Study on the early-onset variant of benign childhood epilepsy with occipital paroxysms otherwise described as early-onset benign occipital seizure susceptibility syndrome

A reappraisal of interictal EEG characteristics in self-limited epilepsy with autonomic seizures, formerly known as Panayiotopoulos syndrome or early-onset benign occipital epilepsy

PURPOSE

In the 2022 New International Classification of Epilepsy Syndromes, self-limited epilepsy with autonomic seizures (SeLEAS), formerly known as Panayiotopoulos syndrome is recognized as an electroclinical syndrome that is clinically characterized by autonomic seizures and electroencephalographically by multifocal EEG foci. EEG studies were reviewed herein and the suitability of the EEG definition to characterize SeLEAS was assessed.

METHODS AND RESULTS

The EEG findings of SeLEAS studies published to date were reviewed and typical sites of EEG foci and their evolutionary changes with age were analyzed. Although previous studies investigated the details of interictal EEG characteristics in a sufficient number of SeLEAS cases, there were few systematically analyzing cross sectional and longitudinal EEG changes except one study. Despite these limited evidence, I propose the following practical and useful EEG definition. The interictal EEG characteristics of SeLEAS are multifocal EEG foci with age-dependent predominant locations; occipital (O) at 2-5 years old, and occipital and frontopolar (synchronous and independent O and Fp spikes) at 4-7 years old and centro-parieto-temporal (CPT) at 6-10 years old. O EEG foci evolve to multifocal EEG foci with a O-Fp or CPT predominance with age and disappear by 12∼16 years old. O-Fp EEG foci may further evolve to generalized spike-wave complexes and rarely to spike-wave activated in sleep. In rare cases, the EEGs do not have epileptic EEG foci.

CONCLUSION

Interictal EEG foci in SeLAES may have different EEG patterns in terms of location and the mode of appearance depending on the age at which EEG is recorded. O-Fp EEG foci may be a specific EEG pattern indicating a diagnosis of SeLEAS.

Epilepsy in Children With Congenital Heart Disease: Risk Factors and Characteristic Presentations

BACKGROUND

Children with a congenital heart disease (CHD) are at a higher risk of developing epilepsy than the general population, but detailed characteristics of CHD-associated epilepsy have not been clarified. The purposes of this study were to determine the risk factors for developing epilepsy associated with CHD and to elucidate the characteristics of such epilepsy.

METHODS

We performed a retrospective cohort study based on medical records of pediatric patients with CHD who were born between January 2006 and December 2016, underwent cardiac surgery at Okayama University Hospital, and were followed up until at least age three years. Multivariate logistic regression analysis was used to determine factors particularly associated with epilepsy occurrence. In patients who developed epilepsy, clinical data on seizure characteristics were further investigated.

RESULTS

We collected data from 1024 patients, and 41 (4.0%) developed epilepsy. The presence of underlying disease (odds ratio [OR]: 2.413; 95% confidence interval [CI]: 1.150 to 4.883) and the Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery score category 2 (OR: 4.373; 95% CI: 1.090 to 29.150) and category 5 (OR: 10.385; 95% CI: 1.717 to 89.016) were significantly related to epilepsy occurrence. Of the 41 patients with epilepsy, 15 (including nine with hypoplastic left heart syndrome) had focal impaired awareness seizures specified as autonomic seizures with vomiting, which tends to escape detection.

CONCLUSIONS

We clarified the risk factors for developing epilepsy in children with CHD. We also found that autonomic seizure with vomiting is an important symptom in these children.

More than one self-limited epilepsy of childhood in the same patient: A multicenter study

OBJECTIVE

We describe the evolution of the electroclinical picture of patients with different types of self-limited epilepsy of childhood (SLEC) occurring at the same or at different times with or without atypical evolutions as well as patients with SLEC associated with childhood absence epilepsy (CAE).

MATERIAL AND METHODS

A multicenter, retrospective, descriptive study was conducted evaluating patients with SLEC who had focal seizures of different types of SLEC including atypical evolutions as well as SLEC associated with absence epilepsy seen at eight Argentinian centers between April 2000 and April 2019. Of 7705 patients with SLEC, aged between 2 and 14 years (mean, 7.5 years), of whom 2013 were female and 5692 male (ratio, 1:2.8), 5068 patients had SLECTS, 2260 patients had self-limited childhood occipital epilepsy Panayiotopoulos type (SLE-P), 356 had self-limited childhood occipital epilepsy Gastaut type (SLE-G), and 21 had self-limited epilepsy with affective seizures (SLEAS). Electroclinical features typical of more than one SLEC syndrome were recognized in 998 (13 %) children.

RESULTS

We recognized three well-defined groups of patients. The most frequent association was SLE-P and SLECTS, the paradigmatic type, but associations of SLE-P and SLE-G, SLECTS and SLE-G, and SLEAS and SLE-P or SLECTS were also recognized. The second-most-common association was SLEC and an atypical evolution. In this group, the most frequent combination was SLECTS with its atypical evolution, opercular status epilepticus, epileptic encephalopathy with continuous spike-and-waves during slow sleep, or Landau-Kleffner syndrome. SLE-P and SLE-G associated with an atypical evolution were also identified. The third, less-frequent group had SLECTS, SLE-P, or SLE-G associated with CAE. These cases support the concept that the different types of SLEC are part of a self-limited childhood seizure susceptibility syndrome.

CONCLUSION

Our study demonstrated that 13 % of our patients with SLEC have with different types of SLEC occurring at the same or at different times with or without atypical evolutions - i.e. CSWSS - as well as patients with SLEC associated with CAE, supporting the concept of the self-limited childhood seizure susceptibility syndrome.

A study on spike focus dependence of high-frequency activity in idiopathic focal epilepsy in childhood

Objective

Spike foci in benign epilepsy with centrotemporal spikes (BECTS) are related to seizure semiologies, but this relationship is inconspicuous in Panayiotopoulos syndrome (PS). We analyzed spike‐associated high‐frequency activity (HFA) and its relationship to spike foci in the electroencephalograms (EEGs) of patients with BECTS and PS in order to elucidate the pathophysiology of these epileptic syndromes.

