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Diagnosing frontal lobe epilepsy in the ED
American Journal of Emergency Medicine xxx (2014) xxx–xxx
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Case Report
Diagnosing frontal lobe epilepsy in the ED
Abstract Frontal lobe seizures are a common form of epilepsy. It has a variable presentation and can often be missed in the emergency department (ED). Missing this diagnosis can lead to a delay in treatment and poor outcome for cognitive function. We hereby present a case of a 14-year-old girl who presented to our ED after the development of abnormal movements. Knowledge of the anatomy behind the development of partial seizures and the best testing modality can aid in the diagnosis. In this review, we attempt to discuss the pathophysiology of frontal lobe epilepsy and what physical examination findings and testing will best lead to a diagnosis. Seizures account for 1% of emergency department (ED) visits, with higher proportions in the pediatric ED [1]. Temporal lobe epilepsy is the most common form. Frontal lobe epilepsy is the second most common afflicting up to 30% of partial epilepsies [2,3]. The etiology of frontal lobe seizures is not entirely clear. Some causes include trauma, tumors, vascular malformations, encephalitis, cortical dysplasia, and idiopathic syndromes [3]. Untreated seizures can cause problems with existing cognitive function including linguistic performance, memory, behavior, and motor coordination [3]. The frontal lobe itself plays an important role in motor function, executive function, eye movements and speech, and linguistic abilities [4]. Frontal lobe epilepsy has a variable presentation [5]. Seizures are generally brief, stereotypic, nocturnal, and frequent [6]. When it affects the motor cortex, it typically shows contralateral clonic movement as well as complex automatism [7]. This diagnosis is frequently missed and often gets classified as psychiatric in origin given a variety of presentations and bizarre behavior. A 14-year old girl presented to the ED with a chief complaint of “twitching” in her right eye and right hand. She reports having intermittent episodes of these movements for the last 2 days, but on the day of presentation, the movements have been sustained. She presented with rhythmic clonic movements in her right eyebrow and right index finger. She was unable to suppress the movement. Otherwise, her physical examination was normal. Initial electroencephalogram (EEG) was not suggestive of seizures. Magnetic resonance imaging (MRI) with contrast revealed a focus of cortical restricted diffusion in the high left central sulcus. She was admitted to the hospital. Stroke workup with echocardiogram, magnetic resonance angiography head and neck, and magnetic resonance venography were negative. The abnormality seen on MRI was thought to be related to focal status epilepticus (see Fig. 1). After a 10-day inpatient stay and multiple antiepileptic regimes, her seizures ceased, and she was discharged home. Frontal lobe epilepsy is second next to temporal lobe epilepsy in prevalence. Other forms of neocortical epilepsy are less common.
Occipital lobe epilepsy tends to present with visual disturbances, whereas parietal lobe epilepsy lacks a distinguishing clinical syndrome but can have localizing somatosensory symptoms. [8,9] Crucially, with such a variable presentation, neocortical epilepsy can be misdiagnosed for psychogenic nonepileptic seizures, sleep disturbances, or motor tics. One of the challenges in diagnosing frontal lobe epilepsy is that it may not reveal itself on EEG. [3,5,7] Magnetic resonance imaging can be a useful diagnostic tool. Most patients will have a normal MRI, but it is one of the more sensitive modalities for diagnosing frontal lobe epilepsy [10]. In addition, it is the only diagnostic tool that has been shown to predict surgical outcome [10]. However, one must have a high suspicion based on the physical examination before pursing further workup. Knowledge of the homunculus can help clue providers that patients presenting with “tics” may actually be having partial seizures, particularly those affecting the primary motor cortex. The motor homunculus is a distorted model of the human body to represent the relative space each body part controls along the motor cortex (see Fig. 2). For example, areas with fine motor movements such as the hands and face have more neurons dedicated to them as compared with the
Fig. 1. Magnetic resonance imaging demonstrates a small area of restricted diffusion in the left frontal lobe, which appears to be in the primary motor cortex.
