Seizures, simple partial
Seizures, simple partial: Excerpt from Professional Guide to Signs & Symptoms (Fifth Edition)
Resulting from an irritable focus in the cerebral cortex, simple partial seizures typically last about 30 seconds and don’t alter the patient’s level of consciousness (LOC). The type and pattern reflect the location of the irritable focus. Simple partial seizures may be classified as motor (including both jacksonian seizures and epilepsia partialis continua) or somatosensory (including visual, olfactory, and auditory seizures).
A focal motor seizure is a series of unilateral clonic (muscle jerking) and tonic (muscle stiffening) movements of one part of the body. The patient’s head and eyes characteristically turn away from the hemispheric focus—usually the frontal lobe near the motor strip. A tonic-clonic contraction of the trunk or extremities may follow.
A jacksonian motor seizure typically begins with a tonic contraction of a finger, the corner of the mouth, or one foot. Clonic movements follow, spreading to other muscles on the same side of the body, moving up the arm or leg, and eventually involving the whole side. Alternatively, clonic movements may spread to the opposite side, becoming generalized and leading to loss of consciousness. In the postictal phase, the patient may experience paralysis (Todd’s paralysis) in the affected limbs, usually resolving within 24 hours.
Epilepsia partialis continua causes clonic twitching of one muscle group, usually in the face, arm, or leg. Twitching occurs every few seconds and persists for hours, days, or months without spreading. Spasms usually affect the distal arm and leg muscles more than the proximal ones; in the face, they affect the corner of the mouth, one or both eyelids and, occasionally, the neck or trunk muscles unilaterally.
A focal somatosensory seizure affects a localized body area on one side. Usually, this type of seizure initially causes numbness, tingling, or crawling or “electric” sensations; occasionally, it causes pain or burning sensations in the lips, fingers, or toes. A visual seizure involves sensations of darkness or of stationary or moving lights or spots, usually red at first, then blue, green, and yellow. It can affect both visual fields or the visual field on the side opposite the lesion. The irritable focus is in the occipital lobe. In contrast, the irritable focus in an auditory or olfactory seizure is in the temporal lobe. (See Body functions affected by focal seizures.)
History and physical examination
Be sure to record the patient’s seizure activity in detail; your data may be critical in locating the lesion in the brain. Does the patient turn his head and eyes? If so, to what side? Where does movement first start? Does it spread? Because a partial seizure may become generalized, you’ll need to watch closely for loss of consciousness, bilateral tonicity and clonicity, cyanosis, tongue biting, and urinary incontinence. (See “Seizures, generalized tonic-clonic,” page 708.)
After the seizure, ask the patient to describe exactly what he remembers, if anything, about the seizure. Check the patient’s LOC, and test for residual deficits (such as weakness in the involved extremity) and sensory disturbances.
Then obtain a history. Ask the patient what happened before the seizure. Can he describe an aura or did he recognize its onset? If so, how—by a smell, a visual disturbance, or a sound or visceral phenomenon, such as an unusual sensation in his stomach? How does this seizure compare with others he has had?
Explore fully any history, recent or remote, of head trauma. Check for a history of stroke or recent infection, especially with fever, headache, or a stiff neck.
Medical causes
Brain abscess
Seizures can occur in the acute stage of abscess formation or after resolution of the abscess. Decreased LOC varies from drowsiness to deep stupor. Early signs and symptoms reflect increased intracranial pressure and include a constant, intractable headache, nausea, and vomiting. Later signs and symptoms include ocular disturbances, such as nystagmus, decreased visual acuity, and unequal pupils. Other findings vary according to the abscess site and may include aphasia, hemiparesis, and personality changes.
Brain tumor
Focal seizures are commonly the earliest indicators of a brain tumor. The patient may report morning headache, dizziness, confusion, vision loss, and motor and sensory disturbances. He may also develop aphasia, generalized seizures, ataxia, decreased LOC, papilledema, vomiting, increased systolic blood pressure, and widening pulse pressure. Eventually, he may assume a decorticate posture.
Head trauma
Any head injury can cause seizures, but penetrating wounds are characteristically associated with focal seizures. The seizures usually begin 3 to 15 months after injury, decrease in frequency after several years, and eventually stop. The patient may develop generalized seizures and a decreased LOC that may progress to coma.
Multiple sclerosis
Focal or generalized seizures may occur with this disorder, usually during the late stages. Other findings include visual deficits, paresthesia, constipation, muscle weakness, spasticity, paralysis, hyperreflexia, intention tremor, gait ataxia, dysphagia, dysarthria, emotional lability, impotence, and urinary frequency, urgency, and incontinence.
Neurofibromatosis
Multiple brain lesions cause focal seizures and, at times, generalized seizures. Inspection reveals café-au-lait spots, multiple skin tumors, scoliosis, and kyphoscoliosis. Related findings include dizziness, ataxia, progressive monocular blindness, nystagmus, and endocrine abnormalities.
Sarcoidosis
Multiple lesions from this disorder affect the brain, producing focal and generalized seizures. Associated findings include a nonproductive cough with dyspnea, substernal pain, malaise, fatigue, arthralgia, myalgia, weight loss, tachypnea, dysphagia, skin lesions, and impaired vision.
Stroke
A major cause of seizures in patients older than age 50, a stroke may induce focal seizures up to 6 months after its onset. Related effects depend on the type and extent of the stroke but may include decreased LOC, contralateral hemiplegia, dysarthria, dysphagia, ataxia, unilateral sensory loss, apraxia, agnosia, and aphasia. A stroke may also cause visual deficits, memory loss, poor judgment, personality changes, emotional lability, headache, urinary incontinence or retention, and vomiting. It may result in generalized seizures.
Special considerations
No emergency care is necessary during a focal seizure, unless it progresses to a generalized seizure. (See “Seizures, generalized tonic-clonic,” page 708.) However, to ensure patient safety you should remain with the patient during the seizure, and reassure him.
Prepare the patient for such diagnostic tests as a computed tomography scan and EEG.
Pediatric pointers
Affecting more children than adults, focal seizures are likely to spread and become generalized. They typically cause the child’s eyes, or his head and eyes, to turn to the side; in neonates, they cause mouth twitching, staring, or both.
Focal seizures in children can result from hemiplegic cerebral palsy, head trauma, child abuse, arteriovenous malformation, or Sturge-Weber syndrome. About 25% of febrile seizures present as focal seizures.
Patient counseling
After the seizure, instruct the patient to record his seizures. Also, emphasize the importance of complying with the prescribed drug regimen and maintaining a safe environment.
Pictures
Book Source Details
- Book Title: Professional Guide to Signs & Symptoms (Fifth Edition)
- Author(s): Springhouse
- Year of Publication: 2006
- Copyright Details: Professional Guide to Signs & Symptoms (Fifth Edition), Copyright © 2006 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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