Utility and Validity of Incidental Video Recordings in the Differential Diagnosis of Consciousness Loss.

BACKGROUND: Loss of consciousness (LOC) is one of the most common reasons for seeking neurological advice in clinics and emergency departments. There is considerable difficulty in determining the nature of the events according to patient reports, and collateral history is often difficult to interpret due to multiple versions and observer interpretations. OBJECTIVES: To examine the utility and validity of incidental video recordings (IVR) in the differential diagnosis of LOC. METHODS: In this retrospective study, I included patients with a documented IVR description. Results were divided into three categories: definite approval (IVR conclusion was decisive and congruent with the gold standard test), partial approval (IVR conclusion was decisive and diagnosis was confirmed by treatment response or clinical course), and inconclusive (IVR conclusion was not decisive, no gold standard test was performed, or the gold standard test was either not decisive or incongruent with the IVR). RESULTS: I evaluated the results of 31 patients with IVR documentation. Overall, in 18 patients (58%), the IVR conclusion was decisive and congruent with the gold standard test. In 8 patients (25.8%), the IVR conclusion was decisive and congruent with the clinical course or treatment response. In 5 patients (16.1%) the IVR was regarded as inconclusive. CONCLUSIONS: IVR have a substantial yield and are highly accurate in the differential diagnosis of LOC, mainly differentiating between epileptic seizures and psychogenic nonepileptic seizures, yet it is utilized in a minority of the patients in real life.

Drug Resistance in Late-onset Epilepsy.

BACKGROUND: The annual incidence of epilepsy increases with age, from nearly 28 per 100,000 by the age of 50 years to 139 per 100,000 by the age of 75 years. Late-onset epilepsy differs from epilepsy at a young age in the prevalence of structural-related epilepsy, types of seizures, duration of seizures, and presentation with status epilepticus. OBJECTIVES: To check the response to treatment in patients with epilepsy with age of onset of 50 years and older. METHODS: We conducted a retrospective study. The cohort included all patients referred to the Rambam epilepsy clinic between 1 November 2016 and 31 January 2018 with epilepsy onset at age 50 years or older and at least one year of follow-up at the recruitment time point and epilepsy not caused by a rapidly progressive disease. RESULTS: At recruitment, most patients were being treated with a single antiseizure medication (ASM); 9 of 57 patients (15.7%) met the criteria for drug-resistant epilepsy (DRE). The mean duration of follow-up was 2.8 ± 1.3 years. In an intention-to-treat analysis, 7 of 57 patients (12.2%) had DRE at the last follow-up. CONCLUSIONS: Late-onset epilepsy, which is defined as a first diagnosis in patients older than 50 years of age, is easy to control with monotherapy. The percentage of DRE in this group of patients is relatively low and stable over time.

Using nirmatrelvir/ritonavir in patients with epilepsy: An update from the Israeli chapter of the International League Against Epilepsy.

Presented herein are recommendations for use of nirmatrelvir/ritonavir in patients with epilepsy, as issued by the Steering Committee of the Israeli chapter of the International League Against Epilepsy. The recommendations suggest that patients on moderate-to-strong enzyme-inducing antiseizure medications (ASMs) and everolimus should not be treated with nirmatrelvir/ritonavir; rectal diazepam may be used as an alternative to buccal midazolam; doses of ASMs that are cytochrome P450 (CYP3A4) substrates might be adjusted; and patients treated with combinations of nirmatrelvir/ritonavir and ASMs that are CYP3A4 substrates or lamotrigine should be monitored for drug efficacy and adverse drug reactions.

Psychogenic nonepileptic seizures: Are they a freeze reaction?

