Focal Impaired Awareness Seizure

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In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan.
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Excerpt

Focal impaired awareness seizures refer to focal seizures that start in one hemisphere of the brain and are associated with impairment in consciousness. Complex partial seizures are now preferably called "focal impaired awareness seizure" or "focal onset impaired awareness seizure." International League Against Epilepsy (ILAE) 2017 classification has categorized seizures based on three key features: the location of seizure onset, level of awareness during a seizure, and other features of seizures. Focal seizures refer to epileptiform activity starting in one area on one side of the brain. If awareness is impaired or affected at any time during the seizure, it is called a focal impaired awareness seizure. Focal seizures are further classified into motor onset (automatisms, atonic, clonic, myoclonic, tonic, epileptic spasms, hyperkinetic) and nonmotor onset (autonomic, emotional, sensory, cognitive, behavior arrest) types. A seizure that starts on one side or one part of the brain and then spreads to both sides, earlier referred to as secondarily generalized seizures, is now preferably termed as "focal to bilateral seizure."

Focal seizures with impaired consciousness can present with or without an aura. Auras can last from a few seconds to 1 to 2 minutes before consciousness is impaired. Consciousness is maximally impaired in the beginning, typically. Most of the seizures with automatisms last longer than 30 seconds, up to 1 to 2 minutes, and sometimes can be as long as 10 minutes. Absence seizures can sometimes present with the 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. Most of the focal impaired awareness seizures arise from the temporal lobe. Extratemporal origin has been reported in at least 10% to 30% of patients.

Seizures of Temporal Lobe Origin

These are the most common type of focal impaired awareness seizures. Stereotyped automatisms occur in about 40% to 80% of patients with temporal lobe epilepsies. Seizures with predominantly oral and manual automatism and some other motor manifestations are highly suggestive of temporal lobe origin. About 60% of temporal lobe seizures have a secondary generalization. Gradual recovery after several minutes of confusion occurs postictally in most patients; however, in some patients, automatic behavior like running or walking about, the non-directed violent behavior may occur. Temporal lobe focal impaired seizures can have features similar to frontal seizures, but temporal lobe focal impaired seizures typically have slower onset and progression and more pronounced confusion. Certain features can help in localizing the seizure onset to one hemisphere. Ictal vomiting, ictal speech, urinary urge, and automatisms with intact consciousness suggest seizure onset in the non-dominant hemisphere, and speech disturbance postictally is suggestive of seizure onset in the dominant hemisphere. Upper limb dystonia lateralizes seizure to the opposite hemisphere.

In young children with focal seizures of temporal lobe onset, behavioral arrest and unresponsiveness are common. Oroalimentary automatisms tend to occur in children older than age 5. The symmetric motor movement of the limbs and head nodding in younger children is typical. In infants, these seizures may be subtle with few automatisms. In very young infants, central apnea can occur. Temporal focal impaired seizures can be confused with absence seizures as both may have automatisms, but temporal seizures are usually longer and are associated with postictal confusion.

Seizures arising from the mesial temporal lobe are characterized by auras such as epigastric sensation, deja vu, a feeling of fear, and unpleasant smells. Autonomic features like tachycardia, flushing, and pallor are common. Auras may be followed by impaired awareness and manual and oroalimentary automatisms. Automatisms in the upper limb and /or pupillary dilatation unilaterally may lateralize seizure to the ipsilateral hemisphere. Dystonia in the upper limbs, head, and eye version on the opposite side can occur.

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 the contralateral hemisphere. Initial aura is usually not prolonged, and impaired awareness is an early feature. Seizures are of shorter duration, and progression to bilateral convulsions is more common than those arising from the mesial temporal lobe.

Seizures of Frontal Lobe Origin

Up to 30% of the patients with focal epilepsy have seizures arising from the frontal lobe. It is the most common extratemporal type. Seizures are accompanied by loss of consciousness in about half of the patients with frontal lobe epilepsy. Focal impaired awareness seizures can arise from various locations within the frontal lobe, except the rolandic strip. These seizures typically are brief, lasting about 30 seconds, occurring in clusters multiple times a day, are often nocturnally occurring during sleep, and have minimal postictal confusion. Motor symptoms are predominant and range from hypermotor thrashing episodes like pelvic thrusting and bicycling movements to asymmetric tonic posturing. Sexual automatisms, bizarre behavior, and vocalizations are common. These seizures often have a stereotypical pattern for each patient. Nocturnal frontal lobe seizures may be mistaken for parasomnias. The ictal EEG may be difficult to interpret because of movement artifacts. Identification based on semiology alone and differentiating from mesial temporal lobe epilepsy may be difficult; however, earliest signs and symptoms and their order of appearance may help in distinction. Seizures with hypermotor features are likelier to have an ictal focus in the orbitofrontal and frontopolar regions. Temporal lobe seizures have more oroalimentary automatisms, gesturing, and fumbling semiology.

Epileptiform activity in frontal convexity can cause clonic seizures, and in the supplementary motor area can cause tonic seizures. Unique semiology of the supplementary sensorimotor cortex includes deviation of head and eye to the side contralateral to seizure onset, the asymmetrical posturing of upper limbs with an extension of arm contralateral to the side of seizure onset, and flexion of the ipsilateral arm. Orbitofrontal region seizures are automotor type and manifest prominently with autonomic phenomena like flushing, vocalization, and automatisms. Anterior cingulate gyrus seizures have predominant motor manifestations like hypermotor seizures and complex motor seizures. Posterior cingulate cortex epilepsies predominantly have altered consciousness and automotor seizures as the main clinical manifestations. Antero-lateral dorsal convexity seizures may manifest with auras such as dizziness, epigastric sensation, behavioral arrest, and speech arrest.

Seizures of Parietal Lobe Region

Seizures from the parietal lobe may be difficult to diagnose because of their subjective nature. Positive and /or negative sensory features are common. Sensorimotor phenomenon and vestibular hallucinations suggest onset in the parietal lobe. Paresthesias, visual hallucinations, visual illusions, somatic illusions, and vertiginous features can occur. Seizures arising from the dominant hemisphere can cause receptive language impairment. Parietal lobe Focal impaired awareness seizures can have auras like epigastric sensations, visual hallucinations, panic attacks, and behavioral arrest. Often, there is an involvement of other lobes as the seizure spreads. When focal seizures from the parietal lobe spread and involve the temporal lobe, loss of consciousness and automatisms may occur.

Seizures of occipital lobe origin

Seizures with ictal origin in the occipital lobe are characterized by a visual aura and are difficult to diagnose, especially in young children. Visual auras, typically of elementary sensations, ictal blindness, versions of the head and eyes to the opposite side, rapid and forced blinking, and oculoclonic activity are some features suggesting the occipital lobe as an origin of focal seizure with impaired consciousness. Seizures from the primary visual cortex can cause bilateral loss of vision in the form of white-out or black-out. A shorter duration of the visual aura (less than 2 minutes) can help to differentiate from a migraine aura, which is typically longer (5 to 15 minutes). Complex-formed visual hallucinations, like pictures of people, animals, etc., are associated with seizure onset in the extra-striate cortex. Other symptoms may result from spread to the temporal or parietal lobes.

Seizures of Insular Lobe Origin

Seizures arising from the insula can mimic frontal, temporal, and parietal lobe seizures. Origin from the insula is suspected when viscerosensitive symptoms (nausea, vomiting, salivation), motor symptoms (tonic, hypermotor, or generalized tonic-clonic movements), and/or sensory symptoms (numbness, tightness, vibration, pain, vertigo) occur at seizure onset.

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