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Jungilligens J, Perez DL. Predictive Processing and the Pathophysiology of Functional Neurological Disorder. Curr Top Behav Neurosci 2024. [PMID: 38755514 DOI: 10.1007/7854_2024_473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/18/2024]
Abstract
The contemporary neuroscience understanding of the brain as an active inference organ supports that our conscious experiences, including sensorimotor perceptions, depend on the integration of probabilistic predictions with incoming sensory input across hierarchically organized levels. As in other systems, these complex processes are prone to error under certain circumstances, which may lead to alterations in their outcomes (i.e., variations in sensations and movements). Such variations are an important aspect of functional neurological disorder, a complex disorder at the interface of brain-mind-body interactions. Thus, predictive processing frameworks offer fundamental mechanistic insights into the pathophysiology of functional neurological disorder. In recent years, many of the aspects relevant to the neurobiology of functional neurological disorder - e.g., aberrant motor and sensory processes, symptom expectation, self-agency, and illness beliefs, as well as interoception, allostasis, and emotion - have been investigated through the lens of predictive processing frameworks. Here, we provide an overview of the current state of research on predictive processing and the pathophysiology of functional neurological disorder.
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Affiliation(s)
- Johannes Jungilligens
- Behavioral Neurology Research Group, Department of Neurology, University Hospital Knappschaftskrankenhaus Bochum, Ruhr University Bochum, Bochum, Germany
| | - David L Perez
- Division of Behavioral Neurology and Integrated Brain Medicine, Department of Neurology, Functional Neurological Disorder Unit, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Division of Neuropsychiatry, Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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Cengiz O, Jungilligens J, Michaelis R, Wellmer J, Popkirov S. Dissociative seizures in the emergency room: room for improvement. J Neurol Neurosurg Psychiatry 2024; 95:294-299. [PMID: 37758452 PMCID: PMC10958294 DOI: 10.1136/jnnp-2023-332063] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 09/07/2023] [Indexed: 10/03/2023]
Abstract
BACKGROUND Dissociative seizures, also known as functional or psychogenic non-epileptic seizures, account for 11%-27% of all emergency seizure presentations. Misdiagnosis as epileptic seizures is common and leads to ineffective and potentially harmful treatment escalations. We assess the potential for diagnostic improvement at different stages of emergency workup and estimate the utility of benzodiazepines. METHODS A retrospective study of all emergency presentations with a discharge diagnosis of acute dissociative seizures seen at a university hospital 2010-2022 was performed to assess clinical characteristics and emergency decision-making. RESULTS Among 156 patients (73% female, median 29 years), 15% presented more than once for a total of 203 presentations. Half of seizures were ongoing at first medical contact; prolonged seizures and clusters were common (23% and 24%). Diagnostic accuracy differed between on-site emergency physicians and emergency department neurologists (12% vs 52%). Typical features such as eye closure, discontinuous course and asynchronous movements were common. Benzodiazepines were given in two-thirds of ongoing seizures, often in high doses and preferentially for major hyperkinetic semiology. Clinical response to benzodiazepines was mixed, with a minority of patients remaining either unaffected (16%) or becoming critically sedated (13%). A quarter of patients given benzodiazepines by emergency medical services were admitted to a monitoring unit, 9% were intubated. CONCLUSIONS Improved semiological assessment could reduce early misdiagnosis of dissociative seizures. Although some seizures seem to respond to benzodiazepines, critical sedation is common, and further studies are needed to assess the therapeutic ratio.
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Affiliation(s)
- Ozan Cengiz
- Department of Neurology, University Hospital Knappschaftskrankenhaus Bochum, Bochum, Germany
| | - Johannes Jungilligens
- Department of Neurology, University Hospital Knappschaftskrankenhaus Bochum, Bochum, Germany
| | - Rosa Michaelis
- Department of Neurology, University Hospital Knappschaftskrankenhaus Bochum, Bochum, Germany
| | - Jörg Wellmer
- Ruhr-Epileptology, Department of Neurology, University Hospital Knappschaftskrankenhaus Bochum, Bochum, Germany
| | - Stoyan Popkirov
- Department of Neurology, University Hospital Knappschaftskrankenhaus Bochum, Bochum, Germany
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Partlow BH, Birkley EL. Cognitive Processing Therapy for Concurrent Posttraumatic Stress Disorder (PTSD) and Psychogenic Nonepileptic Seizures (PNES): A Case Study. COGNITIVE AND BEHAVIORAL PRACTICE 2022. [DOI: 10.1016/j.cbpra.2021.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Poli A, Maremmani AGI, Conversano C, Muscas G, Gemignani A, Pozza A, Miccoli M. Different dissociation and alexithymia domains specifically relate to patients with psychogenic non-epileptic seizures (PNES) and with PNES and comorbid epilepsy (PNES+EP). JOURNAL OF AFFECTIVE DISORDERS REPORTS 2022. [DOI: 10.1016/j.jadr.2021.100296] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Kotwas I, Arthuis M, Cermolacce M, Bartolomei F, McGonigal A. Psychogenic non-epileptic seizures: Chronology of multidisciplinary team approach to diagnosis and management. Rev Neurol (Paris) 2021; 178:692-702. [PMID: 34980511 DOI: 10.1016/j.neurol.2021.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Revised: 11/16/2021] [Accepted: 11/17/2021] [Indexed: 11/17/2022]
Abstract
While the diagnosis and management of psychogenic non-epileptic seizures (PNES) remain challenging, certain evidence-based guidelines exist, which can help to optimize patient care. A multidisciplinary team approach appears to have many benefits. Current recommendations exist for some aspects of diagnosis and management of PNES, including levels of diagnostic certainty as proposed by the International League Against Epilepsy's expert Task Force on PNES. Other aspects of clinical still care lack clear consensus, including use of suggestion techniques for recording PNES and optimal terminology, since the term "functional seizures" has recently been proposed as a possible term to replace "PNES". The present article aims to (1) review current recommendations and (2) discuss our own team's experience in managing patients with PNES. This is organized chronologically in terms of the roles of the neurologist, psychiatrist and psychologist, and discusses diagnostic issues, psychiatric assessment and treatment, and psychotherapeutic approaches.
