Diagnosis of loss of consciousness: When art meets science

Some aspects of neurological care require as much art as science, and this can apply to diagnosis, provision of long-term care, and in tailoring medication to individuals. Transient loss of consciousness (t-LOC) is a common medical complaint, and eliciting the cause of such events is an important and sometimes demanding task. The difficulties in t-LOC diagnosis are increased by the usually incomplete patient subjective experience and the lack of hard neurological signs, each increasing the importance of a clear eyewitness account (often from a fraught relative). In the UK, the scale and extent of this common diagnostic challenge has been recognised and partly dealt with by an increasing network of First Fit clinics, made possible by an accompanying increasing number of neurologists in the last 20 years. Application of expertise to the challenge should go some way to reducing the rate of misdiagnosis and targeting treatment to appropriate individuals, hopefully reducing the historical burden of misdiagnosis in our epilepsy clinics in years to come. Previous attempts to provide objective rating scales to allocate some certainty to individual episodes have helped provide some comfort to hard-pressed clinicians, but there remains no substitute for a targeted and skilled history teased out by an experienced clinician. Arithmetical scoring systems are best at binary decision-making, but picking out one of three or more choices would require either multiple diagnostic tools or a multidimensional tool. Additionally, the variety of clinical manifestations by epilepsy may require an inordinate complexity of questions to keep the scoring sensitive. Epilepsy remains a significant burden in many poorer parts of the world, and the absence of a coherent healthcare system and lack of trained medical staff may require development of nonlabour intensive tools to improve diagnostic accuracy. It will not be practical merely to utilise tools developed and used in Western healthcare settings. Cultural and demographic differences will require emphasis in any applied questionnaires. In most UK clinics,