Ictal Behaviors During Nonepileptic Seizures Differ in Patients with Temporal Lobe Interictal Epileptiform EEG Activity and Patients Without Interictal Epileptiform EEG Abnormalities

Summary: Purpose: Ictal behaviors during psychogenic non-epileptic seizures (NES) vary considerably among individuals, and can closely resemble common semiologies of epileptic seizures (ES). We tested the hypothesis that behaviors during NES in patients who have temporal spikes would more closely resemble behaviors during ES in patients with temporal lobe epilepsy than would behaviors during NES in patients who do not have EEG spikes.
Methods: We identified 20 patients who had interictal temporal EEG spikes and EEG-video recorded NES (Study Group), 133 patients with temporal EEG spikes and recorded ES, without NES (Epileptic Group), and 24 patients with recorded NES and no epileptiform EEG abnormalities, without ES (Nonepileptic Group).
Results: The hypothesis was supported with regard to ictal motor behaviors. Motionless staring or complex automatisms occurred mainly during NES in the Study Group and during ES in the Epileptic Group. In contrast, convulsive movements or flaccid falls were most common during NES in the Nonepileptic Group. Duration of unresponsiveness was longer, and there were fewer postictal states in NES both in the Study and Non-epileptic Groups. Unresponsiveness was briefer and postictal states were more consistent in ES in the Epileptic Group, however.
Conclusions: Stereotyped motor activities during NES presumably represent learned behaviors. Processes underlying acquisition of ictal behaviors of NES probably differ in patients with interictal epileptiform EEG abnormalities compared to those without. Prior experiences and temporal lobe dysfunctions that are associated with epilepsy, and psychological characteristics that are unrelated to interictal epileptic dysfunctions, may determine ictal behaviors during NES.     

Postictal symptoms help distinguish patients with epileptic seizures from those with non-epileptic seizures.

The aim of the study was to assess whether post-ictal symptoms can help distinguish patients who have epileptic seizures from those with non-epileptic seizures (NES). We reviewed the spontaneous responses to the question 'What symptoms do you have after a seizure?' in 16 patients with epileptic seizures (predominantly focal with secondary generalization or generalized tonic-clonic) and 23 NES patients. Six of the 16 patients (38%) vs. only one of 23 NES patients (4.3%) noted post-ictal headache (P = 0.008). Nine epilepsy patients (56%) vs. three NES patients (13%) reported post-ictal fatigue (P = 0.004). Confusion or other symptoms did not distinguish epilepsy patients from those with NES. All epilepsy patients had at least one post-ictal symptom while 12 NES patients (52%) had none (P = 0.001). Therefore, patients evaluated for epileptic vs. non-epileptic seizures who have post-ictal fatigue or headache, are more likely to have epileptic seizures. Patients with a diagnosis of NES who note post-ictal fatigue or headache should be investigated further.     

儿童非癫痫性发作

目的 :探讨儿童非癫痫性发作的各种临床表现形式。方法 :对 35例非癫痫性发作患儿的临床结合脑电图监测进行分析。结果 :35例儿童非癫痫发作中 ,生理性发作占 5 1% ,且平均年龄最小 ,全部患儿经 2 4小时脑电图或录相监测脑电图检查发作间期和 /或发作期均无异常放电 ;本组误诊 2 1例 ,其中癫痫 10例。结论 :儿童的非癫痫性发作表现形式多样 ,以生理性发作最多。儿童非癫痫性发作易误诊为癫痫及其它疾病 ,应用动态脑电图监测对其诊断及鉴别诊断有重要意义。     

Conversion disorder and coexisting nonepileptic seizures in patients with refractory seizures

Nonepileptic seizures (NES) are commonly observed in patients with seizures resistant to antiepileptic drugs (AEDs). However, NES may be symptomatic of different diagnoses, in particular, conversion disorder (CD) and coexisting NES and epileptic seizures (CENES). We compared the clinical characteristics of these disorders in 219 patients with refractory seizures. The prevalence of NES was similar in children (11%) and adults (16%). In both groups, CENES represented the most frequent cause of NES (75%). In adults, CD was associated with a shorter duration of illness and normal neuroimaging and interictal EEG compared with the other groups. Patients with CD represented one-quarter of all patients with AED-resistant seizures with normal presentation during interictal investigations. In both children and adults with AED-resistant seizures, NES are frequently observed and are three times more likely to be CENES than CD.     

