Syncope Vs Seizure

Question 1

Difference between seizures and syncope

Answer 1

Seizure - sudden uncontrolled electrical activity in the brain

• if 2+ at least 1 day apart => epileptic seizure
• can be caused by many mechanisms
• urgent referral for TLOCs with features strongly associated with epileptic seizures

Syncope - loss of consciousness from cerebral hypoperfusion

• can be caused by many mechanisms
• do not routinely refer if there signs of vasovagal syncope even if associated with brief jerking

Question 2

Diagnosis of a seizure

Answer 2

Assess the type - history
Is it epileptic? - neuro imaging, physical
Forming a diagnosis - EEG

Question 3

Causes of syncope

• benign
• malignant

Answer 3

Reflex syncope - fall in HR, BP

• Vasovagal - triggered by emotion, pain, stress
• Carotid sinus syndrome - baroreceptor hypersensitivity to increased pressure lowers HR
• Situational - cough, micturition, defecation

Postural hypotension - volume depletion (diuretics, alcohol, bleeds, diarrhoea)

Cardiogenic - insufficient CO

• arrythmias - heart blocks, brady/tachy
• structural - valvular, MI, myopathy

Question 4

Seizure markers

Answer 4

Before

• prodromal deja vu, jamais vu
• aura
• aphasia

During - episodes last for minutes

• limb jerking
• unusual posture
• tongue biting
• urinary, fecal incontinence

After

• confusion
• amnesia of events before, during and after seizure

Question 5

Syncope markers

Answer 5

Before

• SNS flight or fight response
• head turning trigger carotid sinus syndrome

During - episodes last for seconds
-Brief limb jerking

After
-Tiredness but no confusion

Question 6

Investigations for syncope

-management for outcomes

Answer 6

CV history, exam

• chest pain
• FHx of SCD
• abnormal ECG, examination

Suspecting arrythmias => echo, ECG, angiography

Postural BP - S U90 / S falls by 20+ / D falls by 10+ => postural hypotension
-drug history

If triggered by head turning => Carotid sinus massage - carotid sinus syndrome

If nothing abnormal found => vasovagal

Vasovagal, carotid sinus syndrome, situational - conservative management, avoid triggers
Cardiac cause - treat underlying cause
Orthostatic hypotension - remove precipitants, if ineffective refer to neurology

Question 7

Investigations for seizures

Management depending on outcomes

Answer 7

EEG - only done if history suggests epilepsy
MRI, CT - if a focal cause suspected, used to identify structural abnormalities
-rule in/out psychogenic non epileptic seizures

Assess for triggers => treat underlying cause

Epilepsy - AEDs
PNES - psychiatry, psychology