Epilepsy in brain-injured children

Prevalence and related factors of epilepsy in children and adolescents with cerebral palsy: a systematic review and meta-analysis

Objective

To study the worldwide prevalence and associated factors of epilepsy in children and adolescents with Cerebral Palsy (CP) and to analyze the differences between various subgroups.

Method

We identified all potential studies on the prevalence of epilepsy in children and adolescents with CP from PubMed, Web of Science, and Embase. The search time was from the establishment of the database to November 2022. Randomized effects meta-analysis models were used to calculate the prevalence of epilepsy in CP. Subgroup analysis and meta-regression were utilized to further explore heterogeneity between articles and prevalence disparities between subgroups. The funnel plot and Egger's test were used to investigate potential publication bias.

Results

Seventy-two articles, comprising 53,969 children and adolescents with CP, were included in this study. The results indicated a total epilepsy prevalence of 38.0% (95% CI: 34.8%-41.2%) in CP. The prevalence of epilepsy was 46.4% (95% CI: 41.4%-51.5%) in clinical sample-based studies and 31.6% (95% CI: 28.7%-34.5%) in population-based studies. Meta-regression demonstrated that the sample source, neonatal seizure, family history of epilepsy, EEG or cranial imaging abnormalities, intellectual/cognitive impairment, and topographical types of CP were heterogeneous contributors to the epilepsy prevalence in CP.

Conclusion

Approximately one-third of children and adolescents with CP have epilepsy, and the sample source can significantly impact the total prevalence of epilepsy. Neonatal seizures, family history of epilepsy, EEG abnormalities, cranial imaging abnormalities, severe intellectual disability, and quadriplegia may be contributing factors to epilepsy comorbid in CP. Further study is required to verify the strength of these associations with epilepsy. This study aids in identifying the clinical characteristics of young people with CP at risk of developing epilepsy, which may assist clinicians in the early prevention and diagnosis of epilepsy within this population.Systematic Review Registration: https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=367766, identifier CRD42022367766.

Improving epilepsy control among children with cerebral palsy in rural Bangladesh: a prospective cohort-based study

OBJECTIVE

To define the prevalence and seizure subtypes among children with cerebral palsy (CP) in rural Bangladesh and explore barriers to optimum epilepsy control.

DESIGN

Prospective cohort study.

SETTING

The study was conducted in Shahjadpur, a rural subdistrict of Bangladesh.

PARTICIPANTS

Children (<18 years) with CP and epilepsy identified using the Bangladesh CP Register (BCPR) in the study site.

METHODS

Assessments were conducted in three focused epilepsy clinics overseen by a paediatric neurologist between December 2016 and January 2018, with intervening phone and video-conference follow-ups. Details of event type, frequency and medication compliance were collected. Antiepileptic drugs (AEDs) were prescribed based on seizure type, family income, comorbidity and medication availability.

RESULTS

23.4% (170/726) of the BCPR cohort had a clinical diagnosis of epilepsy of whom 166 were assessed. Following the focused epilepsy clinics, 62.0% (103/166) children were clinically determined to have ongoing epileptic seizures. 62.1% (64/103) had generalised onset tonic clonic seizures, 27.2% (28/103) had focal onset seizures with impaired awareness and 10.7% (11/103) had other seizure types. None of the children with prolonged seizures (31/103) had an emergency seizure management plan. Non-epileptic events were being pharmacologically treated as seizures in 18.1% (30/166) children. Financial constraints were the main reason for non-compliance on follow-up.

CONCLUSIONS

Gaps in optimum epilepsy management in rural Bangladesh are amenable to improvement anchored with local healthcare workers. Training and clinical care focused on recognition of common seizure types, seizure mimics and rationalising use of available AEDs can be facilitated by better referral pathways and telehealth support.

