• Sharon Shmuely, Prisca R Bauer, Erik W van Zwet, J Gert van Dijk, and Roland D Thijs.
• From the Department of Research (S.S., P.R.B., R.D.T.), Stichting Epilepsie Instellingen Nederland, Heemstede, the Netherlands; NIHR University College London Hospitals Biomedical Research Centre (S.S., R.D.T.), UCL Institute of Neurology, Queen Square, London, UK; Lyon Neuroscience Research Centre (P.R.B.), INSERM U1028, CNRS UMR5292, Bron, France; and Departments of Medical Statistics (E.W.v.Z.) and Neurology (J.G.v.D., R.D.T.), Leiden University Medical Centre, the Netherlands.
• Neurology. 2018 Apr 10; 90 (15): e1339-e1346.

ObjectiveWe assessed motor phenomena in syncope and convulsive seizures to aid differential diagnosis and understand the pathophysiologic correlates.MethodsWe studied video-EEG recordings of tilt-induced syncope and convulsive seizures in participants aged 15 years and older. Syncope was defined as (1) loss of consciousness (video-assessed), (2) circulatory changes (accelerating blood pressure decrease with or without bradycardia/asystole), and (3) EEG changes ("slow" or "slow-flat-slow"). We assessed myoclonic jerks and tonic postures of the arms and noted time of occurrence, laterality, synchrony, and rhythmicity (mean consecutive differences of interclonic intervals).ResultsVideo-EEG records of 65 syncope cases and 50 convulsive seizures were included. In syncope, postures occurred in 42 cases (65%) and jerks in 33 (51%). Fewer jerks occurred in syncope (median 2, range 1-19) compared to convulsive seizures (median 48, range 20-191; p < 0.001). Jerks were more rhythmic in seizures compared to syncope (p < 0.001). Atonia was seen in all syncope cases, while this was not observed in any seizure. Jerks predominantly occurred during the slow and postures during the flat EEG phase.ConclusionsJerks and tonic postures were common in syncope, but semiology differed from convulsive seizures. The lack of overlap in the number of jerks suggests that less than 10 indicates syncope and more than 20 a convulsive seizure: the "10/20 rule." Loss of tone strongly favors syncope. The EEG correlates imply that jerks in syncope are likely of cortical origin, whereas tonic postures may result from brainstem disinhibition.© 2018 American Academy of Neurology.

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