Nonepileptic Seizures Research Articles

Paroxysmal nonepileptic events in children and adolescents admitted to the epilepsy monitoring unit: A retrospective study

Several patients are referred to the epilepsy monitoring unit (EMU) to evaluate episodic events that can be challenging to differentiate from epileptic events. The current study aimed to determine the prevalence of non-epileptic events (NEEs) among children and adolescents admitted to the EMU, and the clinical and demographic features of such events. MethodsWe retrospectively evaluated all patients aged 18 years and below who were admitted to the EMU of King Fahad Medical City, Riyadh, KSA, from January 2014 to March 2020. ResultsThe prevalence of NEEs in children & adolescents admitted to the EMU was 25%. Psychogenic events (PNESs, 30%) were the most common type. Movement disorders occurred more often in younger age group, while migraine was seen more often in school-aged children. ConclusionThe prevalence of NEEs was 25%, and this result is similar to that reported in the literature. The distribution of events is mainly based on age. Clinical and video-based assessments are essential in identifying such events to prevent unnecessary treatment with anti-seizure medications.

Principles for delivering improved care of people with functional seizures: Closing the treatment gap.

Patients diagnosed with functional (psychogenic nonepileptic) seizures have similar or greater levels of disability, morbidity and mortality than people with epilepsy, but there are far fewer treatment services. In contrast to epilepsy, the current understanding of pathophysiological mechanisms and the development of evidence-based treatments for functional seizures is rudimentary. This leads to high direct healthcare costs and high indirect costs to the patient, family and wider society. There are many patient, clinician and system-level barriers to improving outcomes for functional seizures. At a patient level, these include the heterogeneity of symptoms, diagnostic uncertainty, family factors and difficulty in perceiving psychological aspects of illness and potential benefits of treatment. Clinician-level barriers include sub-specialism, poor knowledge, skills and attitudes and stigma. System-level barriers include the siloed nature of healthcare, the high prevalence of functional seizures and funding models relying on individual medical practitioners. Through the examination of international examples and expert recommendations, several themes emerge that may address some of these barriers. These include (1) stepped care with low-level, brief generalised interventions, proceeding to higher level, extended and individualised treatments; (2) active triage of complexity, acuity and treatment readiness; (3) integrated interdisciplinary teams that individualise formulation, triage, and treatment planning and (4) shared care with primary, emergency and community providers and secondary consultation. Consideration of the application of these principles to the Australian and New Zealand context is proposed as a significant opportunity to meet an urgent need.

White Matter Structural Connectivity and Its Impact on Psychogenic Non-Epileptic Seizures: An Evidence-Based Review.

Psychiatric non-epileptic seizure (PNES), also known as a form of functional neurological disorders (FND), is a common but still underrecognized disorder presenting seizure-like symptoms and no electrophysiological abnormality. Despite the significant burden of this disorder, the neurobiological mechanisms are not clearly understood, which hinders the development of better diagnosis and treatment. In the recent neuroimaging research on PNES, brain network analysis has become a relevant topic beyond conventional methodologies. The human brain is a highly intricate system of interconnected regions that collaborate to facilitate a wide range of cognitive and behavioral functions. White matter tracts, which are comprised of bundles of axonal fibers, are the primary means by which information is transmitted between different brain regions. As such, comprehending the organization and structure of the brain's white matter network is critical for gaining insight into its functional architecture. This review article aims to provide an overview of the brain mechanisms underlying PNES, with a special focus on analyzing brain networks.

