Semiological Seizure Classification Research Articles

Comparison of 2017 ILAE and Semiological seizure classifications before and after video-EEG monitoring in childhood epilepsy.

Our aim in this study is to evaluate epilepsy classification in children with epilepsy before monitoring (based on information received from the family) and after monitoring (based on video-EEG) by comparing two separate classification systems, namely the 2017 International League Against Epilepsy (ILAE) and Semiological Seizure Classification (SSC) systems. Classifications and methods were compared in terms of simplicity, intelligibility, and applicability during daily outpatient care. The study was performed with 230 recorded seizures of 173 patients aged between 1 and 18 years who underwent video-EEG monitoring and clinical seizure recordings. Seizure types and video-EEG data of the patients were recorded. Seizures were first classified based on information obtained from the parents of the patients in interviews, recorded as "before video-EEG monitoring classification," and a second characterization, based on video EEG-monitoring, was subsequently recorded as "after video-EEG monitoring classification". The consistency of both seizure classifications was evaluated. For both classifications, autonomic seizures were the least congruent seizures (κ=0.27, κ=-0.005). The families generally described the seizures very well; the consistency before and after video-EEG monitoring was good. Focal seizures with impaired awareness were most common in the 2017 ILAE classification (κ=0.6), while for the SSC simple motor seizures were most common (κ=0.84). Among subtypes, clonic-tonic seizures were the most common, and the second most common subtype was dialeptic (κ=0.67). Overall, the harmony between the SSC and ILAE systems was good. The rate of good and excellent coefficients of concordance for both the SSC and 2017 ILAE was determined as 77.8% for the expanded SSC, 48% for the 2017 ILAE, 71.4% for the basic SSC, and 60% for the 2017 ILAE. In practice, it is difficult to determine seizure patterns reliably in cases of childhood epilepsy. Parents, however, can generally describe seizures very well. Although the SSC seems to be superior, both the SSC and 2017 ILAE systems can be applied in daily use. Such classification enables the rise of new concepts and a better understanding of disease groups. The continuing development of classification systems will lead to advancements for patients.

Home Recording And Video Selection: Their use In A Low-Resource Setting For Epilepsy Diagnosis

Objective: In management of epilepsy, identification of an epileptic seizure, classification, epilepsy syndromes, and management decisions relies heavily on seizure semiology. However, since most seizures are not witnessed, obtained semiology has its limitations. This study aimed to determine how many patients could successfully submit a home recording of a seizure event and if adapted video compilations would improve epilepsy diagnosis and classification in a low resource setting.
 Methods: A prospective cross-sectional study carried out at a neurology clinic in a teaching hospital in a low-resource setting. Sixty-seven randomly selected patients with recurrent unprovoked seizures and an informant who had regular observed the seizures and had access to video recording facilities were enrolled. Participants were required to fill an interviewer-administered questionnaire, select from a pre-designed video compilation what best described seizure witnessed, then encouraged on acquisition of video recordings at home. In the absence of video electroencephalography, information obtained was compared with a pre-defined algorithm which combined clinical history, physical examination, EEG results and neuro-images. Accuracy and reliability was calculated for different semiological signs and seizure classification.
 Results: Sixty seven patients were recruited comprising of 30 females and 37 male patients. Only eight (12%) participants returned with an adequate home recording of seizure episode. Incorporating video selection with questionnaire obtained description improved accuracy for generalized seizure (0.85 vs 0.79) and focal onset seizure (0.84 vs 0.73). Test-retest reliability on video selections by informants showed kappa coefficients ranging from 0.88 – 1.000. 
 Significance: Home video recording may not be as practical in our environment depending on the setting as adjustments may be required to make it routine. However, selecting videos from pre-selected video compilation may be a viable alternative to improve accuracy.

