Seizure Semiology ILAE

& Seminar in epileptology
Epileptic Disord 2022; 24 (3): 1-49
1
Department of Clinical
Neurophysiology, Aarhus University
Hospital, Aarhus, Denmark
2
Danish Epilepsy Centre, Dianalund,
Seizure semiology: ILAE
Denmark
3
4
Department of Clinical Medicine,
Aarhus University, Aarhus Denmark
Department of Neurology, Mayo
glossary of terms and their
Clinic, Jacksonville, FL, USA
5
Departments of Neurology,
Neuroscience, Neurosurgery, Yale
University School of Medicine, New
significance
Copyright © 2022 John Libbey Eurotext. Downloaded by DR JOSE ZAPATA BERRUECOS on 21/05/2022.
Haven, Connecticut, USA

6
Department of Neurology -
Biomagnetism, Epilepsy Center,
University Hospital Erlangen,
Germany
Sándor Beniczky1,2,3, William O. Tatum4, Hal Blumenfeld5,
7
Department of Brain and Nervous Hermann Stefan6, Jayanti Mani7, Louis Maillard8,9, Firas Fahoum10,
System, Kokilaben Dhirubhai Ambani
Hospital, Mumbai, India
8
Kollencheri Puthenveettil Vinayan11, Luis Carlos Mayor12,
Department of Neurology and
National Reference Centre for Rare Maria Vlachou1, Margitta Seeck13, Philippe Ryvlin14,
Epilepsies, University Hospital of
Nancy, Nancy, France Philippe Kahane15
9
Research Centre for Automatic
Control of Nancy (CRAN), Lorraine
University, Vandoeuvre, France
10
Neurological Institute, Tel Aviv
ABSTRACT
Sourasky Medical Centre and Sackler This educational topical review and Task Force report aims to address learning
Faculty of Medicine, Tel Aviv
University, Tel Aviv, Israel objectives of the International League Against Epilepsy (ILAE) curriculum. We
11
Department of Pediatric Neurology, sought to extract detailed features involving semiology from video recordings
Amrita Institute of Medical Sciences,
Cochin, Kerala, India and interpret semiological signs and symptoms that reflect the likely localization
12
Department of Neurology, Epilepsy for focal seizures in patients with epilepsy. This glossary was developed by a
Clinic, Fundacion Santa Fe de Bogotá
University Hospital, Bogota, Colombia working group of the ILAE Commission on Diagnostic Methods incorporating
13
EEG and Epilepsy Unit, University the EEG Task Force. This paper identifies commonly used terms to describe
Hospitals and Faculty of Medicine,
University of Geneva, Geneva, seizure semiology, provides definitions, signs and symptoms, and summarizes
Switzerland their clinical value in localizing and lateralizing focal seizures based on
14
Department of Clinical
Neurosciences, Lausanne University consensus in the published literature. Video-EEG examples are included to
Hospital, Lausanne, Switzerland illustrate important features of semiology in patients with epilepsy.
15
Neurology Department, CHU
Grenoble Alpes, Univ. Grenoble Alpes
and GIN Inserm 1216, 38000 Grenoble,
France Key words: glossary, lateralization, localization, epilepsy, seizure semiology,
video-EEG
Received January 03, 2022; Accepted
February 19, 2022
Seizure semiology comprises objective details, such as goosebumps, flushing

signs and subjective symptoms and pallor. Combining EEG that is
reported by patients during epileptic synchronized with the video allows
seizures. Accurate delineation of sei- detailed analysis and sequential elec-
VIDEOS ONLINE zure semiology is essential for properly troclinical correlation from seizure on-
diagnosing and classifying seizures and set to seizure termination.
epilepsy syndromes. Although valuable Information obtained from patients
information can be obtained from the concerning subjective seizure symp-
patients, and from people who have toms (not visible on the video record-
doi:10.1684/epd.2022.1430
Correspondence:
Sándor Beniczky witnessed seizures [1], more detailed ings) are essential for correct
Aarhus University Hospital feature-extraction is possible by review- characterization of the seizures, and
and Danish Epilepsy Center, ing video recordings of the typical for correct localization and lateraliza-
Visby Allé 5, 4293, events [2]. Recent technological tion, as described in detail in a previous
Dianalund, Denmark
advances with high-resolution video seminar in epileptology [1]. The term
<sbz@filadelfia.dk>
<[email protected]> cameras allow recording of subtle aura denotes subjective symptoms at
Epileptic Disord, Vol. 24, No. 3, June 2022 •1

S. Beniczky, et al.
seizure onset that are perceived by the patient. It has 1. Electrographic seizures
been described in focal seizures (i.e., focal aware
seizures and at the onset of focal impaired awareness Electrographic seizures are subclinical and do not
seizures, before impairment of consciousness). Aura have any observable signs or reported symptoms
has also been reported in generalized seizures. despite an unequivocal ictal pattern on EEG:
Epileptic aura must be differentiated from aura 1) sustained spike-wave discharges with a frequency
occurring in non-epileptic paroxysmal events (mi- 2.5 Hz; 2) rhythmic – evolving ictal activity (with a
graine, syncope, dissociative seizures). dynamic evolution in time and space). Electrographic
Our goal is to provide a list of terms that are used to seizures (10 seconds and longer) and electrographic
describe seizure semiology, and to update the status epilepticus (10 minutes and longer) are often
glossary initially developed in the ILAE Commission recorded in critically ill patients [9-12], and also in
report published 20 years ago [3]. Semiology features genetic or developmental / epileptic encephalopa-
were subdivided to reflect similar signs and their
thies (such as patients with ring chromosome 20,

corresponding location. We acknowledge that other Angelman syndrome and related genetic syndromes),
categories are possible. However, our focus was not in neonatal epilepsies [13] and in acute symptomatic
to classify the seizure semiology, but rather, to neonatal seizures.
describe the individual characteristics according to a
commonly accepted terminology, that may be used
individually or in combination to aid in defining the 2. Consciousness
ictogenic network. For further information regarding
definitions and classification of seizures and epilep- Impaired consciousness is of major clinical impor-
sy, the reader is referred to the ILAE position tance in epilepsy, affecting the ability of patients to
statements [4-6]. safely drive, effectively work, and maintain the ability
We also included phenomena that occur immediately to function in society [14-17]. However, because the
after seizure termination to distinguish postictal term “consciousness” is broad, the 2017 ILAE classifi-
semiology and emphasize their clinical relevance. cation adopted the narrower term “awareness” in the
We used modifiers in accordance with what was classification, as a “simple surrogate marker for
previously proposed [7]. For some features, the consciousness” [5]. Another related feature broadly
terminology used to describe semiology applies to used in video-EEG monitoring is assessment of the
the body part that is involved (for example “epigastric responsiveness, which requires behavioral testing of
aura”), and in other cases somatotopic descriptors the patient [18]. It is well-recognized that each
have been added (for example “left hand gestural individual method for assessing consciousness has
automatisms”). Other descriptors of seizures includ- its limitations, and care must be taken to interpret
ing duration, timing, and provoking or facilitating results in the context of potential deficits such as
factors are also listed and defined. motor impairment, aphasia or amnesia [19]. However,
This glossary of terms was designed to address with these caveats in mind, all information should be
learning objectives outlined by the ILAE curriculum included and is of great value in assessing this
and encompass an education review. Section 1.3.3 of clinically important aspect of seizures. Impaired
the ILAE curriculum includes “Extract semiology consciousness typically occurs in generalized seizures
information from video recordings” and section [20-23]. However, impaired consciousness is also very
1.3.4, “Interpret semiological signs and symptoms frequently noted in focal seizures when a large
allowing hypotheses on the localization of focal volume of cortex is involved in the seizure network
seizures”[8]. This report has been developed by a [22, 24-30]. It should be differentiated from amnestic
working group of the ILAE Commission on Dia- seizures, i.e. while the patient may be unable to recall
gnostic Methods involving the EEG Task Force. For events during the seizure, she/he is also unable to
each semiology feature we used the following remember the seizure itself. These features can be
search strategy in PubMed: (((name of the semiology dissociated.
feature [Title/Abstract]) OR (synonym widely used
[Title/Abstract])) AND ((localization [Title/Abstract]) 2.1. Awareness
OR (lateralization [Title/Abstract]))) AND (seizure
[Title/Abstract]). Date for last search was 1/11/2021. In Awareness is commonly used as a surrogate marker
addition, we included papers from citations found in for assessing consciousness during a seizure [5]. It is
reference lists and review articles. Table 1 sum- defined in the 2017 ILAE classification as “knowledge
marizes the most plausible localization and laterali- of self or environment” and assessment depends on
zation accepted for the most important semiological “the ability of the person having the seizure to later
features. Table 2 lists video examples. verify retained awareness” based on “whether
2• Epileptic Disord, Vol. 24, No. 3, June 2022

ILAE glossary of semiological terms
~
Table 1. Key points showing the most accepted localization and lateralization signs for the most important
semiological features.
Semiology features Lateralizing value Localizing value

Awareness D When complete
impairment in TLE
Consciousness Responsiveness ND When partial
responsiveness with
automatisms
Auditory T Posterior - superior
temporal neocortex
Body-perception T, P, O
illusion
Depersonalization
Forced thinking
Gustatory Ins Posterior-dorsal part
Olfactory T, F, Ins Amygdala, orbito-
Sensory frontal cortex,
phenomena posterio-dorsal insula
Non painful CON When unilateral P Sensory cortex (S1)
Somatosensory Painful & CON When unilateral Ins Posterior-superior
thermal insula
Vestibular T, P Posterior temporo-
perisylvian cortex,
including insula
Visual CON When unilateral, O Visual cortex (V1)
mainly elementary
hallucinations
Anger T, F Amygdala, prefrontal
(orbito-frontal)
Anxiety T Amygdala
Ecstatic/bliss Ins Anterior dorsal Insula
Fear T, F Amygdala, orbito-
Affective frontal cortex, anterior
(emotional) cingulate
phenomena Guilt
Mirth
Mystic T
Sadness
Sexual
Aphasia T, P, F Broca, Wernicke, basal
temporal language area
Cognitive
phenomena Dysmnesia
Dysmnesia Amnesia

S. Beniczky, et al.
~
semiological features (continued).

Déjà (jamais)-vu/ Déjà-vu/dreamy T Mesio-temporal
dreamy state state/
reminiscence
Akinetic F Mesial premotor
cortex, inferior F gyrus
Astatic
Atonic
Dystonic CON When unilateral,

mainly in TLE
Epileptic CON When considering the O
nystagmus fast phase
Epileptic spasm CON When unilateral
Eye blinking IPSI
Gyratory CON When preceded by
head version of the
same direction
Head orientation
Elementary Ictal paresis CON F Motor cortex (M1)

motor
Myoclonic/clonic CON F Motor cortex (M1)
phenomena
Myoclonic- atonic
Unilateral tonic CON F
Chapeau de F Anterior prefrontal
gendarme (mainly anterior
Tonic cingulate cortex)
Fencing posture CON When considering the F Supplementary motor
elevated arm area
Unilateral tonic- CON F Premotor and motor
clonic (M1) cortices
Asymmetric IPSI When considering the
Tonic-clonic clonic ending last clonic jerks
Figure-of-four CON When considering the
extended arm
Versive CON When followed by
FBTC
Gestural IPSI When unilateral,
automatisms- mainly in context of
distal TLE
Complex
motor Automatisms Gestural
phenomena automatisms-
genital

~

Gestural
automatisms-
proximal
Ictal grasping F Anterior cingulate
Mimic Hypoth Hypothalamic
automatisms hamartoma when
Gelastic/ isolated and in clusters
dacrystic
Oro-alimentary ND When awareness is
automatisms preserved
Verbal T Related to insulo-
automatisms opercular involvement
Vocal D In context of TLE and
automatisms FLE
Hyperkinetic
behaviour
Bradycardia + T, F Bilateral temporal,
ictal asystole orbito-frontal
Cardiovascular
Tachycardia T
Flushing
Pallor
Cutaneous
Piloerection
Sweating
Epigastric T Mainly when followed
by automatisms
Flatulence
Gastrointestinal Hypersalivation Insulo-

Autonomic opercular
phenomena
Spitting T
Vomiting Ins
Miosis
Pupillary
Mydriasis
Apnea T Mainly when
contralateral spread
Chocking Insulo-
Respiratory opercular
Hyperventilation
Hypoventilation
Urinary ND For ictal urinary urge T

S. Beniczky, et al.
~

Postictal
autonomic signs
Postictal CON When unilateral
blindness
Postictal IPSI In the context of TLE
headache
Postictal language D
dysfunction
Postictal Postictal nose- IPSI In the context of TLE T, F Temporal more than
phenomena wiping frontal
Postictal
pallinacousis
Postictal paresis CON
(Todd’s paresis)
Postictal
psychiatric signs
Postictal
unresponsiveness
D: dominant; ND: non-dominant; CON: contralateral; IPSI: ipsilateral; TLE: temporal lobe epilepsy; FLE: frontal lobe epilepsy; F: frontal; T: temporal;
P: parietal; O: occipital, Ins: insula; Operc: opercular; Ins: insula; Hypoth: hypothalamus.
awareness for events occurring during the seizure was sies, impaired awareness may be more common in
retained or impaired”. However, the postictal recall is dominant hemispheric onset [29, 42, 43], although
also affected by the ictal involvement of language and this could be biased by mainly verbal tests used for
memory, not only awareness per se. Even with these assessment. In most of the temporal lobe epilepsies,
limitations, awareness is used as a core descriptor to the awareness becomes impaired when the seizure
stratify focal seizures in the recent ILAE classification involves neocortical and subcortical structures
of seizures [5]. Patient awareness about the occur- [25, 29].
rence of a seizure is another completely different
attribute, which might be clinically relevant for 2.2. Responsiveness
planning diagnostic and management strategies [31].
Impaired awareness (inability of the person having the Responsiveness during the seizure to questions,
seizure to later verify retained awareness) occurs in commands or other stimuli is used as a descriptor,
generalized or bilateral tonic-clonic seizures with but not as a classifier, because “some people are
uncommon exceptions [23, 32-34]. Most absence immobilized and consequently unresponsive during a
seizures cause impaired awareness [20-23]. However, seizure, but still able to observe and recall their
in some cases during bursts of generalized spike-wave environment” [5]. Despite not being used as a
discharges, the patient does not follow commands classifier, responsiveness during seizures is highly
and is unable to repeat the test words (impaired clinically relevant, for example in evaluating driving
responsiveness), yet after the spike-wave bursts safety [5, 17, 44-46]. Responsiveness is used as a
terminate, the patient is able to recall the commands standard means of assessment in other neurological
and test words given during the seizure, demonstrat- disorders of consciousness [47-49], and is commonly
ing retained awareness during the electroclinical used in epilepsy monitoring units because it is
absence seizure (non-responsive patient with ictal relatively objective and does not rely on patient
EEG correlate) [21, 22, 35-41]. In temporal lobe epilep- subjective report. Testing batteries should be used for

~
Table 2. Seizure semiology: videos.
Semiology Seizure onset and propagation Video link

