{"id":9452,"date":"2021-10-18T21:52:33","date_gmt":"2021-10-18T21:52:33","guid":{"rendered":"https:\/\/medicalcriteria.com\/web\/?p=9452"},"modified":"2025-12-30T20:34:57","modified_gmt":"2025-12-30T20:34:57","slug":"seizures","status":"publish","type":"post","link":"https:\/\/medicalcriteria.com\/web\/seizures\/","title":{"rendered":"Clinical Aspects of the Diagnosis of Epileptic Seizures"},"content":{"rendered":"<div class=\"99c380e4b4a7b96c35d7ddf7dcb434e8\" data-index=\"1\" style=\"float: none; margin:0px 0 0px 0; text-align:center;\">\n<script async src=\"https:\/\/pagead2.googlesyndication.com\/pagead\/js\/adsbygoogle.js\"><\/script>\r\n<!-- MC 2019- Horizontal -->\r\n<ins class=\"adsbygoogle\"\r\n     style=\"display:block\"\r\n     data-ad-client=\"ca-pub-0127150553352455\"\r\n     data-ad-slot=\"3806776041\"\r\n     data-ad-format=\"auto\"\r\n     data-full-width-responsive=\"true\"><\/ins>\r\n<script>\r\n     (adsbygoogle = window.adsbygoogle || []).push({});\r\n<\/script>\n<\/div>\n<p>The clinician must investigate and corroborate key features of the history that help to better characterize seizures while distinguishing epileptic seizures from nonepileptic events. The most common nonepileptic paroxysmal events during childhood and adolescence are syncope, psychogenic nonepileptic events (PNES), pallid and cyanotic breath holding spells, reflux\/Sandifer syndrome, self-gratification disorders, and paroxysmal nonepileptic motor disorders of sleep among others. <!--more--><\/p>\n<p><strong>History and Physical Examination Findings That Help Characterize Seizures<\/strong><\/p>\n<table style=\"border-collapse: collapse; width: 100%;\" border=\"1\">\n<tbody>\n<tr>\n<td style=\"width: 19.2613%;\"><span style=\"font-size: 10pt;\">Predisposing factors<\/span><\/td>\n<td style=\"width: 15.9646%;\"><span style=\"font-size: 10pt;\">Pre-ictal semiology<\/span><\/td>\n<td style=\"width: 43.8034%;\"><span style=\"font-size: 10pt;\">Seizure semiology<\/span><\/td>\n<td style=\"width: 20.9707%;\"><span style=\"font-size: 10pt;\">Postictal semiology<\/span><\/td>\n<\/tr>\n<tr>\n<td style=\"width: 19.2613%;\"><span style=\"font-size: 10pt;\">Family history of seizures or epilepsy<\/span><br \/>\n<span style=\"font-size: 10pt;\">Cognitive and developmental deficits<\/span><br \/>\n<span style=\"font-size: 10pt;\">Precipitating events (trauma, fever, toxins, sleep deprivation, hyperventilation, flashing lights, etc)<\/span><br \/>\n<span style=\"font-size: 10pt;\">Preexisting structural brain lesion<\/span><\/td>\n<td style=\"width: 15.9646%;\"><span style=\"font-size: 10pt;\">Aura (vision of lights or colors, epigastric rising sensation, etc)<\/span><br \/>\n<span style=\"font-size: 10pt;\">Behavioral changes (ie, behavioral arrest\/unresponsiveness or period of confusion)<\/span><br \/>\n<span style=\"font-size: 10pt;\">Automatism (pill rolling, picking, lip smacking)<\/span><br \/>\n<span style=\"font-size: 10pt;\">Tiredness<\/span><br \/>\n<span style=\"font-size: 10pt;\">Irritability<\/span><br \/>\n<span style=\"font-size: 10pt;\">Lack of appetite<\/span><\/td>\n<td style=\"width: 43.8034%;\"><span style=\"font-size: 10pt;\">Order of appearance and duration of every semiologic component<\/span><br \/>\n<span style=\"font-size: 10pt;\">Level of consciousness (ability to understand)<\/span><br \/>\n<span style=\"font-size: 10pt;\">Motor activity (clonic, tonic, tonic clonic)<\/span><br \/>\n<span style=\"font-size: 10pt;\">Sensory abnormality<\/span><br \/>\n<span style=\"font-size: 10pt;\">Predominant side of occurrence of every component<\/span><br \/>\n<span style=\"font-size: 10pt;\">Vocal output (cries, grunts, etc)<\/span><br \/>\n<span style=\"font-size: 10pt;\">Stereotypical facial expressions (facial