Clinical semiology is critical for localization of the epileptogenic zone (EZ). Although early head version, defined as forceful and sustained movement, has been shown to have high localizing value to contralateral frontal eye field, literature has shown that early head version can also arise from a posterior quadrant EZ. Herein, we present a patient with posterior cingulate gyrus (PCG) epilepsy with early ipsilateral head version and a supporting literature review.

We performed the following PubMed search: (versive OR "head movement" OR "head turn" OR "head version") AND ("seizure" OR "stereotactic") resulting in 68 articles from 2003 to 2023. Articles without detailed analysis of EZ or head versive movements were excluded and total of 23 were included in final analysis.

A 34-year-old right-handed female with 30 years history of epilepsy and prior right frontal lobe resection presented for epilepsy surgery evaluation. During her seizures, she reported disorientation with simultaneous versive head turn to the left followed by a leftward gaze. The patient underwent stereotactic EEG with >50 habitual seizures recorded. Ictal onset involved left dorsal PCG, and train stimulation of the left dorsal posterior cingulate sulcus at 2 mA resulted in uncontrollable ipsilateral head turn 5-7 seconds after discharge. No surgery was performed. For the literature review, out of 233 versive seizures, 28% (66/233) had an anterior EZ, while 68% (159/233) had a posterior EZ. Regarding laterality, 87.5% (21/24) of frontal EZ seizures had contralateral versive head turn whereas 28% (23/81) of posterior EZ seizures had ipsilateral versive head turn.

Although head version is a strong lateralizing semiology for contra-lateral frontal seizures, our study provides evidence of early head version related to ipsilateral posterior parietal lobe epilepsy. Our analysis has limitations, given unknown variables in some of the studies reviewed, such as the time-to-head version.