Ictal pouting ('Chapeau de gendarme') in three pediatric cases with cortical dysplasia

Seizure semiology: ILAE glossary of terms and their significance

This educational topical review and Task Force report aims to address learning objectives of the International League Against Epilepsy (ILAE) curriculum. We sought to extract detailed features involving semiology from video recordings and interpret semiological signs and symptoms that reflect the likely localization for focal seizures in patients with epilepsy. This glossary was developed by a working group of the ILAE Commission on Diagnostic Methods incorporating the EEG Task Force. This paper identifies commonly used terms to describe seizure semiology, provides definitions, signs and symptoms, and summarizes their clinical value in localizing and lateralizing focal seizures based on consensus in the published literature. Video-EEG examples are included to illustrate important features of semiology in patients with epilepsy.

Seizure semiology, localization, and the 2017 ILAE seizure classification

In the study of epilepsy, the term semiology is used to comprise the clinical characteristics of a seizure, both subjective symptoms and objective phenomena. It is produced by activation of the symptomagenic zone, and an accurate and comprehensive understanding of the localizing value of seizure semiology is crucial for presurgical evaluation and planning. Myriad publications in epilepsy journals detail correlations between various semiological features and activation of specific cortical regions. Traditionally these studies involved scalp EEG recorded in epilepsy monitoring units. The increasing use of invasive monitoring, and specifically the use of depth electrodes and stereo-electroencephalography, has advanced our understanding of the characteristics of seizures arising from ictal foci deep to the scalp, including the cingulate, insula and operculum. However, the distinction between seizure onset and symptomogenic zones is not always clear. In 2017 the International League Against Epilepsy (ILAE) published an operational classification of seizure types based heavily on seizure semiology. The current paper provides an updated review of the current body of knowledge relating to seizure semiology, incorporating both scalp EEG studies and more recent stereo-electroencephalography discoveries in the framework of the 2017 ILAE classification.

A semiological marker of emotional insulo-cingulate network activation in epileptic human brain

There are limited reports on the "chapeau de gendarme" (CDG) sign, which is considered reliable evidence for the verification of frontal epilepsy. However, several recent reports of scattered cases of extra-frontal epilepsy suggest the complexity of the cortical networks underlying CDG generation. The present study aimed to investigate the anatomo-electro-clinical correlations and explore the cortical mechanisms of the generation of CDG via video-stereoelectroencephalography (SEEG). Patients with focal epilepsy who underwent SEEG and epilepsy surgery in our center from March 2017 to December 2019 were retrospectively reviewed. Ten patients with epilepsy with habitual seizures presenting with CDG were included. Most CDG signs were discerned visually into two chronological components referred to as the "prodromal component" and the "major component." The CDG signs occurred at 2.4-26.1 s after electrical onset and lasted for 2.2-16.6 s. The two sequential components were visually discerned in 64 included seizures of the six patients. The epileptogenic zones were diverse in distribution. Cluster analysis was performed based on the neurophysiological features of distinct cortical areas, and the agranulo-dysgranular insular and cingulate cortices were emphasized. Pearson correlation and linear regression showed a linear relationship between the latencies of CDG onset and the latencies of co-activation of agranulo-dysgranular cingulate and insular cortex in gamma bands. Our results suggest that (1) the CDG sign should be interpreted as a type of facial behavior with social-emotional features and considered a semiological marker of emotional insulo-cingulate cortex involvement in focal epilepsy, and (2) epileptic discharges arising directly from or propagating indirectly into this anterior limbic network have a high likelihood of evoking the CDG sign.

The chapeau de gendarme sign can be evoked by lateral prefrontal epileptic seizures

PURPOSE

The 'chapeau de gendarme' (CDG) sign, characterised by a symmetric down-turned mouth, has been considered as a semiological hallmark of focal epileptic seizures with cingulate or insular involvement. We report three cases in which the CDG sign featured in habitual seizures.

METHODS

The epileptogenic zones of these three patients were localized in the lateral prefrontal cortex by video-stereoelectroencephalography monitoring. A sulcal resection has led to a seizure-free outcome in each patient.

RESULTS

Ictal stereoelectroencephalography demonstrated that ictal discharges arising from the lateral prefrontal cortices were immediately followed by low-voltage fast activity, concomitantly involving the anterior insulo-cingulate cortices, and preceding the onset of the CDG signs. Limited sulcal resection and seizure freedom after surgery confirmed the restricted distributions of the epileptogenic zones in the lateral prefrontal cortex.

CONCLUSION

Our observations led us to speculate that the epileptic discharges could enter the emotional insulo-cingulate cortical system through the prefrontal-cingulate inhibitory projections (feedforward pattern) -arising from the supragranular layers of the lateral prefrontal cortex-and proceed to the deeper layers of the anterior-middle cingulate cortex, trigger the co-occurrence of gamma bands, and evoke a set of exaggerated behaviours, which is often accompanied by the unique facial sign.