Benign epilepsy of children with centrotemporal EEG foci: intelligence, behavior, and school adjustment

Electroencephalographic abnormalities are correlated with cognitive deficits in children with benign childhood epilepsy with centrotemporal spikes: A clinical study of 61 cases

OBJECTIVE

The objective of this study was to explore the effect of spikes on cognition in patients with benign childhood epilepsy with centrotemporal spikes (BECTS) and to identify electroencephalography (EEG) markers enabling early detection of cognitive impairment.

METHODS

Sixty-one children with BECTS diagnoses and 60 age- and education-matched healthy controls were enrolled. Four-hour EEG recordings were analyzed for each patient to check for interictal spikes, high-frequency oscillations (HFOs), nondipole spikes, and other atypical EEG features and to examine the spike-wave index of nonrapid eye movement (NREM) sleep. All 121 children underwent a series of neuropsychological tests to assess cognitive function.

RESULTS

Patients with a high NREM sleep discharge index (≥55%) in the first sleep cycle exhibited significantly lower scores for arithmetic calculation, executive function, and attention and memory tests than patients with a low discharge index (<55%). Eight patients with HFOs exhibited even poorer performance than HFO-negative patients for arithmetic calculation, executive function, vocabulary comprehension, visual perception, vocal perception, spatial memory ability, and response ability. Children with bilateral discharge exhibited poorer ability in three-dimensional spatial imaging test, poorer memory, and slower response than did those with unilateral discharge (P < .05). Nondipole spikes, multiple asynchronous discharges, and generalized spike-wave discharges respectively had an impact on calculation ability, memory, and reaction ability respectively (P < .05).

CONCLUSIONS

Spike frequencies in stage 3 and 4 sleep varied from those observed in stage 1 and 2 sleep; the highest spike frequency was in stage 2 sleep. High NREM sleep discharge index (i.e., ≥55%) and HFOs were linked to the highest risk for cognitive deficit, while bilateral discharges, nondipole spikes, multiple asynchronous discharges, and generalized spike-wave discharges were less indicative of cognitive impairment.

Sequential motor task (Luria's Fist-Edge-Palm Test) in children with benign focal epilepsy of childhood with centrotemporal spikes

This study evaluated the sequential motor manual actions in children with benign focal epilepsy of childhood with centrotemporal spikes (BECTS) and compares the results with matched control group, through the application of Luria's fist-edge-palm test. The children with BECTS underwent interictal single photon emission computed tomography (SPECT) and School Performance Test (SPT). Significant difference occurred between the study and control groups for manual motor action through three equal and three different movements. Children with lower school performance had higher error rate in the imitation of hand gestures. Another factor significantly associated with the failure was the abnormality in SPECT. Children with BECTS showed abnormalities in the test that evaluated manual motor programming/planning. This study may suggest that the functional changes related to epileptiform activity in rolandic region interfere with the executive function in children with BECTS.

Association of language dysfunction and age of onset of benign epilepsy with centrotemporal spikes in children

BACKGROUND

Language dysfunction in children with benign epilepsy with centrotemporal spikes (BECTS) has been well recognized but data regarding its risk factors are heterogenous.

AIMS

To assess language function in children with BECTS and its association with the age of epilepsy onset.

METHODS

We assessed language function in 61 children with BECTS and 35 age and sex-matched controls. Children with BECTS performed significantly worse on all language tasks as compared to controls and overall better language function was positively correlated with older age of the child. Early age at seizure onset demonstrated significant negative correlation with language dysfunction, age below 6 years being related to the lowest performance scores. There was no relationship between the language function and the laterality of epileptic focus, seizure treatment status, or the duration of epilepsy.

CONCLUSION

Children with BECTS have language difficulties that are more pronounced in younger age group. Despite better language functioning in older children with BECTS, their verbal abilities remain inferior to those of children without epilepsy. Early age at seizure onset is a significant factor predicting worse language functioning in children with BECTS.

Atypical hemispheric asymmetries for the processing of phonological features in children with rolandic epilepsy

We assessed language lateralization in 177 healthy 4- to 11-year-old children and adults and atypical asymmetries associated with unilateral epileptic foci in 18 children with benign epilepsy with centrotemporal spikes (BECTS). Dichotic listening results revealed two indices of immature functional asymmetry when the focus was left-sided (BECTS-L). First, children with BECTS-L did not show left hemisphere dominance for the processing of place of articulation, which was recorded in children with BECTS-R and control children. On the contrary, healthy children exhibited a gradual increase in left hemisphere dominance for place processing during childhood, which is consistent with the shift from global to finer-grained acoustic analysis predicted by the Developmental Weighting Shift model. Second, children with BECTS-L showed atypical left hemisphere involvement in the processing of the voiced value (+V), associated with a long acoustic event in French stop consonants, whereas right hemisphere dominance increased with age for +V processing in healthy children. BECTS-L, therefore, interferes with the development of left hemisphere dominance for specific phonological mechanisms.

