title: Can semiology predict psychogenic nonepileptic seizures? A prospective study.
abstract: OBJECTIVE
  Reducing health and economic burdens from diagnostic delay of psychogenic nonepileptic seizures (PNES) requires prompt referral for video electroencephalography (VEEG) monitoring, the diagnostic gold standard. Practitioners make VEEG referrals when semiology suggests PNES, although few semiological signs are supported by well-designed studies, and most VEEG studies neglect to concurrently measure how accurately seizure witnesses can ascertain semiology. In this study, we estimate the value of eyewitness-reported and video-documented semiology for predicting PNES, and we measure accuracy of eyewitness reports.
  
  
  METHODS
  We prospectively interviewed eyewitnesses of seizures in patients referred for VEEG monitoring, to inquire about 48 putative PNES and ES signs. Multiple, EEG-blinded, epileptologists independently evaluated seizure videos and documented the presence/absence of signs. We used generalized estimating equations to identify reliable video-documented PNES and ES signs, and we compared eyewitness reports with video findings to assess how accurately signs are reported. We used logistic regression to determine whether eyewitness reports could predict VEEG-ascertained seizure type.
  
  
  RESULTS
  We analyzed 120 seizures (36 PNES, 84 ES) from 35 consecutive subjects. Of 45 video-documented signs, only 3 PNES signs ("preserved awareness," "eye flutter," and "bystanders can intensify or alleviate") and 3 ES signs ("abrupt onset," "eye-opening/widening," and postictal "confusion/sleep") were significant and reliable indicators of seizure type. Eyewitness reports of these 6 signs were inaccurate and not statistically different from guessing. Consequentially, eyewitness reports of signs did not predict VEEG-ascertained diagnosis. We validated our findings in a second, prospective cohort of 36 consecutive subjects.
  
  
  CONCLUSIONS
  We identified 6 semiological signs that reliably distinguish PNES and ES, and found that eyewitness reports of these signs are unreliable. We offer suggestions to improve the accuracy of eyewitness reports.
authors: Epilepsy Center, Neurological Institute, University Hospitals Case Medical Center, Cleveland, OH, USA. tanvir.syed@uhhospitals.org
authors: Tanvir U
authors: TU
authors: Syed
authors: W Curt
authors: WC
authors: LaFrance
authors: Emine S
authors: ES
authors: Kahriman
authors: Saba N
authors: SN
authors: Hasan
authors: Vijayalakshmi
authors: V
authors: Rajasekaran
authors: Deepak
authors: D
authors: Gulati
authors: Samip
authors: S
authors: Borad
authors: Asim
authors: A
authors: Shahid
authors: Guadalupe
authors: G
authors: Fernandez-Baca
authors: Naiara
authors: N
authors: Garcia
authors: Matthias
authors: M
authors: Pawlowski
authors: Tobias
authors: T
authors: Loddenkemper
authors: Shahram
authors: S
authors: Amina
authors: Mohamad Z
authors: MZ
authors: Koubeissi
mesh_terms: D000328:Adult; D000368:Aged; D004562:Electrocardiography; D004569:Electroencephalography; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D011237:Predictive Value of Tests; D011446:Prospective Studies; D011602:Psychophysiologic Disorders / Q000150:complications / Q000175:diagnosis*; D015203:Reproducibility of Results; D012640:Seizures / Q000150:complications / Q000175:diagnosis* / Q000523:psychology*; D012680:Sensitivity and Specificity; D018709:Statistics, Nonparametric; D014743:Videotape Recording; D055815:Young Adult