Methods

In 35 patients with BECTS and 29 with PS, focal spikes in scalp sleep EEGs were first classified by clustering according to their characteristics, including shape and distribution. For each patient, three or fewer spike clusters were investigated by time‐frequency spectral analysis and single‐dipole analysis using a realistic three‐dimensional head model to explore the relationships between the presence or absence of spike‐associated HFA and the distribution of estimated spike sources.

Results

A total of 159 spike clusters were analyzed (96 in BECTS and 63 in PS). HFA was detected in 73 spike clusters (76.0%) in BECTS and 37 (58.7%) in PS, with a significant difference in the proportion of spike clusters with HFA (p = 0.024 by Fisher's exact test). In BECTS, spikes had relatively uniform distributions, but the proportion of spikes with associated HFA was significantly higher in the spike group with dipoles in the perirolandic areas (42 of 49) than in that with dipoles outside of the perirolandic areas (23 of 36; p = 0.037). In PS, The proportion of spikes with associated HFA was significantly higher in the spike group with dipoles in the occipital lobes (20 of 26) than in that with dipoles outside of the occipital lobes (13 of 33; p = 0.020).

Significance

The proportion of spike‐associated HFA was higher in BECTS than in PS. Particular pathophysiological meaning was indicated in spikes with dipoles in the perirolandic areas in BECTS and in spikes with dipoles in the occipital lobes in PS owing to the high proportions of spike‐associated HFA in these areas.

Long-Term Clinical and Electroencephalography (EEG) Consequences of Idiopathic Partial Epilepsies

Background

Idiopathic partial epilepsies of childhood (IPE) affect a considerable proportion of children. Three main electroclinical syndromes of IPE are the Benign Childhood Epilepsy with Centro-temporal Spikes (BECTS), Panayiotopoulos Syndrome (PS), and Childhood Epilepsy with Occipital Paroxysms (CEOP). In this study we investigated the long-term prognosis of patients with IPE and discussed the semiological and electroencephalography (EEG) data in terms of syndromic characteristics.

Material/Methods

This study included a group of consecutive patients with IPE who had been followed since 1990. Demographic and clinical variables were investigated. Patients were divided into 3 groups – A: Cases suitable for a single IPE (BECTS, PS and CEOP); B: cases with intermediate characteristics within IPEs; and C: cases with both IPE and IGE characteristics. Long-term data regarding the individual seizure types and EEG findings were re-evaluated.

Results

A total of 61 patients were included in the study. Mean follow-up duration was 7.8±4.50 years. The mean age at onset of seizures was 7.7 years. There were 40 patients in group A 40, 14 in group B, and 7 in group C. Seizure and EEG characteristics were also explored independently from the syndromic approach. Incidence of autonomic seizures is considerably high at 2–5 years and incidence of oromotor seizures is high at age 9–11 years. The EEG is most abnormal at 6–8 years. The vast majority (86%) of epileptic activity (EA) with parietooccipital is present at 2–5 years, whereas EA with fronto-temporal or multiple sites become more abundant between ages 6 and 11.

Conclusions

Results of the present study provide support for the age-related characteristics of the seizures and EEGs in IPE syndromes. Acknowledgement of those phenomena may improve the management of IPEs and give a better estimate of the future consequences.

Ictal vomiting as a sign of temporal lobe epilepsy confirmed by stereo-EEG and surgical outcome

Vomiting is uncommon in patients with epilepsy and has been reported in both idiopathic and symptomatic epilepsies. It is presumed to originate in the anterior part of the temporal lobe or insula. To date, 44 cases of nonidiopathic focal epilepsy and seizures associated with ictal vomiting have been reported. Of the 44 cases, eight were studied using invasive exploration (3 stereo-EEG/5 subdural grids). Here, we report a 4-year-and-7-month-old patient with a history of febrile convulsion in the second year of life and who developed episodes of vomiting and complex partial seizures at 3 years of age. Scalp EEG showed no electrical modification during vomiting while the complex partial seizure displayed a clear right temporal origin. Brain MR showed hippocampal volume reduction with mild diffuse blurring of the temporal lobe. Stereoelectroencephalography study confirmed the mesiotemporal origin of the seizures and showed that the episodes of vomiting were strictly related to an ictal discharge originating in the mesial temporal structures without insular diffusion. The patient is now seizure-free (18 months) after removal of the right anterior and mesial temporal structures. In all the reported patients, seizures seemed to start in mesial temporal structures. The grid subgroup is more homogeneous, and the most prominent characteristic (4/5) is the involvement of both mesial and lateral temporal structures at the time of vomiting. In the S-EEG group, there is evidence of involvement of either the anterior temporal structures alone (2/3) or both insular cortices (1/3). Our case confirms that vomiting could occur when the ictal discharge is limited to the anterior temporal structure without insular involvement. Regarding the pathophysiology of vomiting, the role of subcortical structures such as the dorsal vagal complex and the central pattern generators (CPG) located in the reticular area is well established. Vomiting as an epileptic phenomenon seems to be related to the involvement of temporal structures, mainly mesial structures (amygdala) and with an uncertain role of the insula. An intriguing hypothesis is that the ictal discharge in mesial structures determines seizure manifestation that could be explained not only by tonic activation of the cortex, but also by 'release' (reduction of inhibition?) of the CPG responsible for involuntary motor behaviors.

Manifestation of both emetic seizures and sylvian seizures in the same patients with benign partial epilepsy

PURPOSE

Benign childhood epilepsy with centro-temporal spikes (BECTS) and Panayiotopoulos syndrome (PS) have different pathophysiologies and show different types of seizures, yet they overlap in some important respects. In an attempt to understand the ways in which they differ from each other and overlap each other, we performed a detailed investigation on patients who had both characteristic types of seizure manifestations, namely, sylvian seizures and emetic seizures.

SUBJECTS AND METHODS

We recruited consecutive subjects from the EEG database of outpatients who had visited our hospital between 2008 and 2010 and who had been diagnosed with BECTS or PS. As a result, 45 patients with BECTS and 50 patients with PS were selected from the database. Viewing the clinical records of these 95 patients, five patients were selected who had experienced both sylvian seizures and emetic seizures. Next, the clinical features and EEG findings of these five patients were retrospectively observed at the date of investigation: October 1, 2011.