Benign focal epilepsies of childhood

Until relatively recently, genetic influences in partial seizures were thought to be of minimal importance. However, with further identification of childhood benign partial seizures it is becoming clear that inheritance plays a major role in the pathogenesis of these seizures. Diagnostic criteria proposed for benign partial seizures include absence of neurologic or intellectual deficits, family history of epilepsy, onset of seizures after age 2 years, stereotyped brief seizures, frequent nocturnal occurrence, spontaneous remission in adolescence, and electroencephalograms (EEGs) demonstrating spikes with a distinctive morphology and localization superimposed on normal background activity. The two most commonly described benign partial epilepsies of childhood are benign Rolandic epilepsy (BRE) and benign occipital epilepsy (BOE). Both disorders begin in childhood, are associated with characteristic EEG patterns, have seizures that are easily controlled with medication, often are familial, and have an excellent prognosis. The other benign partial seizure disorders in children that have been described are not as well studied as BOE and BRE, and the role of inheritance pattern, if any, is less clear.

Atypical rolandic epilepsy

Typical benign rolandic epilepsy (BRE) is a frequent and well-delineated epileptic syndrome in childhood. Mild cognitive and behavioral difficulties are increasingly recognized in the course of BRE and should not be considered as atypical features. Atypical features are recognized on electroclinical grounds. These features, particularly early age at onset and frequent spikes or spike-wave discharges, seem to be risk factors for neuropsychological deficits but also for an atypical evolution of BRE. Atypical evolutions of BRE are defined by the appearance of severe neuropsychological impairments and continuous spike-and-waves during slow sleep (CSWSS). The clinical expressions of these situations correspond to the syndromes known as atypical benign focal epilepsy of childhood (ABFEC), status of BRE, Landau-Kleffner syndrome (LKS), and CSWSS syndrome, which may be part of a continuum related to BRE.

The combined burden of cognitive, executive function, and psychosocial problems in children with epilepsy: a population-based study

The combined burden of psychosocial (Achenbach scales), cognitive (Raven matrices), and executive function (EF) problems was studied in a population-based sample of 6- to 12-year-old children with epilepsy (n=162; 99 males, 63 females) and in an age- and sex-matched control group (n=107; 62 males, 45 females). Approximately 35% of the children with epilepsy had severe non-verbal cognitive problems. In those that did not, mild cognitive problems (26% vs 11%, p=0.005), EF problems (31% vs 11%, p<0.001), and psychosocial problems (45% vs 10%, p<0.001) were each much more common than among controls. Having problems in two or all three of these areas simultaneously was more frequent among the children with epilepsy (14% vs. 3%, p<0.001 and 4% vs 0%, p<0.001 respectively). Excluding those having remote symptomatic epilepsy aetiology did not change the problem load significantly for the children with epilepsy with the important exception that having severe non-verbal problems was approximately halved from 35 to 18%. In 30 children with benign epilepsy of childhood with centrotemporal spikes, mild cognitive problems were somewhat more common, but psychosocial and EF problems were similar compared with control children.

Memory and phonological awareness in children with Benign Rolandic Epilepsy compared to a matched control group

PURPOSE

In a previous study we demonstrated children with Benign Rolandic Epilepsy have normal intelligence and language ability. However, difficulties in verbal and visual memory and aspects of phonological awareness were found compared to normative data. To address the methodological limitations related to the use of normative data, we compared the same cohort of children with Benign Rolandic Epilepsy to a matched control group.

METHOD

Controls (n=40) matched on age and gender to the Benign Rolandic Epilepsy cohort underwent neuropsychological assessment. The life functioning of the control group was assessed using a modified version of the Quality of Life in Childhood Epilepsy Questionnaire (QOLCE).

RESULTS

The study confirmed the previous findings of memory and phonological awareness difficulties. In addition, the children with Benign Rolandic Epilepsy had significantly lower IQ scores than the matched control group. Paired sample t-tests showed that on 8 of 11 QOLCE scales, children with Benign Rolandic Epilepsy were rated by parents as having poorer life functioning compared to matched controls, including lower parental ratings on the subscales of memory and language.

DISCUSSION

Benign Rolandic Epilepsy has an excellent seizure prognosis, but this study further emphasizes potential cognitive difficulties. Using an age and gender matched control group, the previous findings of memory and phonological awareness difficulties were validated. These problems in cognition were also identified by parents of children with Benign Rolandic Epilepsy as problematic and impacting upon the child's quality of life.

