eMedicine Specialties > Neurology > Seizures and Epilepsy

Complex Partial Seizures: Differential Diagnoses & Workup

Author: Anthony M Murro, MD, Laboratory Director, Professor, Department of Neurology, Medical College of Georgia
Contributor Information and Disclosures

Updated: Oct 11, 2006

Differential Diagnoses

Absence Seizures
Epilepsy in Adults with Mental Retardation
Ambulatory Electroencephalography (EEG)
Epilepsy in Children with Mental Retardation
Aphasia
Epilepsy, Juvenile Myoclonic
Apraxia and Related Syndromes
Epileptic and Epileptiform Encephalopathies
Benign Childhood Epilepsy
Epileptiform Discharges
Benign Neonatal Convulsions
Febrile Seizures
Chronic Paroxysmal Hemicrania
First Seizure in Adulthood: Diagnosis and Treatment
Confusional States and Acute Memory Disorders
First Seizure: Pediatric Perspective
Early Myoclonic Encephalopathy
Focal EEG Waveform Abnormalities
EEG in Common Epilepsy Syndromes
Frontal Lobe Epilepsy
EEG in Status Epilepticus
Frontal Lobe Syndromes
EEG Seizure Monitoring
Identification of Potential Epilepsy Surgery Candidates
Epilepsia Partialis Continua

Other Problems to Be Considered

Confusional arousals
Sleep walking
Sleep talking
Paroxysmal nocturnal dystonia
Night terrors
Benign epilepsy syndromes
Transient ischemic attacks
Migraines

Workup

Laboratory Studies

  • A determination of serum anticonvulsant drug concentrations may be helpful.

Imaging Studies

  • Cranial MRI may be indicated to detect focal brain lesions (see Images 1-2).
    • Reduced hippocampal volume or increased signal on fluid-attenuation inversion recovery (FLAIR) T2-weighted MRI identifies sclerosis of mesial temporal lobe in 80-90% of cases.
    • Gadolinium enhancement is indicated if a neoplasm or vascular malformation is suspected.
    • Subtle cortical changes from cortical dysplasia are often overlooked.
  • During EEG-video monitoring, single-photon emission CT SPECT with the injection of radioisotope immediately at seizure onset (ictal SPECT) may reveal the seizure focus as an area of increased perfusion.
  • Subtraction of ictal SPECT scan from interictal SPECT scans enhances imaging of the seizure focus.
  • Interictal fluorine-18-deoxyglucose (FDG) positron emission tomography (PET) may show a hypometabolic zone ipsilateral to the seizure focus.
  • Specialized PET ligands, such as carbon-11 flumazenil or11 C-labeled methyl-L-tryptophan may help in identifying microdysgenesis or epileptogenic tubers of tuberous sclerosis, respectively.
  • The 3-T phased-array MRI detects lesions with greater sensitivity than the 1.5-T MRI.

Other Tests

  • EEG should be performed in every patient who has experienced a spell and therefore a possible seizure (see Image 3).
    • Epileptiform discharges may indicate the type of seizure and site of the seizure focus.
    • A negative interictal EEG does not exclude a diagnosis of epilepsy.
    • If the waking EEG is negative, a sleep-deprived EEG may demonstrate epileptiform abnormalities.
    • When the EEG and history are nondiagnostic, prolonged EEG-video monitoring is useful for differential diagnosis.
    • Ambulatory EEG may be used in some instances, although it provides less information about seizure behavior than EEG-video monitoring.
  • EEG within 24 hours is more useful in diagnosis of epileptiform abnormalities than later EEG (51 vs 34%).
  • Long-term anticonvulsant therapy with hepatic enzyme–inducing anticonvulsants increases the risk for osteoporosis. In patients receiving such therapy, periodic bone-density measurements may be useful.

Procedures

  • Lumbar puncture may be performed in patients in whom an inflammatory or infectious brain disorder (eg, encephalitis) is suspected.
  • Lumbar puncture is not necessary in every seizure evaluation.

Histologic Findings

Among patients with temporal-lobe epilepsy, the most common pathologic finding is sclerosis of the mesial temporal lobe. Mesial temporal sclerosis refers to hippocampal neuronal loss. Pyramidal cell loss is greater than granule cell loss. Relative sparing of neurons in the CA2 hippocampal area is observed.

More on Complex Partial Seizures

Overview: Complex Partial Seizures
Differential Diagnoses & Workup: Complex Partial Seizures
Treatment & Medication: Complex Partial Seizures
Follow-up: Complex Partial Seizures
Multimedia: Complex Partial Seizures
References
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References

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Further Reading

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Keywords

attacks, convulsions, fainting, spells, impaired consciousness, simple motor automatisms, manual automatisms, oral automatisms, perseverative automatisms, bizarre automatisms, temporal lobe complex partial seizures, parietal lobe seizures, frontal lobe seizures, extratemporal lobe seizures, occipital lobe seizures, complex partial status epilepticus, sudden unexpected death in epilepsy, SUDEP, brain trauma, encephalitis, meningitis, stroke, perinatal brain injuries, vascular malformations, cortical dysplasia, neoplasms, febrile seizures, temporal lobe epilepsy, mesial temporal sclerosis

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Contributor Information and Disclosures

Author

Anthony M Murro, MD, Laboratory Director, Professor, Department of Neurology, Medical College of Georgia
Anthony M Murro, MD is a member of the following medical societies: American Academy of Neurology and American Epilepsy Society
Disclosure: Nothing to disclose.

Medical Editor

Joseph F Hulihan, MD, Vice President, Medical Affairs, Ortho-McNeil Janssen Scientific Affairs, LLC
Joseph F Hulihan, MD is a member of the following medical societies: American Academy of Neurology, American Clinical Neurophysiology Society, American Epilepsy Society, American Headache Society, and American Medical Association
Disclosure: Johnson & Johnson Salary Employment; Johnson & Johnson Stock Employment

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Selim R Benbadis, MD, Professor, Director of Comprehensive Epilepsy Program, Departments of Neurology and Neurosurgery, University of South Florida School of Medicine, Tampa General Hospital
Selim R Benbadis, MD is a member of the following medical societies: American Academy of Neurology, American Academy of Sleep Medicine, American Clinical Neurophysiology Society, American Epilepsy Society, and American Medical Association
Disclosure: Nothing to disclose.

CME Editor

Matthew J Baker, MD, Consulting Staff, Collier Neurologic Specialists, Naples Community Hospital
Matthew J Baker, MD is a member of the following medical societies: American Academy of Neurology
Disclosure: Nothing to disclose.

Chief Editor

Nicholas Y Lorenzo, MD, Chief Editor, eMedicine Neurology; Consulting Staff, Neurology Specialists and Consultants
Nicholas Y Lorenzo, MD is a member of the following medical societies: Alpha Omega Alpha and American Academy of Neurology
Disclosure: Nothing to disclose.

 
 
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