Contents

Search

partial seizure; focal seizure

Pathology: - behavioral & electroencephalographic changes resulting from abnormal electrical activity of only one or part of one cerebral hemisphere Clinical manifestations: - patients may be aware or unaware during partial seizure - aware partial seizures (retained awareness) - generally involve a single neurologic modality - sensory, motor, olfactory, visual gustatory - involve a single region of the body - focal motor seizure of short duration (45-60 seconds), (30-90 seconds) [2] - unaware partial seizures (impaired awareness) - may be associated with an aura such as an unpleasant taste or unexplained fear (deja vu, epigastric butterflies & unreality) [6] - may present as wide-eye staring, chewing, repetitive grabbing at clothing - autonomic symptoms - palpitations, perspiration, vasomotor symptoms (hot flash) - post-ictal state (exhaustion, sleepiness, confusion) of 20 minutes - weekly or monthly occurrence [2] - partial seizures may transform into secondary generalized seizures [2] Special laboratory: - see seizure Radiology: - see seizure Complications: - automobile accidents among persons with undiagnosed partial seizures [5] Differential diagnosis: - absence seizure - both absence seizure & focal seizure may begin as staring spells - focal seizures with impaired awareness have longer duration 15-60 vs < 20 seconds, lower frequency (not many/day) & presence of aura & post-ictal state [2] Management: 1) general - immediate management - diazepam buccal film interictal, ictal/peri-ictal poorly controlled tonic-clonic seizures or focal seizures with impaired awareness [4] - treat unprovoked seizure with risk factors for recurrent seizures - abnormal electroencephalogram or MRI - see seizure (Management section) for additional risk factors [7] 2) first line [2] a) lamotrigine (Lamictal)* b) levetiracetam* c) oxcarbazine* 3) agents of choice in young patients a) carbamazepine (Tegretol) b) phenytoin (Dilantin) c) levetiracetam* d) zonisamide [2] e) alternative agents - lamotrigine (Lamictal)* - locosamide* - oxcarbazine* - topiramate* - valproate* [2] 4) least expensive agents a) carbamazepine b) phenytoin c) phenobarbital [2] 5) women of child-bearing age a) lamotrigine (Lamictal) b) levetiracetam c) avoid valproate & topiramate [2] 6) elderly a) lamotrigine (Lamictal) b) levetiracetam c) gabapentin [2] 7) liver failure a) levetiracetam b) gabapentin c) avoid valproic acid [2] 8) renal failure a) lamotrigine (Lamictal) b) levetiracetam [2] 9) patients with concurrent mood disorder a) carbamazepine (Tegretol) b) lamotrigine (Lamictal) c) oxcarbazine d) valproate e) avoid levetiracetam [2] 10) a single agent is effective in controlling seizures in 50% of patients 11) attempt therapy with alternative agent prior to initiating combination therapy 12) 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 13) neurosurgery for refractory partial seizures - resection of mesial temporal lobe sclerotic lesions is the most common procedure [2] * avoid valproate & topiramate in women of child bearing age [2] * for seizures due to brain metastases for which chemotherapy is planned use valproic acid, lacosamide, lamotrigine or levetiracetam [2]

Related

temporal lobe (psychomotor) epilepsy

Specific

complex partial seizure; focal seizure with impaired awareness epilepsia partialis continua; Kojevnikov's epilepsia; Jacksoninan status epilepticus partial seizure with secondary generalization (Jacksonian seizure) simple partial seizure

General

seizure; epileptic seizure chronic neurologic disease

References

  1. Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 1034-35
  2. Medical Knowledge Self Assessment Program (MKSAP) 11, 17, 18, 19. American College of Physicians, Philadelphia 1998, 2015, 2018, 2021. - Medical Knowledge Self Assessment Program (MKSAP) 19 Board Basics. An Enhancement to MKSAP19. American College of Physicians, Philadelphia 2022
  3. Geriatric Review Syllabus, 7th edition Parada JT et al (eds) American Geriatrics Society, 2010
  4. George J Diazepam Film Shows Promise for Poor Seizure Control. Buccal film placed successfully during seizure clusters. MedPage Today. Dec 06, 2018 - Jung C, et al. The usability of diazepam buccal soluble film as an oral treatment in adult patients with epilepsy. AmericanEpilepsy Society (AES) 2018; Abstract 3.468. - Rogawski M, et al. Pharmacokinetics of diazepam buccal soluble film in adult patients with epilepsy: comparison of bioavailability with peri-ictal and interictal administration. AmericanEpilepsy Society (AES) 2018; Abstract 2.453
  5. George J Car Accidents Common With Undetected Epilepsy - Subtle seizures may include brief hallucinations or deja vu. MedPage Today October 20, 2020 https://www.medpagetoday.com/neurology/seizures/89205 - Pellinen J et al Focal nonmotor versus motor seizures: The impact on diagnostic delay in focal epilepsy. Epilepsia. Oct 10, 2020 PMID: 33078409 https://onlinelibrary.wiley.com/doi/abs/10.1111/epi.16707
  6. NEJM Knowedge+ Neurology
  7. Foster E, Carney P, Liew D et al First seizure presentations in adults: beyond assessment and treatment. J Neurol Neurosurg Psychiatry. 2019 Sep;90(9):1039-1045. PMID: 30948624 Review.