Ayurvedic Management of Psychogenic Nonepileptic Seizures - A Case Report

ABSTRACT Psychogenic nonepileptic seizures (PNES) are characterized by paroxysmal changes in behavior, consciousness, and autonomic function that resemble epileptic seizures (ES). Disturbances of motor, sensory, autonomic, cognitive, and emotional functions could be seen in patients with PNES. PNES is a heterogeneous condition and has a very diverse etiology. Patients with PNES are often misdiagnosed and are exposed to unnecessary antiseizure medications. The present case report deals with a patient diagnosed of having PNES and opted Ayurvedic treatment for better and sustained relief. The purpose of presenting this clinical case report is to explain the difficulties that are generally involved in the Ayurvedic diagnosis and management of PNES. Yoshapasmara or Yoshapatantraka is not a reliable and authentic Ayurvedic diagnostic entity for PNES. The comorbidity of ES and PNES is well recognized in Ayurveda. ES can be correlated with Doshaja Apasmara and PNES with Agantuja Apasmara. The Doshaja and Agantuja Apasmaras are not the discrete, independent diagnostic entities; rather, they are at the both ends of the same spectrum. The patient was diagnosed as having Agantuja Apasmara, treated with Ayurvedic medicines (Saraswata Choorna and Panchagavya Ghrita) and procedures (Nasya and Dhoomapana). The patient got clinically meaningful improvement with Ayurvedic treatment protocol, especially in headache, seizure episodes, and in depressed mood. Agantuja Apasmara is the most suitable Ayurvedic diagnosis for PNES and Ayurvedic treatment seems to be promising in the management of PNES. The present study findings cannot be generalized and further clinical trials with large sample size and with long term follow-up are required.

Unmasking the masquerade: the diagnosis and management of psychogenic nonepileptic seizures.

The diagnosis and management of psychogenic non-epileptic seizures (PNES) is often challenging. This literature review was done to investigate available data on PNES to make recommendations for its management. To research relevant data on the diagnosis and challenges in the management of PNES. The methodology involved a systematic review of relevant studies and review articles by leading authorities in PNES, using the databases of MEDLINE, ScienceDirect, Cochrane, and PubMed. Out of an eventual 211 screened, 15 were selected based on exclusion and inclusion criteria. Concepts such as 'psychogenic nonepileptic seizures, diagnosis, and management' were searched with the key term, 'PNES'. An analysis of 15 articles was undertaken, and the focus was mainly on the diagnostic criterion and the management approaches adopted in the different studies. The results indicated that many of the studies consistently required video EEG (vEEG) as confirmatory tests for the establishment of PNES, in keeping with the staged approach to diagnosis set by the Nonepileptic Seizure Task Force of Epilepsy. Recent studies emphasised early communication and healthy rapport between patients and providers of care in conveying a diagnosis. Pilot studies on the pharmacological and psychological treatments for PNES were promising. The unmasking of the masquerade of PNES is challenging for clinicians in primary and tertiary care. Raising awareness of the condition reduces the burden on health care. Definitive guidelines and more control trials are required. Provocative measures to establish the diagnosis are limited. The feasibility of using the tilt table as a provocative measure is discussed.

Latency of epileptic and psychogenic nonepileptic seizures.

Due to their semiological similarities, psychogenic nonepileptic seizures (PNESs) can occasionally hardly be differentiated from epileptic seizures (ESs), and long-term video-electroencephalographic monitoring (VEM) is needed for the differential diagnosis. To investigate the time of the first clinical event and its distribution on the days of VEM in ES and PNES patients. In total, a consecutive series of 48 PNES and 51 ES patients matched for gender and age were retrospectively and consecutively evaluated. The time distribution of the seizures during the day was noted. Seizure latency was determined as the time in hours from the start of the video-electroencephalographic recording to the first clinical event. The seizure latency was significantly shorter in PNES patients compared to ES patients (p < 0.001). Seventy-two percent of PNES patients and 49.1% of ES patients had their first seizure in the 24 hours of video-EEG recording (p = 0.023). Recording longer than 48 hours was required for 12.5% of PNES patients and 37.3% of ES patients (p = 0.006). While ESs were almost evenly distributed throughout the day, most PNESs occurred during the evening hours (p = 0.011). We observed that the PNESs appeared earlier than the ESs in the VEM and were concentrated during daylight hours. Although not strictly reliable, seizure latency can contribute to the differential diagnosis of ES and PNES.

Status Epilepticus.

Status epilepticus is a neurologic emergency defined as a seizure that lasts longer than 5 minutes. This is the most common neurologic emergency in children, and it is associated with significant morbidity and mortality. Initial seizure management focuses on stabilization of the patient, followed by medication to terminate the seizure. Benzodiazepines, levetiracetam, fosphenytoin, valproic acid and other antiseizure medications can effectively halt status epilepticus. There is a narrow but important differential diagnosis, including prolonged psychogenic nonepileptic seizure, status dystonicus, and nonconvulsive status epilepticus. Focused laboratory testing, neuroimaging, and electroencephalography can be useful in the evaluation of status epilepticus. Sequelae include focal neurologic deficits, cognitive impairment, and behavioral problems. Pediatricians play an important role in the early recognition and treatment of status epilepticus, thereby preventing the acute and chronic harm that can be associated with status epilepticus.