slackening, eyelid fluttering, staring, or eye deviation)<\/span><br \/>\n<span style=\"font-size: 10pt;\">Autonomic features (tachycardia, pallor, sweating, piloerection)<\/span><br \/>\n<span style=\"font-size: 10pt;\">Incontinence<\/span><br \/>\n<span style=\"font-size: 10pt;\">Respiration pattern<\/span><br \/>\n<span style=\"font-size: 10pt;\">Autonomic features (tachycardia, pallor, sweating, piloerection)<\/span><br \/>\n<span style=\"font-size: 10pt;\">Falls or loss of tone<\/span><br \/>\n<span style=\"font-size: 10pt;\">Total duration<\/span><br \/>\n<span style=\"font-size: 10pt;\">Presence of rhythmicity and evolution in frequency of event<\/span><\/td>\n<td style=\"width: 20.9707%;\"><span style=\"font-size: 10pt;\">Sleepiness<\/span><br \/>\n<span style=\"font-size: 10pt;\">Amnesia<\/span><br \/>\n<span style=\"font-size: 10pt;\">Confusion<\/span><br \/>\n<span style=\"font-size: 10pt;\">Headaches<\/span><br \/>\n<span style=\"font-size: 10pt;\">Partial paralysis<\/span><br \/>\n<span style=\"font-size: 10pt;\">Muscular pain<\/span><br \/>\n<span style=\"font-size: 10pt;\">Behavioral changes<\/span><br \/>\n<span style=\"font-size: 10pt;\">Predominant side of every component<\/span><br \/>\n<span style=\"font-size: 10pt;\">Presence of injury secondary to the seizure episode<\/span><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p>The clinician should investigate these features in every patient with a suspected first unprovoked seizure.<\/p>\n<p><strong>Main Differential Features of Seizures, Syncope, and Psychogenic Nonepileptic Seizures<\/strong><\/p>\n<table style=\"border-collapse: collapse; width: 100%; height: 774px;\" border=\"1\">\n<tbody>\n<tr style=\"height: 96px;\">\n<td style=\"width: 15.232%; height: 54px;\"><span style=\"font-size: 10pt;\"><strong>Events in the <\/strong><strong>history that are <\/strong><strong>suggestive of<\/strong><\/span><\/td>\n<td style=\"width: 23.5348%; height: 54px;\"><span style=\"font-size: 10pt;\"><strong>Before the event<\/strong><\/span><\/td>\n<td style=\"width: 30.2503%; height: 54px;\"><span style=\"font-size: 10pt;\"><strong>During the event<\/strong><\/span><\/td>\n<td style=\"width: 30.9829%; height: 54px;\"><span style=\"font-size: 10pt;\"><strong>After the event<\/strong><\/span><\/td>\n<\/tr>\n<tr style=\"height: 312px;\">\n<td style=\"width: 15.232%; height: 217px;\"><span style=\"font-size: 10pt;\">Epileptic seizures<\/span><\/td>\n<td style=\"width: 23.5348%; height: 217px;\"><span style=\"font-size: 10pt;\">Sleep deprivation<\/span><br \/>\n<span style=\"font-size: 10pt;\">Toxic exposure<\/span><br \/>\n<span style=\"font-size: 10pt;\">Toxic withdrawal<\/span><br \/>\n<span style=\"font-size: 10pt;\">Exposure to lights or sounds<\/span><br \/>\n<span style=\"font-size: 10pt;\">Sensory aura<\/span><br \/>\n<span style=\"font-size: 10pt;\">Epigastric rising sensation<\/span><br \/>\n<span style=\"font-size: 10pt;\">Hallucination<\/span><\/td>\n<td style=\"width: 30.2503%; height: 217px;\"><span style=\"font-size: 10pt;\">Stereotyped<\/span><br \/>\n<span style=\"font-size: 10pt;\">Lack of response to stimuli<sup>a<\/sup><\/span><br \/>\n<span style=\"font-size: 10pt;\">Automatisms<\/span><br \/>\n<span style=\"font-size: 10pt;\">Eyes generally opened; if closed, there is no resistance to passive opening<sup>a<\/sup><\/span><br \/>\n<span style=\"font-size: 10pt;\">Hypersalivation<\/span><br \/>\n<span style=\"font-size: 10pt;\">Incontinence<sup>a<\/sup><\/span><br \/>\n<span style=\"font-size: 10pt;\">Short duration (1 min or less)<sup>a<\/sup><\/span><br \/>\n<span style=\"font-size: 10pt;\">Vocalization, if present, consists of simple sounds (crying)<\/span><\/td>\n<td style=\"width: 30.9829%; height: 217px;\"><span style=\"font-size: 