Semiological feature of epileptic seizures originated from subgenual ventromedial prefrontal cortex: Insight from...

Seizures originating from the ventromedial prefrontal cortex (vmPFC) have been infrequently documented in prior literature. The purpose of the present study is to highlight the semiological features of seizures arising from subgenual vmPFC.

We presented three cases with stereoelectroencephalography (SEEG)-confirmed epileptogenic zones localized to the subgenual vmPFC (sg-vmPFC), all achieving favorable surgical outcomes (seizure freedom or significant reduction).

Distinct from the panic-driven behaviors (e.g., agitation, hyperkinetic movements) reported in seizures involving the pregenual anterior cingulate or orbitofrontal cortex, the semiology of our cases was characterized by anxiety-related and risk-assessment behaviors, such as visual scanning, olfactory exploration (sniffing), oral automatisms (lip-licking), and manual exploration (hand fumbling), accompanied by vigilant/anxious facial expressions. These features closely align with the pre-threat phase of the Threat Imminence Continuum Theory, which prioritizes environmental surveillance and threat anticipation over immediate defensive actions.

Based on our findings, we propose that anxiety-dominated behaviors should be recognized as semiological hallmarks of seizures triggered by vmPFC hyperactivation or early ictal involvement. This paradigm challenges traditional classifications that conflate anxiety and panic semiology, offering a refined framework for localizing vmPFC-related epilepsy and tailoring interventions to its unique network dynamics.