Secondary Osteoporosis

Osteoporosis is a global public health problem, with fractures contributing to significant morbidity and mortality. Although postmenopausal osteoporosis is most common, up to 30% of postmenopausal women, > 50% of premenopausal women, and between 50% and 80% of men have secondary osteoporosis. Exclusion of secondary causes is important, as treatment of such patients often commences by treating the underlying condition. These are varied but often neglected, ranging from endocrine to chronic inflammatory and genetic conditions. General screening is recommended for all patients with osteoporosis, with advanced investigations reserved for premenopausal women and men aged < 50 years, for older patients in whom classical risk factors for osteoporosis are absent, and for all patients with the lowest bone mass (Z-score ≤ -2). The response of secondary osteoporosis to conventional anti-osteoporosis therapy may be inadequate if the underlying condition is unrecognized and untreated. Bone densitometry, using dual-energy x-ray absorptiometry, may underestimate fracture risk in some chronic diseases, including glucocorticoid-induced osteoporosis, type 2 diabetes, and obesity, and may overestimate fracture risk in others (eg, Turner syndrome). FRAX and trabecular bone score may provide additional information regarding fracture risk in secondary osteoporosis, but their use is limited to adults aged ≥ 40 years and ≥ 50 years, respectively. In addition, FRAX requires adjustment in some chronic conditions, such as glucocorticoid use, type 2 diabetes, and HIV. In most conditions, evidence for antiresorptive or anabolic therapy is limited to increases in bone mass. Current osteoporosis management guidelines also neglect secondary osteoporosis and these existing evidence gaps are discussed.

Motor Abnormalities and Epilepsy in Infants and Children With Evidence of Congenital Zika Virus Infection

Initial reports of congenital Zika virus (ZIKV) infection focused on microcephaly at birth with severe brain anomalies; the phenotype has broadened to include microcephaly that develops after birth and neurodevelopmental sequelae. In this narrative review, we summarize medical literature describing motor abnormalities and epilepsy in infants with evidence of congenital ZIKV infection and provide information on the impact of these conditions. Specific scenarios are used to illustrate the complex clinical course in infants with abnormalities that are consistent with congenital Zika syndrome. A search of the English-language medical literature was done to identify motor abnormalities and epilepsy in infants with evidence of congenital ZIKV infection by using Medline and PubMed, Embase, Scientific Electronic Library Online, Scopus, the OpenGrey Repository, and the Grey Literature Report in Public Health. Search terms included "Zika" only and "Zika" in combination with any of the following terms: "epilepsy," "seizure," "motor," and "cerebral palsy." Clinical features of motor abnormalities and epilepsy in these children were reviewed. Thirty-six publications were identified; 8 were selected for further review. Among infants with clinical findings that are consistent with congenital Zika syndrome, 54% had epilepsy and 100% had motor abnormalities. In these infants, impairments that are consistent with diagnoses of cerebral palsy and epilepsy occur frequently. Pyramidal and extrapyramidal motor abnormalities were notable for their early development and co-occurrence. Prompt identification of potential disabilities enables early intervention to improve the quality of life for affected children. Long-term studies of developmental outcomes and interventions in children with congenital ZIKV infection are needed.

[Possibilities of treatment optimization in children and adolescents with epilepsy and disturbances of emotion and volition (disphoria)]

AIM

To optimize the treatment of dysphoriain children and adolescents in regard to sex and disease severity.

MATERIAL AND METHODS

Seventy children and adolescents (boys - 45, girls - 25), aged from 6 to 18 years, with different forms of epilepsy and emotion and dysphoric disturbances were studied using CPRS andGCIscales Depending on dysphoria severity, patients were stratified into three groups: mild (n=19 (27.1%), moderate (n=27 (38.6%)) and severe (n=24 (34.3%)).

RESULTS AND CONCLUSION

Dysphoric disorders were significantly more prevalent in boys, hostility and aggression were characteristic of boys as well. These facts impactedtreatment options. Neuroleptics were more frequently used in boys (35.5%) compared to girls(16%).Mild dysphoria didn't require additional treatment besides AED in 78,4%. In 75% cases of moderate dysphoria,systemic treatment with neuroleptics for 6 months was necessary. One-time recommendations for neuroleptic treatment were made in all three groups with the prevalence in a groupof children with severe and moderate dysphoria.

The effect of seizures on functional status of people with spastic forms of cerebral palsy

Background.Cerebral palsy (CP) is the most common childhood motor impairment. Epilepsy affects approximately one third of patients with CP. It is characterized by earlier disclosure, it is more severe and shows greater resistance than that of the general epilepsy treatment, associated with necessity for polytherapy. Its presence can result in gradual loss of function, loss of posture in non-ambulant individuals with severe disabilities and cognitive impairment risk, behavioural disorders and reducing probability of walking.

Aim.The aim of the study was to evaluate the functioning of people with CP with and without epilepsy.

