Case Summary
A 37-year-old right-handed man with spastic quadriparetic cerebral palsy, congenital hydrocephalus, and anxiety was admitted for seizure characterization with video-EEG monitoring. Neurologic examination demonstrated marked upper extremity spasticity and left elbow flexion contracture. Three habitual focal to bilateral tonic-clonic seizures (Figure 1) were recorded on EEG (Figure 2).
Pseudo–figure-of-4 sign with right arm extended and left arm flexed to reproduce a falsely lateralizing number “4” from left elbow flexion contracture in a patient with focal epilepsy and recurrent focal to bilateral tonic-clonic seizures.
EEG demonstrating (A) right temporal ictal rhythmic theta. Onset was obscured by movement and myogenic artifact and (B) interictal right midtemporal sharp waves.
Although the figure-of-4 sign in focal to bilateral tonic-clonic seizures is strongly lateralizing contralateral to the tonically extended arm,1,2 our patient's left arm spasticity restricted extension, leading to a falsely lateralizing figure-of-4 sign. Semiology remains a cornerstone for clinical decision-making, although it requires individualization for comorbid physical disabilities.
Study Funding
The authors report no targeted funding.
Disclosure
C. K. Rao reports no disclosures relevant to the manuscript; W. O. Tatum reports no disclosures relevant to the manuscript. Go to Neurology.org/N for full disclosures.
Appendix Authors
Footnotes
Go to Neurology.org/N for full disclosures.
Teaching slides links.lww.com/WNL/B631
- © 2021 American Academy of Neurology
Disputes & Debates: Rapid online correspondence
- Reader Response: Teaching NeuroImage: Pseudo–Figure-of-4 Sign
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