Answer
C: Focal seizures
Educational Objective
Diagnose focal seizures.
Critique
The patient is experiencing focal seizures with altered awareness (formerly known as complex partial seizures or focal dyscognitive seizures). These seizures typically are infrequent, are associated with “warning” symptoms (aura, which may consist of an epigastric rising sensation or a feeling of déjà vu), last more than 30 seconds, have associated mouth or limb automatisms (semipurposeful repetitive movements), and are followed by confusion and/or exhaustion. Patients who experience this type of seizure often have no memory of the episode itself.
Absence seizures may also present with staring and confusion but typically are more frequent (occurring multiple times per day), last less than 15 seconds, and are associated with immediate recovery, to the point that patients and witnesses may not realize a seizure has occurred. Absence seizures are most characteristic of childhood absence epilepsy, which typically resolves by puberty but also can occur in adults with idiopathic generalized epilepsy syndromes.
Atonic seizures involve the abrupt loss of muscle tone and typically are associated with falling down and a brief loss of consciousness lasting only a few seconds. Atonic seizures are one cause of “drop attacks” in which the patient will suddenly, and without warning symptoms, drop to the ground. Individuals with drop attacks can get themselves up and typically will deny loss of consciousness. Other causes of drop attacks include cataplexy, vertebrobasilar transient ischemic attack, and vestibular pathologies. The patient's seizures do not match the description of atonic seizures.
Myoclonic seizures generally consist of a single jerk of the entire body, usually last less than 1 second, and are associated with retained awareness and no postictal confusion. In contrast, this patient's seizures last at least 45 seconds and are characterized by staring, chewing motions, repetitive grabbing of her clothes, and a 20-minute postseizure period of exhaustion and sleepiness.
Key Point
Focal seizures with altered awareness typically are infrequent, are associated with warning symptoms (aura), last more than 30 seconds, have associated mouth or limb automatisms (semipurposeful repetitive movements), and are followed by confusion and/or exhaustion.
Bibliogrpahy
Dobrin S. Seizures and epilepsy in adolescents and adults. Dis Mon. 2012;58:708-29. [PMID: 23149523] doi:10.1016/j.disamonth.2012.08.011