Epilepsy in children with periventricular leukomalacia

Electroencephalographic Patterns on Follow-Up Visits in Extremely Premature Infants With Periventricular Leukomalacia: An Observational Study

BACKGROUND

Periventricular leukomalacia (PVL) is a common brain injury in premature infants, and epilepsy remains a significant complication. One concerning electroencephalographic (EEG) pattern found is developmental and/or epileptic encephalopathy with spike-and-wave activation in sleep (DEE-SWAS). This pattern is associated with persistent neuropsychological and motor deficits, even without a diagnosis of epilepsy. The purpose of this study is to identify the relationships between various PVL grades and EEG patterns in this population on follow-up visits, especially the occurrence of DEE-SWAS pattern on EEG.

METHODS

This is a retrospective study of <36 weeks gestational age newborns who were followed in the neurodevelopmental clinic at Corewell Health East/Corewell Health Children's Hospital in Royal Oak, Michigan, between 2020 and 2022. Patients' demographics along with prematurity complications, diagnostic head ultrasound (HUS), and EEG studies were reviewed and graded. EEG studies are usually ordered when seizures were suspected.

RESULTS

A total of 155 newborns met the inclusion criteria. Twenty-six patients had PVL. Nine patients had grade 2 to 3 PVL based on HUS review. EEG was performed on 15 patients with PVL at a mean age of 22 months. More severe PVL grades were significantly associated with worse EEG patterns (P = 0.005). Five patients had DEE-SWAS pattern on EEG, all of whom had grade 2 or 3 PVL. Epilepsy was eventually diagnosed in three infants with PVL.

CONCLUSIONS

EEG can help identify important abnormal electrographic patterns in premature infants with PVL early in life; this might give a window of opportunity to intervene early and improve long-term developmental outcomes in this population.

Association of Cystic Periventricular Leukomalacia and Postnatal Epilepsy in Very Preterm Infants

INTRODUCTION

Cystic periventricular leukomalacia (PVL) is the most common white matter injury and a common cause of cerebral palsy in preterm infants. Postnatal epilepsy may occur after cystic PVL, but their causal relationship remains uncertain. Our aim was to validate the contribution of cystic PVL to postnatal epilepsy in very preterm infants and demonstrate their seizure characteristics.

METHODS

This prospective cohort study enrolled 1,342 preterm infants (birth weight <1,500 g and gestational age <32 weeks) from 2003 to 2015. Cystic PVL was diagnosed by serial cerebral ultrasound, and other comorbidities were recorded during hospitalization. Neurological developments and consequences, including epilepsy, were serially accessed until the age of 5.

RESULTS

A total of 976 preterm infants completed a 5-year neurological follow-up; 47 (4.8%) had cystic PVL. Preterm infants with cystic PVL were commonly associated with other comorbidities, including necrotizing enterocolitis stage III, neonatal seizures, and intraventricular hemorrhage during hospitalization. At age 5, 14 of the 47 (29.8%) preterm infants with cystic PVL had postnatal epilepsy. After adjusting for gender, gestational age, and three common comorbidities, cystic PVL was an independent risk factor for postnatal epilepsy (adjust OR: 16.2; 95% CI: 6.8-38.4; p < 0.001). Postnatal epilepsy after cystic PVL was commonly the generalized type (13 of 14, 92.9%), not intractable and most occurred after 1 year of age.

DISCUSSION/CONCLUSION

Cystic PVL would independently lead to postnatal epilepsy. Preterm infants with cystic PVL are at risk of postnatal epilepsy after age 1 in addition to cerebral palsy.

Brain magnetic resonance imaging findings and brain volumetric differences in a large series of benign rolandic epilepsy

BACKGROUND

Several studies with a small sample size have investigated the relationship between structural and functional changes on MRI and the clinical and natural history of BRE. We aim to assess the frequency of incidental epileptogenic lesions on brain MRI in a large cohort of patients diagnosed with BRE and to assess the difference in volumetric brain measurements in BRE patients compared to healthy controls.

