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Frontal Lobe Epilepsy Clinical Presentation

  • Author: Sheryl Haut, MD; Chief Editor: Selim R Benbadis, MD  more...
 
Updated: Dec 30, 2015
 

History

The majority of frontal lobe seizures are thought to be symptomatic, although many patients with frontal lobe seizures have no obvious lesions on magnetic resonance imaging (MRI) scans.

A careful history should focus on specific characteristics of seizure episodes, including a detailed description by eyewitnesses, patterns of occurrence, precipitating factors, and response to medication. Time of day is an important characteristic for seizures originating in the frontal lobe, as the majority of these seizures occur between the hours of 2 am and noon.[5]

Features that help to distinguish frontal lobe seizures from nonepileptic events include stereotyped semiology, occurrence during sleep, brief duration (often < 30 seconds), rapid secondary generalization, prominent motor manifestations, and complex automatisms.

Even when such characteristics are present, however, distinguishing frontal lobe seizures from nonepileptic events remains difficult based on history alone, and patients with frontal lobe epilepsy are often directed first to psychiatrists rather than to neurologists. Details obtained about the seizure semiology may help to identify the specific frontal region of onset.[6, 7]

Other history findings may include the following:

  • Dominant hemisphere involvement - May be indicated by prominent speech disturbances
  • Supplementary motor area (SMA) - Typically involves unilateral or asymmetrical, bilateral tonic posturing; may be associated with facial grimacing, vocalization, or speech arrest; seizures frequently preceded by a somatosensory aura; complex automatisms, such as kicking, laughing, or pelvic thrusting, may be present; responsiveness often preserved
  • Primary motor cortex - Usually simple partial motor seizures with clonic or myoclonic movements and preserved consciousness; jacksonian spread to adjacent cortical areas may occur, and secondary generalization is frequent; speech arrest and contralateral adversive or dystonic posturing may be present
  • Medial frontal, cingulate gyrus, orbitofrontal, or frontopolar regions - Complex behavioral events characterized by motor agitation and gestural automatisms; viscerosensory symptoms and strong emotional feelings often described; motor activity repetitive and may involve pelvic thrusting, pedaling, or thrashing, often accompanied by vocalizations or laughter/crying; seizures often bizarre and may be diagnosed incorrectly as psychogenic
  • Dorsolateral cortex - Tonic posturing or clonic movements often associated with either contralateral head and eye deviation, or less commonly, ipsilateral head turn
  • Operculum - Swallowing, salivation, mastication, epigastric aura, fear, and speech arrest often associated with clonic facial movements; gustatory hallucinations also may occur
  • Nonlocalizable frontal seizures - Rare, manifesting as brief staring spells accompanied by generalized spike/wave on EEG, which may be difficult to distinguish from primarily generalized absence seizures; may present as generalized tonic-clonic seizures without obvious focal onset
  • Nocturnal frontal lobe epilepsy - Autosomal dominant inheritance; seizures occur mainly during sleep; characterized by marked motor manifestations, including dystonic posturing, jerking, bending, and rocking; difficult to distinguish from parasomnias
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Physical Examination

A general physical and thorough neurologic examination should be performed in all patients with epilepsy.

General examination

General examination may reveal signs suggestive of syndromes that may be associated with epilepsy, such as facial dysmorphisms. Skin abnormalities, such as cafe-au-lait spots, hypomelanotic macules, or neurofibromas suggesting neurocutaneous syndromes, may also be found.

Neurologic examination

As structural lesions are common, neurologic abnormalities are common in patients with frontal lobe epilepsy. Pay particular attention to the motor examination.

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Contributor Information and Disclosures
Author

Sheryl Haut, MD Professor of Clinical Neurology, Albert Einstein College of Medicine; Director, Adult Epilepsy, Montefiore Medical Center

Sheryl Haut, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Neurology, American Clinical Neurophysiology Society, American Epilepsy Society, American Neurological Association

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Consultant/DSMB: Acorda;Upsher Smith;Neurelis;Xeris.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Jose E Cavazos, MD, PhD, FAAN, FANA, FACNS Professor with Tenure, Departments of Neurology, Pharmacology, and Physiology, Assistant Dean for the MD/PhD Program, Program Director of the Clinical Neurophysiology Fellowship, University of Texas School of Medicine at San Antonio; Co-Director, South Texas Comprehensive Epilepsy Center, University Hospital System; Director, San Antonio Veterans Affairs Epilepsy Center of Excellence and Neurodiagnostic Centers, Audie L Murphy Veterans Affairs Medical Center

Jose E Cavazos, MD, PhD, FAAN, FANA, FACNS is a member of the following medical societies: American Academy of Neurology, American Clinical Neurophysiology Society, American Neurological Association, Society for Neuroscience, American Epilepsy Society

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Brain Sentinel, consultant.<br/>Stakeholder (<5%), Co-founder for: Brain Sentinel.

Chief Editor

Selim R Benbadis, MD Professor, Director of Comprehensive Epilepsy Program, Departments of Neurology and Neurosurgery, Tampa General Hospital, University of South Florida College of Medicine

Selim R Benbadis, MD is a member of the following medical societies: American Academy of Neurology, American Medical Association, American Academy of Sleep Medicine, American Clinical Neurophysiology Society, American Epilepsy Society

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Cyberonics; Eisai; Lundbeck; Sunovion; UCB; Upsher-Smith<br/>Serve(d) as a speaker or a member of a speakers bureau for: Cyberonics; Eisai; Glaxo Smith Kline; Lundbeck; Sunovion; UCB<br/>Received research grant from: Cyberonics; Lundbeck; Sepracor; Sunovion; UCB; Upsher-Smith.

References
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  9. Laskowitz DT, Sperling MR, French JA, O'Connor MJ. The syndrome of frontal lobe epilepsy: characteristics and surgical management. Neurology. 1995 Apr. 45(4):780-7. [Medline].

  10. Knake S, Triantafyllou C, Wald LL, Wiggins G, Kirk GP, Larsson PG, et al. 3T phased array MRI improves the presurgical evaluation in focal epilepsies: a prospective study. Neurology. 2005 Oct 11. 65(7):1026-31. [Medline].

  11. Bonelli SB, Lurger S, Zimprich F, Stogmann E, Assem-Hilger E, Baumgartner C. Clinical seizure lateralization in frontal lobe epilepsy. Epilepsia. 2007 Mar. 48(3):517-23. [Medline].

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  16. FDA approves Aptiom to treat seizures in adults. US Food and Drug Administration. Available at http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm374358.htm. Accessed: November 12, 2013.

 
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