Comparison of ILAE 2010 and semiological seizure classification in children with epilepsy

ObjectiveThe aim of this study was to compare both ILAE 2010 and semiological seizure classification (SSC) in terms of their applicability and utility and to predict epileptogenic zone in children with epilepsy. MethodsBoth ILAE 2010 classification and SSC which is a part of five dimensional classification were applied for a total 138 children by dividing into younger (≤6y/o) and older (>6y/o) age groups over the last two years as retrospectively. After the assessment of the seizures types, epilepsy syndromes, and etiologies; the data were also compared to evaluate if having correlation between epileptogenic zone and seizure subtypes in both ILAE 2010 and SSC. ResultsILAE 2010 indicated that 66.7% of the patients had focal seizures, 15.9% had generalized seizures, and 14.4% had seizures of unknown origin. The SSC revealed that the most frequent seizure type was simple seizures (56.5%), second frequent one was complex motor seizures (46.4%) and dialeptic seizures (39.9%). To predict epileptogenic zone, SSC was found to be more specific than ILAE in terms of the more subgroups of SSC were related to the more subgroups of epileptogenic zone (p<0.05). Furthermore, there was a clear correlation between focal foci and specific seizure types in older ages, while many foci caused to same seizure types and tend to no clear focal foci with generalized onset in younger ages. On the other hand, the relationship between epileptogenic zone and etiology was more remarkable in the five dimensional classification. SignificancePreference of seizure classification system is unique for each patient and depends on requirements. Therefore, one dimension cannot be sufficient for evaluation the nature of the seizures in some patients. Furthermore, age related evolution of the seizure types should not be ignored due to ongoing maturation state of the brain. ILAE 2010 and SSC have weak and strong points compared to each other. Semiological seizure classification is more informative in terms of identifying the epileptogenic zone which may be important in specific occasions like pre-surgical work up, while ILAE is simple and easier method which can be applied for seizure description and their characteristics in daily practice.

Sleep-wake distribution and circadian patterns of epileptic seizures in children.

Epilepsy is one of the most common chronic neurologic disorders. Daily periodicity of epileptic seizures has been known for over a century. The diurnal patterns of epileptic seizures have also been observed in studies. To investigate the sleep/wake cycle, day/night, and 24-h periodicity of various seizure subtypes and seizure onset localizations in children. We analyzed the clinical seizures of 170 consecutive epilepsy patients who underwent video-electroencephalography (EEG) monitoring over the last 5 years. Semiology of the seizures was classified according to the semiological seizure classification. Origin of the seizures was defined by the onset of ictal activity on EEG. Seizures were evaluated in terms of occurrence during the day (06:00-18:00h) or night (18:00-06:00h), in wakefulness or in sleep, and within a 3-h time interval throughout 24h. A total of 909 seizures were analyzed. Auras, dialeptic, myoclonic, hypomotor, atonic seizures, and epileptic spasms occurred more frequently in wakefulness; tonic, clonic, and hypermotor seizures occurred more frequently in sleep. Auras, dialeptic, and atonic seizures and epileptic spasms occurred more often during daytime; hypermotor seizures occurred more often at night. Generalized seizures were seen most frequently in wakefulness (between 12:00 and 18:00h); frontal lobe seizures were seen at night and in sleep (between 24:00 and 03:00h); temporal lobe seizures were seen in wakefulness (between 06:00 and 09:00h and between 12:00 and 15:00h); occipital seizures were seen during daytime and in wakefulness (between 09:00 and 12:00h and between 15:00 and 18:00h, respectively); parietal seizures were seen mostly during daytime. Seizures in children occur in specific circadian patterns and in specific sleep/wake distributions depending on seizure onset location and semiology.

P52 – 2932: Sleep-wake distribution and circadian patterns of epileptic seizures in children

