Ambiguous paroxysmal events

Fahad Salih Algreeshah MD (Dr. Algreeshah of King Saud Medical City has no relevant financial relationships to disclose.)
Melissa J Freeman MD (Dr. Freeman of USF College of Medicine has no relevant financial relationships to disclose.)
Selim R Benbadis MD (Dr. Benbadis of the University of South Florida and Tampa General Hospital received honorariums and/or consulting fees from SK, Lundbeck, and UCB.)
Jerome Engel Jr MD PhD, editor. (Dr. Engel of the David Geffen School of Medicine at the University of California, Los Angeles, has no relevant financial relationships to disclose.)
Originally released August 15, 2014; last updated July 12, 2019; expires July 12, 2022

Initial evaluation

The initial diagnosis of seizure is based on the history. If first-line treatment fails, the diagnosis is (or should be) questioned and verified. At epilepsy centers, where selected challenging patients are seen, the evaluation typically begins with video-EEG monitoring, which allows a clear diagnosis in the vast majority of cases (Benbadis et al 2004; Benbadis et al 2009). Typically, video-EEG will answer the following questions:

(1) Is it epilepsy or not?
(2) If it is not epilepsy, what is it?
(3) If it is epilepsy, what type?
(4) If seizures are focal, where is the focus?

In this article, we will focus on the first 2 questions. Is it epilepsy or not? If it is not epilepsy, what is it? In the vast majority of cases, the question of “epilepsy or not” is easily answered, so we will focus on the relatively small proportion of situations in which, despite good EEG or video-EEG recordings, the question remains difficult to answer. We will divide “ambiguous” events into clinical and electrographic events.

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