Seizures versus syncope versus Non-Epileptic Seizures


IMA virar Newsletter


Seizures – 6 things to know


1. Seizures can produce any symptom


Seizures happen due to uncontrolled electrical activity in the brain. This uncontrolled electrical activity explodes, lasts for about 1 minute and then stops. The brain is stunned by this electrical jolt from the blue!


Seizures can involve only one part of the brain. They usually cause this part of the brain to become hyperactive.


So for example – if the seizure involves the part of the brain that handles smell, you can get a bad smell. If the seizure involves the part of the brain that “sees”, you may have visual hallucinations. Some people get the feeling of floating outside their body (autoscopy). Some may hear songs they had forgotten long ago… and so on.


Case 1: 

Recently I saw a patient who had recurrent attacks of dizziness. These usually happened at night, were very short (about 1 minute), and terrified the patient. Many doctors had diagnosed her as having  a psychiatric problem. A very well-meaning neurologist thought they could be seizures and sent her to me. 

After listening to the patient, we discussed that these could be seizures. Now, she is much better on standard anti-seizure medications.

Tip: Consider seizures in any patient who reports episodic stereotyped symptoms.



Sometimes, the uncontrolled electrical activity spreads all over the brain. Then, you get dramatic symptoms. The person loses consciousness. His/her entire body first stiffens up (the tonic phase) after which it starts jerking (the clonic phase).


Do these two phases always happen? Not at all!


Often, the tonic phase is very short or absent. The person only has repetitive jerking during the seizure (a clonic seizure). Some children have purely tonic seizures. Their entire body suddenly stiffens up while walking and they fall down.


So how do you recognize a seizure? Remember: “A seizure is a sudden burst of uncontrolled electrical activity in the brain, which usually produces clinical symptoms.”


Epilepsy is the tendency to have recurrent unprovoked seizures. Some patients with seizures (e.g. alcoholics) may not have Epilepsy. But that is a conversation for another day…


2. Other conditions can produce the same symptoms


Many conditions can cause similar symptoms. Lets forget the uncommon conditions (e.g. Narcolepsy) & talk about 2 common conditions:

  1. Syncope (including Cardiac Arrhythmia) &
  2. Non-Epileptic seizures



The brain does not get enough blood/oxygen. Hence the patient loses consciousness. For example, this can happen if the patient gets up suddenly (orthostatic hypotension). But a more serious cause is a problem in the pumping of blood – heart problems.


Cardiac arrhythmias are common in the elderly. They can cause syncope. If left untreated, they can also cause sudden death.


Case 2:


A 70 year old started to pass out. He used to suddenly fall to the ground and stiffen up. His eyes closed. After 20 seconds – he would suddenly sit up completely normal, as if he had woken up from the dead!

His 2d echo, routine ECG, MRI and EEG were all normal. He was started on anti-seizure medications by the neurologist. When he started taking Lacosamide, his episode frequency increased. He started having events almost every day.


When he came to us, we did video-eeg monitoring. We found that he had intermittent complete heart block. This junctional arrhythmia had become worse because of slow sodium-channel blockade by Lacosamide. He had a pacemaker/defibrillator on the same day and has been episode-free since then.

Tip: In an elderly patient with episodic loss of consciousness, try to rule out cardiac arrhythmia before diagnosing seizures. 


Non-Epileptic Seizures:

These are a problem of the mind, rather than the brain. We used to call them pseudoseizures. But this terminology is incorrect. It underestimates the problem. It makes doctors less sympathetic. A better term is Non-Epileptic Seizures (NES).


Non-epileptic seizures (NES) can lead to severe injury, including tongue bite & fractures. They are disabling. A patient with uncontrolled non-epileptic seizures cannot hold a job. Finally, they point to a serious mental health condition. In western studies, 50% of patients with NES have a history of childhood sexual abuse.


Case 3:

Many patients are quickly diagnosed as “non-epileptic” because of their florid psychiatric history. One woman in particular is very clear in my mind.


She was disheveled when she came to my OPD. Her family reported bizarre short events of confusion. Doctors had earlier diagnosed these as non-epileptic seizures. These sometimes happened while the patient was sleeping.

With video-EEG, we were able to determine that these were actually epileptic. She is now much better with anti-seizure medications.

Tip: Having a mental health problem does not rule out epileptic seizures.



