Clinical Seizure Semiology Quiz
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Questions and Answers

Which cortical areas are responsible for eliciting somatosensory auras with clear somatotopic distribution?

  • Broadmann areas 7, 8, 9
  • Broadmann areas 4, 5, 6
  • Broadmann areas 3, 1, 2 (correct)
  • Broadmann areas 10, 11, 12
  • What is the location of the symptomatogenic zone for painful auras?

  • Temporal lobe
  • Frontal lobe
  • Prefrontal cortex
  • Postcentral gyrus and parietal lobe (correct)
  • What is the significance of lateralizing auras in resective epilepsy surgery?

  • They have no impact on surgical outcomes
  • They only provide information on seizure localization
  • They are only seen in patients with somatosensory auras
  • They improve surgical outcomes (correct)
  • What is the relationship between the ictal onset zone and the epileptogenic zone?

    <p>The ictal onset zone may lie in the epileptogenic zone, but not necessarily</p> Signup and view all the answers

    What is the role of the supplementary sensorimotor area (SMA) in somatosensory auras?

    <p>It produces poorly defined paresthesias</p> Signup and view all the answers

    What is the significance of the symptomatogenic zone in seizure semiology?

    <p>It is the area that produces clinical seizure symptoms</p> Signup and view all the answers

    What is the relationship between the epileptogenic zone and the symptomatogenic zone?

    <p>The epileptogenic zone may overlap with the symptomatogenic zone</p> Signup and view all the answers

    What is the importance of resecting the epileptogenic zone in resective epilepsy surgery?

    <p>Resecting the epileptogenic zone improves surgical outcomes</p> Signup and view all the answers

    What is the most likely cause of the primary motor area activation during seizures?

    <p>Activation of the primary motor area (Broadman area 4)</p> Signup and view all the answers

    What is the significance of the last clonic activity in patients with temporal lobe epilepsy?

    <p>It occurs ipsilateral to the seizure onset in more than 80% of the patients</p> Signup and view all the answers

    What is the most likely explanation for unilateral dystonic posturing in temporal lobe epilepsy?

    <p>Spread to ipsilateral basal ganglia</p> Signup and view all the answers

    What is the characteristic feature of asymmetric tonic posturing during a GTC seizure?

    <p>One arm is rigidly extended at the elbow and the opposite extremity is flexed</p> Signup and view all the answers

    What is the most likely lateralization of ictal spitting?

    <p>Right temporal lobe</p> Signup and view all the answers

    What is the location of the symptomatogenic zone in autonomic auras?

    <p>Insula, amygdala, hypothalamus, and midbrain</p> Signup and view all the answers

    What is the most common lateralization of ictal vomiting?

    <p>Non-dominant hemisphere</p> Signup and view all the answers

    What is the predictive value of head and eye deviation for seizure localization?

    <p>90% to 100% contralateral to seizure onset</p> Signup and view all the answers

    What is the possible explanation for imobile limb (unilateral ictal akinesia) during seizures?

    <p>Activation of the negative motor areas</p> Signup and view all the answers

    What is the most likely mechanism of late ipsiversion?

    <p>Exhaustion and inhibition of the Broadman area 6</p> Signup and view all the answers

    What is the characteristic feature of unilateral dystonic posturing in temporal lobe epilepsy?

    <p>It is always contralateral to the seizure onset</p> Signup and view all the answers

    What is the significance of unilateral piloerection in seizure localization?

    <p>Ipsilateral to the seizure focus</p> Signup and view all the answers

    What is the location of the symptomatogenic zone in genital sensations and orgasmic auras?

    <p>Right mesiotemporal and frontal areas</p> Signup and view all the answers

    What is the significance of unilateral clonic activity in seizure localization?

    <p>Contralateral to the seizure focus</p> Signup and view all the answers

    What is the location of the frontal area involved in late ipsiversion?

    <p>Contralateral to seizure onset</p> Signup and view all the answers

    What is the significance of the right prefrontal cortex in orgasm?

    <p>Increased blood flow during orgasm</p> Signup and view all the answers

    What is the percentage of patients where unilateral eye blinking lateralizes to the ipsilateral hemisphere?