The spectrum from BCECTS to LKS: The Rolandic EEG trait-impact on cognition

The laboratory hallmark of BCECTS is the rolandic discharge (RD) in the EEG of patients, occurring in a characteristic topographical, vigilance-related, event-related, and age-related pattern, disappearing during puberty. RDs are present in 2% of healthy children. About 8% of children with RDs have epilepsy. An increased prevalence rate of RDs is found in children with cognitive and behavioral disorders, with headaches and some genetic syndromes. In some patients, the cognitive disorders are transient but in others they are progressive, resulting in stable mental retardation after puberty. A recent study of 36 BCECTS patients addressed the following questions. (1) the possible relationship between the severity of RDs and the neuropsychological deficits; (2) the profile of neuropsychological deficits; (3) changes of cognition related to EEG changes; and (4) effects of therapy. No correlation was found between global IQ and the severity of the RDs. All the children had at least one specific learning disorder (sometimes long-lasting). When the children were treated, a correlation between cognitive and EEG improvement could not be demonstrated. Recently, 21 patients without epilepsy but with attention deficit and hyperactivity and/or learning disorders were studied: an open treatment trial with sulthiame resulted in improved sustained and selective attention. The neurobiology of RDs and their relationship to cognitive dysfunction and epilepsy requires further study.

Intellectual and language findings and their relationship to EEG characteristics in benign childhood epilepsy with centrotemporal spikes

Recent research has revealed that benign childhood epilepsy with centrotemporal spikes (BECTS) causes deficient performance in various neuropsychological areas, without arriving at a definition of a uniform profile. The purpose of this study was to examine intelligence and certain language functions in 24 children with an active centrotemporal focus, comparing them with a group of 16 controls matched for age and schooling. Test results were correlated with several EEG characteristics, including focal versus multifocal presentation of interictal epileptiform activity, lateralization, spike maximum on midtemporal or extratemporal electrodes, and rate of interictal activity when awake and during non-REM sleep. Our study demonstrated that children with BECTS have mild language defects, revealed by tests measuring phonemic fluency, verbal re-elaboration of semantic knowledge, and lexical comprehension. Interictal EEG discharges demonstrated that a high rate of occurrence while awake, multifocal location, and temporal prominence seem to impair the efficiency of some of the neuropsychological functions investigated. However, because the last EEG was obtained within the last 2 months (on average) before the assessment, and because BECTS is a form of epilepsy with signs of cortical hyperexcitability that vary over time in terms of rate, side, and location, the pattern of neuropsychological deficiencies could have changed (at least to some degree) by the time of the test, with respect to the EEG variables considered.

Hemispheric lateralization of cognitive functions in children with centrotemporal spikes

We assessed the impact of unilateral epileptic foci in benign idiopathic partial epilepsy of childhood with rolandic discharges (BECT) on performance and hemispheric specialization in lateralized cognitive functions. Six children with BECT with a left-sided focus (BECT-L), 6 children with BECT with a right-sided focus (BECT-R), and 12 control children were tested in verbal, visual-spatial, and visual-attention tasks, with visual hemifield presentation. Children with BECT-R were impaired in the visual-spatial task relative to those with BECT-L, and the typical left-hemisphere (LH) advantage was not reported in the verbal task in children with BECT-L. Additionally, the classic global superiority effect was lacking in children with BECT-R, which may be due to impaired performance of the right hemisphere specialized in global (vs local)-level processing. These data argue for the deleterious effect of epileptic discharges per se on cognitive functions in the developing brain, and the decisive role of epileptic focus lateralization in specific cognitive impairments and hemispheric specialization.

Spacial perception and spatial memory in children with benign childhood epilepsy with centro-temporal spikes (BCECTS)

Despite the benign prognosis regarding the response of seizures to treatment, some evidence now exists that patients with benign childhood epilepsy with centro-temporal spikes (BCECTS) may have neuropsychological deficits sometimes leading to academic underachievement. There is, however, no general agreement on the exact profile of functions disturbed. This study was designed to identify significant deficits in spatial perception and memory in children with BCECTS (ages 6-10 years) compared with healthy controls matched for age, sex and socioeconomic status. The neuropsychological test battery administered consisted of the HAWIK-III, the "Tübinger Luria Christensen Neuropsychological Test Set for Children", the "Kaufman Assessment Battery for Children" and the "Differential Neuropsychological Test". Twenty-two patients and 22 control subjects completed all tests. Children with BCECTS exhibited significant deficits in higher functions of spatial perception, including spatial orientation, as well as in basal and complex spatial memory. Deficits were independent of the lateralization of the epileptogenic foci and independent of anti-convulsive drug treatment.

