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Specchio N, Wirrell EC, Scheffer IE, Nabbout R, Riney K, Samia P, Guerreiro M, Gwer S, Zuberi SM, Wilmshurst JM, Yozawitz E, Pressler R, Hirsch E, Wiebe S, Cross HJ, Perucca E, Moshé SL, Tinuper P, Auvin S. International League Against Epilepsy classification and definition of epilepsy syndromes with onset in childhood: Position paper by the ILAE Task Force on Nosology and Definitions. Epilepsia 2022; 63:1398-1442. [PMID: 35503717 DOI: 10.1111/epi.17241] [Citation(s) in RCA: 265] [Impact Index Per Article: 132.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2021] [Revised: 03/16/2022] [Accepted: 03/17/2022] [Indexed: 12/30/2022]
Abstract
The 2017 International League Against Epilepsy classification has defined a three-tier system with epilepsy syndrome identification at the third level. Although a syndrome cannot be determined in all children with epilepsy, identification of a specific syndrome provides guidance on management and prognosis. In this paper, we describe the childhood onset epilepsy syndromes, most of which have both mandatory seizure type(s) and interictal electroencephalographic (EEG) features. Based on the 2017 Classification of Seizures and Epilepsies, some syndrome names have been updated using terms directly describing the seizure semiology. Epilepsy syndromes beginning in childhood have been divided into three categories: (1) self-limited focal epilepsies, comprising four syndromes: self-limited epilepsy with centrotemporal spikes, self-limited epilepsy with autonomic seizures, childhood occipital visual epilepsy, and photosensitive occipital lobe epilepsy; (2) generalized epilepsies, comprising three syndromes: childhood absence epilepsy, epilepsy with myoclonic absence, and epilepsy with eyelid myoclonia; and (3) developmental and/or epileptic encephalopathies, comprising five syndromes: epilepsy with myoclonic-atonic seizures, Lennox-Gastaut syndrome, developmental and/or epileptic encephalopathy with spike-and-wave activation in sleep, hemiconvulsion-hemiplegia-epilepsy syndrome, and febrile infection-related epilepsy syndrome. We define each, highlighting the mandatory seizure(s), EEG features, phenotypic variations, and findings from key investigations.
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Affiliation(s)
- Nicola Specchio
- Rare and Complex Epilepsy Unit, Department of Neuroscience, Bambino Gesù Children's Hospital, Scientific Institute for Research and Health Care, Full Member of EpiCARE, Rome, Italy
| | - Elaine C Wirrell
- Divisions of Child and Adolescent Neurology and Epilepsy, Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | - Ingrid E Scheffer
- Austin Health and Royal Children's Hospital, Florey Institute, Murdoch Children's Research Institute, University of Melbourne, Melbourne, Victoria, Australia
| | - Rima Nabbout
- Reference Center for Rare Epilepsies, Department of Pediatric Neurology, Necker-Sick Children Hospital, Public Hospital Network of Paris, member of EpiCARE, Imagine Institute, National Institute of Health and Medical Research, Mixed Unit of Research 1163, University of Paris, Paris, France
| | - Kate Riney
- Neurosciences Unit, Queensland Children's Hospital, South Brisbane, Queensland, Australia.,Faculty of Medicine, University of Queensland, South Brisbane, Queensland, Australia
| | - Pauline Samia
- Department of Pediatrics and Child Health, Aga Khan University, Nairobi, Kenya
| | | | - Sam Gwer
- School of Medicine, Kenyatta University, and Afya Research Africa, Nairobi, Kenya
| | - Sameer M Zuberi
- Paediatric Neurosciences Research Group, Royal Hospital for Children and Institute of Health & Wellbeing, member of EpiCARE, University of Glasgow, Glasgow, UK
| | - Jo M Wilmshurst
- Department of Paediatric Neurology, Red Cross War Memorial Children's Hospital, Neuroscience Institute, University of Cape Town, Cape Town, South Africa
| | - Elissa Yozawitz
- Isabelle Rapin Division of Child Neurology of the Saul R. Korey Department of Neurology, Montefiore Medical Center, Bronx, New York, USA
| | - Ronit Pressler
- Programme of Developmental Neurosciences, University College London National Institute for Health Research Biomedical Research Centre Great Ormond Street Institute of Child Health, Department of Clinical Neurophysiology, Great Ormond Street Hospital for Children, London, UK
| | - Edouard Hirsch
- Neurology Epilepsy Units "Francis Rohmer", INSERM 1258, FMTS, Strasbourg University, Strasbourg, France
| | - Sam Wiebe
- Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
| | - Helen J Cross
- Programme of Developmental Neurosciences, University College London National Institute for Health Research Biomedical Research Centre Great Ormond Street Institute of Child Health, Great Ormond Street Hospital for Children, and Young Epilepsy Lingfield, London, UK
| | - Emilio Perucca
- Department of Neuroscience, Monash University, Melbourne, Victoria, Australia.,Department of Medicine, Austin Health, University of Melbourne, Heidelberg, Victoria, Australia
| | - Solomon L Moshé
- Isabelle Rapin Division of Child Neurology, Saul R. Korey Department of Neurology, and Departments of Neuroscience and Pediatrics, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, New York, USA
| | - Paolo Tinuper
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy.,Institute of Neurological Sciences, Scientific Institute for Research and Health Care, Bologna, Italy
| | - Stéphane Auvin
- Robert Debré Hospital, Public Hospital Network of Paris, NeuroDiderot, National Institute of Health and Medical Research, Department Medico-Universitaire Innovation Robert-Debré, Pediatric Neurology, University of Paris, Paris, France
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Owusu BA. Perceived causes and diagnosis of febrile convulsion in selected rural contexts in Cape Coast Metropolis, Ghana. BMC Pediatr 2022; 22:45. [PMID: 35042467 PMCID: PMC8764833 DOI: 10.1186/s12887-022-03106-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Accepted: 12/29/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Febrile convulsion (FC) is a common seizure disorder among children aged 9 months to 5 years. It is usually benign and self-limiting with favourable prognosis. However, in Ghana, FC is commonly perceived as "not for hospital" and widely diagnosed and managed at home based on several beliefs and practices which are limited in related literature. OBJECTIVE This study explored the perceived causes and diagnosis of FC in selected rural communities in the Cape Coast Metropolis, Ghana. METHODS A descriptive phenomenological study design underpinned the study at five selected communities located not more than 2 Kilometres from the University of Cape Coast Hospital. Purposive and snowball sampling techniques were used to interview 42 participants made up of 27 parents, two grandmothers, seven registered traditional health practitioners, four herbalists, and two faith healers in the communities. The data was analysed using QSR NVivo 12. RESULTS Three perceived causes of FC were identified - biological, social/behavioural, and spiritual. Biological causes include genetic abnormalities and other underlying health conditions. The behavioural factors include poor childcare practices and nutrition. Spiritual causes include harm caused by evil spirits. The diagnosis of FC were observed prior, during and after FC attack, and these includes high body temperature, extreme body jerking, and disability outcomes respectively. CONCLUSION The perceived causes of FC are interplay of complex natural, social and spiritual factors that were deep-rooted in local socio-cultural beliefs and FC experiences. Unlike the attack stage, pre-attack diagnosis were usually missed, or misconstrued to mean other health conditions. These findings indicate the need to intensify maternal and child health (MCH) education programmes on FC in the study area through improved primary healthcare.
