Lateralizing and Prognostic Value of Some Ictal Manifestations in Surgical Treatment of Mesial Temporal Lobe Epilepsy

ABSTRACT

BACKGROUND: Various ictal manifestations of temporal lobe epilepsy have possibly the value of both lateralizing and localizing the epileptogenic zone. Some ictal manifestations such as hand automatism, dystonic limb posture, head turning, and speech phenomenon might distinguish patients with good surgical outcomes from patients with poor out-comes. METHODS: To determine ictal behavioral differences in patients from these groups, we analyzed 207 seizures from 75 patients (group A) who were seizure free after surgery and 172 seizures from 60 patients (group B) who experienced seizures after surgery. All patients had received an anterior temporal lobectomy with amigdalohippocampectomy, and were followed up for at least 1 year. RESULTS: The lateralizing value of ictal semiology was evaluated in group A. Head turning (HT) was shown in 42% of seizures and had a lateralizing significance. Forced HT indicated a contralateral epileptogenic region. Non-forced HT suggested an ipsilateral epileptogenic region. Unilateral dystonic limb posture with or without automatism of the other side occurred in 53% of seizures and had a lateralizing significance, localizing the seizure onset to the contralateral hemisphere. Abnormal speech and vocalization did not have any lateralizing significance. Contralateral dystonic limb posture without ipsilateral automatism was significantly more frequent in group B (p=0.003) as abnormal speech was more frequent in group A (p=0.001). Non-versive head turning had a higher tendency to occur in group A (p=0.0051). There were no statistically significant differences between the two groups in incidences of versive head turning, unilateral hand automatism without dystonic limb posture, vocalization, and normal speech. CONCLUSIONS: Some ictal manifestations might be helpful in predicting the surgical outcome of temporal lobe epilepsy(TLE) patients. The presence of unidentifiable ictal speech could reflect good surgical outcome in TLE patients. When presurgical video analysis reveal an ictal semiology of contralateral dystonic arm posture without ipsilateral hand automatism, careful presurgical evaluation of the epileptogenic region should be contemplated.