心因性非癲癇發(fā)作診斷最低要求得到確定

    Task force identifies minimum requirements to diagnose psychogenic seizures

    國際抗癲癇聯(lián)盟（ILAE）工作組建議，在缺少視頻腦電圖（vEEG）的情況下，醫(yī)生可結(jié)合患者病史、目擊者描述以及發(fā)作視頻，采取分步驟方法診斷心因性非癲癇發(fā)作（PNES） （Epilepsia 2013 Sept. 20 [doi:10.1111/epi.12356]）。

    羅德島醫(yī)院和布朗大學(xué)的W. Curt LaFrance Jr.醫(yī)生及其同事指出，大多數(shù)反復(fù)發(fā)作患者被認(rèn)為患有癲癇，并接受抗癲癇藥物（AED）治療。然而，AED不但對PNES治療無效，反而使病情惡化。因此，早期和準(zhǔn)確識(shí)別PNES至關(guān)重要。但癲癇被公認(rèn)為是PNES發(fā)展的危險(xiǎn)因素，這使問題變得更為復(fù)雜。

    W. Curt LaFrance Jr.醫(yī)生

    該工作組的目標(biāo)是進(jìn)一步明確PNES診斷步驟和準(zhǔn)確性，以改善癲癇和非癲癇發(fā)作患者的治療。如果能夠在沒有vEEG可利用的情況下確診PNES,可為缺乏監(jiān)視條件的中低收入國家提供機(jī)會(huì)。

    作者回顧了有關(guān)PNES診斷方法評價(jià)的醫(yī)學(xué)文獻(xiàn)，這些診斷方法包括利用病史、EEG、動(dòng)態(tài)EEG、vEEG/監(jiān)視、神經(jīng)生理學(xué)、神經(jīng)介質(zhì)、神經(jīng)影像以及神經(jīng)心理學(xué)測試、催眠術(shù)和會(huì)話分析等。

    作者指出， vEEG結(jié)合患者及目擊者提供的病史，可作為PNES的診斷標(biāo)準(zhǔn)。然而，在有些地方尚未開展vEEG,對于有些患者，也難以記錄發(fā)作事件過程。

    為此，工作組建議將PNES診斷的確定性分為4種情況，并明確相關(guān)判定依據(jù)：

    · 明確的PNES:基于臨床病史和有關(guān)日?；顒?dòng)的vEEG視頻。

    · 臨床確認(rèn)的PNES:基于臨床病史、醫(yī)生目擊證明以及無視頻記錄的日常活動(dòng)的動(dòng)態(tài)EEG.最適當(dāng)?shù)那闆r是醫(yī)生目擊到患者發(fā)作并記錄了PNES典型檢查結(jié)果（如抵抗睜眼），或者醫(yī)生通過視頻或親眼目睹了非EEG事件。

    · 很可能的PNES:基于臨床病史、醫(yī)生查看視頻記錄或現(xiàn)場事件以及正常的發(fā)作期間EEG.最適當(dāng)?shù)那闆r是醫(yī)生能夠查看發(fā)作時(shí)的家庭或手機(jī)視頻記錄或親眼目睹發(fā)作。

    · 可能的PNES:基于來自患者和（或）目擊者的臨床病史以及正常的發(fā)作期間EEG.至少患者病史和對事件的描述以及目擊者的描述將有助于識(shí)別可能的PNES,但如果醫(yī)生沒有“觀看發(fā)作視頻或親眼目睹，應(yīng)慎重考慮癲癇其他診斷方法。”

    作者報(bào)告無利益沖突。

    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 desc**tion of events and an eyewitness desc**tion 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.