Material and Methods.The study included 210 patients with a diagnosis of CP, aged 0–18 years. The study was conducted among the patients using the physiotherapy services in centres in southern Poland. The study used the Paediatric Evaluation of Disability Inventory (PEDI) and the classification systems: GMFCS, MACS, and CFCS.

Results.There were significant differences with regards to social functioning (53.7/67.4; W = 179, p = 0.006) and support in the social functioning (65.4/89.9; W = 185.5, p = 0.007) in patients with diplegia. However, mobility (19.55/29.00; W = 392, p = 0.018) and the social functioning (36.95/44.1; W = 418.5, p = 0.042) were lower in epileptic patients with tetraplegia. In patients with hemiplegia, there were no significant differences, although each domain with epilepsy subgroup had a lower rating than the subgroup without epilepsy.

Conclusion.The presence of epilepsy is associated with lower levels of social function in patients with cerebral palsy; particularly, with regard to mobility and selfservice.

Assessment of epilepsy impact on the level of social functioning of people with CP (diplegia, tetraplegia, hemi-plegia) is difficult because ambiguous relationship with mental retardation. The assessment should be undertaken separately for each group of spastic CP.

Surgical management of intractable childhood epilepsy: curative and palliative procedures

Epilepsy surgery is increasingly used to treat intractable childhood-onset epilepsy although it remains an underused treatment option. Advances in technology allowing more accurate identification of the epileptogenic zone along with a better understanding of the benefits of both curative and palliative epilepsy surgery have resulted in an increase of potential candidates. This review covers factors contributing to medical intractability and then details the evaluation of potential surgical candidates. We discuss pre-, peri-, and postoperative variables that lead to curative procedures and highlight the role of palliative epilepsy surgery in cases in which seizure freedom is unlikely.

Factors affecting epilepsy development and epilepsy prognosis in cerebral palsy

A study was conducted between November 2006 and October 2009 to determine the factors predicting the presence and prognosis of epilepsy in patients with cerebral palsy. We enrolled 2 groups of patients: 42 with cerebral palsy in group 1 and 56 patients with cerebral palsy and epilepsy in group 2. The subjects in group 2 were considered to have good epilepsy prognosis if they were free of seizures for the previous year; otherwise they were considered to have poor epilepsy prognosis. In group 2, neonatal epilepsy, family history of epilepsy, and moderate to severe mental retardation were significantly higher than in group 1 (P < 0.05). In univariate analysis, neonatal seizures, epileptic activity as measured by electroencephalography, and polytherapy were found to be predictors of poor epilepsy prognosis. Additionally, the need for long-term medication to control seizures unfavorably affects prognosis. In logistic regression analysis, neonatal seizure and interictal epileptic activity in electroencephalography were found to be independent predictors of poor epilepsy outcome. In addition, logistic regression analysis revealed that increasing age reduces the success of epilepsy treatment. Neonatal seizures, family history of epilepsy, and mental retardation were found to be important and independent predictors of development of epilepsy in patients with cerebral palsy.

Development of epilepsy in newborns with moderate hypoxic-ischemic encephalopathy and neonatal seizures

BACKGROUND

Hypoxic-ischemic encephalopathy (HIE) is one of the most frequent causes of neonatal death or neurological handicaps such as cerebral palsy, mental delay, and epilepsy. Moreover, an acute consequence of HIE are neonatal seizures which can cause an additional brain damage. The neurodevelopmental outcome is known in the mild or severe cases of HIE, but in the moderate conditions the predictivity results, to date, unsatisfying.

OBJECTIVE

The purpose of this prospective study was to appraise the development of post-neonatal epilepsy in a cohort of term infants with moderate HIE and neonatal seizures.

METHODS

This study considered all newborns admitted to Neonatal Intensive Care Unit of the University of Parma between January 2000 and December 2002 for perinatal asphyxia, then followed by Neonatal Neurology Service. In all patients, neonatal variables such as type of delivery, birth weight, gestational age, Apgar scores, the need for resuscitation and assisted ventilation soon after birth, and arterial-blood pH were analyzed.

RESULTS

Ninety-two newborns were enrolled in the study because of perinatal asphyxia. Of these, 27 subjects developed mild HIE, 25 moderate, and five severe HIE. Neonatal seizures were present in 13 subjects with moderate HIE and in all newborns with severe HIE. At the last follow-up, only three infants belonging to patients with severe HIE developed epilepsy.

