¹Sivas Numune Hospital, Psychiatry, Sivas, Turkey

Background: Psychogenic nonepileptic seizures (PNES) are functional neurological events that resemble epileptic seizures but occur in the absence of epileptiform activity on electroencephalography (Tilahun and Bautista, 2022). PNES are frequently misdiagnosed as epileptic seizures, particularly in acute and perioperative settings, resulting in unnecessary antiepileptic treatment, repeated neuroimaging, and prolonged hospitalizations (Lehn et al., 2021). The early postoperative period represents a diagnostic challenge due to physiological stress, anesthetic effects, and transient metabolic changes, which may obscure the recognition of functional neurological presentations (Ramos and Brull, 2016; D’Souza et al., 2020).

Aims & Objectives: To describe a case of psychogenic nonepileptic seizures emerging in the early postoperative period following surgical treatment for Graves’ disease and to highlight clinical features that may aid in differentiating PNES from epileptic seizures in the postoperative context.

Method: We report the case of a 49-year-old woman who developed recurrent seizure-like episodes beginning approximately one hour after thyroid surgery performed for Graves’ disease refractory to medical treatment. Video recordings of the events were reviewed by the neurophysiology team. Comprehensive neurological evaluation, including electroencephalography, neuroimaging, and metabolic investigations, was conducted to exclude epileptic, structural, and metabolic etiologies. Psychiatric assessment focused on clinical semiology, psychosocial history, and mental status examination.

Results: Postoperative episodes were characterized by generalized stiffness and tremor with preserved consciousness, intact responsiveness to verbal commands, and absence of postictal confusion. Video analysis demonstrated irregular, high-frequency tremulous movements without consistent rhythmicity or synchronous limb involvement. Electroencephalography revealed normal background activity without epileptiform discharges (Tatum et al., 2022). Neuroimaging and laboratory investigations, including calcium and thyroid function tests, were unremarkable. The patient reported prodromal awareness prior to episodes and partial interruption of symptoms with verbal suggestion. Psychiatric evaluation identified prior exposure to significant psychosocial stressors and a remote history of conversion-like episodes, without current mood, psychotic, or somatic symptom disorders. Based on the clinical features and diagnostic workup, epileptic seizures were excluded and PNES was diagnosed. Psychoeducation, behavioral strategies, and antidepressant treatment were initiated, resulting in a reduction in seizure frequency during follow-up.

Discussion & Conclusions: PNES should be considered in the differential diagnosis of seizure-like events occurring in the early postoperative period, particularly when consciousness is preserved, motor patterns are non-rhythmic, and EEG findings are normal (Tilahun and Bautista, 2022). Surgical stress and endocrine procedures may act as precipitating factors for functional neurological symptoms in predisposed individuals (Espay et al., 2018). Early recognition of PNES in postoperative settings may prevent unnecessary diagnostic and therapeutic interventions and facilitate timely multidisciplinary management.