A 50-year-old male with a history of seizures presents to the emergency room with episodes characterized by right-sided head and gaze deviation, clonic movements, and postictal lethargy over the past week. Differential diagnoses include complex partial seizures, potential structural lesions due to his cerebral palsy, and hyperglycemia-related seizures. Investigations reveal significant findings in the left frontal lobe, suggestive of frontal lobe seizures, which often manifest with brief, clustered events and a variety of motor symptoms.

1. FRIDAY NOON CONFERENCE
Lets continue the culture……
NARESH MULLAGURI
RESIDENT PHYSICIAN PGY4
DEPARTMENT OF NEUROLOGY
UNIVERISTY OF MISSOURI

2. Chief Complaint
 Emergency Room Consultation – Evaluate the patient for possible Seizure
 50 Year old Caucasian male presented to the ER with the spells of right sided head and gaze
deviation, stretching out of the right upper extremity and flexion of the left upper extremity
with clonic movements of the right upper and lower extremities with labored breathing
lasting for almost 2 to 2 ½ minutes with no loss of consciousness, no bowel or bladder
incontinence, tongue biting.
 The spell was followed by lethargy for about 3-5min to become completely oriented with
amnesia of the event. This is his fourth episode in the past 24hrs but the first seizure started
exactly a week ago with none in the past 6 days until yesterday. For the past week, he had
been experiencing right sided pins and needles sensation in the face starting from eye brow
and marching towards the leg.
 No HA, Nausea or aura prior to the spells like Neck pain, epigastric rising sensation,
automatisms, altered smell or taste or visual phenomenon. Most seizures happened overnight
but he had one seizure in the ER when the resident was evaluating the patient.

3. History continued
 First Seizure in 2003 which is a generalized tonic clonic seizure was worked up and was
prescribed Dilatin. He was on it in the hospital but thought he was cured and stopped
taking it after discharge and remained spell free for the last 13 years. History of partial
status epilepticus at that time and was in ICU.
 He had known history of Cerebral palsy with mild right sided weakness but was on the
high functioning side in terms of cognitive abilities and independent of all the ADLs.
 He had history of right wrist extensor weakness but after the seizures he developed
wrist drop and some right lower extremity weakness.

4. ROS
 Denied any trauma, fever, chills or rigors, neck pain or stiffness, cough, SOB,
diarrhea or constipation, joint pain or swelling, double vision, loss of vision. No
recent infections, vaccinations or changes in any medications.

5. Other Pertinent histories
 PMH: HTN, IDDM, Cerebral Palsy, Seizures
 PSH: None
 FH: No significant Medical problems like Seizures, Stroke or cancer.
 SH: Lives with his wife, married for 13 years. Denied smoking, drinking or usage of
any recreational drugs in the past or currently.
 Medications: Insulin NPH, Glipizide, Lisinopril, Lovastatin, Metformin

7. HISOTORICAL DIFFERENTAL DIAGNOSIS
 Complex Partial Seizures – Frontal lobe given the Semiology of Seizure (SMA)
 Possible Etiology: Structural lesion given the h/o Cerebral Palsy, Hyperglycemia triggering partial
seizures given uncontrolled DM, Less likely infection, Autoimmune or Neoplastic causes.
 The structural lesion can be Stroke from birth injury, Neuronal migration disorder with cortical
dysplasia, vascular abnormalities like Cavernous malformations or AVF, Tumors like Meningioma or
low grade glioma,
 Vascular reasons like Cortical venous thrombosis or embolic stroke in the ACA/MCA territory given
the risk factors like HTN, DM.

8. Physical Examination
 General: Moderately obese gentleman in no distress
 Eyes: Normal conjunctiva, No pallor, Fundus showed clear disc margins
 HEENT: No tongue bite, moist, dentition is poor with no gingivitis, No tonsillar hypertrophy, no
congestion of the posterior pharyngeal wall. No typical syndromic facies.
 RS: Non labored breathing, clear to auscultation bilaterally
 CVS: RRR, S1 and S2 were heard, no murmurs, No carotid bruits, No Pedal edema or JVD
 GI: Soft with no organomegaly.
 MSK: No dislocations or tenderness over the joints, Wasting of the intrinsic hand muscles in the
right hand
 Skin: no bruises or lesions, No neurocutaneous markers like Café au lait spots, ash leaf macules, NF,
port wine stain, telangiectasia.
 Psychiatric: appropriate mood and judgement

9. Neurological Examination
 HMF: Alert, awake and oriented to name, place, person and situation. Speech is clear, naming,
fluency, repetition, comprehension is intact. Able to read the sentences presented. No extinction.
No loss of graphesthesia or astereognosis. No frontal release signs. No extinction or neglect.
 CN: Visual fields are full to confrontation, Pupils were 4mm, round, reactive to light bilaterally for
direct and consensual reflex, accommodation reflex is present. No gaze preference. EOM were
intact, Sensations were intact to light touch, temperature and in both sides of the face in all the
trigeminal distribution. No facial asymmetry, able to close the eyes tightly, able to smile
symmetrically. Soft palate is elevated normally, shoulder shrug is strong bilaterally, tongue
protrudes to midline.
 Motor: Tone is slightly decreased on the right side, Hypothenar eminence atrophy in the right
hand, decreased strength in the right hand grip 3/5, Wrist extension 2/5 with ulnar deviation, hip
flexors, extensors, knee flexors and extensors were 4+/5. Left side is 5/5 in all the muscle groups.
DTRs are 2+/4 in bilateral upper and lower extremities except for decreased right brachioradialis.
No Hoffman’s sign, Plantars were downgoing bilaterally.

