Benign partial epilepsy with secondarily generalized seizures in infancy

Sodium channel blockers are effective for benign infantile epilepsy

OBJECTIVE

To examine the efficacy and tolerance of the antiseizure medications lacosamide (LCM) and levetiracetam (LEV) in patients with benign infantile epilepsy (BIE).

METHODS

The clinical data of 24 children with BIE seen between 2014 and 2020 were collected retrospectively, and treatment, effectiveness, and adverse effects were examined. PRRT2 gene analysis was performed using Sanger sequencing.

RESULTS

Of the 24 children with BIE, 14 were treated with antiseizure medications. PRRT2 gene analysis was performed in 14 children, and mutations were identified in 4, including a pair of siblings. All five children treated with LCM became seizure-free, similar to those treated with carbamazepine. The LCM does was 2 mg/kg/day in all cases. There were no adverse effects in any patient treated with LCM. By contrast, both patients treated with LEV had seizure recurrence. In one patient, LEV was replaced with CBZ, resulting in seizure freedom.

CONCLUSIONS

Low-dose LCM was effective and well tolerated in patients with BIE, whereas LEV was insufficiently effective.

Crises fébriles chez l’enfant : à propos d’une histoire familiale

Les crises fébriles (CF) sont les crises convulsives les plus fréquentes prises en charge dans les services d’urgence dans la population des moins de cinq ans. Elles sont une crise accompagnée de fièvre, sans infection du système nerveux central, se produisant chez les enfants entre six mois et cinq ans. Les critères utilisés et enseignés pour classer les crises en simples ou complexes n’ont pas la même signification en pratique clinique pour prendre la décision d’effectuer une ponction lombaire et/ou une imagerie cérébrale, et pour l’indication de la prescription d’un antiépileptique de recours ou de fond. Certains facteurs sont prédictifs de la récurrence fébrile, tandis que d’autres sont prédictifs d’une épilepsie. À partir de deux cas cliniques de CF complexes, nous proposons une démarche de prise en charge et de faire une revue des syndromes épileptiques survenant au décours des CF chez le jeune nourrisson.

Different experiences of two PRRT2-associated self-limited familial infantile epilepsy

To analyze the clinical characteristics and PRRT2 gene mutation of self-limited familial infantile epilepsy and evaluate the treatment responses of different antiepileptic drugs in self-limited familial infantile epilepsy. We reviewed the clinical feature and genetic mutation results and treatment responses of two sibling sisters. They were detected with the PRRT2 gene mutation through Sanger sequencing. Elder sister was treated with oxcarbazepine oral suspension, while younger sister was treated with levetiracetam oral solution. The two sibling sisters exhibited PRRT2 heterozygous mutation inherited from their mother in c.649dupC p.(Arg217fs). Oxcarbazepine oral suspension had an immediate effect on the elder sister who was treated with it. However, levetiracetam oral solution had no effect on younger sister even though the dose was increased, but she got seizure-free after turning to oxcarbazepine oral suspension. Oxcarbazepine, which plays the mechanism of the sodium channel blockers, has a more significant effect than levetiracetam, which has no mechanism of the sodium channel blockers in self-limited familial infantile epilepsy. The PRRT2 gene of infantile epileptic patients with a family history of infantile convulsions or paroxysmal kinesigenic dyskinesia(PKD) could be detected by sanger sequencing and a biomarker to select antiepileptic drugs which play the mechanism of the sodium channel blockers could be utilized.

Splenial Lesions in Benign Convulsions With Gastroenteritis Associated With Rotavirus Infection

OBJECTIVE

To investigate clinical risk factors for acute magnetic resonance imaging (MRI) abnormalities in patients with benign convulsions with mild gastroenteritis or benign infantile epilepsy.

STUDY DESIGN

We investigated clinical and diffusion-weighted imaging findings in 32 patients with benign convulsions with mild gastroenteritis and 22 patients with benign infantile epilepsy who underwent MRI within seven days of seizure onset between 2010 and 2015.

RESULTS

Diffusion-weighted imaging showed signal hyperintensity in the splenium of the corpus callosum in seven patients with benign convulsions with mild gastroenteritis, but no abnormalities in patients with benign infantile epilepsy. Patients with benign convulsions with mild gastroenteritis with splenial lesions showed a higher rate of rotavirus detection from feces (P = 0.006), higher serum level of C-reactive protein (P = 0.04), and shorter interval between seizure onset and MRI (P = 0.002) than patients with benign convulsions with mild gastroenteritis without splenial lesions. Multivariate analysis revealed rotavirus infection as a significant risk factor for splenial lesions on diffusion-weighted imaging in patients with benign convulsions with mild gastroenteritis (P = 0.02).

CONCLUSIONS

Splenial lesions are often seen during acute period in patients with benign convulsions with mild gastroenteritis. Rotavirus infection is a risk factor for splenial lesions in patients with benign convulsions with mild gastroenteritis, suggesting the role of rotavirus to cause edema in the corpus callosum. From our observations, benign convulsions with mild gastroenteritis with a splenial lesion on diffusion-weighted imaging suggests good outcomes, and extensive evaluation of these patients may be unnecessary.

The clinical and genetic spectrum in infants with (an) unprovoked cluster(s) of focal seizures

BACKGROUND

Self-limited (familial) infantile epilepsy (S(F)IE), formerly known as benign (familial) infantile convulsions (B(F)IC), is an infantile cluster epilepsy with in rule a complete recovery. This form of epilepsy is most often caused by variations in the PRRT2 gene (OMIM #605751).

AIM

To describe the clinical and genetic spectrum of sudden onset clusters of focal seizures in infancy.

METHODS

We retrospectively reviewed all individuals, who presented with unprovoked infantile seizures and selected all infants who had unprovoked clustered focal seizures between 1 and 20 months of age. We described the clinical and genetic spectrum of this cohort.

RESULTS

The data of 23 patients from 21 families were collected. All had an initial diagnosis of S(F)IE which was adjusted in 5 individuals. In 12 individuals a pathogenic variation in PRRT2 gene or complete deletion was identified. Pathogenic variants in PCDH19 and KCNQ2 were found in respectively 3 and 1 individuals. One individual had a non-pathogenic variant in ATP1A3 and in 6 others no variants were identified. The mean cluster duration was 2.9 days (range 1-13) (see Table 1). Twelve infants had only one cluster. All patients had focal motor or non-motor seizures, in 12 (52%) followed by bilateral (tonic)clonic seizures. Positive family history was present in 74% of individuals. In 11/12 (92%) tested families, ≥1 family member carried the pathogenic PRRT2 variant. Age of seizure onset (ASO) averaged 6.2 months (range 2-20 months). Age of latest seizure averaged 16 months (range 2-92). In several interictal EEG (electroencephalogram) recordings multifocal spikes or spike-wave abnormalities were detected. Ictal EEG recordings detected primary focal abnormalities.

CONCLUSION

We described 23 individuals with unprovoked cluster(s) of focal seizures at infancy. It appears to be a heterogeneous group. Half of them had a pathogenic variation in PRRT2 gene. Most had only one cluster of seizures. When clusters reoccur frequently, when seizures are more therapy-resistant and when seizures persist beyond the age of 2 years, another diagnosis or causative gene is likely.

