JNNP: Long-term psychogenic non-epileptic seizures misdiagnosed as status epilepticus: epidemiology and related risks

Status epilepticus is believed to cause irreversible damage after convulsions lasting more than 30 minutes, so most guidelines recommend aggressive treatment within a few minutes in the early stages
.

The guidelines recommend that benzodiazepines should be used as first-line drugs.

But in some emergency situations, this treatment is done at the expense of the accuracy of the diagnosis

The main difference in patients with suspected status epilepticus is partial seizures , also called psychogenic non-epileptic seizures (PNES)
.

Psychogenic non-epileptic seizures (PNES) is one of the most common conversion disorders.

Partial seizures

Because the clinical distinction between epileptic seizures and PNES requires specific expertise, and the treatment of status epilepticus requires almost immediate decision-making, misdiagnosis is prone to occur in the emergency environment, and PPNE is often wrongly treated with non-indication drugs.

.

Retrospective studies have shown that misdiagnosed PPNE patients often take benzodiazepines (the dose is even higher than that of patients with status epilepticus), and therefore often requires endotracheal intubation

Because the clinical distinction between epileptic seizures and PNES requires specific expertise, and the treatment of status epilepticus requires almost immediate decision-making, misdiagnosis is prone to occur in the emergency environment, and PPNE is often wrongly treated with non-indication drugs.

This article was published in " Journal of Neurology, Neurosurgery & Psychiatry " ( Journal of Neurology, Neurosurgery & Psychiatry )

The available raw data from the two largest status epilepticus treatment trials to date was analyzed
.

RAMPART is a randomized double-blind trial comparing intramuscular and intravenous benzodiazepine as first-line treatment for status epilepticus, including 893 patients registered between June 2009 and January 2011

The available raw data from the two largest status epilepticus treatment trials to date was analyzed

In 1210 the patient diagnosis and treatment of status epilepticus in ²

Regarding the effect of first-line treatment with benzodiazepines, 46 cases of PPNE patients in RAMPART data were analyzed
.

Among 14 patients (30%) who received medication (10 mg intramuscular midazolam plus intravenous placebo, or 4 mg intravenous lorazepam plus intramuscular placebo) before admission did not arrive within 10 minutes or reach the hospital Before terminating seizures (primary endpoint)

Overall, the median length of stay for hospitalized patients is 3 days (range 1-7 days)

Relative prevalence of long-term psychogenic non-epileptic seizures in patients by age group and gender

Relative prevalence of long-term psychogenic non-epileptic seizures in patients by age group and gender

The data of 33 PPNE patients in ESETT were used to evaluate the therapeutic effects of first-line and second-line treatments (levetiracetam, fosphenytoin sodium, and sodium valproate)
.

Of the 28 patients who received first-line medication time information, 18 (55%) received benzodiazepine treatment before arriving in the emergency room, and the remaining patients received medication in the hospital
.
Ten patients (31%) were admitted to the ICU and stayed in the ICU for 12 days (median: 1 day)
.
Twelve patients (36%) were admitted to non-ICU wards, and 11 patients (33%) were discharged directly from the emergency room
.
Overall, the median length of stay for hospitalized patients is one day (range 1-12 days)
.
At 20 minutes and 60 minutes after the start of administration, all patients were evaluated for seizure performance and responsiveness
.
At the 20-minute assessment, clinically significant seizures were observed in 9 (27%) patients; at that time, 11 (33%) patients had no improvement in their response to oral or noxious stimuli
.
In the 60-minute evaluation, 3 patients still had clinically significant seizures (9%), while the responsiveness of 9 patients (27%) still did not improve
.
ESETT patients underwent the Agitated Sedation Score (RASS) score at 60 minutes.
Among 11 patients (33%), 13 adverse events were recorded, 4 of which were rated as "serious"
.
According to reports, four events may be related to the research intervention: abdominal pain, allergies, hypotension, and itching
.
The adverse event scores of patients who received benzodiazepines before the arrival of the emergency room were more serious than those who did not receive benzodiazepines (Fisher's exact test = 10.
455, p = 0.
033)
.
Two patients (6%) underwent tracheal intubation
.
Adverse events leading to intubation were recorded as one case of "low level of consciousness" and another case of "cerebrovascular accident"
.

ESETT patients underwent agonistic sedation score (RASS) score at 60 minutes.
Among 11 patients (33%), 13 adverse events were recorded, 4 of which were rated as "serious"
.
According to reports, four events may be related to the research intervention: abdominal pain, allergies, hypotension, and itching
.
The adverse event scores of patients who received benzodiazepines before the arrival of the emergency room were more serious than those who did not receive benzodiazepines (Fisher's exact test = 10.
455, p = 0.
033)
.
Two patients (6%) underwent tracheal intubation
.
Adverse events leading to intubation were recorded as one case of "low level of consciousness" and another case of "cerebrovascular accident"
.

The dynamic sedation score (RASS) score of ESETT patients at the 60-minute assessment

The total misdiagnosis rate of PPNE was 8.
1% in patients 8 years of age or older, and it was as high as 20.
1% in adolescents and young adults
.
It is conservatively estimated that the adverse incidence rate of misdiagnosed PPNE who receives non-indication drug treatment is about 1.
3 cases per 100,000 residents per year
.
Benzodiazepine treatment cannot reliably terminate epileptic activity, because 30% of RAMPART patients with PPNE still have seizures after receiving the study drug
.
26% of pPNES patients reported adverse effects of RAMPART, including respiratory depression requiring intubation
.
27% of pPNES patients in ESETT remained deeply sedated 1 hour after second-line treatment
.
Although benzodiazepines have not caused central apnea, they inhibit genioglossus muscle activity and can cause obstructive apnea that requires intubation
.
The observed misdiagnosis rate of pPNES and the risk of harm from non-indicated treatment should lead to reconsideration of status epilepticus response regimens, especially in clinical trials
.
The highly specific clinical symptom index of PPNE should be considered during treatment, and PPNE should be clearly listed as the exclusion criterion
.

In short, misdiagnosing pPNES as status epilepticus and treating it is a common problem
.
Relieving this problem requires training emergency personnel in clinical diagnosis
.

In short, misdiagnosing pPNES as status epilepticus and treating it is a common problem
.
Relieving this problem requires training emergency personnel in clinical diagnosis
.
Source of this article: Source of this article: Source of this article: Jungilligens  J ,  Michaelis  R ,  Popkirov S Jungilligens  J Jungilligens Michaelis  R Michaelis Popkirov S Popkirov Misdiagnosis of prolonged psychogenic non-epileptic seizures as status epilepticus: epidemiology and associated risks Published Journal of Neurology, Neurosurgery & Psychia  Online First:  06 August 2021.
  Published Online First: doi:  10.
1136/jnnp-2021-326443 doi: leave a message here