An 8-year-old, right-handed female with no initial precipitating injuries or family
history was presented to the casualty with the history of convulsions. Seizure semiology
involves sudden onset of forced head and eye deviation to the left lasting for 20
to 30 seconds with clonic movements of left upper limb. During the episode, the child
remained responsive and there was no involvement of other limbs ([Fig. 1] and [
Video 1
]). Child had a total of four such episodes before hospitalization. General physical
and neurological examination was within normal limits. Her fundoscopy was normal.
Routine investigations and metabolic screens (kidney function tests, liver function
tests, serum calcium and magnesium) were normal. The ictal electroencephalography
(EEG) showed right frontal spike and wave discharges with phase reversal at F8 with
normal background activity. 3.0-T magnetic resonance imaging of brain with contrast
was normal with no evidence of any structural abnormality. She was treated with carbamazepine
at dose of 10 mg/kg/d twice daily. The child is on regular follow-up and has not had
any seizure recurrences.
Fig. 1 Deviation of eye toward left side.
Video 1 Versive seizures. Video showing sudden onset forced head and eye deviation to the
left lasting for 20 to 30 seconds with clonic movements of left upper limb. During
the episode, the child remained responsive.
Differential Diagnosis
Since the seizure semiology is subtle, these events can be mistaken for functional
disorders like panic attacks. Here fear may manifest as focal seizures, which can
be ruled out by electrophysiological studies—EEG/Video EEG. Other less common differentials
include migraine with aura, which can be accompanied by visual symptoms. However,
in these cases there is significant history of photophobia, phonophobia, and absence
of involuntary movements.
Commonly, seizures arising from the insula can mimic frontal, temporal, and parietal
lobe seizures. During the seizure onset, these are associated with somatosensory aura.
Other conditions, like benign paroxysmal vertigo which is considered as a migraine
variant of childhood, are associated with benign paroxysmal torticollis which mimics
versive seizures.
Also, nonepileptic seizure is a seizure like event, which is associated with focal
seizures and abnormal head and neck movements. Generally, these are distinguished
clinically by variable rate and direction of jerking and horizontal movements of the
head.
Discussion
Ictal versive head movement is thought to reflect spread of epileptic activity to
the frontal eye field (FEF).[1] In epileptic seizures from different brain regions, this spread of epileptic activity
may occur sooner or later and after ictal activation of other cortical areas and subsequent
spread to the FEF.[2]
[3] According to the definition by Wyllie et al, only forced, sustained, and unnatural
turning of the eyes and head to one side is termed as versive seizure.[4] Contralateral version is considered as one of the most valuable semiological signs
for lateralization of epileptogenic zone.[5]
Versive seizures are characterized by sustained neck contraction and has a strong
localizing sign. A frontal focus commonly causes a contralateral versive seizure.
However, it should be kept in mind that temporal and occipital foci can also cause
such movements, but the movements can be either ipsilateral, contralateral, or ipsilateral
followed by contralateral. The localization potential of any versive seizures lies
in the fact that, extratemporal onset causes early version as compared with temporal
onset.[4] Additionally, version with preserved sensorium points to frontal ictal onset.[6] Ipsilateral version is mostly encountered in occipital lobe epilepsy.[7] In our patient, clinical and electrophysiological concordance was noted. The therapeutic
relevance of this finding is of importance in the context of epilepsy surgeries.
Epilepsy surgery has become a cardinal treatment alternative in patients with medically
refractory epilepsy. Localization of the epileptogenic zone is pivotal. The tools
available for localization are limited. This is beneficial in case of focal epilepsy
with imaging being negative. This case thus highlights localization value of focal
seizures and its therapeutic implications.
