Awareness
- “Knowledge of self or environment” and assessment depends on “the ability of the person having the seizure to later verify retained awareness” based on “whether awareness for events occurring during the seizure was retained or impaired”.
- The postictal recall is also affected by the ictal involvement of language and memory, not only awareness per se
- Patient awareness about the occurrence of a seizure is another completely different attribute, which might be clinically relevant for planning diagnostic and management strategies
- Impaired awareness (inability of the person having the seizure to later verify retained awareness) occurs in generalized or bilateral tonic-clonic seizures with uncommon exceptions
- Most absence seizures cause impaired awareness
- However, in some cases during bursts of generalized spike-wave discharges, the patient does not follow commands and is unable to repeat the test words (impaired responsiveness), yet after the spike-wave bursts terminate, the patient is able to recall the commands and test words given during the seizure, demonstrating retained awareness during the electroclinical absence seizure (non-responsive patient with ictal EEG correlate)
- Temporal lobe epilepsies
- Impaired awareness may be more common in dominant hemispheric onset
- In most of the temporal lobe epilepsies, the awareness becomes impaired when the seizure involves neocortical and subcortical structures
Clinical features
Focus | Typical Description |
Supplementary sensorimotor area | Bilateral tonic or dystonic postures that are usually asymmetric. Despite vocalization or speech arrest, consciousness is preserved. The typically described fencing posture is rarely seen. |
Orbitofrontal | Staring, alteration of consciousness, olfactory hallucinations and oral and upper extremity automatisms and autonomic signs. Difficult to distinguish from TLE. |
Frontopolar seizures | Near-onset head version with associated loss of consciousness. |
Dorsolateral frontal | Can start with an unspecific aura of cephalic sensation or fear. This is followed by head and eye version and contralateral tonic and clonic activity. If Broca's area is involved, speech arrest or postictal aphasia may be observed. |
Fronto-parietal operculum | Rolandic seizures are characterized by facial (mouth and tongue) clonic movements (which may be unilateral), laryngeal symptoms, articulation difficulty, swallowing or chewing movements and hypersalivation. Sensory (e.g. epigastric) and experiential (e.g. fear) aura and autonomic (urogenital, gastrointestinal, cardiovascular or respiratory) features are common. Gustatory hallucinations are particularly common. |
Cingulate gyrus | Usually involve loss of awareness, oral and upper extremity automatism, behavioral alterations, and autonomic manifestations that include tachycardia and tachypnea. In addition, absence-like events are observed with mesial structure foci. |
Motor cortex seizures | Produce tonic or clonic activity of the contralateral face, arm, or leg depending on the area of origin. Jacksonian march (distal limb to ipsilateral face) is not uncommon especially with involvement of the motor extremity. A postictal Todd's paralysis is occasionally seen. |
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