Complex Partial Seizures in Young Children

Summary: We retrospectively analyzed the clinical manifestations of complex partial seizures (CPS) in children aged 10 years using video and EEG telemetry and evaluated their course, investigations, management, and seizure status at follow-up. Seventeen patients with CPS were studied at the Prince of Wales Children's Hospital (POWCH) and Prince Henry Hospital (PHH) between 1987 and 1992. Because 1.5 of the 17 patients had intractable seizures, the population was selective. Mean age was 6.5 years; 4 patients were aged 2 years. Clinical features were normal or mild intellectual handicap (1 3); hemiplegia (5); and infantile spasms preceding CPS (4); of these, 2 also had simple partial motor seizures. Structural abnormalities were noted on scanning in 9 patients. Eighty-seven seizures were reviewed. Mean duration of each clinical seizure was 59.7 s (total population), 108 s (subgroup 1, aged 2 > years), and 48.5 s (subgroup 2, aged 2 years). Major ictal manifestations were auras (9), staring (9), autonomic changes (6), and automatisms (17). In subgroup 1, automatisms were simple and mainly oroalimentary and gestural. Two patients had no change in surface ictal recordings, and 2 had normal interictal EEGs. At follow-up, 8 patients were seizure-free for 6 months, 1 was partially controlled (more than two seizures a month), and 8 had intractable seizures (two or more seizures a month). Seven patients underwent operation for intractable epilepsy, and 4 achieved a class 1A outcome (Engel classification).     

Correlative Study of Interictal Electroencephalogram and Aura in Complex Partial Seizures

To understand further relationships of the interictal electroencephalogram to the aura in complex partial seizures (CPS), we studied the interictal EEG and aura in 144 patients with CPS. The ages of the patients studied ranged from 31 to 80 years (average 52.44 years). The duration of seizures ranged from 1 to 60 years (average 15.69 years). Seventy patients (49%) reported auras which were classified according to the guidelines recommended by the Commission of the International League Against Epilepsy. Statistical analysis revealed no relationship between presence, laterality, or localization of EEG abnormality and the number or type of aura. The results emphasize that more factors than electrophysiologic localization alone participate in the determination of aura in CPS. Our data support the position that aura has, at most, a limited relationship to lateralization or localization of interictal cerebral dysfunction in CPS.     

Clinical and EEG Features of Complex Partial Seizures of Extratemporal Origin

Summary: Complex partial seizures (CPSs) of extratemporal origin are frequently misdiagnosed. Common reasons for diagnostic errors are failure to recognize the epileptic cause of the attacks or to appreciate localizing clinical seizure characteristics and nonspecific or misleading scalp EEG findings. This report describes clinical characteristics of two types of extratemporal CPSs, frontal and occipital. Frontal lobe CPSs are brief, frequent attacks that begin and end suddenly. They are dominated by complex, semi-purposeful motor automatisms, and vocalization and sexual automatisms are common. Their often bizarre appearance frequently leads to a misdiagnosis of hysteria. Occipital lobe CPSs are characterized primarily by their spread pattern, which can follow various paths. They may mimic temporal lobe CPSs, sensorimotor partial seizures, or supplementary motor partial seizures. Scalp EEGs are frequently misleading. The initial clinical symptoms are the most important clue to correct diagnosis and include elemental visual symptoms, visual loss, eye pulling or movement sensations in the absence of detectable movement, rapid forced blinking or eye flutter, and contralateral eye deviation.     

Effect of Naloxone Infusion on the Rate of Epileptiform Discharges in Patients with Complex Partial Seizures

In experimental studies, endogenous opioids have shown protective effects on seizure recurrence and facilitatory effects on postictal inhibition that were reversed by the opioid antagonist, naloxone. We evaluated the effect of all-night continuous infusion of 10 mg naloxone on the rate of focal interictal epileptiform discharges (FIEDs) during sleep in eight men with complex partial seizures (CPS) during 2 consecutive nights. Patients with abundant FIEDs during the control night showed a mean increase of 39% in the rate of FIEDs per unit of time during the naloxone infusion night. During the naloxone infusion night, mean nocturnal plasma prolactin (PRL) concentrations in this group of patients showed significant elevation, which was correlated with increased density of FIEDs. All-night infusion of naloxone failed to show any effect on the remaining three patients with minimal or no FIEDs during the control night. Mean nocturnal plasma PRL concentrations in this group of patients was significantly lower than in the former group. Our data support the notion that, in response to interictal or ictal discharges, endogenous opioid peptides may exert an inhibitory action that is reversible by administration of naloxone.     

