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Cited by 422Cardiovascular Syncope and Autonomic DisordersEpilepsy research and treatmentPsychosomatic Disorders and Their Treatments

Misdiagnosis of epilepsy: many seizure-like attacks have a cardiovascular cause

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Zaidi, Amir, Clough, Peter, Cooper, Paul, Scheepers, Bruce, Fitzpatrick, Adam P·2000·Journal of the American College of Cardiology
DOI 10.1016/s0735-1097(00)00700-2
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Abstract

Objectives We sought to investigate the value of cardiovascular tests to diagnose convulsive syncope in patients with apparent treatment-resistant epilepsy.Background As many as 20% to 30% of epileptics may have been misdiagnosed. Many of these patients may have cardiovascular syncope, with abnormal movements due to cerebral hypoxia, which may be difficult to differentiate from epilepsy on clinical grounds.Methods Seventy-four patients (33 men, mean age 38.9 +/- 18 years [range 16 to 77]) who were previously diagnosed with epilepsy were studied. Inclusion criteria included continued attacks despite adequate anticonvulsant drug treatment (n = 36) or uncertainty about the diagnosis of epilepsy, on the basis of the clinical description of the seizures (n = 38). Each patient underwent a head-up tilt test and carotid sinus massage during continuous electrocardiography, electroencephalography and blood pressure monitoring. Ten patients subsequently underwent long-term electrocardiographic (ECG) monitoring with an implantable loop recorder.Results In total, an alternative diagnosis was found in 31 patients (41.9%), including 13 (36.1%) of 36 patients taking an anticonvulsant medication. Nineteen patients (25.7%) developed profound hypotension or bradycardia during the head-up tilt test, confirming the diagnosis of vasovagal syncope. One other patient had a typical vasovagal reaction during intravenous cannulation. Two patients developed psychogenic symptoms during the head-up tilt test. Seven patients (9.5%) had significant ECG pauses during carotid sinus massage. In two patients, episodes of prolonged bradycardia correlated precisely with seizures according to the insertable ECG recorder.Conclusions A simple, noninvasive cardiovascular evaluation may identify an alternative diagnosis in many patients with apparent epilepsy and should be considered early in the management of patients with convulsive blackouts.

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  • The frequent use of EEG has been observed in other evaluations of diagnostic pathways for patients with syncope.

    “The frequent use of EEG has been observed in other evaluations of diagnostic pathways for patients with syncope.16,17”

    From Use of an implantable loop recorder to increase the diagnostic yield in unexplained syncope: results from the PICTURE registry (2011) · cites this paper as [17]

    The Methods report that 66 of 74 patients had undergone an interictal EEG, supporting frequent EEG use in this evaluation. However, the patients were referred with recurrent seizure-like episodes and a prior diagnosis of epilepsy; they were not enrolled as a cohort of patients with syncope. (LLM, conf=0.84)

    Experimental — accuracy not yet measured

  • In patients in whom epilepsy was suspected but the treatment has proven ineffective, an attack could have been documented by ILR in 62% of patients, with an arrhythmic cause being responsible in 26%.

    “Patients in whom epilepsy was suspected but the treatment has proven ineffective: in pooled data, an attack could have been documented by ILR in 62% of patients, with an arrhythmic cause being responsible in 26% 137,189-191”

    From 2018 ESC Guidelines for the diagnosis and management of syncope (2018) · cites this paper as [137]

    The Methods (page not available) include patients whose attacks continued despite anticonvulsant treatment and report that 10 patients received an implantable loop recorder. The follow-up passage (page not available) says the recorder identified bradyarrhythmias during attacks in two patients. This supports the clinical setting and an arrhythmic finding, but the paper does not report the pooled figures of 62% with a documented attack or 26% with an arrhythmic cause. (LLM, conf=0.87)

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  • Tilt testing may be helpful in separating syncope with abnormal movements from epilepsy.