Characteristics of patients with nonepileptic seizures

The personality features, neuropsychological data, and ictal characteristics of 23 patients with nonepileptic seizures (NES) were compared to 25 patients with EEG-confirmed epileptic seizure (ES) disorders. A distinctive pattern of seizure, behavior, and personality features was evident in NES patients. NES was characterized by later disease onset and shorter disease duration. NES tends to last significantly longer than ES and rarely results in tongue-biting or self-injury. Patients who develop NES frequently have witnessed seizures prior to developing the disorder and have greater somatic concerns than patients with ES. Neuropsychological group data failed to differentiate NES from ES. However, the absence of group differences may reflect heterogeneity within the NES population. Although many NES patients performed well within normal limits on all neuropsychological measures, most were mildly to severely impaired. Qualitative analysis of neuropsychological data also revealed inconsistencies within the NES group. These findings suggest that a more global neurobehavioral profile may be useful in the diagnosis of NES. Future studies of NES must also recognize that important individual differences may be masked within group data.     

What is the Significance of Subjective Events Recorded During Long-Term EEG Video Monitoring?

Summary: Purpose : Purely subjective events, identified as "seizures" by patients but not accompanied by any clinical or EEG changes, commonly occur during evaluation of patients for intractable epilepsy. We wished to determine the significance of such events.
Methods : We analyzed the frequency of subjective episodes in 379 adults who underwent EEG video monitoring as part of their evaluation for intractable epilepsy and the relationship of these experiences to epileptic and psychogenic nonepileptic (NES) seizures. We examined the results of tests of mental ability and of emotional, psychosocial, and quality of life (QOL) adjustment to determine if individuals with subjective events alone could be distinguished from those with epileptic seizures only, NES only, or no events, by these measures.
Results : We noted subjective events in 39% (147 of 379) of the patients. Of patients with subjective episodes, 52% also had epileptic seizures, 7% had NES, 1% had both epileptic seizures and NES, and 40% had subjective events alone. As a group, patients with subjective events alone were slightly more intelligent and less impaired neuropsychologically than people in the other groups, hut they performed more poorly on several important measures of adjustment.
Conclusions : The identification of persons with purely subjective episodes apart from all other episodes is important both phenomenologically and from a practical viewpoint.     

Clinical trials of carbamazepine for autonomic seizures with and without generalized epileptic seizures

Carbamazepine (CBZ) was used for the treatment of 52 children of autonomic seizures with and without generalized epileptic seizures. Their ages ranged from 4 to 17 years. Their autonomic seizures were recurrent episodic headaches and/or abdominal pains. EEG abnormalities were found in all cases in this study. The abnormal EEG findings consisted of diffuse paroxysmal slow dysrhythmia, generalized spike and wave complexes, focal spike and wave complexes with diffuse slow wave bursts, spike and wave complexes with 14 and 6 Hz positive spikes of 14 and 6 Hz positive spikes. Of the 40 patients with autonomic seizures only, 36 (90%) showed disappearance of pain, and of the remaining 4, 2 showed moderate improvement and 2 showed no change as far as their clinical symptoms were concerned. Of the 12 patients with both autonomic seizures and generalized epileptic seizures, 10 (83%) became free from headache and 2 improved moderately. The efficacy of CBZ was found to be very satisfactory. The effective dosage of CBZ ranged from 3.9 to 11.4 mg/kg/day (total dose, 100 to 400 mg/day) with the mean value of 7.0 mg/kg/day.     

The EEG in nonepileptic seizures.