CONCLUSION

Moderate HIE seems not to be related to post-neonatal epilepsy either if associated or not with neonatal seizures.

Preterm infants with video-EEG confirmed seizures: outcome at 30 months of age

OBJECTIVE

Our aim was to identify early predictors of poor neurodevelopmental outcome and of subsequent epilepsy in very early preterm and late preterm newborns with neonatal seizures.

STUDY DESIGN

Fifty-one preterm infants with gestational age (GA) <or=36 weeks were identified among those admitted to the NICU of University Hospital of Parma between January 1999 and December 2003 and prospectively followed-up. They were subdivided in two Groups: early preterm newborns with a GA <or=29 weeks and those with GA between 30 and 36 weeks. Selection criteria included multiple digital-video-EEG confirmed neonatal seizures and a follow-up of at least 30 months. Independent variables considered for analysis included neonatal risk factors, etiology and type of seizures, EEG activity, and cerebral ultrasound scan examinations.

RESULTS

Ten infants had a favorable outcome, 17 died, and 23 had an adverse outcome. One infant was lost on follow-up. Apgar score at 1 min (O.R.=15.457, 95% CI: 2.236-106.850, p=0.006) and severely abnormal background EEG activity (O.R.=8.298, 95% CI: 1.316-52.301, p=0.024) were independent predictors of abnormal outcome. Nine infants presented post-neonatal epilepsy. Severely abnormal Cerebral Ultrasound scans were predictive of epilepsy (O.R.=13.72, 95% CI: 1.959-96.149, p=0.008).

CONCLUSIONS

Neonatal seizures in preterm infants are associated to a high rate of mortality and severe morbidity in survivors but no definitive differences between the two groups of preterm infants were found. Risk-factors for development of subsequent epilepsy are strongly related to the underlying brain damage.

Epilepsy in children with cerebral palsy

To study the spectrum of epilepsy in children with cerebral palsy, 105 consecutive children with cerebral palsy and active epilepsy, between 1 and 14 years of age, were studied prospectively. A detailed history and examination, electroencephalography (EEG), and computed tomography (CT) were done in all cases. The social quotient was assessed using the Vineland Social Maturity Scale. A retrospective cohort of 452 cases of cerebral palsy was studied to find the prevalence of epilepsy in cerebral palsy. A control group of 60 age-matched children with cerebral palsy but no epilepsy was also studied for comparison of the social quotient. Of the 105 children, 65 were male, 40 of 105 (38%) had a history of birth asphyxia. The mean age of onset of seizures was 18.9 months; 64 (60.95%) had seizure onset before 1 year of age. Children with myoclonic seizures (P < .05) and infantile spasms (P < .01) had seizure onset significantly early in life. Generalized seizures were the most common, followed by partial seizures, infantile spasms, and other myoclonic seizures. Seizures were controlled in 45 (58.1%) children, and polytherapy was required in 40 children. EEG and CT abnormalities were seen in 70.5% and 61% of the children. Seizure control was achieved in 74% of the patients with a normal to borderline social quotient compared with 48.7% with a social quotient less than 70. Social quotient values had a positive correlation with age of onset of seizures (P < .01) and with better control of seizures (P < .01). Of the cohort of 452 children, 160 (35.4%) had epilepsy. The maximum incidence (66%) was seen in children with spastic hemiplegia, followed by quadriplegia (42.6%) and diplegia (15.8%). Epilepsy in cerebral palsy is seen in about one third of cases; it is often severe and difficult to control particularly in children with mental retardation.

Treatment of attention-deficit disorder, cerebral palsy, and mental retardation in epilepsy

Epilepsy in childhood is often associated with other neurologic disorders, including attention-deficit/hyperactivity disorder, cerebral palsy, and mental retardation. A single pathologic process may explain both epilepsy and these associated disorders. However, in some cases, distinct etiologies may be present. Recognition of these problems is essential, as is individualized treatment. Proper classroom placement; behavior modification, speech, occupational, and physical therapies; pharmacological agents; and even surgical procedures have a role in the management of these comorbid disorders. Diagnostic criteria and therapeutic modalities used in these syndromes will be discussed.

