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complex partial seizure; focal seizure with impaired awareness

- partial seizure in which there is an alteration or loss of consciousness. - automatisms may occur & the patient is usually amnestic for the event - it may become generalized. Etiology: 1) temporal lobe (psychomotor) epilepsy (most common) 2) origination from frontal lobes Pathology: - alteration of consciousness typically occurs when the seizure spreads to involve one or both temporal lobes [5] Clinical manifestations: 1) frequent auras, varied, lasting a few seconds 2) consciousness is impaired, but not lost at the onset 3) may present as staring spell with loss of awareness, unresponsiveness 4) movements may be primitive (automatism) - sucking, chewing, lip-smacking 5) movements may be sophisticated - running, fighting, destruction, picking at clothes 6) tonic-clonic movements may be noted 7) duration minutes to hours; 30-90 seconds [5] 8) postictal confusion [5] 9) high incidence of psychiatric disturbance 10) shaking is unilateral & rhythmic [5] 11) may have no recollection of event Special laboratory: - EEG: a) onset is focal b) tonic-clonic movements may occur as epileptiform discharge generalizes Differential diagnosis: - acute otitis media may present with one or more signs suggestive of complex partial seizure [4] Management: 1) lamotrigine is drug of choice - good choice for elderly partients (> 60 years of age) [5] 2) former agents of choice a) carbamazepine (Tegretol) b) phenytoin (Dilantin) 3) alternative agents - primidone (Mysoline) 4) a single agent is effective in controlling seizures in 50% of patients 5) attempt therapy with alternative agent prior to initiating combination therapy 6) vagus nerve stimulation a) implanted nerve stimulation device inserted subcutaneously into chest b) stimulation of vagus nerve every 5 minutes c) for use in conjunction with anticonvulsive agent d) palliative treatment for patients who are not canditates for surgical resection of epileptic foci [5] e) rarely leads to freedom from seizures [5] 7) ketogenic diet a) palliative treatment for patients who are not canditates for surgical resection of epileptic foci [5] b) rarely leads to freedom from seizures [5] 8) temporal lobectomy for refractory temporal lobe epilepsy [5] 9) benzodiazepine for status epilepticus

Related

temporal lobe (psychomotor) epilepsy

General

partial seizure; focal seizure

References

  1. Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 1034-35
  2. Alan Gelb, UCSF, Department of Emergency Services, San Francisco General Hospital, 1998
  3. Mayo Internal Medicine Board Review, 1998-99, Prakash UBS (ed) Lippincott-Raven, Philadelphia, 1998, pg 645, 662
  4. Journal Watch 25(16):132, 2005 Soman TB, Krishnamoorthy KS. Paroxysmal non-epileptic events resembling seizures in children with otitis media. Clin Pediatr (Phila). 2005 Jun;44(5):437-41. PMID: 15965551
  5. Medical Knowledge Self Assessment Program (MKSAP) 14, 16, 17, 19. American College of Physicians, Philadelphia 2006, 2012, 2015, 2021