Complex partial seizures in young children

Staring Spells: How to Distinguish Epileptic Seizures from Nonepileptic Staring

OBJECTIVE

To determine the nature of staring spells and factors distinguishing epileptic from nonepileptic staring spells, we studied the clinical and demographic features of children with staring spells referred to a regional new-onset seizure clinic.

STUDY DESIGN

Our retrospective chart review encompassed 2818 consecutive patients evaluated in the new-onset seizure clinic between September 22, 2015, and March 19, 2018. We identified 121 patients with newly presenting staring spells.

RESULTS

Sixty-two of 121 (51%) children were diagnosed with nonepileptic staring spells and 59 (49%) with epileptic seizures (24 with absence epilepsy, 35 with focal epilepsy). Patients with nonepileptic staring spells were younger (4.8 vs 7.1 years, P = .001) and more likely to have developmental delay (P = .005) than the seizure group. There was an 8.9-month delay on average from the onset of staring spells to the new-onset seizure clinic visit. The emergency department was a referral source for 80% (28/35) of focal seizures. In children with focal seizures, the staring spells typically lasted >1minute (29/35, 83%), whereas only 19 of 62 (31%) of children with nonepileptic staring spells had events lasting this long (P = .04). All children had a routine electroencephalography (EEG) on the day of new-onset seizure clinic visit. EEG was diagnostic in 100% (24/24) of absence seizures and 51% (18/35) of focal seizures.

CONCLUSIONS

In children presenting with staring spells, the differential diagnosis of epileptic staring spells vs nonepileptic staring spells can be made by history and routine EEG. Staring was as likely to be epileptic as nonepileptic spells. Younger children with developmental delay were more likely to have nonepileptic events. Our simple approach based on event duration, postictal symptoms, and EEG allowed identification of epileptic staring on first visit to new-onset seizure clinic but requires validation in future prospective studies including long-term video EEG monitoring and follow-up.

Classification of clinical semiology in epileptic seizures in neonates

The clinical semiology of 61 neonatal seizures with EEG correlates, in 24 babies was analysed. Most seizures (89%) had multiple features during the EEG discharge. The seizures were classified using the prominent clinical feature at onset, and all features seen during the seizure, using an extended classification scheme. Orolingual features occurred most frequently at onset (30%), whereas ocular phenomena occurred most often during the seizure (70%). Orolingual, ocular and autonomic features were seen at onset in 55% of the seizures. Seizure onsets with clonic, tonic and hypomotor features were seen in 20%, 8% and 18% respectively. Clinico-electrical correlations were as follows. The EEG discharge involved both hemispheres in 54% of all seizures, in clonic seizures this was 93%. Focal clonic seizures were associated with EEG seizure onset from the contralateral hemisphere. Majority of the clonic and hypomotor seizures had a left hemisphere ictal EEG onset. Orolingual seizures frequently started from the right hemisphere, whereas ocular and autonomic seizures arose from either hemisphere. There was no significant difference in mortality, morbidity, abnormal neuroimaging and EEG background abnormalities in babies with or without clonic seizures. This study provides insights into neuronal networks that underpin electroclinical seizures, by analysing and classifying the obvious initial clinical features and those during the seizure.

Mesial temporal lobe epilepsy with hippocampal sclerosis: study of 42 children

PURPOSE

We present the electroclinical features, treatment, and evolution of patients with mesial temporal lobe epilepsy with hippocampal sclerosis (MTLE-HS).

MATERIAL AND METHODS

We analyzed the charts of forty-two patients who met the diagnostic criteria of MTLE-HS. The mean follow-up after seizure onset was 10.5 years.