10pt;\">Prolonged period of altered consciousness (sleepiness, confusion, etc) until complete recovery<sup>a<\/sup><\/span><br \/>\n<span style=\"font-size: 10pt;\">Relatively frequent traumatic injury<sup>a<\/sup><\/span><br \/>\n<span style=\"font-size: 10pt;\">Tongue biting relatively frequent and present in the lateral side of the tongue<sup>a<\/sup><\/span><br \/>\n<span style=\"font-size: 10pt;\">There is no recall of the episode or the peri-ictal period<\/span><br \/>\n<span style=\"font-size: 10pt;\">Breathing is frequently deep and prolonged<sup>a<\/sup><\/span><\/td>\n<\/tr>\n<tr style=\"height: 216px;\">\n<td style=\"width: 15.232%; height: 139px;\"><span style=\"font-size: 10pt;\">Syncope<\/span><\/td>\n<td style=\"width: 23.5348%; height: 139px;\"><span style=\"font-size: 10pt;\">Emotional stress<\/span><br \/>\n<span style=\"font-size: 10pt;\">Prolonged standing<\/span><br \/>\n<span style=\"font-size: 10pt;\">Dehydration, hunger, pain<\/span><br \/>\n<span style=\"font-size: 10pt;\">Carotid sinus stimulation<\/span><br \/>\n<span style=\"font-size: 10pt;\">Elevated intrathoracic pressure (micturition, cough)<\/span><\/td>\n<td style=\"width: 30.2503%; height: 139px;\"><span style=\"font-size: 10pt;\">Pallor<\/span><br \/>\n<span style=\"font-size: 10pt;\">Sweat<\/span><br \/>\n<span style=\"font-size: 10pt;\">Repeated movements, if present, occur once on the floor, not while standing<\/span><br \/>\n<span style=\"font-size: 10pt;\">Brief loss of consciousness<\/span><br \/>\n<span style=\"font-size: 10pt;\">Incontinence may occur<\/span><\/td>\n<td style=\"width: 30.9829%; height: 139px;\"><span style=\"font-size: 10pt;\">Uncommon postictal headache or postictal confusion<\/span><br \/>\n<span style=\"font-size: 10pt;\">Rapid and complete return to baseline<\/span><br \/>\n<span style=\"font-size: 10pt;\">Infrequent traumatic injury<\/span><br \/>\n<span style=\"font-size: 10pt;\">Recall of the period around the episode<\/span><br \/>\n<span style=\"font-size: 10pt;\">Tongue biting typically midline or at the tip of the tongue<\/span><\/td>\n<\/tr>\n<tr style=\"height: 408px;\">\n<td style=\"width: 15.232%; height: 364px;\"><span style=\"font-size: 10pt;\">Psychogenic<\/span><br \/>\n<span style=\"font-size: 10pt;\">nonepileptic<\/span><br \/>\n<span style=\"font-size: 10pt;\">events<\/span><\/td>\n<td style=\"width: 23.5348%; height: 364px;\"><span style=\"font-size: 10pt;\">Appearance in a particular context (presence of witnesses, presence of significant others, emotions)<\/span><br \/>\n<span style=\"font-size: 10pt;\">Trance, dreamlike state<\/span><br \/>\n<span style=\"font-size: 10pt;\">Distortion of perception<\/span><br \/>\n<span style=\"font-size: 10pt;\">Sensation of death<\/span><br \/>\n<span style=\"font-size: 10pt;\">Gradual onset<\/span><br \/>\n<span style=\"font-size: 10pt;\">Sometimes the episode can be induced with certain maneuvers<\/span><\/td>\n<td style=\"width: 30.2503%; height: 364px;\"><span style=\"font-size: 10pt;\">Out-of-phase motor activity<\/span><br \/>\n<span style=\"font-size: 10pt;\">Vocalization of complex and purposeful sounds (words)<\/span><br \/>\n<span style=\"font-size: 10pt;\">Forceful closure of the eyes with resistance to passive eye opening<\/span><br \/>\n<span style=\"font-size: 10pt;\">Fluctuating course<\/span><br \/>\n<span style=\"font-size: 10pt;\">Violent movements<\/span><br \/>\n<span style=\"font-size: 10pt;\">Long duration (generally more than 1 minute)<\/span><br \/>\n<span style=\"font-size: 10pt;\">Trashing and grabbing behavior<\/span><br \/>\n<span style=\"font-size: 10pt;\">Pelvic thrusting<\/span><br \/>\n<span style=\"font-size: 10pt;\">Semipurposeful, goal-directed movements<\/span><br \/>\n<span style=\"font-size: 