J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.12.1.25 on 1 February 1949. Downloaded from J. Neurol. Neurosurg. Psychiat., 1949, 12, 25. SYNCOPE AND SEIZURES* BY JOHN KERSHMAN From the Department of Neurology and Neurosurgery, McGill University, and the Montreal Neurological Institute, andfrom the Queen Mary Veterans' Hospital, Montreal, Canada Introduction various parts of the head being symmetrically explored with scalp-to-scalp and scalp-to-ear records. Hyper- Syncope is a clinical syndrome usually caused by ventilation was carried out for three minutes and the vasomotor, reflex, or psychogenic disturbances. record continued for two minutes after. If the record Various authors have emphasized that syncope or was on the borderline of normal, it was repeated after fainting is sometimes difficult to distinguish from hydration and pitressin, using the regime outlined by epilepsy (Weiss, 1935, 1942; Rossen, 1947), and it Penfield and Erickson (1941). In patients who had a has long been suggested that in some instances. history that alcohol was a precipitating factor in the -(Gowers, 1907; Wilson, 1928; Baxter and others, attacks, the following was frequently carried out in 1944) syncopal attacks might be the manifestation addition to the standard E.E.G. The patient was given of an epileptic disorder. In patients with syncope one ounce of whisky in a glass of sweetened fruit juice, the electro-encephidogram between attacks is and this was repeated after one and two hours. An normal, E.E.G. was started within half an hour after the last guest. Protected by copyright. (Levin and others, 1945; Sugar, 1945), although drink. the period of unconsciousness is accompanied by The criteria for abnormality in the E.E.G record are high-voltage slow waves which are reversible based on the author's experience vith many thousands (Forster and others,. 1942; Engel, 1945). In of normal and abnormal tracings in a wide variety of contrast, 90 to 95 per cent. of patients with clinical neurological and psychiatric conditions and in normal epilepsy have an abnormal inter-seizure record persons. and Kershman, 1941, 1944; Gibbs and Abnormalities were classified as focal, diffuse, or (Jasper bilaterally synchronous in accordance with the scheme others, 1943). previously -described (Jasper and Kershman, 1941). The present report deals with a group of 114 This is preferred because it provides a better under- patients who had a history of syncopal attacks or standing of the nature of the abnormal discharges, but similar episodes without loss of consciousness, and it does not differ as far as normal and abnormal criteria all of them had abnormal electro-encephalogranms are concerned from other classifications, such -as that between attacks. None of these patients had a proposed by Gibbs and others (1943). Frequencies definite convulsive seizure. The problems of slower than 7T5 per second and faster than 12f5 per diagnosis and relation to clinical epilepsy will be second were considered abnormal if their amplitude was discussed. larger than the background alpha. Material and Methods Results Most of these 114 patients were members of the Clinically the 114 patients could be divided into http://jnnp.bmj.com/ Canadian Armed Services, and 85 per cent. were between two groups: (a) in 92 patients there was a history 18 and 30 years of age. Over 90 per cent. were men, of at least one attack in which loss of consciousness and those with any evidence of other organic disease occurred; (b) in 22 patients there was no history were excluded. Patients who had a history of at least one convulsive seizure were also excluded and are of loss of consciousness. described in a separate study (Kershman and Elvidge, In both groups the distribution of the various 1948). types of E.E.G. abnormality was surprisingly The method of electro-encephalogram (E.E.G.) similar. examination was essentially the same as described on September 26, 2021 by previously (Jasper, Kershman, and Elvidge, 1940; A. Spells with Loss of Consciousness.-In this Jasper and Kershman, 1941). With each patient a group of ninety-two patients who had syncopal minimum total time of thirty minutes was recorded, spells the commonest E.E.G. abnormality was a diffuse dysrhythmia which occurred in 65 per cent. Read at the 104th Annual Meeting of the American Psychiatric Association, Washington, May 17-20, 1948. (Table I). This consisted of mixed random slow 25 J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.12.1.25 on 1 February 1949. Downloaded from 26 26-^ JOHN KERSHMAN waves usually varying between 2-to 6 per second, continence and recovered about fiften minutes ater or miked fast and slow waves, with fast frequencies feeling weak and dizzy. 