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Epileptic Disorders

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Ictal head roll: a seizure semiology from the anterior prefrontal lobe Volume 24, numéro 1, February 2022

Figure 1

Brain MRI images. (A) Axial T2/FLAIR image showing left temporal encephalomalacia. (B) Coronal T2/FLAIR image again showing left temporal encephalomalacia as well as non-specific, mildly increased FLAIR signal within the right middle temporal gyrus (red circle). (C) Coronal T2/FLAIR image showing bilateral orbitofrontal lobes without any clear pathology.

Figure 2

Scalp EEG. Non-convulsive seizure with unclear onset but maximal evolution over the left anterior quadrant where rhythmic theta is seen (red arrows). Bipolar montage: left temporal chain, left parasagittal chain, central, right parasagittal chain, right temporal chain.

Figure 3

Location of SEEG electrodes on scalp and MRI. L: left; R: right; mOlF: mesial orbitofrontal to lateral frontal; aCaS: anterior cingulate to anterior superior frontal gyrus; mCmS: mid-cingulate to middle superior frontal gyrus; AgpT: amygdala to posterior temporal; AglT: amygdala to lateral temporal; pTlT: posterior temporal to lateral temporal; smG: supramarginal gyrus; HplT: hippocampal to lateral temporal; mTpT: mesial temporal to posterior temporal. The number in parenthesis after each abbreviation indicates the number of electrodes in each lead.

Figure 4

(A-C) SEEG traces. (A) Stereo-EEG showing seizure onset with slow waves in the right mesial orbitofrontal region (seen immediately after montage labeling), followed by diffuse attenuation with overlying gamma activity over the anterior prefrontal region (blue arrows) and then rhythmic alpha activity (red arrows). (B) Seizure evolution with rhythmic alpha activity over the right anterior prefrontal region, with highest amplitude over the right mesial orbitofrontal to lateral frontal area and lower amplitude over the right anterior cingulate area, that evolves to rhythmic beta activity (red arrow), corresponding clinically to a counterclockwise head roll. To a lesser extent, there is rhythmic alpha seen over the left mesial orbitofrontal to lateral frontal region (green arrow). (C) Continuation of the right anterior prefrontal seizure (red arrow) with new-onset independent rapid beta spiking in the L amygdala/ hippocampal region (yellow arrow). L: left; R: right; mOlF: mesial orbitofrontal to lateral frontal; aCaS: anterior cingulate to anterior superior frontal gyrus; AgpT: amygdala to posterior temporal; AglT: amygdala to lateral temporal.

Figure 5

Location of seizure onset on SEEG showing the origin of seizure in the right anterior prefrontal region, encompassing the right mesial orbitofrontal region, innermost four electrodes (RmOlF 1-4) (A) with a spread pattern to the left anterior cingulate region (RaCaS 1-3) (B), finally spreading to the left amygdala region (LAgpT 1-4) (C).