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April 10, 2018; 90 (15) Article

Differentiating motor phenomena in tilt-induced syncope and convulsive seizures

Sharon Shmuely, Prisca R. Bauer, Erik W. van Zwet, J. Gert van Dijk, Roland D. Thijs
First published March 16, 2018, DOI: https://doi.org/10.1212/WNL.0000000000005301
Sharon Shmuely
From the Department of Research (S.S., P.R.B., R.D.T.), Stichting Epilepsie Instellingen Nederland, Heemstede, the Netherlands; NIHR University College London Hospitals Biomedical Research Centre (S.S., R.D.T.), UCL Institute of Neurology, Queen Square, London, UK; Lyon Neuroscience Research Centre (P.R.B.), INSERM U1028, CNRS UMR5292, Bron, France; and Departments of Medical Statistics (E.W.v.Z.) and Neurology (J.G.v.D., R.D.T.), Leiden University Medical Centre, the Netherlands.
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Prisca R. Bauer
From the Department of Research (S.S., P.R.B., R.D.T.), Stichting Epilepsie Instellingen Nederland, Heemstede, the Netherlands; NIHR University College London Hospitals Biomedical Research Centre (S.S., R.D.T.), UCL Institute of Neurology, Queen Square, London, UK; Lyon Neuroscience Research Centre (P.R.B.), INSERM U1028, CNRS UMR5292, Bron, France; and Departments of Medical Statistics (E.W.v.Z.) and Neurology (J.G.v.D., R.D.T.), Leiden University Medical Centre, the Netherlands.
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Erik W. van Zwet
From the Department of Research (S.S., P.R.B., R.D.T.), Stichting Epilepsie Instellingen Nederland, Heemstede, the Netherlands; NIHR University College London Hospitals Biomedical Research Centre (S.S., R.D.T.), UCL Institute of Neurology, Queen Square, London, UK; Lyon Neuroscience Research Centre (P.R.B.), INSERM U1028, CNRS UMR5292, Bron, France; and Departments of Medical Statistics (E.W.v.Z.) and Neurology (J.G.v.D., R.D.T.), Leiden University Medical Centre, the Netherlands.
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J. Gert van Dijk
From the Department of Research (S.S., P.R.B., R.D.T.), Stichting Epilepsie Instellingen Nederland, Heemstede, the Netherlands; NIHR University College London Hospitals Biomedical Research Centre (S.S., R.D.T.), UCL Institute of Neurology, Queen Square, London, UK; Lyon Neuroscience Research Centre (P.R.B.), INSERM U1028, CNRS UMR5292, Bron, France; and Departments of Medical Statistics (E.W.v.Z.) and Neurology (J.G.v.D., R.D.T.), Leiden University Medical Centre, the Netherlands.
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Roland D. Thijs
From the Department of Research (S.S., P.R.B., R.D.T.), Stichting Epilepsie Instellingen Nederland, Heemstede, the Netherlands; NIHR University College London Hospitals Biomedical Research Centre (S.S., R.D.T.), UCL Institute of Neurology, Queen Square, London, UK; Lyon Neuroscience Research Centre (P.R.B.), INSERM U1028, CNRS UMR5292, Bron, France; and Departments of Medical Statistics (E.W.v.Z.) and Neurology (J.G.v.D., R.D.T.), Leiden University Medical Centre, the Netherlands.
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Citation
Differentiating motor phenomena in tilt-induced syncope and convulsive seizures
Sharon Shmuely, Prisca R. Bauer, Erik W. van Zwet, J. Gert van Dijk, Roland D. Thijs
Neurology Apr 2018, 90 (15) e1339-e1346; DOI: 10.1212/WNL.0000000000005301

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Abstract

Objective We assessed motor phenomena in syncope and convulsive seizures to aid differential diagnosis and understand the pathophysiologic correlates.

Methods We studied video-EEG recordings of tilt-induced syncope and convulsive seizures in participants aged 15 years and older. Syncope was defined as (1) loss of consciousness (video-assessed), (2) circulatory changes (accelerating blood pressure decrease with or without bradycardia/asystole), and (3) EEG changes (“slow” or “slow-flat-slow”). We assessed myoclonic jerks and tonic postures of the arms and noted time of occurrence, laterality, synchrony, and rhythmicity (mean consecutive differences of interclonic intervals).

Results Video-EEG records of 65 syncope cases and 50 convulsive seizures were included. In syncope, postures occurred in 42 cases (65%) and jerks in 33 (51%). Fewer jerks occurred in syncope (median 2, range 1–19) compared to convulsive seizures (median 48, range 20–191; p < 0.001). Jerks were more rhythmic in seizures compared to syncope (p < 0.001). Atonia was seen in all syncope cases, while this was not observed in any seizure. Jerks predominantly occurred during the slow and postures during the flat EEG phase.

Conclusions Jerks and tonic postures were common in syncope, but semiology differed from convulsive seizures. The lack of overlap in the number of jerks suggests that less than 10 indicates syncope and more than 20 a convulsive seizure: the “10/20 rule.” Loss of tone strongly favors syncope. The EEG correlates imply that jerks in syncope are likely of cortical origin, whereas tonic postures may result from brainstem disinhibition.

Glossary

LR=
likelihood ratio;
MCD=
mean consecutive difference;
PGES=
postictal generalized EEG suppression;
S=
slow;
SFS=
slow-flat-slow;
TLOC=
transient loss of consciousness

Footnotes

  • Go to Neurology.org/N for full disclosures. Funding information and disclosures deemed relevant by the authors, if any, are provided at the end of the article.

  • Received August 24, 2017.
  • Accepted in final form January 8, 2018.
  • © 2018 American Academy of Neurology
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