Localization of ictal pouting in frontal lobe epilepsy: A case report

Changes in facial expression in frontal lobe epilepsy (FLE) have been described in the literature [1,2]. However, this discrete feature of ictal semiology is often missed because of more striking events such as hypermotor or bizarre behaviors. One such facial feature, characterized by a turned-down mouth, is traditionally described in French as the “chapeau de gendarme,” referring to the shape of the French policeman's hat during the reign of Napoleon. Ictal pouting (IP), which mimics expressions of fear, displeasure, or disgust, appears frequently during focal seizures. IP is described as an inverted smile. It consists of a turned-down mouth with puckering of the lips and symmetrical sustained (N5 s) lowering of the labial commissures, commonly accompanied by contraction of the chin. This very interesting sign of FLE is related to the involvement of the mesial frontal areas, particularly the anterior cingulate cortex (ACC) [3]. We report a case whose ictal semiology consisted only of pouting. Brain magnetic resonance imaging (MRI) studies revealed that focal cortical dysplasia (FCD) in the rightmesial frontal lobe and ACC and tissue histopathology confirmed FCD type IIB.