Clinical and EEG Features of Complex Partial Seizures of Temporal Lobe Origin

Summary: The electrographic and clinical behavioural manifestations of 96 temporal lobe seizures are reviewed from recordings in 19 patients who were submitted to stereotaxic depth electrode implantation in temporal and frontal lobes. Focal onset in hippocampus was recorded in 40% of the seizures. Sixty percent of temporal lobe seizures exhibited a regional seizure onset but in two-thirds of these ictal changes were restricted to amygdaloid and hippocampal structures. Thus, in approximately 80% of seizures, the onset of ictal EEG changes resided in the mesial temporal structures. The main behavioral manifestations observed during seizure discharge restricted to one temporal lobe included warning (67%), motionless stare (24%), automatism (22%), and head-body turning (24%). The predominant ictal behavioural manifestations observed during seizure spread to contralateral temporal and extratemporal structures included warning (3%), motionless stare (36%), automatism (77%), and head-body turning (81%). The direction of head turning did not provide reliable lateralization as to the side of seizure onset.     

Complex Partial Seizures Associated with a Temporomandibular Joint Defect

A case of a 32-year-old man is reported with complex partial seizures secondary to a right inferior temporal epileptic focus immediately overlying an abnormality of the temporomandibular joint, with a defect in the middle temporal fossa that allowed the mandibular condyle to contuse the temporal lobe.     

Can Sharp Waves Localized at the Sphenoidal Electrode Accurately Identify a Mesio-temporal Epileptogenic Focus?

In our patient population that had undergone antero-temporal lobectomy, we found 20 patients with a unilateral sphenoidal/antero-temporal interictal focus. All patients had normal computed tomography (CT) scans. Invasive recordings with subdural electrode arrays placed over and under the temporal lobe were used in every patient. We found that the scalp interictal focus predicted for all patients that both the interictal sharp waves and ictal onset would be mesiobasal/anterotemporal in location on the subdural arrays. Seventy-five percent of these patients had an excellent outcome with temporal lobectomy.     

Felbamate: A Clinical Trial for Complex Partial Seizures

We performed a randomized, double-blind, three-period cross-over study of felbamate (FBM, 2-phenyl-1,3-propanediol dicarbamate: Carter-Wallace 554) in patients with complex partial seizures. Patients continued carbamazepine (CBZ) throughout the study and were observed in the hospital for the entire trial period. The entry criteria required at least six seizures in a 3-week baseline period (and no more than 1 week with a single seizure) with CBZ alone. Thirty subjects were randomized. Two left the study after randomization, 1 owing to seizure exacerbation, and 1 owing to hyponatremia, which may have been related to CBZ therapy. The daily dosage of 50 mg/kg (maximum 3,000 mg) FBM per day was well tolerated by all 28 patients who completed the study. Only mild adverse experience were observed during the trial. FBM reduced CBZ level (p less than 0.0001; 95% confidence interval -28%, -20%). There was no significant difference in seizure frequency between placebo and FBM periods (one-sided p = 0.172), but when a correction was made for the lower CBZ level noted during FBM periods, the data suggested a strong antiseizure effect of FBM.     

Ictal Contralateral Paresis in Complex Partial Seizures

Summary: Certain behaviors that occur during a complex partial seizure (CPS) are useful in lateralizing the side of seizure onset. In 5 (5.3%) of 94 consecutive patients with partial epilepsy, we observed ictal unilateral arm and hand paresis during 27 of 34 CPS. In all these seizures, this behavior occurred contralateral to an epileptogenic temporal lobe, as determined by video-EEG monitoring and surgical outcome. In 5 of the 27 seizures, an observer demonstrated that the paretic arm and hand were flaccid. None of these patients had postictal (Todd's) paralysis. In most of the seizures, the arm ipsilateral to seizure onset had simultaneous purposeful movements or automatisms, sometimes with awkward posturing. Ictal unilateral paresis is distinctly different from ictal dystonia or postictal paralysis and consistently lateralizes seizure onset to the contralateral temporal lobe. Recognition of this particular ictal behavior and comparison to other simultaneous behaviors can aid in the lateralization and possibly localization of the epileptogenic zone.     

Effect of γ-Vinyl GABA on Interictal Spikes and Sharp Waves in Patients with Intractable Complex Partial Seizures

The effect of gamma-vinyl GABA (GVG) on the interictal electroencephalogram (EEG) was studied in 13 patients with intractable complex partial seizures who participated in a single-blind, add-on, multicenter clinical trial of GVG. Precise operational definitions of epileptiform paroxysms were used to evaluate records before and after 3 months and 1 year of treatment with GVG. After 3 months of treatment, six patients exhibited reduction of both epileptiform paroxysms and seizure frequency, four had no change in seizure frequency nor in the EEG, and three had a reduction in seizure frequency but no concomitant reduction of epileptiform paroxysms in the EEG. Ten patients remained in the study after 1 year of treatment. In 4 patients both seizure frequency and EEG epileptiform paroxysms continued to decrease, in 1 patient both seizure frequency and number of EEG paroxysms increased, and in the remaining 3 there was no correlation between seizure frequency and EEG changes.     

