Psychogenic nonepileptic spells in chronic epilepsy patients with moderate cognitive impairment: the need for video EEG monitoring for adequate diagnosis.

Diana Mungall Robinson,Batool F Kirmani

doi:10.1155/2014/121865

Abstract

The objective of our study was to emphasize the importance of intensive video EEG monitoring in patients with a well-established diagnosis of epilepsy with moderate cognitive impairment. The idea was to diagnose new onset frequent atypical events prompting the need for frequent emergency room and clinic visits and hospital admissions. Retrospective chart reviews were conducted on patients with chronic epilepsy with moderate cognitive impairment who had an increased incidence of new onset episodes different from the baseline seizures. Data were acquired from electronic medical records. The hospital's Institutional Review Board gave approval for this retrospective analysis of patient records. We retrospectively analyzed data from three patients with an established diagnosis of epilepsy. Extensive chart reviews were performed with emphasis on type and duration of epilepsy and description of baseline seizures and description of new events. There were two men and one woman with moderate cognitive impairment. One subject had generalized epilepsy and other two had temporal lobe epilepsy. The patients were on an average of two to three antiepileptic medicines. The duration of follow-up in our neurology clinic ranged from 9 months to 5 years. The occurrence of increased frequency of these atypical events as described by the caregivers, despite therapeutic anticonvulsant levels, prompted the need for 5-day intensive video EEG monitoring. New atypical spells were documented in all three patients and the brain waves were normal during those episodes. The diagnosis of pseudoseizures was made based on the data acquired during the epilepsy monitoring unit stay. Our data analysis showed that intensive video EEG monitoring is an important tool to evaluate change in frequency and description of seizures even in cognitively impaired patients with an established diagnosis of epilepsy for adequate seizure management.

Highlights

Epileptic seizures are classified into different types based on the characterization of the events
Retrospective chart reviews were conducted on three patients with chronic epilepsy with moderate cognitive impairment who had an increased incidence of new onset episodes different from the baseline seizures
We report a case series of three patients with an established diagnosis of epilepsy with moderate cognitive impairment

Summary

Introduction

Epileptic seizures are classified into different types based on the characterization of the events. Careful history is the first step in the diagnosis of epileptic and nonepileptic events. Seizures are due to hyperactivity of the cortical neurons or synchronous neuronal activity in the brain and are further classified into partial and generalized seizures based on electroencephalographic (EEG) data and clinical semiology [1, 2]. Psychogenic Nonepileptic Spells (PNES) are a form of conversion disorder during which patients exhibit seizure like activity but the brain waves are normal. Patients with PNES often have history of abusive past and/or other psychiatric disorders [3]. If the patients have nonstereotypical events, intensive video EEG monitoring in an epilepsy monitoring unit is the gold standard to capture new spells for definitive diagnosis to rule out pseudoseizures. Few data are reported in the literature about PNES in this particular subset of patients

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Conclusion