  18. 18. AUTOMATISM •Natural ,repetitive coordinated motor activity that is inappropriate to the situation . •Automatism are usually associated with altered sensorium and amnesia.  Oro-alimentary- lip smacking/ licking, chewing, swallowing.  Manual automatism- involving hand. manipulative ( imply interaction with nearby objects). and non manipulative  Pedal automatisms-involving feet.  Hyperkinetic- bicycling, pelvic thrusting.  Gelastic-involuntary laughter.  Dyscrystic -involuntary crying
  19. 19. Special Seizures All seizures are negative or inhibitory motor seizures except the aphasic seizures that mostly represent negative cognitive seizures  Atonic seizures  Astatic seizures  Negative myoclonic seizures  Akinetic seizures  Aphasic seizures  Hypomotor seizures
  20. 20. Special seizure Features Localization and lateralization Atonic seizures loss of postural tone with falls or head drop. Most frequently in -symptomatic generalized epilepsies (Lennox- Gastaut syndrome) and are usually preceded by a generalized, proximal myoclonic seizure resulting in an abrupt fall. Generalized. (LGS ) Focal - seen in FLE and TLE. these are slower falls and rarely  significant injuries. Astatic seizures It consist of epileptic falls. Most commonly are due to a myoclonic seizure f/ b an atonic . But it can be due to atonic seizures . Hypomotor seizures Decrease or total absence of motor activity. Only used in whom consciousness cannot be tested during or after the seizure (newborns, infants ,children < 3 yr mentally retarded) In focal epilepsy- temporal and parietal lobe epilepsy. Akinetic seizures Inability to perform voluntary movements. The diagnosis only be made in patients who are conscious and cooperative, i.e. they try to perform a movement but are unable to do so (apraxia). Localization -negative motor areas in the mesial and inferior frontal gyri. Negative myoclonic seizures A very brief loss of muscle tone of (<400 ms ) which is appreciated when the affected extremities are elevated or engaged in other activity. The movement observed are similar to observed in asterixis. U/L lateralise to the post- central cerebral cortex . Aphasic seizures Patient is aphasic despite preserved awareness and memory. Can also present as status epilepticus. Lateralize to the dominant hemisphere
  21. 21. I. EPILEPTIC SEIZURE 1. Motor seizure Simplea Complexb Tonica Versivea Hypermotorb Clonica Tonic-clonic Automotorb Myoclonica Epileptic spasma Gelastic 2. Aura Somatosensorya Auditory Olfactory Gustatory Summary of Lüders Classification Psychic Visuala Autonomica Abdominal 3. Dialeptic seizureb 4. Autonomic seizurea 5. Special seizure Atonica Akinetica Astatic Aphasicb Hypomotorb Negative myoclonica II. PAROXYSMAL EVENT Organic Psychogenic a: Localizing modifiers (L, R, axial, gen, bilat, asymm; hand,etc) b: Lateralizing modifiers (left hemispheric or righthemispheric)
  23. 23. LATERALIZATIONIPSILATERAL CONTRALATERAL U/I limb automatism U/L clonic movement Early head deviation U/L dystonia u/l blinking Late head or eye turning Post ictal nose wiping Ictal akinesis Asymmetrical termination of clonic jerks followed by GTCS Post ictal paresis Whole body turning ATLP DOMINANT NON-DOMINANT Ictal aphasia Ictal speech Post ictal dysphasia b/l automatism with preserved consciousness Ictal smile. Spitting, vomiting
  24. 24. Hippocampus Arrest Insula/ Amygdala Epigastric aura , salivation Operculam Oro-alimentary automatism Basal ganglia Limb dystonia SMA ATLP (asymmetric tonic limb movement)
  25. 25. Lateralising sign Lateralizing value Symptomatogenic zone Unilateral dystonic posturing contra lateral Activation of BG , TLE Hemi field visual aura contra lateral Broadman area 17-19 and adjacent area of OLE version contra lateral Broadman area 6 and 8 Ictal aphasia and dysphasia dominant Impairment of language areas Automatisms and preserved consciousness Non dominant , Unknown , left or bilateral hippocampal impairment, TLE
