Tilt Table Testing with Video EEG Monitoring in the Evaluation of Patients with Unexplained Loss of Consciousness

Abstract

It is well established that convulsive movements often accompany syncopal events yet many patients with these clinical features are misdiagnosed with seizures and often referred to epilepsy centers because they are refractory to treatment with anticonvulsant medications. Tilt table testing is the gold standard for diagnosing vasodepressor syncope, but it can fail to provide clinical details that help distinguish convulsive syncope from epileptic seizures and psychogenic events. This study evaluates the diagnostic utility of the addition of video and EEG monitoring during tilt table testing for patients with refractory episodes of unexplained loss of consciousness. Retrospective analysis was performed of 40 consecutive patients who were referred to the Emory Epilepsy Center and underwent tilt table testing with concomitant video-EEG between March 1, 2007 and December 1, 2008. EEG was recorded throughout the study in addition to video recording and single channel EKG. Events were classified as vasodepressor syncope, presyncope, or psychogenic. Tilt combined with video EEG was diagnostic in 26/40 (65%) of patients. Vasodepressor syncope was seen in 17/40 (42.5%), 9 of which had associated involuntary movements. Three patients experienced psychogenic non-epileptic events. Antiepileptic drugs (AEDs) were being prescribed for 17 patients, 7 of which were discontinued as a result of the testing. The majority of patients (38/40) had undergone prior neurological and cardiac evaluation with routine EEG, neuroimaging and/or Holter monitoring. Patients with convulsive syncope are often misdiagnosed and treated with AEDs despite prior neurodiagnostic and cardiac evaluation. Tilt table testing with video-EEG is useful in patients with refractory episodes of unexplained loss of consciousness and can avoid expensive non-diagnostic evaluations as well as ongoing treatment with unnecessary AEDs.

Frequency of a false positive diagnosis of epilepsy: A systematic review of observational studies

“…Twenty-six studies (Table 1) (Ojeda 2012 not included) reported the frequency of false positive diagnosis on 6912 people with epilepsy. The largest study [11] contributed 22% of patients, with the remaining studies ranging in size from 17 [27] to 850 [28] patients. Four studies included paediatric patients ( 18 years) only [28][29][30][31].…”

“…Four were population-based [9,10,24,32] studies recruiting patients from a base population of 75,200 [32], 15,000 [24], 200,000 [9] and 40,000 [10], respectively. Five studies (nine reports [21][22][23]27,[33][34][35][36][37]) recruited patients from head up tilt test (HUTT) or implantable electrocardiogram (ECG) recorder (ILR) centres. The remaining 17 studies recruited patients from epilepsy centres or tertiary hospitals.…”

“…In six studies [20,24,32,[40][41][42], the international classification of epileptic seizures and international classification of epilepsy and epileptic syndromes defined by International League against Epilepsy were used as the terminologies for the final diagnosis. Electroencephalogram (EEG) was used in 12 studies, video electroencephalography (v-EEG) was used in seven studies [27,30,38,41,[43][44][45] and ambulatory electroencephalography (a-EEG) in four [30,41,46,47]. Staff with expertise in epilepsy made the final diagnosis in only seven studies [10,29,32,41,[46][47][48].…”

Home Based Mobile Solution for Video Ambulatory EEG Monitoring

“…Ambulatory EEG recordings have increased yield of pickup of interictal epileptiform discharges (IED) due to longer recording times [8]. Video EEG may even aid the large number of elderly population who are misdiagnosed with the condition when they present with syncope [9]. Studies have also proven that short term video recordings may be used as a screening tool for longer in-patient video EEG recording [10].…”

Диференційна Діагностика Епілепсії Та Рухових Порушень

“…Частота нападів -до декількох разів на тиждень. Порушення свідомості під час нападів не буває, ЕЕГ під час нападу та після нього залишається незмінною (Chatterjee A. et al, 2002;Ohmori I. et al, 2002;Tsai J.D. et al, 2005;Kato N. et al, 2006; Panayiotopoulos C.P., 2010; Wolters E., Baumann C.…”