Objective To investigate the sleep/wake cycle, day/night and 24-hour periodicity of various seizure subtypes and seizure onset localizations in children. Methods We analyzed the clinical seizures of 170 consecutive epilepsy patients who underwent video-electroencephalography (EEG) monitoring over the last 5-year period. Semiology of the seizures was classified according to the semiological seizure classification. Origin of the seizures was defined by the onset of ictal activity in EEG. Seizures were evaluated in terms of occurence during the day (06:00–18:00) or night (18:00–06:00), in wakefulness or sleep and within the 3-hour time interval throughout 24 hours. Results A total of 909 seizures were analyzed. While auras, dialeptic, myoclonic, hypomotor, atonic seizures and epileptic spasms occurred more frequently in wakefulness; tonic, clonic, hypermotor seizures occurred more frequently in sleep. Auras, dialeptic, atonic seizures and epileptic spasms occurred more often during daytime, hypermotor seizures occurred more often at night. Generalized seizures were seen most frequently in wakefulness (between 12:00–18:00 h), frontal lob seizures were seen at night and in sleep (between 24:00–6:00 h), temporal lobe seizures were seen in wakefulness (between 06:00–09:00 h and 12:00 am-15:00 h), occipital seizures were seen during daytime and in wakefulness (between 09:00–12:00 h and 15:00–18:00 h), parietal seizures were seen mostly during daytime. Conclusion Seizures in children occur in specific circadian patterns and in specific sleep/wake distributions depending on seizure onset location and semiology. Recognition of these daily patterns of seizures provides new diagnostic and therapeutic options. To investigate the sleep/wake cycle, day/night and 24-hour periodicity of various seizure subtypes and seizure onset localizations in children. We analyzed the clinical seizures of 170 consecutive epilepsy patients who underwent video-electroencephalography (EEG) monitoring over the last 5-year period. Semiology of the seizures was classified according to the semiological seizure classification. Origin of the seizures was defined by the onset of ictal activity in EEG. Seizures were evaluated in terms of occurence during the day (06:00–18:00) or night (18:00–06:00), in wakefulness or sleep and within the 3-hour time interval throughout 24 hours. A total of 909 seizures were analyzed. While auras, dialeptic, myoclonic, hypomotor, atonic seizures and epileptic spasms occurred more frequently in wakefulness; tonic, clonic, hypermotor seizures occurred more frequently in sleep. Auras, dialeptic, atonic seizures and epileptic spasms occurred more often during daytime, hypermotor seizures occurred more often at night. Generalized seizures were seen most frequently in wakefulness (between 12:00–18:00 h), frontal lob seizures were seen at night and in sleep (between 24:00–6:00 h), temporal lobe seizures were seen in wakefulness (between 06:00–09:00 h and 12:00 am-15:00 h), occipital seizures were seen during daytime and in wakefulness (between 09:00–12:00 h and 15:00–18:00 h), parietal seizures were seen mostly during daytime. Seizures in children occur in specific circadian patterns and in specific sleep/wake distributions depending on seizure onset location and semiology. Recognition of these daily patterns of seizures provides new diagnostic and therapeutic options.

Value of seizure semiology and ictal source analysis in lateralizing and localizing the epileptic zone

Background Sophisticated analysis of seizure semiology and electroencephalography (EEG) has a significant role in lateralizing and localizing the epileptogenic zone. Hence, understanding the pathophysiology of epileptogenic dysrhythmia requires thorough knowledge of how to put the very different pieces of the puzzle together. Objective The aim of the study was to investigate the concordance between seizure semiology, electrophysiological generator, anatomical lesions, and neuropsychological evaluation in patients with partial epilepsy, and to identify the importance of ictal EEG recording and the diagnostic yield of other electrophysiological techniques. Patients and methods Thirty patients with a diagnosis of intractable partial epilepsy and lesional MRI were prospectively included. All of them were clinically evaluated and identified according to semiological seizure classification. Long-term video digital EEG with ictal recording was done, along with a source analysis (SA) study. Results Clinical evaluation by seizure semiology lateralized 73% of the cases and localized 80%. Ictal EEG lateralized 80% of cases and localized 66.9%. SA revealed a much superior power to lateralize and localize (96.7%) the epileptogenic zone, but what is more important is the added value of SA, as it lateralized and localized 96-100% of the cases that failed on semiology. SA has the highest expected value for additional lateralizing and localizing information ( ±7.73 and ±7.30, respectively). Conclusion Seizure semiology and ictal EEG recording with SA are the most accurate ways to lateralize and localize the epileptogenic zone in intractable partial epileptic cases, giving the patient a respectable chance to avoid other invasive diagnostic techniques.