RESULTS

We found that all the patients showed rolandic spikes when they had sylvian seizures, and occipital spikes or multifocal spikes when they had emetic seizures. We also report in detail on one patient who showed two different types of ictal EEG patterns: one of which started in the occipital area and the other of which was located in the rolandic area.

CONCLUSION

Based on these findings, we conclude that widespread cortical hyperexcitability that includes the occipital area is necessary to produce the autonomic seizure manifestations seen in PS.

Panayiotopoulos syndrome: a case series from Turkey

The aim of the study was to evaluate the demographic, clinical, and EEG characteristics of patients with Panayiotopoulos syndrome (PS) and the course of their illness. Thirty-eight patients followed up with a diagnosis of PS between January 2011 and December 2013 were evaluated. We found high rates of personal history of febrile convulsions, breath-holding spells, and family history of febrile convulsions, afebrile convulsion/epilepsy, migraine, and breath-holding spells. Seizures started before the age of eight in 87% of the patients, and the mean age at seizure onset was 4.6 years. Seizures were sleep-related in 81.5%, and autonomic status was seen in a third of the patients. The number of seizures was between 2 and 10 in 66% of the patients. The most common symptoms were ictus emeticus, eye/head deviation, and altered consciousness. Rolandic features were seen in 26% of the patients, and visual symptoms in 5%. Multifocal epileptiform discharges on EEG were identified in 84% of the patients. Two or more antiepileptic drugs were required in only 13% of the patients. Evolution to electrical status epilepticus in sleep and Gastaut-type epilepsy were seen in patients with more than ten seizures. The high rates of febrile convulsions, afebrile convulsions/epilepsy, migraine, and breath-holding spells in the patients and families suggest the importance of genetic factors and, perhaps, a common pathogenesis. However, the high rates of febrile convulsions and breath-holding spells in patients can be related to a misdiagnosis because of the similar symptoms. Despite its disturbing symptoms, PS is a benign epileptic syndrome requiring multiple antiepileptic drug use only in a small proportion of patients.

Benign occipital lobe seizures: Natural progression and atypical evolution

Benign occipital seizure syndromes are benign childhood epilepsy syndromes and are mainly of two types, Panayiotopoulos syndrome, an autonomic epilepsy and idiopathic childhood occipital epilepsy of Gastaut (ICOE-G) including the idiopathic photosensitive occipital lobe epilepsy. Although both these types are categorized as occipital seizures, they are distinct in presentation and management. They can also be tricky to diagnose as visual symptoms may not always be the presenting feature and it is also not very easy to elicit visual hallucinations during history taking. These seizures have a good response to treatment; however, there could be atypical evolution and refractoriness to treatment especially with ICOE-G. We describe three children who presented with visual and non-visual symptoms and the electroencephalography (EEG) in all the three cases showed occipital paroxysms. We have emphasized the clues in the clinical history and EEG leading to the diagnosis of these distinct epilepsy syndromes. We have also discussed the natural course of these epilepsy syndromes with some atypical evolution, which clinicians need to be aware of during treatment of these children.

Genetic generalized epilepsies

In the International League Against Epilepsy's most recent revision of classification and terminology, the term idiopathic epilepsy, previously used to describe those epilepsies whose cause was unknown, but presumed genetic, has been removed. It has been replaced by the term genetic epilepsy, only to be used to describe epilepsy in which the etiology has a known or presumed genetic defect in which seizures are the core symptom of the disorder. The purpose of this article was to review the electroclinical spectrum of those epilepsies that would fall under this new designation of genetic epilepsies in the context of specific generalized epilepsy syndromes providing an update in the clinical, electroencephalographic, and genetic findings in these syndromes.

Pediatric focal epilepsy syndromes

Benign epilepsy with centrotemporal spikes, early-onset childhood occipital epilepsy (Panayiotopoulos syndrome [PS]) and late-onset childhood occipital epilepsy (Gastaut type [LOCE-G]) are the principal pediatric focal epilepsy syndromes. They share major common characteristics: the appearance and resolution of electroclinical features are age related, there is a strong genetic predisposition, the clinical course is often mild with infrequent and easy to control seizures, interictal epileptiform activity is disproportionately abundant when compared with the clinical correlate, and tends to potentiate and generalize during sleep. In this review, we outline the relevant pathophysiology underlying this electroclinical spectrum. Then, the initial description of individual syndromes is followed by a summary of overlapping features and intermediate presentations that question the boundaries between these entities and provide the basis for the concept of a childhood seizure susceptibility syndrome. Additionally, we outline the main features of the related epileptic encephalopathies. An outlook on potential future lines of research completes this review.

Cardiovascular and neuroendocrine features of Panayiotopoulos syndrome in three siblings

OBJECTIVE

Panayiotopoulos syndrome is a benign idiopathic childhood epilepsy characterized by altered autonomic activity at seizure onset.

METHODS

Three siblings with Panayiotopoulos syndrome underwent 24-hour EEG recording and head-up tilt testing with continuous blood pressure and RR interval monitoring. Plasma catecholamines and vasopressin were measured while supine, upright, and during a typical seizure.

RESULTS

Patient 1, a 12-year-old girl, had a history of involuntary lacrimation, abdominal pain, and recurrent episodes of loss of muscle tone and unresponsiveness followed by somnolence. Her EEG revealed bilateral frontotemporal spikes. Patient 2, a 10-year-old boy, had episodic headaches with pinpoint pupils, skin flushing of the face, trunk, and extremities, purple discoloration of hands and feet, diaphoresis, nausea, and vomiting. Tilt testing triggered a typical seizure after 9 minutes; there was a small increase in blood pressure (+5/4 mm Hg, systolic/diastolic) and pronounced increases in heart rate (+59 bpm) and norepinephrine (+242 pg/mL), epinephrine (+175 pg/mL), and vasopressin (+22.1 pg/mL) plasma concentrations. Serum glucose was elevated (206 mg/dL). His EEG revealed right temporal and parietal spikes. Patient 3, an 8-year-old boy, had a history of restless legs at night, enuresis, night terrors, visual hallucinations, cyclic abdominal pain, and nausea. His EEG showed bitemporal spikes.