Nonepileptic seizures are episodes that resemble seizures but are not epileptic. The importance of EEG in the diagnosis of NES is that misread (overread) EEGs are an important contributor to the misdiagnosis of epilepsy. About 20% to 30% of patients with refractory "seizures" seen at epilepsy centers have been misdiagnosed, and the vast majority have psychogenic nonepileptic seizures (PNES). Many such patients have had previous EEGs interpreted as epileptiform. These misdiagnoses based on EEG are easily perpetuated, complicate management, and adversely affect outcome. The reasons for the overinterpretation of EEGs include the common misconception that phase reversals indicate abnormalities and not applying strict criteria to make sharp transients epileptiform. The diagnosis of PNES typically begins with a clinical suspicion and then is confirmed with EEG-video monitoring. However, ictal EEG may be negative in some partial seizures and may be uninterpretable because of artifacts. Movements can generate rhythmic artifacts that mimic an electrographic seizure. Analysis of the ictal semiology (i.e., video) is at least as important as the ictal EEG. Provocative techniques, activation procedures, or "inductions" can also be useful for the diagnosis of PNES.     

Use of the Personality Assessment Inventory as an efficacious and cost-effective diagnostic tool for nonepileptic seizures

Video electroencephalographic monitoring (VEEG) is considered the "gold standard" for making the differential diagnosis between epileptic seizures (ES) and nonepileptic seizures (NES), but is a costly, time-consuming procedure and not readily available in all communities. Of the various diagnostic techniques and measures that have been used, the Personality Assessment Inventory (PAI) has shown promise as an effective psychological screening tool to aid in the differential diagnosis of ES/NES. Using VEEG results as the outcome measure, this study examined the diagnostic effectiveness of the PAI in a group of adults with treatment-refractory seizures. Results indicated that, on psychological screening, patients with NES endorse significantly greater functional consequences of their seizure-like episodes than participants with ES. A "NES Indicator" score, calculated from the PAI Somatization subscales, provided a sensitivity of 84% and specificity of 73% for the diagnosis of NES versus ES. The PAI appears to be a useful screening tool prior to hospital admission for VEEG.     

Spike EEG abnormalities in patients without epileptic seizures: a clinical and long-term follow-up study

A study was conducted on a total of 850 patients who had not previously manifested any epileptic seizures but exhibited at least one spike EEG abnormality. They accounted for 7.2% of the total number of patients without epileptic seizures (850/11,773). Among the 850 patients, 564 were followed up for 1-24 years. Nine boys and one girl, i.e. 1.8% of the 564 patients, had manifested epileptic seizures during the observation period. They expressed the following six characteristics: males, first EEG examination at 0-4 years of age, onset of initial chief complaints at 0-6 years of age, mental retardation, spike and wave EEG abnormalities and past history of perinatal birth injuries. These factors are considered to be efficient in detecting patients liable to manifest epileptic seizures later.     

Clinical utility of EEG in alcohol-related seizures

OBJECTIVE: To study if electroencephalogram (EEG) can discriminate between alcohol-related seizures (ARS) and seizures unrelated to alcohol use. MATERIAL AND METHODS: Alcohol-related seizures was defined as a seizure in a patient with score > or = 8 in the Alcohol Use Disorders Identification Test (AUDIT). Twenty-seven patients with ARS (22 without epilepsy: ARSwE), 21 AUDIT-negative epileptic patients with seizures (ES), and 30 other AUDIT negative patients with seizures (OS) were studied. Thirty-seven epilepsy outpatients and 79 sciatica inpatients were controls. RESULTS: Epileptiform and slow activity were less frequent in the ARSwE than in the ES group. Alpha amplitude was lower in the ARSwE than the other groups. Photoparoxysmal activity was not observed. EEG was associated with a larger negative predictive value (78% probability of non-ARS if EEG was abnormal) than a positive predictive value (55% probability of ARS if EEG was normal). CONCLUSION: A definitely abnormal EEG suggests epilepsy or symptomatic seizures unrelated to alcohol. The predictive value of a normal EEG is limited, but the typical post-ictal finding in ARS is nevertheless a normal low-amplitude EEG record.     

