Panayiotopoulos syndrome: an important childhood autonomic epilepsy to be differentiated from occipital epilepsy and acute non-epileptic disorders

The Reciprocal Relationship between Sleep and Epilepsy

The relationship between sleep and epilepsy is bidirectional. Certain epilepsy syndromes predominantly or exclusively manifest during sleep, with seizures frequently originating from non-rapid eye movement (NREM) sleep. Interictal epileptiform discharges observed on electroencephalograms are most likely to be activated during the deep NREM sleep stage known as N3. Conversely, epileptiform discharges, anti-seizure medications (ASMs), as well as other anti-seizure therapies can exert detrimental effects on sleep architecture. Moreover, the co-occurrence of sleep disorders has the potential to exacerbate seizure control. Understating the relationship between sleep and epilepsy is crucial for healthcare providers. Addressing and managing sleep-related problems in individuals with epilepsy can potentially contribute to improved seizure control and overall well-being. At the same time, improving seizure control can improve sleep quality and quantity, thus further improving the health of individuals with epilepsy.

Panayiotopoulos syndrome: Unusual clinical manifestations

PURPOSE

We retrospectively analyzed the electroclinical features, treatment, and outcome of patients with Panayiotopoulos syndrome (PS) who presented with unusual clinical manifestations.

METHOD

A retrospective, descriptive, multicenter study was conducted evaluating 44 patients with PS who had seizures with an unusual semiology. Data from patients with PS seen at eight Argentine centers between April 2000 and April 2019 were collected.

RESULTS

Twelve patients (29.2%) had ictal syncope or syncope-like epileptic seizures. Three children (7.3%) had recurrent episodes of vomiting. Four patients (9.7%) presented with urinary incontinence associated with autonomic signs and consciousness impairment. One child had hiccups with autonomic manifestations followed by eye deviation. One boy had episodes of laughter with autonomic symptoms followed by loss of consciousness. Six patients (14.6%) had hyperthermia without acute febrile illness with autonomic symptoms as the first manifestation. Six others (14.6%) had focal motor seizures characterized by eye and head deviation in four and eyelid blinking in two. Four patients (9.7%) had ictal headache as the initial manifestation followed by nausea and vomiting. Two children (4.8%) had their first seizure while asleep associated with cardiorespiratory arrest. Two children (4.8%) had oral automatisms, such as sucking and chewing. In two children (4.8%) coughing was the initial manifestation followed by emetic symptoms. One patient (2.3%) had vertigo with a sensation of fear, with eye deviation and unresponsiveness. One child started with continuous spikes and waves during slow sleep, behavior disturbances, and emetic symptoms.

CONCLUSION

In this study, evidence of the existence of unusual clinical cases of PS with typical EEG patterns was found. Outcome was excellent.

More than one self-limited epilepsy of childhood in the same patient: A multicenter study

OBJECTIVE

We describe the evolution of the electroclinical picture of patients with different types of self-limited epilepsy of childhood (SLEC) occurring at the same or at different times with or without atypical evolutions as well as patients with SLEC associated with childhood absence epilepsy (CAE).

MATERIAL AND METHODS

A multicenter, retrospective, descriptive study was conducted evaluating patients with SLEC who had focal seizures of different types of SLEC including atypical evolutions as well as SLEC associated with absence epilepsy seen at eight Argentinian centers between April 2000 and April 2019. Of 7705 patients with SLEC, aged between 2 and 14 years (mean, 7.5 years), of whom 2013 were female and 5692 male (ratio, 1:2.8), 5068 patients had SLECTS, 2260 patients had self-limited childhood occipital epilepsy Panayiotopoulos type (SLE-P), 356 had self-limited childhood occipital epilepsy Gastaut type (SLE-G), and 21 had self-limited epilepsy with affective seizures (SLEAS). Electroclinical features typical of more than one SLEC syndrome were recognized in 998 (13 %) children.

