Ictal semiology in fronto-opercular epilepsy: A systematic review

A systematic review of the ictal semiology of fronto-opercular seizures in focal epilepsy was carried out to assess possible anatomical-clinical correlations and help guide interpretation of ictal semiology during pre-surgical evaluation. PubMed and Embase databases were searched using the following keywords: "fronto-opercular OR frontal opercular OR Frontal operculum OR superior perisylvian OR anterior opercular AND (epilep* or seizure)." The date last searched was November 30th, 2025. Studies were selected if they concerned case series, including at least one fully documented patient and informative case reports with the following criteria: patients who underwent a resection limited to the fronto-opercular cortex, and/or patients for whom the epileptogenic zone (EZ) was proven by intracranial electroencephalogram (iEEG) with insular cortex exploration, and/or by complementary noninvasive explorations. A total of 21 patients with fronto-opercular epilepsy from 16 studies were included in the review. iEEG was performed in 15 (71%) patients and resection in 16 (76%) patients. The confidence level in the EZ was very high (Engel IA) for 5 patients, high (Engel I not specified IA or Engel IB) for 12 patients, and moderate for 4 patients. The presence of an aura was found in 67% (n = 14/21) of the patients with mainly non-painful somatosensory sensations. This was more frequent in patients with an EZ in the precentral Rolandic operculum compared to those with an EZ in the prefrontal operculum (n = 6 versus n = 1, respectively, p = 0.016). Ictal signs comprised elementary motor symptoms, speech dysfunction, complex motor behavior, respiratory symptoms, salivation, and laughter, with preserved consciousness. Pure fronto-opercular epilepsy is rare, consisting mainly of contralateral elementary sensory aura especially for the Rolandic operculum. Common ictal signs are motor orofacial and brachial symptoms with preserved consciousness. Further studies including patients who underwent a successful resection limited to the frontal operculum are needed to confirm these anatomical-clinical correlations.