Seizures (especially in the frontal lobes) can cause prolonged agitation and antisocial behavior. Some people go to jail because of this behavior. Uncontrolled seizures can lead to severe depression. All these symptoms need to be treated compassionately.


3. It is important to ask about the post-episode phase

How do we determine if some has epileptic seizures, syncope or non-epileptic seizures? Let’s discuss this!

Before the event:

Patients with syncope may report lightheadedness, tunnel vision or sounds becoming distant. Onlookers may report paleness of skin or sweating.


Any other symptoms should arouse suspicion for a seizure disorder.  We call such symptoms before a big seizure an “Aura”. An aura is the symptoms produced by a seizure in a small part of the brain, before it spreads. As noted before, auras can be surpisingly varied. One patient I had reported seeing 3 other people around her before the seizure.


Patients with non-epileptic seizures can report an Aura as well. These are also varied.


During the event:

Everyone is scared! Few people remember details during an event. Thus, spending too much time on this part of the history is not productive.


Yes, you can ask about stiffening, shaking, tongue bite and incontinence. They are more common in Epileptic seizures. But, these symptoms can be present in all 3 conditions: epileptic seizures, NES and syncope. 


Tip: Search youtube for “Lempert Syncope” to see the abnormal movements during syncope. You will be surprised to see how much they can resemble seizures.


The following 2 things are most high-yield:


  1. Duration: Non-epileptic seizures can last for a long time (even hours). Most seizures and all syncopal episodes last for 1 minute or less. A longer syncopal episode causes death.


  1. Eyes: If their eyes were open during the event, it is likely to be an epileptic seizure. Conversely, if the eyes were closed, it is likely to be a syncope or non-epileptic seizure.


After the event:

Patients with seizures are usually dazed for a long time. It takes at least 5-10 minutes for the patient to come back to normal. Sometimes they can be groggy or sleep for the entire day.


Patients with syncopal episodes wake up abruptly! They suddenly become perfectly alert! They are bewildered to find all the worried people around them, and their first question usually is “Why are all of you staring at me???”


The recovery after Non-epileptic seizures is usually slow, like Epileptic seizures.


In summary, the following things suggest epileptic seizures:

– Strange symptoms before loss of consciousness (Aura)

– Short loss of consciousness with eyes open

– Slow return to baseline


Yes, there are always exceptions. For example, frontal lobe seizures can have a very short recovery period. But these are the rules.


Case 4:

Read case 2 again. What do you think of it now?


4. Routine EEG and MRI are not very useful for diagnosing Epilepsy


Sometimes, we rely too much on machines. Just like an ECG can be normal in MI, both the MRI and the EEG can be normal in patients with Epilepsy.


In fact:

  • 50% of patients with Epilepsy have a normal MRI
  • 70% of patients with Epilepsy have a normal routine EEG


Tip: Don’t do a CT or use contrast. 



Why do these tests then? For a few reasons:


  • The MRI may show something nasty in the brain like a tumor.
  • An abnormal EEG can confirm the diagnosis of Epilepsy (false positives are uncommon).
  • The kind of abnormality seen on EEG can help to determine the type of antiepileptic used. It can help to plan duration of therapy. For example: Juvenile Myoclonic Epilepsy (JME) usually needs life-long treatment with anti-myoclonic antiepileptics.


Never conclude that the patient doesn’t have epilepsy just because the MRI and EEG are normal. All the patients I have described so far had normal MRIs and EEGs!


We treat the patient, not the tests.


5. When the diagnosis is unclear, Video EEG monitoring is useful.


Assume that you have a patient who is having frequent spells, almost daily. You are not sure she has epileptic seizures, or syncope or non-epileptic seizures. You do an EEG and MRI – as expected, both are normal. What next?


If you take a careful history, you may be able to make a preliminary diagnosis of Epileptic seizures. At this stage, a trial of antiepileptic medications such as levetiracetam is useful. If the events stop, great! But what if the events don’t stop?



Video EEG can give you the answer. We admit the patient for 1 to 7 days, and continuously record EEG and video. In contrast to a routine EEG, the EEG and video during an event can diagnose seizures about 95% of the time.