Psychogenic nonepileptic seizures (PNES) clinically resemble epileptic seizures (ES) but lack epileptic activity at the time of the seizure and are also not due to any other pathophysiological disorder. The integrative cognitive model (ICM) suggests that PNES is an automatic reaction generated from distorted memory and is perceived as uncontrollable and unwanted. Furthermore, the ICM model implies that a PNES event occurs due to an external or internal cue. Intrigued by this assumption, we wanted to examine why a PNES event occurs at a particular moment by investigating the pre-ictal behavior. This study is a retrospective study. We included all patients diagnosed with PNES or ES admitted to our long-term video-EEG monitoring unit (LTVEM) between 01/01/2018 and 30/08/2020. Using thorough video analysis, we checked the patient's state at the onset of the event and looked back to see what the patient was doing before the event onset. We defined 4 types of pre-ictal behavior A. Inactivity. B. Environment arrangement c. Other. D. No apparent pre-ictal behavior. Thirty patients with PNES and 30 patients with ES were included in the study. In total, 46 PNES events and 56 ES events were recorded and analyzed. In 33 /46 PNES seizures (72%), a type A, A + B or C pre-ictal behavior was observed compared to 1/56 ES (1.78%) with type A pre-ictal behavior. All other pre-ictal behavior in the ES group were of type D. Patients with PNES have a unique pre-ictal behavior before most PNES events with motor manifestations. Since the pre-ictal behavior consists mainly of inactivity, we believe it may imply that PNES represents a freeze reaction or a reconstruction of a freeze reaction.

Treating Epilepsy Patients with Investigational Anti-COVID-19 Drugs: Recommendations by the Israeli Chapter of the ILAE.

BACKGROUND: The coronavirus disease-2019 (COVID-19) and its management in patients with epilepsy can be complex. Prescribers should consider potential effects of investigational anti-COVID-19 drugs on seizures, immunomodulation by anti-seizure medications (ASMs), changes in ASM pharmacokinetics, and the potential for drug-drug interactions (DDIs). The goal of the Board of the Israeli League Against Epilepsy (the Israeli Chapter of the International League Against Epilepsy, ILAE) was to summarize the main principles of the pharmacological treatment of COVID-19 in patients with epilepsy. This guide was based on current literature, drug labels, and drug interaction resources. We summarized the available data related to the potential implications of anti-COVID-19 co-medication in patients treated with ASMs. Our recommendations refer to drug selection, dosing, and patient monitoring. Given the limited availability of data, some recommendations are based on general pharmacokinetic or pharmacodynamic principles and might apply to additional future drug combinations as novel treatments emerge. They do not replace evidence-based guidelines, should those become available. Awareness to drug characteristics that increase the risk of interactions can help adjust anti-COVID-19 and ASM treatment for patients with epilepsy.

Stereotypy of psychogenic nonepileptic seizures.

Psychogenic nonepileptic seizures (PNES) are defined as paroxysmal episodes in which epileptic semiology features are manifested, without the characteristic concomitant electrical discharges seen in epileptic seizures. Although many studies have dealt with semiologic classification of PNES, most of the studies did not raise the question of consistency of PNES in the same patient. The aim of this study was to measure the degree of consistency of PNES among individual patients. We retrospectively reviewed medical records and video- EEG records of all adult patients who underwent monitoring in our center from August 1st 2013 to May 31st 2015. Those who were diagnosed with PNES with or without a background of epilepsy were selected for this study. In order to check consistency between seizures, we analyzed patients who had more than one recorded seizure during monitoring. In case of more than 2 recorded seizures, the first two seizures were analyzed. We found 53 patients who had PNES during this period, 29 of them had more than one seizure. All seizures in the same patient were in the same semiology category. In patients with either motor rhythmic or complex motor seizures, we found a main anatomical region involved. The main anatomical region involved was the same in 13 out of 14 patients. Movement frequency was highly similar between the seizures of the same patient, while duration of seizures was significantly different. Despite significant differences in duration between the first and second seizure in patients with PNES, all other aspects tested were highly similar. This shows that recurrent PNES in the same patient are stereotypic. This supports the hypothesis that PNES is probably a dissociative disorder.

Epileptic vs psychogenic nonepileptic seizures: a video-based survey.