10pt;\">Confused staring<\/span><br \/>\n<span style=\"font-size: 10pt;\">Response to stimuli<\/span><br \/>\n<span style=\"font-size: 10pt;\">Directed rage<\/span><\/td>\n<td style=\"width: 30.9829%; height: 364px;\"><span style=\"font-size: 10pt;\">Inconsistent state of altered consciousness (sleepiness, confusion, etc)<\/span><br \/>\n<span style=\"font-size: 10pt;\">Shallow and rapid breathing<\/span><br \/>\n<span style=\"font-size: 10pt;\">Recall of the episode<\/span><br \/>\n<span style=\"font-size: 10pt;\">Correct but partial and feeble motor responses<\/span><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p><sup>a<\/sup>Typical characteristics of generalized motor seizures.<\/p>\n<p>&nbsp;<\/p>\n<p><strong>References:<\/strong><\/p>\n<ol>\n<li>Sansevere AJ, Avalone J, Strauss LD, Patel AA, Pinto A, Ramachandran M, Fernandez IS, Bergin AM, Kimia A, Pearl PL, Loddenkemper T. Diagnostic and Therapeutic Management of a First Unprovoked Seizure in Children and Adolescents With a Focus on the Revised Diagnostic Criteria for Epilepsy. J Child Neurol. 2017 Jul;32(8):774-788. <a href=\"https:\/\/pubmed.ncbi.nlm.nih.gov\/28503985\/\" target=\"_blank\" rel=\"noopener\">[Medline]<\/a><\/li>\n<li>Gavvala JR, Schuele SU. New-Onset Seizure in Adults and Adolescents: A Review. JAMA. 2016 Dec 27;316(24):2657-2668. <a href=\"https:\/\/pubmed.ncbi.nlm.nih.gov\/28027373\/\" target=\"_blank\" rel=\"noopener\">[Medline]<\/a><\/li>\n<li>Alessi N, Perucca P, McIntosh AM. Missed, mistaken, stalled: Identifying components of delay to diagnosis in epilepsy. Epilepsia. 2021 Jul;62(7):1494-1504. <a href=\"https:\/\/pubmed.ncbi.nlm.nih.gov\/34013535\/\" target=\"_blank\" rel=\"noopener\">[Medline]<\/a><\/li>\n<\/ol>\n<p>&nbsp;<\/p>\n<p>Created Oct 14, 2021.<\/p>\n\n<div style=\"font-size: 0px; height: 0px; line-height: 0px; margin: 0; padding: 0; clear: both;\"><\/div>","protected":false},"excerpt":{"rendered":"<p>Sorry, this entry is only available in Espa\u00f1ol.<\/p>\n","protected":false},"author":2,"featured_media":0,"comment_status":"closed","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_lmt_disableupdate":"no","_lmt_disable":"no","_exactmetrics_skip_tracking":false,"_exactmetrics_sitenote_active":false,"_exactmetrics_sitenote_note":"","_exactmetrics_sitenote_category":0,"footnotes":""},"categories":[2],"tags":[2434,2437,490,1401,2435,123,13,2438,2436,2439],"class_list":["post-9452","post","type-post","status-publish","format-standard","hentry","category-neurology","tag-aspectos","tag-aspects","tag-clinical","tag-clinicos","tag-convulsiones","tag-diagnosis","tag-diagnostico","tag-epileptic","tag-epilepticas","tag-seizures"],"modified_by":"Guillermo Firman","_links":{"self":[{"href":"https:\/\/medicalcriteria.com\/web\/wp-json\/wp\/v2\/posts\/9452","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/medicalcriteria.com\/web\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/medicalcriteria.com\/web\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/medicalcriteria.com\/web\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/medicalcriteria.com\/web\/wp-json\/wp\/v2\/comments?post=9452"}],"version-history":[{"count":9,"href":"https:\/\/medicalcriteria.com\/web\/wp-json\/wp\/v2\/posts\/9452\/revisions"}],"predecessor-version":[{"id":9492,"href":"https:\/\/medicalcriteria.com\/web\/wp-json\/wp\/v2\/posts\/9452\/revisions\/9492"}],"wp:attachment":[{"href":"https:\/\/medicalcriteria.com\/web\/wp-json\/wp\/v2\/media?parent=9452"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/medicalcriteria.com\/web\/wp-json\/wp\/v2\/categories?post=9452"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/medicalcriteria.com\/web\/wp-json\/wp\/v2\/tags?post=9452"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}