Focal (Partial) Epilepsy Clinical Presentation

Updated: Mar 14, 2022
  • Author: Muhammad H Jaffer, MD; Chief Editor: Helmi L Lutsep, MD  more...
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Obtaining a description of the seizures from the patient and any witnesses is critical. The description needs to include a description of the patient’s state of awareness during the seizure. Awareness is a surrogate measure for consciousness and should be assessed by whether the person knows who they are and what is going on around them during their seizure; it is distinct from responsiveness.

A focal aware seizure replaces the previous term “simple partial seizure.” A focal seizure with impaired awareness replaces “complex partial seizure.” If a patient’s awareness is impaired for any portion of the seizure, the seizure should be classified as a focal seizure with impaired awareness. If the integrity of the patient’s awareness is unknown, this descriptor does not need to be included.

Next, an elucidation of the early prominent features of the seizure is important to aid in localizing the epileptic focus. These are generally divided into motor and non-motor manifestations. The term “aura” is used to describe a subjective ictal phenomenon for a patient that may precede an observable seizure; an aura is non-motor focal seizure as described below.

Motor manifestations may include the following:

  1. Automatisms: involuntary but coordinated motor activity, which tends to be purposeless and repetitive (eg, lip smacking, patting)

  2. Atonic: focal loss of tone

  3. Clonic: focal repeated, regularly spaced jerking movements

  4. Epileptic spasms: rapid paroxysms of flexion at the waist and flexion or extension of the arms

  5. Hyperkinetic: excessive and highly variable muscular movement (eg, thrashing, pedaling)

  6. Myoclonic: irregular, brief, unsustained focal jerking

  7. Tonic: focal sustained increased tone or stiffening

Non-motor manifestations may include the following:

  1. Autonomic: changes in heart rate, blood pressure, a sensation of heat or cold, sexual arousal, sweating, flushing, piloerection, or gastrointestinal sensations

  2. Behavior arrest: a cessation of movement. To qualify, this should be the predominant feature of the entire seizure (eg, staring)

  3. Cognitive: changes in language function, thinking, or higher cortical functions (eg, déjà vu, jamais vu, hallucinations)

  4. Emotional: clear emotive changes, whether affective or subjective (eg, fear, anxiety, laughing, crying)

  5. Sensory: a change in sensation, which can be somatosensory, olfactory, visual, auditory, gustatory, or vestibular

It is also important to assess whether a focal seizure evolves to tonic-clonic activity bilaterally. This is classified in the new terminology as a “focal to bilateral tonic-clonic” seizure. This is meant to replace the old designation of “secondary generalized tonic-clonic,” to avoid engendering confusion between focal and generalized seizures. [18]

Finally, during the history-taking one should elicit the duration and evolution of the seizure semiology, the frequency of seizures, whether there is any post-ictal state (fatigue, headache, confusion, or psychosis), if any tongue biting or incontinence occurs, and a detailed anti-seizure medication history.

Clinicians should also ascertain any risk factors for epilepsy (perinatal history, family history of epilepsy, head trauma, febrile seizures, dementia, or childhood seizures). It is also crucial to note any temporal patterns to seizures (diurnal, nocturnal, upon awakening, or none). Careful attention should also be paid to whether there are any known triggers (drug use, stress, sleep deprivation, fasting, illness, menstruation, lights).

Smartphone (cellphone) video recordings have emerged as a potentially reliable and useful way to clarify a seizure diagnosis. [19, 20] This is particularly useful in situations where extended EEG monitoring has not availed in capturing the episode in question. Given the ubiquity of smartphones today, caregivers or family of the patient should always be encouraged to take a clear video recording of the episode to be reviewed by their neurologist.


Physical Examination

A detailed neurological examination should be performed to determine whether a focal brain lesion is present, as this may well be the epileptic focus. Physical examination should also focus on examination of the skin, nails, eyes, and other organ systems to ascertain whether any comorbid conditions that confer an increased risk for epilepsy are present.

Neurocutaneous syndromes such as tuberous sclerosis and Sturge Weber syndrome may often present with dermatologic findings. Special attention should also be paid to any dysmorphic features or intellectual disability, as these may disclose clues regarding the presence of brain malformations.

Finally, one should also pay attention to whether there are any signs of potential injuries from convulsive seizures such as tongue bites, lacerations, compression fractures, or shoulder subluxations.

In most focal epilepsies, physical examination is unrevealing.