title: Ictal motor sequences: Lateralization and localization values.
abstract: OBJECTIVE
  To determine the lateralization and localization values of ictal motor sequences in the setting of focal epilepsy ending with a secondarily generalized motor seizure.
  
  
  METHODS
  Retrospectively, the ictal motor sequences were analyzed in patients with focal epilepsy ending with a secondarily generalized motor seizure by three readers blinded to all clinical and electrographic data. One representative seizure per patient was selected. Prevalence, positive predictive value (PPV), and Fleiss Kappa for the following motor signs were calculated: version, unilateral limb tonic posturing, unilateral limb clonic seizure, figure-of-4, M2e, hand dystonia, clonic asymmetric ending, and Todd's paralysis. Sequences of signs with a PPV ≥ 80% were then analyzed to determine their lateralization and localization values.
  
  
  RESULTS
  A total of 47 seizures were studied. The "reliable" motor signs with a robust lateralizing value (PPV > 80%) were version, unilateral tonic posturing, M2e, unilateral clonic seizure, asymmetric clonic ending, and Todd's paralysis. Figure-of-4 and hand dystonia had a relatively low PPV, and therefore were not included in the following sequence analysis, which included only 38 patients with two or more motor signs of high PPV. Multiple combinations of temporal progression of motor signs were seen in these 38 patients, with version being the most common initial motor sign (29 of 38 patients) usually followed by M2e (15 of 29 patients), and/or a focal tonic seizure (7 of 29 patients). Accurate lateralization of the epileptogenic zone (EZ) with a PPV of 100% can be predicted when two or more reliable motor signs point to the same side. However, the various sequences of reliable motor signs did not differentiate between temporal and extratemporal epilepsy.
  
  
  CONCLUSIONS
  The presence of reliable ictal motor signs in focal epilepsy is extremely valuable in lateralizing the EZ, but not in determining the localization of the EZ. This is especially useful when epilepsy surgery is indicated.
authors: Department of Child Neurology, Children's Hospital of Wisconsin/Medical College of Wisconsin, Milwaukee, Wisconsin, U.S.A.
authors: Ahmad
authors: A
authors: Marashly
authors: Department of Neurology, Epilepsy Center, George Washington University, Washington, District of Columbia, U.S.A.
authors: Amr
authors: A
authors: Ewida
authors: Department of Child Neurology, Children's Hospital of Michigan/Wayne State University School of Medicine, Detroit, Michigan, U.S.A.
authors: Rajkumar
authors: R
authors: Agarwal
authors: Department of Neurology, University of Texas Health Sciences Center at Houston, Houston, Texas, U.S.A.
authors: Kyan
authors: K
authors: Younes
authors: Department of Neurology, Epilepsy Center, University Hospitals of Case Medical Center/Case Western Reserve University, Cleveland, Ohio, U.S.A.
authors: Hans O
authors: HO
authors: Lüders
mesh_terms: D015331:Cohort Studies; D004569:Electroencephalography / Q000379:methods; D004828:Epilepsies, Partial / Q000175:diagnosis* / Q000503:physiopathology*; D005260:Female; D006801:Humans; D008297:Male; D012189:Retrospective Studies; D012640:Seizures / Q000175:diagnosis* / Q000503:physiopathology*; D016037:Single-Blind Method; D014743:Videotape Recording / Q000379:methods
keywords: Epileptogenic zone; Focal epilepsy; Lateralization; Semiology