Analysis of ictal semiology: contralateral tonic activity associated with ipsilateral automotor seizure in temporal lobe epilepsy

Ictal semiology is essential for the pre-operative evaluation of candidates for epilepsy surgery. We propose an ictal sign of temporal lobe epilepsy (TLE) termed tonic-automotor (TA), defi ned as contralateral tonic spasm of upper limb associated with ipsilateral hand automotor seizure and often accompanied ipsilateral head turning. We assessed the occurrence and lateralizing/localizing value of TA in TLE, we analyzed 129 seizures in 41 patients with TLE: 90 seizures in 30 patients with TLE of hippocampal sclerosis (TLE/HS) and 39 seizures in 11 patients with TLE of other lesions (TLE/ non-HS). When compared with unilateral automotor seizure and unilateral tonic spasm, TA occurred more frequently in TLE/HS patients (40% vs 10% and 16.7%). In addition, 24 seizures in 12 patients with TA were observed only in TLE/HS patients and contralateral to the seizure focus based on the side of tonic spasm. However, there was no signifi cant difference in the TLE/HS between dominant side and nondominant side. In addition, TA sign occurred relatively early in the ictal phase. Thus, TA may be a more reliable lateralizing sign of epileptogenic zone and a semiologic marker of TLE/ HS patients. Neurology Asia 2012; 17(2) : 109 – 113 Address correspondence to: Xue-feng Wang, Department of Neurology, First Affi liated Hospital of Chongqing Medical University, Chongqing 400016, China; Lun-shan Xu, Department of Neurosurgery, Institute of Surgery Research, Daping Hospital, Third Military Medical University, Chongqing 400042, China. Email: [email protected] INTRODUCTION The gold standard of successful epilepsy surgery is seizure free after resection of epileptogenic zone. A comprehensive pre-operative evaluation of epilepsy, including video electroencephalogram (EEG) monitoring, and neuro-imaging and neuropsychological assessment, is crucial for the localization of epileptogenic zone. The importance of seizure semiology and clinical lateralizing signs has recently been increasingly recognized. Ictal semiology can improve the lateralization and localization of epileptogenic zone and provide additional information for the pre-operative evaluation. Temporal lobe epilepsy (TLE) is a common type of epilepsy in both adults and children. Useful ictal lateralizing signs in TLE patients include abdominal auras, unilateral dystonia, oroalimentary automatism, hand automotor seizure, automatism with preserved responsiveness, versive seizure, unilateral tonic spasm, ictal vomiting, ictal verbalization/vocalization, postictal aphasia, and postictal nosewiping.5-8 On the basis of our analysis of video-EEG documented seizures in TLE, a clinical sign, a combination of contralateral tonic spasm and ipsilateral automotor seizure, was more frequently observed in TLE patients. The majority of previous studies investigated the lateralizing value of single motor sign. Investigations on the combined symptoms are rarely reported. Dupont et al reported that the combination of contralateral dystonic posturing and ipsilateral automatism was observed only in patients with mesial temporal lobe epilepsy (MTLE).9 Asymmetric tonic limb posturing (ATLP, “fi gure-of-4 sign”) is also a combined symptom with bilateral tonic arm posture representing a “4”. Jobst et al found contralateral ATLP in 94% of patients with TLE.10,11 To our knowledge, no study has reported the combination of contralateral tonic spasm and ipsilateral automotor seizure in TLE. The present study aimed to determine the lateralizing and/or localizing value of this sign in TLE. Neurology Asia June 2012