Paroxysmal nonepileptic events in pediatric patients

"Is it a seizure?" Prediction tool for seizure likelihood in children aged 1-24 months admitted for electroencephalographic monitoring of paroxysmal, rhythmic, and repetitive events

OBJECTIVE

Paroxysmal, rhythmic, and repetitive events (PRREs) during infancy can be concerning for possible seizures, especially following perinatal brain injuries. The workup for establishing whether a PRRE represents a seizure involves the use of continuous video-electroencephalography (cVEEG) for event characterization. This study aims to determine the diagnostic yield of cVEEG for evaluating events concerning for seizures in children aged 1-24 months.

METHODS

We performed a single-center retrospective chart review (January 1, 2019-December 31, 2020) and included all children aged 1-24 months admitted for PRRE capture and characterization using cVEEG. Chart abstraction included demographics, birth and family history, known brain injury, event semiology, duration, and frequency, as well as interictal electroencephalographic (EEG) features. For each of these variables, odds ratios for seizure prediction were calculated.

RESULTS

A total of 243 patients were identified for this study. On cVEEG, n = 160 (65.4%) had a target event of concern captured during an initial admission with cVEEG. Whereas n = 41 (25.8%) patients with events captured were confirmed to have seizures, most patients (n = 119) were confirmed to have nonepileptic events. Several variables predicted seizure likelihood during the initial admission with cVEEG, including event duration (>1 min), frequency (occurring ≥3 times per week), and presence of abnormal interictal findings on cVEEG. For patients who did not receive a diagnosis at the time of initial admission with cVEEG, the likelihood of a subsequent epilepsy diagnosis was associated with specific PRRE semiology (motor active or motor passive), longer event duration (>1 min duration), and the presence of interictal abnormal EEG features on initial cVEEG admission. Prediction tools utilizing scoring systems to stratify risk in infants with suspected seizures due to PRREs are included.

SIGNIFICANCE

Unique patient attributes and PRRE characteristics, as well as the presence of EEG interictal abnormalities, can provide valuable insights for discerning children with a higher likelihood of epilepsy diagnosis following cVEEG admission.

Scoping review and expert-based consensus recommendations for assessment and management of psychogenic non-epileptic (functional) seizures (PNES) in children: A report from the Pediatric Psychiatric Issues Task Force of the International League Against Epilepsy

Limited guidance exists regarding the assessment and management of psychogenic non-epileptic seizures (PNES) in children. Our aim was to develop consensus-based recommendations to fill this gap. The members of the International League Against Epilepsy (ILAE) Task Force on Pediatric Psychiatric Issues conducted a scoping review adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-SR) standards. This was supplemented with a Delphi process sent to pediatric PNES experts. Consensus was defined as ≥80% agreement. The systematic search identified 77 studies, the majority (55%) of which were retrospective (only one randomized clinical trial). The primary means of PNES identification was video electroencephalography (vEEG) in 84% of studies. Better outcome was associated with access to counseling/psychological intervention. Children with PNES have more frequent psychiatric disorders than controls. The Delphi resulted in 22 recommendations: Assessment-There was consensus on the importance of (1) taking a comprehensive developmental history; (2) obtaining a description of the events; (3) asking about potential stressors; (4) the need to use vEEG if available parent, self, and school reports and video recordings can contribute to a "probable" diagnosis; and (5) that invasive provocation techniques or deceit should not be employed. Management-There was consensus about the (1) need for a professional with expertise in epilepsy to remain involved for a period after PNES diagnosis; (2) provision of appropriate educational materials to the child and caregivers; and (3) that the decision on treatment modality for PNES in children should consider the child's age, cognitive ability, and family factors. Comorbidities-There was consensus that all children with PNES should be screened for mental health and neurodevelopmental difficulties. Recommendations to facilitate the assessment and management of PNES in children were developed. Future directions to fill knowledge gaps were proposed.

Non-epileptic paroxysmal events at pediatric video-electroencephalography monitoring unit over a 15-year period

OBJECTIVE

Non-epileptic paroxysmal events (NEPEs) are common in pediatric patients and may be misdiagnosed as epileptic seizures. We aimed to study the distribution of NEPEs across age groups and with different comorbidities, and to correlate the patients' presenting symptoms with their final diagnosis after video-EEG.

