Complex partial seizure (CPS) is caused by anomalous electrical brain activity and is more prevalent in adults [1]. While generalized tonic- clonic seizures involve bilateral cerebral cortices and are associated with loss of consciousness, CPS is primarily accompanied by altered sensorium. A majority of CPSs originate in the temporal lobe and have typical symptoms compared to extratemporal seizures. CPS usually lasts for up to two minutes. The onset in a temporal lobe focus is characterized by an unblinking stare and perioral repetitive, unconscious movements called automatisms, while in frontal lobe CPSs, there are tonic-clonic, motor repetitive movements [2]. Extratemporal CPSs quickly spread to involve the frontal lobe and leads to motor symptoms identical to those seen in frontal lobe CPSs.

Other manifestations of CPS are varied and these are hallucinations (gustatory, olfactory), micropsia or macropsia, severe delusions of harm, déjà vu feelings, personality changes such as hyperreligiosity, hypergraphia, and difficulty finishing sentences [3]. Features which help to localize the side of origin of the seizures include [4] [5]:

• Postictal nose wiping - ipsilateral lobe
• Aphasia or dysphasia - dominant lobe
• Unilateral sensory aura, tonic-clonic activity, unilateral dystonia - contralateral lobe

• Yawning

  By Roni Caryn Rabin Ask Well Photo Credit Why Do We Yawn? Reading about yawning makes people yawn. You are probably yawning right now. By Roni Caryn Rabin [nytimes.com]

• Nausea

  Seizures arising from the midline region of the temporal lobe can cause sensations of fear, sensations in the tummy, pallor and nausea. [epilepsyqueensland.com.au]

  Can cause Less Common Side-Effects If individuals experience vomiting and nausea, it usually happens at the initiation of the treatment, then wears off. The uncommon side effect most people are concerned about is hepatic (liver) failure (jaundice). [bbbautism.com]

  Focal onset seizures include: Focal aware seizures During these seizures the person is aware and may experience feelings such as déjà vu, an unpleasant smell or taste, or sensations such as ‘butterflies’ or nausea. [epilepsyfoundation.org.au]

  Symptoms of liver problems include yellowing of your skin or the whites of your eyes, nausea or vomiting, loss of appetite, stomach pain, or dark urine. [aptiom.com]

  The memories are rushing through my sight so quickly that, when I try to latch on, my nausea worsens. I dry heave. I dry heave again. I lie my head down on the desk and begin humming a tune, but I don't know what tune it is. I'm just humming to hum. [tay.kinja.com]

• Abnormal Eye Movement

  CASE REPORT: An 8-year-old boy was referred to the clinic by his pediatric neurologist for a comprehensive examination to rule out a visual cause for the abnormal eye movements observed by the patient's mother. [ncbi.nlm.nih.gov]

• Bright Blue Eyes

  Her bright blue eyes are rimmed with emerald specks of green, the brightness of which belies the hordes of medication I know she takes every day. [oneintwentysix.com]

• Visual Hallucination

  BACKGROUND: A complex partial seizure can cause a variety of visual system signs and symptoms, including visual hallucinations, dilated pupils, and changes in vision. [ncbi.nlm.nih.gov]

  For example, a focal aware seizure from the back of the brain (occipital lobe) may cause a visual hallucination, while a seizure from the side of the brain (temporal lobe) may cause a feeling of déjà vu or a strong emotion. [mountsinai.org]

  Symptoms can include: A rising feeling in the stomach Buzzing in the ear Tingling, numbness or stiffening of the arms, legs or face Visual hallucinations The feeling of déjà vu These symptoms vary for each seizure based on where it started in the brain [sharecare.com]

  During seizure episodes, people can experience auras, muscle jerking, automatisms, altered level of consciousness and convulsions.[1][2] Some characteristic ophthalmologic signs can also be observed including visual hallucinations, illusions, visual field [eyewiki.aao.org]

• Aggressive Behavior

  Speak calmly and softly, as any loud or aggressive behavior may agitate them. “Stay with the patient until the seizure is over, and they are safe and do not appear confused. Some people take longer to recover,” suggests Dr. Pillai. [sharecare.com]