  26. 26. Lateralising sign Lateralising value Symptomatogenic zone Post-ictal palsy 93 % contra lateral Area 4 and 6 Post-ictal nose wiping 92% ipsilateral Unknown , TLE Figure of 4 sign 89% contra lateral SMA , prefrontal area , TLE, ETLE Unilateral sensory aura 89 % contra lateral Area 1,2,3 Tonic activity 89% contra lateral SMA , also possibility of broadman area 6, , anterior cingulate gyrus and subcortical structures FLE
  27. 27. Lateralising sign Lateralising value Symptomatogenic zone Ictal speech 83 % non dominant Areas other than those involved language production Clonic activity 83% contra lateral Area 4 and 6 .FLE Unilateral ictal eye blinking 83% ipsilateral unknown Ictal vomiting 81 % non dominant Medial ,lateral superior and inferior structure of non dominant temporal lobe and papez circuit Ictal spitting 76 % non dominant Possible asymmetry of CAN
  28. 28. Generalized epileptic seizures These are conceptualized as originating at some point within, and rapidly engaging, bilaterally distributed networks. …can include cortical and subcortical structures, but not necessarily include the entire cortex.
  29. 29. GENERALIZED SEIZURES 1. Absence –typical, atypical 2. Myoclonic 3. Clonoc 4. Tonic 5. Tonic clonic 6. Atonic
  30. 30. Focal epileptic seizures These are conceptualized as originating within networks limited to one hemisphere. These may be discretely localized or more widely distributed.…
  31. 31. Focal epilepsies Simple partial seizures , Complex partial seizures. Focal seizure semiology by localization •Frontal lobe epilepsy •Temporal lobe epilesy •Parietal •Occipital •Insular
  32. 32. Symptomatogenic areas Left hemisphere, lateral aspect
  33. 33. Symptomatogenic areas Left hemisphere, mesial aspect
  34. 34. Symptomatogenic areas Left Insula
  35. 35. Frontal lobe seizures •Sudden onset and offset •Short duaration <2min ,frequent . •Nocturnal frequency •Early motor signs ,Dystonic posturing •Bimanual –bipedal automatism •Little or no postictal cofusion •Frequent vocalisation •Stereotyped •Multiple in single night •No wandering/ complex directed behavior •Recall present
  36. 36. localisation Semiological features Primary motor cortex Clonic seizure with or without jacksonian march and todd’s palsy, cortical myoclonus, consciousness preserved Dorso-lateral premotor Complex bizarre automatism ,forced acting is common Supplementary motor cortex Asymmetrical tonic seizures, well known ‘fencing posture’ I/L arm flex and C/L extended (figure of ‘4’) , short duration ,occur in cluster frequently arise out of sleep .ictal vocalisation Mesial frontal hyperkinetic motor behaviour, ictal expression (emotions) Frontal eye field (+/- broca’s) Eye and head deviation ,ictal vocalisation or speech arrest (with broca’s) Orbito-frontal and polar Hyperkinetic automatism with agitation , duration-short post- ictal –brief or nonexistent ,risk of misdiagnosis as psychogenic seizure Rolandic or Frontal opercular area Facial clonic movement ,swallowing hyper salivation, speech arrest Non localising Rare ,staring spell, difficult to distinguish frontal absence ADNFLE autosomal dominant nocturnal FLE Autosomal dominant ,During sleep ,Like parasomnia –jerky , dystonic posturing ,bending rocking
  37. 37. Insular epilepsy Specific features •Hypersalivation is very common •Choking •Throat sensation •Peri-oral paresthesia •Autonomic –retching palpitations •Variable semiology
  38. 38. TEMPORAL LOBE EPILEPSY AURA- Common ( epigastric ) DURATION- 1-2 min and more FREQUENCY- Few per month ONSET- slow behavioural arrest, and stare AUTOMATISM- Simple oro-alimentary VOCALISATION- Simple speech GENERALISATION- Uncommon POSTICTAL- Confusion , aphasia up to minutes
