Abstracts

RATIONALE: The differential diagnosis of nonepileptic seizures is broad, and clinical descriptions can be misleading. METHODS: We present 3 patients with refractory seizures, who were diagnosed as having nonepileptic events and hypoglycemia. These cases illustrate the importance of a thorough medical work-up for atypical seizure episodes. RESULTS: Case 1: A 45-year-old woman had a history of "panic attacks" with inablilty to focus, tingling of her tongue and/or limbs, moving yellow spots, and a cold sweat. These were often associated with unresponsiveness and jerking. Initial video-EEG monitoring recorded 2 events with no EEG change. They were considered nonepileptic, most likely psychogenic in etiology. On no anticonvulsants she improved with psychotherapy and antidepressants. However, spells recurred after 6 months. Repeat video-EEG showed intermittent diffuse delta during 2 events. A glucose finger stick during the next episode was 55. Two pancreatic lesions were found and resected. Pathology confirmed the diagnosis of insulinoma, and spells resolved. Case 2: A 41-year-old man with a history of diabetes had intractable seizures with loss of consciousness and convulsions. Multiple medication trials had no effect. A single typical event and no interictal findings were recorded during video-EEG monitoring. During the event he was unresponsive, with intermittent body jerking. EEG was diffusely slow with semi-rhythmic delta. A glucose fingerstick was 38. Case 3: A 36-year-old woman with multiple medical problems, including hypoglycemia, had new onset generalized convulsions. Video-EEG monitoring recorded typical events, which were not associated with hypoglycemia. There was no electrographic correlate. These events were determined to be psychogenic in origin. CONCLUSIONS: Hypoglycemia is important in the differential diagnosis of refractory seizures. This can be caused by uncontrolled diabetes and rarely by insulinoma. Patients with known hypoglycemia, however, can have both epileptic or (in our case) other types of nonepileptic events. Electrographically, focal or widespread slowing can occur with hypoglycemia. Ictal glucose levels should be drawn in cases of suspected hypoglycemia.