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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Developed in collaboration with, European Heart Rhythm Association (EHRA), Heart Failure Association (HFA), and Heart Rhythm Society (HRS), Endorsed by the following societies, European Society of Emergency Medicine (EuSEM), European Federation of Internal Medicine (EFIM), European Union Geriatric Medicine Society (EUGMS), American Geriatrics Society (AGS), European Neurological Society (ENS), et al.
Guidelines for the diagnosis and management of syncope (version 2009): The Task Force for the Diagnosis and Management of Syncope of the European Society of Cardiology (ESC)
Eur. Heart J.,
November 1, 2009;
30(21):
2631 - 2671.
[Full Text]
[PDF]
|
|
|
|
|
|
|
O. Jolobe
Potential causes of delayed diagnosis include convulsive syncope and cardiogenic vertigo
QJM,
August 11, 2009;
(2009)
hcp112v1.
[Full Text]
[PDF]
|
|
|
|
|
|
|
A Neligan, D R Holdright, F J Rugg-Gunn, and J W Sander
A case of mistaken mesial temporal identity
BMJ,
June 23, 2009;
338(jun23_1):
b2258 - b2258.
[Full Text]
|
|
|
|
|
|
|
Task Force members, M. Brignole, P. Vardas, E. Hoffman, H. Huikuri, A. Moya, R. Ricci, N. Sulke, W. Wieling, EHRA Scientific Documents Committee, et al.
Indications for the use of diagnostic implantable and external ECG loop recorders
Europace,
May 1, 2009;
11(5):
671 - 687.
[Full Text]
[PDF]
|
|
|
|
|
|
|
L Plug and M Reuber
Making the diagnosis in patients with blackouts: it's all in the history
Practical Neurology,
February 1, 2009;
9(1):
4 - 15.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
C. I. Moore and R. Cao
The Hemo-Neural Hypothesis: On The Role of Blood Flow in Information Processing
J Neurophysiol,
May 1, 2008;
99(5):
2035 - 2047.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
M. P. Tan and S. W. Parry
Vasovagal syncope in the older patient.
J. Am. Coll. Cardiol.,
February 12, 2008;
51(6):
599 - 606.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
S. Petkar, P. Cooper, and A. P Fitzpatrick
How to avoid a misdiagnosis in patients presenting with transient loss of consciousness.
Postgrad. Med. J.,
October 1, 2006;
82(972):
630 - 641.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
S. Seri, A. Cerquiglini, and G.F.A. Harding
Visually induced syncope: a nonepileptic manifestation of visual sensitivity?
Neurology,
July 25, 2006;
67(2):
359 - 360.
[Full Text]
[PDF]
|
|
|
|
|
|
|
A. P Fitzpatrick and P. Cooper
Diagnosis and management of patients with blackouts.
Heart,
April 1, 2006;
92(4):
559 - 568.
[Full Text]
[PDF]
|
|
|
|
|
|
|
W. R Garnett
Optimizing Antiepileptic Drug Therapy in the Elderly
Ann. Pharmacother.,
November 1, 2005;
39(11):
1852 - 1860.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
Task Force members, M. Brignole, P. Alboni, D. G. Benditt, L. Bergfeldt, J.-J. Blanc, P. E. B. Thomsen, J. G. van Dijk, A. Fitzpatrick, S. Hohnloser, et al.
Guidelines on management (diagnosis and treatment) of syncope - Update 2004: The task force on Syncope, European Society of Cardiology
Eur. Heart J.,
November 2, 2004;
25(22):
2054 - 2072.
[Full Text]
[PDF]
|
|
|
|
|
|
|
D.J. Farwell, N. Freemantle, and A.N. Sulke
Use of implantable loop recorders in the diagnosis and management of syncope
Eur. Heart J.,
July 2, 2004;
25(14):
1257 - 1263.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
Guidelines on Management (diagnosis and treatment) of syncope - update 2004: The Task Force on Syncope, European Society of Cardiology
Europace,
January 1, 2004;
6(6):
467 - 537.
[Full Text]
[PDF]
|
|
|
|
|
|
|
R. Passman, G. Horvath, J. Thomas, J. Kruse, A. Shah, J. Goldberger, and A. Kadish
Clinical Spectrum and Prevalence of Neurologic Events Provoked by Tilt Table Testing
Arch Intern Med,
September 8, 2003;
163(16):
1945 - 1948.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
J Stone, M Sharpe, P M Rothwell, and C P Warlow
The 12 year prognosis of unilateral functional weakness and sensory disturbance
J. Neurol. Neurosurg. Psychiatry,
May 1, 2003;
74(5):
591 - 596.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
P. Camfield and C. Camfield
Childhood Epilepsy: What Is the Evidence for What We Think and What We Do?
J Child Neurol,
April 1, 2003;
18(4):
272 - 287.
[Abstract]
[PDF]
|
|
|
|
|
|
|
L. Bergfeldt
DIFFERENTIAL DIAGNOSIS OF CARDIOGENIC SYNCOPE AND SEIZURE DISORDERS
Heart,
March 1, 2003;
89(3):
353 - 358.
[Full Text]
[PDF]
|
|
|
|
|
|
|
D. Chadwick and D. Smith
The misdiagnosis of epilepsy
BMJ,
March 2, 2002;
324(7336):
495 - 496.
[Full Text]
[PDF]
|
|
|
|
|
|
|
L. A. Pires, J. R. Ganji, R. Jarandila, and R. Steele
Diagnostic Patterns and Temporal Trends in the Evaluation of Adult Patients Hospitalized With Syncope
Arch Intern Med,
August 13, 2001;
161(15):
1889 - 1895.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
P. E M Smith
IF IT'S NOT EPILEPSY . . .
J. Neurol. Neurosurg. Psychiatry,
June 1, 2001;
70(suppl_2):
ii9 - ii14.
[Full Text]
[PDF]
|
|
|
|
|
|
|
Seizure-Like Spells and the Heart
Journal Watch Psychiatry,
October 18, 2000;
2000(1018):
16 - 16.
[Full Text]
|
|
|
|
|
|
|
Cardiovascular Cause of Seizure-Like Attacks
Journal Watch Cardiology,
September 15, 2000;
2000(915):
1 - 1.
[Full Text]
|
|
|
|
|
|
|
Seizure-Like Spells and the Heart
Journal Watch Neurology,
September 6, 2000;
2000(906):
5 - 5.
[Full Text]
|
|
|
|