METHODS

The case-control study includes 214 typical BRE cases and 197 control children with non-epileptic spells. Brain MRIs were evaluated for abnormalities which were classified into normal and abnormal with or without epileptogenic lesions with categorization of epileptogenic lesions. Brain segmentation was also performed for a smaller group of BRE patients and another healthy control group. Pearson's chi-squared test and two-tailed independent samples t-test were used.

RESULTS

In patients with BRE, 7% had an epileptogenic lesion on their MRI. The frequency of epileptogenic lesion in the control group was 10.2% and not significantly different from those with BRE (p= 0.2). Significantly higher intracranial and white matter volumes were found in BRE patients compared to the healthy group while lower gray matter volume was found in BRE patients. Cortical and subcortical regions showed either higher or lower volumes with BRE. Interestingly, altered subcallosal cortex development which has a known association with depression was also found in BRE.

CONCLUSIONS

Our findings confirm the absence of any association between specific brain MRI abnormalities and BRE. However, the altered cortical and subcortical development in BRE patients suggests a microstructural-functional correlation.

Periventricular hypodensity is associated with the incidence of pre-shunt seizure in hydrocephalic children

BACKGROUND

The seizure incidence in hydrocephalic children has been acknowledged in a lot of studies previously; nonetheless, seizure pathogenesis in these children remains unclear. Its high proportion of hydrocephalic children who underwent shunt surgery suggests that the seizure might be associated with the protocol of shunt placement and/or the shunt existence intracranially; however, this hypothesis could not explain the pre-shunt seizure incidence in hydrocephalic children.

OBJECTIVE

This study aims to evaluate the patients' characteristics and CT findings in pre-shunt hydrocephalic children to identify the possible seizure etiology in these patients.

METHODS

Three hundred and thirty-four children with hydrocephalus were included in this study, including 147 hydrocephalic children with the pre-shunt seizure history and 187 hydrocephalic children presented without the pre-shunt seizure history. The following information was retrieved from the patients' medical records: gender, age, pediatric Glasgow Coma Scale (pGCS) upon admission, and hydrocephalus diagnoses. CT findings were re-evaluated to assess the compression association of sulci and gyri, Sylvian fissures, cisterns, FH/ID ratio, Evan's ratio, and periventricular hypodensity with pre-shunt seizure.

RESULTS

The results show that the pre-shunt seizure incidence is significantly higher in hydrocephalic children aged 1 to 5 years old (63/113 (55%), p = 0.0001), diagnosed with communicating hydrocephalus (97/163 (59%), p = 0.0001) or infectious hydrocephalus (80/109 (73%), p = 0.0001). The presence of periventricular hypodensity is significantly associated with the pre-shunt seizure incidence (132/205 (64.3%), p = 0.0001). Results from univariate analyses suggest significant association between periventricular hypodensity in every location and pre-shunt seizure (p < 0.0001). Multivariate analyses identify that temporal horn in the right lateral ventricle as the location of periventricular hypodensity has the strongest association with the pre-shunt seizure.

CONCLUSION

The presence of periventricular hypodensity in head CT scan is significantly associated with the pre-shunt seizure incidence. Further investigation to confirm this finding and evaluate the possible roles of inflammation in the pre-shunt seizure in hydrocephalic children is important to seek its possible implication on the treatment of pre-shunt seizure in these children.

A myriad spectrum of seizures on magnetic resonance imaging - A pictorial essay

Patients with seizures represent a challenging clinical population both in pediatrics and adults. Accurate diagnosis of the cause of a seizure is important in choosing an effective treatment modality, surgical planning, predicting a prognosis, and follow-up. Magnetic resonance (MR) imaging using a dedicated epilepsy protocol plays a key role in the workup of these patients. Additional MR techniques such as T2 relaxometry and MR spectroscopy show a promising role to arrive at a final diagnosis. The spectrum of epileptogenic causes is broad. Radiologists and physicians need to be updated and require a patterned approach in light of clinical history and electroencephalogram findings to arrive at a reasonable differential diagnosis. This pictorial essay aims to review a few of the common and uncommon causes of seizures and their imaging features.