MOTOR PHENOMENA
Akinetic Aura (presses the alarm button) ! R manual https://www.jle.com/en/revues/epd/e-
automatisms + L arm & leg immobile + facial docs/video_atlas_of_lateralising_and_localising_
automatisms ! non-responsive ! R head & seizure_phenomena_288739/article.phtml?tab=
eyes orientation (not forced) ! oroalimentary videos&cle_video_une=289505
automatisms + bilateral eye blinking ! [403]
proximal head & leg automatisms ! R manual
automatisms + L arm & leg still immobile
Oro-alimentary automatisms + non- https://www.jle.com/en/revues/epd/e-
responsiveness ! atonic seizure with head docs/intracranial_video_eeg_and_surgery_for_

drop and slight R deviation + arms atonia focal_atonic_seizures_296712/article.phtml?tab=
videos&cle_video_une=296336
Atonic
[404]
Muscle atonia of neck (head drop) and trunk Supplementary video 1
Supplementary figure 1
Seizures with negative myoclonus of arms +/- https://www.jle.com/en/revues/epd/e-
head atonia (head drop) docs/induction_of_epileptic_negative_
myoclonus_by_oxcarbazepine_in_symptomatic_
epilepsy_265696/article.phtml?tab=videos&cle_
video_une=285271
[405]
Focal aware seizures: L arm negative (case 6, sec 7.17-7.43)
myoclonus https://www.jle.com/en/revues/epd/e-
docs/semiology_of_typical_and_atypical_
Negative myoclonus rolandic_epilepsy_a_video_eeg_analysis_
110047/article.phtml?tab=videos&cle_video_
une=285253
[406]
Follows command to raise both arms ! R arm https://www.jle.com/en/revues/epd/e-
repetitive negative myoclonus docs/video_atlas_of_lateralising_and_localising_
seizure_phenomena_288739/article.phtml?tab=
[403]
Unilateral eye Left eye blinking while patient describes https://www.jle.com/en/revues/epd/e-
blinking difficulties in speaking (speaking slowly but docs/video_atlas_of_lateralising_and_localising_
coherently) seizure_phenomena_288739/article.phtml?tab=
[403]
Myoclonic jerks in arms https://www.jle.com/en/revues/epd/e-
docs/crossing_the_lines_between_epilepsy_
syndromes_a_myoclonic_epilepsy_variant_with_
prominent_eyelid_myoclonia_and_atonic_
components_310815/article.phtml?tab=videos&
cle_video_une=311030
[407]
Myoclonic
Myoclonic jerks of facial muscles https://www.jle.com/en/revues/epd/e-
docs/myoclonic_jerks_are_commonly_
associated_with_absence_seizures_in_early_
onset_absence_epilepsy_309712/article.phtml?
tab=videos&cle_video_une=309981
[408]

S. Beniczky, et al.
~
Table 2. Seizure semiology: videos (continued).

Myoclonic jerks of facial muscles, eyelids, https://www.jle.com/en/revues/epd/e-
trunk and arms docs/myoclonic_status_epilepticus_as_a_
presentation_of_caspr2_antibody_associated_
autoimmune_encephalitis_303162/article.phtml?
[409]
Bilateral myoclonic jerks, symmetric Supplementary video 2
(Note the surface EMG with myogenic artifact Supplementary figure 2
during brief, bilateral muscle activation)
Tonic (asymmetric: R arm elevation, L arm https://www.jle.com/en/revues/epd/e-
flexion) ! L head version ! bilateral docs/classification_of_paroxysmal_events_and_

asymmetric clonic jerks ! R version ! the_four_dimensional_epilepsy_classification_
terminal L asymmetric clonic jerks ! system_313798/article.phtml?tab=videos&cle_
hypoventilation video_une=313814
Clonic [410]
Bilateral symmetric clonic jerks Supplementary video 3
(Note the surface EMG channels with myogenic Supplementary figure 3
artifact during repetitive, bilateral, rhythmic
muscle activation)
Bilateral myoclonic jerks of shoulders ! atonic https://www.jle.com/en/revues/epd/e-
component involving head drop docs/diaphragm_myoclonus_followed_by_
generalised_atonia_in_a_patient_with_trisomy_
4p_unusual_semiology_in_an_unusual_
condition_305890/article.phtml?tab=videos&cle_
Myoclonic-atonic video_une=306153
[411]
Brief bilateral myoclonic jerks in shoulders ! Supplementary video 4
atonia and fall (Note the surface EMG during Supplementary figure 4
myoclonic jerks and upon cessation)
Oroalimentary automatisms ! bilateral leg https://www.jle.com/en/revues/epd/e-
proximal automatisms ! hyperventilation ! docs/autonomic_symptoms_during_epileptic_
vocal automatisms +R arm dystonic ! non- seizures_110095/article.phtml?tab=videos&cle_
responsive + L arm gestural automatisms ! L video_une=285222
arm exploratory movements ! L postictal nose [295]
wiping, coughing, and unresponsiveness (see
Postictal)
Ictal: L head version ! L gestural automatisms https://www.jle.com/en/revues/epd/e-
! R gestural automatisms + R arm dystonic. docs/postictal_signs_of_lateralizing_and_
Postictal: L nose wiping, R (Todd’s) paresis, and localizing_significance_published_with_
non-fluent aphasia. videosequences_._110069/article.phtml?tab=
(Sequence 1, up to Section 5.05) videos&cle_video_une=285233
(see also Distal Automatisms and Postictal) [374]
Dystonic
Aura (presses the alarm button) !L arm https://www.jle.com/en/revues/epd/e-
automatisms ! non responsive ! R arm docs/video_atlas_of_lateralising_and_localising_
dystonia+ L head orientation ! bilat arm and seizure_phenomena_288739/article.phtml?tab=
leg automatisms + oroalimentary automatisms videos&cle_video_une=289024
! R arm akinesia ! L nose wiping + [403]
responsive + postictal anomia
Head orientation L ! R arm dystonia !non- https://www.jle.com/en/revues/epd/e-
responsive ! ictal cry ! R face tonic ! R arm docs/video_atlas_of_lateralising_and_localising_
tonic extension ! L arm tonic flexion (figure-of- seizure_phenomena_288739/article.phtml?tab=
four) ! bilateral tonic ! bilateral tonic-clonic ! videos&cle_video_une=289022
Asymmetric clonic termination L leg [403]
(See Figure-of-4 & Asymmetric Ictal Termination)

~

Non-responsive ! R head version ! R https://www.jle.com/en/revues/epd/e-
gyratory ! ictal cry ! bilateral tonic – clonic docs/videoeeg_evidence_of_lateralized_clinical_
(lateralizing features of GTCS in IGE) features_in_primary_generalized_epilepsy_
with_tonicclonic_seizures__261669/article.
phtml?tab=videos&cle_video_une=285334
Gyratory
[412]
Focal impaired awareness seizure: fulminant, Supplementary video 5
hyperkinetic behavior ! R gyratory
(see Hyperkinetic)
Epileptic nystagmus pt. indicating aura (according to video https://www.jle.com/en/revues/epd/e-

description) ! brief R face myoclonus ! R docs/epileptic_nystagmus_due_to_a_large_
epileptic nystagmus (fast phase) parieto_temporo_occipital_multilobar_
dysplasia_318835/article.phtml?tab=videos&cle_
video_une=318847
[413]
Ictal paresis (Case 1) Several seizures with L ictal https://www.jle.com/en/revues/epd/e-
hemiparesis ! tetraparesis. In two seizures docs/alternating_hemiplegia_of_childhood_
accompanying eye blinking + L eye version OR presentation_of_two_cases_regarding_the_
seizures with accompanying unconjugated eye extent_of_variability__262373/article.phtml?tab=
movements + oroalimentary automatisms videos&cle_video_une=285256
(Case 1: 0.28-2.28 sec)
[414]
Clusters of epileptic spasms https://www.jle.com/en/revues/epd/e-
docs/epileptic_spasms_in_clusters_without_
hypsarrhythmia_in_infancy__260543/article.
[415]
Clusters of epileptic spasms – One seizure https://www.jle.com/en/revues/epd/e-
(section 1.26) starting with epileptic spasms ! docs/epileptic_spasms_in_clusters_without_
Epileptic spasm bilateral tonic ! bilateral tonic with vibratory hypsarrhythmia_in_infancy__260543/article.
component ! clonic ! epileptic spasms phtml?tab=videos&cle_video_une=285302 +
tonic (descrip)
[415]
Clusters of epileptic spasms Supplementary video 6
(Note the surface EMG channels at the bottom Supplementary figure 5
line and the “diamond shaped” myogenic
artifact)
Bilateral symmetric tonic https://www.jle.com/en/revues/epd/e-
docs/bilateral_symmetric_tonic_posturing_
suggesting_propagation_to_the_
supplementary_motor_area_in_a_patient_with_
precuneate_cortica_276426/article.phtml?tab=
Tonic [416]
Recurrent, bilateral tonic (tonic status https://www.jle.com/en/revues/epd/e-
epilepticus) docs/tonic_status_epilepticus_in_a_
centenarian_woman_313796/article.phtml?tab=
[417]

S. Beniczky, et al.
~

Chapeau de Ictal pouting (chapeau de gendarme) + partially https://www.jle.com/en/revues/epd/e-
gendarme responsive ! postictal agitation + responsive docs/chapeau_de_gendarme_in_a_toddler_
points_to_focal_epilepsy_originating_from_the_
subcentral_gyrus_319960/article.phtml?tab=
[93]
a. Tonic-clonic Oroalimentary automatisms ! L head version https://www.jle.com/en/revues/epd/e-
(GTCS with ! L arm clonic jerks ! bilateral tonic docs/videoeeg_evidence_of_lateralized_clinical_
lateralizing features asymmetric + R arm clonic jerks ! bilateral features_in_primary_generalized_epilepsy_
tonic clonic ! asymmetric clonic ending with
in IGE) with_tonicclonic_seizures__261669/article.
last jerks on the R ! stridor phtml?tab=videos&cle_video_une=285336
[412]
b. Tonic-clonic Ictal cry ! Bilateral tonic symmetric ! Bilateral Supplementary video 7
(GTCS in IGE) tonic-clonic symmetric Supplementary figure 6A, B
(Note the surface EMG channels showing the
gradual “build up” of the muscle artifact during
the tonic phase, followed by gradually longer
“silent” periods corresponding to the clonic
phase of a GTCS)
Aura ! R head version ! tonic ! figure-of- https://www.jle.com/en/revues/epd/e-
four ! bilat tonic-clonic ! postictal docs/classification_of_paroxysmal_events_and_
unresponsiveness the_four_dimensional_epilepsy_classification_
system_313798/article.phtml?tab=videos&cle_
video_une=313811
Figure-of-four [410]
(FBTCS)
Refer to dystonic and asymmetric clonic https://www.jle.com/en/revues/epd/e-
termination docs/video_atlas_of_lateralising_and_localising_
[403]
Refer to tonic-clonic (GTCS with lateralizing https://www.jle.com/en/revues/epd/e-
features in IGE) docs/videoeeg_evidence_of_lateralized_clinical_
features_in_primary_generalized_epilepsy_
with_tonicclonic_seizures__261669/article.
Asymmetric clonic [412]
ending
Refer to dystonic and figure-of-four https://www.jle.com/en/revues/epd/e-
docs/video_atlas_of_lateralising_and_localising_
[403]
Versive Upward eye deviation ! R eye and head https://www.jle.com/en/revues/epd/e-
version ! R Tonic arm flexion ! clonic jerks docs/adversive_seizures_associated_with_
in R side of face and R arm periodic_lateralised_epileptiform_discharges_
pleds_after_left_orbital_contusion_
une=295286
[418]
10 • Epileptic Disord, Vol. 24, No. 3, June 2022

~

COMPLEX MOTOR PHENOMENA
Automatisms
Oroalimentary automatisms ! L gestural https://www.jle.com/en/revues/epd/e-
automatisms ! R head orientation ! Bilateral docs/seizure_ending_signs_in_patients_with_
gestural automatisms ! L head orientation ! dyscognitive_focal_seizures_305235/article.
oro-alimentary automatisms phtml?tab=videos&cle_video_une=305311
(See Oroalimentary) [419]
(Seizure from sleep) opening eyes ! https://www.jle.com/en/revues/epd/e-
oroalimentary automatisms ! R gestural docs/seizure_ending_signs_in_patients_with_
automatisms ! responsive ! R postictal nose dyscognitive_focal_seizures_305235/article.

Distal wiping phtml?tab=videos&cle_video_une=305312
(see Postictal) [419]
Ictal: L head version ! L gestural automatisms https://www.jle.com/en/revues/epd/e-
! R gestural automatisms + R arm dystonic. docs/postictal_signs_of_lateralizing_and_
(see Dystonic and Postictal) [374]
Genital Fearful facial expression + staring ! L head https://www.jle.com/en/revues/epd/e-
version ! tonic posture L arm ! Bilateral tonic docs/autonomic_symptoms_during_epileptic_
posture arms ! tonic-clonic L face ! R arm seizures_110095/article.phtml?tab=videos&cle_
tonic elevation ! Bilateral gestural video_une=285227
automatisms ! nonresponsive ! R hand [295]
genital automatisms ! ictal coughing !
Bilateral proximal leg automatisms (i.e.,
pedaling/bicycling)
Proximal R arm proximal automatisms https://www.jle.com/en/revues/epd/e-docs/lgi_1_
antibody_encephalitis_in_a_seven_year_old_
girl_315902/article.phtml?tab=videos&cle_video_
une=315925
[420]
Mimetic-dacrystic Dacrystic automatisms ! oroalimentary https://www.jle.com/en/revues/epd/e-docs/giant_
automatisms hypothalamic_hamartoma_and_dacrystic_
seizures_273133/article.phtml?tab=videos&cle_
video_une=285409
[421]
Staring ! gelastic automatisms ! Bilateral arm https://www.jle.com/en/revues/epd/e-
proximal automatisms docs/gelastic_seizures_in_ring_chromosome_20_
syndrome_a_case_report_with_video_
illustration_293185/article.phtml?tab=videos&cle_
video_une=294858
[422]
Mimetic- gelastic
L arm gestural self-directed automatisms ! https://www.jle.com/en/revues/epd/e-
ictal vocalization ! gelastic automatisms+ docs/hypothalamic_hamartoma_and_epilepsy_
nonresponsive ! distal Bilateral feet in_children_illustrative_cases_of_possible_
automatisms ! L postictal nose wiping evolutions__262012/article.phtml?tab=videos&
[423]
Oroalimentary Oroalimentary automatisms ! L gestural https://www.jle.com/en/revues/epd/e-
automatisms ! head orientation R ! Bilateral docs/seizure_ending_signs_in_patients_with_
gestural automatisms ! head orientation L ! dyscognitive_focal_seizures_305235/article.
oro-alimentary automatisms phtml?tab=videos&cle_video_une=305311
(see Distal Automatisms) [419]
Epileptic Disord, Vol. 24, No. 3, June 2022 • 11

S. Beniczky, et al.
~

Verbal S1: verbal automatisms (repeating religious https://www.jle.com/en/revues/epd/e-docs/ictal_
passages) ! ictal kissing ! L gestural kissing_and_religious_speech_in_a_patient_
automatisms ! oroalimentary automatisms with_right_temporal_lobe_epilepsy__
(see Mystic) 265692/article.phtml?tab=videos&cle_video_
une=285267
[424]
Vocal S1: R gestural + oroalimentary automatisms ! https://www.jle.com/en/revues/epd/e-
verbal automatism + affective (anger) ! vocal docs/seizure_semiology_of_anti_lgi1_antibody_
automatisms encephalitis_310814/article.phtml?tab=videos&
(see Affective) cle_video_une=311024

