Ipsilateral preictal alpha rhythm attenuation (IPARA): An EEG sign of side of seizure onset in temporal lobe epilepsy

Purpose: Identification of the seizure onset zone is critically important for outlining the surgical plan in the treatment of pharmacoresistant focal epilepsy. In patients with temporal lobe epilepsy (TLE), bilateral ictal scalp EEG changes frequently occur and can make lateralization of the seizure onset zone difficult. We investigated the incidence and clinical utility of unilateral preictal alpha rhythm attenuation as a lateralizing sign of seizure onset in TLE.Methods: Scalp EEG recordings of the seizures acquired during presurgical video-EEG monitoring of 57 consecutive patients with TLE were reviewed retrospectively. Included patients had interictal baseline recordings demonstrating symmetrical posterior alpha rhythm and seizures occurring during wakefulness.Results: We identified a total of 649 seizures in the 57 patients, of which 448 seizures in 53 patients fulfilled the inclusion criteria. Among the 53 included patients, 7 patients (13.2%) exhibited a distinct attenuation of the posterior alpha rhythm prior to the first ictal EEG changes, in 26 of 112 (23.2%) included seizures. Preictal alpha rhythm attenuation in these seizures was ipsilateral to the ultimately determined side of seizure onset (based on video-EEG or intracranial EEG findings) in 22 (84.6%) of these seizures and bilateral in 4 (15.4%), and occurred on average 5.9 & PLUSMN; 2.6 s prior to ictal EEG onsets.Conclusion: Our findings suggest that in some patients with TLE lateralized preictal attenuation of the posterior alpha rhythm may be a useful indicator of side of seizure onset, presumably due to early disruption of thalamotemporo-occipital network function, likely mediated through the thalamus.