Seizure semiology identifies patients with bilateral temporal lobe epilepsy

Laterality in temporal lobe epilepsy is usually defined by EEG and imaging results. We investigated whether the analysis of seizure semiology including lateralizing seizure phenomena identifies bilateral independent temporal lobe seizure onset. We investigated the seizure semiology in 17 patients in whom invasive EEG-video-monitoring documented bilateral temporal seizure onset. The results were compared to 20 left and 20 right consecutive temporal lobe epilepsy (TLE) patients who were seizure free after anterior temporal lobe resection. The seizure semiology was analyzed using the semiological seizure classification with particular emphasis on the sequence of seizure phenomena over time and lateralizing seizure phenomena. Statistical analysis included chi-square test or Fisher's exact test. Bitemporal lobe epilepsy patients had more frequently different seizure semiology (100% vs. 40%; p<0.001) and significantly more often lateralizing seizure phenomena pointing to bilateral seizure onset compared to patients with unilateral TLE (67% vs. 11%; p<0.001). The sensitivity of identical vs. different seizure semiology for the identification of bilateral TLE was high (100%) with a specificity of 60%. Lateralizing seizure phenomena had a low sensitivity (59%) but a high specificity (89%). The combination of lateralizing seizure phenomena and different seizure semiology showed a high specificity (94%) but a low sensitivity (59%). The analysis of seizure semiology including lateralizing seizure phenomena adds important clinical information to identify patients with bilateral TLE.

Professor Hans Otto Lüders

Professor Lüders has made significant contributions to Clinical Neurology and particularly to Epilepsy and Clinical Neurophysiology. Some of his most important contributions include the following: 1.He pioneered the use of chronically implanted, large plates of subdural electrodes in the presurgical evaluation of patient who were candidates for epilepsy surgery. These electrodes were used to record epileptic seizures and by electrical stimulation to establish the location of eloquent cortex. Lately he has also advocated the use in the USA of stereotactically implanted depth electrodes for presurgical evaluation of epilepsy patients who had deep seated epileptic foci which were impossible to assess with subdural electrodes. These techniques were imported from Europe. 2.Mapping studies with subdural electrodes led to the discovery of a number of cortical eloquent areas that had not been described before: a. The basal temporal language area located in the dominant fusiform gyrus. b. The "negative motor areas" located in the caudal region of the inferior frontal gyrus (bilaterally) and immediately in mesial frontal pre-SMA region (also bilaterally). He concluded that these "negative motor areas" most likely correspond to praxis regions. c. The dominant posterior fusiform gyrus which plays a crucial role in processing reading material. Stimulation of that area produces "alexia without agraphia". 3.He developed a new classification of epileptic seizures based exclusively on semiological ictal characteristics. With the development of the semiological seizure classification he also defined several new seizure types: a. Dialeptic seizures, b. Hypnopompic seizures, c. Hypomotor seizures. 4.Working with general epilepsy principles, he established the existence of 6 zones that characterize the epilepsies: the epileptogenic zone, the irritative zone, the seizure onset zone, the epileptogenic lesion, the symptomatogenic zone and functional deficit zone. 5.He described the ictal DC (direct current) shift seen at the beginning of focal seizures and its value for localization of the seizure onset zone.

Clinical events in psychogenic non-epileptic seizures based on semiological seizure classification

Objectives:None of the classifications of psychogenic non-epileptic seizures (PNES) have been widely accepted and used by physicians so far. In this study we aimed at classifying PNES on the basis of a modified version of semiological seizure classification (SSC). We also sought to assess the interrater reliability (IRR) of the PNES diagnosis based on SSC.Methods:We classified PNES into four types on the basis of our modification of SSC: pseudoaura, dialeptic, motor, and special (atonic, astatic, hypotonic) spells. Pseudoauras were not included in the statistical analysis. Ninety-one PNES attacks were observed during the 55 video-EEG sessions recorded for all patients. The interrater agreement was assessed by the kappa coefficient.Results:Twenty-nine women (78·3%) and eight men (21·6%) were surveyed, with a mean age of 28·4 ± 9·6 (range 16–54). The final diagnosis of PNES was established after a mean of 4·5 ± 2·3 years following the onset of PNES attacks in the patients. The mean seizure duration in the PNES was 241 seconds and 40·5% of our patients had PNES longer than 300 seconds. Motor and special PNES were the most common types observed by all the raters. The kappa values for each pair were as follows: Observers I–II 0·51 (p = 0·000), Observers I–III 0·47 (p = 0·000), and Observers II–III 0·73 (p = 0·000).Conclusions:Interobserver agreement was moderate and substantial for three observers who classified PNES according to our modified SSC. The modified version of SSC could be used without difficulty in classifying PNES. Using SSC for PNES both shortens the period before diagnosis and eliminates the need to learn another new and acceptable classification for PNES.