[425]
Hyperkinetic behaviours
Fearful facial expression ! hyperkinetic ! https://www.jle.com/en/revues/epd/e-
vocal automatisms ! non-responsive + docs/seizure_semiology_reflects_spread_from_
gestural + oroalimentary automatisms frontal_to_temporal_lobe_evolution_of_
hyperkinetic_to_automotor_seizures_as_
documented_by_invasive_eeg_video_
recordings_297991/article.phtml?tab=videos&
[426]
Focal impaired awareness seizure: fulminant, Supplementary video 5
Hyperkinetic
hyperkinetic behavior ! R gyratory
Seizure
Focal impaired awareness seizure: ictal fear ! Supplementary video 8
hyperkinetic behavior Supplementary figure 7
(See Affective)
Hyperventilation ! L gestural automatisms ! https://www.jle.com/en/revues/epd/e-
hyperkinetic ! ictal vocalizations ! R head docs/autonomic_symptoms_during_epileptic_
version ! tonic seizures_110095/article.phtml?tab=videos&cle_
(see Hyperventilation) video_une=285223
[295]
SENSORY PHENOMENA
Auditory Ictal fear + auditory hallucinations https://www.jle.com/en/revues/epd/e-
(Note: it is not possible to evaluate hearing in docs/auditory_hallucinations_as_ictal_
this video, but the patient is heard verbalizing phenomena_in_a_patient_with_voltage_gated_
“they are coming” due to auditory potassium_channel_antibody_associated_
hallucinations of someone approaching from limbic_encephalitis_298909/article.phtml?tab=
her left) videos&cle_video_une=299012
[427]
Several seizures starting as focal aware seizures https://www.jle.com/en/revues/epd/e-
with L blurred vision, flashes, and visual docs/benign_idiopathic_occipital_epilepsy_
hallucinations, (as described by the patient) ! report_of_a_case_of_the_early_benign_type_
R eye and head version ! eye blinking ! non- published_with_video_sequences_.
responsive (in some of the seizures) _110057/article.phtml?tab=texte
[428]
Visual
Focal aware NCSE: oculomotor apraxia ! ataxia https://www.jle.com/en/revues/epd/e-docs/b_
! simultanagnosia lint_like_syndrome_as_an_unusual_
representation_of_non_convulsive_status_
epilepticus_292166/article.phtml?tab=videos
[429]

~

L trunk painful sensation https://www.jle.com/en/revues/epd/e-docs/focal_
epilepsy_with_paroxysmal_pain_due_to_
somatic_injury_309906/article.phtml?tab=
[430]
Somatosensory Focal aware seizure: brief abnormal sensation R https://www.jle.com/en/revues/epd/e-
side of neck & R arm ! R arm clonic ! R neck docs/unilateral_abdominal_clonic_seizures_of_
tonic ! R abdominal clonic parietal_lobe_origin_eeg_findings_
une=311824
[431]
AFFECTIVE (EMOTIONAL) PHENOMENA
Anger S1: R gestural + oroalimentary automatisms ! https://www.jle.com/en/revues/epd/e-
ictal speech + affective (anger) ! ictal docs/seizure_semiology_of_anti_lgi1_antibody_
vocalization. S2: L face grimacing ! non-fluent encephalitis_310814/article.phtml?tab=videos&
aphasia (anomia) cle_video_une=311024
S3: R gestural automatisms ! affective [425]
S4: R gestural automatisms ! ictal speech +
affective (anger)
Anxiety Anxiety + hyperventilation ! L somatosensory https://www.jle.com/en/revues/epd/e-docs/long_
aura! vestibular symptoms ! dysarthria ! lasting_seizure_related_anxiety_in_patients_
ictal cry with_temporal_lobe_epilepsy_and_comorbid_
psychiatric_disorders_305196/article.phtml?tab=
[432]
Ictal fear + ictal vocalization ! L head version https://www.jle.com/en/revues/epd/e-
+ dystonic posture ! L hand automatisms + docs/semiological_study_of_ictal_affective_
non-responsive behaviour_in_epilepsy_and_mental_retardation_
limited_to_females_efmr__293200/article.phtml?
Fear
[433]
Focal impaired awareness seizure: ictal fear ! Supplementary video 8
hyperkinetic behavior Supplementary figure 7
(See Hyperkinetic)
Mystic S1: verbal automatisms (repeating religious https://www.jle.com/en/revues/epd/e-docs/ictal_
statement) ! ictal kissing ! L gestural kissing_and_religious_speech_in_a_patient_
automatisms ! oroalimentary automatisms with_right_temporal_lobe_epilepsy__
S2: hyperventilation ! Bilateral gestural 265692/article.phtml?tab=videos&cle_video_
automatisms ! verbal automatisms (repeating une=285267
religious passages) ! musical automatism [424]
(whistling) + Bilateral gestural automatisms !
ictal kissing ! oroalimentary automatisms ! L
gestural automatisms ! oroalimentary ! R
gestural automatisms ! non-responsive
COGNITIVE PHENOMENA
Focal impaired awareness seizure: R gestural Supplementary video 9
automatisms ! ictal aphasia Supplementary figure 8
Epigastric aura (presses the alarm button) https://www.jle.com/en/revues/epd/e-
Aphasia !responsive (follows command to raise R arm) docs/video_atlas_of_lateralising_and_localising_
! ictal aphasia/anomia (unable to name seizure_phenomena_288739/article.phtml?tab=
objects)+ R hand ictal dystonia videos&cle_video_une=289023
[403]

S. Beniczky, et al.
~

L face grimacing ! non-fluent aphasia (seizure 2: 1.02-1.25 sec)
(anomia) https://www.jle.com/en/revues/epd/e-
(see Affective) docs/seizure_semiology_of_anti_lgi1_antibody_
encephalitis_310814/article.phtml?tab=videos&
[425]
AUTONOMIC PHENOMENA
Cardiovascular
Tachycardia Ictal apnea ! tachycardia ! ictal coughing https://www.jle.com/en/revues/epd/e-

(Note the respiratory and ECG signal and video docs/intractable_apnoeic_seizures_in_a_child_
description) with_a_deletion_typically_associated_with_
(see Hypoventilation) williams_syndrome_313319/article.phtml?tab=
[434]
Ictal asystole ! syncope https://www.jle.com/en/revues/epd/e-docs/ictal_
(Note interruption of the ECG signal) asystole_with_intercurrent_cardiopathy_a_
complex_combination_leading_to_delayed_
diagnosis_315811/article.phtml?tab=videos&cle_
video_une=315867
Ictal bradycardia [435]
and asystole
Bradycardia ! ictal asystole ! syncope https://www.jle.com/en/revues/epd/e-
(Note interruption of the ECG signal) docs/syncope_due_to_ictal_asystole_a_
challenging_semiology_318836/article.phtml?
[436]
Cutaneous
Piloerection Ictal piloerection https://www.jle.com/en/revues/epd/e-
docs/autonomic_symptoms_during_epileptic_
seizures_110095/article.phtml?tab=videos&cle_
video_une=285229
[295]
Gastrointestinal
Ictal spitting Focal aware seizure: aura (feeling that she https://www.jle.com/en/revues/epd/e-docs/ictal_
wants to spit) ! ictal spitting spitting_in_non_dominant_temporal_lobe_
epilepsy_an_anatomo_electrophysiological_
correlation_311737/article.phtml?tab=videos&
[437]
Ictal vomiting (Panayiotopoulos syndrome): https://www.jle.com/en/revues/epd/e-
Brief tonic posture of legs ! non- docs/panayiotopoulos_syndrome_videoeeg_
responsiveness + eye deviation upwards ! eye illustration_of_a_typical_seizure__263027/article.
version L ! ictal vomiting (see Section 3.09) phtml?tab=videos&cle_video_une=285259
[438]
Ictal vomiting
Focal aware seizure: aura (patient pressing the https://www.jle.com/en/revues/epd/e-
alarm button) ictal retching ! ictal vomiting ! docs/autonomic_symptoms_during_epileptic_
R arm automatisms ! slight dysarthria seizures_110095/article.phtml?tab=videos&cle_
video_une=285225
[295]

~

Respiratory Dysfunction
Hyperventilation Hyperventilation ! L gestural automatisms ! https://www.jle.com/en/revues/epd/e-
hyperkinetic ! ictal vocalizations ! R head docs/autonomic_symptoms_during_epileptic_
version ! tonic seizures_110095/article.phtml?tab=videos&cle_
(see Hyperkinetic) video_une=285223
[295]
Hypoventilation Apnea ! tachycardia ! ictal coughing https://www.jle.com/en/revues/epd/e-
(Note the respiratory and ECG signals; see docs/intractable_apnoeic_seizures_in_a_child_
Tachycardia) with_a_deletion_typically_associated_with_
williams_syndrome_313319/article.phtml?tab=
[434]
POSTICTAL PHENOMENA
Postictal nose wiping (Seizure from sleep) opening eyes ! https://www.jle.com/en/revues/epd/e-
oroalimentary automatisms ! R gestural docs/seizure_ending_signs_in_patients_with_
automatisms ! responsive ! R postictal nose dyscognitive_focal_seizures_305235/article.
wiping phtml?tab=videos&cle_video_une=305312
(see Distal Automatisms) [419]
Postictal paresis and Ictal: L head version ! L gestural automatisms https://www.jle.com/en/revues/epd/e-
aphasia ! R gestural automatisms + R arm dystook nic. docs/postictal_signs_of_lateralizing_and_
(see also under Dystonic and Distal [374]
Automatisms)
Postictal coughing, Oroalimentary automatisms ! Bilateral leg https://www.jle.com/en/revues/epd/e-
nose wiping and proximal automatisms ! hyperventilation ! docs/autonomic_symptoms_during_epileptic_
unresponsiveness vocal automatisms +R arm dystonic ! seizures_110095/article.phtml?tab=videos&cle_
nonresponsive L arm gestural automatisms ! L video_une=285222
arm exploratory movements ! Postictal: L nose [295]
wiping + coughing, + unresponsiveness
standardized behavioral testing of the patients in ate responses and/or an unusually prolonged reaction
epilepsy monitoring units [18]. An appropriate re- time.
sponse is a composite end-result of functional Responsiveness is lost in generalized tonic-clonic
activities in complex neurological networks, which seizures (GTCS), but not necessarily during general-
might include proper sensory perception and proces- ized myoclonic seizures. In most absence seizures,
sing along with prompt motor execution. These patients are non-responsive, but the responsiveness
responses might be context and culture specific, might be partial [21, 22, 40]. In focal seizures, partial or
affected by the intellectual and emotional level of the complete absence of responsiveness might be seen.
patient [19, 24]. Verbal responses might be more affected in focal
Non-responsive implies lack of response to repeated epilepsies with dominant hemispheric involvement,
questions commands or other external stimuli. Spinal while partial responsiveness during automatisms
reflex withdrawal in response to a noxious stimulus suggests involvement of the non-dominant hemi-
without an appropriate emotional response might still sphere [20, 50, 51].
occur in this non-responsive phase [14, 19, 23]. Motor or behavioral arrest is related but not identical
Partially responsive implies inconsistent, inappropri- to impaired responsiveness. Behavioral arrest is

S. Beniczky, et al.
common in absence seizures and in focal seizures leads to falling without specificity for identifying the
with impaired awareness or impaired responsiveness. underlying mechanism (i.e., from atonic, myoclonic,
However, behavioral arrest may be observed based on or tonic seizures) which is most often ill-defined in the
interruption of ongoing motor activity even if absence of polygraphic video-EEG monitoring that
responsiveness to external stimuli is not assessed. involves recording surface electromyography.
3.3. Atonic
3. Elementary motor signs
Atonic refers to a sudden loss or decrease in muscle
Elementary or simple motor signs involve the skeletal tone involving the head, trunk, jaw, and limbs. Atonic
musculature during seizures. They consist of an seizures typically last 1-2 seconds and can result
increase (positive) or decrease (negative) in contrac- in a loss of postural tone, without tonic, clonic,
tion of a muscle or group of muscles that is unnatural, or myoclonic manifestations. Consequences of
stereotyped and not decomposable into phases. atonic seizures frequently involve falls and injury.
There can be synchronous (or asynchronous) involve- Atonic seizures occur in both generalized and focal
ment of motor signs. They can be isolated events or epilepsies and are a cardinal semiology in Lennox
occur in a repetitive fashion. When they do occur, Gastaut syndrome. Their occurrence in focal
they do so at the same rate of contraction, and in the seizures suggest motor and premotor cortex involve-
various muscle groups in the body. The commonly ment [57].
used term tonic-clonic is an elementary sequence of
motor signs. 3.3.1. Negative myoclonus
Negative myoclonus is used to describe a brief
3.1. Akinetic interruption of muscle tone (<500 msec), like atonic
seizures. This results in a sudden brief lapse in
Akinetic motor signs are those characterized by the movement that may grossly appear like a “positive”
inability to perform voluntary movements with myoclonic jerk which is manifest as a single lighten-
preserved postural tone and awareness. It is a rare ing-like jerk (see 3.5). However, the pathogenesis is
ictal phenomenon and must be distinguished from different [58]. It can occur in a heterogeneous group
motor and behavioral arrest with staring, impaired of epilepsy syndromes disorders, ranging from self-
awareness, and motor arrest. Akinetic motor signs are limited syndromes, atypical self-limited childhood
without strong localizing or lateralizing value. Aki- epilepsy with centrotemporal spikes and electro-
netic motor signs are often associated with dystonic graphic status epilepticus in slow wave sleep, to focal
phenomena (see 3.8), but it can also evolve to include epilepsies involving lesions of the mesial frontal
progressive loss of muscle tone (see 3.3). Muscle tone structures (as in neuronal migration disorders), and
may be lost, but akinesia dominates the semiology. severe static or progressive myoclonic developmental
The same phenomenon can be observed for speech and epileptic encephalopathies.
production (aphemia or speech inhibition). Ictal
akinesia can manifest by an abrupt freezing of one’s 3.4. Eye blinking
gait initiation and may be precipitated by startle [52].
Akinetic motor signs and aphemia must be distin- Ictal eye blinking consists of a series of repetitive tonic
guished from ictal paresis and aphasia respectively contraction of the eyelids during a seizure. This
(see 3.11 and 7.2). Aphemia is characterized by the occurs without any other facial muscle contraction. Its
inability of articulation, including other movements of pathogenesis suggests activation of the trigeminal
the oro-laryngofacial muscles (i.e., inability to purse nerve fibers associated with the blink reflex [59]. Ictal
the lips, stick out the tongue open the mouth or eye blinking must be separated from repetitive facial
swallow voluntary in the presence of preserved clonic jerks that are observed during motor seizures,
comprehension). Akinetic signs are likely to occur as well as from eyelid myoclonia (often associated
during seizures that involve “negative motor” areas with a sustained upward gaze – see next sub-section).
(i.e., mesial premotor cortex and inferior frontal gyrus) The localizing significance of eye blinking remains
[53-55], and can be produced by direct electrical uncertain – though it seems over-represented in
stimulation of the same regions [55, 56]. patients with posterior quadrant epilepsies [60]. Its
lateralizing value, when unilateral, suggests an ipsilat-
3.2. Astatic eral epileptogenic hemisphere [61]. Unilateral ictal
eye blinking is believed to result from cortical blink
Astatic seizures (a.k.a. ”epileptic drop attack”) refer to inhibition of the contralateral eye, due to seizures in
a sudden loss of maintaining an erect posture. This the frontotemporal region [61].

3.5. Myoclonic / 3.6. Clonic leg. The dystonic posture can manifest as flexion or
extension and be proximal or distal, frequently with a
Myoclonic jerks (a.k.a. myoclonus) are a sudden, brief rotatory component. In the context of patients with
(<100-msec) involuntary, single or multiple contrac- temporal lobe epilepsy, unilateral ictal dystonia of the
tion(s) of muscle(s) or muscle groups of variable upper limb almost always lateralizes to the hemi-
topography. The term clonic (synonym rhythmic sphere contralateral to the seizure onset zone [68-70].
myoclonic) should be preferred to account for This sign, however, may have a weak interrater
myoclonic jerks that are regular and repetitive, at a reliability when temporal and extratemporal lobe
low frequency that is typically 0.2-5 Hz. They involve epilepsies are mixed [64] and may be related to ictal
the same muscle groups and vary in duration but are propagation and involvement of the basal ganglia
commonly prolonged. These elementary motor phe- following seizure onset [71].
nomena can occur both in generalized and in focal
seizures. In generalized seizures, they are usually 3.9. Gyratory
bilateral, but not always synchronous and symmetric.

