Diagnosis of Seizures
The selection of a course of treatment and accurate prognostic counseling require correct diagnosis and classification of the epileptic seizure type. Seizures are classified as partial onset or generalized onset by ictal behavior and EEG. The most common diagnostic differential for the adult neurologist is determining whether a paroxysmal, stereotyped neurological event is a primary generalized seizure, a partial seizure, or a nonepileptic event. Nonepileptic events comprise approximately 30% of admissions to our epilepsy-monitoring unit. Although most patients with nonepileptic events have psychogenic seizures, there are other conditions that can be mistaken for epileptic seizures, which are listed in the Table below.
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Differential diagnosis of epileptic seizures

• Syncope of cardiac origin: arrhythmias, congenital heart disease, cardiomyopathy

• Syncope of noncardiac origin: vasovagal, medication induced, orthostatic

• Migraine

• Transient global amnesia

• Cerebrovascular disease

• Metabolic: hypoglycemia, porphyria, renal/hepatic disease, pheochromocytoma

• Psychiatric disease: anxiety/panic disorder, conversion disorder, intermittent explosive disorder

• Sleep disorders: narcolepsy, parasomnias, paroxysmal nocturnal choreoathetosis

• Movement disorders: paroxysmal dyskinesias

• Psychogenic seizures

The history is essential in order to establish the correct diagnosis of a transient, paroxysmal event. Historical details which suggest that the event is a seizure include a warning, absence of pallor or color change, and lack of a postural component. Atypical movements and nonstereotyped behaviors are more usual for the nonepileptic event than are stereotyped, repetitive and well organized tonic-clonic movements, although there are exceptions. Tongue biting, fecal incontinence, and injury are rare in nonepileptic events, but may occur. Precipitating factors for seizures include sleep deprivation, concurrent febrile illness and menstruation. Prior exposure to seizures in a family member, friend, coworker or schoolmate is often found in patients with pseudoepilepsy, with the nonepileptic event closely mimicking the observed seizure.
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Useful diagnostic tests include an EEG awake and asleep and with activation procedures such as hyperventilation and photic stimulation. Special electrodes such as true temporal and sphenoidal increase the yield of detecting mesial frontal or temporal abnormalities. The patient may be asked to reproduce the conditions likely to precipitate the event while the EEG is recorded. A normal EEG does not exclude the possibility of epilepsy. Interictal epileptiform abnormalities will be detected in only 50% of patients with partial epilepsy on the first EEG, in 84% by the third and in 92% by the fourth. The EEG may remain normal even during a partial seizure, particularly a partial seizure of frontal lobe origin. Conversely, an abnormal EEG is not diagnostic of epilepsy. Between 2 to 18% of individuals with focal spikes on their EEG do not have epilepsy. In addition, many normal and pathological EEG transients may resemble epileptiform spikes but not be indicative of an epileptic condition. Only if a behavioral seizure is captured on EEG and characteristic ictal patterns are observed can an epileptic seizure be definitively diagnosed.

Imaging and other physiological testing is usually appropriate. An MRI is the test of choice in an individual with suspected partial epilepsy. The neuroradiologist will look for foreign tissue lesions, (AYM or tumor), for gliosis, and for anatomic abnormalities such as with cortical dysgenesis.
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For patients with persistent, nondiagnosed events, admission to an inpatient video-EEG-monitoring unit may prove the most effective and efficient means to diagnosis. The patient’s behavior and EEG are reviewed by the physician during a typical behavioral event. Other testing can be accomplished, including serum glucose, blood pressure, and EKG monitoring. Interictal and ictal serum prolactin can be determined. Psychiatric and medical consultation can be obtained concurrently. This multidisciplinary, comprehensive approach is most likely to establish the correct diagnosis, define appropriate treatment and to effect long lasting change.