The Masquerades of Temporal Lobe Epilepsy in Childhood

Age-Dependent Seizure Semiology in Temporal Lobe Epilepsy. Fogarasi A, Tuxhorn I, Janszky J, Janszky I, Rásonyi G, Kelemen A, Halász P. Epilepsia 2007;48(9):1697–1702. Epub 2007 May 23. OBJECTIVE: To examine the effects of age on different aspects of temporal lobe seizure semiology. METHODS: We performed a video analysis of 605 archived seizures from 155 consecutive patients (age 10 months to 49 years) selected by seizure freedom after temporal lobectomy. Eighty patients had hippocampal sclerosis (HS). Beside semiological seizure classification, we assessed age dependency of several axes of seizure semiology: ( 1 ) aura, ( 2 ) number of different lateralizing signs, occurrence of ictal ( 3 ) emotional signs, ( 4 ) autonomic symptoms, ( 5 ) automatisms, and ( 6 ) secondary generalization as well as ( 7 ) the ratio of motor seizure components. RESULTS: From the 155 patients, 117 reported aura, 39 had ictal emotional signs, 51 had autonomic symptoms, 130 presented automatisms, while 18 patients showed secondary generalization at least once during their seizures. Altogether 369 (median: 2/patient) different lateralizing signs were recorded. Frequency of HS (p &lt; 0.001), ictal automatisms (p &lt; 0.001), secondary generalization (p = 0.014), number of different lateralizing signs (p &lt; 0.001) increased while the ratio of motor seizure component (p = 0.007) decreased by age. Auras, emotional symptoms, and autonomic signs occurred independently of patients’ ages. Hippocampal sclerosis adjusted linear models revealed that the frequency of automatisms and secondarily generalized seizures as well as the number of different lateralizing signs are HS-independent significant variables. CONCLUSION: Our findings support that brain maturation significantly influences the evolution of some important aspects (motor seizures, lateralizing signs) of temporal lobe seizure semiology. Conversely, other aspects (aura, emotional, and autonomic signs) are independent of the maturation process. This is the first report investigating age dependency of epileptic seizure semiology comparing all age groups.

Response to Koutroumanidis

To the Editors: We appreciate the comments from Dr. Koutroumanidis about our article on autonomic symptoms (AS's) during partial seizures in children. Dr. Koutroumanidis raises some important questions, and we will try to address them briefly below. Regarding the predominant (most important) ictal manifestations seen in our population of children – Typical psychomotor or motor seizures were predominant. Autonomic symptoms occurred frequently, but were not the predominant feature of these seizures. Regarding the timing (early or late in the seizure sequence) of AS's – Most of the AS's appeared later in the seizures. Some of them were typically postictal (or occurred at the end of the ictal episode) – e.g., nose-wiping, vomiting, coughing, hiccupping. Other signs occurred within the ictal period, but late in the session – e.g., genital automatisms, flushing, pallor, hypersalivation. Only a few AS's appeared at an early stage – e.g., epigastric aura and apnea. In short, the occurrence of AS's in these children followed the typical adult pattern of late-appearing AS's, as cited by Dr. Koutroumanidis. Regarding the duration of seizures with and without AS's – The duration of the AS's was usually short and constituted a minor part of the seizure. We did not see any seizures with autonomic status epilepticus, and none of the seizures were characterized exclusively by AS's. Rather, the AS period appeared as part of the whole psychomotor or motor seizure attack. We did not measure the exact length of seizures (an enormous undertaking for 514 attacks), and therefore cannot compare statistically the length of seizures with and without AS's. Regarding signs typical of Panayiotopoulos syndrome (PS) – Loss of muscle tone or awareness, a typical sign of PS, was noted in our semiological seizure classification of “atonic seizure.” Only 4 of 514 seizures (<1%) contained atonic components, so loss of muscle tone was clearly not a characteristic symptom of this patient group. We believe that the differences of our seizure with AS's, as compared to the longer autonomic seizures of PS, result from our special patient population. In our study, all the children had focal, well-localized, therapy-resistant epilepsy – a group very much different from the idiopathic childhood epilepsy population.

