Frontal lobe seizures

1. Neha Sharma

2. »Anatomy and Functions
»Aetiology
»Clinico-anatomical localization
»Diagnosis
»Neurological evaluation
»Treatment
»Impairments

3. »Largest of all lobes
»Myriad functions
»Divided into 3 aspects
˃Dorsolateral
˃Medial
˃Inferior orbital

4. »Precentral region : Primary motor area (4)
»Premotor : SMA – Lateral & Medial (6) Broca’s area (44)
»Frontal eye fields : (8) cortical & subcortical occulomotor associations
»Prefrontal cortex: Heterogenous connections (limbic, temporal, parietal)
»Sensory processing
»Decision making
»Impulse control
»Motor & Visual Memory

7. »5 Axes (ILAE)
»Axis 1 : Ictal phenomenology
»Axis 2 : Seizure type
»Axis 3 : Syndrome
»Axis 4 : Aetiology
»Axis 5 : Impairment

8. »Variety of seizure patterns
»Lobar manifestations rather than disease per se
»Proposed classifications on functional anatomy
˃Central
˃Premotor
˃Prefrontal
Dorsolateral and Medioventral in each
»Postural & tonic motor activity – Posterior
»Complex motor behaviours, autonomic & emotional
manifestations - Prefrontal

9. »Tumours (1/3rd)
˃Low grade gangliogiomas, low grade gliomas, epidermoid tumours
»Birth defects/ CNS malformations
»Vascular malformations
˃Arteriovenous
˃Cavernous angiomas
»Head trauma
»Encephalitis
»Genetic
˃Autosomal Dominant Nocturnal Frontal Lobe Epilepsy (ADNFLE)
»Syndromes
˃Benign Rolandic Epilepsy/BECTS
˃Aqd. Epileptiform Opercular Syndrome

10. »Sudden onset
»Brief
»Sudden termination
»During sleep
»Clusters
»Rapid 20 generalization
»Minimal postictal confusion
»Motor :Clonic, Asymmetric tonic posturing
»Gestural automatisms
»Adaptability

11. »Broca
˃Loss of an area of brain -> loss of function of that area ( Neurologic deficit)
»Jackson
˃Loss of an area of brain -> emergence of new function suppressed by that part ( Release phenomenon) “ Functional Uncoupling”

14. »Rolandic (Central) Epilepsy
»Characteristic “Jacksonian march”
»Focal clonic seizures (contralateral)
»Associated parietal postcentral (sensory) and frontal precentral (motor) “ reflex epilepsy”
˃Triggers : cutaneous stimulation, movement
˃Manifestations : motor , sensory
»Related Startle seizures : Infantile hemiplegia
»Rare : Epilepsia partialis continua

15. »B/L Proximal asymmetrical tonic posturing
˃“Fencing posture”
»Adversion of Head & Eyes
»Speech arrest/ Vocalization : Palilalia
»Facial symptoms
»Infrequent
˃Aura
˃Secondary generalization

17. »Ventral & Dorsal patterns
»Posterior spread – 2o generalisation
»VENTRO-MEDIAL PREFRONTAL
˃Complex partial seizures of frontal lobe origin
˃Intense subjective behavioural agitation : facial, screaming
˃Apparently purposeful gesticulation
˃Autonomic signs

18. »DORSO-LATERAL PREFRONTAL
˃Adversion of eyes preceding head version
˃Directed , compulsive or semi-purposeful automatisms
˃Complex motor patterns
˃Vocalizations without emotive content
˃Visual hallucinations
˃Compulsive thinking
˃Frontal absence

20. »Pavor nocturnus
»Sleep Apnoea
»Pseudo seizures
»Temporal Lobe Epilepsy
»Psychogenic movement disorders
»Familial paroxysmal dystonic choreoathetosis
»Paroxysmal kinesigenic choreoathetosis/ dyskinesia
»Episodic ataxia type I

21. »Neuroimaging
»Structural : MRI
»Functional : Non – invasive – EEG
˃VEEG
˃High resolution scalp EEG – source localization
»PET : FDG , Flumazenil
»Invasive : SEEG

26. »Medications
˃Oxcarbamazepine, Carbamezepine
˃Phenytoin
˃Levetiracetam
˃Gabapentin
»Surgical
˃Lobectomy
˃Multiple Sub - pial Resection
˃Vagus nerve stimulation
»Diet
˃Ketogenic diet

27. »Intellectual Disability
»Education, learning & cognitive function
»Physical health
»Mental & Emotional health
»Driving & Transportation restricted
»Employment
»Pregnancy

28. »H. Gray.Gray’s Anatomy of the Human Body 1st Edn (1918)
»Kliegman R. M. , Stanton B.F. , Geme J. W. S. , Schor N. F., Behrman R.E. Nelson Textbook of Pediatrics 19th Edn. (2012)
»McGonigal A. , Chauvel P. Frontal lobe epilepsy : seizure semiology and presurgical evaluation Practical Neurology, 2004, 4, 260–273
»Piña-Garza J. E. Fenichel’s Clinical Pediatric Neurology 7th edn. (2013)
»Rudolph’s Pediatrics 20th edn
»Brett E. M., Pediatric Neurology 3rd edn. (1997)
»Forfar and Arnell’s Textbook of Pediatrics 6th Edn.