CONCLUSION

Hypertension, tachycardia, and the release of vasopressin suggest activation of the central autonomic network during seizures in familial Panayiotopoulos syndrome. These autonomic and neuroendocrine features may be useful in the diagnosis and may have therapeutic implications.

Atypical benign partial epilepsy: recognition can prevent pseudocatastrophe

To characterize and distinguish atypical benign partial epilepsy of childhood among various epileptic syndromes, we conducted a clinical and electroencephalogram study. Seventeen children with atypical benign partial epilepsy of childhood were followed at our hospital. They all underwent a video/polygraphic study of characteristic daily seizures, facilitating a diagnosis of atypical benign partial epilepsy of childhood. Their clinical and electroencephalogram features were retrospectively analyzed. A video/polygraphic study indicated negative motor seizures including epileptic negative myoclonus, atonic absence seizures, or atonic seizures corresponding to spike-and-wave complexes arising from centro-parieto-temporal regions. Early in the clinical course, these seizures appeared every 4 ± 2 months, and lasted 1-3 months. Interictal sleep electroencephalograms, initially localizing in the centro-parieto-temporal regions, became widespread and displayed continuous, diffuse, spike-and-wave complexes, although the spike-wave index did not exceed 85%. Negative motor seizures responded to ethosuximide, corticotropin, and high-dose steroid, whereas other antiepileptic drugs were much less effective. All patients ultimately entered remission before age 12 years. Patients with atypical benign partial epilepsy of childhood exhibited a characteristic clinical course, and responded favorably to anti-absence treatment. Atypical benign partial epilepsy of childhood should be recognized as a discrete epileptic syndrome. Its early diagnosis leads to the prevention of pseudocatastrophe.

Documentation of autonomic seizures and autonomic status epilepticus with ictal EEG in Panayiotopoulos syndrome

Panayiotopoulos syndrome (PS) is a common childhood susceptibility to autonomic seizures and status epilepticus. Despite its high prevalence, PS has been a source of significant debate. We present ictal EEG documentation of autonomic seizures and autonomic status epilepticus in six cases of PS and a review of 14 reported cases. Interictal EEGs showed spikes of variable locations that often changed with time. Ictal EEG onsets were also variable, starting from wide anterior or posterior regions usually with theta waves intermixed with small spikes and fast rhythms. Ictal vomiting and other autonomic manifestations, as well as deviation of the eyes, did not appear to relate to any specific region of EEG activation. These data document that PS is a multifocal autonomic epilepsy and support the view that the clinical manifestations are likely to be generated by variable and widely spread epileptogenic foci acting on a temporarily hyperexcitable central autonomic network.

Panayiotopoulos syndrome: a clinical, EEG, and neuropsychological study of 93 consecutive patients

PURPOSE

To explore the clinical, electroencephalography (EEG), neuropsychological features, and prognosis of Panayiotopoulos syndrome (PS).

METHODS

Of 1,794 children aged between 1 and 14 years referred for the first afebrile focal seizure, between January 1992 and December 2004, 93 (5.2%) had PS according to clinical criteria.

RESULTS

Age at onset ranged from 1.1 to 8.6 years, and was earlier in children with more than one seizure. Autonomic seizures followed a stereotypical onset and progression. Emesis, pallor, or flushing was almost always among the first symptoms that usually culminated in vomiting (77.4% of patients). More than half (55%) of seizures were longer than 30 min but these did not appear to affect remission and number of seizures. Interictal EEG showed great variability, with 79.5% of patients showing spikes of variable localizations and evolution over time; 16.1% had background abnormalities only, and 5.4% had consistently normal EEG studies. Onsets in five ictal EEGs were posterior or anterior-left or right. On neuropsychological testing, IQ and subtests of Wechsler Intelligence Scale for Children-Revised (WISC-R) were within normal limits, although some minor statistically significant differences were found in arithmetic, comprehension, and picture arrangement in comparison with controls. Cumulative probability of recurrence was 57.6%, 45.6%, 35.1%, and 11.7% at 6, 12, 24, and 36 months, respectively, after the first seizure. Thirty-four (58.6%) of 59 patients treated with antiepileptic drugs continued having seizures before ultimate remission.

DISCUSSION

PS is a uniform childhood susceptibility to autonomic seizures that is related to early age of development and with excellent prognosis with regard to seizure remission and neuropsychological development.

Panayiotopoulos syndrome: an important childhood autonomic epilepsy to be differentiated from occipital epilepsy and acute non-epileptic disorders

Panayiotopoulos syndrome is a common multifocal autonomic childhood epileptic disorder with significant clinical, pathophysiological and management implications. It affects otherwise normal children with onset at around 3-6 years. It is characterized by seizures, often prolonged, with predominantly autonomic symptoms and mainly ictal vomiting. EEG shows shifting and/or multiple foci, often with occipital dominance. Despite characteristic clinical and EEG manifestations Panayiotopoulos syndrome is often confused with occipital epilepsy and acute non-epileptic disorders such as encephalitis, syncope, cyclic vomiting or atypical migraine. This review aims to describe Panayiotopoulos syndrome on the basis of independent major studies and provide clinical clues for diagnosis and management.

Neurobehavioral abnormalities may correlate with increased seizure burden in children with Panayiotopoulos syndrome

Prognostic factors for frequent seizure recurrences were studied in patients with Panayiotopoulos syndrome. The subjects were 79 children fulfilling the criteria of Panayiotopoulos syndrome who were monitored for longer than 2 years. Medical records and electroencephalograms were analyzed retrospectively. The total number of seizures in each patient at the final follow-up ranged from 1 to 22. The 79 patients were classified into three groups: typical Panayiotopoulos syndrome (seizure recurrence = 1-5 times, n = 45), borderline (6-9 times, n = 16), and atypical (>10 times, n = 18). Data analyzed included family history of seizure disorders, peri- and postnatal complications, previous seizure histories, age at epilepsy onset, clinical seizure manifestations, the frequency of status epilepticus, interictal electroencephalographic patterns, and the possible association of neurobehavioral disorders among the three groups. An association with pre-existing neurobehavioral disorders was significantly more frequent in the atypical than in the typical group (P < 0.05), but not significantly different between the typical and borderline or between the borderline and atypical patients (P> 0.05). In patients with Panayiotopoulos syndrome and pre-existing mild neurobehavioral disorders, seizures tend to be pharmacoresistant and to repeat more than 10 times. However, all patients experience seizure remission by 12 years of age, and should not be evaluated for surgery.