You should consider referring the following patients for video-EEG:


  1. Patients with frequent spells, whose diagnosis is not clear.
  2. All patients with medically resistant epileptic seizures (see below)
  3. Patients with suspected non-epileptic seizures who don’t  improve with psychiatric treatment Video-EEG helps in acceptance of the diagnosis. Sometimes, it uncovers diagnostic errors – some of these patients have Epileptic seizures.
  4. Patients with suspected epileptic encephalopathy. For example: If a child gradually stops talking after having seizures.


Case 5.

Last year I had diagnosed a young girl as having Epileptic seizures. I started her on an Antiepileptic and she stopped having seizures.


About 4-6 months ago, there was a death in her family which disturbed her. She started getting repeated seizure-like episodes. Her local neurologists escalated her antiepileptics but she kept having events.


When she contacted us, she was having almost daily events. Her video-EEG captured many non-epileptic events. A psychiatrist counselled her. Her antiepileptics were not changed. She now feels much better but her seizure frequency is yet to decrease.


Tip: Patients can have both epileptic and non-epileptic seizures. 50% of patients with seizures also have non-epileptic events during their lifetime.



6. If seizures do not stop, surgery is an excellent option


About 30% of patients keep having seizures no matter how many medications you start. These patients have “Medically resistant Epilepsy”.


In fact, if 2 antiseizure medications don’t stop seizures, the chances of seizure-freedom with more medications is less than 10%. (Per the paper the precise number is 4% – Kwan, Brodie et al published in NEJM)



The first steps in such a patient are:

(1) Confirm that the patient is actually taking medications.

(2) Confirm the diagnosis with video-EEG if needed


Once you rule out these factors, consider seizure surgery. Removal of the bad part of the brain may lead to seizure freedom in upto 80% of patients.


Case 6:

6 months ago a colleague at Nanavati (Dr. Pradyumann Oak, a renowned stoke expert) referred a patient. He was a young boy with medically resistant epilepsy. He had seen many neurologists, and tried many medications. He had seizures almost twice per week. We rapidly worked him up with a video eeg, Pet scan, fMRI and did the surgery about 10 days after presentation.


He has been completely seizure free since then. His father though is still a bit disappointed…The patient wants to become a doctor now, and the father thinks he should become the principal of the family-run school instead!!!

I recommended a simple surgery to another patient recently. His first question was “If its so good, why hasn’t anyone told me about this before?”

Tip: Because it is so effective, seizure surgery is very common in Western countries. But in India, awareness about it needs to increase.



In some patients, many parts of the brain are abnormal. Sometimes, the abnormal areas are near very important parts of the brain e.g. Broca’s area. In these cases, we implant a device called Vagus Nerve Stimulator (VNS). VNS decreases seizures by about 50%.


Caution: This information is not a substitute for professional care. Do not change your medications/treatment without your doctor's permission.
Dr. Siddharth Kharkar

Dr. Siddharth Kharkar

Dr. Siddharth Kharkar has been recognized as one of the best neurologists in Mumbai by Outlook India magazine and India today Magazine. He is a board certified (American Board of Psychiatry & Neurology certified) Neurologist.

Dr. Siddharth Kharkar is a Epilepsy specialist in Mumbai & Parkinson's specialist in Mumbai, Maharashtra, India.

He has trained in the best institutions in India, US and UK including KEM hospital in Mumbai, Johns Hopkins University in Baltimore, University of California at San Francisco (UCSF), USA & Kings College in London.

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NeuroPlus Epilepsy & Parkinson's Clinic - Dr. Kharkar IconNeuroPlus Epilepsy & Parkinson's Clinic - Dr. Kharkar

near LIC, Dr Balabhai Nanavati hospital, near LIC, Swami Vivekananda Road, LIC Colony, Vile Parle