0735-6757/© 2014 Elsevier Inc. All rights reserved.
Please cite this article as: Phillips L, Walsh M, Diagnosing frontal lobe epilepsy in the ED, Am J Emerg Med (2014), http://dx.doi.org/10.1016/ j.ajem.2014.03.025
2
L. Phillips, M. Walsh
/ American Journal of Emergency Medicine xxx (2014) xxx–xxx
types of antiepileptic drug schedules. However, she was eventually able to become seizure free with optimal drug therapy. In our patient, frontal lobe epilepsy was strongly suspected based on her clinical presentation. Knowledge of the manifestations of neocortical seizures can help aid in diagnostic workup and appropriate evaluation by neurology consultants. Missing such a diagnosis can lead to delays in treatment and existing cognitive performance. This can have a significant impact on the patient’s social interactions, scholastic activity, and overall quality of life. Appendix. Supplementary data Supplementary data to this article can be found online at http://dx. doi.org/10.1016/j.ajem.2014.03.025. Lara Phillips MD Michele Walsh MD Vanderbilt University Medical Center, Nashville, TN E-mail address: [email protected] http://dx.doi.org/10.1016/j.ajem.2014.03.025 References Fig. 2. The motor homunculus is a distorted representation of the human body parts, which correlate to the areas of the primary motor cortex, which controls them.
parts of the brain that correspond to areas such as the torso, which do not control as precise movements. Partial seizures involving the primary motor cortex, like our patient, will produce contralateral hemiclonic activity [7]. This may help lead providers to pursue a further workup. The diffusion abnormality on the MRI in this case demonstrated a small area of restricted diffusion in left frontal lobe. This was anatomically consistent with her symptoms on the right side mapped out onto the left brow and finger on the homunculus primary motor cortex. Frontal lobe epilepsy is unfortunately complicated by pharmacotherapy resistance and may require epilepsy surgery [3]. Some studies suggest that poor seizure control can lead to developmental regression, although this is controversial [3]. Our case exhibited a patient who had drug-resistant frontal lobe epilepsy as she had been tried on more than 2
[1] Pallin DJ, Goldstein JN, Moussally JS, Pelletier AJ, Green AR, Camargo Jr CA. Seizure visits in US emergency departments: epidemiology and potential disparities in care. Int J Emerg Med 2008;1:97–105. [2] Manford M, Hart YM, Sander JW, Shorvon SD. National General Practice Study of Epilepsy (NGPSE): partial seizure patterns in a general population. Neurology 1992;42:1911–7. [3] Braakman HM, Vaessen MJ, Hofman PA, et al. Cognitive and behavioral complications of frontal lobe epilepsy in children: a review of the literature. Epilepsia 2011;52:849–56. [4] Cummings JL, Miller BL. The human frontal lobes: functions and disorders (the science and practice of neuropsychology). In: Bruse LMM, Cummings JL, editors. Conceptual and clinical aspects of the frontal lobes. 2nd ed. New York: The Guilford Press; 2007. p. 2125–9. [5] Jobst BC, Williamson PD. Frontal lobe seizures. Psychiatr Clin North Am 2005;28 (635–51):48–9. [6] Sinclair DB, Wheatley M, Snyder T. Frontal lobe epilepsy in childhood. Pediatr Neurol 2004;30:169–76. [7] Kellinghaus C, Luders HO. Frontal lobe epilepsy. Epileptic Disord 2004;6:223–39. [8] Blume WT, Whiting SE, Girvin JP. Epilepsy surgery in the posterior cortex. Ann Neurol 1991;29:638–45. [9] Salanova V. Parietal lobe epilepsy. J Clin Neurophysiol 2012;29:392–6. [10] Lee JJ, Lee SK, Lee SY, et al. Frontal lobe epilepsy: clinical characteristics, surgical outcomes and diagnostic modalities. Seizure 2008;17:514–23.