Antiepileptic Effects of a Novel Non-invasive Neuromodulation Treatment in a Subject With Early-Onset Epileptic Encephalopathy: Case Report With 20 Sessions of HD-tDCS Intervention

The current clinical investigation examined high-definition transcranial direct current stimulation (HD-tDCS) as a focal, non-invasive, anti-epileptic treatment in a child with early-onset epileptic encephalopathy. We investigated the clinical impact of repetitive (20 daily sessions) cathode-centered 4 × 1 HD-tDCS (1 mA, 20 min, 4 mm ring radius) over the dominant seizure-generating cortical zone in a 40-month-old child suffering from a severe neonatal epileptic syndrome known as Ohtahara syndrome (OS). Seizures and epileptiform activity were monitored and quantified using video-EEG over multiple days of baseline, intervention, and post-intervention periods. Primary outcome measures were changes in seizure frequency and duration on the last day of intervention versus the last baseline day, preceding the intervention. In particular, we examined changes in tonic spasms, tonic-myoclonic seizures (TM-S), and myoclonic seizures from baseline to post-intervention. A trend in TM-S frequency was observed indicating a reduction of 73% in TM-S frequency, which was non-significant [t(4) = 2.05, p = 0.1], and denoted a clinically significant change. Myoclonic seizure (M-S) frequency was significantly reduced [t(4) = 3.83, p = 0.019] by 68.42%, compared to baseline, and indicated a significant clinical change as well. A 73% decrease in interictal epileptic discharges (IEDs) frequency was also observed immediately after the intervention period, compared to IED frequency at 3 days prior to intervention. Post-intervention seizure-related peak delta desynchronization was reduced by 57%. Our findings represent a case-specific significant clinical response, reduction in IED, and change in seizure-related delta activity following the application of HD-tDCS. The clinical outcomes, as noted in the current study, encourage the further investigation of this focal, non-invasive neuromodulation procedure in other severe electroclinical syndromes (e.g., West syndrome) and in larger pediatric populations diagnosed with early-onset epileptic encephalopathy. Clinical Trial Registration: www.ClinicalTrials.gov, identifier NCT02960347, protocol ID: Meiron 2013-4.

Crises fébriles chez l’enfant : à propos d’une histoire familiale

Les crises fébriles (CF) sont les crises convulsives les plus fréquentes prises en charge dans les services d’urgence dans la population des moins de cinq ans. Elles sont une crise accompagnée de fièvre, sans infection du système nerveux central, se produisant chez les enfants entre six mois et cinq ans. Les critères utilisés et enseignés pour classer les crises en simples ou complexes n’ont pas la même signification en pratique clinique pour prendre la décision d’effectuer une ponction lombaire et/ou une imagerie cérébrale, et pour l’indication de la prescription d’un antiépileptique de recours ou de fond. Certains facteurs sont prédictifs de la récurrence fébrile, tandis que d’autres sont prédictifs d’une épilepsie. À partir de deux cas cliniques de CF complexes, nous proposons une démarche de prise en charge et de faire une revue des syndromes épileptiques survenant au décours des CF chez le jeune nourrisson.

The role of EEG in the diagnosis and classification of the epilepsy syndromes: a tool for clinical practice by the ILAE Neurophysiology Task Force (Part 2)

The concept of epilepsy syndromes, introduced in 1989, was defined as "clusters of signs and symptoms customarily occurring together". Definition of epilepsy syndromes based on electro-clinical features facilitated clinical practice and, whenever possible, clinical research in homogeneous groups of patients with epilepsies. Progress in the fields of neuroimaging and genetics made it rapidly clear that, although crucial, the electro-clinical description of epilepsy syndromes was not sufficient to allow much needed development of targeted therapies and a better understanding of the underlying pathophysiological mechanisms of seizures. The 2017 ILAE position paper on Classification of the Epilepsies recognized that "as a critical tool for the practicing clinician, epilepsy classification must be relevant and dynamic to changes in thinking". The concept of "epilepsy syndromes" evolved, incorporating issues related to aetiologies and comorbidities. A comprehensive update (and revision where necessary) of the EEG diagnostic criteria in the light of the 2017 revised terminology and concepts was deemed necessary. Part 2 covers the neonatal and paediatric syndromes in accordance with the age of onset. [Published with educational EEG plates at www.epilepticdisorders.com].

Difficulty of Early Diagnosis and Requirement of Long-Term Follow-Up in Benign Infantile Seizures

PURPOSE

We investigated whether benign infantile seizures can be diagnosed in the acute phase.

METHODS

We retrospectively analyzed the medical records of 44 patients initially diagnosed with acute phase benign infantile seizures. All patients were followed for more than 12 months, and we reviewed patients' psychomotor development and presence or absence of seizure recurrence at the last visit. Patients were divided into the following three groups according to the final diagnosis: benign infantile seizures, benign infantile seizures associated with mild gastroenteritis, and non-benign infantile seizures. We defined benign infantile seizures associated with mild gastroenteritis and benign infantile seizures as those associated with normal psychomotor development and no seizure recurrence 3 months after onset of the first seizure, whereas non-benign infantile seizures were associated with delayed psychomotor development and/or seizure recurrence after 3 months of onset of the first seizure. We analyzed the clinical features in the acute phase and compared them between the groups.

RESULTS

The median age of seizure onset was 7.6 months. A final diagnosis of benign infantile seizures associated with mild gastroenteritis was made in three patients. In the remaining 41 patients, the final diagnosis was benign infantile seizures in 30 (73.2%) and non-benign infantile seizures in 11 (26.8%). In the non-benign infantile seizure group, intellectual disability was diagnosed in eight patients and seizure recurrence in six. There were no significant differences in clinical features between the groups in the acute phase, such as seizure type or seizure duration.

CONCLUSION

About 30% of patients initially diagnosed as having benign infantile seizures did not experience a benign clinical course. Our findings suggest that clinical features in the acute phase are not helpful for predicting benign outcomes in benign infantile seizures and that only long-term follow-up can discriminate benign infantile seizures from non-benign infantile seizures.

Clinical characteristics of seizures associated with viral gastroenteritis in children

OBJECTIVE

We analyzed the clinical features of seizures during gastroenteritis in children by comparing the norovirus and rotavirus pathogen, and the impact of fever, if present, during the seizure episodes.

METHODS

Retrospective analysis was performed on 293 consecutive pediatric patients admitted with viral gastroenteritis to Osaka General Hospital between November 2007 and May 2009. Eighteen patients developed seizures, 12 of whom were positive for norovirus and six for rotavirus, as revealed by antigen detection. Of these 18 seizure patients, eight presented without fever (the aFS group) and 10 presented with febrile episodes (FS group).

RESULTS

Seizure patients in the rotavirus group (83%) were more likely to be febrile than those in the norovirus group (58%). Compared with the aFS group, 90% of patients in the FS group presented seizures at an early stage of gastroenteritis. The frequency of clustered seizures in the FS group was considerably higher than that of febrile seizures in general and was also as high as that of "convulsions with mild gastroenteritis (CwG)". All seizure patients, whether febrile or afebrile, presented with generalized tonic clonic seizures (GTCS), complex partial seizures (CPS), or both. Diazepam (DZP) was less effective and carbamazepine (CBZ) was completely effective for the cessation of seizures in the FS group, similar to the drug response observed in CwG.

CONCLUSIONS

The causative pathogen (norovirus or rotavirus) affected the frequency of febrile episodes during gastroenteritis, but fever had little effect on the clinical features of seizures. However, seizures occurred earlier during gastroenteritis in the FS group. On the whole, the clinical features of febrile seizures during viral gastroenteritis may closely resemble those of "convulsions with mild gastroenteritis" (CwG) than those of febrile seizures in general with respect to the frequency of clustered seizures and the antiepileptic drug responses and may have a pathogenic mechanism distinct from those of febrile seizures due to other causes.