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Affiliation(s)
- Bernard Afriyie Owusu
- Master of Philosophy, Department of Population and Health, University of Cape Coast, Cape Coast, Ghana.
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Adult occipital lobe epilepsy: 12-years on. J Neurol 2021; 268:3926-3934. [PMID: 33900448 DOI: 10.1007/s00415-021-10557-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 04/05/2021] [Accepted: 04/09/2021] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Occipital lobe epilepsies (OLE) comprise 5-10% of focal epilepsies in surgical and paediatric series; with little data from adult medical cohorts. This longitudinal study examined OLE patients, to characterise prevalence, semiology, co-morbidity and prognosis in a neurology outpatient setting. METHODS 24 adult OLE patients identified over 12 months from 1548 patients in a neurologist's service were followed over 12 years. RESULTS 92% of these OLE patients had simple visual hallucinations, misdiagnosed in 40% of cases. 75% had co-morbid interictal migraine and 38% had visual field defects. Only 33% achieved long-term remission, and only 2 /10 (20%) of OLE patients with a structural aetiology were seizure-free. The two patients with migralepsy achieved remission. CONCLUSION Adult OLE accounted for 7.7% of focal epilepsies in this cohort, misdiagnosed or misclassified in 40%. Most patients had co-existing migraine. A minority had migralepsy characterised by a longer aura and good prognosis. Remission rates were lower than that of childhood OLE and general adult epilepsy populations, strengthening the argument for considering epilepsy surgery in drug-resistant OLE patients with a structural cause. Precision medicine will potentially refine diagnosis and management in those OLE patients without an identified cause but is predicated on accurate clinical phenotyping.
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Andrade-Machado R, Benjumea Cuartas V, Muhammad IK. Recognition of interictal and ictal discharges on EEG. Focal vs generalized epilepsy. Epilepsy Behav 2021; 117:107830. [PMID: 33639439 DOI: 10.1016/j.yebeh.2021.107830] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 01/23/2021] [Accepted: 01/26/2021] [Indexed: 01/17/2023]
Abstract
INTRODUCTION The differentiation between focal and generalized epilepsies based on clinical and electroencephalographic features is difficult and sometimes confusing. OBJECTIVE To review the EEG findings in patients with focal epilepsy. METHODS An extensive literature review was done. We used the following Pubmed and Medline descriptors alone and in different combinations for database searching: focal, partial, epilepsy, electroencephalographic findings, and EEG. Additional filters included review, original articles, and language limited to Spanish and English. Using the above criteria, a total of 69 articles showed the interictal and ictal EEG findings in focal epilepsy. DEVELOPMENT Focal epileptiform discharges and persistence of focal abnormalities, characterize the interictal EEG findings in focal epilepsies. To distinguish SBS from primary generalized spike waves are required to note: (a) a lead-in time of at least 2 s, (b) the morphology of the focal triggering spikes clearly differ from that of the bisynchronous epileptiform paroxysms, and (c) the morphology of triggering spikes resemble that of other focal spikes from the same region. Focal and Generalized Epilepsy can coexist. Delayed Lateralization on EEG with inconclusive onset and bizarre semiology confusing semiology should not be confused with generalized onset seizures with focal evolution. CONCLUSIONS A close attention to localization and morphology of epileptiform discharges, the correct interpretation of secondary bilateral synchrony, and provocative maneuvers help to correctly identify the EEG findings leading to diagnose focal epilepsies. The presence of generalized epileptiform activity does not rule out the existence of a focal epilepsy.
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Rudolf G, de Bellescize J, de Saint Martin A, Arzimanoglou A, Valenti Hirsch MP, Labalme A, Boulay C, Simonet T, Boland A, Deleuze JF, Nitschké P, Ollivier E, Sanlaville D, Hirsch E, Chelly J, Lesca G. Exome sequencing in 57 patients with self-limited focal epilepsies of childhood with typical or atypical presentations suggests novel candidate genes. Eur J Paediatr Neurol 2020; 27:104-110. [PMID: 32600977 DOI: 10.1016/j.ejpn.2020.05.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Revised: 03/24/2020] [Accepted: 05/10/2020] [Indexed: 10/24/2022]
Abstract
OBJECTIVE Self-limited focal epilepsies of childhood (SFEC) are amongst the best defined and most frequent epilepsy syndromes affecting children with usually normal developmental milestones. They include core syndromes such as Rolandic epilepsy or "Benign" epilepsy with Centro-Temporal Spikes and the benign occipital epilepsies, the early onset Panayiotopoulos syndrome and the late-onset Gastaut type. Atypical forms exist for all of them. Atypical Rolandic epilepsies are conceptualized as belonging to a continuum reaching from the "benign" RE to the severe end of the Landau-Kleffner (LKS) and Continuous Spike-Waves during Sleep syndromes (CSWS). GRIN2A has been shown to cause the epilepsy-aphasia continuum that includes some patients with atypical Rolandic epilepsy with frequent speech disorders, LKS and CSWS. In the present study, we searched novel genes causing SFEC with typical or atypical presentations. METHODS Exome sequencing was performed in 57 trios. Patients presented with typical or atypical SFEC, negative for GRIN2A pathogenic variant. RESULTS We found rare candidate variants in 20 patients. Thirteen had occurred de novo and were mostly associated to atypical Rolandic Epilepsy. Two of them could be considered as disease related: a null variant in GRIN2B and a missense variant in CAMK2A. Others were considered good candidates, including a substitution affecting a splice site in CACNG2 and missense variants in genes encoding enzymes involved in chromatin remodeling. SIGNIFICANCE Our results further illustrate the fact that atypical SFEC are more likely to have Mendelian inheritance than typical SFEC.
