Historical criteria that distinguish syncope from seizures

Sheldon, Robert S.; Rose, Sarah; Ritchie, Debbie; Connolly, Stuart J.; Koshman, Mary Lou; Lee, Mary Anne; Frenneaux, Michael; Fisher, Michael A.; Murphy, William F.

doi:10.1016/s0735-1097(02)01940-x

Cited by 339 publications

(162 citation statements)

References 26 publications

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“…Guidelines now exist that use clinical history alone to distinguish NCS from seizures (94% sensitivity and specificity; Figure 3) or other forms of syncope (89% sensitivity and 91% specificity). 11,12 Despite this, NCS is still commonly mistaken for epileptic seizures even though the conditions rarely coexist in the same patient. 18 Neurocardiogenic syncope is estimated to constitute 6% to 39% of cases of presumed epilepsy depending on the population studied 19 and therefore erroneous diagnosis may lead to inappropriate treatment with social and economic stigmatization.…”

Section: Discussionmentioning

confidence: 99%

Neurocardiogenic Syncope: Frequency and Consequences of its Misdiagnosis as Epilepsy

Josephson

Rahey

Sadler

2007

Can. j. neurol. sci.

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Neurocardiogenic (vasovagal/vasodepressor) syncope (NCS) is a reflex mediated loss of consciousness resulting from the failure of the autonomic nervous system to maintain adequate cerebral perfusion pressure. 1,2 Excessive peripheral venous pooling of blood in combination with aberrant responses of mechanoreceptors to compensatory cardiac hypercontractility results in a paradoxical reflex bradycardia and drop in peripheral vascular resistance. 3,4 The consequent cerebral hypoperfusion induces a transient loss of consciousness that is associated with abnormal movements (e.g. myoclonic jerks) in 12-90% of patients. 2,[5][6][7][8][9][10] Despite clinical guidelines that distinguish NCS ABSTRACT: Background: Neurocardiogenic syncope (NCS) can be mistaken as a seizure. We reviewed the frequency and diagnostic consequences of this misdiagnosis. Methods: A retrospective review of outpatient adult epilepsy clinic charts (QEII Health Sciences Centre, Halifax, NS) was conducted to identify NCS patients referred with a provisional diagnosis of seizures. Charts were reviewed in detail with an emphasis on the consequences of misdiagnosis. Results: Of 1506 consecutive referrals to the epilepsy clinic, 194 (12.9%) ultimately had a clinical diagnosis of NCS. Mean age was 38 +/-16 years (mean age of syncopal onset was 28 +/-16 years). Two-thirds of referrals were from primary care physicians (including emergency departments) and 18% from neurologists. Thirty-five percent were prescribed antiepileptic drugs (AEDs) prior to referral with eight patients (4.1%) experiencing hypersensitivity reactions. Three of five women had adverse pregnancy outcomes while taking AEDs. One-third of patients had restrictions placed on their driving privileges while 11 patients (5.7%) had their employment interrupted. Diagnostic modalities used in the work-up included EEG (90%), CT head (51%), and MRI head (15%). Conclusions: NCS is commonly misdiagnosed as epilepsy. Some patients had an incorrect diagnosis for > 10 years. Patients with this misdiagnosis are often excessively investigated, inappropriately treated, and have unnecessary restrictions placed on driving and employment. RÉSUMÉ: Syncope neurocardiogénique : fréquence et conséquences d'un diagnostic erroné d'épilepsie.Contexte : Une syncope neurocardiogénique (SNC) peut être prise à tort pour une crise convulsive. Nous revoyons la fréquence et les conséquences d'un tel diagnostic erroné. Méthodes : Nous avons effectué une révision rétrospective des dossiers de patients de la clinique externe d'épilepsie (QEII Health Sciences Centre, Halifax, NS) afin d'identifier les patients ayant présenté une SNC qui y ont été référés avec un diagnostic provisoire de crise convulsive. Les dossiers ont été révisés en détail, particulièrement en ce qui concerne les conséquences d'un diagnostic erroné. Résultats : On a posé ultérieurement un diagnostic de SNC chez 194 (12,9%) de 1506 patients consécutifs référés à la clinique d'épilepsie. L'âge moyen des patients était de 38 ± 16 ans et l'âge moyen au moment ...

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Section: Discussionmentioning

confidence: 99%

Neurocardiogenic Syncope: Frequency and Consequences of its Misdiagnosis as Epilepsy

Josephson

Rahey

Sadler

2007

Can. j. neurol. sci.