Cognition and behavior in children with benign epilepsy with centrotemporal spikes (BECTS)

Characteristics of cognitive deficits in benign childhood epilepsy with centrotemporal spikes (BECTS) remain unclear. The authors screened 200 BECTS children presenting for a clinical trial, finding relative weaknesses in fine motor control, visual learning, and attention in the presence of overall normal intellect, with simple partial seizures associated with more difficulty. Parental concerns for psychosomatic and learning problems were noted. Monitoring select cognitive and behavioral features in BECTS appears appropriate.

Cognitive and behavioral effects of nocturnal epileptiform discharges in children with benign childhood epilepsy with centrotemporal spikes

This review addresses the effects of subclinical localized epileptiform discharges during sleep in children with benign childhood epilepsy with centrotemporal spikes (BCECTS) on cognition and behavior. A diversity of educational deficits, behavioral impairments, language delay, and neuropsychological test results have been reported in children with BCECTS. The occurrence of atypical seizure characteristics seems to be related to language delay, and several atypical EEG characteristics are related to cognitive or behavioral problems. It remains to be shown whether treatment of nocturnal discharges in children with BCECTS is indicated to improve cognitive and behavioral problems.

Cognitive functions evaluated by P300 and visual and auditory number assays in children with childhood epilepsy with occipital paroxysms (CEOP)

PURPOSE

This study was planned to evaluate cognitive functions, especially attention and immediate recall, in children with childhood epilepsy with occipital paroxysms (CEOP), by using P300 and neuropsychological tests, which included visual and auditory number assays. Thirty patients with CEOP, ages ranging from 5 to 17 years were enrolled in the study. Twenty-five healthy children were taken as the control group.

METHODS

Oddball paradigm was used in P300 recordings. The latency and the amplitude of the P300 wave recorded from Cz were taken into consideration. The neuropsychological test battery included visual and auditory number assays.

RESULTS

P300 latency was significantly longer in the CEOP group (p=0.014). The results of the visual and auditory number assay test showed significant decline in the patient group when compared with the normal controls.

CONCLUSIONS

Attention and immediate recall deficits as well as prolonged P300 latencies in children with CEOP can be due to an ongoing epileptic activity either influencing the whole brain or only the occipital lobe which can also be involved in the neuropsychological organization of the human cortex. Therefore, children with CEOP should be evaluated with more detailed neuropsychological tests for possible cognitive deficits.

Oxcarbazepine monotherapy in benign childhood epilepsy with centrotemporal spikes: a clinical and cognitive evaluation

We report on 70 patients (aged 5.2-11.6 years) newly diagnosed with benign childhood epilepsy with centrotemporal spikes (BECTS) who were assigned to oxcarbazepine (OXC) monotherapy. All of them underwent clinical and electroencephalographic examination at baseline and at 3- to 6-month intervals during the study. Psychometric assessment was performed at baseline and after 18 months of treatment with the WISC-III, Illinois Test of Psychomotor Abilities, DSM-IV, and Bender-Santucci test. The Mann-Whitney U test was used to describe differences in the frequency of abnormal findings: (1) at initial evaluation, comparing patients with a matched group of 45 healthy controls, and (2) after 18 months of OXC monotherapy, as an individual follow-up in the patient group. Cognitive assessment at baseline revealed mild learning disabilities in 9% of patients and 7% of controls; all participants had a normal intelligence quotient. During the follow-up, sustained cessation of seizures under medication was observed in 53% of patients; an additional 21% had some relapse but were subsequently rendered seizure free, 21% experienced a >50% improvement, and 5% showed no improvement. Normalization of interictal epileptiform activity was observed in 58% of patients, 35% showed an improvement in the grade of electroencephalographic pathology, and 7% manifested no change at all. The initial mildly weak scores in isolated cognitive domains did not deteriorate, and even improved in some cases, during the course of the study, with concomitant electroencephalographic improvement or normalization and effective seizure control. The results of this study suggest that OXC is effective in preventing seizures and normalizing electroencephalograms and seems to preserve cognitive functions and behavioral abilities as long-term monotherapy in children with typical BECTS.

Evidence for a neurophysiologic auditory deficit in children with benign epilepsy with centro-temporal spikes