Complex Partial Seizures of Hippocampal and Amygdalar Origin

We studied the first clinical manifestations of 72 complex partial seizures (CPS) in 17 drug-resistant patients. CPS were indicated to be of hippocampal-amygdalar origin by scalp and depth EEG. We asked: (a) Do all CPS of hippocampal-amygdalar origin start with an initial motionless stare and/or oroalimentary automatisms? (b) If not, what other clinical manifestations appear at onset of the CPS? Results showed that approximately 39% of CPS begin with motionless staring, 25% with nonfocal discrete movements, 21% with oroalimentary automatisms, 10% with perseverative stereotyped automatisms, and 6% with vocalizations. Nonfocal discrete movements and oroalimentary automatisms were identified as the most common second and third clinical sequential manifestations during a CPS. We conclude that although approximately 60% of CPS of hippocampal-amygdalar origin start with motionless staring or oroalimentary automatisms, 40% do not.     

Association Between Regularly Occurring Complex Partial Seizures and Thyroid Function Parameters

A 28-year-old man with regularly occurring clusters of complex partial seizures was studied over a total of 224 days. His seizure periods lasted 2-4 days and occurred at intervals of 5-6 weeks. Several parameters were studied. The most striking finding was an increase in the serum concentration of thyroxine prior to and during the seizure periods. The concentrations of urine catecholamines and serum cortisol also varied with the seizure periods, but these hormones increased after the seizure periods had begun. To determine if there is a general 4-6-week rhythm in thyroid hormone concentrations, 12 weekly blood samples from 10 healthy male students were analyzed. No rhythmicity was found.     

Electroencephalographic Changes During Simple Partial Seizures

Summary: We analyzed retrospectively the clinical and EEG data in 13 patients with simple partial seizures (SPS). All EEGs were recorded with surface electrodes with the standard 10–20 system and additional closely spaced scalp and subfrontotemporal skin electrodes. Seventy-seven seizures were recorded. We detected electrographic correlates with SPS in 10 of 13 patients (77%) and in 47 of 77 seizures (61%). The most common ictal correlatrd relates were rhythmic theta waves or spikes. Of the SPS with EEG changes, 58% were motor, 14% were sensory, and 28% were psychic seizures. Use of additional electrodes and recording channels may account for the higher incidence of EEG changes in this study than has been reported previously in the literature.     

Dose–Response Study of Vigabatrin as Add-On Therapy in Patients with Uncontrolled Complex Partial Seizures

Summary: Purpose: This placebo-controlled, randomized, double-blind, multicenter study examined the efficacy and safety of three daily doses of vigabatrin (VGB; 1, 3, or 6 g) as add-on therapy in 174 patients with previously uncontrolled complex partial seizures with or without secondary generalization.
Methods: A 12-week pretreatment assessment period was followed by drug therapy with a 6-week titration period and a 12-week maintenance phase.
Results: VGB doses of 3 and 6 g/day reduced median monthly frequency of seizures by 4.3 and 4.5 seizures, respectively, compared with 0.2 seizures for placebo (p = 0.0001). The percentages of patients classified as therapeutic successes (≤50% reduction in seizure frequency) were 7% for placebo and 24, 51, and 54% for patients taking daily VGB doses of 1, 3, and 6 g, respectively; the comparison with placebo was significant for all treatment groups. The linear trend for dose response was highly significant (p ≥ 0.0001) for both median monthly seizure frequency and therapeutic success. Vigabatrin was well tolerated, causing no clinically significant changes in laboratory parameters, brain magnetic resonance imaging, evoked potentials, cognitive function, or psychosocial tests. Fatigue, drowsiness, and dizziness were the most common treatment-related adverse events in all treatment groups. Dropouts due to adverse events were higher in the 6-g/day group.
Conclusions: VGB was significantly more effective than placebo as add-on therapy in reducing seizure frequency. VGB at 3 and 6 g/day produced the best efficacy: however, adverse events may limit the use of the 6-g/day dose in some patients.     

Complex Partial Seizures: Cerebellar Metabolism

We used positron emission tomography (PET) with [18F]2-deoxyglucose to study cerebellar glucose metabolism (LCMRglu) and the effect of phenytoin (PHT) in 42 patients with complex partial seizures (CPS), and 12 normal controls. Mean +/- SD patient LCMRglu was 6.9 +/- 1.8 mg glucose/100 g/min (left = right), significantly lower than control values of 8.5 +/- 1.8 (left, p less than 0.006), and 8.3 +/- 1.6 (right, p less than 0.02). Only four patients had cerebellar atrophy on CT/MRI; cerebellar LCMRglu in these was 5.5 +/- 1.5 (p = 0.054 vs. total patient sample). Patients with unilateral temporal hypometabolism or EEG foci did not have lateralized cerebellar hypometabolism. Patients receiving phenytoin (PHT) at the time of scan and patients with less than 5 years total PHT exposure had lower LCMRglu, but the differences were not significant. There were weak inverse correlations between PHT level and cerebellar LCMRglu in patients receiving PHT (r = -0.36; 0.05 less than p less than 0.1), as well as between length of illness and LCMRglu (r = -0.22; 0.05 less than p less than 0.1). Patients with complex partial seizures have cerebellar hypometabolism that is bilateral and due only in part to the effect of PHT.     