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“…j Key words syncope AE diagnosis AE age distribution AE sex AE signs and symptoms syncope [2,15,27]. Therefore, knowledge about the occurrence of triggers, signs, and symptoms provides important background information for physicians to optimize and personalize their diagnostic strategy.…”

Section: Introductionmentioning

confidence: 99%

Influence of age and gender on the occurrence and presentation of reflex syncope

et al. 2008

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“…Published studies have found that the electroencephalogram (EEG) is of low diagnostic yield when the clinical diagnosis is syncope [2][3][4][5] . Reviews state that EEGs should not be performed routinely in cases of suspected syncope unless there has been a witnessed seizure 6 , there is a history of prior seizures 7,8 , or there are "symptoms suggestive of a seizure" 7,9 . Electroencephalograms ordered by a neurologist might be expected to have a higher diagnostic yield because most neurologists are experienced in evaluating patients with syncope and seizures, and presumably would only refer a patient with suspected syncope for an EEG if there was something ABSTRACT: Background: Prior studies have shown that the electroencephalogram (EEG) is of low diagnostic yield in the evaluation of syncope but have not looked at the yield according to referring physician specialty.…”

mentioning

confidence: 99%

EEG in Suspected Syncope: Do EEGs Ordered by Neurologists Give a Higher Yield?

Poliquin‐Lasnier

Moore

2009

Can. j. neurol. sci.

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Syncope is often difficult to distinguish from a seizure because both can present clinically with a transient loss of consciousness 1 . Published studies have found that the electroencephalogram (EEG) is of low diagnostic yield when the clinical diagnosis is syncope [2][3][4][5] . Reviews state that EEGs should not be performed routinely in cases of suspected syncope unless there has been a witnessed seizure 6 , there is a history of prior seizures 7,8 , or there are "symptoms suggestive of a seizure" 7,9 . Electroencephalograms ordered by a neurologist might be expected to have a higher diagnostic yield because most neurologists are experienced in evaluating patients with syncope and seizures, and presumably would only refer a patient with suspected syncope for an EEG if there was something ABSTRACT: Background: Prior studies have shown that the electroencephalogram (EEG) is of low diagnostic yield in the evaluation of syncope but have not looked at the yield according to referring physician specialty. The goals of this study were to determine if the yield of the EEG is higher when ordered by neurologists and whether EEGs with abnormal findings resulted in any significant change in patient management. Methods: We retrospectively reviewed the records of the EEGs requested for a clinical diagnosis of syncope, convulsive syncope, loss of consciousness, or falls from 2003 to 2007 at our institution. We obtained further information from the medical record of patients with an abnormal EEG. Results: Of 517 EEGs meeting our inclusion criteria, only 57 (11.0%) were read as abnormal. No EEG was positive for epileptiform activity and only 9 (1.6%) showed potentially epileptic activity. EEGs ordered by neurologists did not have a higher yield compared to non-neurologists. Five abnormal EEGs resulted in further investigations being ordered. One patient was ultimately started on phenytoin. Conclusions: EEGs requested for the evaluation of patients with suspected syncope have an extremely low diagnostic yield and do not significantly alter the management of the patients, regardless of the specialty of the referring physician. RÉSUMÉ: L'EEG chez les patients suspects de syncope : les EEG demandés par les neurologues donnent-ils un meilleur rendement? :Contexte : Des études antérieures ont montré que l'électroencéphalogramme (EEG) offre un rendement diagnostique faible dans l'évaluation de la syncope, mais ces études n'ont pas examiné le rendement selon la spécialité du médecin qui réfère le patient. Les buts de cette étude étaient de déterminer si le rendement de l'EEG est plus élevé quand il est demandé par un neurologue et si les EEG dont les résultats sont anormaux entraînaient des changements significatifs dans le traitement du patient. Méthodes :Nous avons revu de façon rétrospective les dossiers des EEG demandés de 2003 à 2007 dans notre institution à cause d'un diagnostic clinique de syncope, de syncope convulsive, de perte de conscience ou de chute. Nous avons tiré des informations complémentaires des dossiers médicaux...

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Historical criteria that distinguish syncope from seizures

Abstract: A simple point score of historical features distinguishes syncope from seizures with very high sensitivity and specificity.

Cited by 339 publications

References 26 publications

Neurocardiogenic Syncope: Frequency and Consequences of its Misdiagnosis as Epilepsy

Neurocardiogenic Syncope: Frequency and Consequences of its Misdiagnosis as Epilepsy

Influence of age and gender on the occurrence and presentation of reflex syncope

EEG in Suspected Syncope: Do EEGs Ordered by Neurologists Give a Higher Yield?

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