Focal seizures without awareness

- Patients with SWA have an electro-clinical distinct form of TLE.
- Diagnostic VEM is performed earlier for SWA than for treatment VEM in SA.
- Older age, referral for “spells”, left TLE, and vague seizure frequencies are characteristic.
- Fewer antiseizure drugs with less follow-up in SWA represent a gap in care.
- Serial VEM is needed to validate effective management of SWA.

ObjectiveTo characterize patients with seizures that only occur without their awareness (SWA).MethodsTwenty-four patients with SWA were retrospectively identified by chart review and subsequently underwent video-EEG monitoring (VEM). Eleven patients met selection criteria for SWA and were never aware of any seizures. A case-matched control group of patients who were always aware (SA) was used for comparison. Statistical analysis included Pearson's Chi-square, Fisher's Exact, and Mann-Whitney.ResultsPatients with SWA were older at seizure diagnosis than those with SA (p = 0.04), were less often referred for evaluation of seizures or epilepsy (p = 0.04), and were referred faster for VEM, despite SWA were significantly less likely to include motor manifestations (p = 0.0004). SWA more often had temporal lobe onsets (p < 0.0001) with left lateralization on ictal EEG (p < 0.0001). At final follow up, patients with SWA had tried fewer antiseizure drugs (p = 0.03), but reported seizure freedom as often as patients with SA (p = 0.4).SignificanceWe suggest that patients with SWA have a unique epilepsy syndrome. Patients with absent recall were older, referred later, had fewer motor signs, and dominant hemisphere limbic localization than patients with SA, but fewer antiseizure drugs are used in treatment. Patients with SWA can be detected from the clinical history, though serial VEM is needed to validate effective management.