Semiology Conference

Sikawat Thanaviratananich
Classification
• Epileptic Paroxysmal Episode
• Epileptogenic Zone: right mesial frontal lobe (anterior cingulate gyrus)
• Semiology: Cephalic aura->Hypermotor Seizure
• Etiology: FCD 1b
• Related Medical Conditions: depression
History
• 30-year-old, right-handed male with medically intractable focal
epilepsy of 22 years duration.

• No risk factors of epilepsy

• At the time of evaluation

• Keppra 500 mg tid
• Topiramate 50-50-100 mg
• Lamotrigine 400-200-500 mg
Interictal epileptiform discharges (Cz>Fz)
Cingulate Epilepsy
Cytoarchitecture
Connections
Afferents
• Frontal lobe (esp. dorsolateral and orbital areas) (mainly to area
24(ACC))
• Parietal lobe (mainly to area 23 (PCC))
• Insula cortex (ACC)
• Small proportion of afferents from the occipital lobe (PCC)
Efferents
• Area 24 (AC)
• Premotor cortex
• Orbito-frontal cortex
• Inferior parietal lobe
• Anterior insular cortex
• Perirhinal cortex
• Laterobasal nucleus of the amygdala
• Area 23 (PC)
• Dorsal prefrontal cortex
• Rostral orbital cortex
• Parietotemporal cortex (posterior part of the inferior parietal lobule and superior
temporal sulcus)
• Parahippocampal gyrus
Functions
• Unilateral or bilateral lesions in the anterior CG->behavioral changes
• Cortical stimulation of the anterior cingulate->autonomic phenomena
and motor responses (nature of the responses differ among studies-
including repetitive movements of the hands, fingers, and lips
(automatisms) and also irresistible urge to grasp something.
Cingulate Seizures
• Semiologic characterization of epileptic seizures originating in the
cingulate cortex is a challenge due to
• Less information on the scalp EEG due to the deep location of CG
• Problems with invasive recording due to the presence or large caliber vessels
and a considerable proportion of the cortex is located inside sulci
• Most cases of cingulate epilepsy, the resections were not limited to only the
cingulated gyrus
Subjects
• Pharmacoresistant epilepsy patients with MRI-defined lesions
confined to the cingulate gyrus with good surgical outcomes after
epilepsy surgery at the CCF and University of Texas Southwestern
Medical Center from 1992-2009
Anatomy
 Findings
Anterior Cingulate Epilepsy (n=10) Posterior Cingulate Epilepsy (n=4)

Typical (Bancaud) (n=6) Atypical(n=4)

Auras Auras in 3 patients (50%) Auras in 1 Pt (25%) Auras in 4 Pt (100%)

-all: fear -Freezing sensation -3 Pt: experiential auras (déjà vu, jamais vu,
-1 Pt : contralat. Ill-defined sensory auras depersonalization)
and freezing sensation -2 Pt: abdominal aura
-1 Pt: gustatory aura
No auras in 3 patients (50%) -1 Pt: subjective feeling of falling

Motor Component All: hypermotor sz All: simple motor seizures Simple motor and automotor sz in 2 Pt
1 Pt had contralateral simple motor sz 1 Pt had automotor seizure
Dialeptic sz in 2 Pt

Vocalization 4 Pt (80%): vocalization 2 Pt(50%): vocalization -

1 Pt (20%): nonmirthful laughter

Consciousness 0 Pt: complete loss of consciousness 4 Pt (100%): complete loss of consciousness -

6 Pt: quick recovery in some or all seizures

2nd GTC 4 Pt: never had 2nd GTC 4 Pt: had 2nd GTC 4 Pt: had 2nd GTC
1 Pt: had one GTC during off AEDs

Interictal Scalp EEG
Ictal Scalp EEG
Median Seizure duration (sec)
Anterior Cingulate Epilepsy (n=10)
Typical (Bancaud) (n=6)
2 Pt: interictal epileptiform d/c in
frontocentral region
4 Pt: no interictal epileptiform d/c
3 Pt: Ictal EEG changes, mostly obscured
by muscle artifacts, when discernible,
pointed to the ipsilateral frontocentral
region
30 sec
Atypical(n=4)
1 Pt: bilateral temporal epileptiform
discharges
3 Pt: no interictal epileptiform d/c
3 Pt: Ictal EEG changes
-2 Pt: Ipsilateral frontocentral region
-1 Pt: bilateral hemisphere
150 sec
Posterior Cingulate Epilepsy (n=4)
Focal slowing
2 Pt: focal slowing in ipsilat temporal region
1 Pt: bilateral temporal slowing
1 Pt: bi-frontal slowing
Interictal epileptiform d/c
4 Pt: had epileptiform d/c
-2 Pt: ipsi. ant. temporal
-1 Pt: ipsi. post. Temporal
-1 Pt: ipsi. frontal
4 Pt: Ictal EEG changes
-1 Pt: ipsilateral temporal
-2 Pt: widespread in ipsilateral
hemisphere
-1 Pt: widespread in bilateral hemisphere
96.8 sec
Thank You