Dacrystic seizures: demographic, semiologic, and etiologic insights from a multicenter study in long-term video-EEG monitoring units

PURPOSE

To provide an estimate of the frequency of dacrystic seizures in video-electroencephalography (EEG) long-term monitoring units of tertiary referral epilepsy centers and to describe the clinical presentation of dacrystic seizures in relationship to the underlying etiology.

METHODS

We screened clinical records and video-EEG reports for the diagnosis of dacrystic seizures of all patients admitted for video-EEG long-term monitoring at five epilepsy referral centers in the United States and Germany. Patients with a potential diagnosis of dacrystic seizures were identified, and their clinical charts and video-EEG recordings were reviewed. We included only patients with: (1) stereotyped lacrimation, sobbing, grimacing, yelling, or sad facial expression; (2) long-term video-EEG recordings (at least 12 h); and (3) at least one brain magnetic resonance imaging (MRI) study.

KEY FINDINGS

Nine patients (four female) with dacrystic seizures were identified. Dacrystic seizures were identified in 0.06-0.53% of the patients admitted for long-term video-EEG monitoring depending on the specific center. Considering our study population as a whole, the frequency was 0.13%. The presence of dacrystic seizures without other accompanying clinical features was found in only one patient. Gelastic seizures accompanied dacrystic seizures in five cases, and a hypothalamic hamartoma was found in all of these five patients. The underlying etiology in the four patients with dacrystic seizures without gelastic seizures was left mesial temporal sclerosis (three patients) and a frontal glioblastoma (one patient). All patients had a difficult-to-control epilepsy as demonstrated by the following: (1) at least three different antiepileptic drugs were tried in each patient, (2) epilepsy was well controlled with antiepileptic drugs in only two patients, (3) six patients were considered for epilepsy surgery and three of them underwent a surgical/radiosurgical or radioablative procedure. Regarding outcome, antiepileptic drugs alone achieved seizure freedom in two patients and did not change seizure frequency in another patient. Radiosurgery led to moderately good seizure control in one patient and did not improve seizure control in another patient. Three patients were or are being considered for epilepsy surgery on last follow-up. One patient remains seizure free 3 years after epilepsy surgery.

SIGNIFICANCE

Dacrystic seizures are a rare but clinically relevant finding during video-EEG monitoring. Our data show that when the patient has dacrystic and gelastic seizures, the cause is a hypothalamic hamartoma. In contrast, when dacrystic seizures are not accompanied by gelastic seizures the underlying lesion is most commonly located in the temporal cortex.

Benign convulsions in newborns and infants: occurrence, clinical course and prognosis

BACKGROUND

During early development severe epilepsies may appear, some with well established occurrence. Benign non-epileptic and epileptic paroxysmal syndromes with excellent prognosis occur in the same period. There are no exact data on their occurrence.

AIM

We have reviewed medical histories of children with benign non-epileptic or benign epileptic events: benign myoclonus of early infancy, benign neonatal sleep myoclonus, benign sleep myoclonus in infancy, benign partial epilepsy in infancy (BPEI) and benign infantile familial convulsions (BIFC) were established. The occurrence, clinical characteristics and prognosis of these syndromes were evaluated.

METHODS

Inclusion criteria were met in 31 children. Research included retrospective analysis of clinical characteristics, laboratory values, neuroimaging and neurophysiological assessments, followed by evaluation of psychosocial development with the use of the Strengths and Difficulties Questionnaire (SDQ), fulfilled by parents.

RESULTS

In our group the incidence of benign non-epileptic convulsions was 6.69 per 10 000 live births and the incidence of benign epileptic convulsions was 1.35 per 10 000. Male/female ratio in the group of children with non-epileptic events was 2.1:1. Among non-epileptic group 5 out of 23 children and among epileptic group 3 out of 8 children had minimal, mild or moderate abnormalities at neurological assessment at the time of the first clinical examination. Nonspecific changes in laboratory values were seen in 6 out of 23 in the non-epileptic and in 1 out of 8 children in the epileptic group. Neurophysiological assessments showed subtle changes in 4/23 in the non-epileptic and 6/8 in the epileptic group. Neuroimaging was not optimal in 5/23 with non-epileptic and 3/8 with epileptic events. Analysis of SDQ did not show significant deviations in psyhosocial development. Statistically significant deviation was observed only in relations with peers (p = 0.009).

CONCLUSIONS

Benign neonatal and infantile convulsions are more frequent than severe epilepsies of the same age period. Results show higher proportion of males with benign non-epileptic conditions. No deviations in further development was found. Laboratory values, neuroimaging and neurophysiological assessments were normal or nonspecifically changed.

Characterization of childhood-onset complex partial seizures associated with autism spectrum disorder

Autism spectrum disorder (ASD) has a close relationship with epilepsy. A previous study showed complex partial seizures (CPS) to be the most frequent type of epileptic seizures in cases of ASD. Patients with childhood-onset CPS were retrospectively studied to investigate the prevalence of ASD and to characterize the association between CPS and ASD. The study cohort comprised 86 patients with CPS manifesting at 1 to 9 years of age. Symptomatic CPS and Panayiotopoulos syndrome were excluded. Patients with ASD (ASD group) were compared with those without ASD (non-ASD group). Of the 86 patients with childhood-onset CPS, 36 (42%) also had ASD. This ASD group was predominantly male (68.6%), with higher rates of intellectual disability (69%), and reported frequent seizures (60% had monthly or more frequent seizures). CPS without secondary generalization were more common in the ASD group (69%) than in the non-ASD group (36%), as were frontal paroxysms on EEG (54.5% vs 30%, respectively). In the non-ASD group, 82% of cases had been seizure free for 2 or more years, in comparison to 50% in the ASD group. ASD is frequently associated with childhood-onset CPS. Male gender, cognitive deficits, frequent seizures, and frontal paroxysms are risk factors for the association of ASD with CPS.

Benign convulsions with mild gastroenteritis: is it associated with sodium channel gene SCN1A mutation?

Benign convulsions with mild gastroenteritis were afebrile seizures associated with gastroenteritis in previously healthy infants or young children. It has been thought to be a continual spectrum of benign infantile convulsions because of overlapping clinical pictures. Recently, molecular genetic studies have suggested a channelopathy in benign infantile convulsions. The authors prospectively studied the clinical features of benign convulsions with mild gastroenteritis in Taiwanese children and clarified the relationship between neuronal sodium channel alpha 1 subunit (SCN1A) gene and benign convulsions with mild gastroenteritis. The clinical pictures in their patients were similar to those of previous studies except for the low rate of positive rotavirus antigen in the stool, which may indicate a season-related viral infection. No mutations in the SCN1A gene were identified in all patients. This study suggested that SCN1A mutations are probably not associated with benign convulsions with mild gastroenteritis. Other possible pathogenic mechanisms need to be researched in the future.

Benign familial and non-familial infantile seizures (Fukuyama-Watanabe-Vigevano syndrome): a study of 14 cases from Saudi Arabia

PURPOSE

Benign infantile seizures [BIS], familial and non-familial, represent a benign, age-related idiopathic syndrome of infancy. The aim of the current paper is to document the presence of the syndrome in Saudi Arabia and in Arab populations and to discuss the characteristic electroclinical features and the benign nature of this syndrome.

