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Focal Onset Impaired Awareness Seizure

Complex Partial Epilepsy

Complex partial seizure is a type of epilepsy seen in adults as well as children. It is characterized by focal seizures accompanied by altered sensorium, behavioral, somatic and cognitive symptoms with automatisms. A detailed history, followed by electroencephalogram and imaging studies, is necessary to confirm the diagnosis.


Presentation

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]
Heart Block
  • This paper describes a patient with complete AV heart-block during a partial complex seizure. Simultaneous EEG/ECG monitoring was used to show the secondary nature of the bradyarrhythmia.[ncbi.nlm.nih.gov]
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]
Olfactory Hallucination
  • These can include gustatory and olfactory hallucinations; micropsia or macropsia; and intense delusions involving bodily harm, déjà vu, or “out-of-body” experiences.[ncbi.nlm.nih.gov]
Aura
  • 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]
  • 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]
  • The clinician must inquire about family history of seizures, any prior history of febrile convulsions, aura, automatisms, disorientation, or unconsciousness.[symptoma.com]
  • 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]
  • At times, I feel as if I am a lone surfer in a tsunami of medication side effects, riding the sickening larger waves of dizziness, confusion, poor appetite, and headaches.[oneintwentysix.com]
  • For example, memory problems, confusion, falls, dizziness, or sensory changes like numbness are often blamed on “getting older.” 2,3 However, these can actually be signs of seizures. 2,3 There are many different signs of seizures because there are many[cdc.gov]
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]
Hyperactivity
  • This patient demonstrates that complex partial seizures may result in uterine hyperactivity during labor, which may result in fetal hypoxia.[ncbi.nlm.nih.gov]
  • The psychiatric comorbidities include depression (36.4%) [ 4 ], anxiety disorders (15-50%) [ 5, 6 ], attention-deficit hyperactivity disorder (ADHD) (29.1%) [ 4 ] and conduct disorder [ 3, 7 ].[panafrican-med-journal.com]
Macropsia
  • 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[symptoma.com]
  • These can include gustatory and olfactory hallucinations; micropsia or macropsia; and intense delusions involving bodily harm, déjà vu, or “out-of-body” experiences.[ncbi.nlm.nih.gov]

Workup

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.

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]
Focal Epileptiform Discharges
  • DEFINITIONS The hallmark of partial seizures in children and adults is focal epileptiform discharges localized to a portion of one cerebral hemisphere.[mdedge.com]

Treatment

  • These patients were treated in a short-term (5 consecutive days) treatment protocol and then released, with weekly phone contact for 6 months following treatment.[ncbi.nlm.nih.gov]
  • In this paper, the author reviews the available literature relevant to the clinical phenomenology and treatment of this topic and illustrates the clinical profiles of 10 treatment-refractory patients admitted to a state hospital with previously undiagnosed[ncbi.nlm.nih.gov]
  • Our clinical researchers have made discoveries related to: new treatments for epilepsy surgery for epilepsy effects of stress on seizures optimal treatment of epilepsy in women who are pregnant or considering pregnancy depression and epilepsy seizure-like[ucepilepsycenter.com]
  • 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]
  • There are various types of treatment for complex partial seizures once the condition has been diagnosed.[healthline.com]

Prognosis

  • Prognosis is variable and may depend on the underlying etiology.[visualdx.com]
  • Prognosis The majority of people with epilepsy are able to live normal lives, with few restrictions on their activities.[brainfoundation.org.au]
  • Prognosis If you have epilepsy and it is not caused by a treatable condition, such as infection, your tendency to have seizures may be life-long and may require long-term treatment with medicines.[drugs.com]
  • The majority of people given a diagnosis of epilepsy have a good prognosis , and their seizures will be controlled by treatment with a single antiepileptic drug (AED), but up to 20%-30% of patients will develop drug-resistant epilepsy, often requiring[cochrane.org]
  • What Is the Prognosis for Seizures in Children? The prognosis for children with seizures depends on the type of seizures. Most children do well, are able to attend regular school, and have no limitations.[emedicinehealth.com]

Etiology

  • The etiology of such psychiatric comorbidities may be related to the seizure or to several other unrelated risk factors.[ncbi.nlm.nih.gov]
  • The most-plausible etiology of the observed ocular movements in this patient is the presence of a tic disorder. Patients with unknown eye movement disorders deserve a thorough evaluation, including a search for systemic causes.[ncbi.nlm.nih.gov]
  • Prognosis is variable and may depend on the underlying etiology.[visualdx.com]
  • […] impairment of consciousness, occurring in a patient with focal epilepsy. complex partial seizure Complex seizure, partial complex seizure Neurology A brief, temporary seizure with multiple elaborate sensory, motor, or psychic components; rare in toddlers Etiology[medical-dictionary.thefreedictionary.com]

Epidemiology

  • Epilepsy in Nigeria - a review of etiology, epidemiology. Benin Journal of Postgraduate Medicine. 2006;8(1):1-25. PubMed Google Scholar[panafrican-med-journal.com]
  • –This article discusses the epidemiology of psychiatric disturbances in patients with epilepsy and reviews the biological mechanisms that underlie behavioral symptoms.[ncbi.nlm.nih.gov]
Sex distribution
Age distribution

Pathophysiology

  • This important pathophysiological consequence of a nocturnal complex seizure was identified by respiratory monitoring during a combined video EEG and sleep study. Diagnostic and therapeutic implications are discussed.[ncbi.nlm.nih.gov]
  • Occasionally, when an episode is seen fortuitously in the laboratory, we may identify pathophysiology previously suspected but not actually seen.[jnnp.bmj.com]
  • The biochemical basis and pathophysiology of status epilepticus. Neurology 1990;40(Suppl 2):13-23. [ Links ] 11. Krumholz A, Sung GY, Fischer RS, Barry E, Bergey GK, Grattan LM.[scielo.br]

Prevention

  • Hospital for Sick Children Health A-Z Search a complete list of child health articles expand_more View All Drug A-Z Search a list of articles about medications expand_more View All Learning Hubs Browse a complete list of content groups Healthy Living & Prevention[aboutkidshealth.ca]
  • Overview, Causes, & Risk Factors Symptoms & Signs Diagnosis & Tests Prevention & Expectations Treatment & Monitoring Attribution View All Overview, Causes, & Risk Factors A seizure is an abnormal change in the electrical activity of the brain.[medicineonline.com]
  • Relief Parkinsons Pediatrics & Maternity Physical Therapy Skin Care Winter Products Oxygen Hospital Supplies Shop by Topic Arthritis Pain Relief Assistive Technology Care for Your Feet Carpal Tunnel Syndrome Diet and Nutrition Emergency Supplies Fall Prevention[activeforever.com]
  • Yet preventative seizure medications (anti-epileptic drugs) are often used by many patients with success. Treatment is tailored to the patient according to the unique symptoms that they report or experience.[rscdiagnosticservices.com]
  • There are several medications that can help prevent focal impaired awareness seizures.[epilepsy.com]

References

Article

  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

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Last updated: 2018-06-21 23:23