The traditional term “Jacksonian march” indicates Gyratory seizures (a.k.a. rotatory, circling, volvular)
spread of unilateral focal clonic movements through refer to seizures where the patient rotates around
contiguous areas on the body. This approximates their long body axis. This involves at least 180 degrees
seizure propagation within the motor homunculus of and occasionally produces one or even more than one
the brain. In focal motor seizures, unilateral clonic turn involving 360 degrees. This phenomenon may be
manifestations have a high lateralizing value to the initiated by a versive head movement in the same
contralateral hemisphere (approximately 90%) [62-64] direction (see 7.13) and may culminate in a focal-to-
and strongly reflect involvement of the motor cortex. bilateral tonic-clonic (FBTC) seizure. Gyratory mani-
Eyelid myoclonia refers to rapid (3.5-6-Hz) eye festations have been reported during focal seizures
blinking, flickering, trembling, fluttering, twitching, and rarely in patients with generalized epilepsies [72].
or jerking. It is often associated with sustained upward During focal seizures, the direction of the rotation
gaze deviation, with and without absences, in patients lateralizes the seizure onset zone to the contralateral
with Jeavons syndrome [65]. The characteristic EEG hemisphere when head version initiates the gyration
correlate is generalized polyspike-wave or general- [73]. In gyratory seizures without a preceding forced
ized spike-wave discharges at 3 to 6 Hz. These head version, the direction of rotation may be
seizures are typically seen after eye closure (eye ipsilateral or contralateral to the side of seizure onset
closure sensitivity) and the patients are photosensi- [73]. The mechanism remains unknown, though basal
tive. It should be distinguished from the repetitive, ganglia involvement [74] and interhemispheric imbal-
3-4-Hz eye blink seen during absence seizures in ance of cortical excitability [75] have been suggested.
patients with idiopathic / genetic generalized epilep-
sy. fMRI studies suggested that eyelid myoclonia with 3.10. Epileptic nystagmus
absences involve a circuit encompassing the occipital
cortex and the cortical-subcortical systems physiolog- Epileptic nystagmus, sometimes described as oculo-
ically involved in the motor control of eye closure and clonic jerks, is a rapid, repetitive movement of the
eye movements [66]. eyeballs probably caused by the epileptiform activity
involved in activation of the cortical region governing
3.7. Myoclonic-atonic saccadic or pursuit eye movements. It is binocular in
most cases and may be preceded or accompanied by
The term myoclonic-atonic, often replaced by the simple visual hallucinations. It is often associated with
more imprecise term myoclonic-astatic, refers to a rotation of the head and eyes that is often in the same
type of generalized seizure associated with a myo- direction as the fast phase of nystagmoid eye
clonic jerk followed by an atonic motor component movement which is most prominent [76]. Epileptic
[5]. This seizure type is the hallmark semiology in nystagmus is mainly seen during seizures of occipital
patients with Doose syndrome [67]. lobe origin, and the fast phase is most often
contralateral to the site of seizure onset [77].
3.8. Dystonic
3.11. Ictal paresis
Dystonia associated with a seizure (ictal dystonia)
consists of sustained contractions involving both Ictal paresis is a rare phenomenon. It is characterized
agonist and antagonist muscles. This produces by weakness or paralysis of a part of one’s body or
athetoid or twisting movements which, when pro- hemibody [78-80]. Ictal paresis must be differentiated
longed, may produce unnatural postures of an arm or from ictal akinesia (see 7.1), ictal immobile limb in

S. Beniczky, et al.
patients with temporal lobe epilepsy [81], and “symmetrical and sustained (>3-sec) lowering of labial
postictal Todd’s paresis (see 9.2). A proper diagnosis commissures with contraction of the chin, mimicking
therefore necessitates video-EEG to test the patient an expression of fear, disgust, or menace” [88]. This
[18] and confirm the ictal origin of the motor deficit. produces a facial expression that is recognized by a
Ictal paresis is almost always contralateral to the turned down mouth that appears as an inverted smile.
seizure onset zone and is likely to be produced by Seizures involving this semiology have been termed
seizures that occur in close vicinity to the primary chapeau de gendarme due to the shape of the hat
motor cortex [82]. used by French police (gendarme) during the reign of
Napoleon. When it occurs early during seizures, it has
3.12. Epileptic spasm a strong localizing value to the frontal lobe [89],
especially the anterior prefrontal and anterior cingu-
An epileptic spasm describes a seizure comprised of late cortices [88, 90]. However, other localizations
sudden flexion, extension, or mixed extension-flex- have also been described [91-93].
ion. Spasms involve predominantly the proximal

head, appendicular and truncal muscles and are more 3.13.2. Fencing posture
sustained than brief clonic and myoclonic move- The fencing posture (a.k.a. fencer’s posture) is a motor
ments, but not as sustained as tonic posturing which sign with tonic extension at the elbow and elevation of
may last 0.5-2 seconds. Typically, spasms consist of a one arm and strongly lateralizes to the contralateral
series of episodes with abduction and extension of hemisphere. In addition, there is associated ipsilateral
both arms. Subtle forms of spasms, with minimal / flexion of the elbow in the ipsilateral upper limb and
discrete manifestations may occur, including head elevation at the shoulder to approximate the posture
nodding, grimacing, smiling, or chin movement. held during fencing. This typically occurs late in the
Epileptic spasms usually occur in clusters, often upon course of a seizure. A similar unilateral posture, M2e,
awakening [83]. They have been classified as general- is a similar semiology beginning with flexion of the
ized seizures, focal seizures and unclassified seizures elbow to about 90 degrees and followed by an
in the current ILAE seizure classification [5]. When abduction of the shoulder to approximately 90
unilateral or asymmetric, they point towards a degrees, associated with external rotation with or
lateralized onset in the contralateral hemisphere without head turning towards the affected arm [94].
but do not have localizing value [84]. The hand may be clenched or open, and the head is
typically deviated towards the hand. The initial
3.13. Tonic description emphasized that a M2e motor posture
should be used as a descriptor only if the contralateral
A tonic seizure consists of a sudden posture involving arm is initially uninvolved or becomes involved in
increased tone resulting in stiffness or tense posture tonic activity later during the seizure. This sign has a
due to sustained muscular contraction that usually strong lateralizing value and points to the contralat-
causes an extension. Seizures with tonic features may eral hemisphere, with an excellent interrater reliability
also affect the flexor muscles. Each event ranges from [64]. It is classically ascribed to the mesial frontal lobe,
a few seconds to minutes in duration. Tonic contrac- and more specifically to the supplementary motor
tion may involve one or more limbs, the body axis and area.
face. When tonic seizures are bilateral, they may be 3.14. Tonic-clonic
symmetric or asymmetric. They can occur in focal and
This is an important ictal motor sequence of events
generalized seizures. Tonic seizures can be precipi-
consisting of a tonic phase followed by a clonic phase.
tated by startle, in which case the tonic contraction is
In GTCS, it may be preceded by sporadic or irregular
bilateral. They may be symmetrical or asymmetrical
myoclonic jerks (myoclonic-tonic-clonic), by an initial
and frequently lead to falls [85]. Unilateral tonic
clonic phase (clonic-tonic-clonic) or by an absence
seizures lateralize to the contralateral hemisphere in
seizure (absence-to-bilateral-tonic-clonic seizure)
approximately 90% of patients with focal epilepsy.
[95]. In focal seizures, the bilateral tonic-clonic phases
However, its localizing value is poor [62-64, 86]. Direct
are typically preceded by other focal semiologies
electrical cortical stimulation has shown that contra-
(FBTC). However, when they occur at night and are
lateral tonic contractions can be elicited by stimulat-
unwitnessed or before its treatment, it may be
ing the mesial premotor and primary motor cortices
impossible to identify the presence of focal signs or
[87].
symptoms. Two types of FBTC have been proposed
3.13.1. Chapeau de gendarme based on their semiology, suspected pathophysiolo-
In the original description, the “chapeau de gen- gy, and potential impact on the risk of SUDEP [96].
darme” sign (a.k.a. ictal pouting) consists of a GTCS type 1 at some point displays the classic

sequence of bilateral and symmetrical tonic posturing It is important to differentiate asymmetric clonic
with arms extended in supination, as in decerebrate ending from asymmetric amplitude of the jerks
posturing (suggesting involvement of the ictal dis- between the two sides of the body, as this alone
charge in the brainstem), followed by bilateral clonic should not be considered as asymmetric clonic
jerking with gradually decreasing frequency, which is ending.
generated by progressively longer silent periods
interrupting sustained tonic activity from inhibition 3.15. Versive
of muscle activation waning until the seizure stops
[97]. GTCS type 2 involves a tonic and clonic sequence Version must be used only to describe an unnatural,
that is often superimposed. When the two phases are forced and sustained movement of the eyes, head,
sequential, the clonic phase has a rhythmic quality trunk or whole body to one side. Small lateral saccadic
that is more sustained, without the exponential and clonic features can be superimposed during
dynamic changes observed in GTCS type 1 [97]. The version. During head-turning, the chin may move
motor features in GTCS type 2 suggest primary laterally but also upward or downward, depending on
involvement of the pre-motor and/or motor cortex, the muscles involved. Occasionally, seizures with
rather than propagation of the ictal discharge to the version can lead the patient to rotate around the long
subcortical and brainstem structures. This is further body axis. In this case, the term gyratory is applied
denoted by awareness that is partially retained in rare (see 3.9). Ictal version does not refer to a gaze
patients with GTCS type 2. Furthermore, the same preference or to other situations where the patient’s
clinical sequence described in patients with GTCS eyes, head or trunk deviate to one side (see 3.16). Ictal
type 2 can be observed unilaterally and asymmetrical- body turning is a term that encompasses different
ly typically pointing to a contralateral seizure onset semiological signs. Ictal version can be seen with focal
zone. Finally, a GTC type 2 can evolve into a GTCS seizures arising from any location. Their lateralizing
type 1, in which case the latter is described as the significance varies depending on the type of version
main semiology of the seizure. GTCS type 1 leads and whether it involves the eyes, head, or body, and
to postictal EEG suppression more frequently whether they are conjugate, sequential, and accom-
than GTCS type 2 [96]. This suggests that patients panying signs that occur [102]. Isolated version
with GTC type 1 might be associated with a higher risk involving the eyes likely involves the contralateral
of SUDEP. frontal eye fields. Direct electrocortical stimulation
has supported this localization by reproducing the
3.14.1. Figure-of-4 sign
same clinical signs [103]. However, when initial visual
The figure-of-4 sign may occur at the onset of the tonic
illusions / hallucinations are congruent with ocular
phase prior to the clonic phase in patients with FBTC
version, this suggests seizures arise from a contrala-
seizures. This semiology consists of unilateral tonic
teral occipital lobe origin. Head version strongly
extension of one arm and tonic flexion of the
lateralizes to the contralateral hemisphere when it is
contralateral arm. The latter may be held in front or
associated with neck extension and occurs in the first
behind the extended arm. This sign is considered to
10 seconds of a FBTC seizure [64, 104, 105]. In the
have a good lateralizing significance [64, 98] with the
situation where two successive head versions occur
extended arm occurring contralateral to the hemi-
prior to a FBTC seizure, it is the movement immedi-
sphere involved in seizure onset. The sequence of
ately preceding the tonic-clonic phase that prevails as
motor signs is important and can be complex, with
the lateralizing sign.
tonic extension of one limb first, followed by the
figure-of-4 sign pointing to the other hemisphere. In
this situation, it is the first manifestation of arm 3.16. Head orientation
extension that prevails to lateralize the seizure onset
zone. Non-versive turning of the head and eyes is a
frequent, but not specific sign when determining
3.14.2. Asymmetric clonic ending lateralization and localization. When it occurs early in
This sign refers to the terminal expression involving temporal lobe seizures, it is often ipsilateral to the
clonic jerks following a focal-to-bilateral-tonic sei- focus [106].
zure. When convulsive seizures terminate asymmet-
rically with unilateral clonic jerks that persist on one
side of the body, this has good lateralizing signifi- 4. Complex motor behaviors
cance for seizure onset. The last unilateral clonic
activity that persists occurs ipsilateral to the hemi- Complex motor behaviors refer to a heterogeneous
sphere of seizure onset, regardless of lobar localiza- group of motor signs and sequences. While some may
tion including temporal or frontal origin [64, 99-101]. look voluntary, the patient has no capacity to control

S. Beniczky, et al.
them during the seizure and they are inappropriate manipulating movements) can be self-directed (virtu-
for the situation. Gestures involving complex motor ally independent of environmental influence) or
behavior may or may not resemble natural move- involve more than self (environmentally influenced).
ments. They can be mixed with elementary In the context of temporal lobe epilepsy, unilateral
motor signs and may be associated with facial manual automatisms lateralize to the ipsilateral hemi-
expressions and verbalization or vocalization sphere mainly when associated with a contralateral
congruent with the motor pattern [107]. The patho- hand dystonia [111].
physiology of complex motor behaviors is unclear
4.1.3. Genital automatisms
and possibly depends on the type of motor involve-
Gestural automatisms are directed to involve the
ment. Features that occur during seizures with
genital region. These complex motor behaviors
complex motor behaviors could be due to a release
may appear with a sexual appearance including
phenomenon of stereotyped inborn networks
fondling, grabbing, scratching among other beha-
with fixed action patterns (central pattern genera-
viors. They are often unilateral and associated with

tors) [108] or due to transient “desynchrony” in
manual automatisms. They are frequently ipsilateral
emotion-regulation networks [109], rather than to a
to the hemisphere involving the seizure onset
specific ictal involvement of an individual area in
zone [112].
the brain.
4.1.4. Ictal grasping
4.1. Automatisms Ictal grasping is defined as a uni- or bi-manual forced
prehensile movement often preceded by reaching. It
The term automatism is used to account for an is either directed towards the patient’s body or
irrepressible, discrete or excessive and repetitive surrounding one’s personal space. It rarely occurs
single motor activity that often resembles a volun- as the main clinical component of the seizure [113]
tary behavior. They may appear to occur with a semi- and is frequently part of hyperkinetic behaviors (see
purposeful act such as disrobing and manipulating 4.2) [114]. It may be reproduced by direct electro-
objects or without the appearance of a purposeful cortical stimulation of the anterior cingulate cortex
behavior such as body rocking. Depending on the [115]. Ictal grasping is often contralateral, but it is
clinical situation at seizure onset (i.e., eating, writing, without consistent lateralizing value.
waving etc.), automatisms may consist of an inap-
4.1.5. Proximal automatisms
propriate continuation of preictal activity. The speed
and amplitude of the movements are most often Proximal automatisms are described when rhythmic
in the context of normal movement but they may repetitive movements of the proximal extremities
also appear to be exaggerated (as in hyperkinetic occur (e.g., pedaling, kicking, wing flapping, body
behaviors; see 4.2), and awareness is usually, but not rolling, rocking, crawling, and copulatory move-
necessarily, impaired. Patients seldom retain aware- ments). These often result in highly visible move-
ness when exhibiting automatisms yet they will ments with high amplitudes and fast speeds. They co-
typically be unaware of them. exist as part of hyperkinetic behavior (see 4.2) and
their localizing significance is unclear, though often
4.1.1. Gestural automatisms are associated with seizure onset in the frontal lobe
Gestural automatisms are rhythmic repetitive move- involving the anterior cingulate or orbito-frontal
ments of the hands and occasionally also of the feet, as cortex, though may also be seen in insular, temporal
distal automatisms. They may also involve the limbs and parietal lobe seizures.
and body axis involving proximal automatisms.
4.1.6. Mimic automatisms
Gestural automatisms may be unilateral or bilateral
Mimic automatisms refer to a stereotyped mimicry or
when they occur (see 4.1.2-4.1.5). They need to be
behavior that resembles the usual way one expresses
distinguished from rhythmic ictal non-clonic hand
oneself to reflect an affect that is not accompanied by
motions (RINCH), which are usually contralateral to
the corresponding emotion. The most frequent types
the focus [107, 110]. RINCH are unilateral, rhythmic,
of mimetic automatisms are laughing (gelastic) [116-
non-clonic, non-tremor hand movements (low-ampli-
118] and crying (dacrystic, quiritarian) [119, 120]
tude milking, grasping, fist clenching, or pill rolling, or
behaviors which, when isolated and occurring in
larger-amplitude hand opening–closing movements),
clusters, should make one consider the possibility of
usually followed by dystonic posturing, sometimes
hypothalamic localization (i.e., hamartoma). Other
with overlap.
localizations also exist, mainly involving the frontal
4.1.2 Distal automatisms and temporal lobes. Laughter can be elicited by direct
Distal automatisms (e.g., tapping, crumbling, fumbling, electrocortical stimulation of the anterior cingulate
grasping, finger snapping, exploratory movements, gyrus, which may be first asymmetric (contralateral to