PATIENTS AND METHODS

A case series of 275 patients with epileptic seizures (age range: 2 months-13 years) were followed over a period of 3 years and 7 months. The inclusion criteria for BIS were as follows (1) age of seizure onset between 2 and 24 months, (2) normal development before, during and after the onset of seizures, (3) normal interictal EEG, (4) normal brain imaging, and (5) good response to treatment. We analyzed these infants with respect to age at seizure onset, sex, physical and neurological examination, consanguinity, frequency and type of convulsions, associated conditions and laboratory and radiological investigations. A waking and sleeping interictal EEG was performed on all patients, and for one patient (No. 1), ictal EEG and video clips were recorded.

RESULTS

Fourteen infants (12.0%) showed electroclinical features consistent with BIS. Eleven patients fulfilled the criteria of benign non-familial infantile seizures (BNFIS), and for three patients, their family pedigrees showed the possibility of benign familial infantile seizures (BFIS). All of the patients responded to anti-epileptic treatment, and 50% of them responded within 3 months.

CONCLUSIONS

To our knowledge, this is the first study to document the presence of BIS (Fukuyama-Watanabe-Vigevano syndrome) in Saudi Arabian and Arab populations. We highlighted the characteristic features of BIS and demonstrated the benign nature of the syndrome.

Prognosis of patients with seizures occurring in the first 2 years

The aim of this study is to determine the prognosis of patients with seizure onset from 1 to 24 months of age in respect to epilepsy, developmental outcome, and neurological status. It also aims to determine predictive factors regarding an unfavorable prognosis. Seventy-five patients were retrospectively analyzed. Univariate analysis revealed the following findings: (1) mental retardation at initial admission, abnormal neurological finding, infantile spasm, use of more than 1 antiepileptic drug, epileptic activity on electroencephalography (EEG) of neonatal seizure, and perinatal anoxia were significant risk factors with regard to developmental outcome; (2) mental retardation at initial admission, abnormal neurological finding, infantile spasm, use of more than 1 antiepileptic drug, epileptic activity on EEG, symptomatic etiology, history of neonatal seizure, and perinatal anoxia were significant risk factors regarding neurological status; and (3) mental retardation at initial admission, neurological abnormality, infantile spasm, use of more than 1 antiepileptic drug, epileptic activity on EEG, status epilepticus, symptomatic etiology, seizure frequency of more than once per week, history of perinatal anoxia, and neonatal seizure were significant risk factors regarding epilepsy prognosis. In addition, multivariate analysis revealed that neurological abnormality and use of more than 1 antiepileptic drug were significant for developmental outcome, that epileptic activity on EEG and use of more than 1 antiepileptic drug were significant for neurological status, and that perinatal anoxia, infantile spasm, and status epilepticus were significant for epilepsy prognosis. These findings suggest that neurological abnormality, use of more than 1 antiepileptic drug, infantile spasm, status epilepticus, and perinatal anoxia are unfavorable predictive risk factors regarding the prognosis of patients with seizures that have an onset from 1 to 24 months of age.

Ictal EEG in patients with convulsions with mild gastroenteritis

The aim of this study is to reveal detailed clinical manifestations and an evolution of ictal EEG discharges of convulsions with mild gastroenteritis (CwG). We recorded ictal EEGs of six patients with CwG. Clinical manifestations included loss of responsiveness, motion arrest, cyanosis, lateral eye deviation, and hemifacial convulsion. Automatism was not observed in any patients. A generalized tonic-clonic convulsion was observed in five of six patients. Ictal EEGs demonstrated that all seizures were of focal onset that evolved into a secondarily generalized seizure. The region of the onset of ictal discharge was the occipital area in three patients, parietal in one, central in one, and frontal in one, respectively. The seizure of patients with CwG is likely to be a partial seizure with secondary generalization.

Ictal EEG in benign partial epilepsy in infancy

The aim of this study is to further clarify ictal electroencephalographic findings of patients with benign partial epilepsy in infancy in order to better understand its neurophysiologic features. The study group consisted of 13 infants with definite benign partial epilepsy in infancy, in whom ictal electroencephalograms were recorded and its benignity was confirmed at 8 years or more. The seizure manifestation was reviewed on the basis of video findings in eight patients in whom simultaneous video-electroencephalography recording was available. In the other five patients, the seizure manifestations were determined according to the observations of physicians, nurses, or technicians. Thirteen seizures from eight patients were complex partial, and six seizures from six patients were secondarily generalized ones. Ictal discharges at the onset of a seizure were focal in all seizures. The site of the origin of seizures was in the temporal area in 10 of 13 complex partial seizures, whereas it was in the parietal or occipital area in all 6 secondarily generalized seizures. Among 13 complex partial seizures, paroxysmal discharges remained focal throughout the seizures in 6 seizures, whereas they spread to one hemisphere in the other 7 seizures. Motion arrest or decreased responsiveness was uniformly observed. Lateral eye deviation was commonly recognized in complex partial seizures, whereas head rotation was observed only in seizures in which hemispheric propagation of ictal discharges was observed. Ictal electroencephalographic findings of patients with benign partial epilepsy in infancy were relatively uniform, suggesting the homogeneity of patients with benign partial epilepsy in infancy.

Antiepileptic treatment against clustered seizures in benign partial epilepsy in infancy

We performed detailed review of clinical course of clustered seizures in patients with benign partial epilepsy in infancy in order to determine the optimal treatment during the acute period. We retrospectively investigated the details of antiepileptic treatment for clustered seizures in 20 patients with benign partial epilepsy in infancy. The temporal course of seizures and the use of antiepileptic drugs were investigated in each patient. Drugs were judged as effective when seizure cessation was achieved after administration of the drug. As the first drug, diazepam/bromazepam was effective in 14% and phenobarbital in 60%. As the second drug, diazepam/bromazepam was effective in 13% and phenobarbital in 40%. As the third drug, phenobarbital was effective in 56%. The efficacy rate of the first dose of phenobarbital was relatively higher than that of diazepam/bromazepam. Persistence of seizures after treatment was relatively shorter and the number of seizures after treatment was relatively smaller in patients treated with PB as the first 2 drugs. In conclusion, the efficacy of diazepam/bromazepam or phenobarbital was insufficient for the cessation of clustered seizures in benign partial epilepsy in infancy.

The spectrum of benign infantile seizures

Benign epilepsies during infancy are a wide topic, which needs both clinical and nosological clarifications. Already in 1963 Fukuyama reported patients with seizures during infancy with a benign outcome. In the late 80s and early 90s, Watanabe reported series of infants with complex partial seizures or partial seizures with secondary generalization, with a normal development before onset and a benign outcome. In the same years Vigevano focused on familial cases: he described several families with seizures with onset around the 6-month of age, and autosomal dominant mode of inheritance. To define this condition, he coined the term "benign familial infantile seizures" (BFIS). Afterwards, studying families with this phenotype, loci on chromosomes 19, 16 and 2 responsible for BFIS were detected. Similar loci were found in families affected by BFIS and subsequent choreoathetosis, and BFIS associated with familial hemiplegic migraine. In most recent years a new form of benign epilepsy has been proposed, with an intermediate onset between the neonatal and infantile age, which was defined with the term benign familial neonatal-infantile seizures (BFNIS). This condition could have some clinical and genetic features overlapping with BFIS. Seizures with a benign outcome have been reported also in infants during episode of mild gastroenteritis (BIS with MG) frequently with positive Rotavirus antigen. Lastly, sleep EEG abnormalities have been reported in children with a peculiar form of epilepsy by Capovilla, who defined this condition as benign infantile focal epilepsy with midline spikes and waves during sleep (BIMSE). Some of these entities have been included in the last classification proposed by the ILAE and have been differentiated in familial and non-familial forms. The aim of this review is to describe these entities, discuss their nosological aspects, pointing out the similarities and differences with benign neonatal seizures and benign focal epilepsies appearing later in life such as early-onset benign occipital seizure susceptibility syndrome (EBOSS), or benign epilepsy of childhood with centro-temporal spikes (BECTS).