Role of Serum Prolactin in Differentiating Tonic Clonic from Psychogenic Non-Epileptic Seizures in Emergency Department-Suez Canal University Hospital

Role of Serum Prolactin in Differentiating Tonic Clonic from Psychogenic Non-Epileptic Seizures in Emergency Department-Suez Canal University Hospital

The influence of transient loss of consciousness in children on the health-related quality of life indicators

Abstract. Any acute, recurrent or inflammatory disease can cause numerous changes in various areas of a child's life from daily duties to emotional and cognitive development, self-esteem, and relationships with other people, as well as can negatively affect his/her contacts with peers, functioning in school or family. The aim of the study was the search for modern scientific achievements in the field of research on the quality of life among children with transient loss of consciousness and their families for a better understanding of the state of the possibilities of using this indicator in the evaluation of the effectiveness of the carried-out treatment and prevention measures. Materials and methods. The following terms were used for the search: «syncope», «epilepsy», «psychogenic transient loss of consciousness», and «quality of life», and «children» in the PubMed Medline and Scopus databases. Only English-language full-text articles published between January 2013 and December 2022 were included in the search. Results. During the past 10 years numerous studies have been published on health-related quality of life in children with epilepsy, and there was only one study among children with vasovagal syncope. Given the typically benign etiology of this disease, children are at high risk of psychological health worsening after experiencing a syncope episode. A diagnosis of epilepsy in early childhood has a profound effect on the child's psychological and physical development. It is important that epilepsy slows down the achievement of children's independence and complicates social relationships and cognitive processes. A number of authors drew attention to the lack of relationship between the quality of life and the frequency of psychogenic non-epileptic seizures in children and proved the key influence of depression and somatoform disorders on the reduction of quality of life. Conclusions. Health-related quality of life study is an important tool for the understanding of disease impact on child’s daily life and family members, which allows you to effectively recognize symptoms for the purpose of their timely correction, and is the final point in assessing the effectiveness of treatment and prevention measures, as well as quality of public health services. The relevance of further quality of life studies in children under the various types of syncope is due to the extremely limited results of observations in this group of patients.

The natural history of epilepsy and nonepileptic seizures in Sturge–Weber syndrome: A retrospective case-note review

ObjectivePatients with Sturge–Weber Syndrome (SWS) experience varying degrees of neurological problems – including epilepsy, hemiparesis, learning disability (LD), and stroke-like episodes. While the range of clinical problems experienced by children with SWS is well recognized, the spectrum of clinical presentation and its treatment during adulthood has been relatively neglected in the literature to date. This study explored the natural history of epileptic and nonepileptic seizures into adulthood in patients with SWS, and their treatment, and investigated whether any clinical factors predict which symptoms a patient will experience during adulthood. MethodsA retrospective case-note review of a cohort of 26 adults with SWS at the National Hospital for Neurology and Neurosurgery (NHNN). Childhood data were also recorded, where available, to enable review of change/development of symptoms over time. ResultsThe course of epilepsy showed some improvement in adulthood – seventeen adults continued to have seizures, while six patients gained seizure freedom, and no one had adult-onset seizures. However, seizures did worsen for some patients. Although no factors reached statistical significance regarding predicting continued epilepsy in adulthood, being male, more severe LD, having required epilepsy surgery, and bilateral cortical involvement may be important. Nonepileptic seizures (NES) also began during adulthood for four patients. SignificanceBy adulthood, there is some degree of improvement in epilepsy overall; while NES may occur for the first time. While the majority of the results did not survive adjustments for multiple comparisons, some interesting trends appeared, which require further investigation in a multicenter national audit. Patients with more neurologically severe presentations during childhood may continue to experience seizures. Careful monitoring and screening are needed during adulthood, to detect changes and newly developing symptoms such as NES, and target treatment promptly.