Please cite this article as: Phillips L, Walsh M, Diagnosing frontal lobe epilepsy in the ED, Am J Emerg Med (2014), http://dx.doi.org/10.1016/ j.ajem.2014.03.025
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Case Report
Diagnosing frontal lobe epilepsy in the ED
Abstract Frontal lobe seizures are a common form of epilepsy. It has a variable presentation and can often be missed in the emergency department (ED). Missing this diagnosis can lead to a delay in treatment and poor outcome for cognitive function. We hereby present a case of a 14-year-old girl who presented to our ED after the development of abnormal movements. Knowledge of the anatomy behind the development of partial seizures and the best testing modality can aid in the diagnosis. In this review, we attempt to discuss the pathophysiology of frontal lobe epilepsy and what physical examination findings and testing will best lead to a diagnosis. Seizures account for 1% of emergency department (ED) visits, with higher proportions in the pediatric ED [1]. Temporal lobe epilepsy is the most common form. Frontal lobe epilepsy is the second most common afflicting up to 30% of partial epilepsies [2,3]. The etiology of frontal lobe seizures is not entirely clear. Some causes include trauma, tumors, vascular malformations, encephalitis, cortical dysplasia, and idiopathic syndromes [3]. Untreated seizures can cause problems with existing cognitive function including linguistic performance, memory, behavior, and motor coordination [3]. The frontal lobe itself plays an important role in motor function, executive function, eye movements and speech, and linguistic abilities [4]. Frontal lobe epilepsy has a variable presentation [5]. Seizures are generally brief, stereotypic, nocturnal, and frequent [6]. When it affects the motor cortex, it typically shows contralateral clonic movement as well as complex automatism [7]. This diagnosis is frequently missed and often gets classified as psychiatric in origin given a variety of presentations and bizarre behavior. A 14-year old girl presented to the ED with a chief complaint of “twitching” in her right eye and right hand. She reports having intermittent episodes of these movements for the last 2 days, but on the day of presentation, the movements have been sustained. She presented with rhythmic clonic movements in her right eyebrow and right index finger. She was unable to suppress the movement. Otherwise, her physical examination was normal. Initial electroencephalogram (EEG) was not suggestive of seizures. Magnetic resonance imaging (MRI) with contrast revealed a focus of cortical restricted diffusion in the high left central sulcus. She was admitted to the hospital. Stroke workup with echocardiogram, magnetic resonance angiography head and neck, and magnetic resonance venography were negative. The abnormality seen on MRI was thought to be related to focal status epilepticus (see Fig. 1). After a 10-day inpatient stay and multiple antiepileptic regimes, her seizures ceased, and she was discharged home. Frontal lobe epilepsy is second next to temporal lobe epilepsy in prevalence. Other forms of neocortical epilepsy are less common.
Occipital lobe epilepsy tends to present with visual disturbances, whereas parietal lobe epilepsy lacks a distinguishing clinical syndrome but can have localizing somatosensory symptoms. [8,9] Crucially, with such a variable presentation, neocortical epilepsy can be misdiagnosed for psychogenic nonepileptic seizures, sleep disturbances, or motor tics. One of the challenges in diagnosing frontal lobe epilepsy is that it may not reveal itself on EEG. [3,5,7] Magnetic resonance imaging can be a useful diagnostic tool. Most patients will have a normal MRI, but it is one of the more sensitive modalities for diagnosing frontal lobe epilepsy [10]. In addition, it is the only diagnostic tool that has been shown to predict surgical outcome [10]. However, one must have a high suspicion based on the physical examination before pursing further workup. Knowledge of the homunculus can help clue providers that patients presenting with “tics” may actually be having partial seizures, particularly those affecting the primary motor cortex. The motor homunculus is a distorted model of the human body to represent the relative space each body part controls along the motor cortex (see Fig. 2). For example, areas with fine motor movements such as the hands and face have more neurons dedicated to them as compared with the
Fig. 1. Magnetic resonance imaging demonstrates a small area of restricted diffusion in the left frontal lobe, which appears to be in the primary motor cortex.
0735-6757/© 2014 Elsevier Inc. All rights reserved.