Classification of benign infantile afebrile seizures

PURPOSE

The aim of this study is to classify infantile cases with benign seizures into known epileptic syndromes, thereby facilitating discussion of clinical factors that could play an important role in diagnosis.

SUBJECTS

Fifty-seven patients with afebrile seizures fulfilling all of the following criteria were enrolled: (1) normal development prior to the onset, (2) no underlying disorders nor neurological abnormalities, (3) onset before the age of four and (4) normal interictal EEG and neuroimaging findings.

RESULTS

Thirty-nine cases (Group A) were characterized by an association of mild gastroenteritis. The remaining 18 cases were divided into two groups according to the seizure type. One group had partial seizures (Group B, 13 cases) while the other was suspected to have generalized seizures (Group C, 5 cases). Age at onset was significantly higher for Group A (19.5 +/- 5.5 months) than Groups B (5.3 +/- 1.8 months) (p<0.001) and C (5.8 +/- 3.5 months) (p=0.038). Positive family history of seizure disorder, seizure cluster tendency, and the efficacy of lidocaine against seizure clusters were common in the three groups.

CONCLUSIONS

Features in Group A were consistent with benign convulsions with mild gastroenteritis (proposed by Morooka) [Morooka, K., 1982. Mild diarrhea and convulsions. Shonika 23, 134-137 (in Japanese)], those of Group B with benign partial epilepsy in infancy [Watanabe, K., Yamamoto, N., Negoro, T., Takaesu, E., Aso, K., Furune, S., Takahashi, I., 1987. Benign complex partial epilepsies in infancy. Pediatr. Neurol. 3, 208-211], and those of Group C with benign infantile convulsions [Fukuyama, Y., 1963. Borderland of epilepsy with special reference to febrile convulsions and so-called infantile convulsions. Seishin Igaku 5, 211-223 (in Japanese)]. The distinction between these syndromes depends upon age at onset, association with gastroenteritis, and ictal symptomatology. In our experience, however, it was not easy to catch seizure type accurately in clinical situations. As far as the results of ictal video-EEG monitoring ever carried out concern, focal initiation of parxysmal discharges was demonstrated in all cases, not only of BPEI but also of apparent generalized seizures examined without exception. These observations led the authors to conclude that the identity of BIC is dubious, most probably it will represent a subtype of BPEI.

Benign partial epilepsy in infancy long-term outcome and marginal syndromes

Benign partial epilepsy in infancy (BPEI) is an infantile epilepsy with excellent seizure and developmental outcome proposed by Watanabe et al. Our telephone interview survey revealed that the long-term outcome of patients with BPEI was also excellent over 8 years of age. Six of 39 patients did not fulfill the criteria of BPEI by the last follow-up. Two patients had a recurrence of unprovoked seizure beyond 2 years of age, three had cognitive problems (mild mental retardation in two and Asperger syndrome in one) and the other had both a recurrence of seizure and mild mental retardation. These results indicates that a large majority of patients diagnosed as possible BPEI at 2 years of age did not have a recurrence of unprovoked seizures and mental problems beyond 8 years of age. Our study also suggested a presence of some marginal syndromes of BPEI. An association of paroxysmal kinesigenic choreoathetosis was observed in three patients. Another three patients had experienced seizures with mild gastroenteritis. The seizure outcome of three patients with mild cognitive problems was quite excellent. These patients can be grouped as a marginal syndrome of BPEI.

Benign Partial Epilepsy in Infancy: Myth or Reality?

PURPOSE

Benign partial epilepsy in infancy (BPEI) was first described by Watanabe in 1987. The aim of this study is to describe a series of infants from the United States to characterize this entity further.

METHODS

Among patients with the diagnosis of epilepsy followed up at our institution between 2002 and 2004, those satisfying the criteria for BPEI were included in a retrospective study.

RESULTS

Sixteen (10.2%) of 150 patients with new onset of epilepsy younger than 2 years were identified. The mean age at seizure onset was 8 months. Four (25%) infants had a family history of benign seizures. All infants were neurologically and developmentally normal at the onset of seizures. The seizures occurred in clusters in 75% of patients, predominantly in wakefulness. The initial manifestation was behavioral arrest with staring (69%) and apnea with cyanosis or pallor (37.5%). These symptoms were followed by deviation of eyes or head or both (56%), mild clonic movements (31%), or increased limb tone (35%). Secondary generalization was noticed in 37.5% of patients. All infants had normal interictal EEGs and brain MRIs. Ictal EEGs disclosed electrographic seizures in 50% of patients (temporal origin in 62% and central in 38%). Fifteen (94%) patients were treated with AEDs with good response. The mean duration of treatment was 12.4 months. The final developmental assessment of all patients was normal.

CONCLUSIONS

We believe that BPEI exists as a unique entity and should be included in the differential diagnosis of epilepsies in infancy with partial origin.

Long-term Follow-up of Patients with Benign Partial Epilepsy in Infancy

PURPOSE

The aim of this study was to investigate the long-term outcome of children with benign partial epilepsy in infancy (BPEI).

METHODS

A telephone-interview survey using a structured questionnaire was conducted with patients who were diagnosed as having possible BPEI at age 2 years and who were 8 years or older at the time of the survey. The data from 39 of 48 patients were available. The median age at the time of the survey was 11.3 years; 18 boys and 21 girls were included.

RESULTS

Three patients had a recurrence of unprovoked seizure beyond age 2 years. Four patients had cognitive problems (mild mental retardation in three and Asperger syndrome in one). An association of paroxysmal kinesigenic choreoathetosis was observed in three patients, and another three had experienced seizures associated with mild gastroenteritis. Major behavioral problems were not recognized in any patients. Four patients were excluded from having definite BPEI at age 5 years, and another two were excluded for having definite BPEI at the last follow-up. Eventually, 33 of 39 patients were categorized as having definite BPEI beyond 8 years of age.

CONCLUSIONS

A large majority of patients diagnosed as possibly having BPEI at age 2 years did not have a recurrence of unprovoked seizures and cognitive problems beyond 8 years of age.

Benign familial infantile seizures

In recent years, numerous publications have reported localization-related epilepsy with onset during early infancy, idiopathic etiology and favourable outcome. In 1963, Fukuyama reported cases occurring in the first 2 years of life characterized by partial seizures, absence of etiologic factors and benign outcome. Watanabe studied the localization and semiology of seizures. Later Vigevano and coworkers directed attention to the presence of cases with a family history of convulsions with benign outcome during infancy, with autosomal dominant inheritance, suggesting the term 'benign infantile familial convulsions' (BIFC). Similar cases have been described by several authors confirming that this is a new syndrome. In the last ILAE proposal of Classification of Epilepsy Syndromes this entity is called benign familial infantile seizures. Benign infantile seizures are divided now into familial and non-familial forms, although the two forms can overlap. Genetic studies led to the identification of a marker on chromosome 19. This was not confirmed by later studies, and genetic heterogeneity was hypothesized. Recently Malacarne studying eight Italian families with BIFC mapped a novel locus on chromosome 2. In 1997, Szepetowski described the association between BIFC and a later occurrence of paroxysmal choreoathetosis. Following the identification of a specific marker on chromosome 16, this entity constitutes a variant of the familial forms, called infantile convulsions and choreoathetosis. The age at onset, the semeiology of the seizures and the genetic data distinguish the benign familial infantile seizures from the benign familial neonatal seizures. Recent data suggested that this type of epilepsy would be due to a channellopathy.