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Affiliation(s)
- I Kotwas
- AP-HM, Timone Hospital, Clinical Neurophysiology, Marseille, France
| | - M Arthuis
- AP-HM, Timone Hospital, Clinical Neurophysiology, Marseille, France
| | - M Cermolacce
- University Department of Psychiatry, AP-HM, Sainte-Marguerite Hospital, Marseille, France
| | - F Bartolomei
- AP-HM, Timone Hospital, Clinical Neurophysiology, Marseille, France; Aix-Marseille Université, Inserm, INS, Institut de Neurosciences des Systèmes, Marseille, France
| | - A McGonigal
- AP-HM, Timone Hospital, Clinical Neurophysiology, Marseille, France; Aix-Marseille Université, Inserm, INS, Institut de Neurosciences des Systèmes, Marseille, France.
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Widyadharma IPE, Soejitno A, Samatra DPGP, Sinardja AMG. Clinical differentiation of psychogenic non-epileptic seizure: a practical diagnostic approach. THE EGYPTIAN JOURNAL OF NEUROLOGY, PSYCHIATRY AND NEUROSURGERY 2021. [DOI: 10.1186/s41983-021-00272-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Psychogenic non-epileptic seizure (PNES) has long been the counterpart of epileptic seizure (ES). Despite ample of evidence differentiating the two, PNES mistakenly diagnosed as ES was still common, resulting in unnecessary exposure to long-term antiepileptic medications and reduced patient’s and caregiver’s quality of life, not to mention the burgeoning financial costs.
Objectives
In this review, we aimed to elucidate various differences between PNES and epileptic seizure with respect to baseline characteristics, seizure semiology, EEG pattern, and other key hallmark features.
Methods
An unstructured search was carried out in PubMed, MEDLINE, and EMBASE using keywords pertinent to PNES and ES differentiation. Relevant information was subsequently summarized herein.
Results
PNES differs significantly with ES in terms of baseline characteristics, prodromal symptoms, seizure semiology, presence of pseudosleep, and other hallmark features (for instance provoking seizure with suggestion). The combined approach, if applied appropriately, can yield high diagnostic yield.
Conclusions
PNES can be clearly differentiated from ES via careful adherence to a set of valid clinical cues. The summarized clinical hallmarks is highly useful to prevent unnecessary ES diagnosis and treatment with AEDs.
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Wieder L, Brown R, Thompson T, Terhune DB. Suggestibility in functional neurological disorder: a meta-analysis. J Neurol Neurosurg Psychiatry 2021; 92:150-157. [PMID: 33219037 DOI: 10.1136/jnnp-2020-323706] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 07/25/2020] [Accepted: 09/22/2020] [Indexed: 11/04/2022]
Abstract
OBJECTIVE Responsiveness to direct verbal suggestions (suggestibility) has long been hypothesised to represent a predisposing factor for functional neurological disorder (FND) but previous research has yielded conflicting results. The aim of this study was to quantitatively evaluate whether patients with FND display elevated suggestibility relative to controls via meta-analysis. METHODS Four electronic databases were searched in November 2019, with the search updated in April 2020, for original studies assessing suggestibility using standardised behavioural scales or suggestive symptom induction protocols in patients with FND (including somatisation disorder) and controls. The meta-analysis followed Cochrane, Preferred Reporting Items for Systematic Reviews and Meta-Analyses and Meta-analyses Of Observational Studies in Epidemiology (MOOSE) guidelines. Data extraction and study quality coding were performed by two independent reviewers. Standardised suggestibility scores and responsiveness to symptom induction protocols were used to calculate standardised mean differences (SMDs) between groups. RESULTS Of 26 643 search results, 19 articles presenting 11 standardised suggestibility data sets (FND: n=316; control: n=360) and 11 symptom suggestibility data sets (FND: n=1285; control: n=1409) were included in random-effect meta-analyses. Meta-analyses revealed that patients with FND displayed greater suggestibility than controls on standardised behavioural scales (SMD, 0.48 (95% C, 0.15 to 0.81)) and greater responsiveness to suggestive symptom induction (SMD, 1.39 (95% CI 0.92 to 1.86)). Moderation analyses presented mixed evidence regarding the extent to which effect sizes covaried with methodological differences across studies. No evidence of publication bias was found. CONCLUSIONS These results corroborate the hypothesis that FND is characterised by heightened responsiveness to verbal suggestion. Atypical suggestibility may confer risk for FND and be a cognitive marker that can inform diagnosis and treatment of this condition.