RESULTS

According to age, we defined three groups. The first group included nine patients that started with seizures before 2 years of age. Motor seizures were the hallmark clinical manifestation. All patients of this group also presented with motor arrest and oro-alimentary automatisms. In three of them, the interictal EEG recordings showed bilateral paroxysms predominantly in anterior regions, in addition to focal abnormalities, and two had an apparently generalized ictal pattern. The second group included 17 patients that started with seizures between 2 and 10 years of age. In this group the automatisms were also oroalimentary, but more complex and the patients had less motor manifestations. The interictal EEG recordings showed temporal abnormalities. The ictal EEG recordings showed lateralized abnormalities with a maximum in the temporal electrodes. The third group included 16 patients that started with seizures between 10 and 16 years of age. The most common clinical manifestation was abdominal aura followed by oroalimentary, gestural, and verbal automatisms. The interictal and ictal EEG recordings showed well-localized abnormalities in temporal lobes. Thirty-eight patients underwent surgical treatment. Thirty-five patients are seizure free.

CONCLUSION

MTLE-HS represents a well-defined and distinct symptomatic epileptic syndrome. Surgical treatment was successful in most patients.

[Intelligence development in children with early-onset epilepsy with complex partial seizures]

OBJECTIVE

Eighty-four outpatients treated for epilepsy with complex partial seizures were followed up 18 years later.

RESULTS

Of these Patients, 35% showed stabile learning disabilities when they were first treated and also 18 years later. These Patients did not achieve a regular school qualification. Forty-eight percent suffered from a psychiatric disorder as classified by the ICD-10. Children with a pathological neurological result in the first examination showed poorer cognitive outcomes than Patients with only mild neurological impairment. The age of onset of the disease did not significantly predict subsequent cognitive abilities. Patients who showed complex partial seizures and generalized seizures showed poorer cognitive outcomes, as did Patients with a psychiatric disorder or psychosocial problems.

DISCUSSION

The study points to the importance of a conjoint neurological and psychiatric treatment to deal with the different impairments and corresponding developmental course of the disease.

Temporal Lobe Epilepsy in Children: Electroclinical Study of 77 Cases

PURPOSE

Temporal lobe epilepsy (TLE) is probably more difficult to recognize in children than in adults. In fact, ictal symptoms in children are less stereotyped and less obvious, and the neuropathological substrate is more heterogeneous than in adults. The aim of this study is to examine the relationships between etiology, age at onset and electroclinical findings in 77 children with TLE, 32 of whom were surgically treated.

METHODS

Electroclinical study including video-EEG recording of seizures in 77 children with TLE. The investigation focused on the first five initial ictal symptoms.

RESULTS

Age at onset was less than 3 years in 39 cases, between 3 and 6 years in 17 cases and older than 6 years in 21 cases. Auras also occurred in younger children but were more common after the age of 6 years. A peculiar initial ictal semiology consisted in staring with arrest, lip cyanosis, and very slight oral automatisms. In some cases, EEG recordings documented seizures starting independently on both temporal lobes. Based on electroclinical and neuroradiological features, we recognized three subgroups: symptomatic TLE due to cortical malformations or nonevolutive tumors, TLE with mesial temporal sclerosis, and cryptogenic TLE.

CONCLUSIONS

A correct electroclinical and neuroradiological approach allows in several cases early recognition of TLE even when onset is earlier than the age of 6 years. A correct definition of the localization relies primarily on video-EEG recording of the seizures, possibly repeated during follow up in cases lacking obvious neuroradiological correlation.

Hypomotor seizures in infants and children

PURPOSE

Hypomotor seizures (characterized by diminished behavioral activity with indeterminate level of consciousness) have been identified as an important seizure type in infants. Our goal was to investigate further the clinical and EEG features of hypomotor seizures.

METHODS

We retrospectively reviewed 110 hypomotor seizures from 34 patients recorded with video-EEG.

