Focal electroclinical features in generalized tonic–clonic seizures: Decision flowchart for a diagnostic challenge

Objective Bilateral tonic–clonic seizures with focal semiology or focal interictal electroencephalography (EEG) can occur in both focal and generalized epilepsy types, leading to diagnostic errors and inappropriate therapy. We investigated the prevalence and prognostic values of focal features in pa...

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Veröffentlicht in:Epilepsia (Copenhagen) 2024-03, Vol.65 (3), p.725-738
Hauptverfasser: Vlachou, Maria, Ryvlin, Philippe, Armand Larsen, Sidsel, Beniczky, Sándor
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creator Vlachou, Maria
Ryvlin, Philippe
Armand Larsen, Sidsel
Beniczky, Sándor
description Objective Bilateral tonic–clonic seizures with focal semiology or focal interictal electroencephalography (EEG) can occur in both focal and generalized epilepsy types, leading to diagnostic errors and inappropriate therapy. We investigated the prevalence and prognostic values of focal features in patients with idiopathic generalized epilepsy (IGE), and we propose a decision flowchart to distinguish between focal and generalized epilepsy in patients with bilateral tonic–clonic seizures and focal EEG or semiology. Methods We retrospectively analyzed video‐EEG recordings of 101 bilateral tonic–clonic seizures from 60 patients (18 with IGE, 42 with focal epilepsy). Diagnosis and therapeutic response were extracted after ≥1‐year follow‐up. The decision flowchart was based on previous observations and assessed concordance between interictal and ictal EEG. Results Focal semiology in IGE was observed in 75% of seizures and 77.8% of patients, most often corresponding to forced head version (66.7%). In patients with multiple seizures, direction of head version was consistent across seizures. Focal interictal epileptiform discharges (IEDs) were observed in 61.1% of patients with IGE, whereas focal ictal EEG onset only occurred in 13% of seizures and 16.7% of patients. However, later during the seizures, a reproducible pattern of 7‐Hz lateralized ictal rhythm was observed in 56% of seizures, associated with contralateral head version. We did not find correlation between presence of focal features and therapeutic response in IGE patients. Our decision flowchart distinguished between focal and generalized epilepsy in patients with bilateral tonic–clonic seizures and focal features with an accuracy of 96.6%. Significance Focal semiology associated with bilateral tonic–clonic seizures and focal IEDs are common features in patients with IGE, but focal ictal EEG onset is rare. None of these focal findings appears to influence therapeutic response. By assessing the concordance between interictal and ictal EEG findings, one can accurately distinguish between focal and generalized epilepsies.
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We investigated the prevalence and prognostic values of focal features in patients with idiopathic generalized epilepsy (IGE), and we propose a decision flowchart to distinguish between focal and generalized epilepsy in patients with bilateral tonic–clonic seizures and focal EEG or semiology. Methods We retrospectively analyzed video‐EEG recordings of 101 bilateral tonic–clonic seizures from 60 patients (18 with IGE, 42 with focal epilepsy). Diagnosis and therapeutic response were extracted after ≥1‐year follow‐up. The decision flowchart was based on previous observations and assessed concordance between interictal and ictal EEG. Results Focal semiology in IGE was observed in 75% of seizures and 77.8% of patients, most often corresponding to forced head version (66.7%). In patients with multiple seizures, direction of head version was consistent across seizures. Focal interictal epileptiform discharges (IEDs) were observed in 61.1% of patients with IGE, whereas focal ictal EEG onset only occurred in 13% of seizures and 16.7% of patients. However, later during the seizures, a reproducible pattern of 7‐Hz lateralized ictal rhythm was observed in 56% of seizures, associated with contralateral head version. We did not find correlation between presence of focal features and therapeutic response in IGE patients. Our decision flowchart distinguished between focal and generalized epilepsy in patients with bilateral tonic–clonic seizures and focal features with an accuracy of 96.6%. Significance Focal semiology associated with bilateral tonic–clonic seizures and focal IEDs are common features in patients with IGE, but focal ictal EEG onset is rare. None of these focal findings appears to influence therapeutic response. 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Focal interictal epileptiform discharges (IEDs) were observed in 61.1% of patients with IGE, whereas focal ictal EEG onset only occurred in 13% of seizures and 16.7% of patients. However, later during the seizures, a reproducible pattern of 7‐Hz lateralized ictal rhythm was observed in 56% of seizures, associated with contralateral head version. We did not find correlation between presence of focal features and therapeutic response in IGE patients. Our decision flowchart distinguished between focal and generalized epilepsy in patients with bilateral tonic–clonic seizures and focal features with an accuracy of 96.6%. Significance Focal semiology associated with bilateral tonic–clonic seizures and focal IEDs are common features in patients with IGE, but focal ictal EEG onset is rare. None of these focal findings appears to influence therapeutic response. 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We investigated the prevalence and prognostic values of focal features in patients with idiopathic generalized epilepsy (IGE), and we propose a decision flowchart to distinguish between focal and generalized epilepsy in patients with bilateral tonic–clonic seizures and focal EEG or semiology. Methods We retrospectively analyzed video‐EEG recordings of 101 bilateral tonic–clonic seizures from 60 patients (18 with IGE, 42 with focal epilepsy). Diagnosis and therapeutic response were extracted after ≥1‐year follow‐up. The decision flowchart was based on previous observations and assessed concordance between interictal and ictal EEG. Results Focal semiology in IGE was observed in 75% of seizures and 77.8% of patients, most often corresponding to forced head version (66.7%). In patients with multiple seizures, direction of head version was consistent across seizures. Focal interictal epileptiform discharges (IEDs) were observed in 61.1% of patients with IGE, whereas focal ictal EEG onset only occurred in 13% of seizures and 16.7% of patients. However, later during the seizures, a reproducible pattern of 7‐Hz lateralized ictal rhythm was observed in 56% of seizures, associated with contralateral head version. We did not find correlation between presence of focal features and therapeutic response in IGE patients. Our decision flowchart distinguished between focal and generalized epilepsy in patients with bilateral tonic–clonic seizures and focal features with an accuracy of 96.6%. Significance Focal semiology associated with bilateral tonic–clonic seizures and focal IEDs are common features in patients with IGE, but focal ictal EEG onset is rare. None of these focal findings appears to influence therapeutic response. 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subjects Convulsions & seizures
EEG
Electroencephalography
Epilepsy
Firing pattern
focal epilepsy
generalized epilepsy
Seizures
semiology
Semiotics
tonic–clonic seizures
title Focal electroclinical features in generalized tonic–clonic seizures: Decision flowchart for a diagnostic challenge
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