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Affiliation(s)
- Lillian Wieder
- Department of Psychology, Goldsmiths, University of London, London, UK
| | - Richard Brown
- School of Health Sciences, The University of Manchester, Manchester, UK
| | - Trevor Thompson
- School of Human Sciences, University of Greenwich, London, UK
| | - Devin B Terhune
- Department of Psychology, Goldsmiths, University of London, London, UK
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Jungilligens J, Wellmer J, Schlegel U, Kessler H, Axmacher N, Popkirov S. Impaired emotional and behavioural awareness and control in patients with dissociative seizures. Psychol Med 2020; 50:2731-2739. [PMID: 31625504 DOI: 10.1017/s0033291719002861] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
BACKGROUND Dissociative seizures (DS) are brief episodes of disrupted awareness and behavioural control that may resemble epileptic seizures. They are thought to arise in the context of impaired emotion processing and disinhibition. In a multi-perspective neuropsychological study, we aim to assess specific metacognitive traits and behavioural features involved in the affective and cognitive underpinnings of DS (emotion recognition and regulation, inhibition, interoception and sense of agency). METHODS Twenty prospectively recruited patients with video-EEG-confirmed DS and 20 healthy controls underwent comprehensive neuropsychological and psychiatric testing using validated questionnaires and structured interviews. Behavioural experimental data was obtained using a custom-made emotional go/no-go task, a digital Libet clock setup and a heartbeat counting paradigm. RESULTS Emotion recognition, as quantified in the emotional go/no-go task, was impaired in the DS group, and correlated with alexithymic traits. Behavioural inhibition, especially under conditions that would require emotion regulation, was also reduced in the emotional go/no-go task compared to controls and was correlated with neuropsychometric measures of emotion regulation. Data from the Libet clock experiment suggested impaired behavioural awareness in DS patients. No evidence of impaired interoceptive awareness was found in the heartbeat counting task. CONCLUSION These results represent comprehensive experimental evidence for alterations in emotional and behavioural awareness and control in patients with DS that yield empirical evidence for current psychopathological models. Our findings offer a more detailed understanding of key pathogenic factors in DS and provide theoretical support for recently developed cognitive-behavioural therapies for DS.
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Affiliation(s)
- Johannes Jungilligens
- Department of Neurology, University Hospital Knappschaftskrankenhaus Bochum, Ruhr University Bochum, Bochum, Germany
- Department of Neuropsychology, Faculty of Psychology, Institute of Cognitive Neuroscience, Ruhr University Bochum, Bochum, Germany
| | - Jörg Wellmer
- Ruhr-Epileptology, Department of Neurology, University Hospital Knappschaftskrankenhaus Bochum, Ruhr University Bochum, Bochum, Germany
| | - Uwe Schlegel
- Department of Neurology, University Hospital Knappschaftskrankenhaus Bochum, Ruhr University Bochum, Bochum, Germany
| | - Henrik Kessler
- Department of Psychosomatic Medicine and Psychotherapy, LWL-University Hospital, Ruhr University Bochum, Bochum, Germany
| | - Nikolai Axmacher
- Department of Neuropsychology, Faculty of Psychology, Institute of Cognitive Neuroscience, Ruhr University Bochum, Bochum, Germany
| | - Stoyan Popkirov
- Department of Neurology, University Hospital Knappschaftskrankenhaus Bochum, Ruhr University Bochum, Bochum, Germany
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The role of short-term video electroencephalogram monitoring for epilepsy and psychogenic seizures. J Clin Neurosci 2020; 82:105-110. [DOI: 10.1016/j.jocn.2020.10.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Revised: 10/05/2020] [Accepted: 10/18/2020] [Indexed: 11/20/2022]
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Hansen AS, Rask CU, Rodrigo-Domingo M, Pristed SG, Christensen J, Nielsen RE. Incidence rates and characteristics of pediatric onset psychogenic nonepileptic seizures. Pediatr Res 2020; 88:796-803. [PMID: 32392575 DOI: 10.1038/s41390-020-0945-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 04/10/2020] [Accepted: 04/11/2020] [Indexed: 02/01/2023]
Abstract
BACKGROUND Pediatric onset psychogenic nonepileptic seizures (PNES) is a highly disabling disorder and potentially misdiagnosed as epilepsy. Still, knowledge regarding PNES in children and adolescents is limited and data on both incidence and characteristics are scarce. This study investigated the incidence rate (IR) and clinical characteristics of pediatric onset PNES, including possible differences when having comorbid epilepsy. METHODS A population-based study of children and adolescents aged 5-17 years with an incident diagnosis of PNES in the Danish healthcare registries between 1996 and 2014. In total, 386 children and adolescents were included after assessment of diagnostic validity using medical record data. RESULTS The IR increased during the study period with the maximum IR observed in 2014 (7.4 per 100,000 person-years). A history of both neurologic and psychiatric problems as well as negative life events was identified. Comorbid epilepsy was confirmed for 55 cases (14.2%) and was associated with intellectual disabilities, school support and prolonged delay in PNES diagnosis. CONCLUSIONS PNES are increasingly diagnosed in children and adolescents, and the clinical profile of both neurologic and psychiatric health problems underscores the need for collaborative pediatric and mental healthcare. These findings provide important information for future healthcare planning in this area. IMPACT This nationwide study is the first to report population-based incidence rates of pediatric onset PNES documenting markedly increasing incidence rates between 1996 and 2014. A history of both neurologic and psychiatric problems as well as negative life events was identified for pediatric onset PNES. Comorbid epileptic seizures were associated with intellectual disabilities, school support and prolonged delay in PNES diagnosis. The clinical profile of both neurologic and psychiatric health problems underscores the need for collaborative pediatric and mental healthcare. The increasing number of children and adolescents diagnosed with PNES is important information for future healthcare planning in this area.
