Kindergarten children's failure to qualify for first grade could result from sleep disturbances

Every year, 7% to 15% of preschool children are found to be underqualified for first grade. We examined whether sleep disturbances are factors in school readiness and their association with neurocognitive skills and behavior. The population included 148 kindergarten students. The study group consisted of 50 students who were assessed by the educational authority as unready for first grade. Children who were scheduled to attend first grade (n = 98) were in the control group. All children/parents filled in a sleep questionnaire and underwent a week of actigraphic sleep/wake study as well as cognitive and behavioral assessments. Children in the study group had significantly shorter total sleep time, reduced sleep efficiency, and increased number of nighttime awakenings. There were significant correlations between sleep variables, and cognitive and behavioral scores. In conclusion, children who fail to qualify for first grade have significantly inferior sleep patterns. Sleep disturbances were associated with cognitive and emotional immaturity.

[Identical, for better and for worse]

We report on identical premature twins (monochorionic diamniotic). As fetuses, they both demonstrated sonographic and MRI evidence of cerebral bilateral ventriculomegaly. Neonatal brain US showed bilateral ventriculomegaly, similar in both twins. During follow-up, these physical and imaging similarities persisted. To the best of our knowledge, this is the first report on similar bilateral ventriculomegaly in Identical Twins (IT). A genetic origin of this finding in our IT is suggested. Should more cases of ventriculomegaly be reported in the future in several sets of IT, cerebral ventriculomegaly can then be added to the list of similar CNS features observed in identical twins.

Apparent life-threatening events: neurological correlates and the mandatory work-up

The purpose of this study was to estimate the prevalence of neurological causes for apparent life-threatening events in infants and assess the neurological work-up mandatory to diagnose such diagnosis, hypothesizing that acute neurological disorders constitute the most common etiology for such an acute event. A retrospective chart review allocated 93 infants fulfilling the criteria of the National Institutes of Health presenting at 1 week to 8 months with apnea, color changes, gagging, unresponsiveness, and alterations of body tone. An underlying neurological etiology was detected in 18 (19%), whereby 15 had seizures and 3 had central apnea. Only one electroencephalography demonstrated epileptic discharges, and brain imaging was intact. Thus, it has been concluded that neurological impairment, mainly that of seizures inducing an apparent life-threatening event, are relatively uncommon. As such, recommendations are that history taking and repeat physical examination still remain the major diagnostic tools before resorting to extensive laboratory studies.

Vigabatrin, lamotrigine, topiramate and serum carnitine levels

Clinical studies indicate a decrease in free and total carnitine in children treated with old-generation antiepileptic drugs (especially valproate). Here, we studied the effect of new-generation antiepileptic drugs on serum carnitine levels. Serum carnitine levels were measured in 91 children: 24 treated with vigabatrin, 28 treated with lamotrigine, and 21 treated with topiramate. These drugs were given as monotherapy (54 children) or polytherapy (19 children). Eighteen additional children treated with valproate served as control subjects. Reduced mean serum carnitine level was evident only in children treated with valproate, with mean free and total carnitine level of 26.9 +/- 8.6 micromol/L and 29.1 +/- 10.4 micromol/L, respectively. In contrast, the mean serum carnitine levels of children treated with vigabatrin, lamotrigine, or topiramate were similar and normal. In these children, the free carnitine levels were 38.5 +/- 7.8 micromol/L, 37.2 +/- 7.7 microg/mL, and 40.4 +/- 8.7 micromol/L, respectively, and total carnitine levels were 43.5 +/- 8.8 micromol/L, 44.4 +/- 9.2 micromol/L, and 45.5 +/- 9.8 micromol/L (+/-S.D.), respectively. Only 4 children (treated with valproate) exhibited considerably lower serum carnitine levels. None of these children had significant clinical adverse effects attributable to carnitine deficiency. In conclusion, these new-generation antiepileptic drugs probably do not cause carnitine deficiency. In contrast, valproate may induce carnitine deficiency, but most cases are asymptomatic.