Psychogenic non epileptic seizures (PNES) are present in up to 30% of patients undergoing video EEG. Delay in PNES diagnosis is an average of 7.2years. Patients are exposed to costly, hazardous medications and other iatrogenic morbidities. Our aim was to investigate the ability to correctly diagnose ES from PNES in different groups and seniorities of medical professionals based on video alone. We showed ten video episodes' recordings (5 PNES, 5 ES) to doctors and nurses from ER, Internal Medicine ward and Neurology department, and inquired about the episodes' nature. 46 participants, 26 non-neurological and 20 neurological personnel. Seniority of responders varied. Epileptologists diagnosed correctly 87.5% of cases, General neurologists 72.8%. Neurology nurses 69.8%, ER nurses 58%, Internal Medicine physicians 54.1% and ER physicians 44.4%. Statistical significant difference between the general physicians to all neurology group professions was >0.05. We pointed out the lack of awareness of first responders to patients presenting with seizures. Neurologist ability to recognize seizures using semiology alone is higher than other medical personnel. Take home messages is the need for video taking of episodes and education plan to first responders.

[UTILITY OF INPATIENT LONG TERM VIDEO EEG MONITORING].

INTRODUCTION: Ambulatory interictal EEG cannot always clarify the nature of spells in patients with suspected epilepsy. Long term Video EEG Monitoring can help to diagnose the nature of recurrent attacks, classify epileptic seizures and aid with the localization of seizures in preoperative epilepsy surgery candidates. OBJECTIVES: The aim of this study was to investigate the usefulness of performing long term video EEG monitoring in patients undergoing this test in Rambam's epilepsy unit. METHODS: This study is a retrospective study that included all consecutive patients undergoing monitoring in our unit from January 2001 to July 2009. Demographic, clinical and monitoring results were collected retrospectively from the patients' files. RESULTS: A total of 722 consecutive monitorings with a total of 637 patients were included in the study. Epileptic seizures were observed in 194 patients (30.5%), non-epileptic events were observed in 220 patients (34.5%), epileptic seizures and psychogenic non-epileptic seizures were observed in ten patients (1.6% ), no events were observed in 200 patients (31.4%) and in 13 patients (2%) we could not determine the nature of the attacks. CONCLUSIONS: Long term video EEG monitoring is highly efficient. In order to maintain its efficacy or even improve it, mainly patients with high seizure frequency should be referred to this test. Due to the low availability of this test in northern Israel, in our opinion, there is a room to expand this service.

Yield of Non-Invasive Phase 1 Presurgical Evaluation in Drug-Resistant Epilepsy Patients.

BACKGROUND: Resective epilepsy surgery is an accepted treatment option for patients with drug-resistant epilepsy (DRE). Presurgical evaluation consists of a phase 1 non-invasive evaluation and a phase 2 invasive evaluation, when necessary. OBJECTIVES: To assess the results of phase 1 evaluation in patients with focal DRE. METHODS: This observational retrospective study was performed in all consecutive DRE patients admitted to our clinic from January 2001 to July 2010, and who underwent a presurgical evaluation which included at least magnetic resonance imaging (MRI) scan and long-term video EEG monitoring (LTVEM). RESULTS: A total of 253 consecutive patients with a diagnosis of DRE (according to the ILAE recommendations) who underwent presurgical evaluation were extracted from our clinic and department registry. In 45 of these patients either imaging or ictal video EEG data were missing; the final analysis therefore involved 208 patients. The combined result of the LTVEM and the MRI scan were as follows: 102 patients (49% of the cohort) had a lesion on the MRI scan, in 77 patients (37% of the cohort) the LTVEM results were localizing and congruent with the MRI findings, and in 25 patients (12% of the cohort) the LTVEM results were either non-localizing or incongruent with the MRI findings. In 106 patients (51% of the cohort) the MRI scan was normal or had a non-specific lesion. The LTVEM was localizing in 66 of these patients (31.7% of the cohort) and non-localizing in 40 (19.2% of the cohort). CONCLUSIONS: Although some of the patients with focal DRE can be safely treated with resective surgery based solely on the findings of phase 1 evaluation, a substantial percent of patients do need to undergo a phase 2 evaluation before a final surgical decision is made.

Psychogenic nonepileptic seizure patterns in patients with epilepsy.

