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temporal lobe (psychomotor) epilepsy

Etiology: - idiopathic * also see differential diagnosis (below) Epidemiology: - most common form of adult-onset focal epilepsy Pathology: - medial temporal sclerosis* - atrophy of hippocampus* * associated with anticonvulsant resistance Clinical manifestations: 1) aura consisting of - poorly described visceral sensation* - nausea, taste or smell sensations - sudden panic, fear & anxiety - deja vu sensation - palpitations - complex visual hallucinations [5] - no visual field disturbance (scintillating scotoma) 2) generally presents with complex partial seizures - nocturnal complex partial seizures common - chaotic movements may awaken patients from sleep 3) stereotyped complex behavioral manifestations a) may be momentary inactivity b) lip smacking, chewing, staring, hand fumbling may occur c) ref [2] describes patient as fidgety d) repetitive vocalizations may occur' e) automatisms may occur (semipurposeful automatic movements) 4) brief episodes of anxiety +/- autonomic symptoms (xerostomia) - duration of episodes is 15-60 seconds, 30-120 seconds [1] 5) loss of awareness, loss of consciousness 6) amnesia, may not remember episodes [1] 7) post-ictal confusion is generally short * [2] describes this as a rising epigastric aura in its analysis of a patient that describes a 'roller coaster' sensation in her stomach Special laboratory: - electroencephalogram (EEG) - a normal EEG does not rule out a seizure disorder - especially so of seizures originating in the medial temporal lobe - nasopharyngeal recordings or sleep studies may be helpful - videoelectroencephalography - prerequisite for temporal lobe resection - confirm seizures seen on video EEG match abnormal findings on MRI neuroimaging Radiology: - magnetic resonance imaging (MRI) a) increased hippocampal intensity on T2-weighted images b) atrophy of hippocampus on T1-weighted images c) hippocampal volumetry - unilateral hippocampal atrophy correlates well with EEG signal lateralization; may be good predictor of response to hippocampal resection d) mesial temporal sclerosis (neuronal loss & gliosis) Differential diagnosis: - panic disorder is without stereotyped features, duration of episodes is 30-90 minutes vs 15-60 seconds - limbic encephalitis (Herpes encephalitis) - rapid onset of fever, headache, confusion, focal neurologic signs - no aura, does not occur in episodes of short duration - panic attacks generall last several minutes to 1 hour - no automatisms, loss of consciousness, post-ictal state - tardive dyskinesia: no aura, loss of consiousness, post-ictal state Management: 1) anticonvulsant therapy - use anticonvulsant indicated for partial seizures 2) surgical resection of part of a temporal lobe [2,3] a) improved chance of becoming seizure-free b) complications - infarcts - wound infections - decline in verbal memory 3) sleep management - donepezil 10 mg QAM improves slow-wave-sleep & memory scores vs zolpidem 6.25 mg QHS in patients with insomnia & refractory temporal lobe epilepsy [6]

Interactions

disease interactions

Related

automatism complex partial seizure; focal seizure with impaired awareness temporal lobe

Specific

anti-leucine-rich glioma inactivated 1 (LGI1) encephalitis

General

focal epilepsy

References

  1. Medical Knowledge Self Assessment Program (MKSAP) 11, 16, 17, 18, 19. American College of Physicians, Philadelphia 1998, 2012, 2015, 2018, 2021. - Medical Knowledge Self Assessment Program (MKSAP) 19 Board Basics. An Enhancement to MKSAP19. American College of Physicians, Philadelphia 2022
  2. Journal Watch 21(17): 142, 2001 Wiebe S et al A randomized, controlled trial of surgery for temporal-lobe epilepsy. N Engl J Med 345:311, 2001 PMID: 11484687
  3. Hurley RA, Fisher R, Taber KH. Sudden onset panic: epileptic aura or panic disorder? J Neuropsychiatry Clin Neurosci. 2006 Fall;18(4):436-43. PMID: 17135371
  4. Jette N, Quan H, Tellez-Zenteno JF et al Development of an online tool to determine appropriateness for an epilepsy surgery evaluation. Neurology. 2012 Sep 11;79(11):1084-93. Epub 2012 Aug 15. PMID: 22895589
  5. Geriatric Review Syllabus, 9th edition (GRS9) Medinal-Walpole A, Pacala JT, Porter JF (eds) American Geriatrics Society, 2016
  6. Anderson P Improving Sleep Boosts Cognition in Refractory Temporal Lobe Epilepsy. Medscape. December 05, 2022 https://www.medscape.com/viewarticle/985015