The diagnostic value of oral lacerations and incontinence during convulsive "seizures"

Purpose: Oral lacerations and urinary incontinence have long been considered useful clinical features for the diagnosis of epileptic seizures; however, both are also reported in patients with psychogenic nonepileptic seizures (PNES). The aims of the study were (1) to investigate whether the presence and nature of oral lacerations or incontinence during convulsive seizures of patients with epilepsy differed from those with PNES, and (2) whether the side of the oral laceration has any correlation with the epilepsy syndrome or lateralization.
Methods: Eighty-four consecutive patients who experienced at least one convulsive event during video-EEG monitoring (VEM) were questioned and examined for oral lacerations and incontinence. Seizure classification was determined by a team of epileptologists based on the VEM findings and other clinical and investigational data, blinded to the oral laceration and incontinence information.
Results: The presence of oral lacerations among patients with epileptic seizures was 26% (17/66), in contrast it was 0% (0/18) with PNES (p = 0.01). Of the oral lacerations sustained by patients during an epileptic seizure, 14 were to the side of the tongue, one to the tip of the tongue, two to the cheek, and three to the lip. No significant relationships were observed between seizure lateralization and oral lacerations. Incontinence occurred in 23% (15/66) of epilepsy patients and 6% (1/18) of PNES patients (p = 0.09). There was no relationship between epilepsy type or lateralization and the prevalence of incontinence.
Conclusions: Despite frequent reports of oral lacerations and incontinence by patients with PNES, objective evidence for this is highly specific to convulsive epileptic seizures.     

Epileptic spasms preceded by partial seizures with a close temporal association

PURPOSE: To investigate the distinctive features of patients with West syndrome who had partial seizures followed by epileptic spasms (PS-ES). METHODS: We examined 45 patients with West syndrome whose epileptic spasms were recorded with simultaneous video-electroencephalography (EEG) monitoring between 1982 and 1996. We investigated the patients who had PS-ES and compared the PS-ES patients with the 37 patients without PS-ES. RESULTS: Of the 45 patients who had epileptic spasms in clusters (ES) and hypsarrhythmia on the interictal EEG, eight (17%) had ES preceded by partial seizures (PS) with a close temporal association. Seven of these eight were female patients. The underlying disorders were tuberous sclerosis (one patient), Aicardi syndrome (one), nonketotic hyperglycinemia (one), and focal cortical dysplasia (one). The etiology was unknown in the remaining four patients, but was suspected to be of prenatal origin in three. Three types of seizure sequence were identified: PS followed several seconds later by ES (two patients), alternating PS and ES starting with PS (three), and PS gradually replaced by ES with overlapping of the two (three). PS-ES disappeared or was replaced by other types of seizures in 1-34 months. Six patients could not walk, and all patients could not speak any sentences at age 3 years. CONCLUSIONS: Compared with patients without PS-ES, those with PS-ES more often had organic brain lesions of prenatal origin, other types of seizures before the onset of ES, asymmetric hypsarrhythmia on the EEG, and poor psychomotor outcome.     

Postictal SPECT in Epileptic Versus Nonepileptic Seizures

Despite advances in video-electroencephalogram (EEG) technology, in many patients distinguishing epileptic seizures from nonepileptic seizures (NES) remains a challenge. Reliable methods to make this distinction are needed. In a pilot study, we performed postictal and interictal single photon emission computed tomography (SPECT) in 22 patients undergoing video-EEG monitoring who had altered responsiveness during an episode. Eleven had seizures, defined as episodes associated with EEG seizure patterns or postictal prolactin (PRL) elevations greater than 1.5 times the highest interictal baseline PRL; 11 had NES. Among the 11 seizures, postictal SPECT was abnormal in seven (regions of hypoperfusion in six and hyperperfusion in one) and normal in four. In six cases (55%), the interictal and postictal SPECT changed. Among the 11 NES cases, postictal SPECT was abnormal in three cases (all hypoperfusion abnormalities) and normal in eight cases. In no case did the interictal and postictal SPECT change. This small sample revealed a trend toward greater hypometabolism (postictal versus interictal) on SPECT for epileptic seizures compared to NES (p < 0.12). There were postictal SPECT changes in two of five seizures unassociated with postictal PRL elevation. Prolactin was elevated in two cases unassociated with change on SPECT. Comparision of postictal to interictal SPECT may help distinguish epileptic seizures from NES. Results from SPECT may also help identify epileptic seizures unassociated with PRL elevation.     

