Differential Diagnosis for Seizure with No Visible Movements

The patient's presentation of a seizure with no visible movements, no blank stares, but an internal sensation, along with a history of previous seizures and stroke, suggests a complex neurological condition. Here's a categorized differential diagnosis:

• Single Most Likely Diagnosis

  • Simple Partial Seizure: This type of seizure, also known as a focal aware seizure, involves a localized area of the brain and does not cause loss of consciousness or convulsions. The patient remains aware and may experience a range of sensations, including auras or internal feelings, which aligns with the patient's description of feeling it "inside."

• Other Likely Diagnoses

  • Complex Partial Seizure: Although the patient does not exhibit blank stares, some complex partial seizures may have subtle manifestations, and the patient's history of seizures could suggest this possibility.
  • Aura without Seizure: Sometimes, patients experience auras (which are essentially simple partial seizures) without progressing to a more generalized seizure. Given the patient's history, this could be a consideration.
  • Psychogenic Non-Epileptic Seizures (PNES): These are episodes that resemble epileptic seizures but are not caused by abnormal electrical activity in the brain. They can be triggered by psychological factors and might be considered, especially if there's a history of psychological trauma or stress.

• Do Not Miss Diagnoses

  • Status Epilepticus: Although the patient does not show overt convulsions, non-convulsive status epilepticus is a life-threatening condition that requires immediate diagnosis and treatment. It can present subtly, especially in patients with a history of seizures.
  • Cerebral Vasculitis or Recurrent Stroke: Given the patient's history of stroke, any new neurological symptoms could indicate a recurrence or a new vascular event, including cerebral vasculitis, which is inflammation of the blood vessels in the brain.

• Rare Diagnoses

  • Epileptic Seizures with Gelastic or Dacrystic Manifestations: These are rare types of seizures that can manifest with laughter (gelastic) or crying (dacrystic) and might not involve obvious motor symptoms.
  • Reflex Seizures: These are seizures triggered by specific stimuli, such as reading, music, or even internal sensations. They can present in various ways, including without visible movements.

Each of these diagnoses requires careful consideration of the patient's history, physical examination, and possibly further diagnostic testing, such as EEG or imaging studies, to determine the underlying cause of the symptoms.