What do you do when they grow up? Approaches to seizures in developmentally delayed adults

Epilepsy and developmental disabilities (DD) often occur together but affect individuals differently and have a complex causal relationship. Most epilepsy in the population with DD is partial or symptomatic generalized. Seizures and antiepileptic drugs (AEDs) can further delay development, and the DD can complicate treatment and adjustment to epilepsy. Medical care and decision making require careful coordination of health care providers and the family, especially because of the trend for the patients to live in group homes. Behavioral and psychiatric disorders are difficult to diagnose but common in those with DD and epilepsy; psychiatric disorders are perhaps up to sevenfold higher in this group than in the general population. Psychotropic medications-antidepressants, anxiolytics (but use caution with benzodiazepines), antipsychotics, and stimulants-are appropriate for those with psychiatric disorders. Diagnostic difficulties may lead to undertreatment, and the motivation to lessen certain behaviors may lead to overtreatment. Because those with DD may be unusually sensitive to adverse effects of both seizures and AEDs, cognitive and behavioral side effects must be carefully monitored. Few relevant studies exist. For some patients, comorbid psychiatric disorders may be treated with one AED, such as carbamazepine, lamotrigine, or valproate. Phenobarbital and phenytoin may be inappropriate for those with epilepsy and DD. Studies have shown some success with oxcarbazepine (for partial and generalized epilepsy) and with adjunctive lamotrigine. For those on medication regimens, perhaps taking combinations of drugs for numerous years, queries about earlier attempts to reduce AEDs and gradual efforts to substitute less toxic mediations are worthwhile. Vagus nerve stimulation and epilepsy surgery for those with medically refractory epilepsy may be options after careful evaluation.

Epileptic and non-epileptic cerebral palsy: EEG and cranial imaging findings

The aims of the study were to compare the clinical types, electroencephalogram (EEG) and cranial magnetic resonance imaging/computed tomography findings of epileptic and non-epileptic cerebral palsy (CP) patients. Seventy-four patients with CP were evaluated in 2 years. Tetraplegic CP had a higher incidence of epilepsy (60.5%). EEG was confirmed abnormal in epileptic CP as 90.3%, and in non-epileptic CP as 39.5%. Focal epileptiform activity, generalized slowing, and multifocal epileptiform activity were significantly frequent in epileptic CP. There were cranial imaging abnormalities of 74.2% in epileptic and 48.8% in non-epileptic CP. Although there was not any statistically significant difference between the two groups, epileptic group revealed more structural abnormalities. Further studies concerning a possible risk of epilepsy development and its relations with the EEG and cranial imaging findings are needed in presenting the other risk factors involved and the factors affecting the CP prognosis.

Epilepsy in children with cerebral palsy

OBJECTIVE

To describe the prevalence and characteristics of epilepsy in patients with cerebral palsy in a tertiary center.

METHODS

a total of 100 consecutive patients with cerebral palsy were retrospectively studied. Criteria for inclusion were follow-up period for at least 2 years. Types and incidence of epilepsy were correlated with the different forms of cerebral palsy. Other factors associated with epilepsy such as age of first seizure, neonatal seizures and family history of epilepsy were also analysed.

RESULTS

follow-up ranged between 24 and 151 months (mean 57 months). The overall prevalence of epilepsy was 62%. Incidence of epilepsy was predominant in patients with hemiplegic and tetraplegic palsies: 70.6% and 66.1%, respectively. First seizure occurred during the first year of life in 74.2% of patients with epilepsy. Generalized and partial were the predominant types of epilepsy (61.3% and 27.4%, respectively). Thirty-three (53.2%) of 62 patients were seizure free for at least 1 year. Neonatal seizures and family history of epilepsy were associated with a higher incidence of epilepsy.

CONCLUSIONS

epilepsy in cerebral palsy can be predicted if seizures occur in the first year of life, in neonatal period and if there is family history of epilepsy.

