temporal lobe (psychomotor) epilepsy
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Etiology
* also see differential diagnosis (below)
Epidemiology
- most common form of adult-onset focal epilepsy
Pathology
- medial temporal sclerosis*
- atrophy of hippocampus*
* associated with anticonvulsant resistance
Clinical manifestations
- aura consisting of
- poorly described visceral sensation*
- nausea, taste or smell sensations
- sudden panic, fear & anxiety
- deja vu sensation
- palpitations
- complex visual hallucinations[5]
- no visual field disturbance (scintillating scotoma)
- poorly described visceral sensation*
- generally presents with complex partial seizures
- nocturnal complex partial seizures common
- chaotic movements may awaken patients from sleep
- stereotyped complex behavioral manifestations
- may be momentary inactivity
- lip smacking, chewing, staring, hand fumbling may occur
- ref[2] describes patient as fidgety
- repetitive vocalizations may occur'
- automatisms may occur (semipurposeful automatic movements)
- brief episodes of anxiety +/- autonomic symptoms (xerostomia)
- duration of episodes is 15-60 seconds, 30-120 seconds[1]
- loss of awareness, loss of consciousness
- amnesia, may not remember episodes[1]
- post-ictal confusion is generally short
*[2] describes this as a rising epigastric aura in its analysis of a patient that describes a 'roller coaster' sensation in her stomach
Diagnostic procedures
- electroencephalogram (EEG)
- a normal EEG does not rule out a seizure disorder
- especially so of seizures originating in the medial temporal lobe
- nasopharyngeal recordings or sleep studies may be helpful
- a normal EEG does not rule out a seizure disorder
- videoelectroencephalography
- prerequisite for temporal lobe resection
- confirm seizures seen on video EEG match abnormal findings on MRI neuroimaging
Radiology
- magnetic resonance imaging (MRI)
- increased hippocampal intensity on T2-weighted images
- atrophy of hippocampus on T1-weighted images
- hippocampal volumetry
- unilateral hippocampal atrophy correlates well with EEG signal lateralization; may be good predictor of response to hippocampal resection
- mesial temporal sclerosis (neuronal loss & gliosis)
Differential diagnosis
- panic disorder is without stereotyped features, duration of episodes is 30-90 minutes vs 15-60 seconds
- limbic encephalitis (Herpes encephalitis)
- rapid onset of fever, headache, confusion, focal neurologic signs
- no aura, does not occur in episodes of short duration
- panic attacks generall last several minutes to 1 hour
- tardive dyskinesia: no aura, loss of consiousness, post-ictal state
Management
- anticonvulsant therapy
- use anticonvulsant indicated for partial seizures
- surgical resection of part of a temporal lobe[2][3]
- improved chance of becoming seizure-free
- complications
- infarcts
- wound infections
- decline in verbal memory
- sleep management
- donepezil 10 mg QAM improves slow-wave-sleep & memory scores vs zolpidem 6.25 mg QHS in patients with insomnia & refractory temporal lobe epilepsy[6]
More general terms
More specific terms
Additional terms
References
- ↑ 1.0 1.1 1.2 Medical Knowledge Self Assessment Program (MKSAP) 11, 16, 17, 18, 19. American College of Physicians, Philadelphia 1998, 2012, 2015, 2018, 2021.
Medical Knowledge Self Assessment Program (MKSAP) 19 Board Basics. An Enhancement to MKSAP19. American College of Physicians, Philadelphia 2022 - ↑ 2.0 2.1 2.2 2.3 Journal Watch 21(17): 142, 2001 Wiebe S et al A randomized, controlled trial of surgery for temporal-lobe epilepsy. N Engl J Med 345:311, 2001 PMID: https://www.ncbi.nlm.nih.gov/pubmed/11484687
- ↑ 3.0 3.1 Hurley RA, Fisher R, Taber KH. Sudden onset panic: epileptic aura or panic disorder? J Neuropsychiatry Clin Neurosci. 2006 Fall;18(4):436-43. PMID: https://www.ncbi.nlm.nih.gov/pubmed/17135371
- ↑ Jette N, Quan H, Tellez-Zenteno JF et al Development of an online tool to determine appropriateness for an epilepsy surgery evaluation. Neurology. 2012 Sep 11;79(11):1084-93. Epub 2012 Aug 15. PMID: https://www.ncbi.nlm.nih.gov/pubmed/22895589
- ↑ 5.0 5.1 Geriatric Review Syllabus, 9th edition (GRS9) Medinal-Walpole A, Pacala JT, Porter JF (eds) American Geriatrics Society, 2016
- ↑ 6.0 6.1 Anderson P Improving Sleep Boosts Cognition in Refractory Temporal Lobe Epilepsy. Medscape. December 05, 2022 https://www.medscape.com/viewarticle/985015