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Affiliation(s)
- Gabrielle Rudolf
- Institut de Génétique et de Biologie Moléculaire et Cellulaire (IGBMC), CNRS U 7104 - Inserm U1258, Illkirch, France; Université de Strasbourg, France; Department of Neurology, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Julitta de Bellescize
- Department of Paediatric Clinical Epileptology, Sleep Disorders and Functional Neurology, Member of the ERN EpiCARE, University Hospitals of Lyon, Lyon, France
| | - Anne de Saint Martin
- Institut de Génétique et de Biologie Moléculaire et Cellulaire (IGBMC), CNRS U 7104 - Inserm U1258, Illkirch, France; Department of Pediatrics, Pediatric Neurology, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Alexis Arzimanoglou
- Department of Paediatric Clinical Epileptology, Sleep Disorders and Functional Neurology, Member of the ERN EpiCARE, University Hospitals of Lyon, Lyon, France
| | | | - Audrey Labalme
- Department of Medical Genetics, Member of the ERN EpiCARE, University Hospital of Lyon, Lyon, France
| | - Clotilde Boulay
- Institut de Génétique et de Biologie Moléculaire et Cellulaire (IGBMC), CNRS U 7104 - Inserm U1258, Illkirch, France; Université de Strasbourg, France; Department of Neurology, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Thomas Simonet
- Department of Cell Biotechnology, University Hospital of Lyon, Lyon, France; Institut NeuroMyoGène, CNRS UMR 5310 - INSERM U1217, Lyon, France
| | - Anne Boland
- Centre National de Recherche en Génomique Humaine (CNRGH), Institut de Biologie François Jacob, Université Paris Saclay, CEA, 91057, Evry, France
| | - Jean François Deleuze
- Centre National de Recherche en Génomique Humaine (CNRGH), Institut de Biologie François Jacob, Université Paris Saclay, CEA, 91057, Evry, France
| | - Patrick Nitschké
- Institut Imagine, Bioinformatic Platform, Université Paris Descartes, Paris, France
| | - Emmanuelle Ollivier
- Institut Imagine, Bioinformatic Platform, Université Paris Descartes, Paris, France
| | - Damien Sanlaville
- Department of Medical Genetics, Member of the ERN EpiCARE, University Hospital of Lyon, Lyon, France; Institut NeuroMyoGène, CNRS UMR 5310 - INSERM U1217, Lyon, France; Université de Lyon - Université Claude Bernard Lyon 1, Lyon, France
| | - Edouard Hirsch
- Institut de Génétique et de Biologie Moléculaire et Cellulaire (IGBMC), CNRS U 7104 - Inserm U1258, Illkirch, France; Université de Strasbourg, France; Department of Neurology, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Jamel Chelly
- Institut de Génétique et de Biologie Moléculaire et Cellulaire (IGBMC), CNRS U 7104 - Inserm U1258, Illkirch, France; Université de Strasbourg, France; Laboratory of Medical Genetics, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Gaetan Lesca
- Department of Medical Genetics, Member of the ERN EpiCARE, University Hospital of Lyon, Lyon, France; Institut NeuroMyoGène, CNRS UMR 5310 - INSERM U1217, Lyon, France; Université de Lyon - Université Claude Bernard Lyon 1, Lyon, France.
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Graziosi A, Pellegrino N, Di Stefano V, Raucci U, Luchetti A, Parisi P. Misdiagnosis and pitfalls in Panayiotopoulos syndrome. Epilepsy Behav 2019; 98:124-128. [PMID: 31369969 DOI: 10.1016/j.yebeh.2019.07.016] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2019] [Revised: 07/04/2019] [Accepted: 07/04/2019] [Indexed: 11/19/2022]
Abstract
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.
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Affiliation(s)
| | - Noemi Pellegrino
- Department of Pediatrics, "G. d'Annunzio" University, Chieti, Italy
| | - Vincenzo Di Stefano
- Department of Neuroscience, Imaging and Clinical Sciences, "G. d'Annunzio" University, Chieti, Italy
| | - Umberto Raucci
- Pediatric Emergency Department, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Anna Luchetti
- Child Neurology, NESMOS Department, Faculty of Medicine & Psychology, "Sapienza" University, c/o Sant'Andrea Hospital, Rome, Italy
| | - Pasquale Parisi
- Child Neurology, NESMOS Department, Faculty of Medicine & Psychology, "Sapienza" University, c/o Sant'Andrea Hospital, Rome, Italy.
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Funata K, Shike T, Takenouchi T, Yamashita Y, Takahashi T. Respiratory arrest at the onset of idiopathic childhood occipital epilepsy of Gastaut. Brain Dev 2018; 40:74-76. [PMID: 28734692 DOI: 10.1016/j.braindev.2017.06.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Revised: 06/28/2017] [Accepted: 06/30/2017] [Indexed: 12/01/2022]
Abstract
Occipital lobe epilepsy of childhood includes two entities: Panayiotopoulos syndrome in pre-school children, and idiopathic childhood occipital epilepsy of Gastaut (ICOEG) in school-age children. The typical initial manifestation of the former is vomiting, and that of the latter is visual hallucinations. Ictal cardiopulmonary arrest at initial presentation has been reported for Panayiotopoulos syndrome, but not for ICOEG. We document a 7-year-old previously healthy girl who experienced an acute elemental visual hallucination of seeing insects, followed by a new-onset generalized seizure. Upon arrival at the local hospital, she was unconscious and soon thereafter, developed respiratory arrest. She was resuscitated and initiated on mechanical ventilation. An electroencephalogram taken three days after seizure cessation showed frequent occipital spikes, consistent with the diagnosis of ICOEG. The sequence of acute elementary visual hallucination followed by a motor seizure, and then witnessed respiratory arrest illustrated occurrence of life-threatening autonomic involvement at initial onset in ICOEG. We speculate that the epileptic propagation from the occipital lobes eventually compromised the respiratory center in the brainstem. The possibility of occipital lobe epilepsy should be considered in school-age children presenting with acute visual hallucination followed by respiratory arrest. Such a presentation should prompt an urgent electroencephalogram and initiation of antiepileptic treatment if indicated.
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Affiliation(s)
- Keiko Funata
- Department of Pediatrics, Yokohama Municipal Citizen's Hospital, Kanagawa, Japan
| | - Tatsuhiko Shike
- Department of Pediatrics, Yokohama Municipal Citizen's Hospital, Kanagawa, Japan
| | - Toshiki Takenouchi
- Department of Pediatrics, Keio University School of Medicine, Tokyo, Japan.
| | - Yukio Yamashita
- Department of Pediatrics, Yokohama Municipal Citizen's Hospital, Kanagawa, Japan
| | - Takao Takahashi
- Department of Pediatrics, Keio University School of Medicine, Tokyo, Japan
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Chen S, Chen Z, Wang S, Wu T, Zhou D, Li Q, Cotton J. Treatments for the idiopathic occipital lobe epilepsies. Hippokratia 2017. [DOI: 10.1002/14651858.cd012895] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Affiliation(s)
- Shengmei Chen
- The First Affiliated Hospital of Hainan Medical University; Department of Neurology; Haikou China
| | - Zhibin Chen
- The First Affiliated Hospital of Hainan Medical University; Department of Neurology; Haikou China
| | - Shurong Wang
- The First Affiliated Hospital of Hainan Medical University; Department of Neurology; Haikou China
| | - Taixiang Wu
- West China Hospital, Sichuan University; Chinese Clinical Trial Registry, Chinese Ethics Committee of Registering Clinical Trials; No. 37, Guo Xue Xiang Chengdu Sichuan China 610041
| | - Dong Zhou
- West China Hospital, Sichuan University; Department of Neurology; No. 37, Guo Xue Xiang Chengdu Sichuan China 610041
| | - Qifu Li
- The First Affiliated Hospital of Hainan Medical University; Department of Neurology; Haikou China
| | - Jennifer Cotton
- The Clatterbridge Cancer Centre NHS Foundation Trust; Wirral UK
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Yalçın AD, Ertaşoğlu Toydemir H. Panayiotopoulos Syndrome with a special emphasis of ictal semiologic features. Epilepsy Res 2017; 131:37-43. [PMID: 28236737 DOI: 10.1016/j.eplepsyres.2017.02.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2016] [Revised: 12/27/2016] [Accepted: 02/14/2017] [Indexed: 11/24/2022]
Abstract
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.
