Dysfunctional white-matter networks in medicated and unmedicated benign epilepsy with centrotemporal spikes

Benign epilepsy with centrotemporal spikes (BECT) is the most common childhood idiopathic focal epilepsy syndrome, which characterized with white-matter abnormalities in the rolandic cortex. Although diffusion tensor imaging research could characterize white-matter structural architecture, it cannot detect neural activity or white-matter functions. Recent studies demonstrated the functional organization of white-matter by using functional magnetic resonance imaging (fMRI), suggesting that it is feasible to investigate white-matter dysfunctions in BECT. Resting-state fMRI data were collected from 24 new-onset drug-naive (unmedicated [NMED]), 21 medicated (MED) BECT patients, and 27 healthy controls (HC). Several white-matter functional networks were obtained using a clustering analysis on voxel-by-voxel correlation profiles. Subsequently, conventional functional connectivity (FC) was calculated in four frequency sub-bands (Slow-5:0.01-0.027, Slow-4:0.027-0.073, Slow-3:0.073-0.198, and Slow-2:0.198-0.25 Hz). We also employed a functional covariance connectivity (FCC) to estimate the covariant relationship between two white-matter networks based on their correlations with multiple gray-matter regions. Compared with HC, the NMED showed increased FC and/or FCC in rolandic network (RN) and precentral/postcentral network, and decreased FC and/or FCC in dorsal frontal network, while these alterations were not observed in the MED group. Moreover, the changes exhibited frequency-specific properties. Specifically, only two alterations were shared in at least two frequency bands. Most of these alterations were observed in the frequency bands of Slow-3 and Slow-4. This study provided further support on the existence of white-matter functional networks which exhibited frequency-specific properties, and extended abnormalities of rolandic area from the perspective of white-matter dysfunction in BECT.

Propofol-induced refractory status epilepticus at remission age in benign epilepsy with centrotemporal spikes: A case report and literature review

RATIONALE

Benign epilepsy with centrotemporal spikes (BECTS) is one of the most common forms of childhood epilepsy, which is expected to resolve before 16 years of age, with mild effects on the cognitive or behavioral functions in adulthood. This study aims to report the first propofol-induced refractory status epilepticus (SE) in patients with BECTS after 16 years of age, and to review SE in BECTS or induced by propofol.

PATIENT CONCERN

A 16-year-old Chinese girl, who was diagnosed with BECTS at the age of 2 years, developed refractory SE induced by propofol administered during the maintenance stage of general anesthesia during a plastic surgery procedure.

DIAGNOSES

Considering her medical history, EEG, and magnetic resonance images, and brain computed tomography, a diagnosis of refractory SE in BECTS was confirmed.

INTERVENTIONS

The patient had been seizure-free for 3 years from treatment with 2 anti-epileptic drugs (AEDs) valproate acid (VPA) and oxcarbazepine (OXC), and had started monotherapy with OXC for 3 months before the seizure incidence. She had undergone blepharoplasty under local anesthesia prior to receiving general anesthesia. During the maintenance state she developed convulsive SE, which was uncontrolled seizure and lasted for 14 hours. The treatment for which included midazolam, diazepam, propofol, VPA, OXC, and levetiracetam (LEV).

OUTCOMES

The prolonged seizure was controlled by diazepam (4 mg/h), propofol (6 mg/kg/h), VPA (2400 mg/d intravenous injection). Subsequently, she was administered VPA (800 mg/d po), OXC (600 mg/d po), and LEV (1000 mg/d po). Finally, on the 17th day she was discharged, and did not have any seizure recurrence and EEG results were normal as noted during the 3-month follow-up.

LESSONS

This was the first report of an SE in BECTS patient past the remission age. This report implied that interventions of sedation or analgesia in a patient after remission age of BECTS might still be at risk of refractory SE and therefore, should be carefully evaluated and monitored during such procedures, especially when an AED medication has been withdrawn or altered.

Development of Ontology for Self-limited Epilepsy with Centrotemporal Spikes and Application of Data Mining Algorithms to Identify New Subtypes

BACKGROUND

Benign rolandic epilepsy or benign childhood epilepsy with centrotemporal spikes (BCECTS) is a common childhood epileptic syndrome. The syndrome resolves in adolescence, but 1-7% of patients have an atypical presentation, some of which require aggressive medical treatment. Early treatment may prevent complications and neurocognitive deterioration. Variants include Landau-Kleffner syndrome (LKS) and electrical status epilepticus during sleep (ESES).

OBJECTIVES

To determine data driven identification of risk factors and characterization of new subtypes of BCECTS based on anontology. To use data mining analysis and correlation between the identified groups and known clinical variants.

METHODS

We conducted a retrospective cohort study comprised of 104 patients with a diagnosis of BCECTS and a minimum of 2 years of follow-up, between the years 2005 and 2017. The medical records were obtained from the epilepsy service unit of the pediatric neurology department at Dana-Dwek Hospital, Tel Aviv Sourasky Medical Center. We developed a BCECTS ontology and performed data preprocessing and analysis using the R Project for Statistical Computing (https://www.r-project.org/) and machine learning tools to identify risk factors and characterize subgroups.

RESULTS

The ontology created a uniform and understandable infrastructure for research. With the ontology, a more precise characterization of clinical symptoms and EEG activity of BCECTS was possible. Risk factors for the development of severe atypical presentations were identified: electroencephalography (EEG) with spike wave (P < 0.05), EEG without evidence of left lateralization (P < 0.05), and EEG localization (centrotemporal, frontal, or frontotemporal) (P < 0.01).

CONCLUSIONS

Future use of the ontology infrastructure for expanding characterization for multicenter studies as well as future studies of the disease are needed. Identifying subgroups and adapting them to known clinical variants will enable identification of risk factors, improve prediction of disease progression, and facilitate adaptation of more accurate therapy. Early identification and frequent follow-up may have a significant impact on the prognosis of the atypical variants.

Changes in functional organization and functional connectivity during story listening in children with benign childhood epilepsy with centro-temporal spikes

Children with Benign Epilepsy with Centrotemporal Spikes (BECTS), despite high likelihood for seizure remission, are reported to have subtle difficulties in language and other cognitive skills. We used functional MRI and a story listening task to examine the effect of BECTS on patterns of activation and connectivity. Language and cognitive skills were assessed using standardized measures. Twenty-four children with recently diagnosed BECTS and 40 typically-developing children participated. In a functionally-defined region of interest in right inferior frontal gyrus, BECTS patients showed a lower level of activation. Across both groups combined, increased activation in superior/middle temporal regions of interest was associated with better language scores. Connectivity in the story processing network was similar between groups, but connectivity within left inferior frontal gyrus was decreased in children with BECTS. These results suggest that language networks are largely maintained in new-onset BECTS, but some subtle changes in activation and connectivity can be observed.

