Predictive value of video alone in diagnosis of epileptic vs paroxysmal nonepileptic events in children

OBJECTIVE

Previous studies examined the use of video-based diagnosis and the predictive value of videos for differentiation of epileptic seizures (ES) from paroxysmal nonepileptic events (PNEE) in the adult population. However, there are no such published studies strictly on the pediatric population. Using video-EEG diagnosis as a gold standard, we aimed to determine the diagnostic predictive value of videos of habitual events with or without additional clinical data in differentiating the PNEE from ES in children.

METHODS

Consecutive admissions to our epilepsy monitoring unit between June 2020 and December 2020 were analyzed for events of interest. Four child neurologists blinded to the patient's diagnosis formulated a diagnostic impression based upon the review of the video alone and again after having access to basic clinical information, in addition to the video. Features of the video which helped to make a diagnosis were identified by the reviewers as a part of a survey.

RESULTS

A total of 54 patients were included (ES n = 24, PNEE n = 30). Diagnostic accuracy was calculated for each reviewer and combined across all the ratings. Diagnostic accuracy by video alone was 74.5% (sensitivity 80.8%, specificity 66.7%). Providing reviewers with basic clinical information in addition to the videos significantly improved diagnostic accuracy compared to viewing the videos alone. Inter-rater reliability between four reviewers based on the video alone showed moderate agreement (κ = 0.51) and unchanged when additional clinical data were presented (κ = 0.51). The ES group was significantly more likely to demonstrate changes in facial expression, generalized stiffening, repetitive eye blinks, and eye deviation when compared with the PNEE group, which was more likely to display bilateral myoclonic jerking.

CONCLUSIONS

Video review of habitual events by Child Neurologists may be helpful in reliably distinguishing ES from PNEE in children, even without included clinical information.

Psychogenic nonepileptic seizures in children-Prospective validation of a clinical care pathway & risk factors for treatment outcome

PURPOSE

The purpose of this study was to prospectively validate a care pathway for psychogenic nonepileptic seizures (PNES) in a pediatric setting. The pathway was developed based on a previous study of patients at our center, which demonstrated positive treatment outcomes of 80% full or partial remission. Sequentially referred patients with PNES in the validation cohort received care prospectively according to the pathway algorithm. It was hypothesized that the validation cohort would achieve outcomes similar to that of the development cohort as a result of standardized care.

METHOD

We performed a retrospective chart review of 43 children sequentially referred, assessed, and treated within a specialized neurology psychology service for suspected PNES over a 5-year period. The majority of patients (n = 41, 95%) met diagnostic criteria for probable, clinically established, or documented PNES, according to the International League Against Epilepsy (ILAE) criteria.

RESULTS

Ages ranged from 6 to 18 years of age at time of diagnosis, with the majority of patients being female (n = 29, 67%) and adolescent (n = 31, 72%). There was a high level of adherence to the care algorithm (n = 34, 84%). The development and validation cohorts were similar across demographic, clinical, and psychological characteristics. Standardized care resulted in high rates of full (n = 27, 63%) and partial (n = 12, 28%) remission, as self-reported at discharge. A 96% decrease in mean monthly frequency of total PNES events was also observed at discharge, as was a significant reduction in healthcare utilization related to PNES (74% fewer ambulance calls and 85% fewer emergency department (ED) visits). Post hoc analyses demonstrated that duration of PNES illness longer than 12 months (at diagnosis) increased odds of not achieving full remission by discharge (odds ratio = 5.94, p = 0.02). Developmental period of onset (child versus adolescent), having abnormal electroencephalogram (EEG) result, previous concussion, chronic versus acute stressor, more than one PNES event type, or additional functional neurological symptoms did not significantly impact treatment response.

CONCLUSIONS

This study demonstrates, for the first time prospectively in a pediatric setting, that standardized care for PNES leads to improved clinical outcomes and reduced healthcare utilization. Delayed diagnosis and treatment of PNES longer than 12 months also appears to be associated with less favorable outcomes in children.

Psychogenic nonepileptic seizures in children - Psychological presentation, treatment, and short-term outcomes

PURPOSE

The purpose of this study was to better understand the etiologies, features, and care outcomes of psychogenic nonepileptic seizures (PNESs) in a pediatric setting.

METHOD

We performed a retrospective analysis of 32 sequentially referred children for suspected PNESs to a neurology psychology service over a 6-year period. After excluding non-PNES paroxysmal events (related to anxiety or migraine), 29 patients were identified with final diagnosis of PNESs. Charts were examined for presenting symptom data, demographics, comorbidities, neurological diagnoses and investigations, as well as psychological assessment, management, and outcome. Treatment consisted of education around diagnosis and of individual psychological treatment, which, in most cases, was cognitive behavioral therapy up to 14 sessions. Additional mental health services including psychiatric medication, family therapy, and admission to day or inpatient treatment were also utilized in a smaller number of cases. Total treatment periods ranged from 4 weeks to 12 months.

RESULTS

The majority of patients identified were adolescent (90%), Caucasian (72%), and female (76%). Preceding psychology referral, point of entry into medical care for PNESs was primarily through the emergency department (66%) or outpatient neurology clinic referral (31%). Whereas 39% of parents described significant internalizing symptoms in their child (BASC-2), patients themselves tended to underreport anxiety or depression as demonstrated by only 16% endorsement on the BYI-II. By contrast, MACI personality assessment response patterns for adolescents demonstrated high levels of psychic tension/anxiety (65%), depressive affect (55%), and maladaptive personality traits including inhibition (45%), submissiveness (35%), and introversion (30%). Appropriate psychological treatment was associated with high rates of full remission (no new events, n=17, 59%) and partial remission (50% or greater reduction in events, n=6, 21%) as self-reported at discharge. Accurate diagnosis and referral to psychology also led to a sevenfold reduction in PNES-related emergency department visits one year after initial psychology visit compared with the preceding year.

CONCLUSIONS

This study suggests that appropriate care for PNESs reduces inappropriate medical investigation and therapy, expedites rates of remission, and decreases health-care utilization in a pediatric setting.