Value of semiology in predicting epileptogenic zone and surgical outcome following frontal lobe epilepsy surgery

Objective: To evaluate the ability of semiology alone in localising the epileptogenic zone (EZ) in people with frontal lobe epilepsy (FLE) who underwent resective surgery. Methods: We examined data on all individuals who had FLE surgery at our centre between January 01, 2011 and December 31, 2020. Descriptions of ictal semiology were obtained from video-EEG telemetry reports and presurgical multidisciplinary meeting summaries. The putative EZ was represented by the final site of resection. We assessed how well initial and combined set-of-semiologies correlated anatomically with the EZ, using a semiology visualisation tool to generate probabilistic cortical heatmaps of involvement in seizures. Results: Sixty-one individuals had FLE surgery over the study period. Twelve months following surgery, 28/61 (46%) were completely seizure-free, with a further eight experiencing only auras. Comparing the semiology database with the putative EZ, combined set-of-semiology correctly lateralised in 77% (95% CI: 69–85%), localised to the frontal lobe in 57% (95% CI: 48–67%), frontal lobe subregions in 52% (95% CI: 43–62%), and frontal gyri in 25% (95% CI: 16–33%). No difference in degree of correlation was seen comparing those with ongoing seizures 12 months after surgery to those seizure free. Significance: Semiology alone was able to correctly lateralize the putative EZ in 77%, and localise to a sublobar level in approximately half of individuals who had FLE surgery. Semiology is not adequate alone and must be combined with imaging and EEG data to identify the epileptogenic zone.