Postictal nose-rubbing in the diagnosis, lateralization, and localization of seizures

Semiology is very useful in the diagnosis and classification of seizures. Some clinical signs occur primarily with specific localization-related epilepsies.

To evaluate postictal nose-rubbing as a potential diagnostic sign and a potential lateralizing or localizing indicator.

We reviewed presurgical prolonged video-EEG results of 50 consecutive patients with right temporal lobe epilepsy (TLE), 50 consecutive patients with left TLE, 50 consecutive patients with frontal lobe epilepsy, 11 consecutive patients with generalized epilepsy, and 100 consecutive patients with nonepileptic events. Videotapes of all events were reviewed independently by two investigators who were blinded to the results of the monitoring. The episodes of nose-rubbing and the hand with which the patient rubbed the nose were recorded.

Nose-rubbing occurred in 25 of 50 (50%) right TLE patients and in 21 of 50 (42%) left TLE patients. Approximately 90% of patients rubbed his or her nose with the ipsilateral hand. Nose-rubbing occurred in 5 of 50 (10%) frontal lobe epilepsy patients. Nose-rubbing was not seen in any patient with generalized epilepsy or nonepileptic events. Postictal nose-rubbing did not occur after secondarily generalized seizures.

Nose-rubbing is an easily observed phenomenon, has high interobserver reliability, and provides useful lateralizing information in patients with TLE. It was less frequently seen in extratemporal lobe epilepsy and was not seen after generalized seizures or nonepileptic events.