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Affiliation(s)
- Anne S Hansen
- Unit for Psychiatric Research, Psychiatry, Aalborg University Hospital, Aalborg, Denmark. .,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.
| | - Charlotte U Rask
- Department of Child and Adolescent Psychiatry, Research Unit, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Maria Rodrigo-Domingo
- Unit for Psychiatric Research, Psychiatry, Aalborg University Hospital, Aalborg, Denmark
| | - Sofie G Pristed
- Unit for Psychiatric Research, Psychiatry, Aalborg University Hospital, Aalborg, Denmark
| | - Jakob Christensen
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.,Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | - René E Nielsen
- Unit for Psychiatric Research, Psychiatry, Aalborg University Hospital, Aalborg, Denmark.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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Popkirov S, Grönheit W, Jungilligens J, Wehner T, Schlegel U, Wellmer J. Suggestive seizure induction for inpatients with suspected psychogenic nonepileptic seizures. Epilepsia 2020; 61:1931-1938. [PMID: 32712967 DOI: 10.1111/epi.16629] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 06/19/2020] [Accepted: 07/05/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To determine the utility of suggestive seizure induction for inpatient work-up of suspected psychogenic nonepileptic seizures (PNES). METHODS Prospective study of epilepsy center inpatient admissions with suspected PNES. Patients were randomized to undergo suggestive induction first (group A) and then, if necessary, long-term video-electroencephalography (EEG) monitoring, or vice versa (group B). Diagnostic pathways were compared. Potential clinical predictors for diagnostic success were evaluated. RESULTS Length of in-hospital stay did not significantly differ between groups. Suspicion of PNES was confirmed in 43 of 77 (56%) patients, evenly distributed between group A (22 of 39) and group B (21 of 38). In nine patients, recorded habitual seizures were epileptic and in 25 cases, no diagnostic event could be recorded. Diagnosis of PNES was ascertained primarily by recording a typical seizure through suggestive induction in 24 patients and through long-term monitoring in 19 patients. In group A (induction first), monitoring was not deemed necessary in 21% of cases. In group B (monitoring first), 13% would have remained inconclusive without suggestive induction. Patients who reported triggers to their habitual seizures were not more likely to have spontaneous or provoked PNES during monitoring or suggestive inducion, respectively. Patients with subjective seizure prodromes (auras) were significantly more likely to have a PNES during suggestive induction than those without (odds ratio [OR] 3.4, 95% confidence interval [CI] 1.1-10.4). There was no significant difference in seizure frequency between patients with spontaneous PNES during long-term monitoring and those with nondiagnostic monitoring sessions. SIGNIFICANCE Our results support the notion that suggestive seizure induction can reduce the number of inconclusive inpatient workups, and can obviate resource-intensive long-term monitoring in one fifth of cases. Patients who are aware of prodromes might have a higher chance of having seizures induced through suggestion.
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Affiliation(s)
- Stoyan Popkirov
- Department of Neurology, University Hospital Knappschaftskrankenhaus Bochum, Ruhr University Bochum, Bochum, Germany
| | - Wenke Grönheit
- Ruhr-Epileptology, Department of Neurology, University Hospital Knappschaftskrankenhaus Bochum, Ruhr University Bochum, Bochum, Germany
| | - Johannes Jungilligens
- Department of Neurology, University Hospital Knappschaftskrankenhaus Bochum, Ruhr University Bochum, Bochum, Germany.,Ruhr-Epileptology, Department of Neurology, University Hospital Knappschaftskrankenhaus Bochum, Ruhr University Bochum, Bochum, Germany.,Department of Neuropsychology, Faculty of Psychology, Institute of Cognitive Neuroscience, Ruhr University Bochum, Bochum, Germany
| | - Tim Wehner
- Ruhr-Epileptology, Department of Neurology, University Hospital Knappschaftskrankenhaus Bochum, Ruhr University Bochum, Bochum, Germany
| | - Uwe Schlegel
- Department of Neurology, University Hospital Knappschaftskrankenhaus Bochum, Ruhr University Bochum, Bochum, Germany
| | - Jörg Wellmer
- Ruhr-Epileptology, Department of Neurology, University Hospital Knappschaftskrankenhaus Bochum, Ruhr University Bochum, Bochum, Germany
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Xinghua T, Lin L, Qinyi F, Yarong W, Zheng P, Zhenguo L. The clinical value of long - term electroencephalogram (EEG) in seizure - free populations: implications from a cross-sectional study. BMC Neurol 2020; 20:88. [PMID: 32164605 PMCID: PMC7066744 DOI: 10.1186/s12883-019-1521-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Accepted: 10/31/2019] [Indexed: 11/10/2022] Open
Abstract
Backgroud This study aimed to explore the clinical value of long - term electroencephalogram (LTM EEG) in seizure-free individuals taking antiepileptic drugs (AEDs) for more than 2 years. We try to look for clinical factors associated with epileptiform activity on LTM EEG in seizure free patients. We hope that the detection of epileptiform activity by the LTM EEG recording can develop the better treatment strategy. Methods The LTM EEG recordings of 770 individuals with a definite diagnosis of epilepsy were assessed. Two hundred sixty-two individuals accorded with the inclusion criteria and exclusion criteria. We collect the demographic and clinical information and LTM EEG data of these 262 individuals. We analysed the data by one-way analysis of variance and Cox proportional hazards models. Results We found that more epileptiform activity were found with LTM EEG recording than regular EEG recording in seizure-free individuals. We found several clinical factors could be associated with epileptiform activity on LTM EEG in seizure free patients by a one-way analysis: symptomatic or cryptogenic epilepsy [hazard ratio (HR) = 2.6], history of cerebral trauma (HR = 7.5), and abnormal imaging findings (HR = 3.1). The following factors suggested a correlation between history of cerebral trauma (HR = 2.4) and history of cerebral surgery (HR = 3.4) with epileptiform activity on LTM EEG presentation by multivariate logistic regression analysis. Conclusions The study indicated a correlation of a number of factors with abnormal LTM EEG presentation: symptomatic or cryptogenic epilepsy, history of cerebral trauma, history of cerebral surgery, and abnormal imaging findings. The LTM EEG recording may help find epileptiform activity in high risk seizure-free individuals. The individuals need be reevaluated the therapeutic strateagies, and increase the hope to reach real seizure-free.