Childhood epilepsy with occipital paroxysms: variations on the theme

This review reports on the various presentations as well as new revealed data relating to the epileptic disorder defined as childhood epilepsy with occipital paroxysms characterized by occipital epileptic discharges recorded by electroencephalography. The initial rigidly delineated subtypes by the International League Against Epilepsy included the following: (a) Panayiotopoulos syndrome-early-onset seizure disorder presenting with prolonged infrequent, nocturnal autonomic seizures, accompanied by eye deviation and ictal vomiting. (b) Gastaut syndrome-late-onset type presenting with short diurnal frequent seizures and visual ictal manifestations along with migrainous headaches. A high percentage of children present, however, with mixed clinical phenomena making it difficult to comply with the rigidly segregated syndromes reported by several authorities including our recent report on 28 children of whom 14 showed mixed phenomena. Therefore, childhood epilepsy with occipital paroxysm should be suspected at any age presenting with nocturnal vomiting, autonomic impairment, focal motor fits with head deviation, migraine headaches, and/or visual perturbations.

Intractable gelastic seizures during infancy: ictal positron emission tomography (PET) demonstrating epileptiform activity within the hypothalamic hamartoma

Gelastic seizures comprise a very rare form of epilepsy. They present with recurrent bursts of laughter voices without mirth and are most commonly associated with the evolution of a hypothalamic hamartoma. The purpose of this article is to describe the second reported ictal fluorodeoxyglucose-positron emission tomography study in a unique case of an infant with intractable gelastic seizures since the neonatal period associated with a hypothalamic hamartoma. The patient presented at 4 months old with recurrent, almost persistent, gelastic seizures consisting of laughter bouts without mirth. The seizures were noticeable at the first week of life and increased in frequency to last up to 12 hours, namely status gelasticus. These gelastic fits were accompanied with focal motor seizures, including unilateral right-eye blinking and mouth twitching. Developmental mile-stones were intact for age. Magnetic resonance imaging of the cortex demonstrated a large hypothalamic hamartoma within the third ventricle, hampering cerebrovascular fluid drainage of the lateral ventricles. An electroencephalography was nondiagnostic. Ictal fluorodeoxyglucose-positron emission tomography demonstrated a large circumscribed hypermetabolic region within the location of the hypothalamic hamartoma, representing localized intense epileptiform activity. The infant became instantly free of all seizure types given minute doses of oral benzodiazepine (clonazepam) and remains completely controlled after 12 months. Her overall development remains intact. This ictal fluorodeoxyglucose-positron emission tomography is the second reported study verifying that the main source of the epileptic activity inducing gelastic seizures originates from the hypothalamic hamartoma itself; therefore, a complementary fluorodeoxyglucose-positron emission tomography study should be considered in any patient presenting with intractable gelastic seizures, especially in those associated with hypothalamic hamartoma, in order to localize the region of epileptiform activity amenable to surgical resection if intensive drug therapy fails.

Typical absence epilepsy presenting prior to age of 3 years: an uncommon form of idiopathic generalized epilepsy

PURPOSE

An attempt to allocate patients with the clinical features and electroencephalography (EEG) abnormalities of typical absence epilepsy presenting before the age of 3 years, similar to childhood and juvenile absence epilepsy (JAE) and delineate the clinical manifestations, EEG abnormalities, therapy and outcome of such an epileptic disorder by conducting a nationwide survey.

RESULTS

Overall, eight infants, six males and two females, abided by the inclusion criteria of typical absence epilepsy: They were born after an unremarkable pregnancy and labor presenting at the age of 12-34 months (mean: 19.6 months) with frequent absences time-linked with an EEG demonstrating generalized occasionally irregular epileptiform discharges of 3-4 Hz spike/wave and normal background activity along with an electrographic photosensitive response in one patient. Neurological examination was intact in all infants. All eight infants were initially treated with valproic acid, of whom seven immediately responded and one had increase in frequency and duration of absences completely aborted with treatment of lamotrigine. Three relapsed after termination of therapy of whom two again presented with recurrent absences and another one with generalized tonic-clonic seizures and as such these children had virtually transformed into a later form of idiopathic generalized epilepsy (IGE) during childhood. All eight patients are seizure-free, seven still on therapy; seven children within a follow-up period of 2-7 years and the most recently diagnosed infant for 6 months. Cognitive skills were found normal in all children within the low normal range in three children with short attention and concentration spans.

