PNESSE 1: Psychogenic status and status epilepticus: Could they be distinguished retrospectively? A survey among neurologists

Mice Harboring a Non-Functional CILK1/ICK Allele Fail to Model the Epileptic Phenotype in Patients Carrying Variant CILK1/ICK

CILK1 (ciliogenesis associated kinase 1)/ICK (intestinal cell kinase) is a highly conserved protein kinase that regulates primary cilia structure and function. CILK1 mutations cause a wide spectrum of human diseases collectively called ciliopathies. While several CILK1 heterozygous variants have been recently linked to juvenile myoclonic epilepsy (JME), it remains unclear whether these mutations cause seizures. Herein, we investigated whether mice harboring either a heterozygous null Cilk1 (Cilk1^+/−) mutation or a heterozygous loss-of-function Cilk1 mutation (Cilk1^R272Q/+) have epilepsy. We first evaluated the spontaneous seizure phenotype of Cilk1^+/− and Cilk1^R272Q/+ mice relative to wildtype littermates. We observed no electrographic differences among the three mouse genotypes during prolonged recordings. We also evaluated electrographic and behavioral responses of mice recovering from isoflurane anesthesia, an approach recently used to measure seizure-like activity. Again, we observed no electrographic or behavioral differences in control versus Cilk1^+/− and Cilk1^R272Q/+ mice upon isoflurane recovery. These results indicate that mice bearing a non-functional copy of Cilk1 fail to produce electrographic patterns resembling those of JME patients with a variant CILK1 copy. Our findings argue against CILK1 haploinsufficiency being the mechanism that links CILK1 variants to JME.

Psychogenic nonepileptic seizures treated as epileptic seizures in the emergency department

OBJECTIVES

We aimed to estimate the rate of psychogenic nonepileptic seizures (PNES) among patients presenting to an emergency department with presumed seizures. We also wanted to identify factors that can assist health care professionals in determining whether these events are likely to be epileptic or nonepileptic.

METHODS

We performed two retrospective audits on patients who were treated for seizures in the department of emergency medicine at the Princess Alexandra Hospital, Brisbane, Australia. Exploratory analyses and logistic regressions were conducted to investigate the characteristics of the presentations and the relationships between our variables of interest.

RESULTS

In the group of all presentations with presumed seizures over a 3-month period (n = 157), a total of 151 presentations (96.2%) presentations were given a primary diagnosis of epileptic seizures. Of these 151 presentations, only 84 (55.6%) presented with epileptic seizures and 40 (26.5%) actually presented with PNES. In the group of patients who presented with prolonged and/or multiple events (n = 213) over a 1-year period, 196 (92.0%) were treated as epileptic seizures. Of these 196 presentations, only 85 (43.4%) presented with epileptic seizures and 97 (49.5%) actually presented with PNES. Several factors were identified to help risk stratify between epileptic seizures and PNES: Duration of events and of the postictal phase, number of events, presence of a structural brain pathology, mental health history, lactate levels and presence of tongue bite, incontinence, and/or vomiting.

SIGNIFICANCE

A large proportion of people who present to emergency departments with events resembling epileptic seizures actually have PNES rather than epilepsy-particularly those patients who present with prolonged and/or multiple events. The rate of misdiagnosis was high. Efforts need to be made to recognize patients with psychogenic nonepileptic seizures earlier and diagnose them correctly to avoid unnecessary iatrogenic harm and to provide adequate treatment.

Psychogenic non-epileptic seizure-status in patients admitted to the intensive care unit

BACKGROUND

Psychogenic non-epileptic seizure-status (PNES-status), defined by psychogenic non-epileptic seizures (PNES) over 30 min, are often misdiagnosed as status epilepticus. We aimed to describe the features of patients who experienced PNES-status, admitted to an intensive care unit (ICU).

METHODS

We screened the patients hospitalized in our epilepsy unit during a 4-year period, with a diagnosis of PNES-status and ICU admission.

RESULTS

Among 171 patients with PNES, we identified 25 patients (15%) who presented 39 episodes of PNES-status leading to ICU admission. Some 76% of the patients were women. The median age at the time of the PNES-status episode was 35 years. Half (48%) alleged a history of epilepsy, but epilepsy was confirmed in only 12%. A history of psychiatric disease was found in 68%. PNES were present in 85% of patients before PNES-status, and semiology of PNES and PNES-status was similar for 79% of the patients, including hyperkinetic movements in 95% of the episodes and suspected loss of consciousness in 87%. Benzodiazepines were administrated in 77% of the episodes, antiepileptic drugs in 87%, and antibiotherapy for a ICU-related infection in 15% of the episodes. Oral intubation was performed in 41% of the episodes. Blood tests showed normal levels of creatine phosphokinase and leucocytes in 90% and 95% of the episodes, respectively. No epileptic activity was found during per-event electroencephalography but interictal epileptic activity was found in 10% of the episodes.

CONCLUSION

Hyperkinetic PNES-status should always be considered as a differential diagnosis of status epilepticus, with a high risk of iatrogenic consequences.

Emergency room diagnoses of psychogenic nonepileptic seizures with psychogenic status and functional (psychogenic) symptoms: Whopping

Collecting 130 electronic medical records and diagnoses from emergency room stays of eleven patients with confirmed psychogenic nonepileptic seizure (PNES) over a 17-year period (2001-2018), 48 different diagnostic terms were retrieved. This emphasized the need for a consensual terminology encompassing not only PNES but also all functional transient (paroxysmal) events, including episodes of motor or sensory deficits, and cognitive symptoms. Rather than defining what it is not (PNES, stroke mimicks…), it would be more accurate to define what it is: a paroxysmal functional event.