The patient is a 37-year-old right-handed woman with a 37-year history of epilepsy. At 5 months of age, following hypoxia due to dehydration from diarrhea, the patient began experiencing absence seizures, with a frequency of approximately five times per day and lasting approximately 2–3 s. At age 34, seizure manifestations evolved to include loss of consciousness, a greeting-like vocalization, and automatisms such as slapping of the right hand or bilateral hand clapping, lasting 5–6 s and occurring almost daily. By age 36, the patient developed psychiatric symptoms, including auditory hallucinations and self-talking behaviors.

Video EEG (VEEG) monitoring revealed interictal sharp wave discharges in the bilateral temporal regions and the right frontal lobe, with a predominant focus in the right temporal region (T8, F8). Ictal EEG recordings demonstrated bilateral temporal sharp waves, maximal over the right temporal lobe, with propagation to the right frontal lobe (Figures 1A,B). MRI revealed cystic degeneration involving the right hippocampus (Figure 1C), and 18F-FDG PET showed reduced metabolism in the right temporal lobe and right prefrontal lobe (Figure 1D).

Based on these findings, a preliminary diagnosis of right TLE was established. Subsequent SEEG evaluation identified interictal rhythmic phase inversion in the right anterior temporal lobe, hippocampus-amygdala complex, and anterior insular cortex, along with persistent slow-wave discharges in the left frontal lobe. Ictal SEEG recordings demonstrated seizure onset in the right anterior temporal lobe, with propagation to the right dorsolateral prefrontal cortex (dlPFC) within 3 s, coinciding with the emergence of right slapping and then clapping automatism (Figures 1E,G,H).

The patient underwent a right anterior temporal lobectomy, including resection of the anterior insula, and frontal operculum cortex, along with SEEG-guided RF-TC of the right insula (Figure 1F). At the 16-month postoperative follow-up, the patient achieved an Engel class I seizure outcome.

The patient is a 38-year-old right-handed woman with a 32-year history of epilepsy and comorbid severe anxiety and depression (Supplementary Table 2). The first generalized tonic–clonic seizure (GTCS) occurred at age 6 following a febrile episode. The current seizure manifestations include two distinct types: one characterized by brief staring episodes with loss of awareness lasting 1–2 min, often preceded by a sensation of palpitations; the other involving loss of awareness accompanied by right leg stomping and right-hand slapping, sometimes leading to urinary incontinence, lasting approximately 3 min. Seizures occur 4–5 times per month.

VEEG monitoring showed interictal sharp wave discharges in the bilateral temporal and frontal lobes, predominantly in the left temporal region (FT7, T7). Ictal EEG revealed fast rhythmic epileptiform discharges originating from both temporal lobes (Figures 2A,B). MRI demonstrated patchy hyperintense in the right temporo-occipital white matter and mild hippocampal atrophy on the right (Figure 2C), while 18F-FDG PET indicated markedly reduced metabolism in the right temporo-occipital lobe (Figure 2D).

Based on a comprehensive evaluation, the patient was diagnosed with temporal lobe epilepsy. It was hypothesized that the epileptic focus originated in the right temporal lobe and subsequently propagated to the left temporal lobe. Due to extensive atrophy in the right temporal lobe, epileptiform activity in the right hemisphere was less pronounced on scalp EEG compared to the left. To further localize the epileptogenic network, SEEG electrodes were implanted. Interictal SEEG revealed delta waves in the left hippocampal head and small sharp wave discharges in the right temporo-parieto-occipital junction and left sensorimotor cortex. Ictal SEEG recordings demonstrated seizure onset in the right hippocampal head, with propagation to the right pars orbitalis of the inferior frontal gyrus 14 s later, coinciding with the onset of slapping automatism (Figures 2E,G,H).

The patient subsequently underwent a standard right anterior temporal lobectomy, including resection of the epileptogenic focus in the orbitofrontal gyrus and the temporo-parieto-occipital junction, as well as SEEG-guided RF-TC of the left hippocampal head, and left orbitofrontal gyrus (Figure 2F). At the 9-month postoperative follow-up, the patient achieved an Engel class I seizure outcome. In addition, the patient’s preoperative severe depression and significant anxiety improved postoperatively, with follow-up assessments showing mild depression and mild anxiety (Supplementary Table 2).

The patient is a 20-year-old right-handed man with an 11-year history of epilepsy. The first GTCS occurred at age 9, lasting approximately 30 s. At age 20, seizures increased in frequency, occurring 2–3 times per month and lasting 3–5 s. Current seizure manifestations include loss of awareness, right hand slapping, and generalized convulsions. Mild obsessive-compulsive symptoms and mild anxiety were reported by the family.

