Portal de Periódicos da CAPES

Errors in EEGs and the misdiagnosis of epilepsy: Importance, causes, consequences, and proposed remedies

2007; Elsevier BV; Volume: 11; Issue: 3 Linguagem: Inglês

10.1016/j.yebeh.2007.05.013

1525-5069

Selim R. Benbadis,

Healthcare Decision-Making and Restraints

The misdiagnosis of epilepsy has been brought to the forefront and the lay public in the United Kingdom because of a high-profile legal case about the misdiagnosis of epilepsy by a pediatric neurologist [ 1 White C. Doctor referred to GMC after inquiry into epilepsy diagnoses. Br Med J. 2001; 323: 1323 Crossref PubMed Scopus (9) Google Scholar , 2 Dyer C. 10m pounds sterling settlement for children misdiagnosed with epilepsy. Br Med J. 2005; 330: 1466 Crossref PubMed Scopus (4) Google Scholar ]. Because roughly 30% of his patients treated for epilepsy were found not to have it, the scapegoat, Dr. Andrew Holton, was suspended in 2001. A £10 million compensation (for parents and children) was approved by a High Court judge in 2005. He appealed in March 2006 and lost the appeal in November 2006. The story triggered a series of articles, including some in the lay press, about this "scandal" and "outrage." And certainly, the 30% misdiagnosis rate ("over 600 children" and "10 years of misdiagnosis") sounds shocking. But is it? A very robust and replicated finding is that about 30% of patients seen at epilepsy centers for refractory seizures do not have epilepsy. In fact, this proportion of about 30% is strikingly consistent in studies from different continents, across age groups from children to elderly, and over the last two decades since the advent of video-EEG monitoring [ 3 Uldall P. Alving J. Hansen L.K. et al. The misdiagnosis of epilepsy in children admitted to a tertiary epilepsy centre with paroxysmal events. Arch Dis Child. 2006; 91: 219-221 Crossref PubMed Scopus (170) Google Scholar , 4 Asano E. Pawlak C. Shah A. et al. The diagnostic value of initial video-EEG monitoring in children: review of 1000 cases. Epilepsy Res. 2005; 66: 129-135 Abstract Full Text Full Text PDF PubMed Scopus (65) Google Scholar , 5 Sabri M.R. Mahmodian T. Sadri H. Usefulness of the head-up tilt test in distinguishing neurally mediated syncope and epilepsy in children aged 5–20 years old. Pediatr Cardiol. 2006; 27: 600-603 Crossref PubMed Scopus (17) Google Scholar , 6 Behrouz R. Benbadis S.R. Late-onset psychogenic nonepileptic seizures. Epilepsy Behav. 2006; 8: 649-650 Abstract Full Text Full Text PDF PubMed Scopus (38) Google Scholar , 7 Duncan R. Oto M. Martin E. Pelosi A. Late onset psychogenic nonepileptic attacks. Neurology. 2006; 66: 1644-1647 Crossref PubMed Scopus (107) Google Scholar , 8 McBride A.E. Shih T.T. Hirsch L.J. Video-EEG monitoring in the elderly: a review of 94 patients. Epilepsia. 2002; 43: 165-169 Crossref PubMed Scopus (126) Google Scholar , 9 Chadwick D. Smith D. The misdiagnosis of epilepsy. Br Med J. 2002; 324: 495-496 Crossref PubMed Scopus (123) Google Scholar , 10 Smith D. Defalla B.A. Chadwick D.W. The misdiagnosis of epilepsy and the management of refractory epilepsy in a specialist clinic. Q J Med. 1999; 92: 15-23 Crossref Scopus (331) Google Scholar , 11 Scheepers B. Clough P. Pickles C. The misdiagnosis of epilepsy: findings of a population study. Seizure. 1998; 7: 403-406 Abstract Full Text PDF PubMed Scopus (177) Google Scholar , 12 Benbadis S.R. Heriaud L. O'Neill E. et al. Outcome of prolonged EEG-video monitoring at a typical referral epilepsy center. Epilepsia. 2004; 45: 1150-1153 Crossref PubMed Scopus (209) Google Scholar , 13 Zaidi A. Clough P. Cooper P. Scheepers B. Fitzpatrick A.P. Misdiagnosis of epilepsy: many seizure-like attacks have a cardiovascular cause. J Am Coll Cardiol. 2000; 36: 181-184 Abstract Full Text Full Text PDF PubMed Scopus (338) Google Scholar , 14 Ribai P. Tugendhaft P. Legros B. Usefulness of prolonged video-EEG monitoring and provocative procedure with saline injection for the diagnosis of non epileptic seizures of psychogenic origin. J Neurol. 2006; 253: 328-332 Crossref PubMed Scopus (27) Google Scholar , 15 Zhu Y. Video/EEG, the epileptic monitoring system. Zhonghua Shen Jing Jing Shen Ke Za Zhi. 1990; 23: 367-370 PubMed Google Scholar , 16 O'Rourke K. McNamara B. Sweeney B.J. Video-EEG recording: a four-year clinical audit. Ir Med J. 2004; 97: 309 PubMed Google Scholar , 17 Bhatia M. Sinha P.K. Jain S. Padma M.V. Maheshwari M.C. Usefulness of short-term video EEG recording with saline induction in pseudoseizures. Acta Neurol Scand. 1997; 95: 363-366 Crossref PubMed Scopus (42) Google Scholar , 18 Koblar S.A. Black A.B. Schapel G.J. Video-audio/EEG monitoring in epilepsy: the Queen Elizabeth Hospital experience. Clin Exp Neurol. 1992; 29: 70-73 PubMed Google Scholar , 19 Lobello K. Morgenlander J.C. Radtke R.A. Bushnell C.D. Video/EEG monitoring in the evaluation of paroxysmal behavioral events: duration, effectiveness, and limitations. Epilepsy Behav. 2006; 8: 261-266 Abstract Full Text Full Text PDF PubMed Scopus (68) Google Scholar ]. The proportion of patients misdiagnosed is also similar to those reported in samples of patients diagnosed with posttraumatic epilepsy [ [20] Hudak A.M. Trivedi K. Harper C.R. et al. Evaluation of seizure-like episodes in survivors of moderate and severe traumatic brain injury. J Head Trauma Rehabil. 2004; 19: 290-295 Crossref PubMed Scopus (67) Google Scholar ], patients referred directly (without video-EEG monitoring) for vagus nerve stimulation [ [21] Attarian H. Dowling J. Carter J. Gilliam F. Video EEG monitoring prior to vagal nerve stimulator implantation. Neurology. 2003; 61: 402-403 Crossref PubMed Scopus (22) Google Scholar ], and patients awarded a "seizure alert dog" [ [22] Krauss G.L. Choi J.S. Lesser R.P. Pseudoseizure dogs. Neurology. 2007; 68: 308-309 Crossref PubMed Scopus (22) Google Scholar ]. The point is: the misdiagnosis of epilepsy is very common. The fact that the patient population of Dr. Holton was not, like that of an epilepsy center, selected as being refractory, makes his percentage a little worse, but not much.