Abstract
OBJECTIVE: To elucidate the lateralizing value of ictal head turning in focal epilepsy and provide guidance for interpreting ictal semiology within the framework of presurgical evaluation. METHODS: We conducted a systematic review of ictal head turning. We included studies reporting ictal head turning (versive, nonversive, and gyration) captured in video-EEG recordings during presurgical evaluation. We assessed potential selection and assessment bias and evaluated confidence in the epileptogenic zone based on reported comparators-including resection site and surgical outcomes, intracerebral EEG, and MRI findings. Studies were classified as high quality if potential bias was low and confidence in the epileptogenic zone was high. RESULTS: Versive head turning is usually contralateral to the epileptogenic zone (high level of evidence). Nonversive head turning is most often ipsilateral to the epileptogenic zone in temporal lobe epilepsy (high level of evidence) and contralateral in occipital lobe epilepsy (moderate level of evidence). In frontal lobe epilepsy, the lateralization of nonversive head turning may vary based on sub-lobar localization, but high-level evidence is lacking. Gyratory seizures are likely contralateral when initiated by versive head turning and evolving into focal-to-bilateral tonic-clonic seizures; in other cases, they may be ipsilateral, particularly in temporal and mesial frontal epilepsy, but the available evidence is insufficient for a definitive conclusion. SIGNIFICANCE: The lateralizing value of ictal head turning depends on its specific characteristics and clinical context.