00:01
When thinking about how to
differentiate seizures from other common
mimics, other common differential
conditions, one is syncope
and in this case we needed to
differentiate seizure from syncope,
and there are some
features we can use
to differentiate between
these two conditions.
00:17
The first is the position
in which they occur.
00:19
Seizures occur in any position,
syncope typically occurs,
when patients are standing upright
from a seated or lying position.
00:26
The duration of a seizure
is often one to two minutes,
about 90 to 95% of seizures
will resolve spontaneously
within the first three minutes.
00:34
Syncope is much shorter,
lasting only 30 seconds
or so when the patient is
has lost consciousness or
have altered awareness.
00:43
The tonic-clonic phase is
present in many motor seizures.
00:47
We can see that with syncope as
well with convulsive syncope,
but again, it's often very short
with a couple of jerks or a couple
of shakes throughout the body
after the patient
has passed out.
00:59
Incontinence is common in patients
with generalized-tonic clonic seizures,
but quite rare and syncope.
01:04
And postictal amnesia
is often present,
sometimes prolonged and seizures lasting
15 minutes up to two hours on average,
but it's very rare and would be
exceptional to see in syncope patients
come right back to after a
convulsive syncope event.
01:23
Some other features of convulsive
syncope that point us in that direction
and some were
present in this case,
we look for triggers like
orthostasis, changing of posture,
or history of
cardiac arrhythmia's,
dehydration or an emotional
stress can precipitate syncope.
01:37
Anxiety, pain, hyperventilation,
and coughing and micturition can be
associated with situational syncope.
01:44
We also think about the
pre-episode description,
convulsive syncope
should lack an aura
that's frequently present
in focal-onset epilepsy.
01:52
We also interrogate and
investigate the episode.
01:55
Convulsive syncope begins with
syncope and ends with a convulsion.
02:00
There typically is
no tongue biting,
and for seizures we often
see lateral tongue biting,
but often don't see tongue
biting and convulsive syncope,
and incontinence is rare.
02:10
After the event,
there is a rapid return to baseline
and really lacking post
event or postictal confusion.
02:18
Events are features that would
favour epileptic seizures
include an aura,
the brief duration of convulsions
lasting one to two minutes
longer than convulsive syncope,
postictal confusion,
abnormal posturing that is stereotyped
the same thing with each event,
amnesia to the event and
continence during the event.
02:36
Events that arise from sleep.
02:38
Convulsive syncope would
be very exceptional,
quite rare to occur out of sleep
and seizures can
occur from sleep.
02:44
Self-injury,
lateral tongue biting,
and eyes opening at
the onset of the event
would favour seizures as
opposed to convulsive syncope.
02:52
So some of these things can help
us in evaluating this patient
and certainly were
helpful in our case.
02:58
How do we differentiate seizures from
psychogenic non-epileptic spells,
functional spells,
these have many names,
behavioral, non-epileptic events,
and a number of other names
have been used to describe,
these we'll call them PNES or
psychogenic non-epileptic spells.
03:15
Again, if we think about the position,
seizures can happen at any position.
03:19
Whether the patient is
standing or lying or seated.
03:22
Psychogenic non-epileptic spells
typically happen when the
patient is lying down and safe.
03:27
The time and place,
seizures can happen day or night.
03:30
Psychogenic non-epileptic spells
are quite uncommon at night
and they usually
occur in the daytime.
03:37
The duration of seizures
is typically very short
resolving within one to
two to three minutes.
03:42
Psychogenic non-epileptic spells
are often less than two minutes,
but sometimes can
be quite prolonged.
03:47
Motor activity is
common in seizures.
03:50
With psychogenic non
epileptic spells,
it's less common in varying motor
activity as described during the events.
03:56
Postictal amnesia is usually
prolonged with seizures,
and quite short with psychogenic
non-epileptic spells.
04:03
And importantly, the eyes are
typically open during a seizure.
04:06
Patients don't close
their eyes often opened
with a staring trance
like appearance,
this distant stare.
04:14
With psychogenic non
epileptic spells,
we often see the eyes are closed
and patients may even have forced
eye closure that is resisted
with eye opening.
04:23
In fact, we can use this
nice mnemonic bad spells
to think about some of the features
of psychogenic non-epileptic spells
that help us to differentiate
between these two disorders.
04:32
The B is breathing,
post event or post convulsion
breathing is typically normal or fast.
04:38
In psychogenic non
epileptic spells,
which is different from seizures
where patients may bright or phrenic.
04:43
Abrupt cessation is a feature of
psychogenic non-epileptic
spells distractibility,
side to side head
movement or limb shaking,
pelvic thrusting,
eyes and mouth shut tight.
04:55
That's a really
important finding
that we asked both patients
and other observers.
05:00
Lack of stereotyped behavior.
05:03
Stereotypic events should
raise the suspicion
for seizure in psychogenic
non-epileptic spells
often lack that
stereotypic nature.
05:11
The spells are different from
spell to spell or event to event
and the semiology what happens
first, second, third,
throughout the event may change
for a psychogenic non-epileptic spell,
which is a typical for seizures.
05:24
And psychogenic non-epileptic
spells often stop and go.
05:27
They can stop and start and stop
and start during the episode
which would raise our
suspicion for this diagnosis.
05:33
Some other features we
see rocking and thrashing
or side to side movements,
pelvic thrusting,
should raise suspicion
for this aetiology.
05:40
We can see bizarre behavior
which can be difficult to differentiate
between frontal lobe epilepsy and PNES,
but should raise suspicion.
05:50
Vocalizations with
emotional content,
out of phase of the
extremity movements
would suggest us psychogenic
non-epileptic diagnosis.
05:59
And again, some other key events
that can suggest a diagnosis of
psychogenic non-epileptic seizures
would be non
traditional triggers,
events that occur in the waiting
room of a clinic or hospital.
06:12
Histrionic behavior
during the examination,
rapid cognitive
postictal recovery,
ability to induce a seizure
and presence of other
conditions like fibromyalgia
chronic pain or chronic
fatigue syndrome,
which can co occur with
psychogenic non-epileptic spells.