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Affiliation(s)
- A Destina Yalçın
- Sişli Etfal Training and Research Hospital, Department of Neurology, Istanbul, Turkey(1); Umraniye Training and Research Hospital, Department of Neurology, Istanbul, Turkey
| | - Hülya Ertaşoğlu Toydemir
- Sişli Etfal Training and Research Hospital, Department of Neurology, Istanbul, Turkey(1); Bakırköy Dr. Sadi Konuk Training and Research Hospital, Department of Neurology, Istanbul, Turkey.
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Meletti S, Ruggieri A, Avanzini P, Caramaschi E, Filippini M, Bergonzini P, Monti G, Vignoli A, Olivotto S, Mastrangelo M, Santucci M, Gobbi G, Veggiotti P, Vaudano AE. Extrastriate visual cortex in idiopathic occipital epilepsies: The contribution of retinotopic areas to spike generation. Epilepsia 2016; 57:896-906. [PMID: 27093945 DOI: 10.1111/epi.13385] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/16/2016] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To provide insight into the pathophysiology of idiopathic childhood occipital epilepsies (ICOEs), by mapping the contribution of retinotopic visual areas to the generation and sustainment of epileptic activity. METHODS Thirteen patients affected by ICOEs (mean age = 10.9 years) underwent a video electroencephalography-functional magnetic resonance imaging (EEG-fMRI) study. A flexible-related fMRI analysis was applied to estimate the shape of the blood oxygen level-dependent (BOLD) response in each patient. Second-level analysis was performed using the interictal EEG discharge (IED)-specific response shape for the ICOE group. The resulting fMRI t-maps were warped to the Population-Average, Landmark- and Surface-based (PALS)-B12 atlas in Caret. For localization purposes, functional results were plotted and compared against 19 retinotopic areas for each hemisphere. A correlation analysis was performed between the hemodynamic maps and electroclinical variables. RESULTS The shape of the group-averaged hemodynamic response in ICOE patients showed an earlier time-to-peak and a more pronounced undershoot than the canonical hemodynamic response function (HRF). The random-effect analysis showed positive hemodynamic changes in the bilateral temporooccipital network. With regard to the retinotopic subdivision of the visual cortex, the primary visual area was consistently spared. Conversely, an extensive involvement of the occipitotemporal cortex, including the fusiform gyrus, and the occipitoparietal areas was observed. Moreover, a linear relationship was detected between the occipital spike-density and BOLD increases at the postcentral gyrus and temporooccipital cortex. SIGNIFICANCE Our data indicate that both the ventral and dorsal visual pathways are involved in spike generation in ICOEs, to extents that vary between patients, and reinforce the concept of benign childhood seizure susceptibility syndrome as a substrate for ICOEs. Finally, these results underscore the need for appropriate neuropsychological testing in these children, aimed at revealing selective impairments in functions subserved by both visual pathways.
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Affiliation(s)
- Stefano Meletti
- Department of Biomedical, Metabolic, and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy.,Neurology Unit, NOCSAE Hospital, AUSL Modena, Modena, Italy
| | - Andrea Ruggieri
- Department of Biomedical, Metabolic, and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Pietro Avanzini
- Department of Neuroscience, University of Parma, Parma, Italy
| | | | - Melissa Filippini
- Child Neuropsychiatry Unit, IRCCS, Institute of Neurological Sciences, Bellaria Hospital, Bologna, Italy
| | | | - Giulia Monti
- Department of Biomedical, Metabolic, and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy.,Neurology Unit, NOCSAE Hospital, AUSL Modena, Modena, Italy
| | - Aglaia Vignoli
- Department of Health Sciences, University of Milano, Milano, Italy
| | - Sara Olivotto
- Brain and Behavior Department, University of Pavia, Pavia, Italy
| | | | - Margherita Santucci
- IRCCS Institute of Neurological Sciences, Bellaria Hospital, AUSL of Bologna, Bologna, Italy.,Department of Biomedical and Neuromotor Science, University of Bologna, Bologna, Italy
| | - Giuseppe Gobbi
- Child Neuropsychiatry Unit, IRCCS, Institute of Neurological Sciences, Bellaria Hospital, Bologna, Italy
| | - Pierangelo Veggiotti
- Brain and Behavior Department, University of Pavia, Pavia, Italy.,Department of Child Neurology and Psychiatry C. Mondino, National Neurological Institute, University of Pavia, Pavia, Italy
| | - Anna Elisabetta Vaudano
- Department of Biomedical, Metabolic, and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy.,Neurology Unit, NOCSAE Hospital, AUSL Modena, Modena, Italy
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Sowell MK, Youssef PE. The Comorbidity of Migraine and Epilepsy in Children and Adolescents. Semin Pediatr Neurol 2016; 23:83-91. [PMID: 27017028 DOI: 10.1016/j.spen.2016.01.012] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Migraine and epilepsy share a number of clinical attributes, including pathophysiology and clinical expression. Both are paroxysmal in nature and thus constitute episodic disorders, yet either may be chronic and/or recurrent. Epileptic seizures and migraine headaches may be mistaken one for the other and may even overlap. In particular, occipital lobe seizures may be misdiagnosed as migraine auras. In this article, we review the relationship between migraine and epilepsy, including the known genetic contributions to both conditions, prodromal, ictal, and postictal headache and shared pathophysiology and treatment options. We describe clinical conditions in which both migraine and epilepsy are prominent features. Lastly, we discuss electronecephaographic abnormalities that have been known to occur in individuals with migraine.
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Affiliation(s)
- Michael K Sowell
- Department of Neurology, University of Louisville School of Medicine, Louisville, KY.
| | - Paul E Youssef
- Division of Child and Adolescent Neurology, Mayo Clinic Rochester, Rochester, MN
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12
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Saitowitz Z, Flamini R, Berenson F. Ictal Epileptic Headache: A Review of Current Literature and Differentiation From Migralepsy and Other Epilepsies. Headache 2014; 54:1534-40. [DOI: 10.1111/head.12432] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/20/2014] [Indexed: 12/01/2022]
Affiliation(s)
| | - Robert Flamini
- Pediatric and Adolescent Neurodevelopmental Associates; Atlanta GA USA
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13
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Değerliyurt A, Teber S, Bektaş O, Senkon G. Panayiotopoulos syndrome: a case series from Turkey. Epilepsy Behav 2014; 36:24-32. [PMID: 24840752 DOI: 10.1016/j.yebeh.2014.04.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2014] [Revised: 04/17/2014] [Accepted: 04/21/2014] [Indexed: 10/25/2022]
Abstract
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.