BACKGROUND: Psychogenic nonepileptic seizures (PNESs) clinically resemble epileptic seizures (ESs) without concomitant electroencephalograph (EEG) changes. Although most studies focus on the differences between ESs and PNESs in different groups of patients, few studies have focused on patients with a comorbidity of PNESs and ESs. OBJECTIVES: The aim of this study, was to establish the pattern of relationships between PNESs and ESs in patients who had both types of events during long-term video EEG monitoring, expecting to find that PNESs would be longer, more frequent, and more dramatic than ESs. METHODS: This retrospective study included only patients who had both ESs and PNESs during long-term video EEG monitoring. RESULTS: 12 patients with both types of seizures during long-term video EEG monitoring were recruited. Taking into account the hypothesized differentiating pattern (number of PNESs ≥ ESs, duration of PNESs ≥ ESs, and semiology of PNESs ≥ ESs), in 8 patients, all 3 conditions were fulfilled; in 3, 2 conditions were fulfilled; and in only 1, none of the conditions were fulfilled. CONCLUSION: Although there are semiological similarities between PNESs and ESs in the PNES + ES group of patients, there is still a recognizable pattern of differences between these 2 states, with characteristics of PNESs resembling those of PNESs in patients with PNESs alone-dramatic and prolonged seizures. Provoking PNESs during long-term video EEG monitoring can cause diversion from the pattern, raising the suspicion of provoking pseudo-PNESs. Although this finding needs to be further investigated provocation should be used cautiously.

Which psychogenic nonepileptic seizure (PNES) patients are more likely to be treated with anti-seizure medications?

BACKGROUND: The average time for psychogenic nonepileptic seizures (PNES) diagnosis is about 7.5 years. Many patients receive inadequate treatment and sometimes even life-threatening treatments such as tracheal intubation during this time. PURPOSE: To determine the risk factors for misdiagnosis of PNES as Epilepsy. METHODS: The medical records of patients who underwent video-electroencephalogram (EEG) monitoring were reviewed retrospectively. Patients who had PNES without epileptic seizures (ES) were included in this study. Baseline personal and monitoring characteristics were collected. The patients were then divided into two groups based on their therapeutic status. Patients in the treatment group were again divided into two groups based on the number of anti-seizure medications (ASM) they were treated with. RESULTS: Fifty-seven patients diagnosed with PNES were included in this study. Thirty-seven patients were under treatment, and 20 patients were not under treatment at the time of monitoring. Motor seizures, abnormal interictal EEG patterns, and pathological brain imaging findings were more frequent among patients in the treatment group (p<0.05). Patients with motor seizures were more likely to be treated with multiple ASM than patients with only dialeptic nonmotor seizures (p<0.05). Lastly, patients in the treatment group were monitored longer and had fewer seizures during monitoring (p<0.05). CONCLUSION: PNES patients with abnormal EEG patterns and pathological brain imaging findings are more likely to be treated with ASM. The pure dialeptic nature of seizures is less likely to be misdiagnosed as ES. In addition, patients with such seizures are less likely to be treated with multiple treatment lines.

Functional seizures: Are they consistent over time?

BACKGROUND: Our previous study showed that functional seizures (FS) are consistent in the same patient during a single video EEG monitoring (VEEG). This study aimed to check whether FS remains consistent across VEEG sessions even after several years. METHODS: The study evaluated the consistency of FS across different VEEG sessions using five criteria: FS type, the main anatomical region involved (specifically, the body part most affected during the seizure), other involved anatomical regions, frequency of movements, and duration of FS. Consistency levels were categorized as low (one consistent axis), moderate (two consistent axes), and high (three or more consistent axes). RESULTS: Fourteen patients were included in the final analysis. The mean time between monitoring was 3.8 ± 2.5 years (0.5-8 year). In 13 of 14 patients, the first and second monitoring events were classified into the same FS category. There was consistency in the main anatomical region involved in 9 out of 12 patients with motor FS. In 9 out of 12 patients with motor FS, the other anatomical regions involved were consistent in both sessions. The mean duration of the FS between sessions was inconsistent in most of the patients. Ten patients were classified with high consistency, one patient with moderate consistency, two patients with low consistency, and in one patient, the events were classified as inconsistent. CONCLUSIONS: Our results show that FS tends to remain consistent in a single patient even after several years, and there is probably no correlation between the degree of consistency and the time between VEEG sessions. These findings have implications for supporting the concept of FS as a consistent phenomenon. Additionally, they may suggest potential avenues for future research to elucidate the origins of FS. Subsequent studies are essential to validate and expand upon these preliminary observations.