METHODS

We retrospectively analyzed video-EEG recordings of children aged one month to 18 years who were admitted between March 2005 and March 2020. Patients who experienced any NEPE while under video-EEG monitorization were evaluated in this study. Subjects with concomitant epilepsy were also included. The patients were first divided into 14 groups according to the basic characteristics of symptoms they reported at admission. The events captured on video-EEG were then classified into six NEPE categories based on the nature of the events. These groups were compared according to video-EEG results.

RESULTS

We retrospectively evaluated 1338 records of 1173 patients. The final diagnosis was non-epileptic paroxysmal event in 226 (19.3%) of 1173 patients. The mean age of the patients was 105.4 ± 64.4 months at the time of the monitoring. The presenting symptoms were motor in 149/226 (65.9%) patients, with jerking being the most common (n = 40, 17.7%). Based on video-EEG, the most common NEPE was psychogenic non-epileptic seizures (PNES) (n = 66, 29.2%), and the most common PNES subtype was major motor movements (n = 19/66, 28.8%). Movement disorders (n = 46, 20.4%) were the second most common NEPE and the most common NEPE (n = 21/60, 35%) in children with developmental delay (n = 60). Other common NEPEs were physiological motor movements during sleep (n = 33, 14.6%), normal behavioral events (n = 31, 13.7%), and sleep disorders (n = 15, 6.6%). Almost half of the patients had a prior diagnosis of epilepsy (n = 105, 46.5%). Following the diagnosis of NEPE, antiseizure medication (ASM) was discontinued in 56 (24.8%) patients.

CONCLUSION

Non-epileptiform paroxysmal events can be difficult to distinguish from epileptic seizures in children, especially in patients with developmental delay, epilepsy, abnormal interictal EEG, or abnormal MRI findings. Correct diagnosis of NEPEs by video-EEG prevents unnecessary ASM exposure in children and guides appropriate management of NEPEs.

Staring Spells: An Age-based Approach Toward Differential Diagnosis

Evaluations to rule out epileptic vs nonepileptic staring spells may entail unnecessary evaluations that can be costly and time consuming. Our study aims to identify common etiologies for staring spells across 3 different pediatric age groups and to propose an age-based clinical guidance to help determine which patients warrant further workup. Methods: This was a single-center retrospective chart analysis of 1496 patients aged 0.0-17.9 years presenting with confirmed staring spell diagnosis from January 2011 to January 2021. The patients were divided into 3 groups based on their age: 0.0-2.9, 3.0-12.9, and 13.0-17.9 years. Patient information collected included demographics, clinical presentation, comorbidities, and final diagnosis. Multilevel likelihood ratios and a receiver operating characteristic curve were determined using 8 of the 11 clinical variables. A total of 1142 patients who met the inclusion criteria were included for the final analysis. The most common final diagnosis was attention-deficit hyperactivity disorder (ADHD) (35%), followed by normal behavior (33%). Generalized and focal epilepsy were diagnosed in 8% and 4% of the patients, respectively. In the 0.0-2.9-year age group, normal behavior was the final diagnosis in 72% patients. In the 3.0-12.9-year and 13.0-17.9-year age groups, ADHD was the most frequent final diagnosis in 46% and 60%, respectively. Overall, ADHD and normal behaviors remain the most common final diagnoses. Multilevel likelihood ratios can be used to develop an age-based guidance to differentiate between epileptic and nonepileptic staring spell diagnoses.

Predictive value of video alone in diagnosis of epileptic vs paroxysmal nonepileptic events in children

OBJECTIVE

Previous studies examined the use of video-based diagnosis and the predictive value of videos for differentiation of epileptic seizures (ES) from paroxysmal nonepileptic events (PNEE) in the adult population. However, there are no such published studies strictly on the pediatric population. Using video-EEG diagnosis as a gold standard, we aimed to determine the diagnostic predictive value of videos of habitual events with or without additional clinical data in differentiating the PNEE from ES in children.

METHODS

Consecutive admissions to our epilepsy monitoring unit between June 2020 and December 2020 were analyzed for events of interest. Four child neurologists blinded to the patient's diagnosis formulated a diagnostic impression based upon the review of the video alone and again after having access to basic clinical information, in addition to the video. Features of the video which helped to make a diagnosis were identified by the reviewers as a part of a survey.