RESULTS

We recognized three well-defined groups of patients. The most frequent association was SLE-P and SLECTS, the paradigmatic type, but associations of SLE-P and SLE-G, SLECTS and SLE-G, and SLEAS and SLE-P or SLECTS were also recognized. The second-most-common association was SLEC and an atypical evolution. In this group, the most frequent combination was SLECTS with its atypical evolution, opercular status epilepticus, epileptic encephalopathy with continuous spike-and-waves during slow sleep, or Landau-Kleffner syndrome. SLE-P and SLE-G associated with an atypical evolution were also identified. The third, less-frequent group had SLECTS, SLE-P, or SLE-G associated with CAE. These cases support the concept that the different types of SLEC are part of a self-limited childhood seizure susceptibility syndrome.

CONCLUSION

Our study demonstrated that 13 % of our patients with SLEC have with different types of SLEC occurring at the same or at different times with or without atypical evolutions - i.e. CSWSS - as well as patients with SLEC associated with CAE, supporting the concept of the self-limited childhood seizure susceptibility syndrome.

Neurocognitive and behavioural profile in Panayiotopoulos syndrome

AIM

To determine neurocognitive performance and behavioural problems in children with Panayiotopoulos syndrome.

METHOD

All 18 children (10 females, 8 males; mean age 4y 7mo; SD 1y 10mo) diagnosed with Panayiotopoulos syndrome at the Kempenhaeghe Epilepsy Center in the Netherlands between 2010 and 2017 were analysed retrospectively. All underwent a neuropsychological/behavioural assessment, an academic assessment, and a 24-hour electroencephalogram.

RESULTS

Mean full-scale IQ (93.5; range 76-123; p=0.04) and performance IQ (93.2; range 76-126; p=0.04) were within the normal range, although significantly lower compared to the normative mean. Verbal IQ (96.3; range 76-118) and processing speed (96.1; range 74-114) were not significantly lower. Simple auditory/visual reaction times, visual attention, visual-motor integration, and verbal memory were significantly lower compared to normative values. On average, patients with Panayiotopoulos syndrome were 8 months behind in arithmetic speed and 11 months behind in reading speed for the number of months in school. Behavioural questionnaires revealed significantly higher scores on reported internalizing behavioural problems.

INTERPRETATION

Children with Panayiotopoulos syndrome demonstrated diffuse cognitive dysfunction in full-scale IQ, performance IQ, visual attention, visual-motor integration, and verbal memory. A high incidence of internalizing behavioural problems was reported. This strongly suggests neuropsychological and behavioural comorbidity in children with Panayiotopoulos syndrome.

WHAT THIS PAPER ADDS

Children with Panayiotopoulos syndrome are at risk for cognitive deficits in various cognitive domains. Children with Panayiotopoulos syndrome are also prone to internalizing behavioural problems. Mild-to-severe academic underachievement was present in more than half of the children with Panayiotopoulos syndrome.

Neurological Etiologies and Pathophysiology of Cyclic Vomiting Syndrome

Cyclic vomiting syndrome is an idiopathic chronic periodic disorder of childhood which may persist into the adult years. Although cyclic vomiting syndrome is considered a central nervous system disorder, it is often managed by a pediatric gastroenterologist. The practitioner should not assume a gastrointestinal or non-neurological cause of symptoms especially if there are coexisting neurological symptoms and signs or if vomiting does not bring relief; this suggests a possible central nervous system cause, which may necessitate a pediatric neurology consultation. Examples of central nervous system causes of cyclic vomiting syndrome that can have subjective and objective neurological findings include abdominal migraine, certain types of epilepsy, structural lesions (tumors, Chiari malformation, demyelinating disease), mitochondrial disease, autonomic disorders, fatty acid/organic acid disorders, urea cycle defects, and cannabinoid hyperemesis syndrome. Improved familiarity with cyclic vomiting syndrome and its mimics may improve the time to appropriate diagnosis and may reduce morbidity related to cyclic vomiting syndrome.