RESULTS

Twenty-seven (79%) patients were younger than 48 months, and seven (21%) were aged 4 to 15 years. Seventy-one (64%) seizures had regional or lateralized EEG onset, arising predominantly from temporal or parietal lobe regions. The other 39 (35%) seizures had generalized onset, usually with abrupt onset of diffuse rhythmic high-amplitude theta activity or diffuse electrodecrement and only rarely (two patients) with slow spike-wave complexes or 3-Hz spike-wave complexes. Hypomotor seizures with generalized EEG onset were significantly shorter than those with regional or lateralized onset (p = 0.01, GEE model). Unsustained head or eye movements and subtle mouth automatisms were commonly seen in hypomotor seizures with either focal or generalized onset. Seventeen percent of hypomotor seizures with focal onset evolved to include version of head and eyes or jerking of one arm, whereas 2% of generalized hypomotor seizures evolved to a cluster of spasms.

CONCLUSIONS

Hypomotor seizures may be either focal or generalized. Regional EEG onsets were most often temporal or parietal, suggesting that focal hypomotor seizures may be a bland form of "complex partial" seizures with no or minimal automatisms, seen predominantly in infants. Generalized hypomotor seizures were rarely associated with an ictal pattern of generalized spike-wave complexes, suggesting a different mechanism from absence seizures seen later in life.

Seizure outcome of intractable partial epilepsy in children

The intractable partial epilepsy outcome information is important in determining not only when epilepsy surgery evaluation should begin but also in deciding who would benefit and what is the likelihood of any benefit from surgery. Medical records of 50 children diagnosed with nontumor-related partial seizures, confirmed by video-electroencephalography (video-EEG), had at least one seizure per week and were followed for at least 2 consecutive years after video-EEGs were reviewed. There were 30 patients who continued with antiepileptic drug treatment after video-EEG. The seizure outcome analysis revealed a significant improvement of seizure control in the first year of follow-up but no difference between the first year and the following 3 years. Only 30% had excellent long-term outcome (seizure free or less than one seizure per 6 months). The presence of focal lesions on neuroimaging was the only risk factor of poor outcome. The other 20 patients underwent epilepsy surgery after video-EEG; 60% attained excellent outcome despite the fact that 90% had focal neuroimaging abnormality. Children whose partial epilepsy remained intractable after 1 year of antiepileptic drug treatment should be evaluated for candidacy of epilepsy surgery, particularly those who have focal lesions on neuroimaging.

Symptomatology of epileptic seizures in the first three years of life

PURPOSE

Few data are available concerning symptomatology of epileptic seizures in infants.

METHODS

We reviewed 296 videotaped seizures from 76 patients aged 1-35 months (mean, 15.1 months) who underwent video-EEG monitoring at our institution from 1988 to 1998. Seizure symptomatology was first classified based on observable behavioral and motor manifestations and then correlated with ictal EEG.

RESULTS

Four seizure types accounted for 81% of all seizures seen in this group: epileptic spasms (24%), clonic seizures (20%), tonic seizures (17%), and hypomotor seizures (20%; characterized by arrest or significant decrease of behavioral motor activity with indeterminate level of consciousness). The remaining seizures included small numbers of myoclonic, atonic, and versive seizures. All 12 focal motor seizures and all five versive seizures were associated with focal EEG seizure patterns, seen in the contralateral hemisphere in all but one patient with versive seizures. Generalized motor seizures (clinically generalized at onset) were accompanied either by focal (19 of 51; 37%) or generalized (32 of 51; 63%) EEG seizures. Hypomotor seizures also were associated with focal (14 of 20; 70%) or generalized (six of 20; 30%) EEG seizures. Four patients with generalized epileptic spasms had generalized EEG seizures in the setting of focal epilepsy based on neuroimaging, interictal EEG, and in two cases also on postresection seizure freedom. Seizure types not seen in this age group included auras, seizures with prominent automatisms (except in one case), and classic generalized tonic-clonic seizures.