Diffuse onset of ictal electroencephalography in a typical case of Panayiotopoulos syndrome and review of the literature

Panayiotopoulos syndrome is a common and benign childhood autonomic epilepsy of debated localization. Although officially considered as occipital epilepsy, this is most likely of multifocal origin. Ictal electroencephalography is the gold standard of seizure localization, but in Panayiotopoulos syndrome, because patients have single or rare seizures, only 7 cases with ictal electroencephalography have been reported. Ictal onsets show variable anterior and more often posterior locations. We describe an 8-year-old girl with 5 nocturnal autonomic seizures typical of Panayiotopoulos syndrome from age 4. The last seizure was captured with electroencephalography and showed a diffuse onset of the ictal discharge, whereas various interictal electroencephalography had infrequent multifocal spikes. This case contributes to the understanding of the pathophysiology of Panayiotopoulos syndrome in favor of a diffuse and multifocal cortical epileptogenicity that triggers an unstable central autonomic nervous system solely or prior to the focal cortical symptoms.

A novel inherited mutation in the voltage sensor region of SCN1A is associated with Panayiotopoulos syndrome in siblings and generalized epilepsy with febrile seizures plus

We report 2 families harboring a novel SCN1A mutation, one of whom had Panayiotopoulos syndrome and the other a phenotype consistent with generalized epilepsy with febrile seizures plus. Two siblings had recurrent episodes of autonomic status epilepticus with focal features consistent with the diagnosis of Panayiotopoulos syndrome. Both have the SCN1A mutation p.Phe218Leu. The mutation was present in their father who has never had a seizure. The same mutation was identified in a child diagnosed with intractable childhood epilepsy with generalized tonic clonic seizures. From the age of 5, he developed complex focal seizures associated with left hippocampal sclerosis. The mutation was present in his mother, aged 25, who had febrile seizures and developed generalized tonic clonic seizures and his sister who had 1 febrile seizure. Our findings suggest that SCN1A mutations may cause susceptibility to an idiopathic focal epilepsy phenotype, the final phenotype depending on other (genetic or nongenetic) factors.

Brain maturation-related spike localization in Panayiotopoulos syndrome: magnetoencephalographic study

Focal spike activities in Panayiotopoulos syndrome involve all brain regions in electroencephalography, and commonly reveal multiple foci, often through occipital predominance. To investigate correlations between developmental brain maturation and spike origin in Panayiotopoulos syndrome, we evaluated age-related or duration-related magnetoencephalographic spike localization in 25 patients with Panayiotopoulos syndrome. Regarding age at examination, patients with frontal spikes were significantly older than patients with spikes on rolandic, parieto-occipital, or calcarine sulci. Occipital spikes were classified into two subgroups, located at the calcarine sulcus and parieto-occipital sulcus. Both calcarine and parieto-occipital localizations were seen in patients around the same age. Follow-up magnetoencephalography was performed on three patients, and demonstrated shifting localization or disappearance of magnetoencephalographic spikes. These results suggest that the location of spike discharges is not directly related to seizure symptoms, but instead indicates maturation-related cortical hyperexcitability in patients with Panayiotopoulos syndrome.

Childhood occipital epilepsy of Gastaut: A study of 33 patients

PURPOSE

To characterize the electroclinical features and evolution of childhood occipital epilepsy of Gastaut (COE-G).

METHODS

Children with electroclinical criteria of COE-G were retrospectively identified and followed-up clinically, and with sleep and awake EEGs between 1990 and 2007.

RESULTS

We identified 33 patients with COE-G. In the same length of time, 201 children with Panayiotopoulos syndrome and 410 children with benign childhood epilepsy with centrotemporal spikes were registered. COE-G had a peak age at onset of 8.5 years. Visual manifestations were the most common ictal event. Ictal deviation of the eyes was frequent. Approximately half of the patients had migraine-like symptoms. In all patients the seizures occurred while awake, and 11 also had seizures during sleep. The majority of the patients had occipital spike-wave discharges when the eyes were closed that disappeared or attenuated when the eyes were opened. Prognosis was excellent in 80% of the cases.

CONCLUSION

This study confirms the existence of COE-G, a rare but well-defined syndrome within the group of idiopathic focal epilepsies in childhood.

Autonomic Status Epilepticus in Panayiotopoulos Syndrome and Other Childhood and Adult Epilepsies: A Consensus View

PURPOSE

To discuss and propose a definition of autonomic status epilepticus (SE), describe its clinical and EEG features, and review what is known about its epidemiology, pathophysiology, differential diagnosis, and management.

METHODS

An international consortium of established researchers in the field was identified from their published work, agreed the purpose of the project, searched the literature, and, by use of e-mail communication, agreed the consensus document.

RESULTS

Autonomic SE is a condition lasting at least 30 min and characterized by epileptic activity causing altered autonomic function of any type at seizure onset or in which manifestations consistent with altered autonomic function are prominent (quantitatively dominant or clinically important) even if not present at seizure onset. It is best described, and probably most commonly encountered in children, with Panayiotopoulos syndrome. However, it also occurs in children with symptomatic epilepsies and, exceptionally, in adults. Its pathogenesis and most appropriate management are poorly understood.

CONCLUSIONS

It is hoped that this document will help clinical recognition of Autonomic SE, reduce misdiagnosis, and promote further interest and studies into what has been a relatively neglected area.

Panayiotopoulos Syndrome: A Prospective Study of 192 Patients

OBJECTIVES

To characterize the electroclinical features and evolution of Panayiotopoulos Syndrome (PS).

METHODS

Children with electroclinical criteria of PS were prospectively identified and followed-up clinically, and with sleep and awake EEGs between February 1990 and 2006.