Epilepsy surgery in children with developmental disabilities

Surgery for treatment of medically uncontrolled epilepsy in children is now widely accepted with reported outcomes similar to those in adults. Epilepsy is reported in 8.8% to 32% of children with mental retardation (MR) and in up to half of children with severe retardation. There has been concern that patients with low IQ will experience unsatisfactory outcomes from epilepsy surgery and not achieve good seizure control. It is appropriate to reassess the prior bias against resective epilepsy surgery in children with MR in view of the changing criteria for potential candidacy for epilepsy surgery in infants and young children. There are three prerequisites for epilepsy surgery: (1) the epilepsy must be medically intractable; (2) the surgery must be feasible, that is, the epileptogenic zone can identified and safely resected; and (3) there is high likelihood of a satisfactory outcome as regards both the epilepsy and the patient's functional status. Patients with MR may have diffuse cerebral dysfunction and diffuse or multifocal epileptogenic regions. Appropriate patient selection is made possible through use of current technology that allows identification of lesions or areas of cerebral dysgenesis, aiding in identification of localized areas of epileptogenesis. Results from various series of patients with MR who have undergone resective surgery for epilepsy have shown that with careful presurgical evaluations, outcomes are similar between patients with normal IQ scores and those with low scores. Surgical protocols specifically for patients with MR and intractable epilepsy are required, including careful definition of desired outcomes.

Characteristics of epilepsy in severely mentally retarded individuals

In order to clarify the characteristics of epilepsy in patients with severe mentally retarded (SMR) subjects, we analyzed 52 SMR subjects with epilepsy from the institute for SMR subjects at Kikuchi National Hospital, Kumamoto, Japan. A total of 61.5% patients had uncontrolled seizures which were resistant to treatment. The most common combinations of seizure types in those not responding to conventional anticonvulsants were generalized tonic-clonic seizures (GTCS) with tonic seizure and GTCS with atypical absence. Their clinical features were characterized by spastic paralysis associated with a slower background electroencephalogram and abnormal computed tomography scans of the head, suggesting the involvement of cortical damage. These findings suggest that a large proportion of epilepsy in SMR subjects does not respond to treatment and that the severity of organic brain damage may therefore affect the natural course of epilepsy in such patients.

Mental retardation subsequent to refractory partial seizures in infancy

Whether seizures are the direct cause of cognitive deterioration in epileptic children is undetermined. This retrospective study aimed to delineate a subgroup of pediatric patients with cognitive deterioration and refractory seizures in the absence of recognized causes for mental retardation. Of the 80 children identified as having mental retardation and refractory seizure disorder, seven (8.7%) had normal cognitive development until at least 1 year of age. Their metabolic status was normal. Five of them suffered repeated frequent partial seizures with onset in the first year of life and two had repeated episodes of status epilepticus. All seven had similar characteristics of early onset partial seizures, six of them had partial seizures secondarily generalized and one had complex partial seizures. The time of peak cognitive deterioration correlated with increases in seizure frequency during that period. Evaluation revealed a well-defined epileptic focus in the absence of neuroimaging abnormality except for hippocampal atrophy in the two children with complex partial seizures and a small vascular malformation in one child. Uncontrolled partial seizures in the first months of life may result in cognitive deterioration.

Epilepsy in patients with spastic cerebral palsy: correlation with MRI findings at 5 years of age

The aim of this study was to determine the relationship between epilepsy and the magnetic resonance imaging (MRI) findings in patients with spastic cerebral palsy at five years of age. We studied 14 patients with congenital anomaly and 116 with perinatal injury. The patients with perinatal injury were subdivided into two groups; those with preterm type injury alone (group P), and those with term type injury with or without preterm type injury (group T). Epilepsy was found in 37 of the 130 patients. The initial type of seizures was partial in 12 patients. infantile spasms in 20 and generalized in five. Kaplan-Meier analysis demonstrated that patients with congenital anomaly had a higher incidence and an earlier onset of epilepsy than those with perinatal injury. Of the patients with perinatal injury, group T patients showed a higher incidence and a later onset of epilepsy than group P patients.

Childhood secondary (symptomatic) epilepsy, seizure control, and intellectual handicap in a nontropical region of South Africa

PURPOSE

To determine the prevalence of secondary (symptomatic) epilepsy and to ascertain levels of seizure control and intellectual function in a clinic population of children drawn from a poor community in a temperate region of South Africa.

METHODS

Detailed review of the records of every child with recurrent seizures who attended a special epilepsy outpatient clinic during 1995.

RESULTS

A total of 1,017 children was studied. In 432 (43%), there was historic, clinical, and radiologic evidence to suggest that epilepsy was symptomatic of underlying brain damage or defect. Acceptable seizure control was maintained with a single standard anticonvulsant drug (AED) in 65% of cases. In the 6 months preceding the study, 37% of the subjects had remained seizure free. Forty-seven percent of the study population were considered to be of subnormal intelligence.

