Ictal body turning and version in generalized epilepsy

Ictal body turning, also known as gyratory or rotatory seizures, involves unidirectional trunk rotation of 180° or more during a seizure and is generally associated with focal epilepsies, particularly temporal and extratemporal types. Similarly, the presence of head version and persistent gaze deviation, often considered strong lateralizing signs, may be observed in some generalized seizures. However, the presence of such focal semiological signs in generalized epilepsies is rarely reported and may result in diagnostic confusion and mislocalization. This case series aims to highlight the occurrence and implications of gyratory seizures and other focal semiological features in patients with drug-resistant generalized epilepsy (GE). We report three patients with drug-resistant GE presenting with ictal body turning and/or version during habitual episodes. All had early epilepsy onset, normal or mildly delayed development, and persistent drug-resistant seizures. Video EEG revealed ictal body turning, often preceded by head version, but the EEG showed classic generalized spike-wave or polyspike discharges without consistent lateralization. Imaging findings were unremarkable. Patients were managed medically, and surgical evaluation was deferred. Ictal body turning and version may be seen as manifestations of focal seizures, but can also occur in GE, representing atypical motor manifestations rather than lateralizing signs. Accurate diagnosis requires a comprehensive video EEG evaluation and exclusion of focal pathology to avoid misdiagnosis and unnecessary surgical interventions. These cases highlight the phenotypic diversity of generalized epilepsies and support tailored management strategies.