RESULTS

We identified 192 patients with PS. In the same length of time 398 children with benign childhood epilepsy with centro-temporal spikes (BCECTS) were registered. PS had a peak age at onset of 5 years. Autonomic manifestations were one of the most common ictal event. Ictal deviation of the eyes and progression to generalized convulsions were also quite frequent. Approximately one third had partial status epilepticus. In all patients except five, the seizures occurred during sleep. One-third also had fits while awake. Sixteen children had concomitant symptoms of rolandic epilepsy and eight developed rolandic seizures after remission of PS seizures. Prognosis was excellent. Eighty-four (44.2%) had a single seizure, 79 (41.2%) had 2-5 fits, and 28 (14.6%) had frequent seizures.

CONCLUSION

PS is less common than BCECTS, but is well defined and easily recognizable by clinical and EEG features, with autonomic manifestations as one of the most common ictal event.

Panayiotopoulos Syndrome: An Important Electroclinical Example of Benign Childhood System Epilepsy

As a result of the converging evidence from multiple large independent studies, Panayiotopoulos syndrome (PS) is now formally recognized as a distinct clinical entity within the spectrum of benign focal epilepsies of childhood. Clinically, PS is manifested by predominantly autonomic seizures and electrographically with multifocal interictal spikes, while the few published ictal recordings have documented onsets of variable lobar topography. These typical electroclinical features do not allow straightforward assignment to a distinctive cortical area, rendering the term "focal"--as we currently understand it--problematic. This is a critical review of the clinical and EEG features of PS, focusing on those characteristics that may shed some light on its so far elusive pathophysiology. We also explore its electroclinical similarities to other idiopathic "focal" epilepsies and its differences to symptomatic focal epilepsies that may also manifest with autonomic ictal symptoms and signs. This methodology allows the formation of a rational hypothesis on the pathophysiology of PS that seems to be emerging as a good model for the so-called "system" (nonsymptomatic) epilepsies, with potentially important taxonomic implications.

A case of Panayiotopoulos syndrome showing an atypical course

We describe herein a patient with Panayiotopoulos syndrome (PS) showing an atypical course. The patient initially had seizures typical of this syndrome from 3 to 5 years of age. EEG showed right occipital high-amplitude sharp and slow-wave complexes followed by brief generalized discharges of slow waves. Sequential EEGs obtained from 5 to 11 years of age showed both multifocal discharges and generalized spike and wave complexes. With these changes in EEG findings, the patient experienced various types of seizures. The seizures were frequent and showed oculocephalic deviation followed by absence, atonic seizures, generalized tonic clonic convulsions and clonic seizures of the eyelids, which were observed between 7 and 10 years of age. Antiepileptic drugs were only partially effective for these seizures. Ictal EEG recorded at 8 years of age revealed high-voltage slow waves from the bilateral frontal and occipital regions prior to diffuse high-amplitude spike-wave bursts. At 9 years of age, magnetoencephalography (MEG) revealed the calculated dipoles of the preceding bifrontal spike-wave discharges to be in the frontal areas, while those of the following generalized spike-wave bursts were in the bilateral mid-temporal areas. In PS, reportedly, dipoles of multifocal epileptic discharges are usually located in the occipital and Rolandic areas. The unique clinical evolution in our case may be associated with the unusual frontal localization of dipoles detected by MEG.

Panayiotopoulos syndrome: a benign childhood autonomic epilepsy frequently imitating encephalitis, syncope, migraine, sleep disorder, or gastroenteritis

BACKGROUND

Panayiotopoulos syndrome is a common idiopathic childhood-specific seizure disorder formally recognized by the International League Against Epilepsy. An expert consensus has defined Panayiotopoulos syndrome as "a benign age-related focal seizure disorder occurring in early and mid-childhood. It is characterized by seizures, often prolonged, with predominantly autonomic symptoms, and by an EEG [electroencephalogram] that shows shifting and/or multiple foci, often with occipital predominance."

OBJECTIVE

The purpose of this review is to provide guidance for appropriate diagnosis and management of Panayiotopoulos syndrome.

CLINICAL FEATURES

Autonomic epileptic seizures and autonomic status epilepticus are the cardinal manifestations of Panayiotopoulos syndrome. Autonomic seizures in Panayiotopoulos syndrome consist of episodes of disturbed autonomic function with emesis as the predominant symptom. Other autonomic manifestations include pallor (or, less often, flushing or cyanosis), mydriasis (or, less often, miosis), cardiorespiratory and thermoregulatory alterations, incontinence of urine and/or feces, hypersalivation, and modifications of intestinal motility. In approximately one fifth of the seizures the child becomes unresponsive and flaccid (ictal syncope) before or often without convulsions. Cardiorespiratory arrest is exceptional. More-conventional seizure symptoms often appear after the onset of autonomic manifestations. The child, who was initially fully conscious, becomes confused and unresponsive. Eyes turn to one side or gaze widely open. Only half of the seizures end with brief hemiconvulsions or generalized convulsions. Convulsive status epilepticus is extremely rare. Autonomic symptoms may be the only features of the seizures. Half of the seizures in Panayiotopoulos syndrome last for >30 minutes, thus constituting autonomic status epilepticus, which is the more common nonconvulsive status epilepticus in normal children. Two thirds of seizures occur during sleep.

EPIDEMIOLOGY

Panayiotopoulos syndrome probably affects 13% of children aged 3 to 6 years who have had 1 or more afebrile seizures and 6% of such children in the 1- to 15-year age group.

DIAGNOSTIC TESTS

An electroencephalogram is the only investigation with abnormal results, usually showing multiple spikes in various brain locations.

PATHOPHYSIOLOGY

Panayiotopoulos syndrome is probably the early-onset and Rolandic epilepsy the late-onset phenotype of a maturation-related benign childhood seizure-susceptibility syndrome. Ictal epileptic discharges in Panayiotopoulos syndrome, irrespective of their location at onset, activate autonomic disturbances and emesis, to which children are particularly vulnerable. The symptoms/sequence of autonomic seizures and autonomic status epilepticus in Panayiotopoulos syndrome are specific to childhood, and they do not occur in adults.

