What is the appropriate treatment for a patient presenting with a Jacksonian march (a type of seizure activity characterized by a progressive spread of seizure activity from one area of the body to another)?

Treatment of Jacksonian March Seizures

For a patient presenting with a Jacksonian march (focal motor seizure with progressive spread), immediate treatment with intravenous lorazepam 4 mg at 2 mg/min should be administered if the seizure is ongoing, followed by a second-line agent such as levetiracetam, fosphenytoin, or valproate if seizures persist after adequate benzodiazepine dosing. 1, 2

Immediate Management of Active Jacksonian Seizure

First-Line Treatment (0-5 minutes)

• Administer IV lorazepam 4 mg at 2 mg/min immediately for any actively seizing patient, with demonstrated 65% efficacy in terminating seizures 1, 2
• Lorazepam is superior to diazepam (65% vs 56% success rate) and has longer duration of action than other benzodiazepines 1
• Check fingerstick glucose immediately and correct hypoglycemia, a rapidly reversible cause 1, 2
• Have airway equipment immediately available before administering lorazepam, as respiratory depression can occur 1
• If IV access is unavailable, consider IM midazolam 10 mg or intranasal midazolam as alternatives 1

Second-Line Treatment (5-20 minutes after benzodiazepines)

If the Jacksonian march continues despite adequate benzodiazepine dosing, immediately escalate to one of these equally effective second-line agents 1, 2:

Preferred options based on safety profile:

• Levetiracetam 30 mg/kg IV (maximum 2500-3000 mg) over 5 minutes: 68-73% efficacy with minimal cardiovascular effects and no cardiac monitoring required 1, 2
• Valproate 20-30 mg/kg IV (maximum 3000 mg) over 5-20 minutes: 88% efficacy with 0% hypotension risk 1, 2
• Fosphenytoin 20 mg PE/kg IV at maximum rate of 150 mg/min: 84% efficacy but 12% hypotension risk requiring continuous ECG and blood pressure monitoring 1, 2
• Phenobarbital 20 mg/kg IV over 10 minutes: 58.2% efficacy but higher risk of respiratory depression 1

Levetiracetam or valproate are preferred over fosphenytoin due to superior safety profiles, particularly the absence of hypotension and lack of cardiac monitoring requirements 1, 2

Management After Seizure Termination

For Self-Limited Jacksonian Seizures

If this is a first unprovoked seizure and the patient has returned to baseline:

• Emergency physicians need not initiate antiepileptic medication in the ED for patients who have had an unprovoked seizure without evidence of brain disease or injury 3
• For patients with a first unprovoked seizure, the strategy of waiting until a second seizure before initiating antiepileptic medication is considered appropriate 3
• Emergency physicians may initiate antiepileptic medication in the ED, or defer in coordination with other providers, for patients who experienced a first unprovoked seizure with a remote history of brain disease or injury (stroke, trauma, tumor) 3

Critical Diagnostic Workup

Immediate imaging is essential to identify the underlying structural cause of Jacksonian seizures:

• All patients should undergo brain imaging with non-contrast CT (NCCT) or MRI 3
• Jacksonian march indicates a focal cortical lesion that requires identification 4
• Search for structural lesions including tumors, infection, infarction, traumatic brain injury, vascular malformations, and developmental abnormalities 3

If acute stroke is suspected (particularly given the capsular warning syndrome can mimic Jacksonian march):

• New onset seizures at the time of acute stroke should be treated with short-acting medications (e.g., lorazepam IV) if not self-limited 3
• A single, self-limiting seizure occurring at stroke onset should not be treated with long-term anticonvulsant medications 3
• Prophylactic use of anticonvulsant medications in patients with acute stroke is not recommended due to possible harm with negative effects on neural recovery 3

Refractory Jacksonian Seizures (Status Epilepticus)

If seizures continue despite benzodiazepines and one second-line agent (>20 minutes), this constitutes refractory status epilepticus 1, 2:

• Initiate continuous EEG monitoring at this stage 1, 2
• Midazolam infusion: 0.15-0.20 mg/kg IV load, then 1 mg/kg/min continuous infusion (80% success rate, 30% hypotension risk) 1, 2
• Propofol: 2 mg/kg bolus, then 3-7 mg/kg/hour infusion (73% efficacy, 42% hypotension risk, requires mechanical ventilation) 1, 2
• Pentobarbital: 13 mg/kg bolus, then 2-3 mg/kg/hour infusion (92% efficacy but 77% hypotension risk requiring vasopressors) 1, 2

Critical Pitfalls to Avoid

• Do not use neuromuscular blockers alone (e.g., rocuronium), as they only mask motor manifestations while allowing continued electrical seizure activity and brain injury 1
• Do not skip to third-line agents until benzodiazepines and a second-line agent have been tried 1
• Do not delay imaging or anticonvulsant administration to search for underlying causes—treat seizures simultaneously while investigating etiology 1, 2
• Recognize that capsular warning syndrome can mimic Jacksonian march with ascending paresthesias, but typically lacks motor components and EEG abnormalities 5
• Do not admit patients with a first unprovoked seizure who have returned to baseline unless there are other concerning features 3

Special Considerations for Jacksonian Seizures

• Jacksonian march indicates focal cortical pathology, and Jackson's original observations suggest the "march" is caused by downstream connections of overactive neurons at the seizure focus rather than simple somatotopic spread 4
• The progressive spread pattern (e.g., hand → arm → face) reflects the organization of motor cortex and its connections 4
• Underlying structural lesions must be identified, as Jacksonian seizures can result from meningiomas, hippocampal sclerosis, or other focal pathology 6, 7