Prognosis after withdrawal of antiepileptic drugs in childhood-onset cryptogenic localization-related epilepsies

The purpose of this study was to clarify the risk factors of relapse following discontinuation of AEDs in patients with childhood-onset cryptogenic localization-related epilepsies. The subjects were 82 patients who fulfilled the following criteria: (1) age at first visit of less than 15 years, (2) follow-up period of more than 5 years, (3) suffering from cryptogenic localization-related epilepsies, and (4) the patient underwent AED withdrawal during the follow-up period. As a basic principle, we decided to start withdrawing AEDs when both of the following two conditions were met: (1) the patient had a seizure-free period of 3 years or more, and (2) there were no epileptic discharges on EEGs just prior to the start of withdrawal. Seizures recurred in eight of the 82 patients (9.8%). Univariate analysis revealed that the following factors were correlated with higher rates of seizure relapse: 6 years of age or higher at onset of epilepsy; 15 years of age or higher at the start of AED withdrawal; 5 years or more from the start of AED treatment to seizure control; five or more seizures before seizure control; and two or more AEDs administered before seizure control. Among these risk factors, 6 years of age or higher at onset and 5 years or more from the start of AED treatment to seizure control were determined by multivariate analysis to be independent risk factors for relapse. Thus, we conclude that the physician should be more careful in discontinuing AEDs in these higher-risk patients groups, and more generous in discontinuing AEDs in lower-risk groups.

Benign familial neonatal-infantile seizures: Characterization of a new sodium channelopathy

We recently reported mutations in the sodium channel gene SCN2A in two families with benign familial neonatal-infantile seizures (BFNISs). Here, we aimed to refine the molecular-clinical correlation of SCN2A mutations in early childhood epilepsies. SCN2A was analyzed in 2 families with probable BFNIS, 9 with possible BFNIS, 10 with benign familial infantile seizures, and in 93 additional families with various early childhood epilepsies. Mutations effecting changes in conserved amino acids were found in two of two probable BFNIS families, in four of nine possible BFNIS families, and in none of the others. Our eight families had six different SCN2A mutations; one mutation (R1319Q) occurred in three families. BFNIS is an autosomal dominant disorder presenting between day 2 and 7 months (mean, 11.2 +/- 9.2 weeks) with afebrile secondarily generalized partial seizures; neonatal seizures were not seen in all families. The frequency of seizures varied; some individuals had only a few attacks without treatment and others had clusters of many per day. Febrile seizures were rare. All cases remitted by 12 months. Ictal recordings in four subjects showed onset in the posterior quadrants. SCN2A mutations appear specific for BFNIS; the disorder can now be strongly suspected clinically and the families can be given an excellent prognosis.

Persistent hyperinsulinemic hypoglycaemia followed as benign infantile convulsion

An 18-month-old boy developed seizures at 3 months of age. He developed normally and, his EEG and brain CT revealed no abnormal findings. The blood sugar level was normal at that time, thus he was diagnosed as having benign infantile convulsion. At 7 months of age seizures reappeared, and hypoglycaemia associated with hyperinsulinism was observed during the seizures. With conservative therapy his blood sugar level was well controlled and he had no further seizures. Hypoglycaemic seizures are sometimes misdiagnosed as epilepsy. We have to pay attention to hyperinsulinemic hypoglycaemia when we see seizures with normal EEG even in infants.

Benign familial infantile seizures: further delineation of the syndrome

Benign familial infantile seizures are an autosomal dominant epilepsy disorder that is characterized by convulsions, with onset at age 3 to 12 months and a favorable outcome. Benign familial infantile seizures have been linked to chromosome 19q whereas infantile convulsions and choreoathetosis syndrome, in which benign familial infantile seizure is associated with paroxysmal choreoathetosis, has been linked to chromosome 16p 12-q12. Many additional families from diverse ethnic backgrounds have similar syndromes that have been linked to the chromosome 16 infantile convulsions and choreoathetosis syndrome region. Moreover, in one large pedigree with paroxysmal kinesiogenic dyskinesias only, the syndrome has also been linked to the same genomic area. Families with pure benign familial infantile seizures may be linked to chromosome 16 as well. In this study, we present a series of 19 families and 24 otherwise healthy infants with benign familial infantile seizures. Two of these families include members affected with benign familial infantile seizures and paroxysmal choreoathetosis. We included patients with normal neurologic examinations, who started having simple partial seizures, complex partial seizures, or apparently generalized seizures without recognized etiology between 2 months and 2 years of age. Neurologic studies were normal, but in all patients, there was a history of similar seizures and age at onset in either the father or the mother. Twenty-four patients (14 girls and 10 boys) were evaluated at our hospital between February 1990 and February 2001. Age at onset, sex, family history of epilepsy and/or paroxysmal dyskinesias, neurologic examination, semiology, distribution, and frequency and duration of seizures were evaluated. Electroencephalographic (EEG) and neuroradiologic studies were also performed. Seizures began between 3 and 22 months of life, with a median age of 5 1/2 months. Nine patients (37.5%) had only apparently generalized seizures, 5 patients (20.8%) had only partial seizures, and 10 patients had both partial and apparently generalized seizures (41.6%). Seizures were invariably brief, occurred during the waking state (100%), and presented mainly in clusters in 12 patients (50%). Interictal EEG was normal in 23 patients (95.8%). Sixteen patients (66.6%) had a confirmed history of convulsions in family members other than parents. Twenty-two patients became seizure free after 30 months of life. Two brothers in the same family had brief paroxysmal episodes of choreoathetosis in the hemibody triggered by stress while awake at 15 and 17 years old, respectively. One of them had paroxysmal choreoathetosis only, and the other was associated with benign familial infantile seizures. One father had brief spontaneous episodes of paroxysmal choreoathetosis when awake at age 18 years. All of them had a good response to antiepilepsy drugs, and neurologic examination and EEG and neuroradiologic studies were normal. Benign familial infantile seizure is a genetic epilepsy syndrome with autosomal dominant inheritance. It may be associated with paroxysmal choreoathetosis (infantile convulsions and choreoathetosis syndrome), which has been linked to the chromosome 16 infantile convulsions and choreoathetosis syndrome region. Patients in families with infantile convulsions and choreoathetosis syndrome could display either benign familial infantile seizures or paroxysmal choreoathetosis or both. It is likely that the disease in families with pure benign familial infantile seizures may be linked to the infantile convulsions and choreoathetosis region as well. We cannot exclude the possibility that the youngest patients may develop choreoathetosis or other dyskinesias later in life.

