Partial complex epilepsy is characterized by focal seizures that impair consciousness. It is most commonly caused by temporal lobe epilepsy but can arise from other brain regions. Diagnosis involves obtaining a detailed history, physical exam, EEG, and MRI brain imaging. Treatment includes antiepileptic medications and potentially surgery for drug-resistant cases. Surgical options include temporal lobectomy for temporal lobe epilepsy, which can cure seizures in over 50% of carefully selected patients. Prognosis depends on seizure frequency and underlying etiology.

1. Partial complex
epilepsy
DR MOHAMMAD A.S KAMIL
COSULTANT NEUROLOGIST

2. Background
O A complex partial seizure starts focally within the
brain and causes impairment of consciousness.
O This definition is based on both clinical and
electroencephalographic (EEG) data.
O A complex partial seizure is most commonly a
manifestation of temporal lobe epilepsy, but the term
is so broadly defined (ie, as any focal seizure with
impairment of consciousness) that it is very
nonspecific.
O For this reason, many clinicians make a point of
distinguishing between temporal and extratemporal
complex partial seizures.

3. Pathophysiology
O Single-photon emission computed tomography
(SPECT) ictal studies show hypoperfusion of the
bilateral frontal and parietal association cortex and
hyperperfusion of the mediodorsal thalamus and
rostral brainstem.
O Ictal effects on these structures resulting from the
spread of epileptic discharges or a transsynaptic
mechanism may mediate impaired consciousness
during complex partial seizures.
O Pathologic studies suggest focal changes that
include neuronal loss, reorganization, neurogenesis,
and altered neurotransmitter receptors.

4. Etiology
O Hippocampal sclerosis (mesial temporal lobe)
O Neoplasms
O Cortical malformations
O Vascular malformations
O stroke
O Central nervous system (CNS) infections
O Immune-mediated CNS inflammation
O Hypoxic-ischemic brain injury
O Head trauma
O Inheritable conditions
O Febrile seizures, especially complex, are associated with an
increased risk of later development of complex partial seizures
and epilepsy.

5. Epidemiology
O The prevalence of epilepsy is approximately
0.5-1 case per 100 persons.
O Complex partial seizures occur in about
35% of persons with epilepsy.
O The incidence of partial seizures in people
younger than 60 years is 20 cases per
100,000 person-years.
O This figure rises to 80 cases per 100,000
person-years in people aged 60-80 years.

6. Prognosis
O The mortality rate in individuals with epilepsy is 2-3
times that in the general population.
O Most deaths are due to the underlying cause (ie,
epilepsy) with the remainder due to accidents,
sudden unexpected death in epilepsy (SUDEP), and
suicides. SUDEP has no apparent cause.
O It occurs in 1 in 2500 persons with mild epilepsy and
1 in 250 persons with severe epilepsy.
O SUDEP is most common among those with frequent
or medically intractable seizures.
O Individuals with epilepsy are at increased risk for
trauma, burns, and aspiration.

7. History
O direct observation or from video recordings , but this is
relatively rare because most patients with epilepsy never have
video recordings.
O Thus, in most situations, symptom assessment is based on
history alone.
O For this reason, a purely semiologic classification has been
proposed and is in use at some centers.
O In this system, seizure types include autonomic, dialeptic,
simple motor (clonic, tonic, tonic-clonic, epileptic spasm,
myoclonic, versive), complex motor (automotor, hypermotor,
gelastic), and negative (aphasic, astatic, atonic, akinetic,
hypomotor, negative myoclonic).
O A thorough history should be obtained from the patient, the
family members, and any relevant witnesses.

8. Aura
O An aura is a subjective sensation and is a simple partial
seizure (ie, the initial part during which the patient is aware).
O Typically, it is of brief duration, rarely lasting longer than
seconds.
O Determining the type of aura present is critical for identifying
the site of cortical onset.
O Eight different varieties are recognized: somatosensory,
visual, auditory, gustatory, olfactory, autonomic, abdominal,
and psychic.
O Auras precede temporal lobe seizures in approximately 80% of
cases.
O The most common auras in temporal lobe seizures are
abdominal (a rising epigastric sensation) and psychic aura
(fear, déjà vu, jamais vu).
O Temporal-parietal-occipital seizures may produce more formed
auras.