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Affiliation(s)
- Tang Xinghua
- Department of Neurology, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Li Lin
- Department of Neurology, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Fan Qinyi
- Department of Neurology, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Wei Yarong
- Department of Neurology, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Pu Zheng
- Department of Neurology, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Liu Zhenguo
- Department of Neurology, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
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Ali F, Seri S, Cavanna AE. Levels of diagnostic certainty for nonepileptic attack disorder in the neuropsychiatry setting. Epilepsy Behav 2020; 103:106875. [PMID: 31937509 DOI: 10.1016/j.yebeh.2019.106875] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Revised: 12/17/2019] [Accepted: 12/17/2019] [Indexed: 11/29/2022]
Abstract
Nonepileptic attack disorder (NEAD) is a medical condition commonly seen in neuropsychiatry services, often as a differential diagnosis of other neuropsychiatric conditions. Recommendations by the International League Against Epilepsy (ILAE) Nonepileptic Seizures Task Force propose a four-level hierarchical approach to the diagnosis of NEAD, based on history, witnessed event, and electroencephalographic (EEG) investigation. We set out to provide the first description of the diagnostic levels of patients with NEAD at a specialist neuropsychiatry clinic. Comprehensive clinical data from 148 consecutive patients with NEAD attending the specialist Neuropsychiatry Clinic run by a single Consultant in Behavioral Neurology were retrospectively reviewed. Patients with NEAD were primarily referred to neuropsychiatry by Consultant Neurologists (n = 94; 63.5%). The majority of patients were female (n = 108; 73.0%), with a disease duration of 7.9 years (standard deviation: 10.4). Anxiety was the most common comorbidity (n = 43; 26.7%). Categorization of patients according to the ILAE Nonepileptic Seizures Task Force criteria was mainly based on clinical features and EEG findings, as only 7 (4.7%) patients had attacks witnessed by a specialist. The largest diagnostic categories were 'possible' (n = 54; 36.5%) and 'clinically established' (n = 40; 27.0%), followed by 'documented' (n = 12; 8.1%) and 'probable' (n = 5; 3.4%). In 125 patients (84.4%), EEGs were performed. Selective serotonin reuptake inhibitors were the most frequently prescribed psychotropic medications (n = 48; 32.4%); 89 patients (60.1%) received behavioral therapy. There were no differences in pharmacological or behavioral management strategies across the patients categorized under different diagnostic levels. Patients with NEAD seen within neuropsychiatry settings are mainly assigned 'possible' and 'clinically established' levels of diagnostic certainty. Difficulty in capturing typical clinical events witnessed by an experienced clinician while on video-EEG can limit the clinical application of the 'documented' diagnostic level. If appropriate, active interventions can be implemented irrespective of diagnostic levels to minimize delays in the neuropsychiatric care pathways.
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Affiliation(s)
- Fizzah Ali
- Department of Neuropsychiatry, University of Birmingham and BSMHFT, Birmingham, UK
| | - Stefano Seri
- School of Life and Health Sciences, Aston Brain Centre, Aston University, Birmingham, UK
| | - Andrea E Cavanna
- Department of Neuropsychiatry, University of Birmingham and BSMHFT, Birmingham, UK; School of Life and Health Sciences, Aston Brain Centre, Aston University, Birmingham, UK; Sobell Department of Motor Neuroscience and Movement Disorders, Institute of Neurology and UCL, London, UK.
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Gogia B, Rai PK, Matthys SA, Mong ER, Rodriguez R, Yassin A, Patel K, Patel C, Todd M. Use of noninvasive induction techniques in the diagnosis of PNES. Epilepsy Behav 2019; 99:106491. [PMID: 31654987 DOI: 10.1016/j.yebeh.2019.106491] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Revised: 08/09/2019] [Accepted: 08/09/2019] [Indexed: 10/25/2022]
Abstract
The diagnosis of psychogenic nonepileptic seizures (PNES) remains challenging. In the correct clinical setting with prolonged electroencephalography (EEG) monitoring, the specificity of provocative techniques to distinguish induced epileptic event from a nonepileptic event approaches 90%. We report our epilepsy monitoring unit (EMU) experience with the use of noninvasive verbal suggestion (VS) during hyperventilation (HV), photic stimulation (PS) as induction technique in making the diagnosis of PNES. In total, 189/423 patients were diagnosed with PNES during the EMU evaluation. Of the 189, 20 had mixed disorder and 169 patients had only PNES, 80 patients (47.3%) had a PNES with induction, and the remaining 89 of 169 patients (52.7%) had a spontaneous PNES episode that did not require induction. Verbal suggestion during HV and PS confirmed the diagnosis of PNES in 47% of the patients who otherwise did not have spontaneous events. Within the group who was diagnosed with PNES following induction, antiepileptic drugs (AEDs) were stopped in 53% of the patients. We believe that this is a large proportion of patients that would possibly remain undiagnosed if no induction were performed.