the stimulation) and then bilateral [121, 122]. A movement. The overall resulting appearance of the
tendency for ictal laugh, though without overt motor behavior can be integrated with physiologic
laughter (hence not qualifying as a gelastic seizure), movement, though may be exaggerated during a
has been described in patients with small hypotha- motor sequence and be aligned with a facial expres-
lamic hamartomas [123]. sion and vocalization. It may also be non-integrated
Other mimic automatisms are rarely identified but appearing unnatural and separated from other
include the expression of negative (e.g., biting, fear, behavioral features [107]. Hyperkinetic behaviors
sadness) [124, 125] and positive (i.e., kissing) emo- are often produced by seizures arising from the
tional valences [126], or musical automatisms (e.g., frontal lobe [137-139]. In frontal lobe epilepsies, the
humming and whistling) [127-129]. behaviors exhibit a clinical continuum. Seizures with
hyperkinetic behavior may originate from the
4.1.7. Oroalimentary automatisms
rostral prefrontal regions, where highly integrated
Oro-alimentary automatisms including chewing, lip
behaviors predominate, or arise from the premotor
smacking, lip pursuing, licking, and swallowing

cortex that produces more elementary motor signs
resemble normal routine behaviors and are frequent-
[107, 139, 140]. However, hyperkinetic behaviors may
ly encountered in patients with temporal lobe
also occur in seizures originating in extra-frontal
seizures, especially those arising from the mesial
regions of the brain. These include the temporal lobe,
structures. Recent findings also suggest that insulo-
the insula or insulo-operculum, and the posterior
opercular involvement is needed to facilitate their
cortex [138].
occurrence [130, 131]. The appearance of preserved
awareness during such automatisms is more likely to
occur during temporal lobe seizures that arise from 5. Sensory phenomena
the non-dominant hemisphere for language [132].
4.1.8. Verbal automatisms Sensory phenomena involve paroxysmal perception
Verbal automatisms reflect the iterative and stereo- of positive (or rarely negative) sensory experiences
typed production of intelligible words or sentences that are not entirely caused by external stimuli, and
and must be distinguished from ictal speech, which is not due to a non-epileptic etiology (e.g. carpal tunnel
the ability of patients to converse during a seizure. syndrome). When these subjective ictal phenomena
The term ictal speech has incorrectly been used as a precede observable signs of a clinical seizure, they are
substitute term for verbal automatisms generating described by patients as a sensory aura. When they
confusion. Verbal automatisms are frequently seen in occur independently, they constitute a focal aware
patients with temporal lobe seizure though lateraliza- sensory seizure [3].
tion is inconsistent. Foreign ictal speech automatisms
5.1. Auditory symptoms
are a rare form of verbal automatisms and are more
likely to occur in patients with seizures arising from
Elementary auditory symptoms are uni- or bilateral
the non-dominant amygdala [133].
buzzing, drumming, ringing, whistling sounds. They
4.1.9. Vocal automatisms can be narrow- (single tone) or broad-band (noise)
Vocal automatisms, or vocalization, refers to single or [141, 142]. Auditory illusions refer to an alteration of
repetitive sounds (e.g., grunts, shrieks, moaning etc.) unimodal auditory perceptions which can consist of a
that do not have the linguistic qualities of language modification of intensity (more or less intense) of tone
like verbal automatisms (see 4.1.8) and are unaccom- (higher or lower pitched) or distance (closer or farther
panied by apnea, tonic, clonic, or tonic-clonic motor away). They may also occur as an echo of the percept
manifestations [134]. Ictal vocalization by itself has no and be perceived monaurally or binaurally [141, 142].
localizing significance but it occurs more frequently in Elaborate auditory hallucinations refer to unimodal
dominant (left-sided) temporal [135] and frontal [136] auditory hallucinations such as voices or melodies
lobe seizures. without multimodal or a clear mnemonic component
[141, 142].
4.2. Hyperkinetic behaviors Auditory phenomena point almost exclusively to the
superior temporal gyrus [143, 144], and rarely to the
Hyperkinetic or hypermotor seizures refer to the long posterior gyrus or the short anterior gyrus in the
quantitative aspect of motor involvement. Hyperki- insula [145].
netic behavior shows an excessive amount and speed Elementary auditory phenomena point to the primary
of motor movement. There is an increased rate and auditory cortex in the superior part of the temporal
acceleration of ictal motor movement and the lobe (Heschl’s gyrus). Elaborate auditory features are
appearance or inappropriate rapid performance of a rare and point to the “interpretive” auditory cortex

S. Beniczky, et al.
comprising the anterior superior temporal gyrus and lingula and ventral temporal cortex. Ictal visual loss is
the planum temporale without clear lateralizing value thought to reflect a disruption of function in the
[143, 146]. calcarine sulcus. This may be either unilateral or
bilateral. Regarding the visual loss, concentric
5.2. Visual symptoms changes of visual fields have a different localizing
value and would point towards a more anterior basal
Visual symptoms may be composed of either positive or medial temporal disturbance [151]. Illusions such as
or negative phenomena during seizures. Positive dyschromatopsia and blurring appears to be more
elementary phenomena are comprised of static or specific for the ventral and medial temporal structures
moving unformed flashes of lights, “spots”, or [148] and often reflects a right hemispheric lateraliza-
“blobs”. They may be white, black or include color, tion. Illusions of movement (kinetopsia) are repre-
remain localized or be non-localized within a visual sented by a disturbance of the lateral occipital and
field (i.e., quadrantic, hemi-field, or occupy the whole lateral occipito-temporal junction [153]. Illusions of
visual field) [147-149]. Negative elementary phenome- size (e.g. micropsia, macropsia and the Alice in
na correspond to transient amaurosis of the entire Wonderland syndrome), shape (metamorphopsia)
visual field or scotoma when it is confined to part or number (polyopia) suggest a disturbance in the
of it (quadrantanopia, hemianopia, tunnel vision) posterior medial parietal region (pre-cuneus and
[147, 148, 150, 151]. Intermediary visual hallucinations occipito-parietal sulcus). Elaborate hallucinations of
are more complex. They may appear as geometric faces point towards a disturbance of the right cuneus,
forms (i.e., stars, circles, triangles, squares, diamond) occipito-parietal sulcus, and the pre-cuneus and
[148, 150] and possess a slightly different sub-lobar fusiform gyrus [148]. Other elaborate hallucinations
localizing value [148]. Visual illusions comprise a great (places, persons, body parts, scenes) would reflect a
variety of visual phenomena affecting an object or its disturbance of the basal and medial temporal
visual background. This spans from visual blurring to structures [151, 157]. Prosopagnosia and distortion
an alteration of size (micropsia/macropsia), color of facial perception are the only reported elaborate
(dyschromatopsia), shape (metamorphopsia), dis- visual deficits described and point to the right
tance or movement (kinetopsia), and number (diplo- temporo-basal/fusiform and inferior occipital gyrus
pia, polyopia) [147, 148, 151-154]. Palinopsia refers to [155, 160, 161].
the persistence or recurrence of a visual object when
the stimulus is no longer present. Elaborate visual 5.3. Gustatory symptoms
phenomena refers to unimodal visual hallucinations
with detailed and meaningful implications such as Gustatory symptoms represent abnormal paroxysmal
faces, people, body parts, animals, and images of tastes within the mouth or in the throat. These are
scenes that occur without a clear mnemonic or usually unpleasant, and may be reported as salty,
affective component, as well as unimodal visual metallic, bitter, sour, acidic or indescribable [162, 163].
hallucinations associated with elaborate negative Gustatory symptoms are sometimes difficult for
phenomena which is dominated by the presence of patients to separate from olfactory symptoms and
prosopagnosia [148, 155-157]. may be associated together in the same subjective
Visual phenomena are a key feature of occipital experience during a seizure.
seizures occurring in 68 - 88% of patients [158, 159]. Gustatory symptoms during seizures are rare (occur-
However, they are not specific for occipital localiza- ring in around 4-8% cases) [162, 164]. They have been
tion and may occur less frequently during parietal, reported in seizures from peri-rolandic, insular and
anterior ventral and medial temporal and occipito- opercular regions, and less frequently from the medial
temporal lobe seizures. Elementary visual hallucina- temporal structures (amygdalohippocampal complex)
tions may reflect the transient disturbance in the without clear lateralizing value [144, 162, 165-167].
calcarine sulcus (primary visual cortex) caused by
seizures, but they may also arise from the lingula, 5.4. Olfactory symptoms
cuneus, and fusiform gyrus. Less often, they arise
more anteriorly from the lateral, basal and medial Olfactory symptoms are defined as a paroxysmal
temporal structures [148, 149]. When located in the unexplained sense of smell. These are usually, but not
center of the visual field, they reflect the disturbance always, unpleasant and can be neutral or even
of the calcarine sulcus. When elementary visual pleasant experiences. Olfactory hallucinations can
symptoms are unilateral, they occur contralateral to be described as an odor of burning, sulfur, alcohol,
the site of seizure onset. Intermediate hallucinations gas, garbage, barbecue, flowers, among other descrip-
have the same localizing and lateralizing value except tions, or be indescribable [168, 169]. These olfactory
that they reflect the disturbances of more anterior symptoms are sometimes difficult to differentiate

from gustatory symptoms by the patients and may be secondary somatosensory area in the parietal oper-
associated in the same subjective ictal experience. culum. Contralateral or bilateral sensory symptoms
Olfactory symptoms during seizures are rare, consti- have also been reported to originate in the supple-
tuting about 0.6% - 16% of all subjective manifesta- mentary sensorimotor area, the superior frontal gyrus
tions [168]. and cingulate motor area [176], and in the posterior-
Olfactory symptoms have been reported mostly in superior part of the insula [145].
seizures arising from medial temporal structures Painful somatosensory auras are described by patients
involving a range of etiologies including tumor and as acute and intense pain (burning sensation, pricking
hippocampal sclerosis though without lateralization ache, throbbing pain or muscle tearing sensation),
value [170, 171]. Electrical cortical stimulation studies affecting the body. Painful auras most often lateralizes
refined and extended these correlations and evoked the hemisphere involved at seizure onset [177].
olfactory symptoms in the medial temporal structures, Painful sensory auras may secondarily produce the
especially the amygdala, piriform cortex and uncus motor behavioral manifestations of pain, involving a
[172], near the olfactory bulb in the medial orbito- corresponding facial expression, verbal complaints
frontal cortex [169], mid-dorsal insula, and around the including shouting and crying, movements in an effort
insular central sulcus [163]. Olfactory auras have no to avoid a perceived stimulus, or autonomic changes
lateralizing value. such as facial pallor or flushing. Painful auras strongly
suggest involvement of the posterior insula and
5.5. Somatosensory symptoms parietal operculum [178]. Painful auras typically are
contralateral to seizure onset but they may be bilateral
Somatosensory symptoms may be described as or even ipsilateral when the painful sensation centers
tingling, numbness, electrical, shock-like sensation, in the face and trunk [179].
pain, or sense of movement [3]. They can be classified Segmental sensory auras involving temperature such
according to the localization and the quality of as warmth and cold are usually described as unpleas-
symptoms as unilateral paresthesia or numbness that ant. They often are unilateral when involving a limb,
follows a somatotopic pattern or displays a “Jackso- and seem to be associated with either somatosensory
nian march” in a segmental unilateral or bilateral or painful auras [180]. They are believed to point to the
distribution or as a painful somatosensory aura or same regions as those associated with painful auras.
sensation of heat [147, 166]. They should be differentiated from a non-localized
Somatosensory auras typically occur in patients with non-lateralized cold sensation associated with shiver-
parietal lobe seizures and represent the most ing which suggests localization in the amygdala.
frequently described aura arising from this region Ictal headache should be strictly differentiated from a
(in 29-63% cases) [165, 173, 174]. They are mostly painful somatosensory aura because they are thought
unilateral sensations, contralateral to the epilepto- to reflect a vascular mechanism rather than an
genic zone [4] but may also occasionally be bilateral or electrophysiologic disturbance involving a localized
even uni- and ipsilateral to seizure onset in 5% and cortical somatosensory area responsible for pain
2.5% of people, respectively [165]. [177]. It does not have localizing value [14] when it
Based on cortical electrical stimulation studies, is encountered, but is more likely to be ipsilateral to
unilateral paresthesia or numbness following a the seizure onset when it occurs in patients with
somatotopic pattern typically point towards the temporal lobe seizures [181].
contralateral primary somatosensory cortex on the
posterior bank of the central sulcus. Face and superior 5.6. Vestibular symptoms
limb paresthesia represent the most common locali-
zation (reflecting the large representation of these Vestibular symptoms may be defined as a sensation of
body parts in the sensory homunculus) and involve spinning or motion involving the body, with or
lateral neocortex, while lower limb paresthesia point without a sensation of unsteadiness [182]. This illusion
towards medial involvement [175]. If the involvement of motion might be described as rotatory symptoms in
of the paresthesia occupies one side of the body, then the up-down or left-right plane, a sense of movement,
seizures are most likely to arise contralateral to the floating, or undefinable sense of body motion [183]. In
involved upper and lower limbs. When involvement practice, it can be difficult to delineate the semiology
of the paresthesia is bilateral, seizures are more likely of vestibular symptoms and differentiate them from
to involve the midline body parts, especially the face the general non-specific term of dizziness that are
and trunk [175]. vague and ill-defined sensations. Vestibular auras are
Unilateral or bilateral paresthesia or numbness of rare, yet important symptoms reported with the
upper and lower limbs with segmental localization highest prevalence in patients with parietal lobe
without a sensory march typically point towards the seizures [165, 173]. However, they are not specific and