  However, unprovoked aggressive behavior is unusual. Left temporal lobe seizures may cause verbal memory abnormalities; right temporal lobe seizures may cause visual spatial memory abnormalities. [msdmanuals.com]

• Delusion of Grandeur

  A 25-year-old male presented with fluctuations in consciousness, aggressive behaviour, hallucination, and delusions of grandeur lasting a few hours. [hindawi.com]

• Aura

  The clinician must inquire about family history of seizures, any prior history of febrile convulsions, aura, automatisms, disorientation, or unconsciousness. [symptoma.com]

  Auras usually last just a few seconds. According to Johns Hopkins Medicine, an aura is a warning sign. These signs take on different forms. [epilepsyu.com]

  Auras Are Warning Signs If you suffer from complex partial seizures, you will often be warned by a simple partial seizure or an aura. [livestrong.com]

  Abstract A man with a grade II astrocytoma in the medial frontal lobe exhibited complex partial seizures, with the aura being a feeling of extreme embarrassment. [ncbi.nlm.nih.gov]

  Simple Focal Seizures (Auras) Simple focal seizures, also known as auras, occur in one area on one side of the brain, but may spread from there. The person does not lose consciousness during a simple focal seizure. [hopkinsmedicine.org]

• Dizziness

  The patient's memory function markedly improved during 10 months' follow-up with antiepileptic treatment, although he described brief attacks of dizziness. A repeat MRI examination showed normal findings. [ncbi.nlm.nih.gov]

  The most common side effects of SABRIL in adults include: problems walking or feeling uncoordinated, feeling dizzy, shaking (tremor), joint pain, memory problems and not thinking clearly, and eye problems like blurry vision, double vision, and eye movements [sabril.net]

  In clinical trials, the most common side effects seen in people who take KEPPRA include sleepiness, weakness, dizziness, and infection. [vimpat.com]

  Distinctive signs can include a change of emotions, involuntary movement of a particular body part, dizziness, and altered senses, such as taste and smells. Generalized onset seizures arise from both sides of the brain at the same time. [utphysicians.com]

• Jamais Vu

  It may consist of a strange smell, taste, sound, or visual disturbance, an unexplained feeling of fear or anxiety, or a sense that everything seems strangely familiar, like it has all happened before (déjà vu), or strangely unfamiliar (jamais vu). [healthlinkbc.ca]

  Conversely, some people find very familiar things become unrecognisable - jamais vu. [charge.org.uk]

  Others say that they sense that everything seems strangely familiar as if it has all happened before (déjà vu), or that things seem strangely unfamiliar (jamais vu). [rscdiagnosticservices.com]

  vu) Parietal lobe seizures may begin with a contralateral sensation, usually of the positive type (electrical sensation, tingling) Occipital lobe seizures may begin with contralateral visual changes, usually of the positive type (eg, colored lines, spots [emedicine.medscape.com]

• Automatic Behavior

  All complex partial seizures were associated with changes in facial expressions, and in 87% of the patients automatic behaviors occurred either initially or at some point during the seizures. [pediatrics.aappublications.org]

  Gradual recovery after several minutes of confusion occurs postictally in most patients, however, in some patients automatic behavior like running, walking about, the nondirected violent behavior may occur. [ncbi.nlm.nih.gov]

  behaviors that may occur in complex seizures can include: Rhythmic eye blinking[8] Sucking movements[8] Eyelid flutter found in occipital lobe seizures[2] Lip smacking found in frontal lobe seizures[5] Staring Can be observed in absence seizures that [eyewiki.aao.org]

  Automatic behaviors, such as lip smacking or swallowing may be seen. The person may stare. Their eyes may seem vacant, dilate, and move up and to one side. [eftx.org]

• Vertigo

  Lateral temporal seizures may have vertigo, auditory (buzzing, ringing), or visual symptoms as initial aura symptoms. Auditory aura in only one ear may lateralize seizure to contralateral hemisphere. [ncbi.nlm.nih.gov]

  When overexcitation is confined to a very small area, the patient with epilepsy may have a strange sensation of déja vu, vertigo, fear, or an odd smell without a source. [rxmarijuana.com]

  Auditory-vestibular Auditory-vestibular cortex involvement appears as a hallucination of sound (tinnitus) and vertigo with or without generalization. [dartmouth.edu]

The most important aspect in CPS workup is obtaining a thorough history of the seizure from the patient, relatives, and observers. The clinician must inquire about family history of seizures, any prior history of febrile convulsions, aura, automatisms, disorientation, or unconsciousness. A detailed physical examination may be normal or may reveal evidence of accidental injuries occurring during the seizure.