Misdiagnosis and pitfalls in Panayiotopoulos syndrome

Panayiotopoulos syndrome (PS) is a frequent (6% among children of 1-15 years) and benign epileptic syndrome, characterized by predominantly autonomic symptoms (emesis, pallor, flushing, cyanosis, mydriasis/miosis, cardiorespiratory and thermoregulatory alterations, incontinence of urine and/or feces, hypersalivation, and modifications of intestinal motility) associated with simple motor focal seizures, which can be followed by secondary generalization. Panayiotopoulos syndrome can be extremely insidious, because it can mimic several condition, such as gastroenteritis, gastroesophageal reflux disease, encephalitis, syncope, migraine, sleep disorders, or even metabolic diseases. This peculiar pleiotropism should be kept in mind by child neurologists and pediatricians and general practitioners, because a wrong diagnosis may lead to inappropriate interventions. The consequences are high morbidity, costly mismanagement, and stress for children and their parents. The availability of electroencephalography (EEG) recording in pediatric Emergency Departments might be useful for a prompt and not-cost-consuming diagnosis. On the other hand, it is important to be aware of the possible, multifaceted, clinical presentations of PS and its clinical, radiological, and neurophysiological features in order to improve both recognition and management.

Pediatric and Adolescent Headache

PURPOSE OF REVIEW

This article provides the practicing neurologist with a comprehensive, evidence-based approach to the diagnosis and management of headache in children and adolescents, with a focus on migraine.

RECENT FINDINGS

Four triptans are now labeled by the US Food and Drug Administration (FDA) for acute migraine treatment in adolescents, and rizatriptan is labeled for use in children age 6 and older. For preventive migraine treatment, the Childhood and Adolescent Migraine Prevention trial demonstrated that approximately 60% of children and adolescents with migraine will improve with a three-pronged treatment approach that includes: (1) lifestyle management counseling (on sleep, exercise, hydration, caffeine, and avoidance of meal skipping); (2) optimally dosed acute therapy, specifically nonsteroidal anti-inflammatory drugs and triptans; and (3) a preventive treatment that has some evidence for efficacy. For the remaining 40% of children and adolescents, and for those who would not have qualified for the Childhood and Adolescent Migraine Prevention trial because of having continuous headache or medication-overuse headache, the clinician's judgment remains the best guide to preventive therapy selection.

SUMMARY

Randomized placebo-controlled trials have been conducted to guide first-line acute and preventive migraine treatments in children and adolescents. Future research is needed to guide treatment for those with more refractory migraine, as well as for children and adolescents who have other primary headache disorders.

Ictal vomiting after cerebellar hemorrhage: A case report

Vomiting is a typical symptom of cerebellar hemorrhage. Usually only supportive care such as antiemetic drugs are available. A 76-year-old woman presented in a light coma. A head CT demonstrated right cerebellar hemorrhage and the hematoma was surgically evacuated. Her intractable vomiting started 3 weeks after surgery. Because her vomiting was unexplained, we checked her EEG, which demonstrated generalized periodic discharges. We diagnosed her with ictal vomiting. Anti-seizure medication was administered and vomiting was rapidly controlled. In conclusion, physicians must be aware that vomiting may rarely occur as a sign of seizures and status epilepticus.

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Ictal vomiting is one of the clinical presentations of status epilepticus.

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Cerebellar hemorrhage is also cause of ictal vomiting.

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EEG demonstrates periodic discharges.

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Adequate antiepileptic drug may ameliorate ictal vomiting.

Glioblastoma Multiforme in a Patient with Celiac Disease: Management of Seizures After Gross Total Tumor Resection

BACKGROUND

A 55-year-old woman with a history of celiac disease presented with focal seizures and a mass lesion located at the left frontal lobe. Management of seizures in these patients is challenging.

CASE DESCRIPTION

The patient underwent a navigation-assisted tumor resection. A week later, she returned to her regular diet, but 12 days after surgery she started the same pattern seizures.

CONCLUSION

A patient suffering from glioblastoma multiforme who presents with seizures and has a history of celiac disease must be treated more aggressively than usual, with dual or triple anticonvulsant scheme therapy, and provided a strict gluten-free diet after tumor resection.

Panayiotopoulos Syndrome with a special emphasis of ictal semiologic features

PURPOSE

The aim was to identify the demographic, electroencephalographic findings, clinical features, especially ictal semiological symptoms of patients diagnosed with Panayiotopoulos Syndrome.

METHOD

The semiologic and EEG findings of 42 patients were reviewed. Statistical analysis was used to determine the frequencies of semiologic features and to define the symptom clusters.

