Psychomotor or Temporal lobe epilepsy
OTHER TYPES OF EPILEPSY is due to a lesion of the temporal lobe or its surrounding area. It is characterised by a peculiar sudden mental state which is usually remembred by the patient afterwards in vivid details. There is subjective awareness of hallucination or illusion of taste, smell, sight or hearing associated with disorientation and confusion. In the dreamy state patient carries out all coordinated purposeful action without any subsequent memory.This is called “Déjà vu phenomenon.”
This dreamy state is often associated with smacking of the lips and champing or swallowing movement.
This term is also used to denote focal epilepsy. An irritative focus starts in any part of the cortex, and then progresses slowly in the remaining part of the cortex. There are only clonic phase of this epilepsy. The initial sites of convulsive attacks are angle of the mouth, thumb, index finger and great toe. Convulsive attack progresses according to the representation of the body in the cerebral cortex. Motor, sensory types are usually seen. Post epileptic Todd’s paralysis is common.
This is characterised by paroxysmal abdominal pain, sweating, incontinence of urine and faeces, salivation, erection of hair,etc.
This is due to a lesion of the sensory cortex characterised by the paroxysmal sensory symptoms involving the sensory structures.
Sensory stimulus like watching television, pouring hot water on vertex of head, certain music or even eating food may precipitate epileptic attack.
First of all it should be decided whether the convulsive seizure is organic or functional (Pseudo seizure). When functional state is excluded organic cause means epilepsy is confirmed.
When epilepsy is concluded it is to be decided whether it is secondary to some cause or idiopathic. When no signs are present the disease is said to be idiopathic. Grand Mal epilepsy should always be differentiated from Hysteria by the following points (see table).
1. EEG: During attack EEG is usually abnormal. In between attack EEG is usually normal. 3 HZ spike and wave activity may be seen in Absence seizure. A cortical spike focus or generalised spike and wave activity may be noted.
2. CT scanning and MRI should be done where clinically neural deficit is present or in aged individuals.
3. Ancillary investigations, e.g., blood bio-chemistry, X-ray chest, ECG etc. may also be done which may be positive in secondary epilepsy.
Anticonvulsant drugs: Opinions still differ as to which drugs will suit best for a particular type of attack. However, the following drugs are used.
Drugs used in Epilepsy
Grand Mal or Major epilepsy (see chart)
For Temporal lobe or Psychomotor epilepsy
Carbamazepine (Tegretol), Dilantin Sodium, in the dose mentioned above are useful. Phenacemide 0.5-5 gm in divided doses may also be given.
For average cases of major epilepsy Phenobarbitone is started first and if there is somnolence or there is no beneficial effect then Dilantin Sodium is used. Sometimes a combination of these two is of great help. All patients of epilepsy are to be employed in some form of work which should not endanger their lives. They should not be allowed to work near fire, machineries or at height. Swimming, cycling or Driving cars should be abandoned. Free mixing, normal activities, e.g., going to school etc. should be allowed. Precipitating factors are to be avoided. The drug is to be continued for minimum 4 years.
Amputation of temporal lobe on the non-dominant side may be done in partial seizures or secondary seizures or when a definite abnormal focus is present in EEG.
Treatment of Status epilepticus
(i) All measures mentioned in the management of coma are to be adopted.
(ii) Whips of chloroform anaesthesia may be given.
(iii) Phenobarbitone sodium 200-800 mg IV slowly may be given.
(iv) Paraldehyde-8-10 cc IM (not more than 5 cc in each side) or 1-2 cc IV diluted with 3 times the volume of saline may also be given.
(v) Dilantin Sodium may be given IV at a rate of 50 mg per minute upto a total dose of 200-500 mg. It is given directly or through normal saline drip. In glucose drip it precipitates. Alternately it may be given IM 250-500 mg daily.
(vi) Diazepam 10 mg IV may be given as a starting dose then 200 mg/litre IV drip for 24 hours. Chlormethiazole 0.8% may be given by IV infusion.
(vii) The precipitating factors like hypoglycaemia, hyponatremia, etc. should be corrected by appropriate therapy.
(viii) Hypotension and respiratory depression are to be corrected.
(ix) After status stage iss over, oral drug regime is to be continued.
In Status epilepticus nonconvulsive type (absence seizure, partial seizure) IV Diazepam; Phenoparbitone, Phenytoin, Carbamazepine are required.
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