Delayed cortical maturation at the centrotemporal brain regions in patients with benign childhood epilepsy with centrotemporal spikes (BCECTS)

Benign childhood epilepsy with centrotemporal spikes (BCECTS) is an epilepsy syndrome commonly found in child and adolescent. Although the prognosis is mostly favorable as long as the seizure is well controlled. However, they are often suffering from the cognitive and behavioral problems which might be the consequences of the initial insults. It is still not clear whether the initial epileptiform discharges has long term impact on the resting-state brain activities at later ages. This study investigated the resting-state brain activities in BCECTS patients with clinical seizure remission stage (n = 16; 11 males) and compared with the non-epileptic, age-matched control subjects. Quantitative electroencephalography (qEEG) revealed a significantly higher absolute power of the theta and alpha waves in BCECTS patients with clinical seizure remission as compared with the non-epileptic control subjects. Interestingly, the differences were observed mainly over the centrotemporal electrodes which are the common sites of the initial epileptiform discharges. The differences were more significant in patients with bilateral epileptiform discharges than those with the unilateral epileptic activities. Typically, the brain wave power continuously decreases with increasing ages. Therefore, higher absolute powers of the brain waves indicate more delayed in cortical maturation compared with the non-epileptic control group. These findings indicated that BCECTS patients have delay cortical maturation at the centrotemporal brain regions even at the clinical seizure remission phase.

Scalp recorded spike ripples predict seizure risk in childhood epilepsy better than spikes

In the past decade, brief bursts of fast oscillations in the ripple range have been identified in the scalp EEG as a promising non-invasive biomarker for epilepsy. However, investigation and clinical application of this biomarker have been limited because standard approaches to identify these brief, low amplitude events are difficult, time consuming, and subjective. Recent studies have demonstrated that ripples co-occurring with epileptiform discharges ('spike ripple events') are easier to detect than ripples alone and have greater pathological significance. Here, we used objective techniques to quantify spike ripples and test whether this biomarker predicts seizure risk in childhood epilepsy. We evaluated spike ripples in scalp EEG recordings from a prospective cohort of children with a self-limited epilepsy syndrome, benign epilepsy with centrotemporal spikes, and healthy control children. We compared the rate of spike ripples between children with epilepsy and healthy controls, and between children with epilepsy during periods of active disease (active, within 1 year of seizure) and after a period of sustained seizure-freedom (seizure-free, >1 year without seizure), using semi-automated and automated detection techniques. Spike ripple rate was higher in subjects with active epilepsy compared to healthy controls (P = 0.0018) or subjects with epilepsy who were seizure-free ON or OFF medication (P = 0.0018). Among epilepsy subjects with spike ripples, each month seizure-free decreased the odds of a spike ripple by a factor of 0.66 [95% confidence interval (0.47, 0.91), P = 0.021]. Comparing the diagnostic accuracy of the presence of at least one spike ripple versus a classic spike event to identify group, we found comparable sensitivity and negative predictive value, but greater specificity and positive predictive value of spike ripples compared to spikes (P = 0.016 and P = 0.006, respectively). We found qualitatively consistent results using a fully automated spike ripple detector, including comparison with an automated spike detector. We conclude that scalp spike ripple events identify disease and track with seizure risk in this epilepsy population, using both semi-automated and fully automated detection methods, and that this biomarker outperforms analysis of spikes alone in categorizing seizure risk. These data provide evidence that spike ripples are a specific non-invasive biomarker for seizure risk in benign epilepsy with centrotemporal spikes and support future work to evaluate the utility of this biomarker to guide medication trials and tapers in these children and predict seizure risk in other at-risk populations.

Could Rolandic spikes be a prognostic factor of the neurocognitive outcome of children with BECTS?

INTRODUCTION

Rolandic epilepsy, also known as benign childhood epilepsy with centrotemporal spikes (BECTS), is one of the most common epileptic syndromes in previously healthy children. Despite what was known about the benignity of this syndrome, there is always more evidence about the involvement of the cognitive functions with different deficits in several domains to be investigated.

AIM OF THE STUDY

The aim of our study was to describe prognostic electroencephalogram (EEG) pattern of an adverse cognitive development to recognize patients at higher risk of lasting cognitive deficits that could need antiepileptic drugs (AEDs) or an improved neurocognitive therapy. In addition, we wanted to investigate the existence of a possible linkage between the number of interictal epileptiform discharges (IEDs) in the EEG and the more pronounced cognitive deficits.

MATERIAL AND METHODS

We performed a case-control study on a cohort of 16 patients (10 male and 6 female) aged 4-14, diagnosed with BECTS who underwent EEG, magnetic resonance imaging (MRI), and neurocognitive assessment at the Pediatric Neurology Unit at the Umberto I Hospital, Sapienza University of Rome. Patients were divided into two groups according to the percentage of IEDs evaluated based on their sleep EEG: group A with less than 50% of the entire EEG invaded by discharges in more than 70% of the total number of EEG performed, so-called with low or intermediate activation. On the contrary, group B had a high activation, with more than 50% of the entire EEG invaded by discharges in the same percentage of the EEG performed. All children were assessed based on a protocol designed to study neuropsychological functions with specific tests chosen depending on age (Wechsler Intelligence Scale for Children IV: WISC IV; Wechsler Preschool and Primary Scale of Intelligence III: WPPSI III). Groups were compared for cognitive outcomes achieved by each patient through Student's t-test with a significance level of p<0.05 (two-tailed).

RESULTS

There is no statistically significant difference in the cognitive outcomes of these patients: Student's t-test showed a statistical significance (p) for each cognitive index always higher than 0.05, demonstrating that the intellectual quotient (IQ) and all other indexes analyzed (verbal comprehension index (VCI), perceptual reasoning index (PRI), working memory index (WMI), and processing speed index (PSI)) are not affected by the difference in EEG anomalies presented by our patients. Interestingly, all patients had an IQ equal to or greater than the Italian average (12 out of 16 patients showed an IQ>100), with selective drops, particularly significant in the WMI and also in the PSI.

CONCLUSIONS

Our results clearly demonstrate the importance of a proper evaluation of patients with this kind of epilepsy, without paying attention only to those with the greatest number of IEDs or seizures because all of them had a neurocognitive impairment, especially in memory. These data may be reinforced by a larger sample for an even more significant statistical value. These results also highlight the importance of a neurocognitive therapy for these children to treat for their specific needs.

Core Health Outcomes In Childhood Epilepsy (CHOICE): protocol for the selection of a core outcome set

BACKGROUND

There is increasing recognition that establishing a core set of outcomes to be evaluated and reported in trials of interventions for particular conditions will improve the usefulness of health research. There is no established core outcome set for childhood epilepsy. The aim of this work is to select a core outcome set to be used in evaluative research of interventions for children with rolandic epilepsy, as an exemplar of common childhood epilepsy syndromes.

METHODS

First we will identify what outcomes should be measured; then we will decide how to measure those outcomes. We will engage relevant UK charities and health professional societies as partners, and convene advisory panels for young people with epilepsy and parents of children with epilepsy. We will identify candidate outcomes from a search for trials of interventions for childhood epilepsy, statutory guidance and consultation with our advisory panels. Families, charities and health, education and neuropsychology professionals will be invited to participate in a Delphi survey following recommended practices in the development of core outcome sets. Participants will be able to recommend additional outcome domains. Over three rounds of Delphi survey participants will rate the importance of candidate outcome domains and state the rationale for their decisions. Over the three rounds we will seek consensus across and between families and health professionals on the more important outcomes. A face-to-face meeting will be convened to ratify the core outcome set. We will then review and recommend ways to measure the shortlisted outcomes using clinical assessment and/or patient-reported outcome measures.

DISCUSSION

Our methodology is a proportionate and pragmatic approach to expediently produce a core outcome set for evaluative research of interventions aiming to improve the health of children with epilepsy. A number of decisions have to be made when designing a study to develop a core outcome set including defining the scope, choosing which stakeholders to engage, most effective ways to elicit their views, especially children and a potential role for qualitative research.