RESULTS

The most common clinical features were nausea (54.8%), vomiting (50.0%), pallor (50.0%), deviation of head and eyes (45.2%), generalized seizures (35.7%), ictal syncope (33.3%) and stomach ache (26.2%). Visual manifestations which were observed in 38.9% of the patients were amaurosis, flashes of colourful lights, flashes of brightful lights, visual hallucinations and blurring of vision. Autonomic status epilepticus was observed in 21.4% of the patients. Cluster analysis of 13 most common symptoms showed a tendency toward 3 clusters. Pallor constituted a subgroup on its own whereas nausea, vomiting, deviation of head and eyes tended to occur together in the second subgroup and the third subgroup included semiologic features some of which were atypical for PS.

CONCLUSIONS

A broad spectrum of typical and atypical clinical features might be observed in patients with PS. Some of the semiologic features of PS might have tendency to occur together. Overlapping of typical autonomic features with some of the atypical features might suggest that PS, RE and ICOE-G were the constituents of the same neurobiological spectrum. Our detailed data might contribute to the awareness of a wide range of variabilites in the electroclinical features of PS.

Episodic Syndromes That May Be Associated With Migraine: A.K.A. "the Childhood Periodic Syndromes"

Previously called "childhood periodic syndromes that are commonly precursors of migraine" in International Headache Classification of Headache Disorders (ICHD)-II, these disorders were renamed "episodic syndromes that may be associated with migraine" in ICHD-III beta. The specific disorders reviewed in this article include: benign paroxysmal torticollis, benign paroxysmal vertigo, abdominal migraine, and cyclical vomiting syndrome, as well as infantile colic, which was recently added under the appendix section in ICHD-III beta.

From focal epilepsy to Dravet syndrome--Heterogeneity of the phenotype due to SCN1A mutations of the p.Arg1596 amino acid residue in the Nav1.1 subunit

OBJECTIVE

The aim of this study was to analyze the intra-/interfamilial phenotypic heterogeneity due to variants at the highly evolutionary conservative p.Arg1596 residue in the Nav1.1 subunit.

MATERIALS/PARTICIPANTS

Among patients referred for analysis of the SCN1A gene one recurrent, heritable mutation was found in families enrolled into the study. Probands from those families even clinically diagnosed with atypical Dravet syndrome (DS), generalized epilepsy with febrile seizures plus (GEFS+), and focal epilepsy, had heterozygous p.Arg1596 His/Cys missense substitutions, c.4787G>T and c.4786C>T in the SCN1A gene.

METHOD

Full clinical evaluation, including cognitive development, neurological examination, EEGs, MRI was performed in probands and affected family members in developmental age. The whole SCN1A gene sequencing was performed for all probands. The exon 25, where the identified missense substitutions are localized, was directly analyzed for the other family members.

RESULTS

Mutation of the SCN1A p.1596Arg was identified in three families, in one case substitution p.Arg1596Cys and in two cases p.Arg1596His. Both mutations were previously described as pathogenic and causative for DS, GEFS+ and focal epilepsy. Spectrum of phenotypes among presented families with p.Arg1596 mutations shows heterogeneity ranged from asymptomatic cases, through FS and FS+ to GEFS+/Panayiotopoulos syndrome and epilepsies with and without febrile seizures, and epileptic encephalopathy such as DS. Phenotypes differ among patients displaying both focal and generalized epilepsies. Some patients demonstrated additionally Asperger syndrome and ataxia.

CONCLUSION

Clinical picture heterogeneity of the patients carrying mutation of the same residue indicates the involvement of the other factors influencing the SCN1A gene mutations' penetrance.

"EEG abnormalities" may represent a confounding factor in celiac disease: A 4-year follow-up family report

OBJECTIVE

The occurrence of celiac disease (CD), electroencephalographic (EEG) abnormalities (with "subtle" seizures or even without any clinical seizures), and neurological disorders has been reported since the 1980s, though there has been no definitive consensus about the possible causal relationship. This topic is further complicated by the occurrence in infancy of 'clinical-EEG pictures' called 'benign epilepsy of infancy'.

METHODS AND RESULTS

Here, we report a 4-year follow-up on two siblings with newly diagnosed biopsy-proven celiac disease showing EEG abnormalities not responsive to a gluten-free diet.

