Lateralizing and localizing value of postictal signs: A systematic review

To present a concise and comprehensive review of the lateralizing and localizing value of postictal signs in focal epilepsy and to provide guidance in the interpretation of the signs for presurgical evaluation of drug-resistant epilepsy. We performed a systematic literature review following the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines to identify the various postictal manifestations of seizures (paresis, psychosis, nose-wiping, automatisms, language deficits, headache, autonomic disturbances, visual impairment, palinacousis, and memory disturbances). We specifically investigated its evidence in the lateralization and localization of the seizure focus by searching three databases (PubMed, Embase, Scopus) until January 03, 2024. We then assessed the possibility of selection and assessment bias and evaluated the confidence in the epileptogenic zone based on brain neuroimaging, intracranial electroencephalography, and surgical outcomes. Studies were classified as high quality if the potential for bias was low and the confidence in the epileptogenic zone was high. The majority of patients with postictal signs had temporal lobe epilepsy (TLE). Signs with the highest incidence of TLE were postictal automatisms (93%), postictal nose-wiping (89%), postictal psychosis (84.9%), postictal language impairment (84.2%), and postictal autonomic signs (83.7%). Language dysfunction had a high occurrence in left TLE (96.4%); nose-wiping had a high occurrence in ipsilateral TLE (82.1%). Paresis was always seen contralaterally to the epileptic focus and was more likely to occur in patients with frontal lobe epilepsy than other anatomical localizations (Odds = 1.5). Finally, patients with occipital lobe epilepsy had a significantly higher incidence of postictal headache (Odds = 8.3) compared to other lobar localizations. Even though occurring after seizure termination, postictal signs can have high lateralizing and localizing value in presurgical planning, along with other ancillary information.