Altered language network in benign childhood epilepsy patients with spikes from non-dominant side: A resting-state fMRI study

Benign childhood epilepsy with centrotemporal spikes (BECTS) is one of the most common childhood epilepsy syndromes, and language deficits associated with BECTS have become a hot topic. This study investigated alterations of the language network in BECTS children with spikes from the non-dominant side in comparison with healthy controls. Twenty-three children with BECTS and 20 age-matched healthy controls were enrolled. Region of interest -based whole brain functional connectivity analysis was used to identify the potential differences in the functional connectivity of the Broca's area between the two groups. Increased positive functional connectivity within the Broca's region was detected mainly at the left superior frontal gyrus (Brodmann area 8), bilateral insula, and anterior and posterior cingulate in the BECTS group. No regions showed significantly decreased connection in the BECTS patients compared to the controls. This study suggested alterations in the language network that was related with the Broca's area in children with BECTS from the non-dominant side. Further studies with longitudinal assessments from the perceptive of functional neuroimaging are needed to illustrate the dynamic course of language development and corresponding neuroimaging evidence.

Evaluation of the language profile in children with rolandic epilepsy and developmental dysphasia: Evidence for distinct strengths and weaknesses

Although benign, rolandic epilepsy (RE) or benign childhood epilepsy with centro-temporal spikes is often associated with language impairment. Recently, fronto-rolandic EEG abnormalities have been described in children with developmental dysphasia (DD), suggesting an interaction between language impairment and interictal epileptiform discharges. To investigate if a behavioral-linguistic continuum between RE and DD exists, a clinical prospective study was carried out to evaluate the language profile of 15 children with RE and 22 children with DD. Language skills were assessed using an extensive, standardized test battery. Language was found to be impaired in both study groups, however RE and DD were associated with distinct language impairment profiles. Children with RE had difficulties with sentence comprehension, semantic verbal fluency and auditory short-term memory, which are unrelated to age of epilepsy onset and laterality of epileptic focus. In children with DD, sentence comprehension and verbal fluency were among their relative strengths, whereas sentence and lexical production constituted relative weaknesses.

Clinical features of benign epilepsy of childhood with centrotemporal spikes in chinese children

This multicenter clinical trial was conducted to examine current practice of benign epilepsy with centrotemporal spikes and especially address the question that in what circumstances 1 antiepileptic drug (AED) should be preferred.Twenty-five medical centers participate in this clinical trial. The general information, clinical information, and treatment status were collected under the guidance of clinicians and then analyzed. Difference between different treatment groups was compared, and usefulness of the most commonly used AEDs was evaluated.A total of 1817 subjects were collected. The average age of the subject was 8.81 years. The average age of onset is 6.85 years (1-14 years). Male-to-female ratio is 1.13:1. A total of 62.9% of the patients are receiving monotherapies, and 10.6% are receiving multidrug therapy. Both age and course of disease of treated rolandic epilepsy (RE) patients are significantly different from those of untreated patients. Bilateral findings on electroencephalography (EEG) are less seen in patients with monotherapy compared with patients with multidrug therapy. Except for 25.4% patients not taking any AEDs, oxcarbazepine (OXC), sodium valproate (VPA), and levetiracetam (LEV) are the most commonly used 3 AEDs. VPA and LEV are commonly used in add-on therapy. OXC and LEV are more effective as monotherapy than VPA.Age of onset of Chinese RE patients is 6.85 years. Bilateral findings on EEG could be a risk factor to require multidrug therapy. In Chinese patients, OXC, VPA, and LEV are most commonly used AEDs as monotherapy and OXC and LEV are more effective than VPA.

[Neuropsychological alterations are frequent in rolandic epilepsy and its atypical developments]

INTRODUCTION

Rolandic epilepsy or benign childhood epilepsy with centrotemporal spikes is called benign because its seizures are usually favourable and due to the spontaneous normalisation of the electroencephalogram on reaching puberty. Nevertheless, evidence has been found of the impact on cognitive development with the presence of heterogeneous cognitive deficits, especially related to persistent intercritical discharges during non-REM sleep. The aim of this study is to examine the epileptogenic networks involved in the neuropsychological disorders of this pathology.

DEVELOPMENT

A common feature of the atypical developments is persistent epileptic activity during slow sleep, which plays an important role in the development of the neurocognitive deficits that are associated to this pathology. Factors such as the age at onset of the epilepsy, the onset of the atypical development, the location of the interictal discharges and the continuous epileptic activity during sleep that persists for more than two years can trigger changes in the functioning of the neurocognitive networks. This may result in deficits in the neuropsychological functions, which may even be irreversible.

CONCLUSIONS

A close clinical and electroencephalographic follow-up is necessary. Moreover, formal neuropsychological studies must be conducted as of the onset of benign childhood epilepsy with centrotemporal spikes. This is even more necessary in cases in which there is an obvious atypical development in order to detect and prevent the neuropsychological deficits before they establish themselves on a definitive basis.

Comparison of auditory event-related potentials between children with benign childhood epilepsy with centrotemporal spikes and children with temporal lobe epilepsy

The abnormal brain discharges observed in benign childhood epilepsy with centrotemporal spikes (BECTS) and temporal lobe epilepsy (TLE) are located close to areas responsible for auditory and language processing. This study aimed to analyze the results of auditory event-related potentials (P300) in children with BECTS and TLE in order to assess whether the epileptic activity in centrotemporal and temporal regions may compromise the integrity and physiology of auditory system structures. This was a prospective, comparative, and cross-sectional study. Group I (GI) consisted of 13 children diagnosed with BECTS, group II (GII), 7 children diagnosed with TLE, and control group (GIII), 16 healthy children, with no hearing or academic complaints. After neurological and basic audiological assessments, P300 was applied. The P300 latency and amplitude were compared between groups. Regarding latency, GI showed 324.1 (+31.5) ms, GII 336.3 (+23.5) ms, and GIII 318 (+27.7) ms. Amplitudes were 4.80 (+3.2) μV in GI, 4.7 (+2.5) μV in GII, and 5.8 (+2.4) μV in GIII. Although children with BECTS showed prolonged latencies and reduced amplitudes, these differences were not considered statistically significant. Children with TLE showed statistically significant prolonged P300 latency compared with the control group (P=0.037). We speculate that abnormal electrical discharges in centrotemporal and temporal regions led to the slowing of auditory processing in our sample.

Altered functional and effective connectivity in anticorrelated intrinsic networks in children with benign childhood epilepsy with centrotemporal spikes

There are 2 intrinsic networks in the human brain: the task positive network (TPN) and task negative network (alternately termed the default mode network, DMN) in which inverse correlations have been observed during resting state and event-related functional magnetic resonance imaging (fMRI). The antagonism between the 2 networks might indicate a dynamic interaction in the brain that is associated with development.To evaluate the alterations in the relations of the 2 networks in children with benign childhood epilepsy with centrotemporal spikes (BECTS), resting state fMRI was performed in 17 patients with BECTS and 17 healthy controls. The functional and effective connectivities of 29 nodes in the TPN and DMN were analyzed. Positive functional connectivity (FC) within the networks and negative FC between the 2 networks were observed in both groups.The patients exhibited increased FC within both networks, particularly in the frontoparietal nodes such as the left superior frontal cortex, and enhanced antagonism between the 2 networks, suggesting abnormal functional integration of the nodes of the 2 networks in the patients. Granger causality analysis revealed a significant difference in the degree of outflow to inflow in the left superior frontal cortex and the left ventral occipital lobe.The alterations observed in the combined functional and effective connectivity analyses might indicate an association of an abnormal ability to integrate information between the DMN and TPN and the epileptic neuropathology of BECTS and provide preliminary evidence supporting the occurrence of abnormal development in children with BECTS.