Age‐Dependent Seizure Semiology in Temporal Lobe Epilepsy

To examine the effects of age on different aspects of temporal lobe seizure semiology. We performed a video analysis of 605 archived seizures from 155 consecutive patients (age 10 months to 49 years) selected by seizure freedom after temporal lobectomy. Eighty patients had hippocampal sclerosis (HS). Beside semiological seizure classification, we assessed age dependency of several axes of seizure semiology: (1) aura, (2) number of different lateralizing signs, occurrence of ictal (3) emotional signs, (4) autonomic symptoms, (5) automatisms, and (6) secondary generalization as well as (7) the ratio of motor seizure components. From the 155 patients, 117 reported aura, 39 had ictal emotional signs, 51 had autonomic symptoms, 130 presented automatisms, while 18 patients showed secondary generalization at least once during their seizures. Altogether 369 (median: 2/patient) different lateralizing signs were recorded. Frequency of HS (p < 0.001), ictal automatisms (p < 0.001), secondary generalization (p = 0.014), number of different lateralizing signs (p < 0.001) increased while the ratio of motor seizure component (p = 0.007) decreased by age. Auras, emotional symptoms, and autonomic signs occurred independently of patients' ages. Hippocampal sclerosis adjusted linear models revealed that the frequency of automatisms and secondarily generalized seizures as well as the number of different lateralizing signs are HS-independent significant variables. Our findings support that brain maturation significantly influences the evolution of some important aspects (motor seizures, lateralizing signs) of temporal lobe seizure semiology. Conversely, other aspects (aura, emotional, and autonomic signs) are independent of the maturation process. This is the first report investigating age dependency of epileptic seizure semiology comparing all age groups.

Semiological Seizure Classification: Before and After Video-EEG Monitoring of Seizures

The study objective was to assess the applicability and reliability of the semiological seizure classification in children with epilepsy in outpatient clinics. Ninety patients (age range, 2-16 years) who experienced clinical seizures during prolonged video-electroencephalogram (EEG) monitoring were evaluated. Semiological seizure classification was performed, first based on history obtained from parents of the patient during outpatient follow-up visits and then based on video EEG-monitoring. Kappa statistics (kappa) were used to evaluate the consistency of the two rounds of semiological seizure classification. Classification based on history yielded the following distribution: simple motor seizures (66.3%), aura (28%), complex motor seizures (15.8%), special seizures (15.8%), dialeptic seizures (9.3%), and autonomic seizures (3.7%). Classification based on video EEG-monitoring yielded a different distribution: simple motor seizures (55.7%), complex motor seizures (26.9%), automotor seizures (26.9%), aura (23%), dialeptic seizures (22.1%), special seizures (9.6%), and autonomic seizures (1.9%). Negative myoclonic seizures (kappa = 1, P = 0.000) and hypermotor seizures (kappa = 0.85, P = 0.000) had excellent consistency; somatosensory aura (kappa = 0.26, P = 0.012) and automotor seizures (kappa = 0.28, P = 0.004) had the lowest consistency. The families or doctors often defined simple motor seizures (decrease of 10.6% from before to after monitoring, kappa = 0.44); the proportion of complex motor seizures changed rather from before to after monitoring (11.1%, kappa = 0.33). Generally, parents can describe seizures quite well. We suggest that semiological seizure classification is a reliable method applicable for everyday use during outpatient visits, especially if seizure semiology is evaluated individually for each component or if the semiological seizure classification is modified or refined for some seizure components (tonic, clonic, versive, conscious, automotor seizures).