RESULTS

A total of 54 patients were included (ES n = 24, PNEE n = 30). Diagnostic accuracy was calculated for each reviewer and combined across all the ratings. Diagnostic accuracy by video alone was 74.5% (sensitivity 80.8%, specificity 66.7%). Providing reviewers with basic clinical information in addition to the videos significantly improved diagnostic accuracy compared to viewing the videos alone. Inter-rater reliability between four reviewers based on the video alone showed moderate agreement (κ = 0.51) and unchanged when additional clinical data were presented (κ = 0.51). The ES group was significantly more likely to demonstrate changes in facial expression, generalized stiffening, repetitive eye blinks, and eye deviation when compared with the PNEE group, which was more likely to display bilateral myoclonic jerking.

CONCLUSIONS

Video review of habitual events by Child Neurologists may be helpful in reliably distinguishing ES from PNEE in children, even without included clinical information.

"It's hard!": Adolescents' experience attending school with psychogenic nonepileptic seizures

Adolescents with psychogenic nonepileptic seizures (PNES) face many challenges in the school setting. Researchers have identified school stressors as potential predisposing, precipitating, and perpetuating factors for PNES. However, few researchers have explored the perspectives of adolescents with PNES regarding their experiences of attending school, where they spend much of their time. Therefore, this qualitative study employed content analysis to explore the experience of attending school as an adolescent with PNES. Ten adolescents (100% female, 80% White) were interviewed. With an overwhelming response of "It's hard!" from respondents, five themes regarding the school experience emerged: stress, bullying, accusations of "faking" seizure events, feeling left out because of the condition, and school-management of PNES. Underlying these themes were expressions of the need for increased understanding from and collaboration among peers, as well as the need for increased understanding from families, healthcare providers, and school personnel including school nurses. Study findings should inform future adolescent PNES research, practice decisions made by healthcare providers in the health and education sectors, education of healthcare and school professionals, and policy development and implementation.

The evaluation of psychogenic non-epileptic seizures (PNES) cases with saline injection method in video-EEG monitorization unit

BACKGROUND

It has been reported that 10 to 30% of patients sent to epilepsy centers with a diagnosis of refractory epilepsy are diagnosed with psychogenic non-epileptic seizure (PNES). A wide variety of provocative methods are used to assist PNES diagnosis.

OBJECTIVE

To investigate the effect of seizure induction on the diagnosis and prognosis of PNES.

METHODS

We retrospectively examined 91 patients with PNES complaints in our video-EEG laboratory. Intravenous saline was administered to all patients for induction of seizures.

RESULTS

Saline injection was performed in 91 patients referred to our EEG lab with PNES initial diagnosis, 57 of whom were female and 34 male. Saline injection triggered an attack in 82 patients (90%).

CONCLUSIONS

In this study we have concluded that provocative methods are practical, cheap and, most of all, effective for patient diagnosis. In clinical practice, explaining the diagnosis is the first and most important step of the treatment, and careful patient-doctor communication has a positive impact on patient prognosis.

When neurologists diagnose functional neurological disorder, why don't they code for it?

Objective:

Clinicians who recognize functional neurological disorders (FND) may not share that diagnosis with patients. Poor communication delays treatment and contributes to substantial disability in FND. Diagnostic (ICD-10) coding, one form of medical communication, offers an insight into clinicians’ face-to-face communication. Therefore, quantifying the phenomenon of non-coding, and identifying beliefs and practice habits that reduce coding, may suggest routes to improve medical communication in FND.

Methods:

We reviewed all pediatric neurology consultations in our hospital from 2017–2020, selecting those in which neurologists explicitly stated an FND-related diagnosis (N=57). We identified the neurological symptoms and ICD-10 codes assigned for each consultation. In parallel, we reviewed all encounters that utilized FND-related codes to determine whether insurers paid for this care. Finally, we assessed beliefs and practices that influence FND-related coding through a nationwide survey of pediatric neurologists (N=460).