Benign focal epilepsy in childhood with centro-temporal spikes (BECTS) is one of the most common forms of epilepsy. Recent studies have questioned the benign nature of BECTS, as they have revealed neuropsychological deficits in many domains including language. The aim of this study was to investigate whether the epileptic discharges during the night have long-term effects on auditory processing, as reflected on electrophysiological measures, during the day, which could underline the language deficits. In order to address these questions we recorded base line electroencephalograms (EEG), sleep EEG and auditory event related potentials in 12 children with BECTS and in age- and gender-matched controls. In the children with BECTS, 5 had unilateral and 3 had bilateral spikes. In the 5 patients with unilateral spikes present during sleep, an asymmetry of the auditory event related component (P85-120) was observed contralateral to the side of epileptiform activity compared to the normal symmetrical vertex distribution that was noted in all controls and in 3 the children with bilateral spikes. In all patients the peak to peak amplitude of this event related potential component was statistically greater compared to the controls. Analysis of subtraction waveforms (deviant - standard) revealed no evidence of a mismatch negativity component in any of the children with BECTS. We propose that the abnormality of P85-120 and the absence of mismatch negativity during wake recordings in this group may arise in response to the long-term effects of spikes occurring during sleep, resulting in disruption of the evolution and maintenance of echoic memory traces. These results may indicate that patients with BECTS have abnormal processing of auditory information at a sensory level ipsilateral to the hemisphere evoking spikes during sleep.

The Neuropsychological and Language Profile of Children with Benign Rolandic Epilepsy

PURPOSE

Benign rolandic epilepsy (BRE) has an excellent prognosis for seizures, but recent research has raised concerns using cognition as an outcome measure. Methodologic problems related to recruitment bias and assessment processes are evident in previous studies. With well-defined criteria for inclusion and comprehensive assessment, the aim of this study was to define the cognitive profile of children with BRE and to assess the effect of interictal EEG activity.

METHODS

Patients (n=42) were recruited from six EEG laboratories. The EEG features analyzed were spike frequency, trains, and laterality. Comprehensive neuropsychological and language assessments were conducted. Group means on cognitive measures were compared with normative means. Tests were correlated with EEG features.

RESULTS

The study demonstrated that children with BRE have normal intelligence and language ability. However, a specific pattern of difficulties in memory and phonologic awareness was found. Furthermore, a large proportion of children had disproportionate scores in these areas compared with intellectual and language ability. EEG features were minimally associated with cognitive difficulties, and no correlation was found with memory indices and tests of phonologic awareness.

CONCLUSIONS

Some children with BRE have specific difficulties in memory and phonologic processing skills, not explained by interictal activity. We recommend that pediatricians ask about academic performance specifically in areas of prereading, reading, spelling, and memory. If difficulties are suspected, assessment targeting phonologic awareness and memory are recommended, as they may not be reflected in overall intellectual and language ability. Difficulties in phonologic awareness affect literacy, and memory problems affect academic performance.

Educational problems with underlying neuropsychological impairment are common in children with Benign Epilepsy of Childhood with Centrotemporal Spikes (BECTS)

INTRODUCTION

Benign Epilepsy of Childhood with Centrotemporal Spikes (BECTS) is one of the most common childhood epilepsies with a good prognosis regarding the seizure and neuropsychological outcomes. However, recent reports indicate the presence of neuropsychological problems in a significant percentage of children with BECTS. Our study was aimed to examine the educational performance and neuropsychological functions along with clinical and electrographic characteristics in a cohort of children with BECTS.

METHODS

We identified a cohort of children with BECTS by screening medical and EEG recordings of patients attending our institute. Data were collected with a standard protocol. Their educational performance was evaluated by an interview with the parents. Neuropsychological and language tests were administered to children who had educational problems. Statistical analysis was done using the chi2-test.

RESULTS

Fifty children (29 boys and 21 girls; mean age of onset of epilepsy 7.84+/-2.87 years) who met the criteria for BECTS were included in this study. Atypical seizure characteristics for BECTS were observed in 26 (52%) children. EEG showed typical centrotemporal spike and wave discharges in all children, 42% of them had a tangential dipole in the frontocentral region. An additional extra-rolandic focus in the EEG was found in seven children (14%). Educational problems were identified in 27 children (54%); 19 of them had neuropsychological or language impairment (p=0.003). We found a statistically significant correlation between the occurrence of educational problems and the absence of a tangential dipole in the EEG (p<0.001). Abnormal language function had a significant correlation with atypical seizure semiology (p=0.021).

CONCLUSION

This study shows that a significant number of children with BECTS have neuropsychological impairment and educational problems.

Neuropsychological functions in idiopathic occipital lobe epilepsy

PURPOSE

Despite the benign prognoses of idiopathic partial epilepsies, particularly regarding the response of seizures to treatment, some evidence now exists that patients with such disorders may have subtle neuropsychological deficits. This study was designed to investigate several modalities of neuropsychological functioning in a group of 21 patients, ranging from 6 to 14 years of age, with idiopathic occipital lobe epilepsy (IOLE). The case patients were compared with 21 healthy controls matched for age, sex, and socioeconomic status.

METHODS

A battery of age-appropriate neuropsychological tests was administered individually to all the participants. Tests were chosen on the basis of age-appropriate norms, their ability to represent a wide variety of functional domains, and their appropriateness in a cross-cultural setting. The tests were selected to measure functioning in six domains: intellectual functioning, attention, memory, academic achievement, visual-motor functioning, and executive functioning; some were further subdivided by their verbal-versus-visual modality of functioning.

