Consciousness in Focal Seizures: Either You're In or You're Out.

Commentary As physicians who treat patients with epilepsy, we find ourselves considering whether the seizures patients describe to us have sufficient impact to warrant removal of driving privileges or other special safety considerations. These decisions are often clear-cut, based on the patients' or observers' descriptions. When a patient indicates that they are not aware of their own activities—or the activities of those around them—it is relatively easy to determine that consciousness is impaired, and therefore driving privileges should be removed. However, there are seizure descriptions that seem to fall on a gray line: For example, the patient who experiences the seizure may relate that they are aware of the presence of others throughout the seizure, can hear conversations, but perhaps cannot report or remember exact conversations because the experience of the seizure is " so intense " that it takes all of the person's attention. Often under these circumstances, the patient will report that they " could " attend to these external stimuli if they " really tried. " Two clinicians, hearing this description, might come to different conclusions as to whether the patient experienced impairment in consciousness. This has led to intense debates about whether seizures can really be subdivided into what (in the old seizure terminology) was described as " simple partial " and " complex partial " (1) and in the new terminology described as " with and without dyscognitive features " (2), or whether seizures lie on a continuum that cannot be arbitrarily divided. The debate took off when the 2001 ILAE Task Force on Classification and Terminology published its new proposed classification and suggested that the terms simple partial and complex partial be abandoned, stating, " These terms are no longer recommended, nor will they be replaced. Ictal impairment of consciousness will be described when appropriate for individual seizures, but will not be used to classify specific seizure types " (3). This issue continues to be hotly debated (4, 5). Recently, readers of the journal Epilepsia were asked to take a poll (results pending at the time of this writing) in which they were asked whether such a dichotomy should be included in the new classification of epilepsy (still in flux) and, if so, what it should be called. Many are unhappy with the term " dyscog-nitive, " newly created for the 2010 ILAE revised classification (2). Those who favor " dichotomy " have offered …