Results:

After diagnosing FND, neurologists selected FND-related ICD-10 codes in only 22.8% of consultations. 96.2% of neurologists estimated that they would code for non-epileptic seizure (NES) when substantiated by EEG; in practice, they coded for 36.7% of such consultations. For other FND manifestations, neurologists coded in only 13.3% of cases. When presented with FND and non-FND scenarios with equal levels of information, neurologists coded for FND 41% less often. The strongest predictor of non-coding was the outdated belief that FND is a diagnosis of exclusion. Coding for FND never resulted in insurance non-payment.

Conclusion:

Non-coding for FND is common. Most factors that amplify non-coding also hinder face-to-face communication. Research based on ICD-10 coding (e.g., prevalence, cost) may underestimate the impact of FND by >4-fold.

Is it really a seizure? The challenge of paroxysmal nonepileptic events in young infants

Paroxysmal nonepileptic events (PNE) comprise of a variety of nonepileptic behaviors and are divided into various types. A more accurate diagnosis is possible by examining the video clip provided by the caregiver. In infants, physiologic PNE accounts for the majority of the PNE. It is important to exclude epilepsy, for which blood tests, electroencephalography, and imaging tests can facilitate differential diagnosis. Since most PNE have a benign progress, symptoms often improve with age and without special treatment. Therefore, it is important to reassure the caregivers after making an accurate diagnosis.

Paroxysmal Nonepileptic Events in a Pediatric Epilepsy Clinic

Aims:

We aimed to study the frequency, age, and gender distribution of paroxysmal nonepileptic events (PNEs) in children referred to epilepsy clinic with the diagnosis of epilepsy. We also evaluated the therapeutic implications of correct diagnosis and co-existence of true epilepsy in this population.

Settings and Design:

All new patients below 18 years attending the Pediatric epilepsy out-patient clinic of PD Hinduja hospital over 6 months were evaluated.

Materials and Methods:

Patients with history of paroxysmal events characterized by abrupt changes in consciousness or behavior or movement were included. They were assessed on description of events aided by recorded videos. If the diagnosis was not confirmed by this preliminary evaluation, further investigations were advised.

Statistical Analysis Used:

Chi-square/Fisher’s exact test was used to analyze differences between categorical variables and Kruskal–Wallis test between continuous variables. The data were analyzed by SAS University Edition. All significance tests were two-tailed with α <0.05.

Results:

Two hundred new patients presenting with paroxysmal events were enrolled over 6 months. After diagnoses, 19% of these children had PNEs, 80% had epileptic events, and 1% remained undiagnosed. Common nonepileptic events seen were physiological in patients below 5 years and psychogenic in older children. Thirty-four percent of patients with PNEs were on anti-epileptic drugs (AEDs). After confirming nonepileptic attacks, only 2.6% patients needed AEDs for coexisting epilepsy which was statistically significant (P < 0.001) change in treatment.

Conclusions:

Epilepsy mimics are common in children and are often misdiagnosed causing undue stress. Correct diagnosis leads to a drastic change in management like withdrawal of drugs, commencing new treatment if needed, and appropriate referrals.

Recognition of Psychogenic Versus Epileptic Seizures Based on Videos

OBJECTIVE

Ictal semiology interpretation for differentiating psychogenic nonepileptic seizures (PNESs) and epileptic seizures (ESs) is important for the institution of appropriate treatment. Our objective was to assess the ability of different health care professionals (HCPs) or students to distinguish PNES from ES based on video-recorded seizure semiology.

METHODS

This study was designed following the Standards for Reporting of Diagnostic Accuracy Studies (STARD) guidelines. We showed in a random mix 36 videos of PNES or ES (18 each) and asked 558 participants to classify each seizure. The diagnostic accuracy of various groups of HCPs or students for PNES versus ES was assessed, as well as the effect of patient age and sex. Measures of diagnostic accuracy included sensitivity, specificity, and area under the curve (AUC).

RESULTS

The descending order of diagnostic accuracy (AUC) was the following (p ≤ 0.001): (1) neurologists and epileptologists; (2) neurology residents; (3) other specialists and nurses with experience in epilepsy; and (4) undergraduate medical students. Although there was a strong trend toward statistical difference, with AUC 95% confidence intervals (CIs) that were not overlapping, between epileptologists (95% CI 93, 97) compared to neurologists (95% CI 88, 91), and neurologists compared to electroencephalography technicians (95% CI 82, 87), multiple pairwise comparisons with the conservative Tukey-Kramer honest significant difference test revealed no statistical difference (p = 0.25 and 0.1, respectively). Patient age and sex did not have an effect on diagnostic accuracy in neurology specialists.