A proposal for a five‐dimensional patient‐oriented epilepsy classification

The recent proposal by the ILAE Task Force for Epilepsy Classification consists of a multi‐axial syndrome‐oriented approach. Epilepsy syndromes, as defined by the ILAE, group patients according to various, poorly defined parameters. The resulting syndromes have frequently no biological significance, with overlap among different syndromes and syndromes changing with age. Additionally, only a minority of patients can be classified syndromatically, and the axes of this classification system convey redundant information. We propose a five‐dimensional, patient‐oriented approach to classifying epilepsies. This approach shifts from the syndrome‐oriented approach to a standard, neurological, methodological, patient‐oriented approach, using independent criteria in each of the five dimensions. Similar to general neurology, the first step in each patient‐physician encounter in epileptology is to take a history of the presenting symptoms and generate a hypothesis regarding the localization and etiology of the symptom within the nervous system. Therefore, the main dimensions of this classification consist of: 1) localization of the epileptogenic zone, 2) seizure semiology classified according to the semiological seizure classification, 3) etiology, 4) seizure frequency, and 5) related medical conditions. These dimensions characterize all of the information necessary for patient management, are independent parameters, and include more pertinent information with regards to patient management than the ILAE axes. All patients can be classified according to this five‐dimensional system even at the initial patient encounter when no detailed test results are available. Information from clinical tests, such as MRI and EEG, are translated into the best possible working hypothesis at the time of classification, allowing for increasing precision of the classification as additional information becomes available. This patient‐oriented classification envisions an epileptic seizure as an independent symptom of a central nervous system dysfunction due to different causes, with various cortical localizations, occurring at various frequencies, and in conjunction with other diseases and clinical symptoms.

Comparison of classifications of seizures: A preliminary study with 28 participants and 48 seizures

Purpose Our aim was to compare three available seizure classifications (SCs), namely, the international classification of epileptic seizures published in 1981 (ICES; Epilepsia 1981;22:489–50); the semiological seizure classification (SSC) by H. Lüders, J. Acharya, C. Baumgartner, et al. (Epilepsia 1998;39:1006–13; Acta Neurol Scand 1999;99:137–41); and the proposal of a new diagnostic scheme for seizures (PDSS) by J. Engel, Jr. (Epilepsia 2001;42:796–803) published in 2001. The three SCs were compared with respect to diagnostic success rates, usefulness, and consistency by a large group of neurologists in this preliminary study. Methods After a training period, 28 blindfed participants with different levels of experience with epilepsy classified videos or written descriptions of 48 randomly selected seizures according to the three SCs. Definite diagnoses of the seizures were established based on all clinical, ictal/interictal EEG, and MRI data. All the participants answered a questionnaire concerning their preferences for SCs after the study. Results The overall diagnostic success rates were 81.4% for ICES, 80.5% for PDSS, and 87.5%, for SSC. Various parameters concerning experience with epilepsy affected success rates positively, without reaching statistical significance, whereas experience with epilepsy surgery appeared to be a parameter significantly affecting the success rate in all SCs. In reliability analysis, Cronbach’s α was 0.94 for ICES, 0.88 for PDSS, and 0.70 for SSC, all showing good agreement in the group. Nineteen reviewers chose SSC, eight chose ICES, and one chose PDSS as their preference in the questionnaire, completed after the end of the study. Conclusion The results of this preliminary study demonstrate that with proper training, physicians treating epilepsy patients can handle new SCs, and emphasize the need for revision of the current classification.