The value of provocation methods in patients suspected of having non-epileptic seizures.

Non-epileptic seizures (NES) are reported in 18-23% of patients referred to comprehensive epilepsy centres. Non-epileptic seizures may also be present in 5-20% of the patients who are diagnosed as having refractory seizures. Because of their prevalence, financial and psychosocial outcomes cannot be ignored and accurate diagnosis is of the utmost importance. Various methods of seizure induction have been developed with the aim of differentiating epileptic from non-epileptic seizures. However, recording the attacks by video-EEG monitoring is the gold standard. In our outpatient EEG laboratory we try to induce seizures with verbal suggestion or IV saline infusion in patients who are referred by a clinician with the diagnosis of probable non-epileptic seizures. In this study we investigated the results of 72 patients who were referred between January 1992-June 1996. Non-epileptic seizures were observed in 52 (72.2%) patients. Thirteen of these patients still had risk factors for epilepsy. We could not decide whether all of their previous attacks were non-epileptic because 10-30% of the patients with NES also have epileptic seizures. For a more accurate diagnosis it was decided that these 13 patients, together with the 20 patients who did not have seizures with induction, needed video-EEG monitoring. Thirty-nine patients who had NES and no risk factors for epilepsy were thought to have pure non-epileptic seizures. We claim that not all patients suspected of having NES need long-term video-EEG monitoring and almost half (54.2%) of the cases can be eliminated by seizure induction with some provocative techniques.     

Medication use,self-reported drug allergies,and estimated medication cost in patients with epileptic versus nonepileptic seizures

The decision to take medication may say as much about a patient’s self-perception as it does about his or her diagnosis. Patient-reported drug allergies often cannot be verified by physicians, and may be a self-perception not always grounded in medical reality. We retrospectively studied medication use and self-reported drug allergies in 346 sequential epilepsy monitoring unit (EMU) inpatients from 1994–96. Because financial concerns play an increasing role in patient care, we also estimated minimum antiepileptic drug (AED) costs. A clear diagnosis was reached in 226/346 (65%) cases. Seventy-four cases were nonepileptic seizures (NES) (33%) and 152 were epileptic seizures (ES) (67%). The NES patients were significantly more likely to be women (76%) than were ES patients (60%) (p < 0.01). The NES and ES patients took an average of 3.6 and 3.3 medications, respectively, at baseline (p > 0.05). The ES patients took more AEDs than NES patients [1.9 and 1.3, respectively (p < 0.01)]. Conversely, NES patients took more non-AEDs at baseline [2.3 vs. 1.4 (p < 0.01)]. The NES patients reported more drug allergies than did ES patients [1.1 vs. 0.8 (p < 0.05)]. Minimum average estimated AED costs for NES patients were $70.04 per month, and for ES patients were $104.22. The tendency to take more medicines and reported more drug allergies by NES patients may reflect a greater tendency to manifest psychologic distress as physical symptoms. This comes at a high cost, with minimum estimated cost of $70 per month.     

Psychogenic,nonepileptic seizures associated with video-EEG-verified sleep

PURPOSE: Nonepileptic seizures (NES) are expressions of a psychiatric disease state, usually conversion disorder, that mimic epileptic seizures (ES) but are not associated with the neurophysiologic changes of epilepsy. Conversion has not been demonstrated to emerge from the sleeping state. Emergence out of sleep is usually considered a virtual exclusion criterion for NES, signifying the presence instead of ES. We sought to test this hypothesis. METHODS: We retrospectively reviewed the video-EEG of all patients admitted to our epilepsy unit over a 3-year period, who were suspected of manifesting NES. We examined the relation between NES and the patients' sleep/wake state in this cohort. Two epileptologists blindly reviewed an intermixture of cases suspected to represent NES emerging out of sleep, together with control cases. Classification of each case was made independently. RESULTS: We found that in a small minority of patients (<1%), NES began either while the patient was sleeping, or within several seconds of arousal, well before a plan to simulate a seizure could likely have been formulated in the wakeful state. CONCLUSIONS: In some cases, NES are not the product of the awake mind, but rather represent a psychiatric condition that can be manifest in sleep.     

