Ictal index finger pointing and politician's fist as localizing clinical signs in a pediatric patient

Abstract

We report a case of a 3-year-old girl who presented with distinct, repetitive episodes featuring highly localizing clinical signs. Each episode began approximately 1 min and 50 s after the onset of electrographic changes, with the patient's right arm extending and her index finger assuming a pointed position (Video 1). Throughout the episode, her eyes largely remained closed, and she was unresponsive to her surroundings, unable to speak.

After about 20 s, the index finger flexed as her hand adopted a pincer posture, followed by the “politician's fist,” along with circular movements resembling “drawing circles in the air.” Electroencephalography (EEG) captured several episodes, with rhythmic spikes peaking in the left frontocentral region (F3/C3) and evolving into the left temporal chain (Video 1 and Figure 1).

As the seizure resolved, her eyes briefly opened, and she momentarily attended to her mother as her right hand lowered. She then blinked before slipping back into stage 2 sleep, remaining postictal and asleep afterward. This was the only semiology that was noted in her case. Brain magnetic resonance imaging (MRI) was unremarkable; however, lumbar puncture revealed a positive titer for anti-NMDA receptor (NMDAR) antibodies.

While ictal hand signs are well documented in adults, their localizing significance in children remains less understood. Previous studies suggest that the “ictal pointer, pincer, and politician's fist” signs often indicate seizure activity in the contralateral frontal and temporal regions.^{1, 2} Source localization software mapped the symptomatic zone to the left fronto-temporal region (Figure 2), commonly associated with anti-NMDAR encephalitis seizures.³ This case demonstrates how ictal signs can assist in accurately localizing focal seizures, further corroborated by diagnostic testing. The delayed clinical onset and downward propagation of the ictal field highlight that ictal semiology reflects seizure propagation rather than the precise seizure onset zone.

Informed consent was obtained from the parents of the patient presented prior to beginning this work.