Abstracts

Rationale: Epilepsy surgery has become an important option in the treatment of patients with medically refractory epileptic seizures (ES). However, many epilepsy centers exclude patients with psychogenic non-epileptic seizures (PNES) from pre-surgical evaluation programs because of the possibility of alternative psychiatric symptoms and postoperative exacerbations of pre-existing PNES. Management of candidates for epilepsy surgery who experience PNES remains unclear, although a few studies have suggested that PNES should not be considered an absolute contraindication to epilepsy surgery. Methods: We present a retrospective case series of patients with both PNES and medically refractory ES. Case 1: 48-year-old female Case 2: 13-year-old male Case 3: 51-year-old female with a previous history of epilepsy surgery Results: Case 1: It was easy to distinguish PNES from ES for her family and herself, because of the difference in seizure semiology, duration, and situation. Detailed interviews supported the fact that the impact of ES on daily living was much stronger than the impact of PNES. Despite a previous history of mental health problems, her current mental state was good and she seemed to have a good understanding regarding her surgery. Additionally, the MRI findings supported a good outcome for surgery. We made the decision to perform a right anteromedial temporal lobectomy. She has been seizure-free for 2 months after the surgery. Case 2: It was hard to distinguish ES from PNES, not only for his family, but also for the medical staff, because both seizure-types were same seizure semiology such as right face clonic movements. Furthermore, detailed interviews by a psychiatrist and psychological testing revealed serious issues regarding his mental state. We eventually made the decision to give priority to the management of his mental state. He gradually became healthy after referral to a child psychiatrist and undergoing various interventions. He reported his clonic seizures happening weekly, though his family and teacher had not seen any seizures lately. It was unclear which seizures were stopped or reduced. However, he and his family have been satisfied with his current situation. Case 3: We were able to record not only stereotyped epileptic seizures, such as hypermotor seizures, but also "PNES-suspected seizures", such as prolonged periods of unresponsiveness, during a 5-day video EEG monitoring. Video EEG revealed prolonged unconsciousness always occurred after hypermotor seizures. Ictal EEG demonstrated rhythmic slowing activity in the right posterior temporal region, which evolved in frequency and morphology, and spread to the left temporal region. There were not any other episodes without epileptic discharges during the monitoring. Detailed interview and psychological testing didn't support the psychosocial characteristics of PNES. We concluded she only had intractable ES, based on the available evidence. We considered that the over-diagnosis and over-impression of PNES delayed the time until further evaluation after her first surgery, although it was unclear whether she has had PNESs or not. Finally, we made the decision to perform VNS implantation for her intractable seizures. Conclusions: To achieve good outcomes in patients with both ES and PNES, comprehensive evaluations, including ictal recording of both habitual seizures, evaluation of mental state by multiple specialist professionals, and evaluation of the impact of both seizure-types on the patients and their family life, are needed. We should make decisions regarding whether to perform surgery in candidates for epilepsy surgery with PNES, dependent on comprehensive assessment by a medical team and the needs of the patient and their family. Funding: None