Monthly Case

Ambiguous seizures | 10-2013

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A 53-year-old patient was admitted to assess the nature of paroxysmal behavioral changes including movements of the right arm that have occurred for a couple of years. The patient is of South-East-European origin, language barrier impedes adequate history taking. During longterm video-EEG-recording, a typical event occurred. After short pausing, the right hand clenches, evolving to high-frequent shaking of the right upper extremity. After a minute or so, the left arm is involved. During this 2-minute-episode, the eyes are squinted. Semiologically, this event complies with a psychogenic non-epileptic seizure, the EEG does not show a corresponding seizure pattern.

After demonstration of the video to the patient’s son, he confirms that his father’s spells largely look like that in the video.

Seven years before, the patient had already undergone video-EEG-recording in the Epilepsy-Center Berlin-Brandenburg. At that time, a seizure was recorded with initial pausing, evolving to automated movements of the right hand. The eyes are open initially, they are closed in the further course of this seizure. Duration of this light automotor seizure was 1 min. Ictal EEG was characterized by a right anterior temporal seizure pattern.

In direct comparison of the two video sequences, psychogenic non-epileptic seizures – in spite of some semiological similarities – are easily separated from automotor epileptic spells. Based on history as taken from the patient, language barrier does not allow this distinction. Based on third party history as taken from the son, the current paroxysmal behavioral changes seem to be of psychogenic non-epileptic origin. Eventually, we were not able to clarify if automotor epileptic seizures exclusively occurred a couple of years ago or if this seizure type is still present in addition to psychogenic seizures.

Pharmacological antiepileptic treatment with lamotrigine was continued without changes. We recommended behavioral therapy by a psychotherapist in the patient’s native language.

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