A suggestive seizure induction technique protocol in a short EEG in children and adolescents

The use of a suggestive seizure induction procedure (SSI) in medicine, particularly in the differential diagnosis of psychogenic nonepileptic epileptic seizures (PNES), is well documented. However, there is no description of standardized suggestion procedures used in children and adolescents. The research presents a standardized method of SSI with a cotton swab soaked in water. The protocol was developed based on of 544 placebo trials over ten years in a center for the differential diagnosis of children and adolescents. The protocol is a safe tool that allows inducing specific behavior in children and adolescents in whom there is a well-founded suspicion of PNES.

Restless sleep disorder in children with epileptic and non-epileptic nocturnal attacks.

Restless sleep disorder (RSD) is an important sleep disorder characterised by the presence of frequent large muscle movements (LMM) during sleep, which may be comorbid to other conditions/diseases. In this study, we investigated the frequency and the characteristics of RSD among children who were evaluated by polysomnography (PSG) due to epileptic and non-epileptic nocturnal attacks. We analysed consecutively children younger than 18 years who were referred for PSG recording due to abnormal motor activities during sleep. The diagnosis of nocturnal events as sleep-related epilepsy was made based on the current consensus. Patients who were referred with suspicion of sleep-related epilepsy, but who were diagnosed to have non-epileptic nocturnal events and children with a definitive diagnosis of NREM sleep parasomnias were also enrolled. Sixty-two children were analysed in this study (17 children with sleep-related epilepsy, 20 children with NREM parasomnia, and 25 children with nocturnal events not otherwise classified [neNOS]). The mean number of LMM, LMM index, LMM-associated with arousal and its index were all significantly higher in children with sleep-related epilepsy. Restless sleep disorder was present in 47.1% of patients with epilepsy, 25% of patients with parasomnia, and in 20% of patients with neNOS. The mean A3 duration and the A3 index were higher in children with sleep-related epilepsy and RSD compared with those with parasomnia and restless sleep disorder. Patients with RSD had lower ferritin levels than those without RSD in all subgroups. Our study demonstrates a high prevalence of restless sleep disorder in children with sleep-related epilepsy, associated with an increased cyclic alternating pattern.

Identifying misconceptions and knowledge gaps in functional neurological disorders among emergency care providers

BackgroundFunctional Neurologic Disorders (FND) are a common but heterogeneous group of disabling conditions. The Emergency Department (ED) is an important venue for care and referral as it is often the first point of contact when patients with FND are faced with a crisis or exacerbation of symptoms. MethodsED providers (n = 273) practicing in the Cleveland Clinic Foundation Northeast Ohio network were invited to participate through secure web application electronic surveys. Data were collected on practice profiles, knowledge, attitudes, management of FND, and awareness of available resources for FND. ResultsSixty providers completed the survey (22% response rate; n = 50 ED physicians, 10 advanced care providers) with 95.0% (n = 57) reporting a lack of understanding about FND. The terms Psychogenic Nonepileptic Seizures and stress induced/stress related disease were used by 60.0% (n = 36) and 58.3% (n = 35) respectively. Ninety percent (n = 53) rated their experience with managing FND patients as at least more difficult. Eighty- five percent (n = 51) agreed with “rule out others” and 60% (n = 36) agreed with “caused by psych stress”. Eighty six percent (n = 50) believe that there is a difference between FND from malingering. Only one respondent was familiar with any FND resources and 79% (n = 47) reported the need for FND specific educational materials. ConclusionThis survey revealed major gaps in knowledge, inaccurate perceptions, and management that differs from the current standard of care among ED providers caring for patients with FND. Educational opportunities are needed to guide diagnosis and evidence-based treatment to optimize management of patients with FND.

Development and Validation of Machine-Learning Models to Support Clinical Diagnosis for Non-Epileptic Psychogenic Seizures

Electroencephalographic (EEG) signal processing and machine learning can support neurologists’ work in discriminating Psychogenic Non-Epileptic Seizure (PNES) from epilepsy. PNES represents a neurological disease often misdiagnosed. Although the symptoms of PNES patients can be similar to those exhibited by epileptic patients, EEG signals during a psychogenic seizure do not show ictal patterns such as in epilepsy. Therefore, PNES diagnosis requires long-term EEG video. Applying signal processing and machine-learning methodologies could help clinicians find helpful information in the clinical diagnosis of PNES by analyzing EEG signals registered in resting conditions and in a short time. These methodologies should prevent long EEG recording sessions and avoid inducing seizures in the subjects. The aim of our study is to develop and validate several machine-learning models on a larger dataset, consisting of 225 EEGs (75 healthy, 75 PNES, and 75 subjects with epilepsy). A deep analysis of our results shows that changes in the evaluation strategy led to changes in accuracy from 45% to 83.98% for a standard Light Gradient Boosting Machine (LGBM) classifier. Our findings suggest that it is necessary to operate a very rigorous control in terms of experimental data collection (patient selection, signal acquisition) and terms of validation strategies to obtain and reproducible results.