CONCLUSIONS

In a children's hospital outpatient population in the Western Cape region of South Africa, the prevalence of secondary epilepsy is higher than is found in developed countries. There is need within the community for preventive measures aimed at reducing the prevalence of perinatal insults, meningitis, tuberculosis, neurocysticercosis, and cerebral trauma.

Characteristics and prognosis of epilepsy in children with cerebral palsy

The aims of the study were to describe the prevalence and characteristics of epilepsy in a population of patients with cerebral palsy in a university referral center and to determine the rate of relapse caused by discontinuation of antiepileptic drugs after a 3-year seizure-free period. A total of 178 consecutive patients with cerebral palsy and epilepsy were prospectively followed for 9.2 +/- 2.4 years after onset of seizures and compared to a control group of 150 epileptic patients without cerebral palsy (median follow-up period, 10.5 years). The overall prevalence of epilepsy was 36.1%. Patients with atonic-diplegic, dystonic, tetraplegic, and hemiplegic cerebral palsy had a higher incidence of epilepsy (87.5%, 87.1%, 56.5%, and 42%, respectively). In all, 134 (75.3%) patients were seizure free for more than 3 years and could discontinue therapy, whereas 44 patients (24.7%) were still on antiepileptic drugs. Eighteen of 134 patients relapsed after a 3-year seizure-free period and subsequent discontinuation of antiepileptic drugs, thus giving a relapse rate of 13.4%. First seizures occurred during the first year of life in 69.7% of the patients with epilepsy and cerebral palsy. Complete control of seizures could be achieved in 65.2% of the patients with cerebral palsy and epilepsy; however, regardless of the prognosis of seizures, epilepsy was a major prognostic factor regarding both the presence of mental retardation and the motor development of children with cerebral palsy.

Clinical aspects and biological bases of drug-resistant epilepsies

The definition of drug-resistant epilepsy (DRE) is elusive and still controversial owing to some unresolved questions such as: how many drugs should be tried before a patient is considered intractable; to which extent side-effects may be acceptable; how many years are necessary before establishing drug resistance. In some cases, the view of epilepsy as a progressive disorder constitutes another important issue. Despite the use of new antiepileptic drugs (AEDs), intractable epilepsy represents about 20-30% of all cases, probably due to the multiple pathogenetic mechanisms underlying refractoriness. Several risk factors for pharmacoresistance are well known, even if the list of clinical features and biological factors currently accepted to be associated with difficult-to-treat epilepsy is presumably incomplete and, perhaps, disputable. For some of these factors, the biological basis may be common, mainly represented by mesial temporal sclerosis or by the presence of focal lesions. In other cases, microdysgenesis or dysplastic cortex, with abnormalities in the morphology and distribution of local-circuit (inhibitory) neurons, may be responsible for the severity of seizures. The possible influence of genes in conditioning inadequate intraparenchimal drug concentration, and the role of some cytokines determining an increase in intracellular calcium levels or an excessive growth of distrophic neurites, constitute other possible mechanisms of resistance. Several hypotheses on the mechanisms involved in the generation of DRE have been indicated: (a) ontogenic abnormalities in brain maturation; (b) epilepsy-induced alterations in network, neuronal, and glial properties in seizure-prone regions such as the hippocampus; (c) kindling phenomenon; (d) reorganization of cortical tissue in response to seizure-induced disturbances in oxygen supply. Such hypotheses need to be confirmed with suitable experimental models of intractable epilepsy that are specifically dedicated, which have until now been lacking.

Epilepsy in very preterm infants: neonatal cranial ultrasound reveals a high-risk subcategory

The aim of this study was to investigate the association between epilepsy and perinatal brain injury in a cohort of 610 infants born preterm at <33 weeks' gestation. The prevalence of epilepsy in this cohort was 4.3% as determined by a postal questionnaire survey. Most children with epilepsy (16 of 24) had high-risk cranial ultrasound lesions including haemorrhagic parenchymal infarction (HPI), posthaemorrhagic hydrocephalus, and cystic periventricular leukomalacia (PVL). Of all the children in our cohort with high-risk brain lesions, those with epilepsy were more likely to have HPI and significantly less likely to have cystic PVL, although it is possible that PVL was not noticed in some cases. Children with epilepsy and high-risk cranial ultrasound lesions also showed more cognitive impairment than children with high-risk lesions but no epilepsy, which suggested more cortical grey-matter damage. We suggest that brain injury has occurred outside the confines of the periventricular white matter in this group of preterm infants with epilepsy.

