We identified 6 semiological signs that reliably distinguish PNES and ES, and found that eyewitness reports of these signs are unreliable. We offer suggestions to improve the accuracy of eyewitness reports.

SUMMARYIn the last 10-15 years the ILAE Commission on Classification and Terminology has been presenting proposals to modernize the current ILAE Classification of Epileptic Seizures and Epilepsies. These proposals were discussed extensively in a series of articles published recently in Epilepsia and Epilepsy Currents. There is almost universal consensus that the availability of new diagnostic techniques as also of a modern understanding of epilepsy calls for a complete revision of the Classification of Epileptic Seizures and Epilepsies. Unfortunately, however, the Commission is still not prepared to take a bold step ahead and completely revisit our approach to classification of epileptic seizures and epilepsies. In this manuscript we critically analyze the current proposals of the Commission and make suggestions for a classification system that reflects modern diagnostic techniques and our current understanding of epilepsy.

Generalized tonic-clonic seizures (GTCS) are the commonest seizure type associated with Sudden Unexplained Death in Epilepsy (SUDEP). This study examines semiological and electroencephalographic differences (EEG) in the GTCS of adults as compared to children. The rationale lies in epidemiological observations that have noted a ten-fold higher incidence of SUDEP in adults. We analyzed video-EEG data of 105 GTCS in 61 consecutive patients (12 children, 23 seizures and 49 adults, 82 seizures) recruited from the Epilepsy Monitoring Unit. Semiological, EEG and 3-channel EKG features were studied. Peri-ictal seizure phase durations were analyzed including tonic, clonic, total seizure, post-ictal EEG suppression (PGES) and recovery phases. Heart rate variability (HRV) measures including RMSSD (root mean square successive difference of R-R intervals), SDNN (standard deviation of NN intervals) and SDSD (standard deviation of differences) were analyzed (including low frequency/high frequency power ratios) during pre-ictal baseline, ictal and post-ictal phases. Generalized estimating equations (GEE) were used to find associations between electro-clinical features. Separate subgroup analyses were carried out on adult and pediatric age groups as well as medication groups (no anti-epileptic medication cessation versus unchanged or reduced medication) during admission. Major differences were seen in adult and pediatric seizures with total seizure duration, tonic phase, PGES and recovery phases being significantly shorter in children (p<0.01). GEE analysis using tonic phase duration as the dependent variable, found age to correlate significantly (p<0.001) and this remained significant during subgroup analysis (adults and children) such that each 0.12 second increase in tonic phase duration correlated with a 1 second increase in PGES duration. PGES durations were on average 28 seconds shorter in children. With cessation of medication, total seizure duration was significantly increased by a mean value of 8 seconds in children and 11 seconds in adults (p<0.05). Tonic phase duration also significantly increased with medication cessation and although PGES durations increased, this was not significant. RMSSD was negatively correlated with PGES duration (longer PGES durations were associated with decreased vagally mediated heart rate variability; p<0.05) but not with tonic phase duration. This study clearly points out identifiable electro-clinical differences between adult and pediatric GTCS that may be relevant in explaining lower SUDEP risk in children. The findings suggest that some prolonged seizure phases and prolonged PGES duration may be electro-clinical markers of SUDEP risk and merit further study.

There are at least five types of alterations of consciousness that occur during epileptic seizures: auras with illusions or hallucinations, dyscognitive seizures, epileptic delirium, dialeptic seizures, and epileptic coma. Each of these types of alterations of consciousness has a specific semiology and a distinct pathophysiologic mechanism. In this proposal we emphasize the need to clearly define each of these alterations/loss of consciousness and to apply this terminology in semiologic descriptions and classifications of epileptic seizures. The proposal is a consensus opinion of experienced epileptologists, and it is hoped that it will lead to systematic studies that will allow a scientific characterization of the different types of alterations/loss of consciousness described in this article.

Summary This article critiques the International League Against Epilepsy (ILAE) 2015‐2017 classifications of epilepsy, epileptic seizures, and status epilepticus. It points out the following shortcomings of the ILAE classifications: (1) they mix semiological terms with epileptogenic zone terminology; (2) simple and widely accepted terminology has been replaced by complex terminology containing less information; (3) seizure evolution cannot be described in any detail; (4) in the four‐level epilepsy classification, level two (epilepsy category) overlaps almost 100% with diagnostic level one (seizure type); and (5) the design of different classifications with distinct frameworks for newborns, adults, and patients in status epilepticus is confusing. The authors stress the importance of validating the new ILAE classifications and feel that the decision of Epilepsia to accept only manuscripts that use the ILAE classifications is premature and regrettable.