Evaluation of different ulegyria patterns with magnetic resonance imaging

Ulegyria is a parenchymal sequel of hypoxic ischemic encephalopathy causing mushroom-like appearance in gyri. Aim of the present study was to evaluate clinico-radiological findings of patients who applied with different clinical features, predominantly epilepsy, and who were found to have ulegyria formations in MRI examinations. The study included a total of 30 patients (12 female and 18 male) who applied with different types of seizures in February 2011-August 2016 period and had brain MRI examinations using 1.5T MRI scanner. Mushroom-shaped gyri accompanied by gliosis and atrophy in subcortical white matter were considered ulegyria. Locations, MRI features and accompanying pathologies of ulegyria formations were studied. Age of the patients ranged from 4 to 62 (mean 26.0 ± 13.8). Both cerebral lobes were involved in 18 patients. In terms of involved area, symmetrical or asymmetrical involvements were observed in occipital lobes in 26 patients, parietal lobes in 19, frontal lobes in 12 and temporal lobes in 4. The most common involvement type was bilateral occipital and bilateral parieto-occipital lobe involvements with five patients each. Lesions were symmetrical in 11 patients. Six patients had cingulate gyrus atrophy. Nineteen patients had different levels of symmetrical or asymmetrical ventricular dilatation. Cranial asymmetry was observed in six patients with unilateral involvement and in one patient with generalized involvement. Although ulegyria predominantly involves parasagittal watershed areas in MRI examinations of patients applying with epilepsy, clinical manifestations and appearance of lesions could vary depending upon the size of involved area and level of injury.

Punctate white matter lesions in full-term infants with neonatal seizures associated with SLC13A5 mutations

INTRODUCTION

Early-onset epileptic encephalopathy caused by biallelic SLC13A5 mutations is characterized by seizure onset in the first days of life, refractory epilepsy and developmental delay. Little detailed information about the brain MRI features is available in these patients.

METHODS

Observational study describing the neuro-imaging findings in eight patients (five families) with mutations in the SLC13A5 gene. Seven infants had an MRI in the neonatal period, two had a follow-up MRI at the age of 6 and 18 months and one only at 13 months. One patient had follow-up MRIs at 11 and 16 months and 3 and 6 years of age, but no neonatal MRI.

RESULTS

All patients presented with refractory neonatal seizures on the first day of life after an uncomplicated pregnancy and term delivery. Six out of seven infants with a neonatal MRI had a characteristic MRI pattern, with punctate white matter lesions (PWML), which were no longer visible at the age of 6 months, but led to gliotic scarring visible on MRI at the age of 18 months. The same pattern of gliotic scarring was seen on the MRIs of the infant without a neonatal scan. One infant had signal abnormalities in the white matter suspected of PWML on T2WI, but these could not be confirmed on other sequences.

CONCLUSION

In infants presenting with therapy resistant seizures in the first days after birth, without a clear history of hypoxic-ischemic encephalopathy, but with PWML on their neonatal MRI, a diagnosis of SCL13A5 related epileptic encephalopathy should be considered.

Risk factors following first spontaneous epileptic seizure in children below 3 years of age

AIM OF THE STUDY

To assess the recurrence rate after the first spontaneous epileptic seizure in pediatric patients, and determine the related risk factors.

MATERIALS AND METHODS

Data from 190 infants (aged between one month and three years) admitted after first spontaneous epileptic seizure to Soochow University Affiliated Children's Hospital between April 2009 and April 2011 were retrospectively analyzed; patients were followed up until April 2014. The recurrence rate and risk factors of recurrence were analyzed based on central nervous system imaging data (computed tomography or magnetic resonance imaging), electroencephalogram (EEG) and developmental quotient assessment.

RESULTS

Of the 190 infants, 11 cases (5.79%) were lost to follow-up. The cumulative recurrence rate of spontaneous epileptic seizure after five years was 52%. A total of 82% recurrence cases occurred within the first year. Age > 24 months (odds ratio (OR) = 0.498༌95% confidence interval (CI): 0.285-0.869) was an independent protective factor, while symptomatic seizure (OR = 1.624, 95% CI: 1.020-2.587), seizure during sleep (OR = 2.779, 95% CI: 1.757-4.397) and epileptic discharge in EEG (OR=3.269, 95% CI: 2.049-5.217) were independent risk factors.

CONCLUSION

Recurrence rate is high in infants after the first spontaneous epileptic seizure, and recurrence is more likely to occur within one year.