Pediatric frontal lobe epilepsy (FLE): Semiological distinctions from adult-onset FLE

To characterize seizure semiology, electroclinical features, and lesion localization in pediatric frontal lobe epilepsy (FLE), and to assess the applicability of the Bonini classification system, with comparison to adult-onset FLE.

We retrospectively analysed clinical, video-EEG, and neuroimaging data from 61 children with FLE who underwent presurgical evaluation between January 2015 and June 2023. Seizure semiology was categorised using Bonini's system. Imaging findings were correlated with semiological features.

The majority of patients had daily seizures (67.2 %) and clustering (88.5 %). Auras were rare (9.8 %), and focal to bilateral tonic-clonic seizures (FBTCS) occurred in only 3.2 %. Motor manifestations dominated the clinical picture, with Group 1 semiology (elementary motor signs) present in 59 % of cases, a frequency significantly higher than reported in adults. Emotional behaviours (Group 4) and integrated gestural behaviours (Group 3) were infrequent. Epileptic spasms occurred in children up to 5 years and were associated with focal lesions. Over half of the patients initially had normal MRIs, with subsequent detection of focal cortical dysplasia in 78.6 % of cases following advanced imaging techniques. There was no clear correlation between lesion location and seizure semiology. Fifty-three patients underwent surgery with 81 % seizure-free outcome after a median follow-up of 36 months.

Pediatric FLE exhibits distinct clinical patterns compared to adult FLE, including higher rates of motor-dominant semiology and lower incidence of auras and FBTCS. Bonini classification is applicable but may require pediatric-specific modifications. Accurate imaging interpretation is essential for identifying subtle dysplastic lesions in children.