9. Impaired consciousness
O Usually, during a complex partial seizure, a patient is unresponsive and
does not remember events that occurred.
O Consciousness may not be impaired completely.
O Although patients typically do not respond to external stimuli, they may
make simple verbal responses, follow simple commands, or continue
to perform simple or, less commonly, complex motor behaviors (eg,
operating a car).
O Impairments in consciousness should be contrasted with psychic
automatisms, in which the patient experiences intense feelings of
strangeness.
O Complex partial seizures are roughly equivalent to what used to be
known as psychomotor seizures.
O In the semiologic classification, they are equivalent to automotor
seizures (automatisms), whereas seizures with alteration of
consciousness without motor phenomena are known as dialeptic
seizures.

10. Automatisms
O Automatisms are nonpurposeful, stereotyped, and repetitive behaviors
that commonly accompany complex partial seizures (in the semiologic
classification, they define automotor seizures).
O The behavior is inappropriate for the situation.
O Verbal automatisms range from simple vocalizations, such as
moaning, to more complex, comprehensible, stereotyped speech.
O The most common automatisms, at least in temporal lobe epilepsy, are
oral (eg, lip smacking, chewing, swallowing) and manual (eg, picking,
fumbling, patting]).
O Unilateral manual automatisms accompanied by contralateral arm
dystonia usually indicates seizure onset from the cerebral hemisphere
ipsilateral to the manual automatisms.
O Automatisms can also be more elaborate, coordinated movements
involving bilateral extremities.
O Bizarre automatisms, such as alternating limb movements, right-to-left
head rolling, or sexual automatisms, may occur with frontal lobe
seizures.

11. O Oroalimentary Lip smacking, tongue
movements,chewing, swallowing, teeth grinding
O Mimetic Acting out the patient’s emotional state
O Manual or pedal Fumbling, tapping, grasping
movements
O Gestural Movement, often in response to external stimuli
O Ambulatory Wandering, walking, running

12. O Vocal Single or repetitive utterances, not words
O Verbal Single or repetitive utterances,
words, or sentences
O Hypokinetic Behavioral arrest, motionless
limbs
O Hyperkinetic Large-amplitude movements
of proximal limbs or trunk, such as pedaling,
thrashing, rocking, or pelvic thrusting
O Gelastic Bursts of laughter without mirth
O Dacrystic Bursts of crying without sadness

13. Temporal versus
extratemporal seizures
O Complex partial seizures can arise from any location but
most commonly arise from the temporal lobe (60%).
O Temporal lobe seizures have highly specific behaviors as
compared with extratemporal seizures.
O Complex partial seizures of temporal lobe origin often
begin with a motionless stare followed by oral or manual
automatisms.
O Frontal lobe seizures often begin with vigorous motor
automatisms or stereotyped clonic or tonic activity.
O Extratemporal lobe seizures may spread quickly to the
frontal lobe and produce motor behaviors similar to
those associated with complex partial seizures of the
frontal lobe.

14. Features of Focal Seizures by
Region of Onset
Temporal Lobe Seizures
Mesial Temporal
O Aura (often epigastric, psychic, affective, olfactory)
O Impaired consciousness
O Fixed stare, widened palpebral fissures
O Early oroalimentary automatisms
O Limb automatisms (ipsilateral to seizure focus)
O Dystonic posturing or clonus (contralateral to seizure focus)
O Postictal confusion and amnesia
Lateral Temporal
O Aura (often auditory hallucinations, complex perceptual or experiential
hallucinations, language dysfunction)
O Late oroalimentary automatisms
O Late manifestations may be indistinguishable from mesial temporal

15. Frontal Lobe Seizures
O Brief seizures, often in clusters
O Little or no postictal confusion
O Rapid secondary generalization
O Prominent motor manifestations (clonic, tonic,
postural)
O Hyperkinetic complex or bizarre automatisms
O Sexual automatisms
O Frequent falls
O Nocturnal predominance
O Status epilepticus

16. Occipital Lobe Seizures
O Elementary visual hallucinations
O Loss of vision
O Sensation of eye movement
O Contralateral or ipsilateral deviation of the eyes
O Forced blinking
O Variable spread to:
Parietal lobe (sensory symptoms)
Temporo-occipital regions (formed visual
hallucinations)
Mesial temporal region

17. Parietal Lobe Seizures
O Somatosensory auras
O Receptive language disturbance (dominant
hemisphere)
O Neglect (nondominant hemisphere)
O Variable spread to:
Occipital lobe (visual hallucinations)
Mesial temporal region
Precentral regions (motor)

18. Physical Examination
O The physical examination is directed so as to
elucidate focal cortical neurologic findings,
such as aphasia, unilateral neglect, apraxia,
or unilateral signs.
O In the vast majority of patients with focal
epilepsies and complex partial seizures, the
neurologic examination yields normal
results.