CONCLUSION

The data presented here delineate a very rare form of idiopathic benign generalized epilepsy presenting with typical absences before age of 3 years and a favorable outcome, similar to childhood and JAE, recognized as distinct IGE syndromes by the International League Against Epilepsy (ILAE) classification.

Effect of high-dose methyl-prednisolone on brainstem encephalopathy and basal ganglia impairment complicating cat scratch disease

Cat scratch disease (CSD) is a zoonotic illness caused by the Gram negative bacillus Bartonella henselae characterized by a small skin lesion at the site of a bite, lick or scratch by a cat, commonly followed by regional lymphadenopathy 1 or 2 weeks later. We report herein on severe neurological complications of CSD combining brainstem encephalopathy and basal ganglia impairment. This 12-year-old female acutely presented to a local hospital with profound coma and a prolonged tonic posturing of extremities. On the neurological examination she was deeply comatose with pin-point pupils and lack of vestibulo-ocular responses, suggestive of brainstem encephalopathy, along with marked rigid hypertonicity suggestive also of basal ganglia impairment. Initially suspecting Herpes simplex encephalitis or acute disseminated encephalomyelitis she was promptly started with high-dose methyl-prednisolone and acyclovir. Her parents apparently reported that she was scratched by a kitten some 4 weeks prior to her present admission and as such, suspecting CSD, she was begun with doxycycline and rifampicin. Her serology had proven positive for IgM antibodies to Bartonella henselae establishing the diagnosis. She regained consciousness after 4 days and the signs of brainstem and extra-pyramidal impairment also gradually abated and disappeared after 10 days. A follow-up exam after a month disclosed mild extra-pyramidal abnormalities which disappeared after 3 months. Although extremely rare, CSD should be also considered in a patient presenting with a severe encephalopathy and associated basal ganglia impairment. The prompt administration of high-dose methyl-prednisolone upon admission may have contributed to the favorable outcome in our patient and therefore should be advocated in any patient presenting with profound encephalopathy regardless the underlying etiology recovered later.

Pediatric-onset gelastic seizures: clinical data and outcome

Gelastic seizures are an extremely rare form of epilepsy defined as automatic bouts of laughter without mirth commonly associated with a hypothalamic hamartoma. The objective was to survey all Israeli children found to develop recurrent gelastic seizures and report presenting symptoms, electroencephalographic and radiologic data, and response to either antiepileptic drugs or surgery. Ten children who developed gelastic seizures at the age of 1 week to 6.5 years (mean, 25 months) at a frequency from 3 bouts per week to >10 prolonged bouts per day were followed for a period of 1.3-12 years (mean, 6 years). Seven cases were defined as symptomatic: cortical magnetic resonance imaging revealed a hypothalamic hamartoma in four patients and cortical abnormalities in three others. Seizure control was achieved in four patients, including a neonate with status gelasticus and hypothalamic hamartoma, and partial control in one more. Five children remained resistant to polytherapy, including three with hypothalamic hamartoma even after two of them underwent hemartoma excision. Thus, children with gelastic seizures may respond relatively well to drug therapy. Four of the 10 patients became seizure free with drug therapy; in three intractable symptomatic cases, surgery was tried but failed in two of the three.

Congenital myopathies in Israeli families

The clinical features of 37 patients from 32 Israeli families with congenital myopathies evaluated between 1983 and 2004 are described: 13 children were diagnosed with congenital fiber type disproportion, 10 had myotubular myopathy, 7 had nemaline myopathy, 5 had central core disease, 1 had actin myopathy, and 1 had multi-minicore disease. There were 7 families (22%) that had parental consanguinity, and 4 families (12%) had more than 1 patient with congenital myopathy. Of the patients, 31 (84%) presented with clinical symptoms before 4 months of age, and 6 children (16%) presented after 1 year of age. Thirteen children (35%) had a severe phenotype with chronic ventilatory dependence or mortality before the age of 11 years. Facial weakness was associated with a severe phenotype. There was a high rate of a severe clinical phenotype in patients with myotubular myopathy (60%) and in patients with nemaline myopathy (57%), whereas in patients with congenital fiber type disproportion and in patients with central core disease, the proportion of a severe phenotype was lower (23% and 0%, respectively).