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Affiliation(s)
- Bhanu Gogia
- Department of Neurology, University of Texas Medical Branch, Galveston, TX 77555, USA.
| | - Prashant K Rai
- Department of Neurology, University of Texas Medical Branch, Galveston, TX 77555, USA.
| | - Samuel A Matthys
- University of Texas Medical Branch School of Medicine, Galveston, TX 77555, USA.
| | - Eric R Mong
- University of Texas Medical Branch School of Medicine, Galveston, TX 77555, USA.
| | - Rafael Rodriguez
- Department of Neurology, University of Texas Medical Branch, Galveston, TX 77555, USA
| | - Ahmed Yassin
- Jordan University of Science and Technology, Department of Neurosciences, Jordan.
| | - Kamakshi Patel
- Department of Neurology, University of Texas Medical Branch, Galveston, TX 77555, USA.
| | - Chilvana Patel
- Department of Neurology, University of Texas Medical Branch, Galveston, TX 77555, USA.
| | - Masel Todd
- Department of Neurology, University of Texas Medical Branch, Galveston, TX 77555, USA.
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15
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Uchitel J, Helseth A, Prange L, McLean M, Ghusayni R, Sachdev M, Hunanyan A, Mikati MA. The epileptology of alternating hemiplegia of childhood. Neurology 2019; 93:e1248-e1259. [PMID: 31484714 DOI: 10.1212/wnl.0000000000008159] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Accepted: 05/01/2019] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To report our experience and investigate 5 original hypotheses: (1) multiple types of epileptic seizures occur in alternating hemiplegia of childhood (AHC), and these can be the initial presentation; (2) epileptiform abnormalities often appear well after clinical seizures; (3) nonepileptic reduced awareness spells (RAS) occur frequently; (4) epilepsy is commonly drug resistant but may respond to vagal nerve stimulation (VNS); and (5) status epilepticus (SE) is common and is usually refractory and recurrent. METHODS We analyzed a cohort of 51 consecutive patients with AHC. RESULTS Thirty-two of 51 patients had epilepsy: 18 focal seizures, frontal more frequently than temporal, and then posterior. Eleven had primary generalized seizures (tonic-clonic, myoclonic, and/or absence). Epileptic seizures preceded other AHC paroxysmal events in 8 (lag 5.63 ± 6.55 months; p = 0.0365). In 7 of 32, initial EEGs were normal, with the first epileptiform EEG lagging behind by 3.53 ± 4.65 years (p = 0.0484). RAS occurred equally in patients with epilepsy (16 of 32) and patients without epilepsy (10 of 19, p = 1.0). Twenty-eight patients had video-EEG; captured RAS showed no concomitant EEG changes. Nineteen patients (59%) were drug resistant. VNS resulted in >50% reduction in seizures in 5 of 6 (p < 0.04). Twelve patients (38%) had SE (9 of 12 multiple episodes), refractory/superrefractory in all (p < 0.001), and 4 of 12 had regression after SE. CONCLUSIONS Epilepsy in AHC can be focal or generalized. Epileptic seizures may be the first paroxysmal symptom. EEG may become epileptiform only on follow-up. Epilepsy, although frequently drug resistant, can respond to VNS. RAS are frequent and nonepileptic. SE often recurs and is usually refractory/superrefractory. Our observations are consistent with current data on AHC-ATP1A3 pathophysiology.
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Affiliation(s)
- Julie Uchitel
- From the Division of Pediatric Neurology, Duke University Health System, Duke University School of Medicine, Durham NC
| | - Ashley Helseth
- From the Division of Pediatric Neurology, Duke University Health System, Duke University School of Medicine, Durham NC
| | - Lyndsey Prange
- From the Division of Pediatric Neurology, Duke University Health System, Duke University School of Medicine, Durham NC
| | - Melissa McLean
- From the Division of Pediatric Neurology, Duke University Health System, Duke University School of Medicine, Durham NC
| | - Ryan Ghusayni
- From the Division of Pediatric Neurology, Duke University Health System, Duke University School of Medicine, Durham NC
| | - Monisha Sachdev
- From the Division of Pediatric Neurology, Duke University Health System, Duke University School of Medicine, Durham NC
| | - Arsen Hunanyan
- From the Division of Pediatric Neurology, Duke University Health System, Duke University School of Medicine, Durham NC
| | - Mohamad A Mikati
- From the Division of Pediatric Neurology, Duke University Health System, Duke University School of Medicine, Durham NC.
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16
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Welfare consequences for people diagnosed with nonepileptic seizures: A matched nationwide study in Denmark. Epilepsy Behav 2019; 98:59-65. [PMID: 31299534 DOI: 10.1016/j.yebeh.2019.06.024] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2019] [Revised: 06/09/2019] [Accepted: 06/11/2019] [Indexed: 02/08/2023]
Abstract
OBJECTIVE We aimed to evaluate the excess direct and indirect costs associated with nonepileptic seizures. METHODS From the Danish National Patient Registry (2011-2016), we identified 1057 people of any age with a diagnosis of psychogenic nonepileptic seizures (PNESs) and matched them with 2113 control individuals. Additionally, 239 partners of patients with PNES aged ≥18 years were identified and compared with 471 control partners. Direct costs included frequencies and costs of hospitalizations and outpatient use weighted by diagnosis-related group, and specific outpatient costs based on data from the Danish Ministry of Health. The use and costs of drugs were based on data from the Danish Medicines Agency. The frequencies of visits and hospitalizations and costs of general practice were derived from National Health Security data. Indirect costs included labor supply-based income data, and all social transfer payments were obtained from Coherent Social Statistics. RESULTS A higher percentage of people with PNES and their partners compared with respective control subjects received welfare benefits (sick pay, disability pension, home care). Those with PNES had a lower employment rate than did controls for equivalent periods up to three years before the diagnosis was made. The additional direct and indirect annual costs for those aged ≥18 years, including transfers to patients with PNES, compared with controls, were €33,697 for people with PNES and €15,121 for their partners. SIGNIFICANCE Psychogenic nonepileptic seizures have substantial socioeconomic consequences for individual patients, their partners, and society.