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Affiliation(s)
- Aydan Değerliyurt
- Department of Pediatric Neurology, Ankara Pediatrics, Hematology-Oncology Training and Research Hospital, Ankara, Turkey.
| | - Serap Teber
- Department of Pediatric Neurology, Ankara Pediatrics, Hematology-Oncology Training and Research Hospital, Ankara, Turkey
| | - Omer Bektaş
- Department of Pediatric Neurology, Ankara Pediatrics, Hematology-Oncology Training and Research Hospital, Ankara, Turkey
| | - Gözde Senkon
- Department of Pediatrics, Ankara Pediatrics, Hematology-Oncology Training and Research Hospital, Ankara, Turkey
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Bonini F, Egeo G, Fattouch J, Fanella M, Morano A, Giallonardo AT, di Bonaventura C. Natural evolution from idiopathic photosensitive occipital lobe epilepsy to idiopathic generalized epilepsy in an untreated young patient. Brain Dev 2014; 36:346-50. [PMID: 23815968 DOI: 10.1016/j.braindev.2013.06.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2013] [Revised: 05/29/2013] [Accepted: 06/04/2013] [Indexed: 12/01/2022]
Abstract
Idiopathic photosensitive occipital lobe epilepsy (IPOE) is an idiopathic localization-related epilepsy characterized by age-related onset, specific mode of precipitation, occipital photic-induced seizures--frequently consisting of visual symptoms--and good prognosis. This uncommon epilepsy, which usually starts in childhood or adolescence, has rarely been observed in families in which idiopathic generalized epilepsy also affects other members. We describe a nuclear family in which the proband showed electro-clinical features of idiopathic photosensitive occipital lobe epilepsy in childhood, which subsequently evolved into absences and a single generalized tonico-clonic seizure in early adolescence. His mother had features suggestive of juvenile myoclonic epilepsy. This case illustrates a continuum between focal and generalized entities in the spectrum of the so-called idiopathic (genetically determined) epileptic syndromes.
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Affiliation(s)
- Francesca Bonini
- Institut de Neurosciences des Systèmes, INSERM UMR 1106, Aix-Marseille Université, Marseille, France.
| | - Gabriella Egeo
- Neurology Unit, Department of Neuroscience, "Sapienza" University, Rome, Italy; San Raffaele Pisana, IRCCS, Rome, Italy
| | - Jinan Fattouch
- Neurology Unit, Department of Neuroscience, "Sapienza" University, Rome, Italy
| | - Martina Fanella
- Neurology Unit, Department of Neuroscience, "Sapienza" University, Rome, Italy
| | - Alessandra Morano
- Neurology Unit, Department of Neuroscience, "Sapienza" University, Rome, Italy
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Campbell S. Epileptiform transients of the occipital lobe in pediatrics. Neurodiagn J 2013; 53:217-228. [PMID: 24046970 DOI: 10.1080/21646821.2013.11079908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
Differentiating between benign occipital transients and epileptic discharges from the occipital lobes is imperative. Focal occipital spikes and sharp waves are not always associated with benign disorders. The occurrence of occipital spikes and spike and wave complexes depends on the child's age, the maturation of the occipital cortex, and the cortex's connection with other structures (Beaumanoir et al. 1993). Clinical manifestations also evolve as the patient ages. Seizure semiology is due to the maturation of the visual system and its connections. An infant from birth to twelve months of age could experience autonomic symptoms such as pallor and vomiting with possible minor motor movements. Visual symptoms and/or headaches are usually not noticed until between five and seven years of age. These visual phenomena can continue into adulthood.
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Affiliation(s)
- Stefan Campbell
- Clinical Neurophysiology Laboratory, Texas Children's Hospital, Houston, Texas, USA.
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Abstract
Benign epilepsy with centrotemporal spikes, early-onset childhood occipital epilepsy (Panayiotopoulos syndrome [PS]) and late-onset childhood occipital epilepsy (Gastaut type [LOCE-G]) are the principal pediatric focal epilepsy syndromes. They share major common characteristics: the appearance and resolution of electroclinical features are age related, there is a strong genetic predisposition, the clinical course is often mild with infrequent and easy to control seizures, interictal epileptiform activity is disproportionately abundant when compared with the clinical correlate, and tends to potentiate and generalize during sleep. In this review, we outline the relevant pathophysiology underlying this electroclinical spectrum. Then, the initial description of individual syndromes is followed by a summary of overlapping features and intermediate presentations that question the boundaries between these entities and provide the basis for the concept of a childhood seizure susceptibility syndrome. Additionally, we outline the main features of the related epileptic encephalopathies. An outlook on potential future lines of research completes this review.
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Carney PW, Harvey AS, Berkovic SF, Jackson GD, Scheffer IE. Siblings with refractory occipital epilepsy showing localized network activity on EEG-fMRI. Epilepsia 2013; 54:e28-32. [PMID: 23294395 DOI: 10.1111/epi.12076] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/13/2012] [Indexed: 11/30/2022]
Abstract
The benign occipital epilepsies of childhood include Panayiotopoulos and Gastaut syndromes; a third syndrome, idiopathic photosensitive occipital epilepsy may also begin in childhood or adolescence. We describe siblings with occipital epilepsy characterized by refractory, frequent, brief visual seizures and normal magnetic resonance imaging (MRI). Electroencephalography (EEG) with functional MRI (fMRI) supports localization of interictal epileptiform activity to the occipital lobes. Our hypothesis is that the siblings share a genetic focal epilepsy arising from a localized occipital network. Although they share many features of Gastaut syndrome, their refractory ongoing seizures in adolescence is unusual and likely due to underlying genetic determinants.
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Affiliation(s)
- Patrick W Carney
- Epilepsy Research Centre, Austin Health, Department of Medicine, University of Melbourne, Heidelberg, Victoria, Australia
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Abstract
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.
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Affiliation(s)
- Federico Vigevano
- Department of Neuroscience, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy.
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Sánchez Fernández I, Loddenkemper T, Peters JM, Kothare SV. Electrical status epilepticus in sleep: clinical presentation and pathophysiology. Pediatr Neurol 2012; 47:390-410. [PMID: 23127259 DOI: 10.1016/j.pediatrneurol.2012.06.016] [Citation(s) in RCA: 95] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2012] [Accepted: 06/20/2012] [Indexed: 10/27/2022]
Abstract
Electrical status epilepticus in sleep involves an electroencephalographic pattern where interictal epileptiform activity is potentiated in the transition from wakefulness to sleep. Near-continuous spikes and waves that occupy a significant proportion of nonrapid eye movement sleep appear as a result of sleep-potentiated epileptiform activity. This electroencephalographic pattern appears in different electroclinical syndromes that present three common characteristics with different degrees of severity: seizures, sleep-potentiated epileptiform activity, and neuropsychologic regression. Continuous spikes and waves during sleep comprise the severest epileptic encephalopathy in the electroclinical spectrum. Landau-Kleffner syndrome presents with intermediate severity. Some "benign" pediatric focal epileptic syndromes represent the mildest end of this continuum. Based on published data, we provide a framework for clinical and electrical events. The underlying mechanisms leading to sleep potentiation of epileptiform activity in electrical status epilepticus in sleep are incompletely understood. A genetic basis or acquired early developmental insult may disrupt the normal maturation of neuronal networks. These factors may dynamically alter normal processes of brain development, leading to an age-related pattern of electroclinical expression of electrical status epilepticus in sleep.
