Electroclinical features and surgical outcomes in cingulate epilepsy - A single- centre experience

Cingulate epilepsy can mimic extratemporal as well as temporal lobe epilepsy. We aimed to characterize the clinical presentation, electrophysiological features, imaging findings, and surgical outcomes in patients undergoing resection for cingulate epilepsy at a tertiary epilepsy center in South India.

We reviewed our prospectively maintained surgical database, identifying patients who underwent lesionectomy involving the cingulate cortex, including lesions extending to adjacent areas (cingulate plus- supplementary motor area, medial pre-frontal cortex, sensori-motor areas, pre-cuneus and posterior parietal cortex) between 1995 and 2023. Clinical features, seizure semiology, EEG findings, imaging characteristics, histopathology, and postoperative outcomes were analyzed.

Out of 493 patients who underwent extratemporal resections in the study period, 25 patients (mean age 20 years; 56% female) were included. Of these, 19 had anterior and six had posterior cingulate lesions. Seven had cingulate plus lesions. Hypermotor seizures were the most common semiology (n = 14;56%), followed by focal dyscognitive seizures in 7 (28%). MRI detected lesions in 96% of cases, predominantly focal cortical dysplasia. Ictal EEG findings were non-localizing or bilateral in 21 (84%). Lesionectomy resulted in Engel class I outcomes in 76% of patients at one year and 72% at last follow-up (mean follow-up duration: 2.6 years). Intraoperative electrocorticography showed persistent spikes post-resection in 36%. Intracranial monitoring was required in one patient (4%). Postoperative complications, primarily transient motor deficits occurred in 24%.

Cingulate epilepsy presents with diverse and often non-specific semiology, and scalp EEG frequently lacks clear localization. Non-invasive surgical outcomes are favorable, especially in lesional cases. This study represents the largest single-center series of cingulate epilepsy from the Indian subcontinent and reinforces the role of high-resolution imaging and careful multidisciplinary evaluation in successful surgical management.