CONCLUSIONS

The repertoire of seizure manifestation in the first 3 years of life appears to be limited. In infants, focal motor seizures are reliably associated with focal EEG seizures in the contralateral hemisphere, whereas generalized motor and hypomotor clinical seizures may be either focal or generalized on EEG. Epileptic spasms may be seen in focal as well as generalized epilepsies. Video-EEG monitoring and neuroimaging may be critical for clarifying the focal or generalized nature of the epilepsy in infants.

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.

Recognition and classification of seizures in infants

PURPOSE

We wished to assess the reliability of the International League Against Epilepsy (ILAE) seizure classification system applied to infantile seizures and to test a proposed new classification.

METHODS

We first analyzed 39 seizures in 20 infants (aged 1-26 months) recorded with simultaneous closed-circuit television and EEG (CCTV/EEG). EEGs and videotapes of all seizures were independently analyzed by two epileptologists blinded to clinical histories. Videotapes of each seizure were reviewed without simultaneous EEG (phase 1), and printouts of ictal EEGs were assessed without behavioral correlates (phase II). The observers classified seizures according to ILAE criteria. Interrater agreement was assessed by the kappa statistic.

RESULTS

Agreement on EEG features (phase II) was moderate (= 0.54) in identifying focal ictal onsets and substantial (= 0.79) in identifying generalized onsets. In contrast, analysis of videotapes showed substantial disagreement between observers in terms of classifying seizures as partial or generalized. Therefore, agreement between observers for partial was slight (= 0.14) and fair for generalized seizures (= 0.26). Similarly, conclusions of the observers as compared with those of a consensus panel were divergent for both partial (= 0.18) and generalized seizures (= 0.30). We therefore developed an alternative classification scheme and retested interrater agreement in a review of 50 seizures in 25 other infants. With this classification scheme, there was substantial agreement between observers (= 0.72).

CONCLUSIONS

With clinical observations and interictal EEGs, seizures in infants cannot be reliably classified by current ILAE criteria. In contrast, a proposed new classification scheme based solely on semiology showed substantial reliability.

Complex partial seizures of temporal lobe origin in children of different age groups

The semiology of complex partial seizures (CPS) of temporal lobe origin in adults is well known and is important in establishing seizure localization in patients considered for epilepsy surgery. In contrast, the behavioral features of temporal lobe seizures (TLS) in children described in the literature have not been consistent. In the present study, we investigated children with TLS to compare their attacks to TLS occurring in adults. The study was based on video recordings of 29 children with TLS aged 18 months to 16 years. Children were included, if they became seizure-free after temporal lobectomy (except 4 children with a marked reduction in seizure frequency and 1 with isolated auras), and if clear unitemporal seizure onset in ictal EEG-recordings, unilateral radiological lesions, and corresponding histopathological findings were detected. Children aged > 6 years had TLS with features similar to those of adults. In younger children, typical semiology included symmetric motor phenomena of the limbs, postures similar to frontal lobe seizures in adults, and head nodding as in infantile spasms. We concluded that the clinical features of TLS in younger children can be misleading and should therefore be considered with caution in selecting patients for surgical procedures on the temporal lobe.

Complex partial status epilepticus in childhood

We report 5 pediatric patients (2 male, 3 female; age range: 4-8 years) with complex partial status epilepticus (CPSE). Four patients had previous illnesses and mild motor or mental retardation. In 2 patients, CPSE was induced by inappropriate management or selection of antiepileptic drugs. Clinical features varied and automatisms were observed in 3 patients. In 1 patient, decreased physical tone with syncope and impaired consciousness with amaurosis were observed. The episodes of CPSE were continuous in 3 patients and recurrent in 2 patients. In 4 patients, ictal electroencephalographic (EEG) findings, including video-EEG analyses of 3 patients, demonstrated persistent focal epileptic features. Intravenous diazepam abolished CPSE in 3 patients with brief periods of definite EEG localizations remaining. In 4 patients, seizure prognoses were favorable after appropriate treatments; in 1 patient, seizures were intractable even after antiepileptic drug administration.