Focal seizures associated with the chapeau de gendarme sign or ictal pouting of insular origin

• Published in: Epilepsy & behavior reports Vol. 12; p. 100347
• Main Authors: Wiwchar, Logan D., Hader, Walter, Pauranik, Anvita, Joseph, Jeffrey T., Appendino, Juan P.
• Format: Journal Article
• Language: English
• Published: United States Elsevier Inc 01-01-2019; Elsevier
• Subjects: Chapeau de gendarme; Epilepsy; Focal; Ictal pouting; Insula; SEEG; Insula; SEEG; Chapeau de gendarme; Focal; Ictal pouting; Epilepsy
• ISSN: 2589-9864; 2589-9864
• DOI: 10.1016/j.ebr.2019.100347

We report a teenager with childhood onset focal seizures associated with the chapeau de gendarme sign or ictal pouting of anterior insular lobe origin. The chapeau de gendarme sign has been associated with frontal lobe seizures in patients with focal epilepsy. However, in this case, stereo-electroencephalography (SEEG) localized seizures to the anterior insular cortex prior to her typical clinical manifestations. Surgical resection of the insular and frontal-lobe network resulted in seizure freedom. We propose that the anterior insular cortex should be a site of investigation during pre-surgical phase 2 evaluation in patients exhibiting the chapeau de gendarme sign during focal seizures.
•Chapeau de gendarme seizures or ictal pouting could have insular lobe involvement at electrical seizure onset.•Phase 2 investigation should include insular monitoring when assessing for this kind of seizures.•Pediatric population could also have chapeau de gendarme or ictal pouting seizures.•Ripples were associated with epileptogenicity in insular cortex requiring resection.