Short duration of benign partial epilepsy in infancy

It has previously been reported that benign partial epilepsy in infancy constitutes up to 29% of the epilepsies presenting in the first 2 years of life. To determine the proportion of benign partial epilepsy in our epilepsy population, we retrospectively reviewed 331 patients with greater than two afebrile seizures in the first 2 years of life between 1993 and 2000. Inclusion criteria were (1) partial seizures with or without secondary generalization, (2) normal development, (3) no other neurologic abnormalities, (4) normal interictal electroencephalograms (EEGs), and (5) good response to treatment. Exclusion criteria included seizures that (1) were caused by acute central nervous system insult, (2) occurred only within the first month of life, and (3) lasted longer than 30 minutes. Of 331 patients, 22 (6.6%) fulfilled the criteria with a minimum of 2 years and a mean of 4 years of follow-up off antiepilepsy drug treatment. Six (27%) had complex partial seizures, and 16 (73%) had complex partial seizures with secondary generalization. Neuroimaging studies were normal in all patients. Of the 6 patients with ictal EEGs, 3 had a temporal lobe focus, 1 had an occipital lobe focus, and the remaining 2 had dual foci. Median onset was 4.0 months (range 0.8-9.3). Seizures remitted within 4 months in 20 (91%). Mean duration of seizure persistence was 2.1 months (range 0-8.3) and was longer in treated patients. Median age at last seizure was 6.4 months (range 2-18). Nineteen were treated with antiepilepsy drugs. At last follow-up (mean duration of 52.2 months), all patients were seizure free and off antiepilepsy drugs. Benign partial epilepsy in infancy is an epilepsy syndrome of short duration and is easily recognized using accepted classification criteria. Benign partial epilepsy in infancy appears to be an idiopathic localization-related epilepsy with a favorable prognosis. The incidence in our population is not as common as previously reported. Based on our findings, we suggest weaning of antiepilepsy drugs 6 months after seizure onset.

Normally developed infant with a suppression burst pattern on electroencephalography in the neonatal period

The background activity on neonatal electroencephalography (EEG) is a good prognostic indicator. An EEG suppression burst pattern usually indicates severe brain dysfunction and has been considered to be associated with a serious neurodevelopmental outcome. We report here a 2-year-old girl who developed generalized convulsions without any perinatal brain insult at 3 days of age. At that time, her EEG constantly showed a suppression burst pattern, and her prognosis was considered to be poor. However, her seizures were well controlled with the oral administration of carbamazepine, and the suppression burst pattern on EEG disappeared at 27 days of age. Unexpectedly, she developed normally for the following 2 years. Although children with normal development, despite the appearance of suppression burst, are extremely rare, and the reason why this patient showed a favorable outcome remains unknown, the clinical course of this patient proved that an EEG suppression burst pattern is not always associated with a poor prognosis.

Benign idiopathic partial epilepsies in infancy

In infancy, partial epilepsies have been considered with suspicion for their probable association with brain lesions. Japanese authors first described partial epilepsies in infancy with a favorable outcome and called them benign partial epilepsy in infancy with complex partial seizures. Similar, but familial, cases with onset during the first year of life were described some years later and called benign infantile familial convulsions. Similar familial cases with subsequent choreoathetosis were described in 1997 and called infantile convulsions and choreoathetosis. Benign infantile convulsions have also been described in association with mild gastroenteritis. Interictal electroencephalography (EEG) was always normal in all of these forms. More recently, a new epileptic syndrome characterized by partial seizures with onset between ages 13 and 30 months, a benign outcome, and characteristic EEG abnormalities in the vertex regions during sleep has been described. There is also an early-onset benign childhood occipital seizure susceptibility syndrome that can start in infancy.

Prevalence of positive anticardiolipin antibody in benign infantile convulsion

We report six anticardiolipin antibody (aCL)-positive cases among 18 children with epilepsy showing various seizure types in our initial study. These six cases revealed normal coagulation tests. As three of these six cases involved benign infantile convulsion (BIC), we further investigated the high frequency of positive aCL-Immunoglobulin (Ig) G in BIC in our subsequent study of nine cases that included three cases from the previous study and an additional six BIC cases followed and/or diagnosed by co-author (T.K.). As a result, eight of nine BIC cases were positive for aCL-IgG and the values of aCL-IgG decreased over long-term observation in three of these cases. The frequency of positivity for aCL-IgG in BIC was obviously higher than that of controls. Based on these results, we suggest that some immunological responses may be responsible for the pathogenesis of BIC.

Five-year follow-up of patients with partial epilepsies in infancy

The aim of this study is to clarify the long-term outcome of patients with partial epilepsies that begin in the first 2 years of age. Thirty-nine infants who experienced partial epilepsies with onset by 2 years of age were followed until they were at least 5 years of age. Seizure and developmental outcome were investigated in relation to the following items: delayed psychomotor development before onset of seizures; interictal electroencephalogram (EEG) abnormalities; abnormal neuroimaging; family history of epilepsy; and history of neonatal seizures. Thirty-three infants achieved freedom from seizures and 27 achieved normal development. Delayed development before the onset and abnormal interictal EEG correlated with both poor seizure and developmental outcome. Abnormal neuroimaging findings correlated with a poor seizure outcome. A history of neonatal seizures and lack of a family history of epilepsy correlated with poor developmental outcome. The combination of the first four factors predicted a normal outcome with a sensitivity of 0.79 and a specificity of 0.87. The seizure and developmental outcomes were better in this study than those in previous studies. The combination of the four factors will be useful for predicting the outcomes in patients with partial epilepsies in infancy.

Migrating partial seizures in infancy: two new cases

Two infants presented at 3 weeks and 3 months of age with intractable partial seizures. Extensive investigations failed to identify an underlying cause. There was no response to antiepileptic drug therapy and no developmental progress following the onset of the seizures. In both infants there was a distinctive pattern of seizures that arose independently from multiple regions of both hemispheres. Interictal electroencephalograms revealed multifocal epileptiform activity. The infants died aged 9 and 12 months. One underwent postmortem examination, which was normal with no hippocampal sclerosis. These infants fulfill the diagnostic criteria of the syndrome of migrating partial seizures in infancy described by Coppola and colleagues in 1995.

Co-segregation of benign infantile convulsions and paroxysmal kinesigenic choreoathetosis

We report seven families and two sporadic cases in which benign infantile convulsions and paroxysmal kinesigenic choreoathetosis were co-segregated. Clinical investigations included physical and neurological examinations, blood electrolyte values, interictal and ictal electroencephalograms, and computed tomography or magnetic resonance imaging of the brain. The family pedigree was confirmed and the clinical history of the relatives was obtained. Seventeen individuals developed infantile convulsions followed by paroxysmal dyskinesias during childhood or adolescence. Six had only infantile convulsions, and two had only paroxysmal dyskinesias. The seizures never persisted into childhood or recurred in adulthood. The seizure type was a complex partial seizure, with or without secondary generalization, in nine of 14 patients. Paroxysmal dyskinesias, a subgroup of paroxysmal kinesigenic choreoathetosis, occurred for less than 5 min. The attacks of dyskinesias began at age 5-12 years in most patients, and tended to remit in adulthood. The mode of inheritance was apparently autosomal dominant in four of the families (17 affected individuals), who were diagnosed with ICCA syndrome (infantile convulsions and paroxysmal choreoathetosis). However, the condition occurred only among siblings in three families (six patients), and sporadically in two patients, suggesting genetic heterogeneity in this distinct co-segregation.

Benign partial epilepsies in infancy

Benign partial epilepsies are not rare in infancy and comprise two forms, although both are closely related. One is partial epilepsy with complex partial seizures (CPS) and the other one with secondarily generalized seizures (SGS). The most frequent site of seizure origin was in the temporal area in the former and central, parietal or occipital area in the latter. The former has not been well recognized because of subtle seizure manifestations and a favorable outcome. Its unique characteristics should be emphasized because it may be difficult to diagnose it unless we know its presence. Benign convulsions are also common in infancy. Most of them may belong to partial epilepsy with SGS, although confirmation with ictal EEG recording is necessary for accurate diagnosis. Some are familial and many of them seem to show an autosomal dominant pattern, but some seem to have autosomal recessive inheritance.

Early recognition of benign partial epilepsy in infancy

PURPOSE

The aim of this study is to determine how precisely we can recognize the outcome in infants with epilepsy beginning in the first year of life.

