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poglycemia, cataplexy, paroxysmal ataxia and choreoathetosis, recurrent transient global amnesia, and hysterical pseudoseizures Often, in emergency departments, it is dif cult to differentiate the postictal effects of an unwitnessed seizure from mild confusion following cerebral concussion or from a brief loss of consciousness produced by a subarachnoid hemorrhage The clinical differences between a seizure and a syncopal attack are considered in Chap 18 Here it is emphasized that no single criterion stands inviolate The authors have erred in mistaking akinetic seizures for simple faints and vasovagal and cardiac faints for seizures If blood is tested after the episode in question, elevation in creatine kinase (persistent for hours) and prolactin (for up to 10 min) may be helpful in the diagnosis of a convulsive seizure Postictal confusion, incontinence, and a bitten tongue clearly bespeak seizure rather than syncope Absence attacks may be dif cult to identify because of their brevity Helpful maneuvers are to have the patient hyperventilate in order to evoke an attack or to observe the patient counting aloud for 5 min Those with frequent absence attacks will pause or skip one or two numbers The diagnosis of complex partial seizures is the most dif cult These attacks are so variable and so often induce disturbances of behavior and psychic function rather than obvious interruptions of consciousness that they may be mistaken for temper tantrums, hysteria, sociopathic behavior, or acute psychosis The careful questioning of witnesses of an attack is essential Verbalizations that cannot be remembered, walking aimlessly, or inappropriate actions and social behavior are characteristic As stated above, we have placed emphasis on amnesia for the events of at least part of the seizure as a crucial criterion for the diagnosis of temporal lobe epilepsy In all obscure forms of epilepsy, prolonged EEG and video monitoring may prove diagnostic A mild complex partial seizure, consisting of a brief loss of consciousness and lip-smacking, may be mistaken for an absence unless it is kept in mind that the former (but not the latter) is commonly followed by a period of confusion and dysphasia when the language areas are involved Epilepsy complicated by states of constitutional mental dullness and confusion poses special problems in diagnosis Most epileptic patients seen in a general hospital or in of ce practice show no evidence of mental retardation, regardless of the type of seizure Undoubtedly, seizures are more common in the mentally retarded, but recurrent seizures in themselves seldom cause intellectual deterioration (Ellenberg et al); when this does happen, one should suspect an underlying degenerative or hereditary metabolic disease An exception to this statement is the patient with frequent and uncontrolled subclinical seizures (nonconvulsive status) who is drugged or in a postseizure psychotic state Hospital admission and a systematic study of the seizure state and drug levels are necessary in the analysis of this problem Migraine should not be mistaken for a seizure, for reasons discussed on page 153 One feature of the focal neurologic disorder of classic migraine is particularly helpful namely, the pace of the sequence of cerebral malfunction over a period of minutes rather than seconds, as in partial epilepsy Even this criterion may fail occasionally, especially if both migraine and partial seizures are joined, eg, as expressions of a vascular malformation of the brain Useful in the identi cation of a transient ischemic attack (TIA) and its separation from partial epilepsy are the patient s age, evidence of disease of the heart or carotid arteries, and the lack of disorder of consciousness or amnesia Again, if the ischemic attack is marked by an evolution of symptoms, they tend to develop more.

slowly than those of a seizure, and by their nature TIAs tend to produce a focal loss of function without convulsions However, a limb-shaking TIA and convulsive phenomena at the outset of basilar artery occlusion may be nearly impossible to distinguish from epilepsy Drop attacks (falling to the ground without loss of consciousness) remain an enigma (page 329) In most cases, we have failed to substantiate their association with circulatory disturbances of the vertebrobasilar system and seldom have we observed them to be an expression of atonic or myoclonic epilepsy, but such an occurrence has been reported with the Lennox-Gastaut syndrome In some instances they represent simple unexpected falls, especially in stout older women who are sedentary The degenerative disease progressive supranuclear palsy may also present itself in this way (Chap 39) Regarding the distinction of narcolepsy, paroxysmal ataxia or choreoathetosis, transient global amnesia, hysterical fugues, panic attacks, and REM sleep behavior disorder from seizures, it is suf cient to be aware of the diagnostic criteria for each of these conditions

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