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Ictal cerebral blood flow in psychogenic non-epileptic seizures: a preliminary SPECT study
  1. James Olver1,
  2. Luis Fernando Castro-de-Araujo1,
  3. Saul Alator Mullen2,
  4. Terry O’Brien3,
  5. Salvatore U Berlangieri4,
  6. Lucy Vivash5,
  7. Dennis Velakoulis6,
  8. Meir Lichtenstein7,
  9. Richard Kanaan8
  1. 1Department of Psychiatry, Austin Health, University of Melbourne, Heidelberg, Victoria, Australia
  2. 2Epilepsy Research Centre, Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
  3. 3Department of Neurology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
  4. 4Department of Molecular Imaging and Therapy, Austin Health, Heidelberg, Victoria, Australia
  5. 5Department of Medicine, Melbourne Brain Centre, University of Melbourne, Melbourne, Victoria, Australia
  6. 6Department of Psychiatry, Neuropsychiatry Unit, Royal Melbourne Hospital, Melbourne, Victoria, Australia
  7. 7Department of Nuclear Medicine, Royal Melbourne Hospital, Melbourne, Victoria, Australia
  8. 8Department of Psychiatry, Austin Health, University of Melbourne, Heidelberg, Victoria, Australia
  1. Correspondence to Dr Richard Kanaan, Chair of Psychiatry, Austin Health, University of Melbourne, Heidelberg, VIC 3084, Australia; richard.kanaan{at}unimelb.edu.au

https://doi.org/10.1136/jnnp-2018-320173

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    Understanding the mechanism of psychogenic non-epileptic seizures (PNES) is challenging. A recent review grouped currently hypothesised psychological models into four: (1) traumatic dissociation, (2) hard-wired anxious-arousal responses, (3) conversion defences and (4) conditioned behaviours, but concluded that determining which of these was correct, if any, went far beyond the available evidence.1 Patients’ subjective reports may lend striking support to some models, but are necessarily post-hoc, and susceptible to iatrogenic suggestion.2 Neuroimaging, such as functional MRI, provides more objective evidence, but is typically restricted to the inter-ictal phase because of potential movement during the scan.3 Single photon emission computed tomography (SPECT) would have distinct advantages in imaging of the peri-ictal state as the tracer injection and uptake occur at the time of the seizure while the scanning can be completed later, after the seizure has finished, overcoming the motion issues. The ictal scan could then be compared with an inter-ictal SPECT to determine the ictal contribution to cerebral blood flow. This process is standard for epilepsy surgery workup, and we combined the databases from two epilepsy surgery centres to find opportunistic cases where the ictal scans of potential surgery cases proved to be of PNES—either because the initial epilepsy diagnosis was mistaken or because the scan captured a comorbid non-epileptic …

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    Footnotes

    • Contributors JSO wrote the manuscript, LFC conducted the analysis, RAK conceived the project and wrote the manuscript; all other authors obtained the data and edited the manuscript.

    • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

    • Competing interests None declared.

    • Patient consent for publication Not required.

    • Provenance and peer review Not commissioned; externally peer reviewed.