    <p>80-85%</p> Signup and view all the answers

    Which of the following is NOT a possible mechanism of ictal nystagmus?

    <p>activation of the basal ganglia</p> Signup and view all the answers

    In what percentage of patients does preservation of speech during complex partial seizures lateralize to the non-dominant hemisphere?

    <p>&gt;80%</p> Signup and view all the answers

    What is the likelihood of ictal aphasia being predictive of the dominant hemisphere involvement?

    <p>around 65%</p> Signup and view all the answers

    What is the most likely theory for Todd's paralysis?

    <p>exhaustion of the primary motor areas</p> Signup and view all the answers

    Which of the following brain regions is NOT involved in ictal speech arrest?

    <p>cingulate gyrus</p> Signup and view all the answers

    What is the likely mechanism of postictal aphasia?

    <p>postictal exhaustion of language areas</p> Signup and view all the answers

    What is the characteristic of Todd's paralysis in rare cases?

    <p>it is sometimes bilateral with suspected SMA involvement</p> Signup and view all the answers

    What is the most common lateralizing post-ictal sign in patients with temporal lobe epilepsy?

    <p>Postictal nosewiping</p> Signup and view all the answers

    What is the speculated mechanism behind peri-ictal water drinking in patients with non-dominant temporal lobe epilepsy?

    <p>Propagation of ictal discharges from mesial temporal structures to hypothalamus</p> Signup and view all the answers

    Which of the following lateralizing post-ictal signs is more often associated with extra-temporal lobe epilepsy?

    <p>Postictal cough</p> Signup and view all the answers

    What is the characteristic of hypermotor seizures in terms of consciousness?

    <p>Preserved consciousness is common</p> Signup and view all the answers

    What is the typical duration of hypermotor seizures?

    <p>Usually short, less than 1 minute</p> Signup and view all the answers

    Which hemisphere is usually involved in postictal cough?

    <p>Non-dominant hemisphere</p> Signup and view all the answers

    What is the speculated mechanism behind postictal nosewiping in patients with temporal lobe epilepsy?

    <p>Activation of central autonomic network, especially amygdala</p> Signup and view all the answers

    What is the typical time frame for peri-ictal water drinking in patients with epilepsy?

    <p>Up to 2 minutes after seizure termination</p> Signup and view all the answers

    Study Notes

    Clinical Seizure Semiology: Helpful Hints for Lateralization and Localization

    • Ictal discharges originate from the epileptogenic zone, which activates the symptomatogenic zone, producing clinical semiology.
    • Resective epilepsy surgery is successful only if the epileptogenic zone is completely resected, and ictal semiology provides clues for lateralization and localization.

    Auras

    • Somatosensory auras:
      • Elicited by activation of contralateral somatosensory cortex (Broadmann areas 3, 1, 2)
      • Poorly defined paresthesias can also be seen with activation of the supplementary sensorimotor area (SMA)
      • Usually lateralizing but not necessarily localizing
    • Painful auras:
      • Mostly contralateral to seizure onset
      • Symptomatogenic zone is in the postcentral gyrus and parietal lobe
    • Autonomic auras:
      • Ictal piloerection is observed rarely (0.15% of patients undergoing vEEG monitoring studies)
      • Unilateral piloerection or initially unilateral piloerection is usually ipsilateral to the seizure focus
      • Symptomatogenic zone involves larger autonomic network including insula, amygdala, hypothalamus, and midbrain
      • Genital sensations and orgasmic auras are observed more in women and with right TLE