CONCLUSION

Visual recognition of PNES by HCPs or students varies overall proportionately with the level of expertise in the field of neurology/epilepsy.

Psychopathological features in referred adolescents with psychogenic nonepileptic seizures with or without epilepsy

Psychogenic nonepileptic seizures (PNES) are episodic manifestations that mimic epileptic seizures (ES) although not associated with electroencephalogram (EEG) abnormalities. Psychogenic nonepileptic seizures and ES, however, can often cooccur. Emotional distress in adolescents can trigger PNES, but the psychopathological and personality features are still unknown. The aim of this study was to explore psychopathological features in a sample of referred youth with PNES, with or without ES, compared with a control group with ES. Thirty-four patients aged 12 to 21 years, 19 females and 15 males, were included in the study, 15 patients with PNES, 7 with PNES and ES, and 12 with ES. The three groups were compared according to psychiatric categorical diagnoses, psychopathological dimensions, life stressors, and personality traits, including alexithymia, interpersonal reactivity, and resilience, all assessed with structured measures. Patients with PNES, with or without ES, were more severely impaired, had a higher incidence of mood disorders, more frequent lifetime traumatic experiences, and lower resilience. All the three groups presented alexythimic traits and emotional dysregulation. Major limitations are the small sample size and the lack of a control group of healthy subjects. Disentagling psychopathological characteristics in PNES can help clinicians to focus diagnostic approaches and therapeutic interventions.

Spectrum of Nonepileptic Paroxysmal Events in Children from Southern India

Background Nonepileptic paroxysmal events (NEPEs) present with episodes similar to epileptic seizures but without abnormal electrical discharge on electroencephalogram (EEG). NEPEs are commonly misdiagnosed as epilepsy. Epilepsy is diagnosed on the basis of a detailed history and examination. Emphasis during history to rule out the possibility of NEPE is important. The wrong diagnosis of epilepsy can lead to physical, psychological, and financial harm to the child and the family. Hence, this study was planned.

Objective The objective of the study is to evaluate clinical profile, frequency, and spectrum of NEPE in children.

Materials and Methods This is a prospective observational study. Patients with NEPE between January 2014 and August 2016 aged < 18 years were enrolled. NEPEs were diagnosed on the basis of history, home video, and EEG recordings. Patients were divided into different categories according to age, specific type of disorder, and system responsible. Patients were followed for their NEPE frequency and outcome.

Results A total of 3,660 children presented with paroxysmal events; of them 8% were diagnosed with NEPE. Patients diagnosed with NEPE were classified into three age groups on the basis of their age of onset of symptom; of the total 285 patients, there were 2 neonates (0.7%), 160 infants (56%), and 123 children and adolescents (43.1%). Fifty-eight percent patients were boys. The most common diagnoses were breath-holding spells 113 (39%), followed by syncope 38 (13.3%) and psychogenic nonepileptic seizures 37 (12.9%). About 9 and 5% of patients had concomitant epilepsy and developmental delay, respectively.

Conclusions NEPEs account for 8% of paroxysmal events. Most common NEPEs were breath-holding spells among infants and syncope and “psychogenic nonepileptic seizures” in children and adolescents.

Psychogenic nonepileptic seizures in pediatric population: A review

INTRODUCTION

Psychogenic nonepileptic seizures (PNES) are observable abrupt paroxysmal changes in behavior or consciousness that resemble epileptic seizures, but without concurrent electroencephalographic abnormalities.

METHODS

In this manuscript, we reviewed literature concerning pediatric PNES and focused on those articles published in the last 10 years, in order to try to understand what the state of the art is at the moment, particularly as regards relationship and differential diagnosis with epilepsy.

RESULTS

Psychogenic nonepileptic seizures have been extensively described in literature mainly in adults and less frequently in children. Despite the potential negative impact of a misdiagnosis (unnecessary investigations and antiepileptic drugs, structured pathological behavioral patterns), in literature there is little information regarding the real prevalence, clinical features, treatment, and outcome of PNES in children and adolescents.