Childhood epilepsy with occipital paroxysms: difficulties in distinct segregation into either the early-onset or late-onset epilepsy subtypes

The Commission on Classification and Terminology of the International League Against Epilepsy Childhood rigidly segregated epilepsy with occipital paroxysms into 2 separate syndromes with different predominant seizure types: early-onset seizure susceptibility type consisting of prolonged infrequent, nocturnal autonomic seizures and accompanied by eye deviation and ictal vomiting and late onset with short diurnal frequent seizures and visual ictal manifestations along with throbbing headaches. Epileptic clinical manifestations and electroencephalographic data were analyzed in 28 patients with suspected occipital lobe epilepsy in an attempt to segregate them into either the early or late forms according to the International League Against Epilepsy classification. Electroencephalography in 25 children demonstrated occipital epileptiform paroxysms compatible with the suspected epileptic syndrome. Only 14 (50%) children complied with the rigid criteria of either early-onset or late-onset presentations. The other 14 (50%) children presented with mixed diverse epileptic phenomena such as short-lived seizures in infancy or prolonged seizures during childhood, not complying with either rigid syndrome (ie, short-lived epileptic blindness at an early age or vomiting during later childhood). Despite present attempts to rigidly segregate childhood epilepsy with occipital paroxysms into 2 distinct epileptic syndromes, a high percentage of children still present with various mixed clinical phenomena. Therefore, clinicians should be aware of possible unique and unusual presentations of occipital lobe epilepsy at various ages.

Childhood-onset idiopathic intracranial hypertension: relation of sex and obesity

The purpose of the present study was to perform a meta-analysis of all children with idiopathic intracranial hypertension reported since 1997 combined with our experience in order to investigate sex distribution and frequency of obesity among young children up 11 years of age vs adolescents at age 12-17 years. Overall, 244 children diagnosed with idiopathic intracranial hypertension were found suitable for the proposed meta-analysis: 132 (54%) were younger than 11 years of age; 72 (55%) were male and 60 (44%) were female. In contrast, of 112 older children (age 12-17 years), 79 (70%) were female. The association between age and obesity could be analyzed in 147 patients: only 19 (26%) out of 74 younger children up to age 11 years were reportedly obese, whereas 47 (64%) out of 73 older children were found obese. Differences in age at presentation, sex, and obesity were statistically significant (P < 0.01). Thus, a wide-scale meta-analysis of childhood-onset idiopathic intracranial hypertension revealed that the female/male ratio in children younger than age 11 years seems to be fairly equal, with a relatively low rate of obesity, contrasting to a majority of females in the group of adolescents at high risk to become obese.

Tumor necrosis factor blockade in the management of children with orphan diseases

Tumor necrosis factor (TNF) blockade has been used successfully to treat a number of rheumatic disorders that have a substantial burden of illness. In children, the TNF antagonists are used mainly for the treatment of juvenile idiopathic arthritis (JIA). There are, however, a variety of rare systemic inflammatory diseases, in which TNF blockade appears promising. Preliminary data in adults suggest that several forms of vasculitis appear to be responsive to TNF antagonists-Behcet's disease, polyarteritis nodosa, Wegener granulomatosis, among others. Some of them respond better to infliximab, a chimeric monoclonal anti-TNF antibody, than to etanercept, a recombinant p75 TNF receptor. We describe our limited experience with infliximab in the treatment of three children with rare vasculitic conditions.

Adolescence peroneal neuropathy associated with rapid marked weight reduction: case report and literature review

PURPOSE

We report herein an uncommon presentation of peroneal nerve palsy and possible myelopathy in an adolescent associated with marked uncontrolled weight loss during a relatively short period.

CASE PRESENTATION

He presented with left drop foot accompanied with sensory impairment at the foot dorsum. Neurophysiologic studies revealed a severe neuropathy of the left peroneal nerve with evidence of a conduction block at the left fibular head suggestive of entrapment neuropathy.