A semiological classification of status epilepticus

The classification of status epilepticus (SE) has been a subject of discussion for many years, yet no satisfactory agreement has been reached. Due to their complexity, status episodes often defy classification according to the current international classification scheme. The semiological seizure classification (SSC) has been in use in several epilepsy centers for more than a decade, and has proven to be a valid approach to the classification of epileptic seizures. Based on the detailed analysis of more than 100 episodes of SE documented with video‐EEG recordings, the authors now present a proposal for a semiological classification of status epilepticus (SCSE). The SCSE reflects the assumption implied by all modern definitions of SE that “there are as many types of status as there are types of seizures” and relies on the same principles as the SSC, focusing on the main clinical manifestations and the evolution of the status episode. The clinical manifestations of SE are subdivided into semiological components and classified along three axes: the type of brain function predominantly compromised by the seizure activity, the body part involved, and the evolution over time. Each axis contains several subcategories, so that many different levels of accuracy are possible. The SCSE, just like the SSC, is meant to be part of a comprehensive epilepsy classification which classifies as independent variables (epileptogenic zone, ictal semiology, etiology, related medical conditions) the main features of the patient's epilepsy, allowing for each variable maximum flexibility. [Published with videosequences]

Another seizure classification--Semiological Seizure Classification

The International League Against Epilepsy (ILAE) introduced in 1981 a seizure classification based on clinical semiology, interictal EEG findings, and ictal EEG patterns. Such classification depends heavily on detailed electroclinical correlation. After 20 years' progress in epileptology, many clinicians have found it difficult to make a "definite" seizure diagnosis clinically without a series of electrophysiological examinations, particularly in the infants, and further advancement in epileptology has findings have made the previous classification inefficient. Lüders and colleagues have proposed a classification, Semiological Seizure Classification (SSC), based exclusively on ictal semiology, which was published in the official journal of ILAE-EPILEPSIA in 1998. The EEG, neuroimaging and other laboratory results should be analyzed separately and then integrated to define the epileptic syndromes. The seizure diagnosis is thus made through a "what-you-see-is-what-you-get" way. It has also provoked an extensive discussion about the necessity of this new classification. In this review, we present the original guideline, which has been used at The Cleveland Clinic Foundation for years, to introduce another method of epileptic seizure classification.

Diagnosis of Epilepsy

Diagnosis of Epilepsy

Of cabbages and kings: some considerations on classifications, diagnostic schemes, semiology, and concepts.

Laws are like sausages, it is better not to see them being made. Otto von Bismark To the extent to which a new classification of seizures resembles a law or a sausage, it might be preferable to ignore how the classification is made. In the special ar- ticles that follow, we choose to take the opposite ap- proach. These articles will expose to public scrutiny some of the deliberations and debate in this controversial area. Peter Wolf submitted the lead article. I asked Drs. Engel, Luders, Avanzini, and Berg to provide responses. All articles were subject to peer-review and revision. These authors have debated their points of view for years. The thought underlying their positions has educa- tional value, even in the absence of a full consensus. The articles in this section occasionally refer to per- sonalities or processes internal to the International League Against Epilepsy (ILAE), the owner of this Jour- nal. I chose not to edit out such references, so the readers could see the sausage being made, but the primary pur- pose clearly is not criticism of persons or processes, but of ideas. Contrary to widespread opinion, the ILAE has not yet issued a suggested revised classification of sei- zures or syndromes. Discussion remains at the level of what such a classification should accomplish and com- prise. As we proceed, we might keep in mind the advice of Albert Einstein that "Things should be made as simple as possible—but no simpler." Few areas in epileptology will have such a great need for wise simplicity.

Application of semiological seizure classification to epileptic seizures in children

To better define seizure characteristics and to examine whether semiological seizure classification (SSC) can be appropriately applied to the seizures of infants and children, we studied 152 videotaped seizures recorded in 133 children. Seizure semiology was described on the basis of a series of behavioural, sensory, and motor phenomena according to SSC. Special emphasis was placed on whether one semiology can be representative of a patient’s whole semiology sequence. If one semiology was able to represent the whole sequence, the seizure was classified according to SSC. Ninety of 152 seizures (59.2%) could be classified as a single seizure type by SSC. However, only 19 of 53 seizures (35.9%) consisting of two semiologies, three of 24 seizures (12.5%) consisting of three semiologies, and one of eight seizures (12.5%) consisting of four semiologies could be classified according to SSC. Although SSC is very efficient, it is more accurately a descriptive terminology for clinical ictal events than a classification system.