CONCLUSION

Psychogenic nonepileptic seizures are common but frequently missed entity in pediatric population. Diagnosis could be difficult, especially in those children who have both epileptic and nonepileptic seizures; video EEG and home video can help clinicians in diagnosis. More studies are needed to better classify PNES in children and facilitate diagnosis and treatment.

Home Videos as a Cost-Effective Tool for the Diagnosis of Paroxysmal Events in Infants: Prospective Study

Background

The diagnosis of paroxysmal events in infants is often challenging. Reasons include the child’s inability to express discomfort and the inability to record video electroencephalography at home. The prevalence of mobile phones, which can record videos, may be beneficial to these patients. In China, this advantage may be even more significant given the vast population and the uneven distribution of medical resources.

Objective

The aim of this study is to investigate the value of mobile phone videos in increasing the diagnostic accuracy and cost savings of paroxysmal events in infants.

Methods

Clinical data, including descriptions and home videos of episodes, from 12 patients with paroxysmal events were collected. The investigation was conducted in six centers during pediatric academic conferences. All 452 practitioners present were asked to make their diagnoses by just the descriptions of the events, and then remake their diagnoses after watching the corresponding home videos of the episodes. The doctor’s information, including educational background, profession, working years, and working hospital level, was also recorded. The cost savings from accurate diagnoses were measured on the basis of using online consultation, which can also be done easily by mobile phone. All data were recorded in the form of questionnaires designed for this study.

Results

We collected 452 questionnaires, 301 of which met the criteria (66.6%) and were analyzed. The mean correct diagnoses with and without videos was 8.4 (SD 1.7) of 12 and 7.5 (SD 1.7) of 12, respectively. For epileptic seizures, mobile phone videos increased the mean accurate diagnoses by 3.9%; for nonepileptic events, it was 11.5% and both were statistically different (P=.006 for epileptic events; P<.001 for nonepileptic events). Pediatric neurologists with longer working years had higher diagnostic accuracy; whereas, their working hospital level and educational background made no difference. For patients with paroxysmal events, at least US $673.90 per capita and US $128 million nationwide could be saved annually, which is 12.02% of the total cost for correct diagnosis.

Conclusions

Home videos made on mobile phones are a cost-effective tool for the diagnosis of paroxysmal events in infants. They can facilitate the diagnosis of paroxysmal events in infants and thereby save costs. The best choice for infants with paroxysmal events on their initial visit is to record their events first and then show the video to a neurologist with longer working years through online consultation.

Sibling-Controlled Study of Parental Bonding, Coping, and Urgent Health-Care Use in Families With Children With Nonepileptic Seizures

Objectives

Pediatric psychogenic nonepileptic seizures (PNES) is a functional somatic symptom condition with significant health-care service burden. While both family and individual factors play an important role in the development and maintenance of PNES, little is known about what predicts urgent health-care use in families with children who have PNES. The aim of the current study was to explore whether child coping and parental bonding styles influence the decision to seek urgent medical care in these families.

Methods

Data were analyzed from youth of age 8-18 years, 47 with PNES, and their 25 sibling controls. Parents provided the number of youth emergency room visits and hospitalizations in the preceding year. Youth completed a questionnaire about their coping styles and a measure about their mothers' and fathers' bonding styles. Using a mixed model with family as a random effect, we regressed urgent health-care use on participant type (youth with PNES or sibling), parental bonding style, and youth coping style, controlling for number of child prescription medications.

Results

Higher urgent health-care use was associated with having PNES, coping via monitoring, and perceiving one's father to be rejecting and overprotective. Lower urgent health-care use was associated with coping via venting and with perceiving one's mother to be caring and overprotective.

Conclusions

This study provides preliminary empirical support for family-based clinical efforts to reduce child urgent health-care use by enhancing effective child coping skills and improving parental response to child impairment and distress in families with youth with PNES.