  39. 39. Differences medial and lateral TLE MTLE ( aura, arrest, automatism, amnesia) LTLE Epigastric aura (MC) ,olfactory ,psychic (fear) Auditory, cephalic (vertiginous illusion ) ,experimental , complex aura Motionless stare (behr arrest ) Anxious ,agitated behaviour Speech arrest in dominant Vocalization Early oro-alimetary and hand automatism Early complex automatism (gross truncal) I/L limb automatism and C/L dystonic posturing Less automatism, no dystonia. Less sec. generalization Frequent sec. generalisation
  40. 40. Temporal Extra-temporal Limbic aura Aura (Area specific) Hypomotor activity , stare motionless arrest ( behr arrest ) Hypermotor ,vocalization Complex motor movement Primary motor movement Dystonic posturing Tonic posturing Slow evaluation Fast evolution >1 min. duration brief
  41. 41. Temporal plus /pseudotemporal Early motor features (version, eye deviation) ET aura –sensory and throat sensation Early age No antecedent event High frequency ,clustering Frequent generalisation
  42. 42. Clinical characteristics of temporal and frontal CPS CLINICAL TEMPORAL FRONTAL AURA Common, epigastric Vague, nonspecific DURATION 1-2 min Brief 10-60 sec FREQUENCY Few per month Several per week ONSET Slow behavioural arrest, and stare ,sleep activation Abrupt forceful movement, frequent sleep activation AUTOMATISM Simple oro-alimentary Complex bipedal bizarre SPEECH Simple verbalization speech in non dominant seizure Complex ,loud vocalization (grunting ,screaming ) GENERALISATION Uncommon Common POSTICTAL Confusion , aphasia up to minutes Absent or minimal
  43. 43. Parietal lobe epilepsy •Next most likely source of seizure after TLE and FLE •Best recognized manifestation is -sensory aura – numbness, tingling, pins and needles, burning pain. •With sensory march- post central primary sensory cortex . •Without sensory march- second sensory area (parietal operculum ) •Seizures without parietal lobe symptoms- most of have no parietal symptoms but rather manifestation resulting from spread to occipital ,temporal, or frontal.
  44. 44. Occipital lobe epilepsy SENSORY SYMPTOMS- •VISUAL HALLUCINATION cardinal symptom (20-70 %) brief, multicloured and circular may be only manifestation postictal headache (nonspecific -TLE) •VISUAL ILLUSION •BLINDNESS MOTOR SYMPTOMS – •b/l blinking, nystagmoid eye movements, eye deviation (c/l) •One distinctive feature –it develop and propogate posteriorly very slowly (Eye deviation seen in OLE is much slower than in FLE and TLE )
  45. 45. Panayiotopoulos syndrome •Common idiopathic childhood occipital seizure disorder •Often prolonged •Predominantly autonomic symptoms
  46. 46. Gelastic (laughing) Hypothalamic –brief ,no mirth/emotions ,many, preserved awareness. Frontal- unnatural, no mirth/emotions ,automatism , preserved awareness Temporal- post temporal, amygdala, natural, prolong mirth/emotions DD –GELASTIC SYNCOPE.
  47. 47. Dacrystic- quiritarian (crying) Post temporal –with tears sometimes Frontal- unnatural ,forced Hypothalamic-brief
  48. 48. Rare report of seizure •Seen is cerebellar ganglioglioma •Characterizes by hemifacial twitching ipsilateral to lesion and at same times contralateral head and eye deviation or contralateral nystagmus.
  49. 49. Clinical approach to patient with epilepsy Age of seizure onset-(neonatal ,childhood, juvenile, elderly) Warning symptoms -Aura (abdominal, sensory, visual, no aura ) What happens during seizures -(awareness, automatism, incontinence/tongue bite ) Post-ictal period- (confusion, aphasia, preserved speech, paralysis , immediate recovery-no confusion ) Diurnal variation (early morning/ after awakening, any time, during sleep )
  50. 50. Thanks