ETIOLOGY

As for the underlying etiology of acute peroneal neuropathy (PN) and possible myelopathy associated with marked weight loss, it has been suggested that rapid loss of the subcutaneous tissue may lead to entrapment of the peroneal nerve at the fibular head leading to foot drop. Body fat percentage was found remarkably low for age at 10% (normal value for age for males: 22.3%) indicative of massive rapid weight reduction markedly depleting fat stores.

CONCLUSION

When an adolescent presents with acute foot drop, PN associated with rapid uncontrolled weight reduction should be taken into account. Prompt resumption of a balanced diet including vital nutritional ingredients may avoid permanent neurological damage and probably assist in recovery from severe flaccid weakness of the lower extremity.

Outcome of children with juvenile absence epilepsy

The incidence and natural history of childhood absence epilepsy are well documented, but those of juvenile absence epilepsy are poorly delineated. We conducted a retrospective chart study to evaluate the incidence and outcome of patients with juvenile absence epilepsy by retrieving the medical records of consecutive patients with juvenile absence epilepsy who were evaluated in three pediatric neurology outpatient clinics in Israel. Inclusion criteria included the onset of epilepsy after the age of 10 years and follow-up until at least 15 years of age. The patients with an electroencephalogram (EEG) suggestive of myoclonic epilepsy (polyspike and wave) were excluded from the study. Seventeen patients (10 female and 7 male) fulfilled the inclusion criteria for juvenile absence epilepsy. They presented with epilepsy at a mean age of 11.94 years (range 10-16.5 years). The mean duration of follow-up was 6.05 years (range 2-12 years). Five patients (29.4%) had a family history of epilepsy. All 17 patients had a normal neurodevelopmental status. Eight patients (47%) experienced generalized tonic-clonic seizures. At follow-up, eight patients (43.7%) were seizure free. Only three (37.5%) of the patients who experienced generalized tonic-clonic seizures were seizure free during follow-up compared with five (55.5%) patients without generalized tonic-clonic seizures. Our results indicate that the outcome of patients with juvenile absence epilepsy is less favorable than children with childhood absence epilepsy and that the presence of generalized tonic-clonic seizures is a predictor for poorer outcome.

Headache, cerebrovascular symptoms, and stroke: the Atherosclerosis Risk in Communities Study

OBJECTIVE

To evaluate the occurrence of stroke/TIA symptoms and ischemic stroke events among those with a lifetime history of migraine or other headaches with some migraine features in a biracial cohort of older adults.

METHODS

Participants were 12,750 African-American and white men and women from the Atherosclerosis Risk in Communities Study (1993 to 1995). The participants were queried about their lifetime headache history and characterized using modified International Headache Society diagnostic criteria. Stroke/TIA symptoms were classified using a computerized diagnostic algorithm, and ischemic stroke events were identified and validated using medical records. Multivariate logistic regression was used to assess the relationship between headache types and stroke/TIA symptoms and ischemic stroke events.

RESULTS

Migraine with aura was strongly associated with stroke symptoms (odds ratio [OR] 5.46, 95% CI: 3.64 to 8.18), TIA symptoms (OR 4.28, 95% CI: 3.02 to 6.08), and verified ischemic stroke events (OR 2.81, 95% CI: 1.60 to 4.92). Similarly, other headaches with aura were significantly associated with stroke symptoms (OR 3.68, 95% CI: 2.26 to 5.99) and TIA symptoms (OR 4.53, 95% CI: 3.08 to 6.67). In contrast, the associations for migraine without aura and other headaches without aura were not as consistent or robust.

CONCLUSIONS

Migraines and other headaches, particularly those accompanied by aura, were associated with an increased occurrence of stroke/TIA symptoms and ischemic stroke events.

