Focal seizures

Case history #1

An 18-year-old girl presents with several episodes of confusion over the past several months. Typically, she experiences a warning signal, which she describes as a rising sensation within her abdomen that travels upward through her chest. She is usually unaware for a few minutes, but others have told her that during these episodes she smacks her lips, picks at her clothing, and is unable to speak. After the event, she feels tired, has a headache, and prefers to lie down. She notes that her memory has not been as good as it was in the past, and her school grades have declined. Her medical history is notable for several febrile seizures as a young child, although she was not treated for seizures at that time. An aunt was diagnosed with seizures many years ago.

Case history #2

A 70-year-old man presents with a tonic-clonic seizure. His wife states that during the past month there have been times when he does not respond when spoken to, mumbles words that do not make sense, and stares in a motionless way. After several minutes, he is usually responsive. His past medical history includes hypertension and hypercholesterolemia. He had a stroke during the preceding year, which resulted in weakness of the right extremities and loss of expressive language. Although he recovered most motor and language deficits, he still walks with a limp on the right side and sometimes uses the wrong word.

Other presentations

Patients may present complaining of features consistent with auras, such as memory-related phenomena (déjà vu, jamais vu), emotional changes (fear, panic, anxiety), autonomic changes (flushing, pallor, sweating, piloerection, warmth, coolness), visual distortions (changes in depth perception, shapes, or colors) or hallucinations (seeing formed and unformed shapes, objects, or people), auditory hallucinations (ringing sensations, tunes), or gustatory or olfactory changes. These symptoms may or may not be followed by alteration of awareness.

An alternative presentation is repeated focal impaired awareness seizures without recovery between them. These may or may not evolve to bilateral tonic-clonic seizures, and can present as behavioral changes only, which can be interpreted as a confused state. This constitutes status epilepticus (please refer to our topic "Status epilepticus").