CONCLUSIONS

This family report indicates that in patients with neurologically asymptomatic CD and EEG abnormalities, it is advisable to make a differential diagnosis between EEG abnormalities associated with CD and an incidental association with cortical hyperexcitability, with "subtle" seizures or even without any clinical seizures.

PRACTICE IMPLICATIONS

A long follow-up may sometimes be required, as it was in the family described here, to clarify the etiopathogenetic and therapeutic relationships between clinical and EEG features in CD.

Gastroesophageal reflux disease vs. Panayiotopoulos syndrome: an underestimated misdiagnosis in pediatric age?

Autonomic signs and symptoms could be of epileptic or nonepileptic origin, and the differential diagnosis depends on a number of factors which include the nature of the autonomic manifestations themselves, the occurrence of other nonictal autonomic signs/symptoms, and the age of the patient. Here, we describe twelve children (aged from ten months to six years at the onset of the symptoms) with Panayiotopoulos syndrome misdiagnosed as gastroesophageal reflux disease. Gastroesophageal reflux disease and Panayiotopoulos syndrome may represent an underestimated diagnostic challenge. When the signs/symptoms occur mainly during sleep, a sleep EEG or, if available, a polysomnographic evaluation may be the most useful investigation to make a differential diagnosis between autonomic epileptic and nonepileptic disorders. An early detection can reduce both the high morbidity related to mismanagement and the high costs to the national health service related to the incorrect diagnostic and therapeutic approaches. To decide if antiseizure therapy is required, one should take into account both the frequency and severity of epileptic seizures and the tendency to have potentially lethal autonomic cardiorespiratory involvement. In conclusion, we would emphasize the need to make a differential diagnosis between gastroesophageal reflux disease and Panayiotopoulos syndrome in patients with "an unusual" late-onset picture of GERD and acid therapy-resistant gastroesophageal reflux, especially if associated with other autonomic symptoms and signs.

Panayiotopoulos syndrome: a case series from Turkey

The aim of the study was to evaluate the demographic, clinical, and EEG characteristics of patients with Panayiotopoulos syndrome (PS) and the course of their illness. Thirty-eight patients followed up with a diagnosis of PS between January 2011 and December 2013 were evaluated. We found high rates of personal history of febrile convulsions, breath-holding spells, and family history of febrile convulsions, afebrile convulsion/epilepsy, migraine, and breath-holding spells. Seizures started before the age of eight in 87% of the patients, and the mean age at seizure onset was 4.6 years. Seizures were sleep-related in 81.5%, and autonomic status was seen in a third of the patients. The number of seizures was between 2 and 10 in 66% of the patients. The most common symptoms were ictus emeticus, eye/head deviation, and altered consciousness. Rolandic features were seen in 26% of the patients, and visual symptoms in 5%. Multifocal epileptiform discharges on EEG were identified in 84% of the patients. Two or more antiepileptic drugs were required in only 13% of the patients. Evolution to electrical status epilepticus in sleep and Gastaut-type epilepsy were seen in patients with more than ten seizures. The high rates of febrile convulsions, afebrile convulsions/epilepsy, migraine, and breath-holding spells in the patients and families suggest the importance of genetic factors and, perhaps, a common pathogenesis. However, the high rates of febrile convulsions and breath-holding spells in patients can be related to a misdiagnosis because of the similar symptoms. Despite its disturbing symptoms, PS is a benign epileptic syndrome requiring multiple antiepileptic drug use only in a small proportion of patients.

Idiopathic focal epilepsies

In this chapter we include a series of epilepsies with onset in pediatric age characterized by focal seizures, idiopathic etiology, normal psychomotor development, and a benign course related to the spontaneous remission of seizures without sequelae. These entities are age-dependent and seizures tend to disappear spontaneously. For these reasons often the drug treatment is not necessary. On the basis of genetic assessment idiopathic focal epilepsies can be divided into two groups: nonautosomal dominant and autosomal dominant. In the group of nonautosomal entities we include benign epilepsy with centro-temporal spikes, Panayiotopoulos syndrome, idiopathic childhood occipital epilepsy described by Gastaut, and benign idiopathic midline spikes epilepsy. Seizures are rare, sometimes prolonged, as autonomic status in Panayiotopoulos syndrome. A common feature is the presence of peculiar EEG interictal paroxysmal abnormalities. In the group with an autosomal dominant mode of inheritance we include benign familial infantile seizures and benign familial neonatal-infantile seizures. These entities are characterized by partial seizures in cluster, self-limited in a brief period during the first months of life. There are no typical interictal EEG abnormalities. In some families a mutation in SCN2A, the gene coding for the 2α subunit of the voltage-gated sodium channel, has been described.

