Localizing and Lateralizing Significance of Initial, Mid-ictal and Ictal-end Head Position in Versive Seizures with Secondary Generalization
Akshaya Rathin Sivaji1, Imtiaz Nazam1, Fizza Tariq1, Suraj Thyagaraj1, Neel Fotedar1
1Epilepsy Center, Neurological Institute, University Hospitals, Cleveland Medical Center
Objective:

To study the localizing & lateralizing significance of initial, mid-ictal and ictal-end head position in versive seizures with secondary generalization.

Background:

Version, defined as forced, sustained, and involuntary turning of the eyes and head. A highly reliable lateralizing sign of epileptogenic-zone to contralateral hemisphere. However, does not have a localizing significance.

 

Design/Methods:
We retrospectively analyzed video-EEG recordings of 50 patients with focal-epilepsy for various head position changes during version evolving into secondary GTCS. We calculated the latency of onset of version from seizure onset and latency of secondary generalization from version. We excluded patients with generalized-epilepsy.
Results:

The latency of version from seizure onset(T1) was 47.6±10.2sec and 27.7±10.7sec in temporal-lobe and frontal-lobe groups, respectively(p <0.0001). Occipital-lobe group had longest latency of 93.4±54.4sec(p <0.0001). The latency of secondary GTCS(T4) from initial version was 15.9±3.7sec in temporal-lobe group compared to frontal-lobe and parietal-lobe groups at 20.4±7.0sec(p=0.0097) and 21.6±10.1sec(p=0.0377). Occipital-lobe group had shortest latency at 10.6±5.3 sec(p=0.0085).

In 44 out of 50 patients, the head position evolved to a midline position from initial version. In 20 out of 50 patients, the head position further evolved to an ictal-end head position by the end of the GTC phase. In these 20 patients, the ictal-end head position was contralateral to the direction of initial version in 100% of cases. This ictal-end head position was ipsilateral to the seizure-onset zone in 100% of the cases. 10 out of these 20 patients had corresponding ipsilateral ictal-end clonic movement.

Conclusions:

Latency of onset of initial version has a localizing significance for seizure-onset zone with the frontal-lobe group having the shortest, while occipital-lobe group has the longest. This is consistent with the relative physical distance of the frontal eye-field from these seizure-onset zones. Ictal-end head position contralateral to the initial version occurs in 40% of focal-epilepsies and is always ipsilateral to the seizure-onset zone.  

10.1212/WNL.0000000000208388
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