Head-up tilting is a useful provocative test for psychogenic non-epileptic seizures

Abstract

Differentiating psychogenic non-epileptic attack disorder (NEAD) from true epilepsy is difficult. This often results in a misdiagnosis and unnecessary and ineffective treatment. Prolonged EEG/video recording is the most sensitive tool for differentiating NEAD from epilepsy, but is costly and therefore limited in availability. Provocative tests, particularly the use of saline injection, can reduce the length of monitoring but give rise to ethical dilemmas. This study assesses the value of head-up tilt testing as a provocative test for NEAD. Twenty-one patients (17 female, mean age 34.6 +/- 11.5 years) with recurrent seizure-like episodes and a clinical diagnosis of NEAD were studied. Patients were tilted to 80( composite function )on an electric tilt table with footplate support for up to 45 minutes during continuous ECG, EEG and blood pressure monitoring. Seventeen patients (81%) experienced typical symptoms (non-epileptiform limb shaking in 15 patients, absence in one patient, myoclonic jerking in one patient) during head-up tilt without significant EEG abnormalities or haemodynamic changes. The mean time to onset of seizure-like activity was 13.2 +/- 11 minutes (range 0-31 minutes). No patients suffered injury or any other significant side-effect. Provocative testing using suggestion and head-up tilt is a sensitive tool for diagnosing NEAD and represents a safe, simple and inexpensive outpatient technique for investigating patients with suspected NEAD.

Teste de inclinação (Tilt-test): do necessário ao imprescindível

“…The test is also very useful in the differentiation with epileptic symptoms, and the identification of the dysautonomia syndrome in these patients avoids the social limitations imposed by the diagnosis of epilepsy and side-effects resulting from the anticonvulsant medication 50 . In addition, it is possible to characterize the psychogenic syncope during the HUTT, when the patient simulates the syncope episode, without any sign of related hemodynamic change 51 . Other diagnoses associated with syncope, such as orthostatic intolerance and Postural Orthostatic Tachycardia Syndrome, also may be revealed or confirmed by HUTT.…”

The semiology of tilt-induced psychogenic pseudosyncope

“…Psychogenic events are amenable to suggestion and can be induced by tilt-table testing. 9,[11][12][13] A clinical suspicion of PPS is a recognized indication for tilt-table testing by the European Society of Cardiology. 3 Herein, we present the semiology of PPS based on the analysis of consecutive episodes of tilt-evoked proven psychogenic apparent TLOC documented with video, EEG, ECG, and blood pressure (BP) measurements.…”

“…12 PPS can also be provoked with placebo maneuvers, leading to apparent TLOC in 90% of patients with PPS. 10 The diagnosis of PPS does not exclude additional diagnoses, particularly of a somatic nature.…”

Managing psychogenic pseudosyncope: Facts and experiences

“…Tilt-table testing with continuous HR, BP, EEG and video monitoring is particularly useful: the tilting maneuver is sufficiently suggestive to elicit apparent TLOC in 81% of patients with PNES [30]. Furthermore, this approach enables the clinician to investigate the major causes of TLOC in one comprehensive test.…”