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The Role of Semiology in the Work-Up of Frontal Lobe Epilepsy: In the Eye of the Beholder

Commentary The most fundamental basis of the study of epilepsy relies on a solid and accurate understanding of two concepts: the central neuronal networks that govern human behavior and the brain’s anatomy that provides the structural framework for various patterns of connectivity. A thorough analysis of a seizure’s semiology is therefore an essential foundation in the attempt to localize and define a patient’s epilepsy because it provides a unique and precious opportunity to appreciate this critical and dynamic duo of function and anatomy as it pertains to an individual clinical scenario. While this is a self-evident fact, it is often overlooked in the current era of “high-tech”—expensive neuroimaging and diagnostic tests that overshadow the current conduct of presurgical work-ups for intractable epilepsy. This commentary will use a growing body of literature—including the work by Bonini et al. highlighted here—to achieve two goals: 1) to address the diagnostic and localizing role of semiology in epilepsy surgery evaluations, and 2) to highlight the mechanistic and clinical benefits of a more comprehensive view of the systems underpinning ictal manifestations. Let’s define first the question at hand. Although the lateralizing value of several semiological signs—such as clonic head version, hand dystonia, postictal aphasia, and Todd’s palsy—are well-established (1), the value of semiological signs to localize epilepsy has been more controversial, particularly in the context of the frontal lobe epilepsies. The study at hand by Bonini et al. and several others with similarly stated goals (2–5) share many similarities in their methodology: all analyze semiological signs using some variation of the statistical methods of cluster analysis, and all rely on the investigator’s interpretation of recorded video-EEG evaluations in patients with a presumed frontal lobe epilepsy localization. Similarly, their findings highlight some common themes: First, somatosensory and Jacksonian clonic semiology supported a perirolandic localization with 22 out of 24 lesional cases involving this region in Manford et al.(2) Frontal Lobe Seizures: From Clinical Semiology to Localization.