Seizures in the de-institutionalized patients with early brain injuries

The number of individuals with early brain injury and multiple disabilities discharged from institutions had increased steadily over the past 10 years. The most frequently encountered problems by patients with early brain injury and epilepsy placed in the community were reviewed. Unavailability of specialized services, inadequate reimbursement, high turnover and lack of knowledge by caregivers, lack of understanding/acceptance of the concepts of seizure intractability and pseudoseizures, unrealistic expectations by overseeing agencies and/or family, and side effects of antiepileptic medications were the most common seizure-related problems afflicting these patients. Everything else being equal, good exchange of information between the various caregivers and continued education of caregivers, both time consuming endeavors, are the crucial factors for the successful management of seizures in this population.

Surgical treatment for epilepsy: a retrospective Swedish multicenter study

The characteristics of patients suffering from drug resistant epilepsy, including the results of the preoperative evaluation and epilepsy surgery were retrospectively analyzed in a Swedish multicenter 10-year cohort of children and adults. Altogether 152 patients (65 children and 87 adults) treated during the period 1980-1990 in three epilepsy centers were included and followed-up 2 years after surgery. Median age at onset of seizures was 4 years for the children and 12 years for the adults. A localization related epilepsy was present in 85% of the children and in 95% of the adults. The mean number of seizure types in the children was 1.7 (range 1-4) and in the adults 1.8 (range 1-4). The median monthly seizure frequency was 52 and 15 for children and adults respectively. Resective surgery was performed in 143 cases (94 temporal, 31 extratemporal, 9 multilobar and 9 major resection procedures) and palliative procedures in 16 cases (13 callosotomies and 3 stereotactic amygdalotomies). Postoperative neurological deficits were detected in 9% of the patients after temporal lobe resections and in 15% of the patients after extratemporal and multilobar resection procedures. Two years after resective surgery 53% of the children and 49% of the adults were seizure free. Another 25% of the patients had a more than 50% reduction of seizure frequency. In the postoperative non seizure free group of patients there was a negative correlation between decrease in weighted seizure severity and decrease in seizure frequency. This finding stresses the need for including other parameters than seizure frequency when evaluating the outcome of epilepsy surgery.

Impairments, disabilities and handicaps in children and adolescents with epilepsy

The patterns of motor and sensory impairments, disabilities and handicap were assessed in 217 children and adolescents with epilepsy. Motor and sensory dysfunctions were found to be common even in children without major additional neurodisorders such as cerebral palsy and mental retardation. Handicap was most severe in the dimensions of physical independence and orientation and increased significantly with duration of epilepsy. It was more severe when the onset of seizures was early and when secondary generalized seizures were present. Handicap was significantly reduced after epilepsy surgery.

Characteristics of seizures in a population-based series of mentally retarded children with active epilepsy

PURPOSE

The characteristics of seizures were analysed in a population-based study of active epilepsy in 6- to 13-year-old mentally retarded children.

METHODS

The search procedure included diagnostic registers, EEG registers, and registers of the Education of the Subnormal. Medical files were scrutinized, and clinical examinations and interviews with parents or caretakers or both were performed.

RESULTS

The median age of seizure onset was 1.3 years, 3.1 for children with mild retardation and 0.8 for children with severe retardation. Among the 98 children identified, current seizure groups were partial in 20, generalized in 59, and mixed in 19. The prevailing seizure types were tonic-clonic, myoclonic, atypical absences, and partial complex seizures, present in 42, 33, 23, and 23 children, respectively. A total of 46 children had more than one seizure type. Seizures every day/week occurred in 44 children. There was a constancy between seizure type at onset and later seizure type. Neonatal seizures (n = 25), infantile spasms (n = 12), and status epilepticus (n = 37) occurred independent of one another. Prognostic factors for poor neurologic outcome were early onset of epilepsy, infantile spasms as onset type, and prior neonatal seizures. Children with only partial seizures less frequently had severe mental retardation, cerebral palsy, and visual impairment than those with only generalized seizures.

CONCLUSIONS

Epilepsies in children with mental retardation are characterized by severe seizure manifestations. The brain damage giving rise to mental retardation and epilepsy is probably the main factor in terms of seizure outcome.