RESULTS

The results revealed no significant difference in basic neurophysiological functions between the patient and control groups, although the case patients' performance scores were lower in attention (p < 0.01) and memory (p < 0.01), as well as in intellectual functioning (p <.05).

CONCLUSIONS

The possibility of subtle cognitive deficits in IOLE patients should always be considered, though further studies are necessary to elaborate their precise and long-term effects.

Cognitive and behavioral effects of carbamazepine in children: data from benign rolandic epilepsy

The effects of antiepileptic drugs on cognition are difficult to delineate, yet of critical importance for children with epilepsy. We investigated the cognitive and behavioral effects of carbamazepine in children with benign rolandic epilepsy. Ten subjects with benign rolandic epilepsy were evaluated with and without carbamazepine treatment. Fourteen unmedicated subjects with migraine headache evaluated twice served as a control group. Subjects were 6 to 12 years of age, fluent in English, and not mentally retarded. We found that children with benign rolandic epilepsy were quicker on a visual-search task and recalled stories better when not treated than when treated with carbamazepine. After correction for multiple comparisons only the memory finding remained significant. Higher carbamazepine serum level was associated with slower performance on the same visual-search task. This latter finding did not meet multiple comparison criteria. Numerous significant practice effects were found within the control group. Comparisons with reliable change indices identified two subjects with benign rolandic epilepsy with particularly poor scores while receiving carbamazepine. These findings suggest some effects on memory from carbamazepine; however, they do not support meaningful dosage-related effects, within the recommended range. Significant practice effects confirmed the need to control for such effects when evaluating treatments. Finally, identification of two subjects who performed more poorly while on carbamazepine suggests that some children might experience particular difficulties while receiving this medication and highlights the need to investigate individual subject responses to treatment.

Benign epilepsy of childhood with centrotemporal spikes

Benign epilepsy of childhood with centrotemporal spikes (BECT) is the most common partial epilepsy syndrome in the pediatric age group, with an onset between age 3 and 13 years. The typical presentation is a partial seizure with parasthesias and tonic or clonic activity of the lower face associated with drooling and dysarthria. Seizures commonly occur at night and may become secondarily generalized. They are usually infrequent and may not require antiepileptic drugs but, if treated, they tend to be easily controlled. Children with BECT are neurologically and cognitively normal. The EEG shows characteristic high-voltage sharp waves in the centrotemporal regions, which are activated with drowsiness and sleep. In this typical form, BECT is easily recognized. However, atypical cases are common and the definition of BECT can become blurred. Although further investigations are not required in cases with typical clinical and EEG findings and normal neurologic examinations, neuroimaging studies may be required in atypical cases to rule out other pathology. The long-term medical and psychosocial prognosis of BECT is excellent, with essentially all children entering long-term remission by mid-adolescence.

Localization analysis of neuronal activities in benign rolandic epilepsy using magnetoencephalography

Benign epilepsy of childhood with rolandic spikes (BECRS) is an electroclinical syndrome characterized by partial sensorimotor seizures with centrotemporal spikes. We report a detailed localization analysis of spontaneous magnetic brain activities in seven BECRS patients using magnetoencephalography (MEG). All patients had BECRS diagnosis with typical seizures and electroencephalographic findings and five patients had minor psychomotor deficits. MEG was recorded over both parieto-temporal regions using a 2x37-channel biomagnetic system. The collected data were digitally bandpass-filtered (2-6, 14-30, or 1-70 Hz) to analyze slow- and fast-wave magnetic activities and rolandic spikes. Slow-wave activity was increased in four hemispheres of three patients. Increased fast-wave activity was found in all five patients with minor neuropsychological deficits. The presence of increased fast-wave magnetic brain activity appeared to cause functional anomalies in the higher brain function processes. In the spike analysis, the dipoles of rolandic spikes which constantly manifested anterior positivity in direction were concentrated in the superior rolandic region in four cases and the inferior rolandic region in three cases. The localizations of increased slow- and fast-wave activities were identical with those of the spikes. The seizure profiles were frequently characterized by the spike locations. Source localizations of the focal brain activities and rolandic spikes by MEG will contribute to the different diagnosis and pathophysiological elucidation of BECRS.