VEEG showed interictal sharp wave discharges in the bilateral frontal lobes (F3, F7, F4, F8). Ictal EEG revealed high-amplitude transient sharp waves in the right frontal and temporal lobes (F8, F4, T4, T6), followed after 3 s by generalized electromyographic artifacts, predominantly in the bilateral temporal regions (Figures 3A,B). MRI showed no significant abnormalities, while 18F-FDG PET indicated reduced metabolism in the right frontal and right temporal lobes (Figures 3C,D).

Based on these noninvasive findings, a preliminary diagnosis of FLE was made, with possible temporal involvement. The patient subsequently underwent SEEG monitoring. Interictal SEEG showed epileptiform discharges in the right hippocampus, orbitofrontal gyrus, anterior insular cortex, and frontal lobe. Ictal SEEG demonstrated seizure onset in the right inferior frontal gyrus, with propagation to the right OFC after 4 s, coinciding with the onset of slapping automatism (Figures 3E,G,H).

The patient underwent resection of the right orbitofrontal gyrus and anterior insula, along with SEEG-guided RF-TC targeting the bilateral frontal lobe and right orbitofrontal gyrus (Figure 3F). At the 50-month postoperative follow-up, the patient achieved an Engel class II seizure outcome. The patient exhibited no obsessive-compulsive or anxiety symptoms after surgery (Supplementary Table 2).

The patient is a 12-year-old right-handed girl with a 2-year history of epilepsy, experiencing more than 10 seizures per month. She exhibited three seizure types: absence seizures characterized by brief staring and impaired awareness; hand clapping seizures and shouting, and generalized tonic–clonic seizures. The hand clapping seizures were characterized by shouting, bilateral hand clapping, accompanied by bilateral leg stomping and impaired awareness, lasting approximately 1 min. The hand clapping seizures were the most frequent seizure type in this patient.

VEEG showed interictal sharp wave discharges in the bilateral frontal lobes and left temporal lobe, with a predominant focus in the left frontal lobe (AF7, F7). Ictal EEG recordings revealed epileptiform discharges in the left frontal and temporal lobes, which propagated to the contralateral side within 2 s. The seizures began with a panic emotion, followed by shouting, bilateral hand clapping, bilateral knee flexion, and impaired awareness (Supplementary Figures 1A,B). MRI findings were consistent with Tuberous Sclerosis Complex (TSC), showing several patchy hyperintensities in the bilateral frontoparietal lobes (Supplementary Figure 1C). 18F-FDG PET revealed reduced metabolism in the left frontal lobe (Supplementary Figure 1D).

Based on this comprehensive evaluation, the patient was diagnosed with frontal lobe epilepsy. SEEG was subsequently performed, revealing interictal slow-wave in the left anterior PFC and orbitofrontal gyrus, as well as fast rhythmic discharges in the right superior parietal lobule. Ictal SEEG recordings localized seizure onset to the left anterior PFC, with propagation to the left dorsal ACC after 7 s. Both regions exhibited discharge evolution after 9 s when the clapping occurred (Supplementary Figures 1E,G,H).

The patient underwent resection of the epileptic focus in the left frontal lobe, along with SEEG-guided RF-TC of the bilateral cingulate gyrus, left orbitofrontal gyrus, and left ventromedial PFC (Supplementary Figure 1F). At the 15-month postoperative follow-up, the patient remained seizure-free and was classified as Engel class I.

The patient is a 49-year-old right-handed woman with a 47-year history of epilepsy, a 20-year history of mania, and a 1-year history of OCD. At age 2, following a febrile convulsion, the patient began experiencing bilateral upper limb spasms lasting 1–2 min, occurring 2–3 times per week. At age 29, the patient exhibited manic symptoms, including aggression. Current seizure manifestations include altered awareness, a fixed gaze, and limb spasms and GTCS. Over the past year, the patient developed compulsive behaviors, characterized by excessive laundry washing, sweeping, and intermittent clapping.

VEEG revealed interictal sharp wave discharges in the bilateral frontotemporal regions, predominantly in the left temporal lobe (F7, T3). Ictal EEG demonstrated independent seizure onsets in both temporal lobes (Supplementary Figures 2A,B). MRI showed scattered small patchy hyperintensities in the bilateral frontoparietal lobes and atrophy of the bilateral hippocampi (Supplementary Figure 2C). 18F-FDG PET revealed hypometabolism in the bilateral frontal and parietal lobes (Supplementary Figure 2D).

