Early Versive Head Turn Semiology Related to Ipsilateral Posterior Cingulate: A Case Report and Literature Review

Versive head turns, characterized by forced and involuntary head movements leading to sustained unnatural positioning, are consistently recognized as reliable indicators of contralateral hemisphere involvement. This study presents a case demonstrating ictal semiology marked by the simultaneous onset of blurred vision, spinning, distorted voice, and an early left-versive head turn. The versive head turn semiology correlated with rapid ictal discharges in the ipsilateral posterior cingulate gyrus and was reproducible with direct cortical stimulation during stereoelectroencephalography evaluation. A comprehensive literature review (from 1994 to 2023) was conducted to investigate the relationship between early ictal head version semiology, either contralateral or ipsilateral, and localization of the ictal onset regions. Analysis of 105 patients revealed that 87% exhibited early contralateral head version noted from seizures originating from anterior regions (frontal lobe or anterior/midcingulate regions), compared with 56% in posterior regions (parietal, occipital, or posterior cingulate areas) and 44% in the temporal lobe. When comparing anterior to temporal regions, the anterior group had an eightfold higher likelihood of contralateral versive seizures (odds ratios = 8.1, 95% confidence interest, 1.72-38.35, P = 0.0038), indicating a significantly higher likelihood of ipsilateral early head version in temporal lobe seizures. There was no significant difference in the likelihood of ipsilateral head version between the anterior and posterior groups or between the posterior and temporal groups. These findings underscore the need for cautious interpretation of early head versive signs alone as indicators of contralateral hemisphere epileptogenic zone, advocating for consideration of ipsilateral hemisphere epileptogenic zone involvement in presurgical hypotheses, in selected patients.