Is it a seizure or is it syncope: going over the basics again
12Apr09
Nitin K. Sethi, MD
Assistant Professor of Neurology
New York-Presbyterian Hospital
Weill Cornell Medical Center
New York, NY 10065
I have written about this before but thought this would be a good time to go over the basics again. So let us begin with an example. Our main actor (lets call him John) is working in his office. The clock strikes 12 and he decides to step outside to smoke. It has been a tough day at work for John. Went out with a couple of friends last night and had one too many Jack Daniels on the rocks (with a slice of lime!!!). This liberal indulgence in the bubby resulted in John waking up dehydrated and with the worst hangover of his life. That combined with a cold he is still nursing and you can imagine John is a very unhappy camper.
So John steps out to smoke. Lights up and takes a deep puff. Ahhhhhhhhhhhhhh. And then it happens. He feels light headed, dizzy, his vision starts to grey and before he knows it he is on the floor. His friend who sees him fall, rushes to help him. By the time he reaches John, John is already coming around. He attempts to get up on his feet and asks his friend what happened. He is alert and oriented and apart from a bruised ego, he feels well.
Now lets go to case scenario number 2. John is again our main actor. In this case though John is having a good day. He slept well the night before and steps out to have a smoke. He lights up. Ahhhhhhhhhhh. Life sure feels good. And then it happens. He stiffens up. A cry is heard (we call this the epileptic cry) and then he takes a hard fall to the ground. After falling to the ground, he is noted to “shake” by his friend who has since rushed to his side ( I saw him shaking–both arms and legs, it was horrible. He was foaming at the mouth and I thought he was going to die is how his friend describes the event to the EMS later on!!!). After a minute, John stops shaking but he does not come around immediately. He remains confused and disoriented till the arrival of the EMS 15 minutes later. John later tells the doctor in the ER that he has bitten his tongue and lost control of his bladder (wet his pants) during the episode.
So after presenting these two case scenarios, my question to you is in which scenario did John have a syncope (fainting episode) and which was a seizure?
In the next post we shall pick up John’s story from the ER. Hopefully we can make him feel better.
Is it a seizure or is it syncope? the story continues….13Apr09
So our story ended with John in the ER. As many of you rightly guessed the first case scenario represents a typical syncopal episode while in the second case John had a generalized convulsion (seizure).
So what are the points in the history which favor syncope and which favor a seizure?
When a patient presents to a neurologist with an episode of loss of consciousness, it is imperative that we try to elucidate the underlying cause. As you can imagine the treatment of both these conditions is very different.
Syncope (fainting) can come either from the heart (we call this cardiogenic syncope) or from the brain (we call this neurogenic syncope or vasodepressor syncope or more commonly as vasovagal syncope). So for example you can faint (have a syncopal episode) if you have a sudden massive heart attack, or a transient arrhythmia of the heart (the heart beat fluctuates). As you can imagine these are potential lethal causes and hence patient’s who present with syncope are frequently evaluated for these cardiac conditions. Tests like ECG, prolonged 24 ECG (electrocardiogram) and sometimes an echocardiogram are ordered. Vasovagal syncope on the other hand is more benign and our patient John likely had a vasovagal syncopal episode in case scenario No 1. Another classical example of vasovagal syncope is when someone faints when he or she sees blood for the first time (frequently reported in medical students when they go into the OR for the first time).
So what are the points which favor syncope?
1. Feeling light-headed prior to the episode
2. Feeling dizzy as if you are about to faint.
3. Blurring of vision at the onset of the episode ( Doctor I felt light headed, a little woosy, my vision started to go black and then I passed out)
4. Syncope usually occurs in an upright position (patient is usually standing when it occurs). Syncopal patients usually do not shake (that is they do not have convulsive movements. There is an entity called syncopal convulsion where in the episode starts with a syncope but then goes on to become a seizure. I shall not go into the details here as then it shall become confusing).
5. Usually the loss of consciousness is of very short duration. Once they fall to the ground and the blood rushes to their brain (as gravity has been eliminated), they rapidly regain consciousness.
6. They are not confused after the episode. They come around rapidly and know where they are (they are not confused and disoriented after the episode).
7. Syncopal patients usually do not bite their tongue or have loss of bladder control (wet their patients) during an episode.
What are the points which favor a seizure?
1. Patients who have a seizure do not get the type of prodomal symptoms which patients with syncope do. Meaning they do not feel light-headed, dizzy as if they are about to pass out. Seizures frequently occur out of the blue with no warning whatsoever. That said and done, some patients with seizures which come from the temporal lobe may get an aura. Multiple different types of auras have been reported in temporal lobe epilepsy (smell of burning rubber, metallic taste in the mouth, a rising sensation in the tummy among many others).
2. Seizures can occur in any position-standing, sitting, lying in bed and frequently in sleep too.
3. Patients who have a convulsion shake. We call this tonic clonic movements of the arms and legs (first they are noticed to stiffen up, the eyes may roll up or get deviated to one side and later jerking of the arms and legs occur).
4. The tongue may get caught inbetween the teeth as the patient is stiffening up or when they are having a convulsion (shaking). This frequently leads to a tongue bite (usually on the lateral border of the tongue).
5. When the patient stiffens up, the muscles of the urinary bladder go into a spasm and the patient may end having loss of bladder control (wet their pants). This may also occur when the seizure finally ends and the muscles relax.
6. Frequently patients after a seizure are confused and disoriented for a while. We call this the post ictal state.
7. Seizures frequently lead to loss of muscle tone. The patient falls and hits the ground hard. This may lead to cranio-facial injuries and even fractures. Patients with syncope on the other hand do not fall hard, rather thay seem to ease themselves to the ground.
As you can see now syncope and seizures may resemble each other superficially but a good history is usually able to clarify the diagnosis.