[Cognitive profile of children with newly onset benign epilepsy with centro-temporal spikes before treatment:a study of computerized cognitive testing in epilepsy]

OBJECTIVE

Benign epilepsy with centro-temporal spikes (BECTs) is a common idiopathic partial epileptic syndrome in childhood, which often affect the pre-school and school-age children and a considerable proportion have comorbidity including lower academic achievement and cognitive impairment. Few studies involved the psychocognitive assessment in such a drug-treatable epileptic syndrome especially in the newly diagnosed and medications-naive group. This study aimed to investigate the cognitive characteristics of children with newly onset BECTs before treatment.

METHOD

Forty-one outpatients with newly diagnosed BECTs who visited the Clinic during the periods from October 2012 to May 2014 before the medications against epilepsy and 41 healthy controls recruited from regular school in Beijing during the period from July 2013 to March 2014, who matched in age and gender underwent battery testing by computerized cognitive testing in epilepsy (CCTE). The BECTs group included 41 children, 20 boys and 21 girls, mean age (8.2 ± 1.7) years, the age of onset of epilepsy 4.5-11.5 years (the age of onset <8 years in 25 cases, ≥ 8 years in 16 cases). The cognitive characteristics and associated factors were analyzed. The primary data including correct answer numbers and reaction times were analyzed by independent sample t-test between the two groups of children with BECTs and healthy controls based on SPSS 18.0 statistical software.

RESULT

Raw data of 9 tasks' scores collected from BECTs and healthy control children were continuous variables in accordance with normal distribution. BECTs children performed significantly worse than controls in choice reaction time ((618+158) vs. (524+254) ms), three-dimensional mental rotation (11 ± 10 vs. 18 ± 12) and visual tracing (10 ± 6 vs.15 ± 6), t=2.01, 3.03 and 3.47, P<0.05, <0.01 and <0.001, respectively.While other 6 tasks showed no significant difference between the two groups (P>0.05 for all comparisons). BECTs boys performed significantly worse than girls on simple substraction tasks compared with standard nine score ((4.7 ± 1.5) vs. (5.6 ± 1.2), t=-2.24, P<0.05). Other 8 tasks showed no significant difference between boys and girls (P>0.05 for all comparisons). Other 9 tasks showed no significant differences between the two groups of BECTs children whose age of onset was before 8 years and those who started seizure ≥ 8 years (P all >0.05). The standard nine scores of simple substraction from the three BECTs groups of dominance sides of spikes and waves during NREM showed significant difference (P<0.05). BECTs children with bilateral discharges performed significantly worse than the other two groups dominantly right or left discharges (4.7 ± 1.2 vs. 6.0 ± 1.2 vs. 4.9 ± 1.4, P all <0.05). There was no significant difference between the two groups with right and left side dominance discharges (P>0.05). Other 8 tasks showed no significant differences among the three groups (P>0.05 for all comparisons).

CONCLUSION

Although EEG discharges index below 50% during NREM period, while newly diagnosed BECTs children before treatment with medications against epilepsy performed poorer on tasks of choice reaction time, three-dimensional mental rotation, and visual tracing. The two factors of male and bilateral discharges during NREM period correlate with dysfunction of simple subtraction, the mechanism needs further study and the cognitive function of epilepsy children should be evaluated and followed up, in order to provide psychologic baseline data for persistent cognitive disturbance.

Interhemispheric Connectivity in Drug-Naive Benign Childhood Epilepsy With Centrotemporal Spikes: Combining Function and Diffusion MRI

Decreased intelligence quotients (IQ) have been consistently reported in drug-naive benign childhood epilepsy with centrotemporal spikes (BECTS). We aimed to identify the neurophysiological basis of IQ deficits by studying interhemispheric and anatomical functional connectivity in BECTS patients. Resting-state functional and structural magnetic resonance images were acquired in 32 children with BECTS and 25 healthy controls. The IQ was estimated using Wechsler Intelligence Scale for Children China-Revised. The functional connectivity between bilateral homotopic voxels was calculated and compared between groups. Homotopic regions showing abnormal functional connectivity in patients were adopted as regions of interest for analysis by diffusion-tensor imaging tractography. The fractional anisotropy, fiber length, and fiber number were compared between groups. Abnormal homotopic connectivities were correlated with IQ in BECTS patients. Compared with control subjects, patients showed decreased IQ, and decreased voxel-mirrored homotopic connectivity (VMHC) in the bilateral frontal lobule and cerebellum. The performance and full scale IQ significantly increased with the VMHC strength of the middle frontal gyrus (MFG) in controls but not in BECTS patients. A significant negative correlation was observed between VMHC in the premotor cortex and disease duration. Microstructural features within white matter tracts connecting functionally abnormal regions did not reveal any differences between groups. This study provides preliminary evidence for the disrupted functional cooperation between hemispheres in children with BECTS. The findings suggest that the hyposynchrony between the bilateral MFG may be involved in the decreased IQ of BECTS patients.

[The atypical developments of rolandic epilepsy are predictable complications]

INTRODUCTION

The development of atypical features in rolandic epilepsy is part of a clinical spectrum of phenotypes that are variable, idiopathic and age-dependent, as well as having a genetically determined predisposition.

AIM

To study the electroclinical characteristics suggesting an atypical development in rolandic epilepsy.

PATIENTS AND METHODS

A retrospective search was performed in 133 children diagnosed with atypical benign focal epilepsy (ABFE), Landau-Kleffner syndrome and continuous spike-wave during sleep (CSWS). Nine patients were selected, all of whom presented atypical clinical features and an electroencephalogram (EEG) pattern of electrical status epilepticus during sleep (ESES) in the course of their rolandic epilepsy.

RESULTS

The average age at onset of rolandic epilepsy was 5 years. Patients showed a deterioration of both their clinical features and their EEG recording one and a half years later, on average. ABFE was observed in three of them and CSWS in six. No cases of Landau-Kleffner syndrome were found. The EEG in wakefulness showed the focus to be in the left centrotemporal region in six patients and in three of them it was on the right-hand side. All the patients presented ESES in the EEG during sleep. An atypical pattern was observed in the regional ESES in three of the patients. Moreover, cognitive and behavioural disorders were detected due to deficits in specific learning areas, such as language, memory, attention and restlessness.

CONCLUSIONS

The early onset of rolandic epilepsy, the appearance of new seizures with an increased frequency and the frontocentrotemporal focus in the EEG, which increases in frequency, both in wakefulness and in sleep, are all electroclinical characteristics of an atypical development.

[Efficacy of levetiracetam combined with short-term clonazepam in treatment of electrical status epilepticus during sleep in children with benign childhood epilepsy with centrotemporal spikes]

OBJECTIVE

To study the efficacy of levetiracetam (LEV) combined with short-term clonazepam (CZP) in the treatment of electrical status epilepticus during sleep (ESES) in children with benign childhood epilepsy with centrotemporal spikes (BECCT).