10. Examination continued…
 Sensory: Intact in all the four extremities to light touch, pain, temperature and vibration. No extinction.
 Coordination: FTN is intact on the left side and HTS is intact bilaterally
 Gait: Not assessed.

11. Differential Diagnosis
 Complex partial seizure - Frontal Lobe seizure with SMA involvement– Structural lesion including
congenital malformations to tumor or new infarct. Todd’s paralysis in the Right upper extremity
 Hyperglycemia induced Complex partial Seizure.
 Vascular malformations, CVT and Embolic stroke still prevails.

12. Investigations
 WBC : 7.4
 HGB: 15.9
 PLT: 189
 Normal BMP
 Glucose – 336
 CT Head: Irregular sulcation pattern with in the Left Frontal Lobe with focal parenchymal atrophy and
scattered left frontal lobe dystrophic calcifications.

13. MRI Brain with and without contrast

14. Types of Frontal Lobe Seizures
 Supplementary Motor Area Seizures
 Cingulate Seizures
 Anterior Frontopolar seizures
 Orbitofrontal Seizures
 Dorsolateral Seizures
 Opercular Seizures
 Motor Cortex Seizures

15. General Characteristics of FLE
 Prominence of Motor manifestations – automatisms as well as tonic – clonic activity.
 Rapid secondary generalization - little or no evidence of focal onset
 Focal clonic activity with or without march
 Prominent asymmetric tonic posturing
 Complex, bizarre motor automatisms
 Explosive onset and sudden ending with minimal postictal confusion
 Frequent, brief seizures often in clusters

17.  The frontal lobe is the largest lobe and gives rise to seizures with distinctive features depending on the area of the frontal
lobe involved. Motor features are prominent and range from hypermotor thrashing attacks with pelvic thrusting and
bipedal automatisms to asymmetric tonic posturing. Frontal lobe seizures may begin with a brief aura, even when seizures
occur from sleep. Seizures are typically brief, and can have prominent vocalization, bizarre behavior, urinary incontinence,
and head and eye deviation. Frontal lobe seizures may be exclusively nocturnal and often cluster. The ictal EEG may not
show ictal patterns or may be obscured by movement artifact.

CAUTION When consciousness is impaired, frontal dyscognitive seizures can be difficult to distinguish from absence
seizures.

CAUTION Nocturnal frontal lobe seizures can be mistaken for parasomnias, however:

Frontal lobe seizures are usually brief events (< 2 minutes), with stereotyped features seen from seizure to seizure and
preserved awareness. Parasomnias are usually longer in duration (> 10 minutes), have variable features from event to event
and are characterized by a confusional state with the patient having no memory of the event afterwards.
 In parasomnias, clustering is rare and the common non-REM parasomnias typically occur 1-2 hours after falling asleep, in
the first cycle of deep slow wave sleep. Nocturnal frontal lobe seizures typically occur throughout the night, and more
frequently within half an hour of falling asleep or awakening.

CAUTION Frontal lobe seizures may be mis-diagnosed as non-epileptic seizures as there may be bilateral motor
phenomena with preserved awareness, and the ictal EEG can be normal.

19. SMA seizures
 Frequent, brief episodes occuring in clusters
 Explosive onset and offset with no post ictal confusion
 Nocturnal preponderence
 Prominent tonic posturing usually of the contralateral upper extremity
 Contraversive head and eye deviation
 Fencing or M2e posture
 Preservation of consciousness in some
 Postictal Todd’s palsy (mild)

20. Motor cortex Seizures
 Mainly simple motor seizures
 Focal motor tonic-clonic, clonic movements with or without Jacksonian march
 Localized, rhythmix or arrhythmic, clonic movements contralateral to the focus
 Distal>proximal
 Hand(thumb) and face(Lips) preferentially affected(Homunculus of penfield)
 Remains highly localized or march to neighboring motor regions
 Myoclonic Seizures: Predominantly facial or distal in the limbs
 Tonic Postural motor seizures

21. Frontal lobe CPS
 Frequent, brief seizures occurring in clusters
 Sudden onset and offset with little or no postictal confusion, Consciousness partially
retained but commonly amnestic for episodes
 Nocturnal preponderance
 Complex motor automatisms-semi purposeful motor activity often in combination
with tonic clonic motor manifestations
 Vocalization from simple humming to shouted expletives
 Prominent mood changes
 Sexual automatisms
 Overall bizarre hysterical appearance ”Pseudo voluntary nature”
 Commonly misdiagnosed as Psychogenic attacks.

23. Difference between FLE and TLE