Current Therapeutic Options in Severe Guillain-Barre?? Syndrome

The classical form of Guillain-Barré syndrome (GBS) refers to an acute monophasic demyelinating motor and sensory polyneuropathy characterized by symmetric ascending flaccid weakness, along with sensory impairment and, less commonly, autonomic perturbations. Pure motor axonal forms, axonal motor, and sensory forms, as well as pure autonomic forms, have also been identified. A complex immune-mediated process leads to segmental demyelination accompanied with axonal involvement in protracted cases. Establishing strategies of immunomodulation may therefore halt and even reverse the harmful autoimmune insult to peripheral nerves. The present article reviews the current immunomodulatory options in severe GBS. A recent Cochrane meta-analysis of 6 randomized studies showed no significant improvement using corticosteroids, including either oral or intravenous methylprednisolone. Combined methylprednisolone and immunoglobulins shortened the time lapse to regain independent walking. Plasmapheresis (PE) was the first effectively proven method of immunomodulation, followed by intravenous immunoglobulins (IVIG). Both methods are comparable in their beneficial effect and were used either separately or in combination, but PE was more frequently associated with severe adverse effects requiring cessation of therapy, including a bleeding diathesis. In addition, PE is feasible only in major referral centers requiring the appropriate equipment and trained personnel. In addition, younger children may be at risk for bleeding after insertion of wide catheters. Therefore, in cases of severe GBS, IVIG is recommended as the first-line drug using a total empiric dose of 2 g/kg administered over 2 consecutive days, especially in children proven highly effective with negligible adverse effects. In protracted cases, the addition of intravenous corticosteroids to IVIG should be considered, which may shorten the duration to regain independent walking. If such therapy fails, PE should be applied using centrifugal blood separators with 5% albumin as the substitute solution.

Extrapyramidal parkinsonism complicating acute organophosphate insecticide poisoning

The aim of this study is to report our experience with a child who developed extrapyramidal perturbations complicating acute organophosphate insecticides poisoning and to review the literature reporting on basal ganglia impairment associated with this poisoning. Our patient had developed overt parkinsonism presenting with a resting tremor, expressionless face, and lack of blinking along with marked cogwheel rigidity and a stooped, slow gait. He was alert, coherent, and cooperative, yet agitated. The parkinsonian perturbations developed 5 days after an accidental ingestion of a raw eggplant sprayed with the organophosphate dimethoate (Rogor) when he had already recovered from the acute cholinergic crisis, the first stage of organophosphate poisoning. Such a presentation was initially perceived by his caregivers as severe reactive depression or even psychosis. Once a parkinsonian syndrome was diagnosed, he was begun on amantadine and completely recovered within 1 week with no relapse of symptoms. Basal ganglia impairment should be considered in any patient who develops extrapyramidal symptoms such as marked rigidity and bradykinesia or choreoathetosis while recovering from the acute cholinergic phase of organophosphate insecticide poisoning. Thus, administration of a drug such as amantadine, which probably enhances neurotransmission, may hasten the rate of recovery and prevent long-term neurologic and emotional sequelae.

Asthma and incident cardiovascular disease: the Atherosclerosis Risk in Communities Study

BACKGROUND

A possible association between asthma and cardiovascular disease has been described in several exploratory studies.

METHODS

The association of self-reported, doctor diagnosed asthma and incident cardiovascular disease was examined in a biracial cohort of 45-64 year old adults (N = 13501) followed over 14 years.

RESULTS

Compared with never having asthma, the multivariate adjusted hazard ratio (HR) of stroke (n = 438) was 1.50 (95% CI 1.04 to 2.15) for a baseline report of ever having asthma (prevalence 5.2%) and 1.55 (95% CI 0.95 to 2.52) for current asthma (prevalence 2.7%). The relative risk of stroke was 1.43 (95% CI 1.03 to 1.98) using a time dependent analysis incorporating follow up reports of asthma. Participants reporting wheeze attacks with shortness of breath also had greater risk for stroke (HR = 1.56, 95% CI 1.18 to 2.06) than participants without these symptoms. The multivariate adjusted relative risk of coronary heart disease (n = 1349) was 0.87 (95% CI 0.66 to 1.14) for ever having asthma, 0.69 (95% CI 0.46 to 1.05) for current asthma at baseline, and 0.88 (95% CI 0.69 to 1.11) using the time dependent analysis.

CONCLUSIONS

Asthma may be an independent risk factor for incident stroke but not coronary heart disease in middle aged adults. This finding warrants replication and may motivate a search for possible mechanisms that link asthma and stroke.