Utilizing risk-controlling prediction calibration to reduce false alarm rates in epileptic seizure prediction.

Introduction: Epilepsy is a neurological disease characterized by sudden, unprovoked seizures. The unexpected nature of epileptic seizures is a major component of the disease burden. Predicting seizure onset and alarming patients may allow timely intervention, which would improve clinical outcomes and patient quality of life. Currently, algorithms aiming to predict seizures suffer from a high false alarm rate, rendering them unsuitable for clinical use. Methods: We adopted here a risk-controlling prediction calibration method called Learn then Test to reduce false alarm rates of seizure prediction. This method calibrates the output of a "black-box" model to meet a specified false alarm rate requirement. The method was initially validated on synthetic data and subsequently tested on publicly available electroencephalogram (EEG) records from 15 patients with epilepsy by calibrating the outputs of a deep learning model. Results and discussion: Validation showed that the calibration method rigorously controlled the false alarm rate at a user-desired level after our adaptation. Real data testing showed an average of 92% reduction in the false alarm rate, at the cost of missing four of nine seizures of six patients. Better-performing prediction models combined with the proposed method may facilitate the clinical use of real-time seizure prediction systems.

Knowledge and emotional attitudes of health care practitioners regarding patients with psychogenic nonepileptic seizures.

BACKGROUND: Psychogenic nonepileptic seizures (PNESs) are paroxysmal events that resemble epileptic seizures without concomitant changes in electroencephalograms (EEGs) or any other physiological cause. These seizures are one of the most common and dramatic conversion disorders. First responders treat many PNES patients with unnecessary emergency abortive medication and sometimes even intubate them. Several of our PNES patients have complained they have experienced harsh attitudes from health care practitioners (HCPs), especially during their stay in the emergency room (ER). OBJECTIVE: To assess the emotional attitude of HCPs toward PNES patients. METHODS: We handed a questionnaire containing 23 questions regarding PNES patients to HCPs from emergency medicine, internal medicine, and neurology disciplines. The questions dealt with three categories: diagnosis, management, and emotional attitudes. RESULTS: Overall, 47 HCPs participated in this study: 11 ER, 18 internal medicine, and 18 neurology practitioners. The HCP from those disciplines showed high knowledge and good management practice of PNES patients. On the other hand, the HCPs agreed with most emotional attitude statements regarding PNES patients, reflecting a high percentage of negative emotional attitudes toward this group of patients. We did not find any correlation between negative emotional attitude and HCP department, profession, or seniority. CONCLUSIONS: Although HCPs in our center perform good management practice regarding PNES patients, most reported a negative emotional attitude. This finding implies that what PNES patients feel regarding the harsh attitudes is also reflected by HCP views. Emotional attitudes towards PNES patients may not depend solely on the level of knowledge of the HCPs.

ANTECEDENTES: Crises não epilépticas psicogênicas (CNEPs) são eventos paroxísticos que se assemelham a crises epilépticas sem alterações concomitantes nos eletroencefalogramas (EEGs) ou não causadas por qualquer outra causa fisiológica. Essas convulsões são um dos distúrbios de conversão mais comuns e dramáticos. Os socorristas tratam muitos pacientes com CNEP com medicamentos abortivos de emergência desnecessariamente e às vezes até os entubam. Vários de nossos pacientes com CNEP queixaram-se de atitudes duras dos profissionais de saúde (HCPs), especialmente durante a permanência na sala de emergência (SE). OBJETIVO: Avaliar a atitude emocional dos profissionais de saúde em relação aos pacientes com CNEP. MéTODOS: Entregamos um questionário contendo 23 perguntas sobre pacientes com CNEP aos profissionais de saúde das disciplinas de medicina de emergência, medicina interna e neurologia. As questões tratavam de três categorias: diagnóstico, manejo e atitudes emocionais. RESULTADOS: No geral, 47 profissionais de saúde participaram deste estudo: 11 ER, 18 medicina interna e 18 profissionais de neurologia. Os profissionais de saúde dessas disciplinas apresentaram alto conhecimento e boa prática de manejo dos pacientes da CNEP. Por outro lado, os profissionais de saúde concordaram com as afirmações da maioria das atitudes emocionais em relação aos pacientes da CNEP, refletindo um alto percentual de atitudes emocionais negativas em relação a esse grupo de pacientes. Não encontramos nenhuma correlação entre atitude emocional negativa e departamento de HCP, profissão ou antiguidade. CONCLUSõES: Embora os profissionais de saúde de nosso centro tenham uma boa prática profissional de manejo em relação aos pacientes com CNEP, a maioria relatou uma atitude emocional negativa. Esse achado implica que o que os pacientes da PNES sentem em relação às atitudes duras também se reflete na visão do HCP. Atitudes emocionais em relação aos pacientes da CNEP podem não depender apenas do nível de conhecimento dos profissionais de saúde.