Please cite this article as: Phillips L, Walsh M, Diagnosing frontal lobe epilepsy in the ED, Am J Emerg Med (2014), http://dx.doi.org/10.1016/ j.ajem.2014.03.025
2
L. Phillips, M. Walsh
/ American Journal of Emergency Medicine xxx (2014) xxx–xxx
types of antiepileptic drug schedules. However, she was eventually able to become seizure free with optimal drug therapy. In our patient, frontal lobe epilepsy was strongly suspected based on her clinical presentation. Knowledge of the manifestations of neocortical seizures can help aid in diagnostic workup and appropriate evaluation by neurology consultants. Missing such a diagnosis can lead to delays in treatment and existing cognitive performance. This can have a significant impact on the patient’s social interactions, scholastic activity, and overall quality of life. Appendix. Supplementary data Supplementary data to this article can be found online at http://dx. doi.org/10.1016/j.ajem.2014.03.025. Lara Phillips MD Michele Walsh MD Vanderbilt University Medical Center, Nashville, TN E-mail address: [email protected] http://dx.doi.org/10.1016/j.ajem.2014.03.025 References Fig. 2. The motor homunculus is a distorted representation of the human body parts, which correlate to the areas of the primary motor cortex, which controls them.
parts of the brain that correspond to areas such as the torso, which do not control as precise movements. Partial seizures involving the primary motor cortex, like our patient, will produce contralateral hemiclonic activity [7]. This may help lead providers to pursue a further workup. The diffusion abnormality on the MRI in this case demonstrated a small area of restricted diffusion in left frontal lobe. This was anatomically consistent with her symptoms on the right side mapped out onto the left brow and finger on the homunculus primary motor cortex. Frontal lobe epilepsy is unfortunately complicated by pharmacotherapy resistance and may require epilepsy surgery [3]. Some studies suggest that poor seizure control can lead to developmental regression, although this is controversial [3]. Our case exhibited a patient who had drug-resistant frontal lobe epilepsy as she had been tried on more than 2
[1] Pallin DJ, Goldstein JN, Moussally JS, Pelletier AJ, Green AR, Camargo Jr CA. Seizure visits in US emergency departments: epidemiology and potential disparities in care. Int J Emerg Med 2008;1:97–105. [2] Manford M, Hart YM, Sander JW, Shorvon SD. National General Practice Study of Epilepsy (NGPSE): partial seizure patterns in a general population. Neurology 1992;42:1911–7. [3] Braakman HM, Vaessen MJ, Hofman PA, et al. Cognitive and behavioral complications of frontal lobe epilepsy in children: a review of the literature. Epilepsia 2011;52:849–56. [4] Cummings JL, Miller BL. The human frontal lobes: functions and disorders (the science and practice of neuropsychology). In: Bruse LMM, Cummings JL, editors. Conceptual and clinical aspects of the frontal lobes. 2nd ed. New York: The Guilford Press; 2007. p. 2125–9. [5] Jobst BC, Williamson PD. Frontal lobe seizures. Psychiatr Clin North Am 2005;28 (635–51):48–9. [6] Sinclair DB, Wheatley M, Snyder T. Frontal lobe epilepsy in childhood. Pediatr Neurol 2004;30:169–76. [7] Kellinghaus C, Luders HO. Frontal lobe epilepsy. Epileptic Disord 2004;6:223–39. [8] Blume WT, Whiting SE, Girvin JP. Epilepsy surgery in the posterior cortex. Ann Neurol 1991;29:638–45. [9] Salanova V. Parietal lobe epilepsy. J Clin Neurophysiol 2012;29:392–6. [10] Lee JJ, Lee SK, Lee SY, et al. Frontal lobe epilepsy: clinical characteristics, surgical outcomes and diagnostic modalities. Seizure 2008;17:514–23.
Please cite this article as: Phillips L, Walsh M, Diagnosing frontal lobe epilepsy in the ED, Am J Emerg Med (2014), http://dx.doi.org/10.1016/ j.ajem.2014.03.025