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Affiliation(s)
- Iván Sánchez Fernández
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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21
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Bruni O, Novelli L, Mallucci A, Corte MD, Romeo A, Ferri R. Benign Rolandic and Occipital Epilepsies of Childhood. Sleep Med Clin 2012. [DOI: 10.1016/j.jsmc.2011.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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Labate A, Sturniolo M, Pucci F, Quattrone A, Gambardella A. Migraine attack triggering a generalised seizure: is this a case of migralepsy or ictal epileptic headache? Neurol Sci 2011; 33:957-9. [DOI: 10.1007/s10072-011-0850-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2011] [Accepted: 10/29/2011] [Indexed: 11/30/2022]
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23
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Chan SC, Lee WT. Benign epilepsy in children. J Formos Med Assoc 2011; 110:134-44. [PMID: 21497276 DOI: 10.1016/s0929-6646(11)60023-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2010] [Revised: 07/02/2010] [Accepted: 07/05/2010] [Indexed: 10/18/2022] Open
Abstract
The diagnosis of benign epilepsy syndrome should meet the following criteria: age-related and self-limited; good response to medication; and no obvious neurological sequelae after seizure. However, the current concept of benign epilepsy syndrome has been challenged because of the advancements in genetic studies, neuroimaging, and molecular techniques. Many studies have revealed that the prevalence of behavioral problems and learning difficulties as well as subtle cognitive deficits is higher among patients with benign epilepsy, compared with the normal population. Here, we review updated results of these studies to show the latest and broad comprehensive knowledge of benign epilepsy in children.
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Affiliation(s)
- Sook-Cheng Chan
- Department of Pediatrics, National Taiwan University Hospital, Taipei, Taiwan
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Alves-Leon SV, Nunes RG, Andraus MEC, Biagini Junior JC, Hemb M, Genofre MA. Clinical and electroencephalographic characteristics of benign occipital epilepsy of childhood in two tertiary Brazilian hospitals. ARQUIVOS DE NEURO-PSIQUIATRIA 2011; 69:648-53. [DOI: 10.1590/s0004-282x2011000500014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/29/2010] [Accepted: 04/19/2011] [Indexed: 11/21/2022]
Abstract
This study intended to investigate the clinical and electroencephalographic benign occipital epilepsy of childhood (BOEC) characteristics in a population sample of patients from two tertiary Brazilian hospitals. We analyzed retrospectively 4912 electroencephalograms (EEGs) records, and the included patients were submitted to a new clinical and EEG evaluation. Were included 12 (0.92%) patients; 4 (33.3%) with criteria for early BOEC; 6 (50%) for late form and 2 (16.7%) with superimposed early and late onset forms. After new investigation, 2 (16.7%) had normal EEG; 4 (33.3%) had paroxysms over the occipital region; 3 (25%) over the temporal posterior regions and 3 (25%) over the posterior regions. Sharp waves were the predominant change, occurring in 8 (66.6%); spike and slow wave complexes in 1 (8.3%) and sharp and slow wave complexes in 1 (8.3%). Vomiting, headache and visual hallucinations were the most common ictal manifestations, presented in 100% of patients with superimposed forms. Vomiting were absent in the late form and headache was present in all forms of BOEC.
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Jonsson P, Eeg-Olofsson O. 10-year outcome of childhood epilepsy in well-functioning children and adolescents. Eur J Paediatr Neurol 2011; 15:331-7. [PMID: 21371918 DOI: 10.1016/j.ejpn.2011.02.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2010] [Revised: 01/12/2011] [Accepted: 02/05/2011] [Indexed: 11/17/2022]
Abstract
BACKGROUND A population based study of epilepsy in children from a Swedish county including all children aged 1 month to 16 years was reported in 2006. AIM To describe the medical outcome, seizure types, epilepsy syndromes, treatment, individual and family history in children from this study who were well-functioning in January 1997 and the outcome after 10 years. METHODS Forty-five individuals, 11-21 years, 19 females, and their parents responded to a questionnaire and the hospital records were reviewed. RESULTS At the end of the 10-year period 75.6% of the patients were in remission. Focal seizures and focal seizures with secondary generalization were found in 57.8%. Rolandic epilepsy had been diagnosed in 33.3%, other idiopathic focal epilepsies in 11.0%, cryptogenic and symptomatic focal epilepsies in 22.2%, childhood absence epilepsy in 8.9%, juvenile absence epilepsy and Jeavons syndrome in each 2.2%, West syndrome in 4.4%, and other "generalized" epilepsies in 15.5%. The patients had a history of simple febrile seizures in 15.6% and of primary headache in 24.4%. Monotherapy with antiepileptic drugs was used by 64.4%, and valproate was the most common first drug of choice. A family history of epilepsy was found in 44.4%, febrile seizures in 17.7%, and primary headache in 57.8%. A coincidence of focal and generalized epilepsy phenotypes was found in some families. CONCLUSIONS Longitudinal studies are of importance in epilepsy epidemiology. Our results reflect the selection of only well-functioning individuals with epilepsy from the population based original study.
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Affiliation(s)
- Pysse Jonsson
- Department of Women's and Children's Health/Neuropaediatrics, Uppsala University, Uppsala, Sweden
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Gonzalez-Duarte A, Norcliffe-Kaufmann L, Martinez J, Rodriguez AJ, Kuzniecky R, Axelrod F, Kaufmann H. Cardiovascular and neuroendocrine features of Panayiotopoulos syndrome in three siblings. Epilepsy Behav 2011; 21:296-300. [PMID: 21474385 DOI: 10.1016/j.yebeh.2011.03.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2010] [Revised: 02/08/2011] [Accepted: 03/05/2011] [Indexed: 11/18/2022]
Abstract
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.
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Martín Del Valle F, Díaz Negrillo A, Ares Mateos G, Sanz Santaeufemia FJ, Del Rosal Rabes T, González-Valcárcel Sánchez-Puelles FJ. Panayiotopoulos syndrome: probable genetic origin, but not in SCN1A. Eur J Paediatr Neurol 2011; 15:155-7. [PMID: 20813567 DOI: 10.1016/j.ejpn.2010.08.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2010] [Revised: 07/28/2010] [Accepted: 08/09/2010] [Indexed: 11/16/2022]
Abstract
Panayiotopoulos syndrome is encompassed in the classification of the ILAE in idiopathic focal epilepsies. Mutations in the SCN1A gene have been associated with the development of this syndrome. We present two cases of Panayiotopoulos syndrome in two monozygotic twins, who underwent a molecular analysis of SCN1A, but no alteration was found. These cases suggest a genetic origin, and SCN1A appears to be associated with the outcome but not with the development of this syndrome.
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Affiliation(s)
- F Martín Del Valle
- Paediatric Neurology Unit, Paediatric Service, Infanta Elena Hospital, Av Reyes Católicos 21, CP 28340 Valdemoro, Madrid, Spain.