PROGNOSIS

Panayiotopoulos syndrome is remarkably benign in terms of seizure frequency and evolution. Autonomic status epilepticus imparts no residual neurologic deficit. The risk of epilepsy in adult life seems to be no higher than in the general population. However, autonomic seizures are potentially life-threatening in the rare context of cardiorespiratory arrest, an area in which additional study is required. MISDIAGNOSIS: The clinical features of Panayiotopoulos syndrome are frequently mistaken as nonepileptic conditions such as acute encephalitis, syncope, migraine, cyclic vomiting syndrome, motion sickness, sleep disorder, or gastroenteritis. The consequence is avoidable misdiagnosis, high morbidity, and costly mismanagement.

MANAGEMENT

Education about Panayiotopoulos syndrome is the cornerstone of management. Prophylactic treatment with antiepileptic medication may not be needed for most patients. Autonomic status epilepticus in the acute stage needs thorough evaluation; aggressive treatment may cause iatrogenic complications including cardiorespiratory arrest.

EEG Dipole Characteristics in Panayiotopoulos Syndrome

PURPOSE

Panayiotopoulos syndrome (PS) is a type of benign childhood partial epilepsy that is frequently associated with abundant multifocal spikes other than main occipital spikes on the EEG. In this study, we investigated the characteristic features of dipoles in PS.

METHODS

We performed dipole analysis of the interictal occipital spike discharges seen in 10 children with PS (group A) and in 10 children with other types of symptomatic localization-related epilepsy (group B). We analyzed the dipoles of the averaged spike in each patient.

RESULTS

In group A, the averaged occipital spikes in each patient showed dense dipole locations in the mesial occipital area; in group B, widely scattered dipole locations were observed. In Group A, the geometric centers of the dipoles at each time point (such as at the main negative peak and before or after the main peak) were estimated in the neighboring locations. In contrast, they tended to be scattered in group B.

CONCLUSIONS

Our study reveals that PS has high dipole stability, similar to that of rolandic epilepsy. From the electroencephalographic view, this seems to indicate a close link between these two syndromes.

Panayiotopoulos syndrome: a consensus view

The aim of this paper is to promote the correct classification of, and provide guidelines on, the diagnosis and management of Panayiotopoulos syndrome (PS). An international consortium of established researchers in the field collaborated to produce a consensus document. The resulting document defines PS, characterizes its electro-clinical features, considers its likely pathogenesis, and provides guidance on appropriate management. We conclude that PS is a common idiopathic, benign seizure disorder of childhood, which should be classified as an autonomic epilepsy, rather than an occipital epilepsy.

Recurrent autonomic status epilepticus in Panayiotopoulos syndrome: video/EEG studies

We describe a neurologically and developmentally normal child with infrequent seizures characterized by emetic symptoms and other autonomic phenomena and interictal spikes that satisfy the diagnostic criteria of Panayiotopoulos syndrome (PS). Two video/EEG recordings, taken a year apart, revealed prolonged autonomic seizures and other subtle behavioral changes, suggesting that episodes of nonconvulsive status epilepticus in PS may be more frequent than appreciated.

A Magnetoencephalographic Study of Patients with Panayiotopoulos Syndrome

PURPOSE

Panayiotopoulos syndrome (PS) is a newly identified type of benign childhood epilepsy characterized by ictal vomiting and eye deviation. It is usually accompanied by occipital spike discharges; however, its classification as an early-onset benign childhood occipital epilepsy is controversial. To characterize this condition further, we examined the localization of equivalent current dipoles (ECDs) of spike discharges by magnetoencephalography (MEG) in patients with PS.

METHODS

We studied 13 patients with a mean age at time of examination of 5 years (range, 3-14 years). MEG was measured by using a whole-head 204-channel neuromagnetometer with simultaneous EEG recordings. The estimated locations of ECDs of each peak of the spike discharges were overlaid on magnetic resonance images of the brain.

RESULTS

Eleven (84.6%) patients showed clustered ECDs in the areas alongside the parietooccipital sulcus (eight of 13; 61.5%) and/or the calcarine sulcus (four of 13; 30.8%). Despite Fp-O synchronization of the spike discharges in the scalp EEG of five patients, no frontal locations of ECDs were found. All five (38.5%) boys with sylvian seizures, who also showed clustered ECDs in rolandic areas, had an earlier age at onset and higher seizure frequency than did other patients. ECD orientations were regular in all but one patient, who showed irregular and dispersed ECDs alongside bilateral calcarine sulci.

CONCLUSIONS

Our results demonstrate localized cortical hyperexcitability in the areas alongside major cortical sulci in PS and indicate that PS is closely related to benign childhood epilepsy with centrotemporal spikes.

Epilepsia occipital benigna da infância de início precoce (tipo Panayiotopoulos): aspectos clínicos e eletrencefalográficos evolutivos em 14 crianças

Foram estudadas as características evolutivas clínico-eletrencefalográficas de 14 crianças com epilepsia occipital benigna da infância de início precoce (tipo Panayiotopoulos). O tempo médio de segmento foi 50,5 meses. A idade média na primeira crise foi 3,7 anos. O número total de crises foi até 3 crises em 11 casos, numerosas em 3; o período médio entre a primeira e a última crise foi 14,5 meses. Em 4 casos as crises tiveram duração prolongada, constituindo estado de mal parcial. Atividade epileptiforme (AE) occipital foi observada em todos os casos no primeiro EEG e, foi também, extra-occipital, em 3 casos. Houve bloqueio da AE occipital, pela abertura dos olhos, em 4 casos; em 3 casos foram observadas, também, pontas evocadas. O EEG normalizou-se em 9 casos, em um período médio de 29 meses.