S. Beniczky, et al.
may also be encountered in patients with temporal symptomatology such as dreamy state (“mental
[144, 171], occipital [184], insular [167] and occasional- diplopia”), autoscopy, affective signs or symptoms,
ly frontal lobe seizures. At a sub-lobar level, focal or conscious automatic behavior. Therefore, it is not
cortical electrical stimulation studies during SEEG specific regarding localization and has been reported
emphasize the importance of the posterior perisylvian in frontal, temporal, insular, parietal and occipital lobe
region involving the supra-marginal gyrus, inferior seizures. Depersonalization needs to be differentiat-
parietal lobule, angular gyrus, superior and middle ed from derealization, which refers to the altered
temporal gyri, pre-cuneus, and insula. Vestibular perception of one’s surroundings that is experienced
phenomena have no consistent lateralizing value. as a sensation of unreality.
5.7. Body-perception illusion 5.9. Forced thinking
Somatagnosic auras result from a disturbance of Forced thinking is defined as involving intrusive
unimodal somatosensory (proprioceptive and tactile) thoughts, ideas, or words in people and should be
self-representation of the body. Autoscopic symp- differentiated from both a dreamy state and complex
toms result from a disturbance of multimodal self- sensory hallucinations [190, 191]. According to some
integration of body including visual perception of authors, the definition also includes an overwhelming
one’s body, either from an internal perspective of impulse to perform a certain act [192]. Due to the low
the body (autoscopic hallucination), or from an number of cases in the studies, the lateralizing and
external perspective (out-of-body-experience), or localizing value of ictal forced thinking remains
when patients cannot decide whether one’s self is uncertain. Most likely, the symptomatogenic zone
located inside the physical properties of the body or resides in the dominant frontal lobe [190].
reside outside of it (heautoscopic hallucination) [185].
Somatagnosic auras comprise non-visual, illusions of
the body such that one feels disconnected, dislocated 6. Affective (emotional) features
or a sense of movement, experiences phantom limbs
or reduplication, or deformity involving a body part Affective semiologies encompass an alteration in
[185]. These are rare but suggest a non-dominant mood or an apparent emotional experience or
(right) temporo-parietal junction as the site of seizure observation that is manifest by patients during
involvement [186]. seizures. Often, these subjective ictal symptoms are
Autoscopic hallucinations are rare, tend to be more reported at the onset of the seizures and may be
often perceived in the contralateral visual field and followed by other semiologies. When motor signs
suggest right (non-dominant) medial occipitoparietal occur simultaneously with them, the expression of an
cortex (pre-cuneus and occipito-parietal sulcus) affective (emotional) feature is classified under mimic
involvement [148, 187]. automatisms (see 4.1.6). The majority of ictal experi-
An out-of-body-experience typically points to the ences of emotion are unpleasant, such as anxiety and
non-dominant lateral parietal lobe [174, 186], but also fear (60%), and depression (20%), while ictal joy is only
may occur with seizures arising from the dominant rarely reported [193]. In one study, across all regions
temporoparietal region [188]. of interest, 58% of reported subjective affective
experiences were negatively valenced and unplea-
5.8. Depersonalization sant, whereas 15% of experiences were positive and
pleasant [194]. Clinical observations have often
Depersonalization is defined as the detachment from reported that patients with seizures arising from
oneself, either the mind or body. In addition, this may limbic structures lateralized to the right side of the
involve being a detached external observer of oneself brain have a higher incidence of emotional distur-
during a seizure. Depersonalization is not at all bances, such as fear and anxiety, than those who have
specific to epileptic seizures. It is classified as a seizures arising from the left side [195]. The emotions
symptom according to the DSM-5, involved in a with negative valence are most often formed from the
dissociative disorder [189], and is often encountered left (dominant) hemisphere, and those with a positive
in anxiety and panic disorders, as well as obsessive- or pleasant valence (or neutral valence) [196] are most
compulsive disorder, severe stress, use of recreational often lateralized to the right (non-dominant) hemi-
drugs and even in normal people following severe sphere [193, 196]. In 100 children, based on a study to
sleep deprivation. There is a phenomenological assess the value of focal seizures, emotions with
overlap between autoscopic phenomena (out-of- positive (pleasant) character were significantly more
body experience) and depersonalization. When asso- frequent during right-sided seizures while negative
ciated with epilepsy, it is associated with various ictal emotions did not lateralize the seizure onset zone.

Emotional semiologies are typically associated with seizures lateralized to limbic structures on the left
involvement of the limbic structures. The best-known side [195]. However, there have been some inconsis-
examples of affective symptoms are fear and anxiety. tent reports regarding the lateralizing value of ictal
These are generally considered to reflect involvement anxiety [203-207] making lateralization less distinct.
of the amygdala during temporal lobe seizures. Video- Seizures with anxiety when they arise from the mesial
EEG monitoring identified affective auras in 18% of 184 temporal structures involve the limbic network and
patients with temporal lobe epilepsy who underwent especially the amygdala, [172, 204, 208-210]. However,
resective surgery [197]. In this study, affective aura was they may also be widely distributed within the
unable to lateralize or localize the seizures. They were temporal lobe [211], including the temporal neocortex
more likely to be negative auras (15%) than positive and any of the limbic structures (i.e., amygdala,
(3%) while ictal affective behavior was present in 22% hippocampus and parahippocampal gyrus) [212].
of patients (10% positive, 14% negative) [197]. Overall, the best examples of ictal anxiety are
generally considered to reflect involvement of the
6.1. Anger amygdala. Other locations include the temporal pole

and frontal lobe when they are associated with
Anger may occur in patients with seizures associated anxiety/panic during seizures [205]. The insula has
with a strong feeling of annoyance, displeasure, or also been implicated during SEEG evaluation [145].
hostility. Focal emotional seizures with anger are
distinguished from episodes of dyscontrol such as 6.3. Fear
temper tantrums and rage reactions (sudden, out-of-
control bursts of anger) by unorganized, purposeless, Fear is an intense, unpleasant emotion caused by the
non-goal-directed aggression. In addition, stereo- belief that someone or something is dangerous and
typed evolution during each event, and the presence likely to inflict pain or perform a physical threaten-
of other features and semiologies are often present. ing act. Ictal fear or ictal panic is the most frequently
The lateralization of anger is uncertain though reported ictal affective manifestation and is reported
possibly left hemispheric in adults [196], whereas it in 10-15% of patients with focal seizures [213]. The
may be the opposite in children; right hemispheric lateralization is inconsistent, though right hemi-
EEG foci were found to be more common in children spheric involvement is more probable than the left
who exhibited emotional impairments such as anger [196, 214-217], and either of the hemispheres may be
[198]. Focal seizures with anger localize to the mesial involved. Most patients with epilepsy and ictal fear
temporal networks [199], especially the amygdala have a seizure onset zone in the mesial temporal
[200]. This was noted in early studies involving direct lobe [172, 218], usually associated with involvement
electrical stimulation [172]. Those symptoms may also of the amygdala [208, 219]. In addition, the hippo-
arise from the prefrontal and orbitofrontal cortex less campus [171, 218] may be linked to patients with
frequently [196, 201]. more severe or “burned out” disease [220]. Fear
True ictal aggression, defined as intense anger appearing early in a clinical seizure may also
followed by hostile, injurious or destructive behavior, implicate the lateral temporal neocortex [221],
is extremely rare and may be seen extending into the orbital frontal cortex [222] and anterior cingulate
postictal phase. It can manifest as severe agitation network [219, 223, 224]. Occipital seizure onset
with self-injury and destruction of property. In a assessed by intracranial EEG has rarely been
review of 24 cases, most patients suffered from focal reported and raises the issue of seizure propagation
epilepsy and psychiatric co-morbidities such as to the mesial temporal networks [214, 224, 225].
alcohol dependence or other drug addiction. After Seizures occur in mesial frontal and orbitofrontal
careful analysis, no predominant focus side or epilepsies, and ventromedial frontal lobe epilepsy
localization could be identified [202]. may be associated with facial expressions of fear
[137]. Emotional facial expressions including fear are
6.2. Anxiety observed significantly more frequently in hyperki-
netic seizures of frontal vs temporal lobe origin
Anxiety during a focal aware seizure may produce a when followed by bilateral facial contraction, in
feeling of worry, nervousness, or unease typically contrast to the corners of the mouth dropping
about an imminent event, or something with an in temporal seizures [226]. Affective symptoms
uncertain outcome. Clinical observations have often manifesting as fearful screaming and terrified
reported that patients with focal seizures arising from expression have been associated with ictal involve-
limbic structures within the right side of the brain ment of the amygdala and hippocampus, the
have a higher incidence of emotional disturbances orbitofrontal region, and the anterior cingulate
including anxiety (and fear) than those who have gyrus [219].

S. Beniczky, et al.
6.4. Sadness confirmed in larger studies with either left or right

lateralization possible [233, 234]. In the prior reports
Although a seizure is often associated with depres- of single or small series of patients with ecstatic
sion, that emotional state is unusual as an ictal seizures, a temporal lobe origin was initially suspected
experience alone [227]. Sadness during seizures [233], yet no precise localization was demonstrated
reflects the condition or quality of feeling sad or until recently, when Picard and Craig proposed the
being unhappy and encompassing a feeling or anterior dorsal insula as the origin of intense positive
showing sorrow. The lateralization is ill-defined and feelings experienced during ecstatic epileptic sei-
uncertain though the left hemisphere has demon- zures [231, 234-236]. The anterior cingulate has also
strated symptoms of sadness [120, 196, 228]. Ictal been noted during electrical stimulation studies to
depression or sadness has been reported by 1% of reproduce pleasure [237], euphoria and a sense of
patients with focal epilepsy arising from the temporal well-being [238]. Also, rare cases involving the left
lobe [213, 221] (rarely during electrical cortical stimu- frontal [239], right occipital [240] and parietal lobe
lation). They can also occur in seizures arising from [241] as well as the hypothalamus [242] in a case report
the mesial temporal region [120], orbito-frontal cortex have been reported, though in the latter case, this was
[196], and the anterior insula in a single patient during felt to be likely due to activation of the insula. Most
electrical stimulation studies [228]. Seizures associa- have been described with focal epilepsies, but a case
ted with sadness often accompany seizures with was reported with generalized epilepsy induced by
laughing in the setting of a hypothalamic hamartoma. watching television [243].
Focal seizures associated with sadness may be
accompanied by lacrimation, sad facial expressions 6.7. Mystic
and sobbing when they arise from a hypothalamic
hamartoma [229]. Mystic seizures or experiences with altered state of
consciousness impart a religious or spiritual meaning
6.5. Guilt to a person during seizures. This experiential affect
involves a sensation that the person becomes one
Guilt is an affective symptom involving an emotional with God or believes in the spiritual apprehension of
feeling of having done wrong or failed in an truth that is beyond the intellect. Religious attribu-
obligation. No clear data is available regarding tions are rarely divulged though may include clair-
possible lateralizing value and therefore the laterali- voyance, telepathy, autoscopy, religious phrases,
zation is uncertain [213], though considering the prayer, being in the presence of God, and auditory
valence, it possibly points to the left hemisphere or visual hallucinations of religious figures [232].
[196, 230]. Given the paucity of information regarding There is a predominance of right lateralization as the
guilt and focal seizures, there is insufficient localizing critical site of religious experience due to the
information. emotional nature [244]. Mystical experiences have
been most often linked to the temporal lobe
6.6. Ecstatic feeling / bliss [234, 245, 246]. Mystic, religious, and spiritual experi-
ences have also been reported to involve neocortical
Focal aware seizures with a positive affective compo- areas when visual and auditory hallucinations or
nent are infrequently characterized by ecstasy or a complex ideation occur [246].
sense of bliss, and more commonly involve negative
sensations such as fear, anxiety, or panic. Ecstatic 6.8. Sexual
seizures evoke a feeling of bliss and intense positive
emotion, enhanced physical well-being, and clarity Sexual experiences of desire, arousal or orgasmic aura
with heightened self-awareness or perception of the may infrequently be involved in the ictal features of
external world with an overwhelming feeling or focal epilepsies. They are more often observed in
expression of happiness or joyful excitement. An women [247]. Sexual auras do not have strong
ecstatic phenomenon is an altered state of conscious- lateralizing value though most arise from the right
ness with a sense of “hyper-reality”, and complete hemisphere [248]. Sexual auras often stem from the
present-moment awareness with a feeling of union mesial temporal structures [248, 249] but also have
with the universe [231]. Pleasure has been described been noted arising from the anterior cingulate cortex
as elation, intense pleasure, serenity, gladness, joy, [194]. For seizures marked by sexual automatisms such
exhilaration, and completeness [227]. Left lateraliza- as masturbatory behavior, pelvic thrusting or similar
tion was suspected and an overlap with right automatisms, although typically attributed to tempo-
lateralization with the presence of religious overtones ral lobe disease, frontal lobe seizures using depth EEG
[232], though consistent lateralization has not been electrodes have also been described [250].

7. Cognitive ictal semiology important to distinguish an ictal component from

aphasia that is more commonly identified in the
postictal state. Ictal aphasia can be manifest as
7.1. Dysmnesia
Wernicke’s (receptive), Broca’s (expressive), or global
(mixed) aphasia. It may be difficult to differentiate
Dysmnesia is the disturbance of memory and compri-
aphasia in patients with impaired consciousness,
ses ictal amnesia, feelings of familiarity (déjà vu),
unless behavioral testing specifically addresses spe-
unfamiliarity (jamais vu), a dreamy state and reminis-
cific components of language [18]. Inability to name
cence that may be seen in patients with seizures.
objects has been referred to as ictal anomia. Ictal
7.1.1. Amnesia aphasia suggests involvement of the speech and
Ictal amnesia implies that the patient cannot recall language areas (Wernicke, Broca, basal temporal
events during the seizure, or at least a part of the language area) in the dominant hemisphere. In an
seizure. It does not have localizing or lateralizing value. SEEG study of patients with temporal lobe epilepsy,
Ascertaining this semiology feature is important, as it different patterns of ictal aphasia were identified:
allows determining awareness of the patient during impaired comprehension was associated with poste-
seizures. This helps classify focal seizures based on the rior lateral involvement, anomia and reduced verbal
current ILAE seizure classification system [5]. In fluency with the anterior mediobasal structures,
practical terms, if a patient cannot recall events during whereas Wernicke’s aphasia with rapid verbal output
a focal seizure, then the seizure is classified as a focal (“jargonaphasia”) was found with basal temporal
impaired awareness seizure. However, ictal amnesia involvement [253]. However, in a large study involving
and awareness are not completely synonymous, ictal aphasia in patients with focal epilepsies, this
because, exceptionally, seizures can present with semiological presentation had limited localizing value
isolated ictal amnesia, yet with clear awareness [251]. within the dominant hemisphere and was most
However, detailed observation is required to distin- commonly seen in patients with seizures originating
guish and separate these two cognitive semiologies [5]. from the parieto-occipital regions, and even with
7.1.2. Déjà / jamais vu / dreamy state seizures spreading from the non-dominant to domi-
These experiential phenomena consist of: (1) déjà vu or nant language areas of the brain [254].
a feeling that one has lived through the present
situation before; (2) jamais vu as the feeling one has 8. Autonomic seizure semiology
experienced the situation for the first time, despite
having been in the situation before; (3) a dreamy state Autonomic symptoms and signs are common accom-
with vivid memory-like hallucinations. These symp- panying features of focal or generalized seizures, and
toms suggest a symptomatogenic zone in the temporal these include cardiovascular (palpitations, tachycar-
lobe, primarily the mesial structures (amygdala and dia), respiratory (hyperventilation), cutaneous (feel-
hippocampus) and the sub-hippocampal structures ings of heat of cold, piloerection), gastrointestinal
(rhinal cortices), without lateralizing value. The tempo- (bloating or nausea, retching and vomiting) and
ral neocortex might also play a significant role in genitourinary (urinary urge, sexual arousal) phenom-
producing these phenomena. Of note, these symptoms ena. When autonomic signs occur early and promi-
are not specific to patients with epilepsy and can occur nently in a focal seizure, then the event is recognized
in other neurologic and psychiatric conditions [172]. as a focal autonomic seizure (a subset of focal aware
7.1.3 Derealization seizures- non-motor) [5]. Some autonomic phenome-
Derealization refers to the altered perception of one’s na, such as ictal vomiting, ictal urinary urge or
surroundings that are experienced as unreal. It should coughing, may have lateralizing or localizing value.
be differentiated from depersonalization (see section When ictal symptoms and signs are confined to the
5.8). Although usually reported in patients with autonomic nervous system, these may be mistaken for
psychiatric conditions (depression, anxiety), case non-epileptic events. It is also important to distinguish
reports and small case series have revealed derealiza- between subjective symptoms (autonomic auras) and
tion in epileptic seizures. Due to the low number of objective autonomic phenomena (autonomic seizure)
cases, the localization is uncertain, but it is most likely during seizures.
associated with temporal lobe epilepsy [252].
8.1. Cardiovascular manifestations
7.2. Aphasia
Common cardiovascular manifestations include
Ictal aphasia is the inability to comprehend or alterations in heart rate and rhythm, blood pressure,
formulate language during focal seizures. It is ECG changes and chest pain.