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Wakamoto H, Nagao H, Fukuda M, Watanabe S, Motoki T, Ohmori H, Ishii E. Idiopathic childhood occipital epilepsy of Gastaut: report of 12 patients. Pediatr Neurol 2011; 44:183-6. [PMID: 21310333 DOI: 10.1016/j.pediatrneurol.2010.10.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2010] [Revised: 08/18/2010] [Accepted: 10/07/2010] [Indexed: 10/18/2022]
Abstract
This study sought to present clinical and outcome data of patients with idiopathic childhood occipital epilepsy of Gastaut, to validate previously reported characteristics of this epilepsy. The study group was comprised of 12 affected children (three boys and nine girls), with a median age of onset at 10.3 years. Common ictal manifestations included elementary visual hallucinations (75.0%), blindness or blurring of vision (50.0%), headache (50.0%), and secondarily generalized tonic-clonic seizures (58.3%). Interictal electroencephalography revealed occipital spike-wave paroxysms reactive to eye closure and opening in all patients, accompanied by spike-wave activity in the extra-occipital areas in four (33.3%), and by generalized spike-wave discharges in two (16.7%). One patient exhibited the onset of occipital lobe seizures 1 year after manifesting absence epilepsy. Seizure remission occurred in 81.8% of cases, in half of which medication was discontinued by late adolescence. This study confirmed the previously delineated electroclinical features of epilepsy syndrome, with additional aspects including the frequent association of generalized tonic-clonic seizures and atypical evolution from childhood absence epilepsy.
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Affiliation(s)
- Hiroyuki Wakamoto
- Department of Pediatrics, Ehime Rehabilitation Center for Children, Toon-Shi, Ehime Prefecture 791-0212, Japan.
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Schrader D, Shukla R, Gatrill R, Farrell K, Connolly M. Epilepsy with occipital features in children: factors predicting seizure outcome and neuroimaging abnormalities. Eur J Paediatr Neurol 2011; 15:15-20. [PMID: 20829080 DOI: 10.1016/j.ejpn.2010.08.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2010] [Revised: 08/12/2010] [Accepted: 08/16/2010] [Indexed: 11/20/2022]
Abstract
PURPOSE The objective of this retrospective study was to identify clinical and EEG features in children with occipital epilepsy that predict MR imaging abnormalities and seizure outcome. METHODS Patients with clinical and/or EEG features indicating occipital lobe involvement were identified from the epilepsy database at a tertiary children's hospital. The clinical and EEG features were analyzed to identify the most important predictors of abnormal MR imaging and seizure outcome. RESULTS Sixty-six patients were identified: 21 had symptomatic epilepsy with abnormal MR imaging; 12 patients had probable symptomatic epilepsy based on an abnormal neurological exam; 33 patients had normal neurological development, normal neurological examination and normal neuroimaging. Twenty-two of these 33 patients satisfied criteria for idiopathic occipital syndromes: Panayiotopoulos syndrome (9 patients), Gastaut type idiopathic childhood occipital epilepsy (12 patients) and idiopathic photosensitive occipital epilepsy (1 patient). Eleven patients could not be classified. Early age of seizure onset and an abnormal neurological examination were significant predictors of abnormal MR imaging. None of the variables examined were strong predictors of seizure outcome. CONCLUSION Early age of seizure onset and an abnormal neurological examination are the best predictors of abnormal MR imaging in children with epilepsy with occipital features.
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Affiliation(s)
- Dewi Schrader
- Division of Pediatric Neurology, Department of Pediatrics, University of British Columbia and British Columbia's Children's Hospital, 4480 Oak Street, Vancouver, BC, V6H 3V4, Canada
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Specchio N, Trivisano M, Vigevano F, Fusco L. Idiopathic West Syndrome followed by childhood absence epilepsy. Seizure 2010; 19:597-601. [DOI: 10.1016/j.seizure.2010.07.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2010] [Revised: 07/23/2010] [Accepted: 07/30/2010] [Indexed: 11/28/2022] Open
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Specchio N, Trivisano M, Claps D, Battaglia D, Fusco L, Vigevano F. Documentation of autonomic seizures and autonomic status epilepticus with ictal EEG in Panayiotopoulos syndrome. Epilepsy Behav 2010; 19:383-93. [PMID: 20797915 DOI: 10.1016/j.yebeh.2010.06.046] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2010] [Accepted: 06/26/2010] [Indexed: 11/19/2022]
Abstract
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.
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Affiliation(s)
- Nicola Specchio
- Division of Neurology, Bambino Gesù Children's Hospital IRCCS, Rome, Italy.
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Specchio N, Trivisano M, Di Ciommo V, Cappelletti S, Masciarelli G, Volkov J, Fusco L, Vigevano F. Panayiotopoulos syndrome: a clinical, EEG, and neuropsychological study of 93 consecutive patients. Epilepsia 2010; 51:2098-107. [PMID: 20528983 DOI: 10.1111/j.1528-1167.2010.02639.x] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
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.
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Affiliation(s)
- Nicola Specchio
- Division of Neurology, Bambino Gesù Children's Hospital IRCCS, Rome, Italy.
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Migraine and Epilepsy: A Focus on Overlapping Clinical, Pathophysiological, Molecular, and Therapeutic Aspects. Curr Pain Headache Rep 2010; 14:276-83. [DOI: 10.1007/s11916-010-0121-y] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Electroencephalographic generalized features in idiopathic childhood focal epilepsies. Seizure 2010; 19:222-5. [PMID: 20303800 DOI: 10.1016/j.seizure.2010.02.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2009] [Revised: 01/21/2010] [Accepted: 02/12/2010] [Indexed: 11/23/2022] Open
Abstract
PURPOSE Idiopathic focal epilepsies in childhood including benign childhood epilepsy with occipital paroxysms (BEOP) or benign childhood epilepsy with centro-temporal spikes (BCECTS) are characterized by specific focal electrographic patterns as the name indicates. Generalized spike-wave discharges in children with idiopathic focal epilepsy can suggest a neurobiological continuum with the idiopathic generalized epilepsies. We assessed the prevalence of generalized epileptiform discharges and generalized seizures in BEOP/BCECTS patients. METHODS Between August 2005 and November 2008, we identified 220 cases with electroclinical features typical of idiopathic focal epilepsies, 172 patients with BCECTS and 48 patients with BEOP, excluding patients whose neurological examinations or brain MRI were abnormal. We analyzed gender, age at onset, manifestation of generalized seizures, and serial EEG records to detect generalized abnormalities. RESULTS Of our population, 42 patients (19.1%, 22 boys), 30 (17.4%) of 172 BCECTS patients and 12 (25.0%) of 48 BEOP patients, showed generalized spike-wave discharges once or more during follow-up. The typical 3-Hz generalized spike wave discharge was noticed in 7 patients and concurrence with clinical generalized seizure was observed in 11. CONCLUSION A relatively high incidence of generalized spike-wave discharge and concurrence with generalized seizure were observed in patients with BEOP/BCECTS, with the incidence being higher in BEOP patients than in those with BCECTS. It may be inferred that idiopathic focal epilepsy is not a fixed syndrome but is a part of a broad, age-related, benign, seizure susceptibility syndrome.
