Diagnosis and differential diagnosis

Epilepsy is a clinical rather than a laboratory diagnosis, and diagnostic errors most commonly occur due to inadequate history and physical examination. The accuracy of diagnosis has improved with the establishment of a universally agreed upon classification. In some instances there may be confusion between sleep arousal disorders and epilepsy.(53)

The differential diagnosis includes complex partial seizures of temporal origin and pseudoseizures. (54,56) Frontal-lobe complex partial seizures differ from those of temporal lobe origin in that the amnesia of frontal-lobe seizures is more pronounced than the extent of loss of consciousness. Moreover, frontal-lobe involvement is associated with unilateral or bilateral tonic posturing and pedalling movements, partial and not complete loss of consciousness, and eye and head deviation to the contralateral side. In complex partial seizures of temporal lobe origin, oroalimentary and repetitive hand automatisms, and looking around are characteristic. Lastly, sensory, gustatory, or olfactory hallucinations in frontal-lobe epilepsy must be differentiated from psychotic disorders such as schizophrenia and manic psychosis.

The distinction between true seizures and pseudoseizures can be difficult. Children with pseudoseizures commonly also have true seizures. Emotional dysphoria can precipitate true seizures and many children with chronic seizures have psychiatric diagnoses. Frontal-lobe seizures may be confused with pseudoseizures. Frontal complex partial seizures differ from pseudoseizures in that pseudoseizures have a gradual onset and longer duration, while frontal-lobe seizures start slowly and last less than 1 min.(53) Pseudoseizures include thrusting or rolling movements rather than the rhythmic flexion and extension clonic movements seen in frontal-lobe epilepsy. Still, it may be difficult to distinguish pseudoseizures, and video and electroencephalograph monitoring with depth electrodes may be necessary to definitively diagnose frontal-lobe epilepsy.

Other features differentiating pseudoseizures are as follows.

1. The seizure occurs when the child is observed, but not when alone.

2. The seizures are gradual rather than of sudden onset.

3. Uncontrolled flailing occurs, rather than true tonic-clonic movements.

4. The seizure is accompanied by histrionics, with screaming and shouting.

5. Painful stimuli are avoided during an attack; pain is avoided.

6. There is a sudden cessation of the seizure, with immediate return to an alert and responsive state.

7. There is absence of paroxysmal discharge during an attack on electroencephalography. (57)

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