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cur day or night, regardless of the position of the patient; syncope rarely appears when the patient is recumbent, the only common exception being the Stokes-Adams attack The patient s color usually does not change at the onset of an epileptic attack; pallor is an early and almost invariable nding in all types of syncope except those due to chronic orthostatic hypotension or hysteria, and it precedes unconsciousness An epileptic attack, as indicated above, is more sudden in onset; if an aura is present, it rarely lasts longer than a few seconds before consciousness is abolished The onset of syncope is usually more gradual, and the prodromal symptoms are quite distinctive and different from those of seizures In general, injury from falling is more frequent in epilepsy than in syncope, because protective re exes are instantaneously abolished in the former (Nevertheless, cardiogenic syncope is an important cause of hurtful falls, especially in the elderly) Tonic spasm of muscles with upturning of the eyes is a prominent and often initial feature of epilepsy, but this occurs only rarely and late in the course of a faint; however, twitching and a few clonic contractions of the limbs may occur several seconds after the patient has fainted (see above) Urinary incontinence is a frequent occurrence in epilepsy, but it need not occur during an epileptic attack and may occasionally occur with syncope, so that it cannot be used as a means of excluding entirely the latter disorder The return of consciousness is slow in epilepsy, prompt in syncope; mental confusion, headache, and drowsiness are common sequelae of seizures, and physical weakness with clear sensorium of syncope (a brief period of grogginess may follow vasodepressor syncope) Repeated spells of unconsciousness in a young person at a rate of several per day or month are much more suggestive of epilepsy than of syncope The EEG may be helpful in differentiating syncope from epilepsy In the interval between epileptic seizures, the EEG, particularly if repeated once or twice, shows some degree of abnormality in 50 to 75 percent of cases, whereas it should be normal between syncopal attacks Sometimes one must resort to continuous EEG monitoring by tape recording or telemetry to clarify the situation (this can be combined with continuous ECG recording) Another useful laboratory marker of a seizure, especially if unwitnessed, is an elevation of the serum creatine kinase (CK) concentration; such a nding occurs only infrequently in the rare case of syncope associated with extensive muscle trauma Elevated prolactin levels have not proved discriminating enough for routine use in separating seizure from syncope but remain useful in distinguishing both of these from other causes of loss of consciousness, particularly hysteria, in which such elevations do not occur No single one of these criteria will absolutely differentiate epilepsy from syncope, but taken as a group and supplemented by the EEG, they usually enable one to distinguish the two conditions.

In patients who complain of recurrent faintness or syncope but do not have a spontaneous attack while under observation of the physician, an attempt to reproduce attacks may prove to be of great assistance in diagnosis Here it is important to recall that normal persons can faint if made to squat and overbreathe and then to stand erect and hold their breath (Valsalva maneuver) Prolonged standing at attention in the heat often causes even well-conditioned soldiers to faint, as does compression of the chest and abdomen while holding one s breath, as in the parlor trick of adolescents ( fainting lark )

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