1[is mother, who witnessed occasionally predominating. Characteristically in the attack, said that no convulsive movements occurred. this group there was almost a complete absence of The second attack happened late at night while reading. His eyes felt tired and he recalled some twitching of his normal alpha frequencies (7 5 to 12-5 per second). lips. His air-crew comrades who saw the spell did not Bilaterally synchronous abnormalities were pre- notice any convulsive movements but again there was sent in 29 per cent., the commonest form (17 per urinary incontinence. There was no history of child- cent.) being 6 per second rhythms and 4, 5, and 7 hood seizures, no family history of epilepsy or fainting, per second variants. Typical 3 per second slow and no history ofhead injury. wave and spike discharges were infrequent, being The E.E.G. (Fig. 1) showed diffuse slow irregularity in seen in only 5 5 per cent. and variants of this all head regions with no appreciable alpha. There was activity occurred in 6 5 per cent. a definite increase in voltage and amount of abnormality with hydration.. It should be emphasized that in this TABLE I and subsequent examples, the E.E.G. records were taken SYNCOPAL SPELLS WITH LOSS OF CONSCIOUSNESS from interseizure periods and no patient had a record during one ofthe actual spells described. Type of E.E.G. No. % 2. N. W.P. Fainting Spells with MixedFast and Slow abnormality Dysrhythmia.-This patient was a 29-year-old airframe Diffuse dysrhythmia 60 65 mechanic referred because of fainting spells. There Bilaterally synchronous dis- were about six in the past year and a half, and usually turbances .. 26 29 they came on when he was tired or after standing a 3/sec. wave and spike .. 5 5.5 long time at roll call, but they also occurred without 3/sec. variants .. 6 6-5 any obvious cause. He gave a history of fainting easily 6/sec. rhythms and variants 15 17 when he cut himself and bled even slightly, or whenguest. Protected by copyright. he Focal abnormality 6 6 saw anybody else hurt. He complained of dizziness on Total . 92 100 bending over, excessive sweating, headaches, dizzy spells, blurring of vision, and heartburn with gastric pain for the past three years, usually -after meals. A barium In 6 per cent. the pathological E.E.G. activity series of the gastro-intestinal tract was normal. His could be localized to a discrete cortical area, and pulse was rapid and there was a coarse tremor of his in every instance it was in the temporal region as outstretched hands. A diagnosis of anxiety neurosis far as could be determined from scalp electrodes. had been made. The E.E.G. (Fig. 2) showed mixed fast and slow EXAMPLES waves, very little alpha, and a sharp increase in the 1. F.R.B. Syncopal Spells with Diffuse Slow Dys, abnormal activity with hyperventilation. rhythmia.-This patient, a sergeant-navigator on opera- Comment.-A history of vasomotor instability, tional duty in England, was repatriated because of two spells of unconsciousness in three years. The first nervousness, postural dizziness, and frank anxiety occurred during training after he had been working all states was quite common in patients of this group night. Shortly after he had his breakfast, while reading with syncope and diffuse dysrhythmia. Often the the.newspaper, -he suddenly felt a choking sensation, spells occurred only under special conditions of stood up and fell unconscious. He had urinary in- stress and fatigue, but in other cases there were no LO - LEL http://jnnp.bmj.com/ RO0- RE Hyd L O - L E RO- RE A-11)~~~~~~~ on September 26, 2021 by uv1W7s"A FIG. 1.-Patient F.R.B. Syncope with diffuse slow dysrhythmia. LO-LE is the from the left occiput to -the left ear lobe. RO-REis the record from the right occiput to the rightrecordear lobe. The first two lines show the generalized slow irregularity in the resting record. The lower two lines show the increase im abnormality after hydration. J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.12.1.25 on 1 February 1949. Downloaded from SYNCOPE AND SEIZURES , 27 -LF LE RF -RE 2 Mi hv ISec I 00 UV FIG. 2.-Patient N.W.P. Fainting spells with mixed fast and slow dysrhythmia. LF-LE is the E.E.G. from the left frontal region to the left ear lobe; RF-RE is the homologous record from the right side. The lower two lines show the marked increase in voltage and amount of abnormality with rhythmic bisynchronous tendencies after two minutes hyperventilation. guest. Protected by copyright. obvious precipitating factors, and there might be 4. R.A.C. Fainting Spell with 3 per second Abnor- a vague history of fainting spells in childhood. In malities.-This airman, aged 21, was referred because of many patients the syncope was preceded by a brief a single fainting spell which occurred after he had given aura of " dizziness," " blackness," "blurring of blood at a Red Cross donor clinic.