A simple, noninvasive cardiovascular evaluation may identify an alternative diagnosis in many patients with apparent epilepsy and should be considered early in the management of patients with convulsive blackouts.

This paper reports the results of a population study designed to assess the standards of epilepsy care within a geographical population in relation to diagnosis, seizure management and quality of life. One of the findings was the unexpectedly high frequency of the misdiagnosis of epilepsy. Forty-nine of 214 patients with a primary diagnosis of epilepsy were subsequently found to have been misdiagnosed following a specialist review and investigations. All except two have been withdrawn from antiepileptic medication. The diagnosis of epilepsy was disputed in a further 26 patients. Of the 49 patients, 20 were found to have cardiovascular or cerebrovascular pathology. Seven had only ever experienced a single seizure and a further 10 were found to have underlying psychopathology. Such observations support the view that epilepsy is frequently misdiagnosed and this paper discusses some of the implications of misdiagnosis.

The aim of this study was to determine whether intranasal midazolam is a safe and effective rescue medication in adolescent and adult patients with severe epilepsy. This field trial was designed to test the feasibility of the use of intranasal midazolam as an alternative to rectal diazepam in a cohort of patients with severe epilepsy who require rescue medication as part of their treatment. A dose of intranasal midazolam (5 mg if the patient weighed less than 50 kg and 10 mg if the patient weighed over 50 kilograms) was prescribed for those who had previously responded to other rescue medication. Midazolam was prescribed buccally if excessive head movement accompanied seizures. The protocol reverted to the usual rescue medication if there was no response to midazolam within 10 minutes. Vital signs were monitored for half an hour following the administration of the treatment. Twenty-two patients received 84 treatment episodes and 79 of these were considered clinically effective. Five treatment failures were recorded, three due to poor technique in delivering the midazolam. Two patients were successfully retried on midazolam and a third is awaiting a retrial of this drug. The two other treatment failures received the drug buccally. In the first patient the clinical opinion was that this was possibly a psychogenic non-epileptic seizure. The other patient responded initially, but within an hour had another seizure requiring further rescue treatment. No significant adverse effects were reported. Our study shows that intranasal midazolam, when used appropriately, is an effective treatment in those who require rescue treatment. There are clear advantages in the use of midazolam over diazepam in the treatment of acute seizures. These include the favourable pharmacokinetic and pharmacodynamic properties of midazolam as well as the potential of a more acceptable and dignified administration route.

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Differentiating psychogenic non-epileptic attack disorder (NEAD) from true epilepsy is difficult. This often results in a misdiagnosis and unnecessary and ineffective treatment. Prolonged EEG/video recording is the most sensitive tool for differentiating NEAD from epilepsy, but is costly and therefore limited in availability. Provocative tests, particularly the use of saline injection, can reduce the length of monitoring but give rise to ethical dilemmas. This study assesses the value of head-up tilt testing as a provocative test for NEAD. Twenty-one patients (17 female, mean age 34.6 +/- 11.5 years) with recurrent seizure-like episodes and a clinical diagnosis of NEAD were studied. Patients were tilted to 80( composite function )on an electric tilt table with footplate support for up to 45 minutes during continuous ECG, EEG and blood pressure monitoring. Seventeen patients (81%) experienced typical symptoms (non-epileptiform limb shaking in 15 patients, absence in one patient, myoclonic jerking in one patient) during head-up tilt without significant EEG abnormalities or haemodynamic changes. The mean time to onset of seizure-like activity was 13.2 +/- 11 minutes (range 0-31 minutes). No patients suffered injury or any other significant side-effect. Provocative testing using suggestion and head-up tilt is a sensitive tool for diagnosing NEAD and represents a safe, simple and inexpensive outpatient technique for investigating patients with suspected NEAD.