METHODS

Fifteen children (9 boys and 6 girls) diagnosed with BECCT with ESES, who had continuous spike-and-wave accounting for over 85% of the non-rapid eye movement sleep as monitored by 24-hours ambulatory EEG or 3-hours video EEG, were enrolled. The clinical manifestations and EEG characteristics of patients were retrospectively analyzed. These children received two months of CZP treatment in addition to oral LEV [20-40 mg/(kg·d)]. All patients were followed up for 6-18 months.

RESULTS

The 15 children were orally given LEV in the early stage, but showed no improvement when reexamined by EEG or had seizures during treatment. Then, they received LEV in combination with short-term CZP. Re-examinations at 1 and 6 months after treatment showed that 14 cases had significantly reduced discharge (only little discharge in the Rolandic area) or no discharge, as well as completely controlled seizure; one case had recurrent ESES and two epileptic seizures during follow-up. The recurrent case received the combination therapy again, and re-examinations 1 and 6 months later revealed normal EEG; no seizure occurred in the 8 months of follow-up.

CONCLUSIONS

LEV combined with short-term CZP is effective and has few side effects in treating ESES syndrome among children with BECCT.

Reduced structural connectivity between sensorimotor and language areas in rolandic epilepsy

Introduction

Rolandic epilepsy (RE) is a childhood epilepsy with centrotemporal (rolandic) spikes, that is increasingly associated with language impairment. In this study, we tested for a white matter (connectivity) correlate, employing diffusion weighted MRI and language testing.

Methods

Twenty-three children with RE and 23 matched controls (age: 8–14 years) underwent structural (T1-weighted) and diffusion-weighted MRI (b = 1200 s/mm², 66 gradient directions) at 3T, as well as neuropsychological language testing. Combining tractography and a cortical segmentation derived from the T1-scan, the rolandic tract were reconstructed (pre- and postcentral gyri), and tract fractional anisotropy (FA) values were compared between patients and controls. Aberrant tracts were tested for correlations with language performance.

Results

Several reductions of tract FA were found in patients compared to controls, mostly in the left hemisphere; the most significant effects involved the left inferior frontal (p = 0.005) and supramarginal (p = 0.004) gyrus. In the patient group, lower tract FA values were correlated with lower language performance, among others for the connection between the left postcentral and inferior frontal gyrus (p = 0.043, R = 0.43).

Conclusion

In RE, structural connectivity is reduced for several connections involving the rolandic regions, from which the epileptiform activity originates. Most of these aberrant tracts involve the left (typically language mediating) hemisphere, notably the pars opercularis of the inferior frontal gyrus (Broca’s area) and the supramarginal gyrus (Wernicke’s area). For the former, reduced language performance for lower tract FA was found in the patients. These findings provide a first microstructural white matter correlate for language impairment in RE.

The relationship between sleep-activated interictal epileptiform discharges and intelligence in children

This study investigates the relationship between interictal epileptiform discharges (IEDs) during sleep in children with benign rolandic epilepsy (BRE) and cognitive test scores as measured by the Wechsler Intelligence Scale for Children-Fourth Edition (WISC-IV) with the hypothesis that, as IEDs increase, cognitive test scores decrease. Studies have shown that generalized seizures and status epilepticus can negatively impact cognition (Dodrill 2004), that children with epilepsy have lower cognitive function on average than children without epilepsy and that children with epilepsy and abnormal electroencephalograms (EEGs) have lower cognitive function than children with epilepsy and normal EEGs (Bailet et al. 2000). Studies have also indicated that as IEDs decrease, neurocognitive test scores increase (Baglietto et al. 2001). The current study evaluated sleep-activated IEDs in children with the specific syndrome of benign rolandic epilepsy based on the frequency of LEDs in sleep in relation to cognitive test scores. Neuropsychological test scores from the WISC-IV were gathered along with the number of spikes per minute detected in EEG recordings. Statistical analysis revealed a negative correlation between spike frequency and both processing speed and coding scores, though the relationship did not reach statistical significance. This study concludes that there may be correlations between increased spike density and cognitive test scores, or there might be other factors impacting cognition in BRE, but a larger sample is needed to further investigate. In addition, it is possible that a negative result in the present study represents good news, that the number of IEDs in BRE does not harm the brain by negatively impacting cognition.

Sleep and behavioral problems in rolandic epilepsy

Although patients with benign childhood epilepsy with centrotemporal spikes exhibit a benign course of the disease, some of them display sleep and behavioral problems. Sixty-one patients with rolandic epilepsy, aged 6-11 years, were included in this study. The patients were divided into two subgroups according to the presence of seizures over the preceding 6 months. The control group comprised 25 patients without epilepsy and with similar characteristics in terms of age and sex. All patients underwent evaluation of sleep (Sleep Disturbance Scale for Children) and behavior (Lithuanian version of the Child Behaviour Checklist). Only patients who had had seizures over the preceding 6 months displayed significantly higher scores for sleep problems (disorders of excessive daytime sleepiness, disorders of sleep-wake transition, and scores for total sleep problems), worse sleep quality (longer sleep-onset latency), and behavioral problems (anxiety/depression, social problems, thought problems, attention problems, and aggressive behavior) than the patients of the control group. Our data add to evidence that active epilepsy has an impact on sleep and behavior. Clinically significant sleep problems were related to the higher risk of behavioral problems. Parents' ratings for existing sleep problems were sensitive to Sleep Disturbance Scale for Children scores above normal values.

Evaluation of a neurotherapy program for a child with ADHD with Benign Partial Epilepsy with Rolandic Spikes (BPERS) using event-related potentials

BACKGROUND

We hypothesized that there would be a good response to relative beta training, applied to regulate the dynamics of brain function in a patient with benign partial epilepsy with Rolandic Spikes (BPERS), associated with neuropsychiatric deficits resembling the symptoms of attention deficit-hyperactivity disorder (ADHD).

CASE REPORT

The patient, E.Z., age 9.3, was suffering from neuropsychiatric symptoms, cognitive dysfunction, especially attention deficits, and behavioral changes, rendering him unable to function independently in school and in many situations of everyday life. He was treated for epilepsy, but only slight progress was made. The patient took part in 20 sessions of relative beta training combined with behavioral training. We used standardized neuropsychological testing, as well as ERPs before the experiment and after the completion of the neurotherapy program. Neuropsychological testing at baseline showed multiple cognitive deficits. Over the course of neurotherapy, E.Z.'s verbal and non-verbal IQ increased significantly. His cognitive functions also improved, including immediate and delayed logical and visual recall on the WMS-III, maintaining attention on the WMS-III, and executive functions, but remained below norms. Physiologically, the patient showed substantial changes after neurotherapy, including fewer spikes and an increased P300 NOGO component.

CONCLUSIONS

The cognitive deficits characteristic for ADHD in a child with BPERS may be unresponsive to antiepileptic treatment, but are reversible after a carefully selected neurotherapy program, combined with antiepileptic treatment. Event Related Potentials (ERPs) in the GO/NOGO task can be used to assess functional brain changes induced by neurotherapeutical programs.

Clinical and neuropsychological correlation in patients with rolandic epilepsy

OBJECTIVES

To evaluate the presence of neurological soft signs (NSS) and to correlate them with the Wechsler Intelligence Scale for Children (WISC III) in patients with rolandic epilepsy (RE).