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17
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Morbidity and mortality of nonepileptic seizures (NES): A controlled national study. Epilepsy Behav 2019; 96:229-233. [PMID: 31181511 DOI: 10.1016/j.yebeh.2019.03.016] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2018] [Revised: 03/10/2019] [Accepted: 03/10/2019] [Indexed: 02/01/2023]
Abstract
UNLABELLED Nonepileptic seizures (NES, psychogenic NES-PNES) are associated with significant morbidities. We evaluated the morbidities and mortality in a national group of children, adolescent, and adult patients before and after a first diagnosis of PNES. METHODS From the Danish National Patient Registry (1998-2013), we identified 1057 people of all ages with a diagnosis of NES and matched them with 2113 control individuals by age, gender, and geography. Comorbidities were calculated three years before and after diagnoses. RESULTS Patients with PNES showed increased comorbidities 3 years before and after diagnosis in almost all the diagnostic domains. The strongest associations were identified with other neurological diseases (after diagnosis, Hazard Ratio (HR): 38.63; 95% Confidence Interval (CI): 21.58-69.13; P < 0.001), abnormal clinical and laboratory findings (HR: 46.59; 95 CI: 27.30-79.52; P < 0.001), other health-related factors (HR: 12.83; 95%CI: 8.45-19.46; P < 0.001), and psychiatric comorbidities (HR: 15.45; 95% CI: 9.81-24.33). Epilepsy was identified in 8% of the patients with PNES. We found especially frequent comorbidity involving overweight, depression, anxiety, dissociative somatoform condition, other convulsions, lipothymias, reports of pain and other symptoms in several organ systems, and several reports of minimal traumas to the head, trunk, and extremities. Mortality was higher in patients with NES than in controls (HR: 3.21; 95% CI: 1.92-5.34; P < 0.001). CONCLUSION Morbidity is more frequent in several domains, including neurological, psychiatric, and other diseases, before and after a diagnosis of NES. Mortality is significantly higher in patients with PNES as compared to controls.
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18
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Popkirov S, Jungilligens J, Schlegel U, Wellmer J. Research on dissociative seizures: A bibliometric analysis and visualization of the scientific landscape. Epilepsy Behav 2018; 83:162-167. [PMID: 29705627 DOI: 10.1016/j.yebeh.2018.03.041] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Revised: 03/30/2018] [Accepted: 03/31/2018] [Indexed: 11/26/2022]
Abstract
Dissociative seizures are a common and often elusive differential diagnosis in epilepsy centers. Considering their high prevalence, long diagnostic delays, and disappointing rates of treatment response, scientific research dedicated to dissociative seizures is surprisingly scarce. In order to chart the scientific landscape of dissociative seizures and to visualize thematic clusters and trends in research, a comprehensive bibliometric analysis was performed. The Web of Science database was examined to identify relevant English language documents from the last half-century. A total of 1751 documents with titles referring to dissociative seizures were identified. Automated textual analysis of all titles and abstracts revealed that research clusters around three major topics: differential diagnosis in epilepsy centers, management and treatment, and psychopathology. Time analysis of term networks revealed that the focus of clinical research has moved from diagnostic procedures to treatment approaches. Furthermore, interest within etiological research is shifting from an emphasis on early life trauma and personality traits to the role of anxiety and emotion regulation. With respect to individual contributing authors, a relatively small network of prolific scientists with a remarkable degree of collaboration emerges. By mapping relevant publications, it becomes evident that dissociative seizures still represent a subject mostly within the realm of neurology and epileptology, with a tendency to settle in the latter domain. This analysis sheds light on an important niche subject and highlights trends in research focus and output.
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Affiliation(s)
- Stoyan Popkirov
- Department of Neurology, University Hospital Knappschaftskrankenhaus, Ruhr University Bochum, In der Schornau 23-25, 44892 Bochum, Germany.
| | - Johannes Jungilligens
- Ruhr-Epileptology, Department of Neurology, University Hospital Knappschaftskrankenhaus, Ruhr University Bochum, In der Schornau 23-25, 44892 Bochum, Germany; Department of Neuropsychology, Institute of Cognitive Neuroscience, Faculty of Psychology, Ruhr University Bochum, Bochum, Germany
| | - Uwe Schlegel
- Department of Neurology, University Hospital Knappschaftskrankenhaus, Ruhr University Bochum, In der Schornau 23-25, 44892 Bochum, Germany
| | - Jörg Wellmer
- Ruhr-Epileptology, Department of Neurology, University Hospital Knappschaftskrankenhaus, Ruhr University Bochum, In der Schornau 23-25, 44892 Bochum, Germany
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19
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An Overview of Psychogenic Non-Epileptic Seizures: Etiology, Diagnosis and Management. Can J Neurol Sci 2018; 45:130-136. [DOI: 10.1017/cjn.2017.283] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
AbstractThe purpose of this review is to provide an update of the research regarding the etiology, diagnosis and management of psychogenic non-epileptic seizures (PNES). A literature search using Pubmed, Ovid MEDLINE and EMBASE database was performed from 2000 up to August 2017. We have evaluated the different factors leading to PNES as well as the diagnostic approach and management of this disorder which continue to be very difficult. The coexistence of epilepsy and PNES poses special challenges and requires the coordinated efforts of the family physicians, psychiatrists, psychologists and neurologists. Although this condition has an overall poor prognosis, a multidisciplinary approach in the diagnosis and management of this disorder would likely improve the outcomes. We have proposed a diagnostic and treatment algorithm for PNES and suggested a national registry of patients suffering from this condition. The registry would contain data regarding treatment and outcomes to aid in the understanding of this entity.