METHODS

We performed a prospective 5-year follow-up study on 63 patients who developed epilepsy in the first year of life. We first judged that patients met the criteria of "possible benign partial epilepsy in infancy (BPEI)" on enrollment in this study. At 2 years of age, we reevaluated the seizure and developmental outcome in the patients who were diagnosed as having "possible BPEI." We finally judged that patients met the criteria of "definite BPEI" at age 5 years. "Possible BPEI" was defined as epilepsy meeting all the following conditions: (a) complex partial seizures and/or secondarily generalized seizures; (b) normal psychomotor development and neurologic findings before onset; (c) normal interictal electroencephalograms; (d) normal cranial computed tomography (CT) and magnetic resonance imaging (MRI) findings; and (e) no seizures during the first 4 weeks of life. "Definite BPEI" was defined as epilepsy meeting all the following criteria in addition to those of "possible BPEI": (a) normal psychomotor development beyond age 5 years, and (b) no seizures beyond age 2 years.

RESULTS

Thirty-two of the 63 patients met the inclusion criteria completely and were included in the "possible BPEI" group. Twenty-five of the 32 patients completed the 5-year follow-up. At age 2 years, four patients were excluded from the "possible BPEI" group because of seizure recurrence and/or delayed development. By age 5 years, one had a recurrence of seizures, and another exhibited mildly delayed psychomotor development. We finally diagnosed 19 patients as having "definite BPEI." "Definite BPEI" accounted for 76% of the patients diagnosed as having "possible BPEI" at the first presentation and 90% of those who met the conditions on reevaluation at age 2 years.

CONCLUSIONS

Recognition of BPEI is possible, to some extent, at the first presentation, and reevaluation at age 2 years is useful for a more precise diagnosis.

Benign partial epilepsy in infancy and early childhood with vertex spikes and waves during sleep: a new epileptic form

International epilepsy classification includes different epileptic syndromes with favourable outcomes in paediatric age, both partial and generalised. This is true in childhood while no partial benign forms are accepted in infancy. In 1987, Watanabe first described a new entity and he defined it as 'benign complex partial epilepsies in infancy'. In 1992, Vigevano referred similar but familial cases whose seizures had secondary generalisation. Both these forms had no interictal EEG abnormalities neither awake nor during sleep. This article presents a survey of 12 cases of partial epilepsy with favourable outcome differing from Watanabe and Vigevano's cases, both for the presence of interictal EEG abnormalities only during sleep and for seizure picture. All our patients are neurologically and neuroradiologically normal. Psychomotor development is unremarkable. Age onset range is 13-30 months. All cases present characteristic spikes and waves during slow-sleep in vertex cerebral areas. Awake EEG is always normal, at follow-up too. Our cases have such homogeneous electroclinical features as to hypothesise a new partial idiopathic epileptic syndrome with favourable outcome in infancy and early childhood. We propose to define it as 'benign partial epilepsy in infancy and early childhood with vertex spikes and waves' (BVSE).

Epilepsy in the first year of life: a review

The prevalence of epilepsy is highest during the first year of life. Approximately 50% of patients with seizure onset between 1 and 12 months of age suffer from West syndrome. The rest have one of 12 well-delineated epilepsy syndromes, or in most cases have what are classified as generalized or partial seizures. The outcome of infants with partial seizures is significantly worse than that of patients with generalized seizures. This is true not only for symptomatic partial seizures but also for a subgroup of infants with cryptogenic partial seizures.

Epileptic disorders with onset in the first year of life: neurological and cognitive outcome

We examined prospectively a series of 150 children with epilepsy beginning in the first year of life. We classified the types of epilepsy into five categories: West syndrome, other epileptic encephalopathies, generalized, partial and undetermined epilepsies. Of 150 patients, 15 died; 135 were followed for at least 4 years. In order to define possible factors influencing prognosis we evaluated neurological and cognitive outcome and made percentage comparisons between groups, for aetiology, age of onset, family history of epilepsy, and psychomotor development before onset. Epileptic encephalopathies as well as the symptomatic forms of West syndrome showed a very poor neurological and cognitive outcome. As previously recognized, only cryptogenic forms of West syndrome had a benign prognosis. For the generalized epilepsies, analysis of different factors, namely late age at onset, cryptogenicity and absence of primary cognitive impairment, indicated a good prognosis. In contrast, partial epilepsies usually had a poor outcome, irrespective of the aetiology, whether cryptogenic or symptomatic.

[Benign infantile convulsions. French collaborative study]

BACKGROUND

Benign infantile non febrile seizures are not well known, leading us to study their clinical and EEG characteristics.

METHODS

Between 1981 and 1994, we assembled 34 patients with the following inclusion criteria: non febrile seizures between 1 month and 2 years of age, normal personal history, no abnormality on clinical, biological and radiological investigations, normal developmental outcome with at least 1 year follow-up.

RESULTS

These 34 patients were recognized as 14 familial cases (identical seizures affecting parents) and 11 non familial cases. The other nine cases had different or undefined epilepsy in the family. The clinical and EEG characteristics were the same: at the mean age of 6 months, brief partial seizures (often secondarily or apparently generalized) occurring in a cluster of two to 12 episodes a day for a mean duration of 2.5 days, with ictal EEG showing focal discharge, often slow waves or focal spikes on post-ictal tracing and normal interictal EEG.

CONCLUSION

The clinical and EEG characteristics are important in order to recognize this type of infantile convulsions (familial or not familial), which have a good prognosis and need no aggressive treatment.

Staring spells in children: descriptive features distinguishing epileptic and nonepileptic events

OBJECTIVE

To identify questions sensitive and specific for staring spells of epileptic (absence seizures [AS]) or nonepileptic etiology to increase the yield of history taking.

STUDY DESIGN

A questionnaire was completed by parents of 40 children who presented with staring spells. Results from 17 children with AS and 23 with nonepileptic staring (NES) were compared.

RESULTS

Features with moderate sensitivity (43% to 56%) but high specificity (87% to 88%) for NES included preserved responsiveness to touch, lack of interruption of playing, and initial identification by a teacher or health professional. These features were more frequent in NES than in AS (P = .013, .016, .030). Body rocking occurred only in NES, but sensitivity was low (13%). Features with high specificity (91% to 100%) for AS included limb twitches, upward eye movements, and urinary incontinence; but sensitivities were low (13% to 35%).

CONCLUSION

In children with normal interictal electroencephalography findings and without neurologic disease, staring spells are most likely nonepileptic when parents report preserved responsiveness to touch, body rocking, or initial identification by a teacher or health professional without limb twitches, upward eye movements, interruption of play, or urinary incontinence. In these cases a diagnosis of NES may be confidently applied, with confirmation based on long-term follow-up.

Clinical study on localization-related epilepsy in infancy without underlying disorders

A clinical study of 15 patients without underlying disorders whose first seizures occurred before 1 year of age was performed to determine the characteristics of localization-related epilepsies in infancy. The patients were retrospectively divided into two groups: the seizure-controlled group (10 patients) and the refractory group (five patients). The seizure-controlled group included patients whose seizures were controlled completely within 1 year after onset; the refractory group included all other patients. The characteristics of the refractory group were as follows: (1) interictal electroencephalography showed focal abnormalities, particularly on the left side, and (2) all of the patients exhibited developmental retardation. Even in the seizure-controlled group, 40% of the patients exhibited developmental retardation, and all of them were indistinguishable from patients with benign complex partial epilepsies in infancy at the onset of the seizures. Aggressive treatment should be re-evaluated for early-onset localization-related epilepsies.