Electrographic Seizures vs Psychogenic Nonepileptic Events. Louann Carnahan, DO

Transcription

1 Electrographic Seizures vs Psychogenic Nonepileptic Events Louann Carnahan, DO

2 Objectives Definitions Causes Distinguishing features Treatment Cases (time permitting)

3 Definitions Electrographic seizure Paroxysmal, transient episode of alteration in awareness, behavior, somatosensory, motor activity, or visual symptom that is caused by abnormal rhythmic electrical brain discharges Epileptic seizures PNEE Paroxysmal, transient episode of alteration in awareness, behavior, somatosensory, or motor activity that is not associated with abnormal rhythmic electrical brain discharges Psychogenic nonepileptic seizures Pseudoseizures

4 Causes Electrographic Seizures Abnormal rhythmic electrical brain discharges PNEE A subtype of conversion disorder Neurologic symptoms or deficits in the absence of pathologic disease Psychological stressors manifest specifically as physical symptoms resembling electrographic seizures

5 Why does correct diagnosis matter? On average, 25% of referrals for intractable epilepsy diagnosed as PNEE Delay in correct diagnosis of PNEE on average between 1-7 yrs Unnecessary exposure to AEDs and potential negative side effects Unnecessary invasive treatment (e.g. intubation and sedation for perceived status epilepticus)

6 Distinguishing Features on History* Electrographic seizures +/-Epilepsy risk factors Perinatal complication, developmental delay, febrile seizures, hx meningitis/encephalitis, +FHx seizures/epilepsy, hx significant/severe TBI, hx stroke or known CNS lesion Very stereotypic so pts or family usually do not have a hard time describing history or event semiology PNEE Multiple Psychiatric risk factors Uncontrolled depression, anxiety, PTSD, bipolar, schizophrenia, or other psych conditions Hx past abuse, traumatic event, or assault Hx chronic pain, fibromyalgia Pts or family may have a hard time describing history or event semiology or there are inconsistencies *No single feature is sensitive or specific for electrographic seizure vs PNEE, must take into account whole clinical picture

7 Distinguishing Features on History* Electrographic seizures PNEE Multiple AEDs at therapeutic doses not effective +/- Pt exposure to someone close with epilepsy and has witnessed someone else s seizures Occurence in doctor s office *No single feature is sensitive or specific for electrographic seizure vs PNEE, must take into account whole clinical picture

8 Distinguishing Features in Event Semiology* Electrographic seizures Occur directly out of electrographic sleep architecture PNEE Occur out of waking background activity when pt appears to be asleep High cluster of events w/in short amount of time or in 1 day *No single feature is sensitive or specific for electrographic seizure vs PNEE, must take into account whole clinical picture

9 Distinguishing Features in Event Semiology* Electrographic seizures Brief duration Usually <1-2 minutes Eyes open Vocalization: A brief guttural yell at beginning of a GTC sz PNEE Long duration >2 minutes Waxing and waning over long period (15-30min or up to hrs) Eyes closed Vocalization: Moaning throughout event, crying, coughing *No single feature is sensitive or specific for electrographic seizure vs PNEE, must take into account whole clinical picture

10 Distinguishing Features in Event Semiology* Electrographic seizures Motor activity: Stereotyped Synchronous Builds and progresses LOC during a GTC seizure PNEE Motor activity: Variable direction, frequency, amplitude Asynchronous Waxes and wanes Retained awareness or incomplete loss of consciousness during a whole body shaking event Thrashing or flailing of limbs Squirming or writhing Facial grimacing Foward pelvic thrusting Side-to-side rolling Side-to-side head or limb shaking Back arching *No single feature is sensitive or specific for electrographic seizure vs PNEE, must take into account whole clinical picture

11 Treatment Electrographic seizures AEDs and, if necessary, other more invasive epilepsy treatments (implanted devices or surgery) PNEE Psychiatry and psychotherapy No AED if pt does not have concomittant epilepsy or other beneficial indication (eg, mood stabilization or migraine prevention)

12

13 Case 1 MM: 18 y/o RH woman Event Semiologies: Triggers: Initial thoughts? A. Electrographic seizures B. PNEE C. Need more information

14 Case 1 MM: 18 y/o RH woman Studies: Epilepsy Risk Factors: Psychiatric Risk Factors:

15 Case 2 NL: 67 y/o RH woman Event semiology: Triggers: Initial thoughts? A. Electrographic seizures B. PNEE C. Need more information

16 Case 2 NL: 67 y/o RH woman Event semiology: Triggers: Epilepsy Risk Factors Psychiatric Risk Factors

17 Case 2 NL: 67 y/o RH woman Studies:

18 Case 3 AN: 23 y/o RH woman Event semiology: Triggers: Initial thoughts? A. Electrographic seizures B. PNEE C. Need more information

19 Case 3 AN: 23 y/o RH woman Event semiology: Triggers: Epilepsy Risk Factors: Psychiatric Risk Factors:

20 Case 3 AN: 23 y/o RH woman Studies:

21 Case 4 TL: 57 y/o RH woman Event semiology: Triggers: Initial thoughts? A. Electrographic seizures B. PNEE C. Need more information

22 Case 4 TL: 57 y/o RH woman Event semiology: Triggers: Epilepsy Risk Factors: Psychiatric Risk Factors:

23 Case 4 TL: 57 y/o RH woman STUDIES:

24 Case 5 TN: 32 y/o RH man with intellectual disability and hx intractable epilepsy Event Semiologies Triggers: Epilepsy Risk Factors: Psychiatric Risk Factors:

25 Case 5 TN: 32 y/o RH man with mild intellectual disability and diagnosis of intractable epilepsy Studies:

26

27 References 1. Chen, DK, L, WC. Diagnosis and Treatment of Nonepileptic Seizures. CONTINUUM: Lifelong Learning in Neurology: February 2016 Vol 22 Issue 1, Epilepsy p Biller, J. (2012). Practical neurology. Lippincott Williams & Wilkins. 3. Ropper, A. H. (2014). Adams and Victor's principles of neurology (10th ed). New York: McGraw-Hill Medical Pub. Division. 4. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM- 5), American Psychiatric Association, Arlington Benbadis, S. R. (2005). A spell in the epilepsy clinic and a history of chronic pain or fibromyalgia independently predict a diagnosis of psychogenic seizures. Epilepsy & Behavior, 6(2), DeToledo, J. C., & Ramsay, R. E. (1996). Patterns of involvement of facial muscles during epileptic and nonepileptic events Review of 654 events.neurology, 47(3),