METHODS

Forty children and adolescents aged between 9 and 15 years were studied. They were divided into two groups: G1 - patients with RE (n=20) - and G2 - healthy controls without epilepsy (n=20). They were assessed with the Quick Neurological Screening Test (QNST II) - clinical trial to search for NSS -, and the WISC III - neuropsychological test.

RESULTS

No statistical difference between groups was found in WISC III and QNST II. However, children with poorer motor skills had worse performance in the QNST II and also in the execution intelligence quotient - IQ (p=0.001) and in total IQ (p=0.004), thus showing a positive correlation between them.

CONCLUSIONS

The QNST II is a good screening tool for the neurologist to detect abnormalities in fine motor skills.

KCNQ2 abnormality in BECTS: benign childhood epilepsy with centrotemporal spikes following benign neonatal seizures resulting from a mutation of KCNQ2

The molecular pathogenesis of benign childhood epilepsy with centrotemporal spikes (BECTS) remains unclear whereas mutations of the KCNQ2 and KCNQ3 genes have been identified as causes of benign familial neonatal convulsions. We report here a girl with benign neonatal convulsions followed by BECTS, for whom a mutation of KCNQ2 was identified. This case may provide the clue to the understanding of the molecular pathogenesis of BECTS.

[Benign childhood epilepsies: academic difficulties and behavioural disorders]

INTRODUCTION

Some papers published in the literature have shown that patients can present behavioural disorders and learning difficulties in benign childhood epilepsies (BCE).

AIMS

To review the patients diagnosed with BCE in our hospital and to determine whether they present such disorders.

PATIENTS AND METHODS

The study consisted in a retrospective review of the medical records of patients diagnosed with BCE. An electroencephalogram (EEG) or video-EEG-polygraph recordings were performed on all patients during sleep. The Wechsler Intelligence Scale for Children was used to evaluate intelligence.

RESULTS

Data were collected for 102 patients diagnosed with BCE. Dispersed attention was observed in 51.6% of the patients with rolandic epilepsy and 16.2% displayed an impulsive temperament. In the group of patients with Panayiotopoulos syndrome, 30.3% displayed dispersed attention and 27.3% presented an impulsive temperament. A psychometric evaluation was carried out in 43 patients. The overall mean intelligence quotient was 95 (range: 55-126). In the three groups, academic achievement was good in approximately half the sample, regular in about 30% and poor in around 15%. In the group with rolandic epilepsy, the EEG showed a relation between frontal (p = 0.039) and occipital paroxysms (p = 0.004) and poorer academic achievement. In this group, the children with behaviours classed as dispersed, impulsive or hyperactive showed left-side paroxysms more frequently (p = 0.030).

CONCLUSIONS

BCE are conditions with a good prognosis, but seem to be associated to learning and behavioural disorders. Neuropsychological studies should be conducted on these patients to detect these disorders.

Sleep behavior disturbances in rolandic epilepsy

The relationship between specific epilepsy syndromes and particular sleep symptoms has not been well delineated. The authors' aim was to test the hypothesis that children with rolandic epilepsy exhibit more frequent sleep problems and daytime sleepiness compared with children without epilepsy. They compared parent-reported sleep behaviors of 43 children with rolandic epilepsy aged 6 to 16 years recruited from 5 US pediatric neurology centers with a historical reference and sleep clinic sample using the Child Sleep Habits Questionnaire. The authors compared the differences in mean frequency of sleep problems and patterns. Total Children's Sleep Habits Questionnaire scores were significantly higher (P < .001) in the rolandic epilepsy sample than reference. Parents of children with rolandic epilepsy reported a significantly shorter sleep duration (P < .006), more frequent parasomnias (P < .008), and increased daytime sleepiness (P < .001). Thus, parents of children with rolandic epilepsy reported more problematic sleep and daytime impairment compared with a reference sample of children.

[Transitory cognitive dysfunction in rolandic epilepsy]

Forty-four patients with rolandic epilepsy (32 boys, 12 girls), aged from 5 to 14 years, were examined in the prospective study during 5 years. Before the antiepileptic treatment, most of patients had transitory cognitive disturbances. There were the impairment of verbal functions, especially verbal intellect, while non-verbal intellect remained intact; dyspraxia, impairment of auditory-speech memory, disturbances of arbitrary regulation and optical-motor coordination. The cognitive impairment was not severe and did not impact on learning of school program. No significant correlations were found between the lateralization of regional EEG changes and the character of cognitive dysfunction though the age-related lateralization of the focal epileptiform activity was shown: the right-side localization of central-temporal EEG spikes predominated in children at the age of 6.29 +/- 0.9 years, the left-side localization - in children at the age of 8.4 +/- 1.4 years. The clinical remission was achieved 4-5 years earlier than the recovery of cognitive functions. Valproates used as monotherapy or in the combination with ethosuximidum and levetiracetam were drugs of choice.

Seizure in benign epilepsy with centro-temporal spikes

Rolandic epilepsy is frequent in children but seizures are rarely seen by the physician or captured by video-EEG monitoring. In most children the attacks are few and sporadic and generally occur at night. Also, a high percentage of children with benign epilepsy with centro-temporal spikes (BECTS) have characteristic centro-temporal spikes based on routine EEG monitoring and therefore do not require further tests such as telemetry or sleep studies. We report a video-EEG recording of a seizure in a patient with rolandic epilepsy which may be useful for educational purposes.

Somatotopic distribution of peri-rolandic spikes may predict prognosis in pediatric-onset epilepsy with sensorimotor seizures

OBJECTIVE

Peri-rolandic spikes are typically seen in benign childhood epilepsy with centro-temporal spikes. However, some cases of epilepsy with peri-rolandic spikes manifest with medical intractability or cognitive dysfunction. The present study evaluated whether spike source localization is predictive of different prognosis of epilepsy and/or cognitive function.

METHODS

The localization of peri-rolandic spikes was compared between 6 patients whose seizure remitted under age of 15 years with no cognitive impairment (benign group) and 6 patients with either intractable epilepsy or cognitive dysfunction (non-benign group). The sources of epileptic spikes were approximated by the single equivalent current dipole (ECD) model using whole-head magnetoencephalography.

RESULTS

The spike locations in the benign group were significantly lateral (14.8±5.3 versus 5.3±3.3 mm, p<0.05), anterior (11.6±2.1 versus 3.7±4.8 mm, p<0.01), and inferior (27.7±3.6 versus 12.0±10.0 mm, p<0.01) to those in the non-benign group. Seizures tended to involve the laryngo-pharyngo-oro-facial area in the benign group and the facial-hand-foot area in the non-benign group.

CONCLUSION

The clear difference in spike dipole location between benign group and non-benign groups.

SIGNIFICANCE

Spike localization may be useful for predicting prognosis in epilepsy with sensorimotor seizures and spikes along with central sulcus.