Routine laboratory tests should include serum electrolytes, calcium, and magnesium levels to exclude other causes of seizures. Urine drug screen should be performed in patients known to be on antiepileptic medications.

Electroencephalography (EEG) is performed as part of the seizure workup in all cases. It is more sensitive in the immediate period following a seizure. However, findings may be non-specific in CPS as the seizure activity is at the subcortical level and patients may be mistaken as suffering from a psychiatric disorder instead.

Neuroimaging with magnetic resonance (MR) scans is indicated to detect CPS associated brain anomalies of the gray matter, tumors, trauma-related sequelae, and lesions of vascular origin [6] [7]. During seizures, single photon emission computed tomography (SPECT) and positron emission tomography (PET) reveal increased metabolic activity in the region of abnormal electrical brain functioning while a "cold footprint" is noted in these regions in the postictal phase [8] [9] [10].

Cerebrospinal fluid analysis is ordered in patients with seizures who are suspected to have an infectious or inflammatory disease.

• Temporal Intermittent Rhythmic Delta Activity

  Temporal intermittent rhythmic delta activity is predictive of temporal lobe epilepsy. Bitemporal sharp wave foci may be noted in 25% to 30% of the patients. [ncbi.nlm.nih.gov]

• Periodic Lateralized Epileptiform Discharges

  Abstract We describe a patient in whom the only electrographic manifestation of a complex partial seizure recorded by video-EEG telemetry was periodic lateralized epileptiform discharges (PLEDs) with a left anterior temporal emphasis. [ncbi.nlm.nih.gov]

• Temporal Intermittent Rhythmic Delta Activity

  Temporal intermittent rhythmic delta activity is predictive of temporal lobe epilepsy. Bitemporal sharp wave foci may be noted in 25% to 30% of the patients. [ncbi.nlm.nih.gov]

• 3 Hz Spikes

  Absence seizures can sometimes present with same symptomatology however ictal EEG will show generalized 3-Hz spike-wave complexes. Symptoms of focal seizures with impaired awareness depend on the area of the brain it is arising from. [ncbi.nlm.nih.gov]

1. Khoshbin S. Seizure disorders. In: Stern TA, Herman JB, eds. Psychiatry Update and Board Preparation. 2nd ed. New York, NY: McGraw-Hill. 2004; 287–293.
2. Kotagal P, Arunkumar G, Hammel J, Mascha E. Complex partial seizures of frontal lobe onset statistical analysis of ictal semiology. Seizure. 2003; 12(5):268-281.
3. Geschwind N. Behavioral changes in temporal lobe epilepsy. Psychol Med. 1979;9:217–219.
4. Loddenkemper T, Kotagal P. Lateralizing signs during seizures in focal epilepsy. Epilepsy and Behavior. 2005; 7:1-17.
5. Horvath R, Kalmar Z, Feher N, Fogarasi A, Gyimesi C, Janszky J. Brain lateralization and seizure semiology: ictal clinical lateralizing signs. Ideggyogy Sz.2008; 61(7-8):231-237.
6. King MA, Newton MR, Jackson GD, et al. Epileptology of the first-seizure presentation: a clinical, electroencephalographic, and magnetic resonance imaging study of 300 consecutive patients. Lancet. 1998; 352(9133):1007-1011.
7. Knake S, Triantafyllou C, Wald LL, et al. 3T phased array MRI improves the presurgical evaluation in focal epilepsies: a prospective study. Neurology. 2005; 65(7):1026-1031.
8. Warwick JM. Imaging of brain function using SPECT. Metab Brain Dis. 2004;19:113–123
9. Newberg AB, Alavi A. PET in seizure disorders. Radiol Clin North Am. 2005;43:79–92
10. Roffman JL, Stern TA. A Complex Presentation of Complex Partial Seizures. Prim Care Companion J Clin Psychiatry. 2006; 8(2): 98–100