Neuropsychological, intellectual, and behavioral findings in patients with centrotemporal spikes with and without seizures

Forty children (23 boys, 17 girls) with centrotemporal spikes (rolandic focus) with and without seizures (mean age 8.4 years +/- 4.8 SD), and 40 healthy controls matched for age, sex, and socioeconomic status were assessed for their neuropsychological, intellectual, and behavioral outcome. Compared with the controls, patients were significantly impaired in their IQ, visual perception, short-term memory, in their psychiatric status and in some subtests in a fine motor performance task. No significant differences could be computed for a simple finger-motor speed exercise or a linguistic performance test. In patients, deficits in IQ were significantly correlated with frequency of spikes in the EEG, but not with frequency of seizures, lateralization of the rolandic focus, or time since rolandic focus was diagnosed. It was concluded that a rolandic focus is not as benign as once thought.

Attention problems in epilepsy: possible significance of the epileptogenic focus

Investigation of the relation between epilepsy and cognition presents serious methodologic problems because several factors may contribute to impair neuropsychological performances in epileptic persons. Benign epilepsy of childhood with rolandic paroxysmal discharges (EPR) may be a very useful model of investigation in relation to opportunity to examine subjects without brain damage, therapy, and negative environmental influences. Thus, neuropsychological dysfunction in patients with EPR may support the hypothesis that epilepsy itself plays a specific role in the genesis of cognitive disturbances. We assessed the impact of the laterality of the epileptogenic focus on cognition of children with EPR. All subjects performed a figure cancellation task, a test used to evaluate mainly attention mechanisms and abilities in processing visuospatial information. Results showed that children with right-sided (or bilateral) focus scored worse, whereas children with left-sided focus performed as well as the control subjects. Our data agree with those of studies suggesting that focal discharges may be related to poor cognitive performance. Evidence of a concordance between neurophysiologic and neuropsychologic findings may have great practical and theoretical implications in management of epileptic patients.

Idiopathic epilepsy and school achievement

Forty one children (20 boys, 21 girls) aged 6-10.8 years (mean age 8.6 years) who were affected with idiopathic epilepsy underwent neuropsychological (Wechsler Intelligence Scale for Children, Bender test) and behavioural assessment (Personality Inventory for Children; this was also used in a matched control group). Further information was obtained by teachers' reports. School underachievement occurred in 25 children (61%). Statistical analysis showed no influence of sex, social background, age of onset, seizure type, duration of illness, features seen on electroencephalography, and treatment. School failure was due to poor performance in almost all academic fields, and was associated with higher visuomotor impairment; children showing good school performance had a higher mean IQ and less visuomotor impairment. The behaviour of children with epilepsy who had a good academic performance did not differ from that of their healthy peers. Emotional maladjustment (social skill impairment, depression, poor motivation, and low self esteem) was associated with poor school performance. Such problems, that may complicate the course of idiopathic epilepsy and require an appropriate educational programme, should be carefully considered by the clinician.

Neuropsychological features of benign partial epilepsy in children

Rolandic paroxysmal epilepsy (RPE) is a useful model for investigating the complex links between epilepsy and cognitive dysfunction. 44 children with RPE who met the following (among other) criteria: negative CT scan, freedom from drug treatment, and IQ greater than or equal to 80, were assigned to three subgroups by side of EEG focus: left, right and bilateral. A neuropsychological battery elicited small differences in cognitive performance between the whole group and the controls and among the subgroups, only partially correlated with EEG side. A follow-up assessment showed that the short falls had disappeared along with the seizures and EEG anomalies, thus confirming the benign nature of RPE. Our findings suggest too that the mere presence of paroxysmal cortical activity is enough to trigger cognitive dysfunction.

Language lateralization in children with benign partial epilepsy

To investigate the relationship between epilepsy and hemispheric asymmetries for language, a dual-task procedure was used to assess language lateralization in children with benign rolandic childhood epilepsy. In the sample selection, care was taken to include factors believed to influence both the mental capabilities of epileptic patients and the individual functional cerebral organization. Results suggest that the interhemispheric prevalence pattern is related to the focus site. Controls as well as epileptic patients with a right hemispheric focus showed the expected left language lateralization; conversely, children with a left unilateral focus showed a different pattern of functional representation, suggesting an involvement of the right hemisphere in language mechanisms. It is emphasized that this atypical cerebral organization is found in subjects with no structural lesion and no therapy. It seems likely that the presence of a focal epileptic activity itself can alter the cerebral mechanisms underlying cognitive functions. A relationship between this modified hemispheric specialization and subtle neuropsychological dysfunctions observed in the children with focal epilepsy is suggested.

Spelling errors made by children with mild epilepsy: writing-to-dictation

Errors and corrections made by 64 mildly epileptic children of at least average intelligence who were attending ordinary elementary schools when writing in response to dictation (writing-to-dictation) were assigned to one of 28 descriptive error categories. Numbers and types of errors were compared with those obtained in 630 form-matched, healthy control subjects (Wilcoxon's two-sample test, less than or equal to 0.01). Epileptic children made significantly more errors than control subjects. Separate error categories had no diagnostic power. The groups could not be distinguished on the basis of skill-related errors. However, performance errors (erroneous deviations from the intended product), were found to be made more frequently by epileptic children. Epileptic children made more corrections and also left more errors uncorrected than control children. No relationship could be established with illness variables. Deficient problem-solving strategies, probably resulting from emotional concomitants of epilepsy, may explain the results.