    “Tilt testing may be helpful in separating syncope with abnormal movements from epilepsy. 137”

    From 2018 ESC Guidelines for the diagnosis and management of syncope (2018) · cites this paper as [137]

  • In the EGSYS 1 population, reflecting the clinical context in 2001, the rates of MRI and/or CT scan were 20%.

    “In the EGSYS 1 population, reflecting the clinical context in 2001, the rates of MRI and/or CT scan were 20%.17”

    From Use of an implantable loop recorder to increase the diagnostic yield in unexplained syncope: results from the PICTURE registry (2011) · cites this paper as [17]

    The Methods describe 74 patients previously diagnosed with epilepsy and report brain CT or MRI in 53 of them. Our copy does not identify an EGSYS 1 population or report its imaging rate; searches for EGSYS 1, 2001, and the 20% figure did not locate the claimed result. The rate in this paper's different population cannot establish or refute the EGSYS 1 rate. (LLM, conf=0.78)

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Cites

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1 of the 33 references couldn’t be matched to a known paper.

Research works printed but not linked: 4

  1. Gastaut H. Syncopes: generalized anoxic cerebral seizures. In: Magnus O, Lorentz de Haas AM, editors. The Epilepsies. New York: Elsevier, 1974:815-35.
  2. Chadwick D. Epilepsy. J Neurol Neurosurg Psychiatry 1994;57:264 - 77.
  3. Fitzpatrick AP, Sutton R. Blood pressure and heart rate during positive and negative 60° head-up tilt testing. Eur J Card Pac Electrophysiol 1991;1:25-30.
  4. Silvani S, Ciucci G, Verita E, et al. Correlation between positivity type of tilt test and simultaneous EEG: preliminary results (abstr). Pro- ceedings of the VII International Symposium on Progress in Clinical Pacing 1998;48.

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Authors
Zaidi, A., Clough, P., Cooper, P., Scheepers, B., & Fitzpatrick, A. P.
Affiliations
  • Manchester Royal Infirmary (GB)
  • Salford Royal Hospital (GB)
Corresponding author
Zaidi, Amir
ORCID
Cooper, Paul
Venue
Journal of the American College of Cardiology
Publisher
Elsevier BV
Published
2000-07
Volume
36
Issue
1
Pages
181-184
ISSN
0735-1097 (ISSN-L)
DOI
10.1016/s0735-1097(00)00700-2
OpenAlex
W2045800993
Cited by
422
References
33
Citations by year
2026: 9 · 2025: 10 · 2024: 14 · 2023: 12 · 2022: 12 · 2021: 12 · 2020: 14 · 2019: 23 · 2018: 19 · 2017: 18 · 2016: 24 · 2015: 22 · 2014: 22 · 2013: 20 · 2012: 13
FWCI
9.36
Type
journal article
Language
en
Open access
Licence
Locations
  • Journal of the American College of Cardiology (publishedVersion)
  • PubMed (publishedVersion)
Topics
  • Health Sciences › Medicine › Surgery › Cardiovascular Syncope and Autonomic Disorders
  • Health Sciences › Medicine › Psychiatry and Mental health › Epilepsy research and treatment
  • Health Sciences › Medicine › Psychiatry and Mental health › Psychosomatic Disorders and Their Treatments
Keywords
epilepsy misdiagnosis, convulsive syncope, cardiovascular syncope, vasovagal syncope, drug-resistant epilepsy, head-up tilt, carotid sinus massage, implantable loop recorder, bradycardia, hypotension, psychogenic non-epileptic seizures, seizure-like events
MeSH terms
Adolescent, Adult, Aged, Blood Pressure, Diagnosis, Differential, Diagnostic Errors, Electroencephalography, Epilepsy, Female, Heart Rate, Humans, Male, Middle Aged, Seizures, Electrocardiography, Ambulatory, Blood Pressure Monitoring, Ambulatory, Tilt-Table Test, Syncope, Vasovagal

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