Magnetic Resonance Imaging in Localization of EEG Depth Electrodes for Seizure Monitoring

Preoperative evaluation of patients with medically refractory complex partial seizures requires intensive EEG monitoring. Part of this process may include insertion of depth electrodes into temporal lobe structures. Although many imaging methods have been used for stereotactic placement of the electrodes, only computed tomography (CT) has been used to verify position after implantation. We studied 30 patients in whom magnetic resonance imaging (MRI) was used to visualize the position of stainless-steel electrodes stereotactically implanted in the temporal lobes. The procedure is noninvasive, does not utilize radiation, and has the additional advantages of multiplanar capability, increased soft tissue contrast, and lack of bony artifacts commonly associated with CT.     

Type I/II Complex Partial Seizures: No Correlation with Surgical Outcome

Three complex partial seizure (CPS) types have been described based upon the behaviors seen at the onset of the ictal event. Type I CPSs are preceded by a motionless stare and have been correlated with a temporal focus, whereas Type II CPSs are not preceded by a motionless stare and have been correlated with an extratemporal focus. A third type of CPS, temporal lobe syncope, has been correlated with bilateral mesial temporal foci. We examined the utility of this CPS classification system in predicting surgical outcomes by reviewing our patients who had undergone surgical excision of their epileptogenic foci for the treatment of medically refractory CPSs. Forty-six consecutive patients were evaluated, with the seizure focus ultimately found to be temporal in 41 and frontal in 5. All 5 patients with frontal foci had Type II CPSs; of the 41 patients with temporal foci, 20 had Type I and 21 had the Type II CPSs. Twenty of 26 patients with Type II CPSs and 18 of 20 patients with Type I CPSs had a good or excellent outcome. Although our data suggest that patients with frontal foci have Type II CPSs, the reverse is not true. Furthermore, CPS type is not correlated with the surgical outcome, since there was no significant difference between the CPS type and the category of surgical outcome.     

Postictal Psychosis After Partial Complex Seizures: A Multiple Case Study

Bouts of unusually frequent partial complex seizures originating in the temporal lobe, that sometimes became secondarily generalized, induced psychotic episodes in 9 patients. In 7, the increase in seizures occurred at a time when antiepileptic drugs (AEDs) were being reduced during intensive EEG monitoring with a view to surgical treatment of intractable epilepsy. According to DSM-III-R criteria, the postictal psychosis resembled an organic delusional syndrome which was paranoid in 7 and schizophreniform in 1 and an organic mood syndrome in 1. A high incidence of ictal fear, of bilateral independent epileptogenic discharge, and of small foreign tissue lesion were unexpected findings and appeared to represent risk factors, especially in patients otherwise handicapped by an epileptic personality disorder. Recognition of postictal psychosis in this setting and in others is important both prognostically and therapeutically. Postictal psychosis does not constitute a contraindication to surgical treatment of epilepsy.     

Reversible Amnesia Associated with a Left Temporal Hematoma in a Case of Right Temporal Complex Partial Seizures

Summary: We report the case of a 44-year-old woman with complex partial seizures (CPS) of right frontotemporal origin who developed generalized amnesia after undergoing intracranial electrode implantation complicated by left hippocampal hemorrhage. Serial memory testing disclosed recovery from the amnesic disorder, while repeated magnetic resonance imaging (MRI) showed resolution of her left hippocampal hemorrhage in a 2-month period. A second intracarotid amytal procedure confirmed the capability of her left temporal region to support memory. Consequently, aright orbitofrontotemporal lobectomy was performed without complication.     

Intractable Complex Partial Seizures Associated with Posterior Cerebral Artery Giant Aneurysm: A Case Report

Summary: Giant aneurysms have rarely been reported in association with intractable complex partial seizures (CPS). We report a 30-year-old man with intractable CPS since age 18 years. Seizure onset was electrically localized to right temporal lobe. Preoperative neuroimaging studies showed a partially thrombosed giant aneurysm of the right posterior cerebral artery. Selective arnygdalo- hippocampectomy and occlusion of the posterior cerebral artery did not cause deficits. The patient has been seizure-free for 15 months after operation. We review the relevant literature on aneurysms as a cause of epilepsy.