Improving the treatment of functional seizures through a public specialist outpatient clinic

ObjectivesWe performed an audit of the first 12 months of clinical operations to assess the feasibility of a newly established public outpatient clinic for the assessment and treatment of functional (psychogenic nonepileptic) seizures (FS). MethodClinical notes for the first 12 months of the FSclinic weresystematicallyreviewed with data compiled onreferral pathways, clinic attendance, clinical features, treatments, and outcomes. ResultsOf eighty-two new FS patients referred to the clinic, over 90% attended. Patients were diagnosed with FS after comprehensive epileptological and neuropsychiatric review, mostly with typical seizure-like episodes captured during video-EEG monitoring, and most accepted the diagnosis. Most had FS at least weekly, with little sense of control and significant impairment. The majority of individuals had significant psychiatric and medical comorbidity. Predisposing, precipitating, and perpetuating factors were readily identified in >90% of cases. Of 52 patients with follow-up data within12 months, 88% were either stable or improved in terms of the control of their FS. ConclusionThe Alfred functional seizure clinic model, the first dedicated public outpatient clinic for FS in Australia, provides a feasible and potentially effective treatment pathway for this underserved and disabled patient group.

MODIFI: protocol for randomised feasibility study of eye-movement desensitisation and reprocessing therapy (EMDR) for functional neurological disorder (FND)

IntroductionFunctional neurological disorder (FND) refers to an involuntary loss of control over and/or aberrant perception of the body. Common presenting symptoms are functional (non-epileptic) seizures, and functional motor disorder, for...

Psychogenic Nonepileptic Seizures-High Mortality Rate Is a 'Wake-Up Call'.

Patients with epilepsy have an elevated mortality rate compared to the general population and now studies are showing a comparable death ratio in patients diagnosed with psychogenic nonepileptic seizures. The latter is a top differential diagnosis for epilepsy and the unexpected mortality rate in these patients underscores the importance of an accurate diagnosis. Experts have called for more studies to elucidate this finding but the explanation is already available, embedded in the existing data. To illustrate, a review of the diagnostic practice in epilepsy monitoring units, of the studies examining mortality in PNES and epilepsy patients, and of the general clinical literature on the two populations was conducted. The analysis reveals that the scalp EEG test result, which distinguishes a psychogenic from an epileptic seizure, is highly fallible; that the clinical profiles of the PNES and epilepsy patient populations are virtually identical; and that both are dying of natural and non-natural causes including sudden unexpected death associated with confirmed or suspected seizure activity. The recent data showing a similar mortality rate simply constitutes more confirmatory evidence that the PNES population consists largely of patients with drug-resistant scalp EEG-negative epileptic seizures. To reduce the morbidity and mortality in these patients, they must be given access to treatments for epilepsy.

Focal tonic seizures with asymmetrical posturing could allow voluntary movements: a lesson to not be misled for a non-epileptic event.

This report documents the clinical features of supplementary motor area seizures with voluntary movements in two patients. The first case describes a 13-year-old boy with a 2-year history of nocturnal seizures, characterized by an asymmetrical brief tonic posture followed by bilateral rapid hand shaking, but without impaired awareness. Magnetic resonance imaging revealed no abnormalities. Video electroencephalogram indicated interictal focal spikes and ictal activity 2 s before clinical onset in the frontal midline area. The patient stated that he purposely shook his hands to lessen the seizure-induced upper limb stiffness. The second case describes a 43-year-old man with a 33-year history of nocturnal seizures, characterized by an asymmetric brief tonic posture, with the right hand grabbing to hold this posture, but without impaired awareness. Video electroencephalogram indicated that he voluntarily moved his right hand during the latter part of the seizures; however, no clear ictal electroencephalogram change was noted. Magnetic resonance imaging revealed a mass lesion in the right medial superior frontal gyrus. Fluorodeoxyglucose-positron emission tomography and ictal single-photon emission computed tomography indicated ictal focus in the mesial frontal area, as confirmed by invasive electroencephalogram and seizure freedom after surgery. Both patients had typical supplementary motor area seizures, except they could perform voluntary movements in the body parts. The co-occurrence of supplementary motor area seizures and voluntary movements is clinically useful, as it may help avoid the inaccurate and misleading diagnosis of non-epileptic events such as psychogenic non-epileptic seizures.