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  • Avatar Paras Prabhu ★★★★★ 6 months ago
    Out patient is epileptic from about 10 years and her seizure gotten worse during the past year with the frequency of about 3-4 times a week.So we consulted … More Dr. Kharkar. He tried a few medicines, and within 1.5-2 months now the patient is feeling very well now. There are no seizures for 14 days currently.Dr. tried to keep medicines as minimum as possible. He also tried to keep the cost of the treatment minimum.When some of the medicines started showing side-effects, he was quick to switch the medicines to the better options.Overall I think we are getting a best of the available treatments. We thank you very much Dr. Kharkar.
  • Avatar Dr Shobha Sankhe ★★★★★ a month ago
    Dr Kharkar is gem of a doctor with tremendous patience, empathy, genuine concern for his patients .He guides them very methodically & scientifically … More for their neurological ill healthOur epilepsy patient is extremely happy with his treatment , Patient feels better by just visiting him too!May his selfless service to humanity flourish to reach all the needy patients!!
  • Avatar shrruti khanna ★★★★★ a month ago
    I consulted Dr Sidharth for my sister who has become very hyper and aggressive and we could not understand the issue. Keeping in mind she is someone with … More special needs Dr Sidharth was extremely understanding of the situation and did not put her through unnecessary investigation and avoided a very long stay at the hospital. He was infact more keen on her returning home to her natural environment. We highly appreciate Dr Sidharth for his effort and for looking into the matter with utmost care. It was a very difficult decision for my family to get my sister admitted but we are glad we did it under his care.Thankyou Doc.
  • Avatar Prashant Purohit ★★★★★ a month ago
    my name is prashant purohit. I m become completely bed ridden from last 9 months and was unable to walk. I couldnt find out the cause even after visiting … More many doctors and many hospital in Ahmedabad nd jodhpur.started losing hope. A good friend of mine suggested to visit a neurologist. After searching a lot, I came to know about Dr. Siddharth Kharkar and took his appointment in Nanavati Hospital. He examined and said that he suffered from \u201cPKD(PAROXYSMAL KNESIGENIC DYSKNESIA\u201c. He assured us to reverse this in 5 days time. And indeed this happened. I started recovering miraculously. today I am fully well fit I m walking as normal . Many Many thanks to Dr. Siddharth Kharkhar sir for giving me a new life.
  • Avatar Sanjay Pradhan ★★★★★ 7 months ago
    Dr. Kharkar is truly exceptional. He is extremely knowledgeable. But simultaneously, he is extremely patient and kind - taking the time and care to respond … More to all the questions. It is rare to come across a doctor who is not in a hurry to get on to the next patient, but instead, focuses on the one in front with full attention, expertise and compassion. A great experience.
  • Avatar N N ★★★★★ a year ago
    We visited Dr. Kharkhar for treatment regarding my mum - who is a multi-stroke patient and has aphasia. Certain medications were creating complications … More with her condition and Dr. Kharkhar was able to help mitigate the issue. We found him and his approach to be incredibly compassionate, considerate, individualized and patient-friendly. He advice is astute, up-to-date and empathetic. His treatment always comes from a deeply human place and is about seeing how to help the patient and their caregivers feel more at ease. Something that is quite rare and refreshing within the medical community.We feel that he genuinely cares about the patients that he is treating and is always kind and respectful in his communication. Moreover, his admin team is very efficient and prompt and it's a pleasure to deal with them.Would highly recommend Dr Kharkhar himself - though we must say our experience with Nanavati hospital itself has been less than ideal.Hope this helps.
  • Avatar Manish Ranjan ★★★★★ a year ago
    I have been visiting Dr Kharkar for treatment of my father. He is a very friendly doctor. He listens to our concerns with lot of patience. He also explains … More the issue in much greater details. He has really been of great help. My father is much better now.
  • Avatar Pinakin Shah ★★★★★ a year ago
    One of the best Dr. Gives complete attention and time to listen to patient's history, issues. Explains various options of treatment with pros and … More cons.
  • Avatar Lawrence Castellino ★★★★★ a year ago
    Exceptional experience with an expert,Dr. Kharkar is a knowledge house. It is rare nowadays to find doctors with patience, knowledge, and a flair for … More handling patient’s questions, besides Dr. Kharkar’s bedside manners are exemplary. I am privileged to be treated by such an amazing soul. I have told him and will repeat it here that “I am advancing my move back to India although I am a US Citizen, because I know I am in good hands and will be well taken care of. Thanks Dr. Kharkar for your selfless service!
  • Avatar Hemant Kansara ★★★★★ a year ago
    Great doctor!! Really appreciate.The doctor diagnosed to my sister correctly and start treatment, she has good improvement after taking medicine prescribed … More by doctor as no epilepsy attake. We have good experience with the doctor. Thank you

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Noted as one of the best Neurologists in Mumbai

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Ex-Assistant Professor, University of Alabama, USA

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