Epileptic seizures in a patient with mitochondrial myopathy, encephalopathy, lactic acidosis and strokelike episodes (MELAS)

This study reports a case of MELAS with epileptic seizure, and reviews the characteristics of seizures in patients with this syndrome. They are characterized by: (1) generalized and/or partial seizures, (2) frequent association with visual symptoms and hemiparesis, and (3) posteriorly predominant EEG abnormalities.     

The diagnostic value of urinary incontinence in the differential diagnosis of seizures

PurposeUrinary incontinence may occur both in epileptic seizures (ES) and in non-epileptic events (NEE) such as psychogenic nonepileptic events (PNEEs) and syncope. A comprehensive search of the literature to determine the accuracy of this physical finding and its prevalence in epileptic seizures and syncope is still lacking.To undertake a systematic review to determine sensitivity, specificity and likelihood ratios (LR) of urinary incontinence in the differential diagnosis between ES and NEEs (including syncope and PNEEs).MethodsStudies evaluating the presence of urinary incontinence in ES and NEEs were systematically searched. Sensitivity, specificity, positive and negative likelihood ratio (pLR, nLR) of incontinence were determined for each study and for the pooled results.ResultsFive studies (221 epilepsy patients and 252 subjects with NEEs) were included. Pooled accuracy measures of urinary incontinence (ES versus NEEs) were: sensitivity 38%, specificity 57%, pLR 0.879 (95% CI 0.705–1.095) and nLR 1.092 (95% CI 0.941–1.268). For each comparison (epileptic seizures versus NEEs; ES versus syncope; ES versus PNEEs), pooled accuracy measures for urinary incontinence showed a statistically not significant pLR (the 95% CI of the pooled value included 1, and the LR value of 1 has no discriminatory value).ConclusionsA pooled analysis of data from the literature shows that urinary incontinence has no value either in the differential diagnostic between ES and syncope/PNEEs. Systematic reviews with pooled analyses of data from the literature allow an increase in statistical power and an improvement in precision, representing a useful tool to determine the accuracy of a certain physical finding in the differential diagnosis between ES and other paroxysmal events.     

Game-related seizures presenting with two types of clinical features.

We evaluated 22 patients with epileptic seizures in which the seizures were triggered by various games or game-related materials. Based on whether spontaneous seizure coexisted or not, these 22 patients were divided into two groups. Ten patients who experienced seizures exclusively while playing or watching specific games were referred to as Group I, while 12 patients that had both game-induced and spontaneous seizures were classified as Group II. The patients in Group I had a middle-age onset (39.1 years) with a male predominance (90%). The electroencephalogram (EEG) or brain magnetic resonance imaging revealed non-specific abnormalities in 60%, and the partial onset seizure was recognized in 30% of patients. Antiepileptic drugs had uncertain benefits in this group. In Group II, patients had a male predominance (67%), with onset during adolescence (16.3 years). Most of them had generalized tonic-clonic seizures, myoclonic seizures, and absences, and 42% showed epileptiform discharge on EEG. These 12 patients were categorized into idiopathic generalized epilepsies. Although photosensitivity was an important factor, higher mental activity seemed to be significant precipitants of seizures in Group II. Antiepileptic drugs were necessary and valproic acid alone or combined with clonazepam was effective in this group. The results showed that game-related seizures are not a unique and homogeneous syndrome and may consist of different mechanisms. Teenage onset, coexistent spontaneous seizure, and associated idiopathic generalized epilepsies were crucial factors in the determination of antiepileptic drug therapy. Moreover, avoiding the related games altogether may be a more productive preventive measure.