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20
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Rao SR, Slater JD, Kalamangalam GP. A simple clinical score for prediction of nonepileptic seizures. Epilepsy Behav 2017; 77:50-52. [PMID: 29111502 DOI: 10.1016/j.yebeh.2017.09.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Revised: 08/21/2017] [Accepted: 09/10/2017] [Indexed: 11/26/2022]
Abstract
Psychogenic nonepileptic seizures (PNES), often mistaken for epilepsy in community practice, require inpatient video-EEG (VEEG) monitoring for diagnostic confirmation. We developed a simple score designed for use in an outpatient setting to predict the subsequent VEEG diagnosis of PNES. We retrospectively compared fifty-five consecutive patients with VEEG-proven PNES (N1=55) with a group of randomly selected patients with VEEG-proven epilepsy (N2=55). Patients were divided into two groups: I) a 'truly retrospective' group of 27 patients with PNES and 27 patients with epilepsy whose data served to develop the score, and II) a 'pseudoprospective' group of 28 patients each with PNES and epilepsy to whom the score was applied. Six features in the history of the Group I cohort appeared more prominent in patients with PNES than patients with epilepsy and were assigned escalating numerical values as follows: number of declared drug allergies (0, 0.5, 1), number of declared comorbidities (0, 0.5, 1), number of previous invasive medical interventions of any type (0, 0.5, 1), and a history of significant psychological or physical trauma (0 or 1). In addition, a score was assigned to verbal description of the seizures themselves as being consistent (=0), atypical (=1), or indeterminate (=0.5) for epilepsy. The values were added to yield an omnibus score ranging from 0 to 6. Scoring of Group II subjects in a blinded fashion revealed that in general patients with PNES had higher scores, and the majority obtained a score >2; most patients with epilepsy scored <1.5. Group difference in the mean between the PNES and epilepsy cohort was highly significant (p<0.0001, Wilcoxon rank-sum test). Our score is a simple clinical instrument based on the patient history that may find use in the triage of patients awaiting hospitalization for VEEG and in pre-VEEG counseling.
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Affiliation(s)
- Sindhu R Rao
- Department of Neurology, University of Texas Health Science Center, 6431 Fannin, Houston, TX, USA
| | - Jeremy D Slater
- Department of Neurology, University of Texas Health Science Center, 6431 Fannin, Houston, TX, USA
| | - Giridhar P Kalamangalam
- Department of Neurology, University of Texas Health Science Center, 6431 Fannin, Houston, TX, USA.
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21
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Erba G, Bianchi E, Giussani G, Langfitt J, Juersivich A, Beghi E. Patients' and caregivers' contributions for differentiating epileptic from psychogenic nonepileptic seizures. Value and limitations of self-reporting questionnaires: A pilot study. Seizure 2017; 53:66-71. [PMID: 29132064 DOI: 10.1016/j.seizure.2017.11.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2017] [Revised: 10/26/2017] [Accepted: 11/04/2017] [Indexed: 10/18/2022] Open
Abstract
PURPOSE Questionnaires investigating semiology and comorbidities of psychogenic non-epileptic seizures (PNES) have been used mainly to help physicians expedite referrals to epilepsy centres for confirmation of diagnosis rather than as alternative diagnostic tool when video-EEG monitoring (VEM), the current gold standard, is not available or is inconclusive. METHODS We developed one structured questionnaire for patients, exploring subjective experiences and vulnerabilities and one for eyewitnesses, focused on features observable during typical events to study prospectively 50 consecutive adult patients with PNES or epileptic seizures (ES) admitted for VEM. A list of variables representing specific signs, symptoms and risk factors was obtained from each question. Specificity (SP) and sensitivity (SE) of each variable were calculated analyzing patient's and witness' responses against the final diagnosis. Statistical significance was assessed using the Fisher's exact test. RESULTS Twenty-eight patients' questionnaires (17 PNES, 11 ES) were eligible for analysis. Seven variables with high SE and SP, of which 5 statistically significant, emerged as diagnostic predictors. They comprised three historical items: head injury, physical abuse and chronic fatigue; two warning signs: heart racing and tingling or numbness; one triggering sign: headache; one postictal symptom: physical pain. Sixteen witness questionnaires (6 PNES, 10 ES) were available. Side-to-side head movements and eyes closed were the statistically significant variables. CONCLUSION Pending further refinements, ad hoc questionnaires specifically designed for patients and eyewitnesses, may represent a practical tool for distinguishing ES from PNES in settings without sophisticated facilities or when VEM is inconclusive.
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Affiliation(s)
- Giuseppe Erba
- Department of Neurology, SEC, University of Rochester, Rochester, NY, United States
| | - Elisa Bianchi
- Laboratory of Neurological Disorders, Department of Neuroscience, IRCCS-Istituto di Ricerche Farmacologiche "Mario Negri", Milan, Italy
| | - Giorgia Giussani
- Laboratory of Neurological Disorders, Department of Neuroscience, IRCCS-Istituto di Ricerche Farmacologiche "Mario Negri", Milan, Italy
| | - John Langfitt
- Department of Neurology, SEC, University of Rochester, Rochester, NY, United States
| | - Adam Juersivich
- Department of Neurology, SEC, University of Rochester, Rochester, NY, United States
| | - Ettore Beghi
- Laboratory of Neurological Disorders, Department of Neuroscience, IRCCS-Istituto di Ricerche Farmacologiche "Mario Negri", Milan, Italy.
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