Based on these multimodal findings, the patient was diagnosed with TLE and temporal-plus epilepsy syndrome. SEEG monitoring revealed interictal rhythmic high-amplitude discharges in both hippocampi, persistent sharp discharges in the right operculum and orbitofrontal gyrus, and intermittent sharp discharges in the left operculum. Ictal SEEG recordings localized seizure onset to the bilateral hippocampal head, with propagation to the bilateral pars orbitalis of the inferior frontal gyrus after a few seconds, followed by the onset of GTCS. Notably, right hand patting behaviors were observed during interictal recordings, corresponded with epileptiform discharges in the right operculum and orbitofrontal gyrus (Supplementary Figures 2E,G,H). During the course of VEEG and SEEG monitoring, the patient experienced five left temporal seizures and two right temporal seizures.

Given the presence of prominent psychiatric symptoms, severely impaired cognitive function, and a lack of caregiving support, a combined surgical strategy was adopted. The patient underwent an anterior capsulotomy to address OCD symptoms and a standard left anterior temporal lobectomy for epilepsy control, along with SEEG-guided RF-TC targeting the right hippocampal head, right anterior insular cortex, and right orbitofrontal gyrus (Supplementary Figure 2F). At the 6-month postoperative follow-up, the patient achieved an Engel class II seizure outcome. Compulsive OCD behaviors, including repetitive washing disappeared after surgery.

In all four patients with documented slapping or clapping automatisms during seizures (Cases 1–4), SEEG revealed ictal propagation to frontal subregions at or just prior to the appearance of the motor behavior. Notably, the OFC, dlPFC, and ACC were consistently involved (Figure 4). These regions are known for their roles in motor execution, emotional modulation, and inhibitory control (Aouizerate et al., 2004)—functions that may become dysregulated during seizure activity, resulting in stereotyped, semi-purposeful behaviors such as slapping.

Our data support previous observations that motor automatisms, especially complex bilateral behaviors like clapping or slapping, are more often associated with FLE, particularly in the orbitofrontal and mesial frontal circuits (Fohlen et al., 2004; Waterman et al., 1987; Schönecker et al., 2019). Importantly, two patients in our series (Cases 1 and 2) were ultimately diagnosed with TLE but demonstrated clear frontal involvement during the automatisms, consistent with the “temporal-plus” epilepsy concept (Kahane et al., 2015), Which refers to temporal lobe epilepsy with early and consistent seizure propagation to neighboring extratemporal regions, such as frontal area, particularly when propagation occurs rapidly through frontotemporal networks.

The fifth case in our series further extends the significance of these findings by illustrating a convergence between epileptic networks and compulsive behaviors. This patient, diagnosed with TLE and comorbid OCD, demonstrated interictal patting behaviors—which coincided with epileptiform discharges in the orbitofrontal gyrus and opercular regions, areas heavily implicated in OCD pathophysiology (Aouizerate et al., 2004; Amo et al., 2004). Remarkably, the patient’s compulsive behaviors resolved following capsulotomy and epilepsy surgery, underscoring the shared neural substrate hypothesis of epilepsy and OCD.

Our findings are congruent with neuroimaging and lesion studies suggesting that fronto-striato-thalamic circuits, especially those involving the OFC and ACC, are central to compulsivity (Schönecker et al., 2019; Saxena and Rauch, 2000; Milad and Rauch, 2012; Menzies et al., 2007). In epileptic patients, chronic network dysfunction—manifested as both seizures and psychiatric symptoms—may be underpinned by abnormal oscillatory activity or pathological connectivity within these circuits. The slapping automatism, when viewed in this light, may represent a behavioral expression of underlying prefrontal dysregulation, shared by both seizure propagation and obsessive-compulsive symptoms.

This case series has direct clinical implications for the pre-surgical evaluation and planning in patients with focal epilepsy, especially those presenting with slapping or clapping automatisms. While such automatisms may be superficially classified as “motor” features with presumed frontal origin, our SEEG data emphasize the need for careful multimodal assessment, including consideration of temporal onset with frontal propagation.

Notably, all five patients underwent tailored resections or thermocoagulation informed by SEEG-defined epileptogenic networks. Three patients achieved Engel Class I outcomes, and two achieved Class II, confirming the effectiveness of network-based surgical interventions. Additionally, the observed improvement in psychiatric symptoms following surgery in Case 5 encourages a broader perspective on surgical goals—not just seizure freedom, but also the amelioration of comorbid neuropsychiatric dysfunction.

This study is limited by its small sample size, short follow-up duration and retrospective design. Future research should investigate the prevalence and electrophysiological correlates of slapping automatisms in larger cohorts, ideally integrating quantitative analysis of SEEG dynamics, functional connectivity, and longitudinal psychiatric assessments.