From the Guidelines
The presence of mesial temporal sclerosis (MTS) on MRI in patients with psychogenic non-epileptic seizures (PNES) is uncommon, but when detected, it suggests the possibility of coexisting epileptic seizures, emphasizing the need for thorough evaluation with video-EEG monitoring to guide appropriate treatment. The literature indicates that most patients with PNES have normal MRI findings without evidence of structural brain abnormalities such as MTS 1. However, some studies have reported a small subset of PNES patients (approximately 2-10%) who may have concurrent MTS on MRI. This coexistence is important to recognize because some patients have both epileptic seizures and PNES (dual diagnosis), with the epilepsy often predating the development of PNES.
Key Considerations
- MTS is strongly associated with temporal lobe epilepsy, and its presence on MRI should prompt clinicians to consider the possibility of epileptic seizures rather than solely PNES 1.
- Video-EEG monitoring remains the gold standard for differentiating between PNES and epileptic seizures, regardless of MRI findings 1.
- Understanding the relationship between MTS, PNES, and epileptic seizures is crucial to avoid misdiagnosis and ensure appropriate treatment, whether it be antiseizure medications for epilepsy or psychological interventions for PNES.
Imaging Recommendations
- MRI is the imaging modality of choice for evaluating structural lesions in epilepsy, including MTS, due to its excellent gray-white matter differentiation and multiplanar imaging capability 1.
- Dedicated seizure protocols and acquisition on 3T magnets are important considerations to improve lesion detection, including the use of coronal T1-weighted imaging, high-resolution volume acquisition, and fluid-attenuated inversion recovery sequences to assess for hippocampal signal abnormality and atrophy 1.
From the Research
MRI Evidence of Mesial Temporal Sclerosis in Patients with Psychogenic Non-Epileptic Seizures
- There is no direct evidence in the provided studies regarding MRI evidence of mesial temporal sclerosis in patients with psychogenic non-epileptic seizures 2, 3, 4, 5, 6.
- The studies primarily focus on the diagnosis, management, and treatment of psychogenic non-epileptic seizures, as well as their distinction from epileptic seizures.
- Some studies discuss the importance of EEG findings and video-EEG monitoring in diagnosing psychogenic non-epileptic seizures 3, 6, but do not mention MRI evidence of mesial temporal sclerosis.
- Mesial temporal sclerosis is a condition often associated with epileptic seizures, and its presence on MRI may be used to support a diagnosis of epilepsy.
- However, the provided studies do not explore the relationship between mesial temporal sclerosis and psychogenic non-epileptic seizures, and therefore do not provide any relevant MRI evidence 2, 3, 4, 5, 6.