Competent kids: children and adolescents with a chronic illness

The social and personal competence of children and adolescents with a seizure disorder or an orthopaedic condition was assessed by parents and teachers. The contributions to these assessments of characteristics of the child, the intensity of the illness, and the child's temperament were explored using a hierarchical regression model. Parents and teachers rated all children as functioning fairly well. Children with a seizure disorder were perceived as significantly less competent than were their healthy peers (P less than 0.05). Across health status groups, children received higher competence scores from their parents than they did from their teachers (P less than 0.05). Competence scores did not differ according to the age of the child. The patterns of variables that predicted ratings of competence differed according to illness type and rater. Indicators of illness intensity explained a larger share of the variance in competence ratings for children with a seizure disorder (25%) than for children with an orthopaedic condition (5%). For children in this latter group, temperament explained a much larger proportion of the variance in both parents' (29%) and teachers' (42%) ratings of competence than did the illness intensity variables.

Rolandic paroxysmal epilepsy: a long term study in 150 children

150 children with Rolandic paroxysmal epilepsy (RPE) aged 3 to 12 years were followed up clinically and by EEG for 16 years. Antiepileptic drugs were administered initially for 2 years and then suspended for 6-12 months. Treatment was resumed in the 29 patients who had seizures during the drug-free interval and was maintained for a further 5 years. 80.6% of all patients were in clinical remission after the 2-year treatment period. Some patients had seizures while on drugs, others during the drug-free interval. Seizure frequency declined with age. No seizures occurred after the age of 14 or in the 8 years following final discontinuation of drug therapy. The need for prolonged drug treatment is therefore questioned.

Cognitive and behavioural characteristics of children with idiopathic epilepsy in a low-income area of Ankara, Turkey

Fifteen school-age children with idiopathic epilepsy but with no other neurological symptoms were compared with non-epileptic children, matched for age, on four cognitive tests selected to measure specific cognitive skills at two levels of functioning, and a behaviour rating scale. All children were from a low-income district of Ankara, Turkey. Epileptic children did as well as controls on the recognition of a geometric designs test but were significantly inferior at drawing these designs, suggesting some deficit at a cognitive level involving coordination of perception and motor activity. In language functioning, they were significantly poorer on the receptive test but not on the expressive test. They had significantly more behavioural problems than either the control group or their own siblings, those related to fears and anxiety being most prominent. However, in comparison with their siblings, they also had significantly more problems related to conduct- disobedience and inattention. These findings provide further evidence for the importance of some form of counselling for school-age epileptic children and their families.

Long-term prognosis in two forms of childhood epilepsy: typical absence seizures and epilepsy with rolandic (centrotemporal) EEG foci

Findings in children seen between 1955 and 1965 during the year of onset of typical absence seizures (90 patients) or rolandic epilepsy (79 patients) were analyzed by actuarial methods. One hundred and eighteen patients were followed for more than 15 years. Rolandic epilepsy is a true benign epilepsy ending with puberty. Although school and family problems are common during the acute stage of the disease, the social adaptability of such patients is excellent. We considered only typical absences occurring as a first epileptic sign in normal children. Myoclonic or atonic absences have a poor prognosis. Many patients with simple and automatic absences experience remission 15 years after withdrawal of medication. The overall cessation rate in those experiencing absences was only 57.5%, however, and 36% of patients developed tonic-clonic seizures. Social adaptability was often inadequate. Simple and automatic absences (constituting a homogeneous group) are not truly a benign form of epilepsy, even though prognosis for those afflicted is better than that for those with other forms of primary generalized epilepsy.

Benign epilepsy of children with centrotemporal EEG foci: a follow-up study in adulthood of patients initially studied as children

A group of patients with benign epilepsy of children with centrotemporal EEG foci, consisting of 40 patients reported 10 years ago, has been reinvestigated. Thirty-seven of these patients were reinvestigated. They were 26-34 years old (mean, 29 years). The observation time from the first seizure was 13-27 years (mean, 21 years). Thirty-six patients had been seizure free for 14-23 years (mean, 18.5 years); 32 patients had stopped medication 5-22 years ago (mean, 18.5 years); and 5 patients had had problems in obtaining their drivers' licenses. No epileptic discharges were found in those 24 patients who volunteered for a new EEG study. The conclusion is drawn that this common seizure disorder in children has a good long-term prognosis.