Pediatric Hospital Medicine

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Chapter 2 • Seizure

TABLE 2.11 CLINICAL MANIFESTATIONS OF PNES VERSUS EPILEPTIC SEIZURES PNES EPILEPTIC SEIZURE Duration Prolonged Shorter, usually lasts < 5 min Clinical symptoms Fluctuating symptoms Stereotypical symptoms Consciousness Preserved consciousness

Alteration of consciousness

Onset and resolution

Slow onset with gradual escala tion of intensity; slow resolution

Abrupt onset and resolution

Postictal phase None or brief

Present

Emotional state Negative emotional state typi cally at end of event: crying, fear, moaning

May cry at onset

Semiology

Head moving side to side with eyes closed Predominantly motor semiology with disorganized movement of bilateral extremities followed by dialeptic (impaired awareness or responsiveness) or hypomotor events (latter more common in younger children)

Head turned uni laterally, eyes open, “staring” Rhythmic movements of extremities

■ DIAGNOSTIC STUDIES The diagnosis is grounded in the “rules of 2,” which has a positive predictive value of 85%: a minimum of 2 events weekly, events refrac tory to a minimum of 2 antiepileptic drugs, a minimum of 2 normal EEGs. 1 Prolonged EEG monitoring is the gold standard for diagnosis in conjunction with typical clinical findings. 1,3 See Table 2.12 for recom mended diagnostic testing. ■ MANAGEMENT Management of PNES is largely supportive and best achieved in the outpatient setting, with emphasis on patient and family education on the diagnosis. Emphasizing that these events do not lead to brain PNES, psychogenic nonepileptic seizures. Data from Patel H, Blake H, Dunn D. Psychogenic nonepileptic seizures in children and adoles cents. Indian Pediatr . 2021;58(3):259-265; Operto FF, Coppola G, Mazza R, et al. Psychogenic nonepileptic seizures in pediatric population: a review. Brain Behav. 2019;9(12):e01406; Patel H, Dunn DW, Austin JK, et al. Psychogenic nonepileptic seizures (pseudoseizures). Pediatr Rev . 2011;32(6):e66-e72.

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