Simple Partial Seizures Clinical Presentation

Updated: Feb 22, 2016
  • Author: Jane G Boggs, MD; Chief Editor: Selim R Benbadis, MD  more...
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Presentation

History

The International Classification of Epileptic Seizures (ICES) lists 18 categories of simple partial seizures (SPS). [9] All types of SPS can be seen with subsequent complex partial, secondarily generalized seizures. The suspicion of SPS is based on a history consistent with the typical, reproducible patterns seen with the various SPS categories.

Motor simple partial seizures

In motor SPS, clonic discharges in the sensorimotor cortex cause jerky, rhythmic movements that may remain restricted to one body segment or spread by "jacksonian march." [10] Subtypes of motor SPS are as follows:

  • Benign focal epilepsy of childhood
  • Epilepsia partialis continua
  • Tonic supplementary motor area (SMA) and premotor region discharges

Benign focal epilepsy of childhood accounts for 15-25% of childhood epilepsy and eventually remits by age 16 years. Typical seizures are simple and motor, affect the face or arm, and occur soon after falling asleep or awakening. As it usually remits by age 16 years, this syndrome does not always require treatment.

Epilepsia partialis continua (ie, Kojewnikoff syndrome) includes stereotypical periodic to semiperiodic clonic activity that may persist for years and is often refractory to treatment. [11] Clonic jerking usually involves the thumb or great toe, and may or may not spread to other body parts.

Epilepsia partialis continua has been associated with stroke, tumor, trauma, hypoxia, Rasmussen encephalitis, syndrome of mitochondrial encephalomyopathy, lactic acidosis, and stroke (MELAS), subacute sclerosing panencephalitis (SSPE), and adult nonketotic hyperglycinemia.

Tonic SMA and premotor region discharges produce sustained contractions and unusual postures of a limb [11] . In 72% of cases, SMA seizures are not associated with impaired consciousness. Versive-smooth or jerky, tonic contractions of head and eye muscles, usually on the side contralateral to the discharge, often are followed by a secondarily generalized tonic-clonic seizure. Phonatory activation of the primary or supplementary motor cortex produces vocalizations, speech arrest, or aphasia.

Sensory simple partial seizures

Somatosensory-primary sensory cortex seizures usually elicit positive or negative sensations contralateral to the discharge. [4] Symptoms associated with seizures from the postcentral gyrus include the following:

  • Tingling
  • Numbness
  • Pain
  • Heat
  • Cold
  • Agnosia
  • Phantom sensations
  • Sensations of movement

Abdominal pain usually originates from the temporal lobe, and genital pain from the mesial parietal sensory cortex. The posterior parietal cortex is the likely origin of limb agnosia.

Supplemental sensory-secondary sensory cortex seizures may have ipsilateral or bilateral positive or negative sensations or vague axial or diffuse sensations.

Visual-calcarine cortex discharges produce elemental hallucinations including scintillations, scotomata, colored lights, visual field deficits, or field inversion. The visual association cortex is the probable location of origin of complex visual hallucinations and photopsias.

Auditory SPS from the auditory cortex typically are perceived as simple sounds, rather than words or music. Olfactory-uncinate seizures originate from the orbitofrontal cortex and the mesial temporal area. Perceived odors are usually unpleasant, often with a burning quality.

Gustatory seizures usually are associated with temporal lobe origin, although the insula and parietal operculum also have been implicated. Perceived tastes are typically unpleasant, often with a metallic component.

Vestibular seizures originate from various areas, including frontal and temporal-parietal-occipital junction. Symptoms include vertigo, a tilting sensation, and vague dizziness.

Psychic SPS arise predominantly from the temporal and limbic region, including the amygdala, hippocampus, and parahippocampal gyrus. Perceptual hallucinations or illusions are usually complex, visual or auditory, and are rarely bimodal.

Déjà vu and jamais vu phenomena may occur. Fear is usual, but SPS can elicit happiness, sexual arousal, anger, and similar responses. Cognitive responses include feelings of depersonalization, unreality, forced thinking, or feelings that may defy description.

Autonomic simple partial seizures

Autonomic SPS can involve the following symptoms [12] :

  • Abdominal
  • Cardiovascular
  • Respiratory
  • Papillary
  • Urogenital
  • Other

Abdominal sensation phenomena are common in mesial temporal epilepsy but can arise from the operculum and occipital region. Symptoms include nausea, pain, hunger, warmth, and "epigastric rising" sensations, and may be associated with piloerection (ie, gooseflesh).

The most common cardiac manifestation of any seizure is sinus tachycardia with arrhythmias, with bradycardia occurring infrequently. [13] Some patients have chest pain or a sensation of palpitation that mimics cardiac disease.

Respiratory inhibition has been reported with electrical stimulation of the temporal regions. [14] Pupillary symptoms include miosis, mydriasis, hippus, and unilateral pupillary dilatation.

Seizures from the superior portion of the posterior central gyrus can result in genital sensations, while sexual auras arise more from the limbic or temporal regions. Ictal orgasms have been reported, although rarely, in association with seizures arising from various cerebral locations. [15]

Rare autonomic symptoms include perspiration, lacrimation, ictal enuresis, or flushing.

Postictal neurological deficits can occur after an SPS as a negative manifestation of the function affected by the seizure (eg, Todd paralysis).

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Physical Examination

The physical examination may show subtle or obvious neurological focality. Immediately following SPS, the focality may become more pronounced owing to postictal inhibition (eg, Todd paralysis).

If an examination is performed during SPS, no impairment of awareness or responsiveness is observed. Preservation of awareness implies that a person is able to recount simple events that happen during the ictus. This is best established by giving a specific, uncommon 2-syllable word to the patient during the SPS and asking for its recall soon after the seizure has resolved.

Preservation of responsiveness implies that a person is able to carry out simple commands or directed volitional actions. This is best established by asking the patient to perform simple, unilateral and bilateral neurological functions during the SPS.

However, responsiveness may appear to be impaired because of interference by the motor manifestations of the SPS. If the patient is unable to perform a task because of the manifestations of the SPS but recollects the instructions afterwards, this recollection implies that responsiveness was preserved.

Motor, sensory, special sensory, psychic, and autonomic manifestations may begin in a small anatomical area and spread to a larger area of the body. This has been termed as "jacksonian march," and it typically progresses along contiguous parts of the body in a reproducible pattern.

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