Benign epilepsy of childhood with centrotemporal spikes (BECTS): to treat or not to treat, that is the question

The goal of this review is to assess the value of treating versus not treating benign epilepsy (of childhood) with centrotemporal spikes (BECTS). Among 110 recommendations from 96 articles, two-thirds generally favored and one-third generally did not favor treatment with antiepileptic drugs (AEDs). Two studies concluded that all patients should be treated, but most investigators added qualifications, for example, treating those with early onset, multiple seizures at onset, and large numbers of seizures, especially generalized tonic-clonic seizures, and limiting treatment to 1 year. Other studies made treatment dependent on epileptiform discharges or amelioration of symptoms. Specific AEDs were reviewed, and in the largest number of positive studies, valproic acid or carbamazepine was favored. Among the studies generally opposing treatment, none opposed treatment for all patients in all circumstances. Usually, qualifications to treat were added, for example, if generalized tonic-clonic seizures occurred or if there was a change in quality of life. One AED associated with negative effects was carbamazepine, treatment with which can result in the development of epileptic negative myoclonus, absence seizures, and generalized spike-wave complexes on the EEG. Thus, if treatment is planned, valproic acid may be considered the drug of choice in BECTS. Although many neurologists oppose treatment; twice as many studies concluded in favor of treatment. The typical benign aspect of this disorder may allow for nontreatment to be without serious consequences.

Rolandic discharges: clinico-neurophysiological correlation

OBJECTIVE

The aim of this study was to analyze neurophysiologic aspects of rolandic discharges.

METHODS

We reviewed 45 electroencephalograms of patients divided into two groups: those with benign childhood epilepsy with centrotemporal spikes (BCECTS) and symptomatic partial epilepsy (SPE), following ILAE criteria (1989). The EEG data analyzed were: horizontal dipole discharges, double spike phenomenon, the extension of epileptiform discharges and background activity.

RESULTS

There was a predominance of horizontal dipole between patients with BCECTS compared with patients with SPE; however, this difference was not statistically significant. There was also no statistically significant difference between the two groups when the double spike phenomenon and the extension of discharges beyond the rolandic area were considered. The slower background activity in the SPE group was the only variable with statistical significance.

CONCLUSIONS

This study revealed similarities between rolandic discharges of two different epilepsy groups. The only reliable parameter to differentiate the groups was the background activity.

SIGNIFICANCE

Our findings suggest that most EEG rolandic features are not pathognomonic of BCECTS, as they are related to the area of the discharges and not to the epileptic syndrome itself.

[An atypical progression of rolandic epilepsy: the value of single-photon emission computerised tomography co-registered to magnetic resonance imaging]

INTRODUCTION

The complicated forms of rolandic epilepsy progress with a continuous spike-wave pattern in slow-wave sleep. Experiments conducted in cats suggest that this pattern can only appear if there is bilateral thalamic insult. AIM. To determine whether thalamic hypoperfusion is associated with the complicated variants of rolandic epilepsy.

PATIENTS AND METHODS

A group of 24 children were studied over a period of six years following their first epileptic seizure. During the follow-up an interictal magnetic resonance scan and single-photon emission computerised tomography (SPECT) were performed. Results were examined to ascertain whether there were asymmetries in the distribution of cerebral blood flow through structures, using parametric statistical maps. The brain SPECT was performed when progression to atypical benign partial epilepsy in infancy was diagnosed and in typical forms of rolandic epilepsy when there was some mild neuropsychological deficit that led the specialist to suspect the existence of a focal cortical lesion.

RESULTS

Bilateral thalamic hypoperfusion was found in all patients diagnosed with atypical benign partial epilepsy in infancy, which was correlated with the presence of continuous spike-waves during the slow-wave phase of non-REM sleep.

CONCLUSIONS

Bilateral thalamic hypoperfusion seems to be a necessary condition for the atypical progression of rolandic epilepsy.

[A prospective, open, controlled and randomised study of clobazam versus carbamazepine in patients with frequent episodes of Rolandic epilepsy]

INTRODUCTION

To date no controlled, randomised studies with flexible dose regimens have been conducted in children with rolandic epilepsy, and therapy is therefore still empirical.

AIM

To evaluate the effectiveness and safety of clobazam (CLB) compared with that of carbamazepine (CBZ) in rolandic epilepsy.

PATIENTS AND METHODS

A prospective, open, controlled and randomised study was carried out to compare CBZ and CLB in children with rolandic epilepsy with a follow-up over a two-year period. A random sample of 45 patients was taken and 38 of them finished the study. A flexible dose regimen was indicated. Control of seizures, academic performance, behaviour, adherence to treatment, parents' degree of satisfaction and side effect profiles were all evaluated.

RESULTS

Both drugs were equally effective at controlling seizures (94.1% of patients with CLB and 100% of those with CBZ were free of seizures on ending the study; p = 0.26). CLB controlled seizures earlier (33.3 +/- 45 days versus 48.2 +/- 72.3; p < 0.05) and had fewer side effects than CBZ (side effects appeared in three patients with CLB and in eight of those on CBZ; p = 0). In two of the patients taking CBZ, the seizures got worse and a series of cognitive-behavioural complications also appeared.

CONCLUSIONS

CBZ is an effective drug in rolandic epilepsy, but it may be associated with exacerbation of seizures as well as with cognitive-behavioural impairment. CLB in monotherapy seems to be an effective and better tolerated drug in this kind of epilepsy.

Deficit of endogenous spatial orienting of attention in children with benign epilepsy with centrotemporal spikes (BECTS)

Attention difficulties have been reported in children with benign epilepsy with centrotemporal spikes (BECTS) but have not yet been fully specified. The aim of this study was to evaluate the functions of exogenous and endogenous spatial orienting of attention and alerting in these children. Two versions of the spatial cueing paradigm and an alerting task, including trials with and without warning signal, were performed by 25 children with BECTS aged 6-12 years and 25 controls matched for age, gender and IQ. In these three tasks, patients were slower and made more omissions than controls. The alert effect amplitude was comparable in both groups at the longer SOAs (450 ms and 800 ms) while, at the shortest SOA (100 ms), it was greater in controls than in the BECTS group. In the first version of the spatial cueing task (peripheral cues and no probability information), the validity effect amplitude, measured by longer response times (RTs) in invalid trials compared to valid trials, was comparable in both groups. In the second version (central cues and a 75% probability that the target would appear at the cued location), the validity effect was larger in the BECTS group compared to controls because of a higher cost of invalid trials compared to neutral trials. These results suggest the existence of impairments in the endogenous orienting of attention in children with BECTS, in particular an attention disengagement deficit, while exogenous orienting of attention appears to be preserved.

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.

EEG Characteristics Related to Educational Impairments in Children with Benign Childhood Epilepsy with Centrotemporal Spikes

PURPOSE

Learning and behavioral difficulties often occur in benign childhood epilepsy with centrotemporal spikes (BCECTS). In recent years, several electroencephalogram (EEG) characteristics have been related to the occurrence of learning and behavioral problems.

METHODS

From 28 children medical, school and psychological reports were present and children were rated according to a 4-point scale for educational and behavioral impairment (Part 1). Thirty 24-h EEG recordings were reanalyzed for spike frequency, the presence of atypical EEG criteria, and the presence of a nondipole spike. EEGs were scored during wakefulness, first hour of sleep and whole night sleep (minus the first hour of sleep) separately (Part 2).

RESULTS

The presence of I: an intermittent slow-wave focus during wakefulness, II: a high number of spikes in the first hour of sleep (and during whole night sleep), and III: multiple asynchronous bilateral spike-wave foci in the first hour of sleep correlates significantly with a sum score > or = 3 which indicates a complicated course with educational or behavioral impairment. It is sufficient to analyze an EEG during wakefulness and a sleep EEG for only the first hour of sleep instead of a whole night recording to demonstrate those EEG criteria.

