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Misdiagnosis of epilepsy: many seizure-like attacks have a cardiovascular cause
Open accessAbstract
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.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]
Experimental — accuracy not yet measuredThe source backs part of the claim, not all of it — or backs it for a different population, condition or comparison.
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“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]
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“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]
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“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]
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Developed in collaboration with, European Heart Rhythm Association (EHRA), Heart Failure Association (HFA), and Heart Rhythm Society (HRS), societies, E. B. T. F., European Society of Emergency Medicine (EuSEM), European Federation of Internal Medicine (EFIM), European Union Geriatric Medicine Society (EUGMS), American Geriatrics Society (AGS), European Neurological Society (ENS), et al. (2009) · European Heart Journal · doi:10.1093/eurheartj/ehp298 · Cited by 2,040
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Metadata
- 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)
- 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
- bronze
- doi.org
- Licence
- Locations
- Journal of the American College of Cardiology (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiovascular Syncope and Autonomic Disorders
- Health Sciences › Medicine › Clinical Neurology › 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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