Seizure imitators monitored using video-EEG in children with intellectual disabilities

Diagnosis of seizure imitators in children is often challenging, and individuals with intellectual disability (ID) could be at additional risk of seizure imitator misdiagnosis. We aimed to elucidate distinct features of clinical semiology among children of different intellectual levels, which may help in distinguishing seizure imitators from epilepsy in such individuals. We retrospectively compared semiological features of seizure imitators in children with and without ID captured using video-electroencephalography (video-EEG). Seizure imitators were classified based on the definition of the International League Against Epilepsy (ILAE). A total of 67 individuals (mean age: 8.4 years, SD: 4.2 years) with seizure imitators documented using long-term video-EEG were identified, in which 27 patients had normal IQ/DQ, 20 had moderate ID, and 20 had severe ID. There was no statistically significant difference in the semiological features of seizure imitators between individuals with ID and those without ID; similarly, no difference was found between those with moderate ID and severe ID compared with individuals with normal IQ/DQ. Among all the patients, altered responsiveness mimicking cognitive or absence seizures was most frequently observed (36%), followed by jerks mimicking myoclonic seizures (22%). The most common seizure imitators among all the patients were unclassifiable nonepileptic seizures per the ILAE definition (28 cases, 42%), followed by day dreaming (24 cases, 36%) and physiological myoclonus (14 cases, 21%). In summary, the present study found no marked difference in semiological features of seizure imitators between patients with ID and those without ID regardless of ID severity, suggesting the necessity of early video-EEG for correct diagnosis.

Utility of long-term video-EEG monitoring for children with staring

OBJECTIVE

Staring spells are a common reason for referral to overnight epilepsy monitoring unit (EMU) evaluation. However, inpatient EMU admissions are expensive and time consuming. This study determined what percentage of those referred for staring had a confirmed epileptic seizure on long-term video-EEG monitoring (LTM) and developed a scoring system to help prioritize which patients should undergo this procedure.

METHODS

We performed a four-year retrospective chart review of all children at a tertiary pediatric hospital who received LTM (long-term monitoring) for the purposes of characterizing staring. The two goals were to: a) assess how often an LTM admission captured a staring spell that was diagnosed as a seizure and b) determine if any baseline factors predicted this particular positive result. We coded several characteristics of the most recent prior routine EEG if available. We also coded parental reports of the duration, frequency, and breakability of the events as well as post-ictal mental status and the presence/absence of automatisms. Finally, we coded previous neurological and psychiatric diagnoses and medications, as well as family history of epilepsy.

RESULTS

Of the 276 admissions, only 29 (11%) captured a staring spell and diagnosed it as seizure. Several baseline variables predicted the likelihood of this positive result. Based on this information, we created a scoring system as follows: -3 points if the previous EEG was normal, -1 point if the child took a medication for a psychiatric condition, +1 point if the child took an anti-epileptic drug for epilepsy, and +1 point if the spells lasted less than 1min. If the total score was zero or less, staring spells diagnosed as seizures rarely occurred (less than 5% of the studies).

SIGNIFICANCE

Our scoring system shows how consideration of prior EEG findings, medication history, and staring spell duration can help prioritize patients for LTM admission to evaluate if staring spells are epileptic seizures.

Psychogenic Nonepileptic Seizures: Diagnosis, Management, and Bioethics

BACKGROUND

The diagnosis and management of psychogenic nonepileptic seizures (PNES) is often challenging and fraught with discord and disagreement between patients, parents, and physicians. Furthermore, there are ethical challenges when making the diagnosis, communicating this information, and instituting management.

METHODS

We reviewed the current body of knowledge regarding the characteristic differences between epileptic seizures and PNES, and the high incidence of psychiatric comorbidities. An ethical analysis was made of diagnosis and management based on ethical principles, virtue ethics, and the social contract that health professionals have with patients.

RESULTS

Key distinctions between PNES and epilepsy lie in both patient and seizure characteristics. Long duration, eye closure, asynchronous movements, frequent recurrence in the same context, intra-ictal awareness, and lack of post ictal state are useful in helping establish the diagnosis. Psychiatric comorbidities, history of abuse, cognitive impairment, and multiple non specific somatic complaints are some salient patient features that should increase suspicion for the diagnosis of PNES. However, definitive diagnosis rests on capturing the events on video EEG.

CONCLUSION

Effective diagnosis and management of PNES requires the use of video EEG and an early collaborative approach between pediatricians, neurologists, psychiatrists, nursing staff, and other professional colleagues. Ethical questions that may arise should be addressed with the virtues of competence, courage, compassion, prudence, and honesty; and the principles of respect beneficence, and the avoidance of unnecessary harm.