S. Beniczky, et al.
8.1.1. Sinus tachycardia 8.2.3. Sweating

Sinus tachycardia is the most common ictal autonomic Sweating has been described in early reports of
sign, occurring in 82% of patients with epilepsy [255]. patients with seizures [276, 277]. It usually occurs in
Ictal sinus tachycardia was observed in 12% of patients association with other symptoms including shivering
with subclinical seizures, 71% of focal seizures, 64% of [285], abdominal pain, headache and vertigo [286] or
generalized seizures, and 76% with mixed seizure with the sensation of generalized coldness [287]. Most
types. Ictal tachycardia often preceded EEG changes reports are anecdotal, and more recent reports have
and occurred more frequently in patients with linked unilateral facial sweating to anti-Ma2-positive
temporal rather than extratemporal seizures [255]. autoimmune encephalitis associated with testicular
Views on the lateralizing value of ictal tachycardia are teratoma [288]. However, there are no systematic
conflicting [255-257]. On the other hand, unlike studies to provide consistent lateralizing or localizing
bradycardia, tachycardia does not help differentiate value in patients with ictal sweating.
epileptic from non-epileptic paroxysmal events [258].
8.2.4. Piloerection
8.1.2. Bradycardia and ictal asystole Piloerection is defined as erection of the hairs of the
Bradycardia and ictal asystole are much less frequent skin due to contraction of the tiny arrectores pilorum
(0-2%) than ictal tachycardia [259-263]. This is usually muscles that elevates the hair follicles above the rest
observed in patients with temporal lobe seizures [264- of the skin, moving the hair vertically and appearing to
271], but also rarely arises from other areas, such as “stand on end” (gooseflesh or goosebumps). Piloer-
the left cingulate [272]. While some authors suggest ection is a rare sign that is seen in 0.40-0.65% of
left lateralization [265, 273], the majority of studies did patients in large VEM series [289, 290]. Piloerection is
not confirm a lateralizing value for ictal bradycardia usually associated with other autonomic symptoms,
[267, 268, 270, 271]. Bradycardia may occur in the such as sweating, flushing, and shivering. There is a
context of respiratory depression [274]. Falls and strong association with temporal lobe epilepsies
myoclonus were observed with prolonged ictal including the insula and amygdala. However, laterali-
asystole (mean: 14.8 7 s) [269, 275]. Thus, loss of zation is inconsistent [290-293]. Recent reports reveal a
muscle tone or bilateral asymmetric jerky limb strong representation of autoimmune encephalitis
movements during a seizure suggest the possibility and gliomas as a cause of seizures associated with
of ictal asystole [275]. piloerection [289, 293, 294].
8.2. Cutaneous ictal phenomena 8.3. Gastrointestinal ictal phenomena
8.2.1. Flushing 8.3.1. Epigastric aura

Flushing from skin hyperperfusion has been reported Epigastric aura was the earliest autonomic symptom to
by several authors as part of the autonomic manifesta- be recognized as an aura [276]. It is also the most
tions of seizures [276-278]. Large series evaluating common visceral symptom in adult epilepsy patients
autonomic symptoms found that flushing occurred in [295, 296] and occurs significantly more often in those
patients with both temporal and extratemporal lobe with TLE as opposed to ETLE [297] with a probability of
epilepsies, without clear lateralizing value [279]. Ictal 73.6%. It occurs more frequently in patients with mesial
flushing should be differentiated from the effects temporal epilepsies comparedtothose withneocortical
produced by pheochromocytoma, carcinoid syn- TLE [297, 298]. Epigastric auras followed by oral and
drome, mastocytosis, “hot flushes” in postmenopaus- manual automatisms are highly indicative of TLE with a
al women, and asymmetric facial flushing (a.k.a., probability of 98.3% [297]. Epigastric aura (mainly
Harlequin syndrome). without automatisms) has been reported inETLE (frontal
lobe, insula). While some early studies reported
8.2.2. Pallor
epigastric auras more often in patients with seizures
Pallor is extremely common as a prodromal sign in
arisingfromthenon-dominanttemporal lobe[299, 300],
patients with syncope occurring in up to 93% of cases
more recent studies did not find any lateralizing
[280]. However, pallor can rarely be an ictal sign
significance for epigastric auras [69, 296-298, 301, 302].
[276, 277]. In children, ictal pallor has been associated
with focal seizures arising from the mesial temporal 8.3.2. Hypersalivation or sialorrhea
lobe and lateralized to the left side in 10 of 11 cases in Hypersalivation or sialorrhea is the excessive produc-
one study [281]. It has also been reported in tion of saliva during a seizure. It is a rare occurrence
association with ictal fear related to amygdala atrophy seen in TLE patients, occurring in 2% of patients
[282] and bilateral perisylvian polymicrogyria [283], evaluated for epilepsy surgery [303] and 9.4-12% of TLE
and in patients with Panayiotopoulos syndrome in smaller series [296, 304]. Ictal hypersalivation
[278, 284]. appears to suggest a mesial temporal localization

without clear lateralizing significance [296, 303, 304]. frequently seen in epileptic seizures than in patients
Invasive EEG recordings in isolated cases have with non-epileptic events [258].
implicated the perisylvian frontal operculum [305]
8.4.1. Hypoventilation
and the insula [306].
Hypoventilation and oxygen desaturation of <90%,
8.3.3. Spitting <80% and <70% was observed in 33.2%, 10.2% and
Spitting is an infrequent symptom reported in 0.3-2% of 3.6% of all seizures recorded in patients with drug-
patients with temporal lobe seizures [296, 307-310], and resistant epilepsy, respectively [332]. Another study
several studies implicate non-dominant lateralization reported the presence of ictal hypoxemia in 70.8% of
[296, 310-312]. However, the left temporal lobe has also patients experiencing 79 seizures. In this cohort,
been involved in case reports [309, 313, 314]. In a case desaturation was mild (mean: 92.5%) in 46% of all
report evaluated with invasive EEG electrodes, although seizures, moderate in 39% (mean: 81.5%), and severe
the seizure onset zone was in the left mesial temporal in 14% (mean: 64.7%) [333]. Oxygen desaturation
lobe, the ictal spitting coincided with the propagation of lasting longer than 70 seconds with a nadir of 83% has
the ictal discharge to the right temporal lobe, implicat- been reported during focal seizures without evolu-
ing the latter as the symptomatogenic zone [312]. Direct tion to bilateral tonic-clonic seizures. This supports
electrical stimulation studies during invasive EEG the hypothesis of centrally mediated hypoventilation
monitoring have identified the entorhinal cortex as a during focal epileptic seizures [258].
site involved in ictal spitting [311]. Ictal spitting does not
8.4.2. Apnea
occur in association with ictal vomiting, ictal coughing,
Apnea was reported to occur in approximately 40% of
or ictal fear, suggesting there are different sites in the
seizures recorded in adult series with duration lasting
brain that mediate these symptoms with unique
for more than 10 seconds (range: 10-63 seconds; mean:
specificity [308]. Although ictal spitting has been
24 seconds) based on polygraphic measurements
reported as a gastrointestinal autonomic phenomenon,
[274, 333]. Prolonged central apnea (60 seconds)
it has a clear motor component and could also be listed
occurred in 6.3% of patients in association with severe
under automatisms.
hypoxemia during seizures with blood oxygen satu-
8.3.4. Vomiting ration levels (SpO2) of less than 75%. Similarly,
Vomiting is a striking feature when it occurs and is not episodes with ictal apnea have been reported in
uncommon in self-limited childhood occipital epilep- neonates and children with TLE [279, 334]. Central
sies. In adult patients evaluated for epilepsy surgery, apnea may precede seizure onset recorded on scalp
ictal vomiting has been reported in patients with TLE, EEG in more than a half of cases, and rarely persists
especially involving the mesial structures. Seizures into the postictal period. Patients typically do not
commonly originate from the right hemisphere [315- recall ictal apneas, and therefore this might remain
320], but also may involve the left temporal lobe [321- unrecognized without respiratory monitoring [333].
323]. A recent series on ictal vomiting failed to Oxygen desaturation less than 90% significantly
demonstrate consistent lateralization [324]. Intracranial correlated with temporal lobe localization at seizure
recordings have also suggested that the symptomato- onset, right hemispheric seizure lateralization, and
genic zone may reside in the anterior insula when contralateral hemispheric propagation [332]. The
vomiting results from propagation of the ictal activity degree of desaturation correlated with seizure dura-
from the mesial temporal structures to the insula tion and propagation and involved the contralateral
[325, 326]. hemisphere [335]. No significant differences were
seen between mesial and neocortical temporal lobe
8.3.5. Flatulence
seizure onsets [336]. On intracranial EEG recordings in
Flatulence is a rare symptom that occurs in 0.6% of
patients with mesial TLE, 68.4% showed ictal apnea,
patients [327]. It suggests temporal and insular
either accompanied by, or following seizure onset.
involvement during seizure propagation, but is
Apnea may be the principal or sole manifestation in
without any lateralizing value [327, 328]. According
15% of TLE cases [337].
to anecdotal reports, rare related gastrointestinal
symptoms including an ictal urge to defecate 8.4.3. Choking
[329, 330] and ictal burping [331] may localize to the Choking due to acute laryngospasm as an isolated
right temporal lobe. event associated with nocturnal seizures may rarely
represent an ictal manifestation [338]. Nocturnal
8.4. Respiratory dysfunction choking can occur in sleep-related hypermotor
seizures associated with nocturnal frontal lobe
Respiratory dysfunction, specifically hypoventilation epilepsy, and may be misdiagnosed as sleep apnea
(bradypnea), apnea, and oxygen desaturation, is more syndrome due to abnormal nocturnal motor activity

S. Beniczky, et al.
and excessive daytime somnolence [339]. Localizing 8.6. Urinary and genital ictal phenomena
information about ictal choking is sparse, however,
anecdotally, ictal choking observed during stimula- 8.6.1. Urinary sensations
tion studies has implicated the frontal operculum Urinary sensations are rarely an autonomic symptom
[340] and anterior insula [341, 342]. In patients with associated with focal seizures in which the patient
insular seizures, the semiology typically begins in develops an intense desire to urinate. The frequency
patients who are fully consciousness and experience a is estimated to range from 0.8 to 8% of patients
sensation of laryngeal constriction that is often [358]. It has been reported to arise from the non-
associated with unpleasant paresthesia, affecting dominant hemisphere and more specifically from the
large cutaneous territories [343]. temporal lobe [358-360]. There are some reports of
ictal single-photon emission computed tomography
8.4.4. Hyperventilation
studies that demonstrate hyperperfusion involving
Hyperventilation may occur during focal seizures.
the right temporal lobe (superior temporal gyrus) and
However, there is a lack of precise prevalence for

insula.
patients with ictal hyperventilation because respiration
is not routinely evaluated during video-EEG monitor- 8.6.2. Genital signs
ing. Tachypnea was found in approximately a half of Genital signs are rare in patients with focal seizures.
patients in a series of children with epilepsy [344], They are comprised of various sexual manifestations
especially in those with focal seizures. It was found to be and genital automatisms. Sexual symptoms in patients
more common in older children, females, individuals with seizures include erotic and genital sensations
with frontal lobe seizures, and seizures with right-sided (see 4.1.3) and signs of sexual arousal, orgasm, and
lateralization [345]. While hyperventilation is more sexual or genital automatism. Genital automatisms
common in children with FLE, adults with seizures and consist of grabbing, fondling, and scratching the
hyperventilation are more likely to have TLE [346] and genitals during or immediately following a seizure
seizures that arise from mesial rather than neocortical [248]. Several reports pointed to a non-dominant
structures [347]. In patients with FLE, hyperventilation mesial temporal lobe as the most frequent localiza-
was noted to occur in seizures arising from the tion. Sexual automatisms were reported to be more
frontopolar and the orbitofrontal regions [348]. Hyper- frequent in men than in women [361]. Sexual behavior
ventilation and shortness of breath that occurs during with extratemporal seizures is rare. A study of 15
focal seizures with an emotional content must be patients implicated three different regions of the
differentiated from non-epileptic panic attacks with brain including the perisylvian region, anterior
hyperventilation [295, 349] because right temporal cingulate gyrus and paracentral lobule [362]. One
seizures with ictal anxiety and hyperventilation can case report described a patient with a right amygdalar
mimic non-epileptic panic attacks [204]. tumor, with ictal symptoms of feeling transformed to
another gender, which has been coined “ictal
8.5. Pupillary ictal phenomena delusional misidentification syndrome” [363].
8.5.1. Miosis
Miosis is a rare autonomic sign that has been
9. Postictal phenomenology
described as a part of generalized photosensitive
Postictal neurological deficits and/or psychiatric signs
epilepsies [350] and in patients with focal epilepsies
and symptoms are often accompanied by diffuse or
involving the temporal, parietal and occipital lobe.
focal slowing or postictal generalized EEG suppres-
The localizing and lateralizing value for miosis in
sion after the clinical signs of the seizure have ended
patients with epilepsy is uncertain [351-354].
[364]. Many of these signs and symptoms are
8.5.2. Mydriasis attributed to intrinsic inhibitory mechanisms which
Mydriasis is a common sign seen bilaterally when it is contribute to seizure termination. The duration of a
associated with seizures in patients with either GTCS postictal state is variable and can be up to several days.
or FBTC seizures. This is due to widespread activation However, while some symptoms (headache, muscle
of the cortical and subcortical structures of the brain aches, postictal psychiatric symptoms) may last
that influence the sympathetic nervous system longer, most postictal features last 5-30 minutes
[295, 349]. Unilateral mydriasis is rarely reported to [365]. Prolonged postictal altered consciousness or
occur in patients with temporal lobe seizures prolonged postictal focal neurological deficits should
[256, 355] or occipito-temporal seizures, and appears raise the suspicion of ongoing seizures and non-
ipsilateral to the seizure onset zone [356]. It has also convulsive status epilepticus. In these cases, patients
been reported to occur in the contralateral pupil of a should be expeditiously evaluated with EEG [9, 11].
young boy with left frontal seizures [357]. Rarely, in the peri-ictal and postictal state, patients

may succumb to sudden unexpected death in sentence) occurred in 100% of 62 seizures, and
epilepsy (SUDEP) [366]. patients took more than 68 seconds to read a test
phrase correctly [380]. Overall, postictal speech
9.1. Unresponsiveness disturbances correctly lateralized to the dominant
hemisphere in 81.3% of all patients, regardless of
Unresponsiveness was the most common phenome- which kind of dysfunction was documented (i.e. no
non (mean frequency of 96%) in a recently published statistically significant difference, although one must
systematic review and meta-analysis of 45 studies on recognize the small groups of paraphasias).
the postictal state [367]. Recovery from postictal
unresponsiveness may take seconds to minutes [368]. 9.5. Nose wiping
9.2. Paresis Nose wiping has been observed significantly more