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Berg AT, Berkovic SF, Brodie MJ, Buchhalter J, Cross JH, van Emde Boas W, Engel J, French J, Glauser TA, Mathern GW, Moshé SL, Nordli D, Plouin P, Scheffer IE. Revised terminology and concepts for organization of seizures and epilepsies: report of the ILAE Commission on Classification and Terminology, 2005-2009. Epilepsia 2010; 51:676-85. [PMID: 20196795 DOI: 10.1111/j.1528-1167.2010.02522.x] [Citation(s) in RCA: 2787] [Impact Index Per Article: 199.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The International League Against Epilepsy (ILAE) Commission on Classification and Terminology has revised concepts, terminology, and approaches for classifying seizures and forms of epilepsy. Generalized and focal are redefined for seizures as occurring in and rapidly engaging bilaterally distributed networks (generalized) and within networks limited to one hemisphere and either discretely localized or more widely distributed (focal). Classification of generalized seizures is simplified. No natural classification for focal seizures exists; focal seizures should be described according to their manifestations (e.g., dyscognitive, focal motor). The concepts of generalized and focal do not apply to electroclinical syndromes. Genetic, structural-metabolic, and unknown represent modified concepts to replace idiopathic, symptomatic, and cryptogenic. Not all epilepsies are recognized as electroclinical syndromes. Organization of forms of epilepsy is first by specificity: electroclinical syndromes, nonsyndromic epilepsies with structural-metabolic causes, and epilepsies of unknown cause. Further organization within these divisions can be accomplished in a flexible manner depending on purpose. Natural classes (e.g., specific underlying cause, age at onset, associated seizure type), or pragmatic groupings (e.g., epileptic encephalopathies, self-limited electroclinical syndromes) may serve as the basis for organizing knowledge about recognized forms of epilepsy and facilitate identification of new forms.
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Affiliation(s)
- Anne T Berg
- Department of Biology, Northern Illinois University, DeKalb, IL 60115, USA.
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Liu GT, Volpe NJ, Galetta SL. Visual hallucinations and illusions. Neuroophthalmology 2010. [DOI: 10.1016/b978-1-4160-2311-1.00012-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Michael M, Tsatsou K, Ferrie CD. Panayiotopoulos syndrome: an important childhood autonomic epilepsy to be differentiated from occipital epilepsy and acute non-epileptic disorders. Brain Dev 2010; 32:4-9. [PMID: 19386455 DOI: 10.1016/j.braindev.2009.03.002] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2008] [Revised: 03/01/2009] [Accepted: 03/02/2009] [Indexed: 10/20/2022]
Abstract
Panayiotopoulos syndrome is a common multifocal autonomic childhood epileptic disorder with significant clinical, pathophysiological and management implications. It affects otherwise normal children with onset at around 3-6 years. It is characterized by seizures, often prolonged, with predominantly autonomic symptoms and mainly ictal vomiting. EEG shows shifting and/or multiple foci, often with occipital dominance. Despite characteristic clinical and EEG manifestations Panayiotopoulos syndrome is often confused with occipital epilepsy and acute non-epileptic disorders such as encephalitis, syncope, cyclic vomiting or atypical migraine. This review aims to describe Panayiotopoulos syndrome on the basis of independent major studies and provide clinical clues for diagnosis and management.
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Caraballo R, Koutroumanidis M, Panayiotopoulos CP, Fejerman N. Idiopathic childhood occipital epilepsy of Gastaut: a review and differentiation from migraine and other epilepsies. J Child Neurol 2009; 24:1536-42. [PMID: 19955346 DOI: 10.1177/0883073809332395] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The purpose of this review is to provide guidance for appropriate diagnosis and management of idiopathic childhood occipital epilepsy of Gastaut. The typical clinical features are visual seizures that typically consist of brief elementary visual hallucinations, which are mainly multicolored and circular. Ictal blindness and deviation of the eyes are also common symptoms. The seizures are usually frequent and diurnal. The electroencephalography is the only investigation with abnormal results, showing occipital spikes and often occipital paroxysms demonstrating fixation-off sensitivity. Brain magnetic resonance imaging is used to exclude symptomatic occipital epilepsy. Patients usually respond well to antiepileptic medication and about two-thirds remit by the age of 16 years. Idiopathic childhood occipital epilepsy of Gastaut is frequently misdiagnosed as migraine with visual aura, acephalgic, or basilar migraine. Differentiation from symptomatic occipital epilepsy, particularly when children are otherwise normal, can be difficult. Most children need prophylactic antiepileptic medication.
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Affiliation(s)
- Roberto Caraballo
- Neuropediatric Department, Hospital de Pediatría Prof. Dr. Juan P. Garrahan, Buenos Aires, Argentina.
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Rudolf G, Valenti MP, Hirsch E, Szepetowski P. From rolandic epilepsy to continuous spike-and-waves during sleep and Landau-Kleffner syndromes: insights into possible genetic factors. Epilepsia 2009; 50 Suppl 7:25-8. [PMID: 19682046 DOI: 10.1111/j.1528-1167.2009.02214.x] [Citation(s) in RCA: 65] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Epilepsy is a frequent neurologic disease in childhood, characterized by recurrent seizures and sometimes with major effects on social, behavioral, and cognitive development. Childhood focal epilepsies particularly are age-related diseases mainly occurring during developmental critical periods. A complex interplay between brain development and maturation processes and susceptibility genes may contribute to the development of various childhood epileptic syndromes associated with language and cognitive deficits. Indeed, the Landau-Kleffner syndrome (LKS), the continuous spike-and-waves during sleep syndrome (CSWS), and the benign childhood epilepsy with centrotemporal spikes (BCECTS) or benign rolandic epilepsy, are different entities that are considered as part of a single continuous spectrum of disorders. Genetic predisposition with simple to complex modes of inheritance has long been suspected for this wide group of childhood focal epilepsies. Recent reports on the involvement of the SRPX2 and ELP4 genes with possible roles in cell motility, migration, and adhesion have provided first insights into the complex molecular bases of childhood focal epilepsies.
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Affiliation(s)
- Gabrielle Rudolf
- Service de Neurologie, Hôpitaux Universitaires de Strasbourg, 1 place de l'Hôpital BP 426, Strasbourg cedex, France.
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Crompton DE, Berkovic SF. The borderland of epilepsy: clinical and molecular features of phenomena that mimic epileptic seizures. Lancet Neurol 2009; 8:370-81. [PMID: 19296920 DOI: 10.1016/s1474-4422(09)70059-6] [Citation(s) in RCA: 76] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Paroxysmal losses of consciousness and other episodic neurological symptoms have many causes. Distinguishing epileptic from non-epileptic disorders is fundamental to diagnosis, but even this basic dichotomy is often challenging and is certainly not new. In 1907, the British neurologist William Richard Gowers published his book The Border-land of Epilepsy in which he discussed paroxysmal conditions "in the border-land of epilepsy-near it, but not of it" and their clinical differentiation from epilepsy itself. Now, a century later, we revisit the epilepsy borderland, focusing on syncope, migraine, vertigo, parasomnias, and some rarer paroxysmal disorders. For each condition, we review the clinical distinction from epileptic seizures. We then integrate current understanding of the molecular pathophysiology of these disorders into this clinical framework. This analysis shows that, although the clinical manifestations of paroxysmal disorders are highly heterogeneous, striking similarities in molecular pathophysiology are seen among many epileptic and non-epileptic paroxysmal phenomena.
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Affiliation(s)
- Douglas E Crompton
- Epilepsy Research Centre, Department of Medicine (Neurology), University of Melbourne, Austin Health, Heidelberg, Victoria, Australia
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