Snapshot A 39-year-old man presents to the emergency department due to abnormal movement of his left arm. These involuntary abnormal movements last a few minutes and he is aware during these episodes. He also endorses right-sided headaches that are worse in the morning. Medical history is unremarkable. Physical examination is normal. An MRI brain with and without gadolinium demonstrates a right-sided ring-enhancing lesion in the primary motor cortex. Neurosurgery is consulted for removal and histopathological assessment of the mass. (Brain neoplasm) Introduction Definition generation of epileptiform activity in a focal brain region that does not cause any alteration in conciousness Etiology Structural brain abnormality neoplasm hippocampal sclerosis (seen in temporal lobe epilepsy) head trauma vascular malformations stroke perinatal injury cortical dysplasia Pathogenesis The structural brain lesion results in electrogenic variation, creating a focus for epileptogenesis Presentation Symptoms/physical exam dependent on where in the brain the seizure arises from contralateral arm movements if the seizure generates from the region that controls arm movements in the motor cortex no alterations in conciousness (key differentiating feature from complex partial seizures) Imaging MRI brain with and without contrast indication imaging study of choice for the evaluation of first seizure in the emergency setting, CT head with and without contrast is preferred due to how quickly images can be obtained Studies Electroencephalogram (EEG) indication part of the initial evaluation of patients presenting with a first seizure Differential Psychogenic nonepileptic seizures (PNES) differentiating factors most seizure episodes are in front of a witness seizures do not occur during sleep variable and asynchronous muscle movement Migraine with aura differentiating factors patients typically have a pulsatile/throbbing headache Treatment Medical antiepileptic drugs (AED) indication started in patients who are at increased risk of seizure recurrence first address treatable causes of seizure (e.g., hypoglycemia) choice of AED depends on a number of factors (e.g., side-effect profile, cost, and comorbid conditions) Complications Behavioral and cognitive alterations Aspiration Prognosis Partial seizures are at higher risk of seizure recurrence than generalized seizures