Disengagement and inhibition of visual-spatial attention are differently impaired in children with rolandic epilepsy and Panayiotopoulos syndrome

We assessed voluntary orientation and reorientation of visuospatial attention in 313 healthy 6- to 22-year-old participants, 30 children suffering from benign epilepsy with centrotemporal spikes (BECTS) and 13 children with Panayiotopoulos syndrome (PS). The developmental section highlights the late development of reorienting skills. Only children with BECTS-R showed a strong tendency toward a rightward bias in attentional orientation. Additionally, a unilateral deficit of disengagement characterizes the patients with BECTS-R and comorbid ADHD. Right rolandic spikes seem to aggravate subclinical reorienting difficulties. Finally, children with PS failed to diffuse inhibition, except in the nearest area outside the attentional focus. This deficit could be attributed to the typical occipital-to-frontal spreading of the spikes in PS. By showing distinct attentional deficiencies according to the epileptic syndrome and the epileptic focus lateralization in BECTS, the results provide new evidence for alterations of attentional mechanisms by interictal epileptic activity, which probably contribute to learning difficulties.

Fever as a seizure precipitant factor in Panayiotopoulos syndrome: a clinical and genetic study

PURPOSE

To examine fever as a precipitating factor for focal seizures in patients with Panayiotopoulos syndrome (PS) and evaluate the role of SCN1A in PS patients with seizures triggered by fever.

METHODS

From January 2000 to June 2008, we identified patients referred for seizures who fulfilled the criteria of PS. Patients were divided into two groups, according to the presence (group A) or the absence (group B) of seizures triggered by fever. Electroclinical features of the two groups were compared. In addition, an analysis of SCN1A in patients of group A was performed.

RESULTS

Thirty patients fulfilled the inclusion criteria. Eleven patients (36%) had at least one focal autonomic seizure triggered by fever (group A). In group A, 7/11 patients (63.5%) had the first focal autonomic seizure during a febrile illness. Two of these 7 patients were misdiagnosed at the onset of PS. The median age at the onset of PS was slightly lower in group A than in group B (p=.050). Moreover, patients in group A more frequently had a positive familial history of febrile seizures (FS) (p=.047). No mutations of SCN1A were found in any of the 10 patients screened.

CONCLUSION

Fever is a common trigger for focal autonomic seizures in PS. Knowing that an autonomic manifestation during fever can be an epileptic seizure could facilitate diagnosis and prevent unnecessary investigations and erroneous treatments. Moreover, our data show that SCN1A gene does not contribute significantly to susceptibility to autonomic seizures during fever in patients with PS.

Cardiovascular and neuroendocrine features of Panayiotopoulos syndrome in three siblings

OBJECTIVE

Panayiotopoulos syndrome is a benign idiopathic childhood epilepsy characterized by altered autonomic activity at seizure onset.

METHODS

Three siblings with Panayiotopoulos syndrome underwent 24-hour EEG recording and head-up tilt testing with continuous blood pressure and RR interval monitoring. Plasma catecholamines and vasopressin were measured while supine, upright, and during a typical seizure.

RESULTS

Patient 1, a 12-year-old girl, had a history of involuntary lacrimation, abdominal pain, and recurrent episodes of loss of muscle tone and unresponsiveness followed by somnolence. Her EEG revealed bilateral frontotemporal spikes. Patient 2, a 10-year-old boy, had episodic headaches with pinpoint pupils, skin flushing of the face, trunk, and extremities, purple discoloration of hands and feet, diaphoresis, nausea, and vomiting. Tilt testing triggered a typical seizure after 9 minutes; there was a small increase in blood pressure (+5/4 mm Hg, systolic/diastolic) and pronounced increases in heart rate (+59 bpm) and norepinephrine (+242 pg/mL), epinephrine (+175 pg/mL), and vasopressin (+22.1 pg/mL) plasma concentrations. Serum glucose was elevated (206 mg/dL). His EEG revealed right temporal and parietal spikes. Patient 3, an 8-year-old boy, had a history of restless legs at night, enuresis, night terrors, visual hallucinations, cyclic abdominal pain, and nausea. His EEG showed bitemporal spikes.