CONCLUSIONS

On basis of our reanalysis we can possibly conclude that the aforementioned EEG characteristics correlate with educational impairments, and that analysing an EEG recording during wake and the first hour of sleep is sufficient to look adequately for those EEG criteria in children with BCECTS.

Is Rolandic epilepsy associated with abnormal findings on cranial MRI?

Rolandic epilepsy (RE) is designated an idiopathic epilepsy syndrome, and hence no lesional abnormalities are expected on MRI exam. Recent reports suggest that MRI abnormalities are not only common, but may be specific for temporal lobe epilepsy, and lateralized to the side of EEG discharges. However, no controlled study has been performed to test the hypothesis of association between MRI abnormalities and Rolandic epilepsy. We performed an unmatched case-control study to test the hypothesis of association between MRI abnormalities and Rolandic epilepsy, using 25 typical RE cases and 25 children with migraine. Two independent examiners rated the MRIs for abnormalities. Examiners were blinded to the study hypothesis and identity of case and control exams. Fifty-two percent of RE exams contained at least one abnormality: peri/hippocampal abnormality (one case), non-localized congenital malformation (seven cases), subcortical parenchymal hyperintensities (two cases), periventricular parenchymal hyperintensities (one case), dilated perivascular spaces (six cases). There was no difference between the number or type of abnormalities in cases and controls. No type of abnormality lateralized to the hemisphere from which the EEG spikes emanated. The odds ratio of association between MRI abnormalities and RE was 0.87, 95% CI: 0.18-4.33 after adjusting for potential demographic and technical factors. We conclude that routine cranial MRI abnormalities are common in RE, but no more common than in controls, and not specific for RE.

Benign childhood epilepsy with centro-temporal spikes: correlation between clinical, cognitive and EEG aspects

Benign childhood epilepsy with centro-temporal spikes (BECTS) is a form of epilepsy with no demonstrable anatomical lesion showing spontaneous seizure remission. During the active phase of the disease the children may show cognitive deficits. The objective of this study was to assess, in children with BECTS, the relationship between clinical-EEG aspects and performance in the school performance test (SPT), Raven's progressive matrixes test and the Wechsler Intelligence Scale for Children (WISC-III). Forty-two 7 to 11 year old children were included and the following tests carried out: anamnesis, neurological examination, electroencephalogram (EEG), SPT, Raven's test and WISC-III. The children with BECTS had normal IQ values but showed inferior performance in the SPT more frequently than "healthy" children, paired with respect to age and maternal scholastic level. There was moderate positive correlation between WISC-III results and the age when the seizures started and the educational level of the parents. On the other hand, aspects linked to the epileptic nature of BECTS, such as the number of seizures, time since last seizure and the number and lateralization of the centro-temporal spikes on the EEG, showed no correlation with the neuropsychological tests.

Epileptiform EEG discharges in benign childhood epilepsy with centrotemporal spikes: reactivity and transitory cognitive impairment

The reactivity of rolandic spikes (RS) and the occurrence of transitory cognitive impairment (TCI) during RSs were assessed in 33 children with benign childhood epilepsy with centrotemporal spikes (BECTS). The children were assessed simultaneously with EEG and computerized neuropsychological testing in a visual discrimination between words and pseudowords task (DWPT). In 20 (60.6%) children, there were insufficient RS to assess the occurrence of TCI. Of 13 children with RS between stimulus presentation and response, only 2 (15.4%) made a significantly greater proportion of errors during RS than during RS-free periods, characterizing the occurrence of TCI. The RS appear to be easily inhibited by the DWPT. TCI occurred in a limited number of cases and did not impair school performance. There is a need to study other tasks and search for other factors influencing cognitive abilities in children with BECTS.

Autosomal dominant inheritance of centrotemporal sharp waves in rolandic epilepsy families

PURPOSE

Centrotemporal sharp (CTS) waves, the electroencephalogram (EEG) hallmark of rolandic epilepsy, are found in approximately 4% of the childhood population. The inheritance of CTS is presumed autosomal dominant but this is controversial. Previous studies have varied considerably in methodology, especially in the control of bias and confounding. We aimed to test the hypothesis of autosomal dominant inheritance of CTS in a well-designed family segregation analysis study.

METHODS

Probands with rolandic epilepsy were collected through unambiguous single ascertainment. Siblings in the age range 4-16 years underwent sleep-deprived EEG; observations from those who remained awake were omitted. CTS were rated as present or absent by two independent observers blinded to the study hypothesis and subject identities. We computed the segregation ratio of CTS, corrected for ascertainment. We tested the segregation ratio estimate for consistency with dominant and recessive modes of inheritance, and compared the observed sex ratio of those affected with CTS for consistency with sex linkage.

RESULTS

Thirty siblings from 23 families underwent EEG examination. Twenty-three showed evidence of sleep in their EEG recordings. Eleven of 23 recordings demonstrated CTS, yielding a corrected segregation ratio of 0.48 (95% CI: 0.27-0.69). The male to female ratio of CTS affectedness was approximately equal.

CONCLUSIONS

The segregation ratio of CTS in rolandic epilepsy families is consistent with a highly penetrant autosomal dominant inheritance, with equal sex ratio. Autosomal recessive and X-linked inheritance are rejected. The CTS locus might act in combination with one or more loci to produce the phenotype of rolandic epilepsy.

Ketogenic diet: electrophysiological effects on the normal human cortex

PURPOSE

To explore the cortical electrophysiology of the ketogenic diet (KD) in the normal human. KD is effective against refractory epilepsy, but its precise mechanism is obscure. At the transmitter level, an enhancement of GABA inhibition has often been proposed.

METHODS

We studied eight healthy volunteers undergoing a "classic" KD for 2 weeks. We measured several biochemical variables at baseline (T0), after 1 week (T1) and 2 weeks (T2) of KD, then 3 months after the KD conclusion (T3). Ketosis was quantified as 24-h ketonuria. At the same time, we studied the motor cortical excitability by means of transcranial magnetic stimulation (TMS). We also quantitatively evaluated the EEG signal in search of frequency shifts over the rolandic areas.

RESULTS

Significant (p < 0.05) neurophysiological changes appeared at T2. These consisted of a strengthening of short-latency cortical inhibition (SICI), a TMS index which is thought to reflect GABA-A inhibition in the cortex. Then, there was an enhancement of the beta EEG band over the perirolandic region, similar to that following administration of GABA-A agonists. All changes disappeared at T3.

CONCLUSIONS

A standard, short-term KD affected the cortical physiology of the normal human. The main changes were an augmented SICI and an increased perirolandic beta EEG activity, which are compatible with a lower level of neural excitation within the cortex.

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

PURPOSE

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

METHOD

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

RESULTS

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

DISCUSSION

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

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.

Diagnostik sylvischer und perisylvischer Epilepsien

The insula is a hidden part in the cerebral cortex about which relatively little neurological research has been done. The present manuscript describes architectural and evolutionary aspects of the insula reilii as well as its function, towards a better understanding of seizure semiology. As the literature of such casuistry is poor, some own cases are presented. Seizure semiology, imaging, magnetoencephalographic reports, resective epilepsy surgery, radiosurgical treatments, and thermolesions are described. Magnetic source imaging as noninvasive treatment can deliver important information for the involvement of sylvian and perisylvian regions in focal pharmacoresistant epilepsies.