Driving regulations for epilepsy in Europe

BackgroundAcross Europe, there are differences regarding driving restrictions for patients with epilepsies and seizures. In the light of increasing mobility, knowledge about those different regulations is of high importance for counseling patients, and physicians. MethodsA structured online survey was sent to the official representatives of the different European ILAE chapters, asking for the local driving restrictions for patients with epilepsies, first seizures, syncopes, and psychogenic non-epileptic seizures. ResultsThe survey was sent to 38 chapters or representatives of 47 European Countries. 33 chapters answered. The majority of countries require 1 year of seizure-freedom for the ability to drive (Group 1, former categories A, B, B + E, F, G. H, K, L, and P; driving license which authorizes its holder to drive vehicle classes categories of the motor vehicle), usually with the need to continue antiseizure medication (ASM). Some countries have much stricter regulations before allowing for driving. Legal regulations after a first unprovoked seizure differ between 6 months for Group 1 license holders in most European countries, and one year in Luxembourg and Malta. In Serbia, there is no legal regulation for this special situation. The situation after a first seizure is even more complex for Group 2 license holders (former categories C1, C1+E, C, C + E, D1, D1+E, D, D + E). ConclusionKnowledge of the different recommendations of the individual European countries is of high relevance in the counseling of epilepsy patients. Europe-wide regulations, e.g. following the IBE-recommendations are needed to facilitate the patients’ situation.

Video-EEG-monitoring to guide antiseizure medication withdrawal

BackgroundDiscontinuing anti-seizure medication (ASM) should be considered in persons with epilepsy with long-term seizure freedom. Clinicians should also pursue ASM withdrawal in persons with one-time seizures without increased recurrence risk and those with suspected non-epileptic events. However, ASM withdrawal is associated with the risk of recurring seizures. Monitored ASM withdrawal in an epilepsy monitoring unit (EMU) could help better evaluate the risk of seizure recurrence. Here, we investigate the practice of EMU-guided ASM withdrawal, assess its indications, and aim to determine positive and negative predictors for successful withdrawal.MethodsWe screened the medical records of all patients admitted to our EMU between November 1, 2019, and October 31, 2021, and included patients of at least 18 years admitted with the aim of permanent ASM withdrawal. We defined four groups of withdrawal indications: (1) long-term seizure freedom; (2) suspected non-epileptic events; (3) history of epileptic seizures but not fulfilling diagnostic criteria of epilepsy; and (4) seizure-freedom after epilepsy surgery. Successful withdrawal was defined according to the following criteria: no recoding of (sub)clinical seizure activity during VEM (groups 1, 2, and 3), patients did not meet the International League Against Epilepsy (ILAE) definition of epilepsy (groups 2 and 3) [14], and patients were discharged without ongoing ASM treatment (all groups). We also evaluated the prediction model by Lamberink et al. (LPM) for the risk of seizure recurrence in groups 1 and 3.Results55/651 (8.6%) patients fulfilled the inclusion criteria. Withdrawal indications were distributed as follows; group 1: 2/55 (3.6%); group 2: 44/55 (80%); group 3: 9/55 (16,4%); group 4: 0/55. Overall, ASM withdrawal was successful in 90.9%. The sensitivity of the LPM for a 2-year 50% relapse risk threshold was 75%, the specificity 33.3%; for a 5-year relapse risk respectively 12.5% and 33.3%, suggesting that the model is not suitable for risk assessment in patients with one-time seizures or acute-symptomatic seizures, who constituted most of the evaluated patients.ConclusionsOur study suggests that EMU-guided ASM withdrawal could be a helpful tool to support clinical decision-making and improve patient safety. Prospective, randomized trials should further evaluate this method in the future.