often in patients with temporal rather than extra-
Paresis (Todd’s paresis) may occur after focal motor or temporal lobe epilepsy [381-384]. It was shown to be
FBTC seizures. A large study showed postictal paresis in ipsilateral to the hemisphere of seizure onset in 86.5%
6% of FBTC seizures [369]. However, this could be an of patients with TLE, and patients with extratemporal
underestimate, due to often insufficient postictal lobe epilepsy performed ipsilateral nose wiping in
testing of the patients. Postictal paresis may last from 54.5% of all seizures [370].
minutes to hours [369]. It lateralizes to the contralateral
hemisphere, regardless of whether the seizure spreads 9.6. Headache
to the contralateral hemisphere on surface EEG or not
[370-373]. However, postictal paresis can also be Headache occurs in 41.6-66% of patients with seizures
bilateral. Postictal paresis develops after ictal involve- with a duration lasting from minutes to hours [367, 385].
ment of the motor cortex, most often in frontal lobe Younger age at seizure onset and longer duration of
seizures. However, it has also been documented in epilepsy, drug-resistant epilepsies, and tonic-clonic
seizures originating in temporal, parietal and occipital seizures are additional risk factors [386]. Postictal
lobes [374]. Sensory deficits following seizures have headache often manifests with severe migraine-like
been rarely reported and can be missed if sensation is features. In temporal lobe epilepsy, postictal headache
not specifically tested or symptoms addressed [375]. was found to be ipsilateral to the site of seizure onset in
90% of cases [387]. However, no significant lateraliza-
9.3. Blindness. tion value was found in patients with frontal lobe
epilepsies [388]. Peri-ictal headache was more likely to
Following seizures, loss of vision may occur on one be ipsilateral to the seizure onset in patients with
side of the visual field (hemianopsia) or both sides temporal lobe epilepsies (90%) than in those with
(amaurosis) [376, 377]. The duration typically lasts extratemporal lobe epilepsies (12%) [181].
from seconds to hours [367]. It has been reported in
two-thirds of patients with childhood occipital epi- 9.7. Palinacousis
lepsy of Gastaut [378]. Postictal blindness points to
involvement of the visual cortex and has been Palinacousis involving preservation of an external
described in patients with occipital and temporal auditory stimulus or retained fragment of a previously
lobe seizures. Ictal homonymous hemianopsia later- heard sentence may occur after seizure cessation.
alizes to the contralateral hemisphere [379]. These auditory illusions have been described in a few
cases, though the localizing and lateralizing value of
9.4. Language dysfunction this symptom is uncertain [389].
Language dysfunction comprises Broca’s, Wernicke’s 9.8. Autonomic signs

and global aphasia, anomia, paraphasia and errors in
repetition and writing. Approximately 38% of patients Autonomic signs comprise a wide range of pheno-
experience language impairment, with duration typi- mena including ictal tachycardia, bradycardia, arrhyth-
cally of seconds to minutes [367, 380]. Postictal speech mia, hypersalivation, coughing, apnea, tachypnea,
disturbances can be indicative of seizure localization changes in blood pressure, hyperthermia, and neuro-
or seizure propagation [380]. Most postictal language genic edema [368, 390]. Postictal coughing occurs in
disturbances occur in patients with focal seizures both temporal and extratemporal lobe epilepsies and
associated with either onset or propagation to the may only be indicative of a temporal lobe seizure
dominant temporal lobe [374]. In one study, postictal onset when seizures are represented by a stereotypi-
language delay (time from last ictal EEG to reading a cal semiology. Coughing may be due to a different

S. Beniczky, et al.
mechanism and occur independent of additional 10.1. Unilateral

autonomic signs or symptoms [391]. Rarely, postictal
autonomic features can be life-threatening. Respira- Exclusive or virtually exclusive involvement of one
tory depression and cardiac dysfunction, occurring side as a motor, sensory or autonomic phenomenon.
after a GTCS (including FBTC seizures), are critical
factors in SUDEP [366]. A postictal breathing pattern 10.2. Bilateral
may also be a useful clinical sign in terms of
differentiating epileptic seizures from non-epileptic Involvement of both left and right sides; bilateral
seizures; the presence of postictal hyperpnea is more manifestations may be symmetric or asymmetric.
likely to occur after an epileptic seizure than a non-
epileptic event [392]. 10.3. Centricity
9.9. Psychiatric symptoms and syndromes Axial (trunk, including neck), proximal limb, distal
limb.
These include delirium, psychosis, catatonia, impaired
cognition and amnesia [368]. These do not have 10.4. Incidence
localizing or lateralizing value. Delirium, changes in
perception (hallucinations), thoughts (incoherence, The number of seizures within a time period or the
delusions) and catatonia may last for hours to days number of seizure days per unit of time (i.e., 3-4
[368, 393]. Postictal delirium may transition into seizures/month).
postictal psychosis, including violent bizarre or
sexually inappropriate behavior. The prevalence of 10.5. Cluster
postictal psychosis ranges between 2% and 7%,
independent of type of epilepsy [368, 394]. It can The incidence of seizures within a given period
develop after a “lucid phase” when the patient (usually one or a few days) that exceeds the average
recovers from initial postictal confusion, only to incidence over a longer period for the patient (i.e., 3-5
reappear six hours to a week later [395]. The mean seizures over 8 hours). Note that this definition does
duration of postictal psychosis is variable, lasting up to not apply to the presence of a cluster of epileptic
9-10 days (range: 12 hours - 3 months) without spasms (which denotes repetitive occurrence / series
treatment. Approximately a half of patients with of epileptic spasms).
postictal psychotic symptoms also have a history of
psychiatric disorders, such as depression, anxiety and 10.6. Provocative factor
attention deficit disorder [396]. Postictal psychosis
occurs more often after a cluster of GTCS [395]. Endogenous or exogenous elements that are capable
Postictal psychosis is a treatable condition, which left of triggering seizures in people with chronic epilepsy
untreated, is associated with serious patient-related and evoking seizures in susceptible individuals
morbidity and mortality [395]. Homicide during the without epilepsy. It is important to distinguish
postictal psychosis has been described in a single case facilitating factors that temporarily increase seizure
report [397]. Postictal depressive and anxiety symp- risk from precipitating factors (i.e., the specific
toms may occur for more than 24 hours and within triggers in reflex epilepsies). Acute symptomatic
five days following a seizure [398]. For focal epilepsy, seizures are often referred to as “provoked” seizures.
18% of patients showed postictal depressive symp-
toms, characterized by anhedonia, helplessness, self- 10.7. Prodrome
deprecation or suicidal thoughts. Postictal dysphoric
symptoms are more likely in temporal plus epilepsies, The subjective constellation of a non-specific, broad
compared to pure temporal lobe epilepsies [399]. spectrum of “warning” symptoms (such as an ill-
Postictal anxiety lasts from minutes to hours, and is localized sensation or agitation) that heralds the onset
often accompanied by depression. of an epileptic seizure but does not form part of it [3].
The duration is over 30-60 minutes, and it may persist
for up to several days prior to seizure onset.
10. Somatotopic modifiers and time-related
features
11. Conclusion
Some ictal phenomena can occur in different parts of
the body, hence the somatotopic modifiers should be Scalp and invasive video-EEG monitoring has been
added to the respective ictal phenomena [3, 5]. instrumental to update and define terminology, and

provide lateralizing and localizing significance to lateralization value is higher when more features are
semiology in patients with epilepsy. Often, several present. Ictal fear followed by hyperkinetic behavior
semiological features occur during the same seizure suggests seizure involvement of the frontal lobe,
(either simultaneously or in a sequence), due to while fear followed by distal gestural and oro-
propagation of the seizure within the network alimentary automatisms suggests a focus in the
(table 2). Seizure semiology is dynamically produced temporal lobe. Seizures starting in the posterior
by interconnected structures, in which specific quadrant of the brain (occipital and parietal lobes)
electrophysiologic interconnections, rather than often show rapid propagation to anterior structures
anatomical location, likely play an important role (frontal and temporal lobes) and may manifest
in clinical expression [400]. Seizure propagation without a visual aura. A detailed interview about the
within an epileptic network and the corresponding symptoms and possible occurrence of auras (includ-
evolution in time of the seizure semiology have ing those that occurred in the past but do not exist
been compared to “words in a meaningful sentence” anymore) may be important for determining localiza-
[401]. tion. Seizures with motor manifestations suggesting

Observing and reporting the onset and propagation of frontal or temporal lobe seizure onset might begin
the ictal semiology is essential for correct interpreta- with a sensory aura, indicating onset in the parietal or
tion, as it relates to the clinical significance and seizure occipital lobe, propagating to the frontal lobe.
network. The timing is important. In general, the earlier Recognition of the combination and sequence of
a semiology feature occurs in a seizure, the stronger its different ictal signs facilitates identification of a
localizing and lateralizing value. This underscores the diagnostic “gestalt” for seizure dynamics in an
importance of signs and symptoms associated with an individual patient [402]. &
aura. Auras (focal aware seizures) typically precede
other clinical signs. Yet, the epileptogenic zone and Supplementary material.
seizure onset zone may reside in an area of “silent” Supplementary data accompanying the manuscript are available
cortex that does not generate a clinical sign or at www.epilepticdisorders.com.
symptom, and the first ictal manifestation appears as
the consequence of seizure propagation.
Disclaimer.
Symbols can be used to describe the dynamics and This report was written by experts selected by the International
temporal sequence of a seizure. The plus sign (+) League Against Epilepsy (ILAE) and was approved for publication
between the phenomena signifies that signs occur by the ILAE. Opinions expressed by the authors, however, do
simultaneously. Arrows to the right (!) indicate the not necessarily represent the policy or position of the ILAE.
next sign in the sequence over time (table 2). For
example: epigastric aura ! oro-alimentary automa-
Disclosures.
tisms ! left gestural automatisms + right hand
The authors do not have conflicts of interest relevant for this work.
dystonic posturing + ictal aphasia ! versive hand
movement to the right + figure-of-4 sign with
extension of the right elbow ! bilateral tonic-clonic References
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Legend for video sequences
Supplementary video 1
A patient with an atonic seizure, presenting as atonia of the neck and trunk musculature.
Key words for video research on www.epilepticdisorders.com
Phenomenology: atonic seizure (drop attack)

Localization: generalized
Syndrome: epileptic encephalopathy not otherwise classified
Aetiology: unknown
An infant with a myoclonic seizure showing a sudden, very brief bilateral muscle jerk of the upper limbs. The
second movement is a reactive movement, as the spontaneous seizure jerk scares the child.
Phenomenology: myoclonic seizure, generalized
Syndrome: early myoclonic encephalopathy
Aetiology: genetic disorder

S. Beniczky, et al.
A patient with a bilateral synchronous clonic seizure.
Phenomenology: clonic seizure
Syndrome: unknown
Aetiology: unknown
A young child with a generalized seizure, starting with a bilateral muscle jerk in the shoulders (myoclonic),
followed by muscle activity cessation (atonia), resulting in a fall.
Phenomenology: myoclonic atonic seizure
Syndrome: Doose syndrome
Aetiology: idiopathic
A focal seizure with impaired awareness arising from the frontal lobe during sleep. Note that the patient is
sleeping on a mattress on the floor with protective mattresses around him. The seizure starts with fulminant
hyperkinetic behavior, followed by a gyratory movement of the body to the right. The patient’s awareness is
impaired and he is not responding to the nurse’s commands. In the immediate postictal phase, the patient
becomes responsive, and is able to point to the window, in response to the verbal command.
Phenomenology: hypermotor seizure, gyratory (not from the existing list)
Localization: frontal prefrontal mesiolateral
Syndrome: focal, non-idiopathic frontal (FLE)
Aetiology: unknown
An infant with clusters of epileptic spasms. Note the typical gestalt of the spasms with flexion in the neck and
simultaneous abduction in the shoulders and flexion in the hips.
Phenomenology: spasm (epileptic)
Syndrome: west syndrome
Aetiology: genetic disorder
Generalized tonic-clonic seizure occurring during sleep. The patient lies in the bed in prone position. The
seizure starts with ictal crying -the characteristic sound produced by the forced push of air through the
airways, due to the tonic contraction of the diaphragm. Symmetric tonic contraction of all four limbs is then
observed, followed by symmetric clonic jerks which gradually decrease in frequency.
Phenomenology: generalized, tonic-clonic seizure
Syndrome: idiopathic generalized not specified
Aetiology: idiopathic/genetic predisposition

The patient is sitting in bed and watching TV. The seizure starts abruptly with fearful behavior, followed by
integrated automatisms. During the seizure, there is impaired awareness. After the seizure ends, the patient
answers the nurse’s questions and follows commands.
Phenomenology: fear, hypermotor seizure
Localization: frontal, prefrontal mesial
Syndrome: focal non-idiopathic frontal (FLE)
Aetiology: focal cortical dysplasia
A focal impaired awareness seizure that starts with gestural automatisms and continues with ictal aphasia. The
patient does not follow verbal commands, but follows visual clues.
Phenomenology: aphasic seizure, cognitive (not in the list), automatisms
Localization: left temporal lobe
Syndrome: focal non-idiopathic mesiotemporal (MTLE with or without HS)
Aetiology: hippocampal sclerosis

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& Seminar in epileptology

Epileptic Disord 2022; 24 (3): 1-49

Haven, Connecticut, USA

Seizure semiology comprises objective details, such as goosebumps, ﬂushing

Epileptic Disord, Vol. 24, No. 3, June 2022 •1

thies (such as patients with ring chromosome 20,

2• Epileptic Disord, Vol. 24, No. 3, June 2022

Semiology features Lateralizing value Localizing value

Epileptic Disord, Vol. 24, No. 3, June 2022 •3

Semiology features Lateralizing value Localizing value

Dystonic CON When unilateral,

Elementary Ictal paresis CON F Motor cortex (M1)

4• Epileptic Disord, Vol. 24, No. 3, June 2022

Semiology features Lateralizing value Localizing value

Gastrointestinal Hypersalivation Insulo-

Epileptic Disord, Vol. 24, No. 3, June 2022 •5

Semiology features Lateralizing value Localizing value

6• Epileptic Disord, Vol. 24, No. 3, June 2022

Semiology Seizure onset and propagation Video link

responsiveness ! atonic seizure with head docs/intracranial_video_eeg_and_surgery_for_

Epileptic Disord, Vol. 24, No. 3, June 2022 •7

Semiology Seizure onset and propagation Video link

ﬂexion) ! L head version ! bilateral docs/classiﬁcation_of_paroxysmal_events_and_

8• Epileptic Disord, Vol. 24, No. 3, June 2022

Semiology Seizure onset and propagation Video link

Epileptic nystagmus pt. indicating aura (according to video https://www.jle.com/en/revues/epd/e-

Epileptic Disord, Vol. 24, No. 3, June 2022 •9

Semiology Seizure onset and propagation Video link

10 • Epileptic Disord, Vol. 24, No. 3, June 2022

Semiology Seizure onset and propagation Video link

automatisms ! responsive ! R postictal nose dyscognitive_focal_seizures_305235/article.

Epileptic Disord, Vol. 24, No. 3, June 2022 • 11

Semiology Seizure onset and propagation Video link

(see Affective) cle_video_une=311024

12 • Epileptic Disord, Vol. 24, No. 3, June 2022

Semiology Seizure onset and propagation Video link

Epileptic Disord, Vol. 24, No. 3, June 2022 • 13

Semiology Seizure onset and propagation Video link

Tachycardia Ictal apnea ! tachycardia ! ictal coughing https://www.jle.com/en/revues/epd/e-

14 • Epileptic Disord, Vol. 24, No. 3, June 2022

Semiology Seizure onset and propagation Video link

Epileptic Disord, Vol. 24, No. 3, June 2022 • 15

16 • Epileptic Disord, Vol. 24, No. 3, June 2022

bilateral, but not always synchronous and symmetric.

Epileptic Disord, Vol. 24, No. 3, June 2022 • 17

ion. Spasms involve predominantly the proximal

18 • Epileptic Disord, Vol. 24, No. 3, June 2022

Epileptic Disord, Vol. 24, No. 3, June 2022 • 19

viors. They are often unilateral and associated with

20 • Epileptic Disord, Vol. 24, No. 3, June 2022

smacking, lip pursuing, licking, and swallowing

Epileptic Disord, Vol. 24, No. 3, June 2022 • 21

22 • Epileptic Disord, Vol. 24, No. 3, June 2022

Epileptic Disord, Vol. 24, No. 3, June 2022 • 23

5.7. Body-perception illusion 5.9. Forced thinking

24 • Epileptic Disord, Vol. 24, No. 3, June 2022

6.1. Anger amygdala. Other locations include the temporal pole

Epileptic Disord, Vol. 24, No. 3, June 2022 • 25

6.4. Sadness conﬁrmed in larger studies with either left or right

424. Ozkara C, Sarý H, Hano glu L, Yeni N, Aydo