Epilepsy Differential Diagnosis

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The following should be considered in the differential diagnosis of epilepsy -SYNCOPE (VASOVAGAL) ATTACKS

These attacks occur usually when the patient is standing and result from a global reduction of cerebral blood flow.

Prodromal pallor, nausea and sweating occur; if the patient sits down, the attack may pass off or proceed to a brief loss of consciousness.

Tonic and clonic movements may develop if impaired cerebral blood flow is prolonged ('anoxic' seizures).

Mechanism: Peripheral vasodilatation with drop in blood pressure followed by vagal overactivity with fall in heart rate.

Syncopal attacks occur in hot, crowded rooms (e.g. classroom) or in response to pain or emotional disturbance.

'Reflex' syncope from cardiac slowing may occur with carotid sinus compression. Similarly, cough syncope may result from vigorous coughing. CARDIAC ARRHYTHMIAS

Seen in situations such as complete heart block (Adams-Stokes attacks).

Prolonged arrest of cardiac rate or critical reduction will progressively lead to loss of consciousness - tonic jerks - cyanosis/stertorous respiration - fixed pupils and extensor plantar responses.

On recovery of normal cardiac rhythm, the degree of persisting neurological damage depends upon the duration of the episode and the presence of pre-existing cerebrovascular disease. In suspected patients, electrocardiography is mandatory. Continuous (24 hours) ECG monitoring may be necessary. MIGRAINE

The slow evolution of focal hemisensory or hemimotor symptoms in complicated migraine contrasts with the more rapid 'spread' of such manifestations in simple partial seizures. Basilar migraine may produce a transient loss of consciousness. HYPOGLYCAEMIA

Amongst other neuroglycopenic manifestations, seizures or intermittent behavioural disturbances may occur. A rapid fall of blood sugar is associated with symptoms of catecholamine release, e.g. palpitations, sweating, etc. In 'atypical' seizures exclude a metabolic cause by blood sugar estimation when symptomatic. EPISODIC CONFUSION

Intermittent confusional episodes caused by drugs (e.g. barbiturates) or toxins (e.g. solvents).

PANIC ATTACKS Hyperventilation can induce focal sensory symptoms. NARCOLEPSY

Inappropriate sudden sleep episodes may easily be confused with epilepsy (see page 103). PSEUDOSEIZURES (non epileptiform seizures)

A difficult distinction lies between genuine epilepsy and attention seeking, hysterical or malingering episodes in which violent shaking and feigned loss of consciousness occurs. Often true epileptics will also manifest such attacks. Patients are usually suggestible, manipulative and with personality disorder. Many affected women have histories of sexual exploitation. EEG studies, serum prolactin and muscle enzyme studies may help discriminate.

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