CLINICAL STUDIES: SYNCOPE
Misdiagnosis of epilepsy: many seizure-like attacks have a cardiovascular cause
Amir Zaidi, MRCP*,
Peter Clough, MSc ,
Paul Cooper, MD ,
Bruce Scheepers, MD and
Adam P. Fitzpatrick, MD, FACC*
* Manchester Heart Centre, The Royal Infirmary, Manchester, United Kingdom
David Lewis Centre for Epilepsy, Cheshire, United Kingdom
Department of Neurology, Centre for Clinical Neurosciences, Hope Hospital, Salford, United Kingdom. Dr. Zaidi received an educational grant from Medtronic, Inc
Manuscript received August 29, 1999;
revised manuscript received December 30, 1999,
accepted March 1, 2000.
Reprint requests and correspondence: Dr. Amir Zaidi, Manchester Heart Centre, The Royal Infirmary, Oxford Road, Manchester, M13 9WL, United Kingdom
amir{at}mhc.cmht.nwest.nhs.uk
OBJECTIVES
We sought to investigate the value of cardiovascular tests to diagnose convulsive syncope in patients with apparent treatment-resistant epilepsy.
BACKGROUND
As many as 20% to 30% of epileptics may have been misdiagnosed. Many of these patients may have cardiovascular syncope, with abnormal movements due to cerebral hypoxia, which may be difficult to differentiate from epilepsy on clinical grounds.
METHODS
Seventy-four patients (33 men, mean age 38.9 ± 18 years [range 16 to 77]) who were previously diagnosed with epilepsy were studied. Inclusion criteria included continued attacks despite adequate anticonvulsant drug treatment (n = 36) or uncertainty about the diagnosis of epilepsy, on the basis of the clinical description of the seizures (n = 38). Each patient underwent a head-up tilt test and carotid sinus massage during continuous electrocardiography, electroencephalography and blood pressure monitoring. Ten patients subsequently underwent long-term electrocardiographic (ECG) monitoring with an implantable loop recorder.
RESULTS
In total, an alternative diagnosis was found in 31 patients (41.9%), including 13 (36.1%) of 36 patients taking an anticonvulsant medication. Nineteen patients (25.7%) developed profound hypotension or bradycardia during the head-up tilt test, confirming the diagnosis of vasovagal syncope. One other patient had a typical vasovagal reaction during intravenous cannulation. Two patients developed psychogenic symptoms during the head-up tilt test. Seven patients (9.5%) had significant ECG pauses during carotid sinus massage. In two patients, episodes of prolonged bradycardia correlated precisely with seizures according to the insertable ECG recorder.
CONCLUSIONS
A simple, noninvasive cardiovascular evaluation may identify an alternative diagnosis in many patients with apparent epilepsy and should be considered early in the management of patients with convulsive blackouts.
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Abbreviations and Acronyms
| | ECG | = electrocardiogram or electrocardiographic | | EEG | = electroencephalogram or electroencephalographic |
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