Yes, interestingly it is still largely a matter of clinical accruement. First seizure suffers from most misdiagnosis. JNNP 2008; 79(10): 1144-7

Dear Howan: I can not  find de JNNP 2008. Can you send the reference ?

I think this is the paper link: http://jnnp.bmj.com/content/79/10/1144

This question is very interesting and of great importance in clinical practice. Once someone has wrongly been diagnosed as having epilepsy it could potentially label the person for life as an epileptic (along with the psychological implications for the patient and their quality of life) and adversely affect future care and treatment.

I believe one of the most useful approaches is to get a good history from the patient and any witnesses present during the attack. Was it really a seizure, which type and why did it happen? Any triggers? is it the first time? Are their any patterns of the circumstances under which they occur? A few good questions to ask the patient is how he/she felt before the attack, and after the attack. In cases of epileptic seizures, patients do not remember what has happened during the seizure, so obtaining a collateral history from a witness can be really informative.

Asking the patient how they felt after the seizure can point towards the right diagnosis. Taking a long time to recover, feeling tired, confused and having a sore tongue after the attack indicate that a seizure might have happened.

History can also point out whether its syncope. The person might feel nauseated, sweaty or become pale prior to vasovagal or neurocardiogenic syncope. Situational syncope, especially in the elderly, can commonly occur as micturition, cough or effort syncope. Some people also suffer from carotid hypersensitivity, where their carotid baroreceptors are hypersentive to pressure. In these cases the symptoms can be elicited or severe slowing of their heart rate can happen on carotid sinus massage.

It is also important to highlight that jerking of limbs does not necessarily indicate a seizure but could also be due to cerebral hypoperfusion.

Abnormalities on EEG would be the gold standard but epileptic fits occur rarely and this makes it a difficult approach to use. Therefore good history taking would be one of the most important tool in making the diagnosis.

The following link is the NICE guideline used in the UK for diagnosis and management of epilepsies: https://www.nice.org.uk/guidance/cg137/chapter/1-guidance#diagnosis-2

This paper might also be useful: http://jnnp.bmj.com/content/70/suppl_2/ii3.extract

Hope this helps

Hi Howan - Indeed it is a misdiagnosis especially in the A & E context. Unless further investigated, the three "maladies" would have been known and treated easily.

Thank you Rose for pointing towards Howan's article, it is pretty enlightening indeed.

Dear Khaled, your comprehensive article on syncope and childhood epilepsy really impress me. Unfortunately, it is rare for it to be practised in my country owing to a simpler labelling of psychogenic, pseudosyncope or inorganic syncope a.k.a. psychiatric disorder. I wish it could be practised here (my country) - to be fair to all the "infected" patients.

Appreciate your kind input Muzammil - labelling and stigmatising patients without proper, elaborate or definitive PMH and others' observation is synonymous to finding them guilty without trial. Your input shed greater lights to those who are on the frontline (ED) in determining the thin line thus enabling the patients to be treated and accorded the respect they duly deserve.

Appreciate our camaraderie on this issues - thank you all.

Dear all.

History, History & history from patient & witness ( if applicable) will give the answer.

If the patient remembers preictal feeling of being dizzy, cloudiness before eyes, no emotional feeling , & no postictal phase are evidence prov. diagnosis of syncope. the same patient need to be followed for any evidence of postictal state, environment , any evidence of physical injury etc. EEG is unreliable for diagnosis. Post ictal raised serum prolactin may point towards seizure.

When my husband was in graduate school he awakened one morning feeling headache and general stiffness like coming down with a cold.  Looked in the mirror and saw he had a black eye!  And he was sure he had not been to the pub the night before.  He has a seizure disorder that rarely generalizes to a tonic clonic seizure, so he figured that was what happened and he accidentally gave himself a black eye.  So he was lucky to be able to ride the bus to class and was careful with medication.  Does  point to the dangers of nocturnal general seizures too.  If the person sleeps face down or ends up with face scrunched into soft bedding there is a risk of suffocation.  

As a P.S.  He also was not diagnosed until he had his first grand mal at age 16.  His description of "I have a strange feeling come over me in a wave starting in my stomach area" was ignored by doctors or just said to be nerves.  He had a bad fall on the playground as a six year old resulting in a year of bad headaches that caused a lot of missed school, needing a repeat of first grade.  This was in 1956 when of course MRI and other imaging was not available and one did not do EEG "just" for a young boy's bump on the head.

``Strange feeling come over me in a wave staring in my stomach area``.

Points to , Temporal lobe epilepsy. 

Exactly.  That is his diagnosis.  

Hi Dr Mariam:

Your question is very important and interesting.

Fits are of a variety of types depending on the type, cause and manifestation. Epileptic seizures, also called as seizures, fits or epileptic fits, are brief episode of signs or symptoms that occur in response to abnormal excessive or synchronous neuronal activity in brain.

Focal seizures are preceded often by an aura and jerking activity that starts from certain muscle and spreads to surrounding muscles with the progressive generalization (focal point to other regions in the hemisphere to the other hemisphere in secondary generalized epileptic seizures). Such type of cascade is not manifested in psychological fits (like in hysteria) or syncope (that is like brain ischemia wherein a transient loss of consciousness and postural tone occurs due to decreased blood flow to brain), presyncope or other type of fits.

This shows that:

1.Brief and transient loss of consciousness occurs in syncope that constitutes the fainting as according to the extent of cerebral anemia, sudden decrease in BP, heart block etc; whereas abrupt loss of awareness in most of the epilepsy seizures (generalized ones mainly tonic-clonic or grand mal) occurs and the epilepsy patient drops down anywhere during crossing the busy road, driving etc.

2. The hysteric fits are the uncontrollable outburst of emotion or fear, mostly expressed as irrationality, laughter, weeping, or such other manifestations, whereas the epileptic seizures are abnormal excessive or synchronous neuronal activity in brain.

Furthermore, syncope occurs to the extent of the decreased blood flow to the entire brain usually with low BP, and it is short loss of consciousness and muscle strength, occurring by a fast onset, short duration, and spontaneous recovery, whereas epilepsy fit/ seizure is characterized by uncontrolable jerking movements to momentary but complete loss of awareness (e.g absence seizures) with postictal symptoms before returning to normal consciousness.

In fact, it is quite difficult to make a precise differential diagnosis for epilepsy seizures and syncope and other fits, since epilepsies are of several types- jerking movements (Jacksonian march or focal seizures, and their synchronizations leading to generalization), confused or dazed appearance with no response (complex partial seizures), tonic-clonic seizures, tonic seizures, clonic seizures, atonic seizures, absence seizures, status epilepticus etc. Furthemore, epilepsy seizures may be the convulsive or non-convulsive ones.

I hope this clarifies.

Prof Zahir

Dear Prof Zahir,

Thank you for your elaborate and informative feedback.

Your findings are different from what I anticipated but significant nonetheless.

Unfortunately, the public hospitals in my country only prefer a shortcut and negative approach to stigmatize such "neurological"  or cardiac-based patients.

This is made worst by Medical Social Workers (MSWs) who control what the doctors could diagnose, dictate the mode of intervention and stop treatment according to their liking, gender or ethnic bias towards the poor patients.

It is pathetic when a sick patient is diagnosed by an MSW instead of physicians because the instant prejudice are highly remarkable and very damaging just because they manage the fund which does not belong to them but apportioned greatly towards patients benefit.

Your input is greatly appreciated, Prof Zahir.

Best regards.

Mariam.