19. Differentials
O Absence Seizures
O Aphasia
O Apraxia and Related Syndromes
O Benign Childhood Epilepsy
O Benign Neonatal Convulsions
O Confusional States and Acute Memory Disorders
O Epilepsia Partialis Continua
O Epilepsy, Juvenile Myoclonic
O Epileptic and Epileptiform Encephalopathies
O Parasomnias
O Psychogenic Nonepileptic Seizures

20. Approach Considerations
O Laboratory studies aim to rule out potential
causes or triggers for seizures.
O Routine workup for all patients should
include electroencephalography (EEG) and
magnetic resonance imaging (MRI) of the
brain; most of the time, the results will be
normal.

21. Lab Studies
O Electrolyte levels, including sodium,
potassium, magnesium, and calcium
concentrations, should be assessed.
O If antiepileptic drugs are being used, drug
concentrations should be obtained.
Consider a urine drug screen.

22. Magnetic Resonance
Imaging of Brain
O The purpose of the initial brain MRI is to exclude an obvious
structural lesion as the cause.
O The procedure should include contrast with gadolinium to allow
assessment of possible neoplastic and vascular etiologies.
O More subtle etiologies, such as mesial temporal sclerosis
(MTS) and cortical dysplasia, only become important if the
seizures prove intractable and surgery is considered.
O MRI with temporal cuts gives attention to hippocampal volumes
in assessment for temporal lobe epilepsy.
O Hippocampal atrophy predominates as seizures are
maintained throughout the life of a patient with temporal lobe
epilepsy.
O Subtle cortical changes due to cortical dysplasia are often
overlooked.

23. Increased signal on fluid-attenuation inversion
recovery (FLAIR) T2-weighted MRI can detect
sclerosis of the mesial temporal lobe in 80-90% of
cases

24. MRI shows right temporal lobe cavernous
hemangioma in a patient being considered
for epilepsy surgery

25. Electroencephalography
O EEG within 24 hours is more sensitive for diagnosing
epileptiform abnormalities than later EEG is (51%
sensitivity vs 34%), but it is often impractical.
O When epileptiform discharges are present, they help
localize the seizure focus .
O A negative interictal EEG does not exclude a
diagnosis of epilepsy.
O If the waking EEG is negative, a sleep-deprived EEG
may demonstrate epileptiform abnormalities

26. Lumbar Puncture
O may be indicated for a patient with new-
onset seizure when an acute inflammatory
or infectious process is being considered.
O However, it is not indicated in patients with
chronic epilepsy.

27. Anticonvulsant Therapy
O treatment with antiepileptic medication
should always be initiated once a diagnosis
of epilepsy is made.
O All current antiepileptic drugs (AEDs), with
the exception of ethosuximide, can be used
in the treatment of complex partial seizures.
O Monotherapy is always initially preferred
over polytherapy for treating seizures.

28. Surgical Treatment of
Epilepsy
O is indicated for patients who have frequent, disabling
seizures despite adequate trials of 2 or more
anticonvulsants.
O Two recent studies reported slightly better results: after
treatment with multiple AEDS, 11%6 and 16%7 became
seizure free. It is interesting that 52% of patients treated
surgically in one of these studies became seizure free.
O ‘‘New’’ AEDs do not appear to be more effective than
older drugs.
O Surgical procedures include temporal lobectomy,
extratemporal resections, corpus callosotomy,
placement of a vagus nerve stimulator,
hemispherectomy, and multiple subpial transection.

29. O The hallmark pathology of medial temporal lobe
epilepsy (TLE) ismesial temporal sclerosis (MTS),
found in approximately 65% of patients with
intractable partial epilepsy.
O Surgically excised hippocampus in these
patients almost invariably shows focal cell loss
and gliosis.
O An anterior temporal lobectomy is the most
common operative procedure for intractable
partial epilepsy.
O Although higher figures are cited routinely, in
the only controlled study, 58% of surgically
compared with 8% of medically treated patients
were free of disabling seizures at 1 year.

30. O Favorable prognostic indicators include an early
age of seizure onset, medial temporal lobe
seizure onset, and pathologically identified MTS
or foreign-tissue lesion
O In one series, approximately 90% of patients with
concordant MRI-identified hippocampal atrophy
and interictal temporal epileptiform discharges
had an excellent operative outcome.
O The outcome of surgical treatment in non
lesional TLE is less favorable.

31. O Bell and colleagues assessed the seizure
outcome of 40 patients who underwent an
anterior temporal lobectomy with a normal MRI
head study,
O Twenty-four of 40 patients were seizure free
after surgery.
O Patients with normal left hippocampal volumes
preoperatively may also be of greater risk for the
development of memory problems after surgery.

32. Thank you
Neuroscinces hospital