Prevalence of ictal injuries in functional (psychogenic nonepileptic) seizures: A systematic review and meta-analysis

A Multidisciplinary Approach to Nonepileptic Events

OBJECTIVE

This article provides a guide for neurologists managing nonepileptic events (NEEs), a complex intersection of neurology and psychiatry. It covers risk factors, pathophysiology, current treatment approaches, and prognosis, with specific management strategies for challenging scenarios such as patients with intellectual disabilities and comorbid epilepsy.

LATEST DEVELOPMENTS

An emphasis on strong communication and coordinated care among health care specialists improves patient outcomes and reduces unnecessary medical consultations and procedures. This approach is now recognized as essential for addressing the complex presentation and comorbidities associated with NEEs.

ESSENTIAL POINTS

NEEs are prevalent and highly disabling, and multiple pathophysiologic mechanisms for these events have been proposed. Mortality is comparable with that of patients with treatment-refractory epilepsy, and prognosis is better for children than adults. Achievable treatment goals for adults include improved quality of life and reduced frequency and severity of events, even if complete remission of NEEs is not achieved. Enhanced communication and coordinated care through multidisciplinary care teams enable the efficient use of individual expertise at different treatment stages to address the presentation, risk factors, and comorbidities associated with NEEs, resulting in a better quality of life for patients.

Epilepsy Therapies Symposium | Do We Really "Outgrow" Seizures?

Initiation and maintenance of antiseizure therapy can be relatively straightforward in most patients. Depending on epilepsy type, patients may be more or less likely to enter remission or a resolution of their epilepsy and the International League Against Epilepsy developed clinically guiding definitions in this regard. The mechanisms by which resolution or remission are achieved are poorly understood which complicates clinical decision making and risk estimate for future seizure relapse. The impetus for the maintenance of medical therapy in a seizure-free patient is also age-dependent. In children, one ought to consider the unknown effects of antiseizure medications on the developing brain while family planning, lifestyle, education, or employment are some of the issues that affect the decision making in adults. Patients who enter remission following surgical remediation of their epilepsy represent a distinct category and medication discontinuation is influenced by a number of factors. Another important consideration is comorbidities that often affect medication choices and maintenance. When formulating a management strategy, patient preferences together with careful evaluation and precise and accurate epilepsy diagnosis are key towards guiding medical or surgical management, prognostication for seizure freedom, relapse risk, options for medication discontinuation, and understanding risks and types of comorbidities.

New-onset psychogenic nonepileptic seizures after intracranial neurosurgery: A meta-analysis

BACKGROUND

The epidemiology of psychogenic non-epileptic seizures (PNES) is still unclear. Although approximately 14 million people need neurosurgical care annually, there is a dearth of thorough analysis on PNES occurrence following surgery. This study seeks to estimate the proportion of newly diagnosed PNES.

METHODS

We conducted a literature search of the PubMed, Ovid, CINAHL, and Cochrane Library databases up to December 2023. We identified studies using an observational design on the occurrence of PNES in patients who underwent intracranial surgery, and confirmed diagnosis using video-EEG. Estimates are reported as proportions using random effects models. We reported both 95 % CIs and prediction intervals (PI). We assessed the risk of bias and identified the pooled odds ratio (OR) for mutually exclusive groups. The heterogeneity was investigated using the I² statistic and significance determined using Cochran's Q-test. Post-hoc Egger's regression test, and several sensitivity analyses were performed. This study was registered in PROSPERO (CRD42023488611).

RESULTS

Of the 1766 unique studies identified, 86 were selected for full-text review. Eight studies (n = 3,699) were eligible for inclusion. Studies, spanning from 1995 to 2017, primarily focused on epilepsy surgeries. The pooled proportion was 3 % (95 % CI 2 %-5 %; 95 % PI 0 %-11 %). Temporal resections indicated twofold increase of PNES comparing to either resections (OR 2.05, 95 %CI 0.81-5.19). The risk of bias assessment indicated satisfactory quality for included studies, and heterogeneity in estimates was mainly explained by publication year of studies and their rounded sample size.

CONCLUSIONS

Given the estimations, there is expected impact of intracranial procedures on functional seizures epidemiology. Further efforts need to understand the contribution of brain resections to PNES incidence.

Do we intervene less and slower in the epilepsy monitoring unit for psychogenic seizures?

PURPOSE

Individuals with psychogenic non-epileptic seizures (PNES) can be stigmatized in healthcare settings. We aimed to compare intervention rate (IR), intervention time (IT), and adverse event (AE) rate between PNES and epileptic seizures (ES) in the epilepsy monitoring unit (EMU).

METHODS

We used a prospective database of consecutive admissions to our centre's EMU between August 2021 and September 2022. We excluded purely electric seizures and vague, minor spells with no EEG correlate. We therefore only included electroclinical seizures and PNES. We compared the IR, IT, and AE rate between PNES and ES, as diagnosed by an epileptologist during EEG monitoring. We performed the same comparisons between spells occurring in people admitted with a high vs low suspicion of PNES (HSP vs LSP). We also verified if ITs became longer with repeated PNES.

RESULTS

We analyzed 586 spells: 43 PNES vs 543 ES, or 133 HSP vs 453 LSP. Our univariate analyses showed that IR was higher for PNES than for ES (93 % vs 61 %, p <.001) but that IT and AE rate were similar across groups. This higher IR was only apparent outside weekday daytime hours, when EEG technologists were not present. HSP did not differ from LSP in terms of IR, IT, and AE rate. As PNES accumulated in individual patients, IT tended to be longer (Spearman's correlation = 0.42; p =.012).

SIGNIFICANCE

Our EMU staff did not intervene less or slower for PNES. Rather, IR was higher for PNES than for ES, but IT tended to be longer with repeat PNES.