Autonomic seizures and autonomic status epilepticus peculiar to childhood: diagnosis and management

Autonomic seizures and autonomic status epilepticus in children have a high prevalence, manifest with dramatic clinical symptoms, and have important clinical and management implications. They probably affect approximately 13% of children aged 3-6 years with one or more nonfebrile seizures, or 6% in the age group 1-15. The primary cause is an idiopathic age-dependent epileptogenic susceptibility (Panayiotopoulos syndrome), but 10-20% are due to cerebral pathology. Autonomic seizures and autonomic status epilepticus have been best studied in Panayiotopoulos syndrome, which has been confirmed worldwide in more than 800 cases and recently recognized in the new classification scheme of the International League Against Epilepsy. Seizures start with autonomic symptoms, mainly emesis, while the child is usually fully conscious. Other more conventional seizure manifestations often ensue, but autonomic manifestations commonly predominate to the end of the seizure. Ictal syncope (transient loss of consciousness and postural tone) is an intriguing common symptom. Half of the seizures last longer than 30 minutes, constituting autonomic status epilepticus. Prognosis is invariably excellent except for the symptomatic cases. The interictal EEG shows great variability from normal to severely epileptogenic, often with multifocal spikes. Pathophysiology of Panayiotopoulos syndrome is unknown, but it is likely that they are due to diffuse maturation-related epileptogenicity activating susceptible-for-children emetic centers and the hypothalamus. Thus, Panayiotopoulos syndrome is not occipital epilepsy, with which it is often erroneously equated. Autonomic seizures and autonomic status epilepticus are frequently misdiagnosed and often treated as encephalitis, atypical migraine, cardiogenic syncope, or other unrelated medical conditions such as gastroenteritis. This review examines the existing evidence, provides a means of improving diagnostic yield, and proposes practice parameters and guidelines for the diagnosis and management of autonomic seizures and autonomic status epilepticus in children.

EEG in children with early-onset benign occipital seizure susceptibility syndrome: Panayiotopoulos syndrome

PURPOSE

We analyzed sequential changes in the localization of EEG foci along with age to identify a specific EEG pattern, and the relation between the clinical manifestations and the EEG pattern in patients with Panayiotopoulos syndrome (PS).

METHODS

The subjects were 76 children, who had been followed up >2 years with repeated EEG examinations at 6-month intervals. Analysis of EEG findings included the determination of localization of spike foci, as a function of age, by using cross-sectional data, and the identification of subgroups with homogeneous EEG patterns. Then we compared certain clinical features among these subgroups.

RESULTS

In the cross-sectional EEG study, the occipital EEG spike focus was most frequently seen between ages 2 and 5 years. Independent and synchronous frontopolar and occipital spikes (Fp-O spikes) and centroparietotemporal (CPT) EEG spike foci had increased incidences between ages 4 and 7 years, and between ages 6 and 10 years, respectively. We subclassified the 76 patients into the following five subgroups based on the evolutional changes in epileptic EEG foci, which frequently showed shifting, multiplications, and generalization: (a) persistent occipital focus group (O group), (b) Fp-O spikes group (Fp-O pattern group), (c) generalized EEG pattern group, (d) CPT foci group (CPT group), and (e) no epileptic EEG focus group. The Fp-O group showed the latest age at onset of epilepsy. The generalized EEG pattern group had the highest frequency of seizures as well as recurrences of status epilepticus (SE), as well as the longest active seizure period among the five groups.

CONCLUSIONS

These results indicated that the EEG foci in most of patients with PS are frequently shifting location, multiplying, and propagating diffusely with age, rather than persistently localizing in the occipital region. In addition, the EEG patterns showed a certain trend and roughly corresponded to certain clinical characteristics. However, the prognosis of the seizures appeared to be favorable regardless of the EEG pattern.

A study of 43 patients with panayiotopoulos syndrome, a common and benign childhood seizure susceptibility

PURPOSE

To determine prevalence, clinical, EEG features, and prognosis of Panayiotopoulos syndrome and to examine the proposition that clinical manifestations are more important than EEG findings.

METHODS

We analyzed retrospectively the clinical and EEG records of 1,340 children with one or more focal seizures seen in the last 18 years, supplemented with a prospective study from 1998. Panayiotopoulos syndrome was defined by clinical criteria, mainly ictal emesis, irrespective of EEG findings.

RESULTS

We analyzed 43 of 90 patients with Panayiotopoulos syndrome who were seizure free >2 years. Girls predominated. Mean age at first seizure was 5 years. Seizures consisted mainly of autonomic manifestations; ictal emesis was often the first symptom, culminating in vomiting in 86%. Of nonautonomic manifestations, lateral eye deviation was the most common; visual symptoms were exceptional. Impairment of consciousness ensued in all seizures, half of which ended with hemi or generalized convulsions. Nearly 46.5% of cases had at least one seizure >30 min, constituting autonomic status epilepticus. Seizures during sleep (84%) were more common than those in wakefulness. EEG showed occipital spikes in 29 patients. Of the other 14 cases, five had extraoccipital abnormalities or brief generalized discharges, and nine had normal awake and sleep EEG. Prognosis was excellent. All 43 children have been free of seizures for > or =2 years, 53% having a single seizure, and 47%, an average two to three seizures.

CONCLUSIONS

Panayiotopoulos syndrome is common and needs wider recognition. EEG shows occipital or extraoccipital abnormalities, is normal in one third of patients, and does not determine clinical manifestations or prognosis, which is excellent despite the high prevalence of lengthy seizures.

Early-onset occipital idiopathic epilepsy: a syndrome to be treated?

The purpose of this study was to evaluate prognostic factors in early-onset childhood epilepsy with occipital paroxysms. We studied retrospectively a population of 46 patients, which was divided into three groups according to seizure frequency group 1, patients experiencing a single seizure (3396); group 2, patients experiencing two to six seizures (48%); and group 3, patients experiencing more than six seizures (20%). The mean follow-up period was about 5 years in the three groups. At the end of the first 6 months of this retrospective follow-up, the average number of seizures was higher in group 3 (2.9 seizures) than in groups 2 and 1 (1.8 and 1 seizure, respectively). We suggest that low seizure frequency in the first 6 months of follow-up could have prognostic value. We propose that the introduction of anti-epilepsy drugs be delayed for 6 months following epilepsy onset and be subsequently limited to patients with frequent seizure recurrence.

Magnetoencephalographic analysis in a case of early-onset benign childhood occipital seizures

We report a 12-year-old boy who had one seizure comprising deviation of the eyes followed by impairment of consciousness for 30 minutes at the age of 6 years. No visual hallucination or ictal vomiting was observed. Interictal electroencephalography showed repetitive spikes and spike-wave discharges over the left occipital lobe. Magnetoencephalography revealed that the estimated dipoles were clustered in the left cuneus on magnetic resonance imaging, which corresponded to the area of peripheral vision and the associated visual cortex but not to the central visual cortex. Magnetoencephalography is advantageous for determining the electrophysiologic mechanism of early-onset benign childhood occipital seizures.