What type of seizure is characterized by a patient's eyes rolling up and crossing their arms, potentially indicating a generalized tonic-clonic seizure or a focal seizure with automatisms?

Seizure Type with Eyes Rolling Up and Arm Crossing

The clinical presentation of eyes rolling upward with arm crossing most likely represents a focal seizure with secondary generalization or a generalized tonic-clonic seizure, though the specific arm positioning (crossing) may indicate asymmetric tonic posturing suggestive of focal onset. 1

Key Distinguishing Features

Tonic Phase Characteristics

• Eyes rolling upward is a common feature during the tonic phase of both generalized-onset and focal-onset bilateral tonic-clonic seizures 1, 2
• Arm crossing or asymmetric arm posturing strongly suggests focal onset rather than primary generalized seizures, as symmetrical movements are more typical of generalized-onset seizures 1, 3, 4
• The "figure of four sign" (one arm extended, one flexed) is significantly more frequent in focal-onset bilateral tonic-clonic seizures compared to generalized-onset 3, 4

Critical Timing and Movement Patterns

• If the abnormal posturing begins BEFORE the fall, this indicates epilepsy (likely focal onset) 1
• If movements are asymmetrical or restricted to one side, focal seizure is more likely 1, 4
• Keeling over stiffly suggests tonic phase epilepsy, whereas flaccid collapse suggests syncope 1

Diagnostic Approach

Essential Historical Details to Obtain

• Duration of loss of consciousness: >1 minute strongly favors seizure over syncope (mean 74-90 seconds for seizures vs. 20 seconds for syncope) 1
• Presence of aura: Rising abdominal sensation, unusual smell/taste, or déjà vu suggests focal seizure with secondary generalization 1
• Post-ictal state: Prolonged confusion or sleepiness lasting more than a few minutes, muscle aches, or tongue biting (especially lateral tongue) points to epilepsy 1
• Head turning: Prolonged head version suggests epileptic seizure; brief head turning (<30 seconds) can occur in syncope 1, 4

Focal Signs Favoring Focal-Onset Seizures

• Head version (especially early in the seizure) is significantly more common in focal-onset bilateral tonic-clonic seizures 4
• Eye version (forced deviation) strongly suggests focal onset 4
• Preceding automatisms (oral automatisms like chewing, smacking, or blinking) indicate focal seizure, though these can rarely occur in syncope 1, 4
• Unilateral facial clonic activity or mouth deviation significantly favors focal onset 4

Classification Based on Presentation

Most Likely: Focal-Onset Bilateral Tonic-Clonic Seizure

The combination of eyes rolling up with asymmetric arm positioning (crossing) most strongly suggests a focal-onset seizure that secondarily generalizes 3, 4. Key supporting features include:

• Asymmetric tonic posturing during the seizure 1, 3
• Presence of multiple focal signs in combination reliably indicates focal onset 3
• Longer seizure duration favors focal-onset over generalized-onset 4

Alternative: Generalized-Onset Tonic-Clonic Seizure

If the arm movements are symmetrical and synchronous rather than truly "crossed," this could represent a generalized-onset tonic-clonic seizure 1. However, focal signs (including asymmetric posturing) can occasionally occur in generalized-onset seizures, though less frequently 3, 4.

Special Consideration: Eyelid Myoclonic Seizures

If the "eyes rolling up" is accompanied by rapid eyelid fluttering/twitching with brief impairment of consciousness, consider eyelid myoclonic epilepsy, which can progress to generalized tonic-clonic seizures 2, 5. This syndrome is characterized by:

• Rapid abnormal eye blinking with upward eye rolling 2
• Slight backward head movement 2
• Photosensitivity and eye closure sensitivity 2
• More common in girls, onset age 6-8 years 2

Critical Pitfalls to Avoid

• Do not assume all movements indicate epilepsy: Syncope can produce myoclonic jerks, but these are typically asynchronous, limited in scope, and occur AFTER the fall 1
• Do not rely on urinary incontinence to differentiate seizure from syncope—it occurs in both 1
• Eyes closed during unconsciousness suggests psychogenic pseudoseizure or psychogenic pseudosyncope, NOT epilepsy 1
• Pelvic thrusting suggests psychogenic non-epileptic seizures or rarely frontal lobe seizures 1
• Prolonged duration (>5 minutes) suggests psychogenic non-epileptic seizures rather than true epileptic seizure 1

Immediate Management Considerations

• Obtain detailed eyewitness account focusing on timing of movements relative to loss of consciousness 1
• Check for structural causes (hippocampal sclerosis, cortical dysplasia) if focal onset is suspected, as these are associated with secondary generalization 1, 6
• Consider EEG within 24 hours (diagnostic yield 51%) 7
• Evaluate for metabolic triggers (hypocalcemia, hypomagnesemia) that can provoke seizures 1, 7