Syncope Vs Seizure: the quest for an answer

One of the readers of my blog sent me an interesting query. Here is her history. My response to it follows. I have deleted her name and hidden her email address to maintain her confidentiality.


HISTORY

Hi! I was grocery shopping in Wal-mart when I had my episode. I was walking to the front of the store after shopping for about an hour. My vision kept blacking out. It was like someone just turned out the lights. I would be able to see again and I would be standing there staring at something. This happened about 4 or 5 times over a ten minute span. The next thing I knew I was waking up in the hospital. Apparently I hit the ground started convulsing, my eyes rolled back and I was foaming at the mouth. I bit the side of my tongue, my body was horribly sore the next couple of days, but I didn’t have any bladder issues. I had no memory of the seizure or what had happened. I kept going in and hour for the next couple of hours. I busted my head on the floor which required staples. I had memory problems and balance issues for the next week. I then made an appointment with a neurologist. He thinks I have syncope. He sent me for my EEG to rule out epilepsy, but we haven’t got the results back yet. While I was having my EEG I started having facial spasms during the flashing light portion of the test. I’m reading about syncope and some of it just doesn’t fit. I am a HUGE salt eater. I crave salty foods all day! So if that was it, wouldn’t my diet be treating the syncope? Also, my sister has epilepsy. Her seizures are triggered by flashing lights. I have never had a seizure before. I have passed out in the past, but it was because of hypoglycemia. I don’t have any issues with heat or pain or seeing blood. It just doesn’t affect me. I just don’t know if he’s got the correct diagnosis and would like someone else’s opinion. Thanks!

Dear A,
                 thank you for writing in to me.  Your history has intrigued me and hence I shall dwell over it a little before offering my humble opinion.  It goes without saying, this opinion is offered without taking your history in person and examining you.  You should follow what your doctor tells you.  He/ she shall be the best person to guide further diagnostic and management issues.  Your recent event had features of both syncope as well as a seizure/ convulsion. So what in your history points towards syncope?
PRODROMAL FEATURES: meaning things which you felt prior to passing out. You felt light headed, your vision was blurred/ tunneled/ kept going in and out (it always fascinates me how patients use different words to describe the same symptom). Prior to a syncopal event patients may feel as if they are about to pass out/ faint. They may look pale (all the blood was drained out from the face), they may feel/ complain that their legs feel weak/ woobly.
I am uncertain what to make of the staring episodes which followed soon after. By staring do you mean you were unable to concentrate (may occur with syncope) or do you mean you had impairment in your level of consciousness and awareness ( goes more towards a seizure).
Anyways let us move forward. The next thing you remember is waking up in the hospital. From the bystander history, you were noticed to have convulsive movements. During the seizure, you lost body tone leading to a hard fall which cracked open your skull.  During the convulsion itself your eyes rolled back into your head, you foamed from the side of the mouth and bit the side of your tongue. Yes biting the side of the tongue goes more towards a seizure than biting the tip of your tongue. I am not sure who figured that one out though. You did not have loss of bladder control. Post the seizure, you were not yourself  for the next few days with a slow return to the baseline.
There I think I have summarized your history well. Well what happens next? Your history has features of both syncope as well a seizure.  I would have asked a few more questions:
1) did you feel anything prior to the event. We call these auras. Any strange smell, any strange taste and so forth.
2) have you ever had a seizure before.
3) any history of febrile convulsions?
4) are you prone to syncope: were you dehydrated, sick with the flu and so forth.
Well let us move forward. I am taking you step by step as I work through this history. So the doctor ordered an EEG (test to look at the brain waves). Why the EEG? Well simple if the EEG shows abnormal brain waves (I use the word misfiring of the brain), it points towards a seizure. If the EEG is normal, it may point towards syncope. That said and done, patients with seizures may have a normal EEG.
We do not have the EEG results. But during the test you mention something happened to you. Your face started twitching while photic stimulation was been carried out (flashing lights). Your sister has epilepsy and you say her seizures are triggered by flashing lights (usually patients who have primary generalized epilepsy have these kind of seizures).
So where does all this lead to?  My opinion: it is possible you have an underlying seizure disorder.
My recommendations: I would try my level best to rule out or rule in seizures. This may need a longer duration EEG study, if the first one is unrevealing. The decision to start anti-convulsant therapy shall be guided by all the above : history, examination findings, EEG findings and neuroimaging findings (CT scan or MRI brain).
THE BEST PERSON TO MAKE THAT DECISION–YOUR CURRENT DOCTOR AND NOT ME OVER THE INTERNET.  
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