心因性非癫痫发作诊断最低要求得到确定

    Task force identifies minimum requirements to diagnose psychogenic seizures

    国际抗癫痫联盟（ILAE）工作组建议，在缺少视频脑电图（vEEG）的情况下，医生可结合患者病史、目击者描述以及发作视频，采取分步骤方法诊断心因性非癫痫发作（PNES） （Epilepsia 2013 Sept. 20 [doi:10.1111/epi.12356]）。

    罗德岛医院和布朗大学的W. Curt LaFrance Jr.医生及其同事指出，大多数反复发作患者被认为患有癫痫，并接受抗癫痫药物（AED）治疗。然而，AED不但对PNES治疗无效，反而使病情恶化。因此，早期和准确识别PNES至关重要。但癫痫被公认为是PNES发展的危险因素，这使问题变得更为复杂。

    W. Curt LaFrance Jr.医生

    该工作组的目标是进一步明确PNES诊断步骤和准确性，以改善癫痫和非癫痫发作患者的治疗。如果能够在没有vEEG可利用的情况下确诊PNES,可为缺乏监视条件的中低收入国家提供机会。

    作者回顾了有关PNES诊断方法评价的医学文献，这些诊断方法包括利用病史、EEG、动态EEG、vEEG/监视、神经生理学、神经介质、神经影像以及神经心理学测试、催眠术和会话分析等。

    作者指出， vEEG结合患者及目击者提供的病史，可作为PNES的诊断标准。然而，在有些地方尚未开展vEEG,对于有些患者，也难以记录发作事件过程。

    为此，工作组建议将PNES诊断的确定性分为4种情况，并明确相关判定依据：

    · 明确的PNES:基于临床病史和有关日常活动的vEEG视频。

    · 临床确认的PNES:基于临床病史、医生目击证明以及无视频记录的日常活动的动态EEG.最适当的情况是医生目击到患者发作并记录了PNES典型检查结果（如抵抗睁眼），或者医生通过视频或亲眼目睹了非EEG事件。

    · 很可能的PNES:基于临床病史、医生查看视频记录或现场事件以及正常的发作期间EEG.最适当的情况是医生能够查看发作时的家庭或手机视频记录或亲眼目睹发作。

    · 可能的PNES:基于来自患者和（或）目击者的临床病史以及正常的发作期间EEG.至少患者病史和对事件的描述以及目击者的描述将有助于识别可能的PNES,但如果医生没有“观看发作视频或亲眼目睹，应慎重考虑癫痫其他诊断方法。”

    作者报告无利益冲突。

    By: KAREN BLUM, Internal Medicine News Digital Network

    In areas where video electroencephalography is not available, clinicians can use a staged approach to diagnosing psychogenic nonepileptic seizures, incorporating medical histories, eyewitness accounts, and video recordings of seizure activity, an international study group has found.

    Most patients with recurrent seizures are presumed to have epilepsy and are treated with antiepileptic drugs （AEDs）， but AEDs do not treat psychogenic nonepileptic seizures （PNES） and could exacerbate them. Therefore, early and accurate recognition of PNES is “of paramount importance,” according to an International League Against Epilepsy task force led by Dr. W. Curt LaFrance Jr. of Rhode Island Hospital and Brown University, Providence. It noted, however, that the matter is complicated by the fact that epilepsy is a recognized risk factor for the development of PNES.

    The task force's report aims “to provide greater clarity about the process and certainty of the diagnosis of PNES, with the intent to improve the care for people with epilepsy and nonepileptic seizures,” the authors wrote. “The ability to diagnose PNES when vEEG is not available may open opportunities to lower and middle income countries where monitoring is not available.”

    The authors reviewed the medical literature to evaluate approaches to diagnosing PNES, including taking a history; electroencephalogram （EEG）； ambulatory EEG; video EEG/monitoring; neurophysiologic, neurohumoral, neuroimaging, and neuropsychological testing; hypnosis; and conversation **ysis （Epilepsia 2013 Sept. 20 [doi:10.1111/epi.12356]）。

    The combination of video EEG, along with history taken from patients and witnesses, offers the diagnostic standard, “however, vEEG is not available in some locations, and in some patients, events cannot be recorded,” the authors said.

    The group suggested four categories of certainty for PNES diagnosis, and what clinicians would need:

    · Documented PNES relies on clinical history plus a vEEG recording of habitual events.

    · Clinically established PNES is defined by a clinical history, clinician witness, plus ambulatory EEG recording of habitual event（s） without video. This would be appropriate if a clinician witness observed a seizure and documented the exam findings typically found in PNES, like resisted eye-opening, or if a clinician could review a non-EEG event by video or in person.

    · Probable PNES is determined by a clinical history, a clinician review of video recording or live events, and a normal interictal EEG. This would be appropriate if a clinician could review a home or cell phone video recording of seizure activity or witness it live.

    · Possible PNES relies on clinical history from the patient and/or witness and a normal interictal EEG. At minimum, a patient's history and description of events and an eyewitness description could help identify possible PNES, but without the clinician “observing the ictus on video or in person, an alternative diagnosis of epilepsy would have to be considered very carefully.”

    The authors reported no conflicts of interest.