The Effect of Anti-seizure Medications on the Propagation of Epileptic Activity: A Review.

The propagation of epileptiform events is a highly interesting phenomenon from the pathophysiological point of view, as it involves several mechanisms of recruitment of neural networks. Extensive in vivo and in vitro research has been performed, suggesting that multiple networks as well as cellular candidate mechanisms govern this process, including the co-existence of wave propagation, coupled oscillator dynamics, and more. The clinical importance of seizure propagation stems mainly from the fact that the epileptic manifestations cannot be attributed solely to the activity in the seizure focus itself, but rather to the propagation of epileptic activity to other brain structures. Propagation, especially when causing secondary generalizations, poses a risk to patients due to recurrent falls, traumatic injuries, and poor neurological outcome. Anti-seizure medications (ASMs) affect propagation in diverse ways and with different potencies. Importantly, for drug-resistant patients, targeting seizure propagation may improve the quality of life even without a major reduction in simple focal events. Motivated by the extensive impact of this phenomenon, we sought to review the literature regarding the propagation of epileptic activity and specifically the effect of commonly used ASMs on it. Based on this body of knowledge, we propose a novel classification of ASMs into three main categories: major, minor, and intermediate efficacy in reducing the propagation of epileptiform activity.

Longitudinally Extensive Transverse Myelitis in a Lupus-Neuromyelitis Optica Overlap.

Transverse myelitis is an inflammatory lesion of the spinal cord, occurring in different autoimmune, infectious, and traumatic diseases but is the hallmark of neuromyelitis optica (NMO), a rare neurologic autoimmune disease. Patients with systemic lupus erythematosus (SLE) may develop transverse myelitis as a neuropsychiatric complication of active disease; however, at times, NMO co-exists as an additional primary autoimmune condition in a SLE patient. Correct diagnosis of a SLE-NMO overlap is important not only for the different disease course and prognosis compared with SLE-related LETM, but especially for the emerging and highly specific NMO treatment options, not established for SLE-related LETM-such as anti-aquaporin 4 antibodies, anti-VEGF antibodies, complement modulation, or IVIg.

Hyperimmune gammaglobulin for the treatment of West Nile virus encephalitis.

BACKGROUND: West Nile virus, the etiologic agent of West Nile fever, is an emerging mosquito-borne disease. WNV was recognized as a cause of severe human meningoencephalitis in elderly patients during outbreaks in various parts of the world. OBJECTIVES: To analyze WNV encephalitis therapy and its outcome after prescribing hyperimmune gammaglobulin therapy. METHODS: Eight subjects with WNV encephalitis were treated with supportive therapy and 5 days of IVIG 0.4 g/kg/day containing high WNV antibodies obtained from healthy blood donors. RESULTS: Patients who were treated with IVIG as soon as possible exhibited an improvement in their symptoms. All subjects presented with high fever, progressive confusion and headaches, nausea and vomiting. The Glasgow Coma Screen for six patients ranged between 8 and 13 and all were discharged with a score of 15. The remaining two subjects died during their hospitalization. CONCLUSIONS: In severe WNV infection, where the disease affects the central and/or peripheral nervous system, early intervention with IVIG together with supportive treatment is recommended.