Functional / non-epileptic spell work-up
Recommended: Video-EEG (ambulatory or epilepsy monitoring unit); MRI Brain to exclude structural is the preferred imaging study for functional / non-epileptic spell work-up. Distinguishes PNES from epilepsy.
Recommended study
Video-EEG (ambulatory or epilepsy monitoring unit); MRI Brain to exclude structural
Distinguishes PNES from epilepsy. MRI usually normal in PNES; imaging is supportive of exclusion.
If the default doesn't apply
Suspected mixed (PNES + epilepsy)
Prolonged video-EEG with provocation
No contrast
Watch-outs
Avoid stigmatizing language
PNES is a real neurologic-psychiatric disorder. Communicate diagnosis carefully and refer to behavioral health.
Status PNES vs status epilepticus
Difficult to distinguish at bedside — err on the side of treating as status until EEG clarifies.
Pearls
- Eyes closed during 'seizure' suggests PNES; epileptic seizures usually have eyes open.
- Side-to-side head shaking, pelvic thrusting, asynchronous limb movements suggest PNES.
- Lactate / prolactin rise after generalized convulsive epileptic seizure but not after PNES.