A 62-year-old man is brought to the emergency department after losing consciousness at church 30 minutes earlier. The patient was attending a service with his wife when he suddenly became unresponsive. He was noted to have brief jerking movements of the arms. The patient was helped to the floor and became responsive and was back at his baseline mental status after about 2 minutes. In the emergency department, the patient is awake and alert, and he has mild tongue pain. The patient had a similar episode 3 weeks ago; while sitting on the toilet, he became disoriented and then found himself lying on the bathroom floor. He had no lightheadedness or chest pain prior to these events. Medical history includes hypertension, myocardial infarction, and stroke with no residual neurologic deficit. Vital signs are within normal limits, and there are no orthostatic changes. A small, nonbleeding laceration is present on the lateral border of the tongue. The lungs are clear on auscultation, and heart sounds are normal. Neurologic examination reveals normal cranial nerves; there is no focal weakness or sensory loss. Which of the following findings in this patient are most indicative of epileptic seizure compared to syncope?

Question

A 62-year-old man is brought to the emergency department after losing consciousness at church 30 minutes earlier.  The patient was attending a service with his wife when he suddenly became unresponsive.  He was noted to have brief jerking movements of the arms.  The patient was helped to the floor and became responsive and was back at his baseline mental status after about 2 minutes.  In the emergency department, the patient is awake and alert, and he has mild tongue pain.  The patient had a similar episode 3 weeks ago; while sitting on the toilet, he became disoriented and then found himself lying on the bathroom floor.  He had no lightheadedness or chest pain prior to these events.  Medical history includes hypertension, myocardial infarction, and stroke with no residual neurologic deficit.  Vital signs are within normal limits, and there are no orthostatic changes.  A small, nonbleeding laceration is present on the lateral border of the tongue.  The lungs are clear on auscultation, and heart sounds are normal.  Neurologic examination reveals normal cranial nerves; there is no focal weakness or sensory loss.  Which of the following findings in this patient are most indicative of epileptic seizure compared to syncope?

Quizplus · Accepted Answer

11ec25c8_d58a_254d_bc81_73bda51a16f8_MD0003_00 Epileptic seizure results from a temporary hypersynchronization of electrical networks in the brain and typically manifests as a period of involuntary movements or actions that may be accompanied by loss of consciousness (LOC). Confirmation of epileptic seizure can be challenging because a number of conditions, including transient ischemic attack, migraine, panic attack, and psychogenic nonepileptic seizure (formerly known as pseudoseizure), can have similar presentation and must be considered in the differential diagnosis. Syncope can be especially difficult to differentiate from epileptic seizure, and accurate diagnosis largely depends on a detailed history of the event. Evidence of tongue biting is the most reliable finding to differentiate epileptic seizure and syncope. It has low sensitivity (33%) but high specificity (96%) for epileptic seizure (ie, very few false positives), making it highly useful in confirming the diagnosis when present. Lateral tongue biting is likely even more specific for epileptic seizure as frontal tongue biting is occasionally seen with syncope. (Choice A) Although abnormal convulsive movements of the extremities are common with epileptic seizure, they can also occur with syncope (due to transient cerebral hypoperfusion and hypoxia). The timing of convulsive movements (ie, before or after LOC) can help distinguish seizure from syncope, but the presence of the movements alone is not helpful. (Choice C) Episodic nature of symptoms is typical of syncope and most other diagnoses in the differential for epileptic seizure. It is not usually helpful in confirming the diagnosis. (Choice D) Patient position at onset of symptoms is relatively unhelpful in differentiating seizure from syncope. Although vasovagal syncope occurs in a standing position, cardiac syncope (eg, due to ventricular tachycardia) can, like seizure, occur in any position. (Choice E) A postictal period of ongoing confusion or other symptoms (eg, extremity weakness) is typical following epileptic seizure, and the duration of the period is highly variable (ranging from seconds to hours or even days). A long postictal period can be helpful in differentiating seizure from syncope, but this patient's return to baseline in 2 minutes is similar to a typical episode of syncope and is not significantly helpful. Educational objective: Epileptic seizure can present similarly to a number of other conditions and can be especially difficult to differentiate from syncope. Tongue biting, especially of the lateral tongue, is highly specific for epileptic seizure and can be helpful in confirming the diagnosis. References: Value of tongue biting in the differential diagnosis between epileptic seizures and syncope. (http://www.ncbi.nlm.nih.gov/pubmed/22770819) Value of tongue biting in the diagnosis of seizures. (http://www.ncbi.nlm.nih.gov/pubmed/7487261) The diagnostic value of urinary incontinence in the differential diagnosis of seizures. (http://www.ncbi.nlm.nih.gov/pubmed/23142708)

A 62-Year-Old Man Is Brought to the Emergency Department After