CONCLUSION

Hypertension, tachycardia, and the release of vasopressin suggest activation of the central autonomic network during seizures in familial Panayiotopoulos syndrome. These autonomic and neuroendocrine features may be useful in the diagnosis and may have therapeutic implications.

Benign nocturnal alternating hemiplegia of childhood: two cases with positive evolution

Benign nocturnal alternating hemiplegia (BNAH) of childhood is distinct from the classic form of malignant alternating hemiplegia of childhood [1]. It is characterized by hemiplegic attacks occurring exclusively during sleep [2]. It can be misdiagnosed as migraine, nocturnal frontal lobe epilepsy, benign rolandic epilepsy, Panayiotopoulos syndrome, or sleep-related movement disorder [1-4]. Only nine patients have been described to date, with typically, a normal development [1,5-7]. In order to insist about the benignity of the affection, we report two cases: a new three-year-old boy suffering from BNAH and a patient already published to show positive evolution at fourteen years of age. BNAH is a rare disorder but may be underdiagnosed. Making an early diagnosis can help to describe to the parents the good prognosis without treatment.

Documentation of autonomic seizures and autonomic status epilepticus with ictal EEG in Panayiotopoulos syndrome

Panayiotopoulos syndrome (PS) is a common childhood susceptibility to autonomic seizures and status epilepticus. Despite its high prevalence, PS has been a source of significant debate. We present ictal EEG documentation of autonomic seizures and autonomic status epilepticus in six cases of PS and a review of 14 reported cases. Interictal EEGs showed spikes of variable locations that often changed with time. Ictal EEG onsets were also variable, starting from wide anterior or posterior regions usually with theta waves intermixed with small spikes and fast rhythms. Ictal vomiting and other autonomic manifestations, as well as deviation of the eyes, did not appear to relate to any specific region of EEG activation. These data document that PS is a multifocal autonomic epilepsy and support the view that the clinical manifestations are likely to be generated by variable and widely spread epileptogenic foci acting on a temporarily hyperexcitable central autonomic network.

Panayiotopoulos syndrome: a clinical, EEG, and neuropsychological study of 93 consecutive patients

PURPOSE

To explore the clinical, electroencephalography (EEG), neuropsychological features, and prognosis of Panayiotopoulos syndrome (PS).

METHODS

Of 1,794 children aged between 1 and 14 years referred for the first afebrile focal seizure, between January 1992 and December 2004, 93 (5.2%) had PS according to clinical criteria.

RESULTS

Age at onset ranged from 1.1 to 8.6 years, and was earlier in children with more than one seizure. Autonomic seizures followed a stereotypical onset and progression. Emesis, pallor, or flushing was almost always among the first symptoms that usually culminated in vomiting (77.4% of patients). More than half (55%) of seizures were longer than 30 min but these did not appear to affect remission and number of seizures. Interictal EEG showed great variability, with 79.5% of patients showing spikes of variable localizations and evolution over time; 16.1% had background abnormalities only, and 5.4% had consistently normal EEG studies. Onsets in five ictal EEGs were posterior or anterior-left or right. On neuropsychological testing, IQ and subtests of Wechsler Intelligence Scale for Children-Revised (WISC-R) were within normal limits, although some minor statistically significant differences were found in arithmetic, comprehension, and picture arrangement in comparison with controls. Cumulative probability of recurrence was 57.6%, 45.6%, 35.1%, and 11.7% at 6, 12, 24, and 36 months, respectively, after the first seizure. Thirty-four (58.6%) of 59 patients treated with antiepileptic drugs continued having seizures before ultimate remission.

DISCUSSION

PS is a uniform childhood susceptibility to autonomic seizures that is related to early age of development and with excellent prognosis with regard to seizure remission and neuropsychological development.