    Lateralizing Ictal Signs

    • Head and eye deviation (version):
      • Contralateral to seizure onset (90% to 100% of reported cases) if occurs immediately before secondary generalization
      • Most likely caused by activation of FEF and motor areas to precentral gyrus (areas 6 and 8)
    • Late ipsiversion:
      • Late ipsiversion at the end of the GTC seizure is highly predictive of ipsilateral to seizure focus
      • Most likely mechanism is exhaustion and inhibition of Broadman area 6 in the seizure onset hemisphere
    • Unilateral clonic activity:
      • Usually contralateral to seizure focus
      • Most likely caused by activation of the primary motor area (Broadman area 4)
    • Significance of last clonic activity:
      • Few studies in patients with temporal lobe epilepsy revealed that last clonic jerk occurred ipsilateral to seizure onset in more than 80% of patients
      • Possible theory explains this by metabolic or ischemic exhaustion, lack of neurotransmitters vs postictal inhibitory depression
    • Unilateral dystonic posturing:
      • A reliable lateralizing sign in temporal lobe epilepsy
      • Almost always contralateral to seizure onset (>95% of patients)
      • Most likely explanation is spread to ipsilateral basal ganglia (by some SPECT studies)
    • Asymmetric tonic posturing:
      • Striking asymmetry during the tonic phase of a GTC seizure
      • One arm is rigidly extended at the elbow and opposite extremity is flexed at the elbow
      • Also called “figure-of-4-sign”
      • Extended elbow found to be contralateral to seizure onset (70 to 94% of patients)
    • Immobile limb (unilateral ictal akinesia):
      • Almost always contralateral in reported cases
      • Most cases in literature are TLE cases
      • Possible explanation is activation of the negative motor areas
    • Ictal spitting:
      • Almost always lateralizes to right (non-dominant) temporal lobe
      • Exact mechanism is unknown but could be related to a release phenomenon or cortical activation phenomenon
    • Ictal vomiting:
      • Usually lateralizes to non-dominant hemisphere
      • Rare left-sided cases were also reported
      • Insula, mesial temporal structures, and also mesial frontal region were all associated with ictal vomiting
    • Unilateral eye blinking:
      • Lateralizes to the ipsilateral hemisphere (usually temporal) in 80-85% of patients
      • Exact mechanism and symptomatogenic zone is unknown
    • Ictal nystagmus:
      • Often associated with seizures arising from posterior regions
      • In almost every reported case, EEG changes were contralateral to the fast phase of the nystagmus
      • Possible mechanisms:
        • activation of cortical saccade areas
        • activation of slow ipsiversive smooth pursuit regions
        • activation of the cortical opto-kinetic regions and subsequently subcortical structures including nucleus of the optic tract
    • Ictal speech:
      • Preservation of speech during complex partial seizures usually lateralizes to the non-dominant hemisphere in >80% of patients
      • Exact mechanism is unknown
    • Ictal speech arrest (aphasia):
      • Ictal aphasia can only be present in the conscious patient
      • Suggestive but not predictive of the dominant hemisphere involvement (around 65%)
      • Stimulation studies showed involvement of inferior frontal gyrus (Broca), supramarginal and superior temporal gyrus, and basal temporal area

    Lateralizing Post-Ictal Signs

    • Todd's paralysis:
      • Always contralateral to seizure onset
      • Most likely theory is “exhaustion of the primary motor areas”
      • Rare cases of bilateral cases were also described in literature with suspected SMA involvement
    • Postictal aphasia:
      • Epileptogenic zone is in the language-dominant hemisphere
      • Need to be differentiated from postictal confusion
      • Likely mechanism is postictal exhaustion or active inhibition of language areas
    • Postictal nosewiping:
      • Defined as “wiping or rubbing of the nose during or within 60 seconds of seizure termination”
      • Most common in patients with TLE and it is ipsilateral to seizure onset side in 75-90% of cases
      • Exact mechanism is unknown:
        • Activation of central autonomic network, especially amygdala, resulting in increased nasal secretions?
        • Use of ipsilateral hand might be related to neglect or mild post-ictal paralysis?
    • Postictal (ictal) cough:
      • Can be observed during ictal or post-ictal period
      • More often with temporal lobe epilepsy but can be seen with extra-temporal too
      • Usually non-dominant hemisphere involvement
      • Exact mechanism is unknown but postulated theories involve increased secretions or activation of the central autonomic system
    • Peri-ictal water drinking (seeking):
      • This behavior is described as “during a seizure or up to 2 minutes after seizure termination”
      • Usually in patients with non-dominant temporal lobe epilepsy
      • Speculated theory: Propagation of ictal discharges from mesial temporal structures to hypothalamus

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    Test your knowledge on lateralization and localization in clinical seizure semiology, including ictal discharges and epileptogenic zones. Helpful hints for resective epilepsy surgery.

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