Concomitance of childhood absence and Rolandic epilepsy

Clinical Significance of Incidental Rolandic Spikes in Children With Absence Epilepsy

PURPOSE

Absence epilepsy and benign epilepsy of childhood with central temporal spikes are common childhood epilepsy syndromes. Although 3-Hz generalized spike-wave discharges are almost always associated with absence seizures, rolandic spikes can be present in individuals without rolandic seizures. The co-occurrence of 3-Hz generalized spike-wave and rolandic spikes is very rare. Our objective was to compare clinical features of patients with absence epilepsy with and without rolandic spikes, to determine if the additional feature of rolandic spikes has any clinical significance.

METHODS

Clinical information of 17 children with absence epilepsy and rolandic spikes was compared to an age-matched control group of 90 children with absence epilepsy.

RESULTS

Although most patients had excellent seizure control at follow-up, epilepsy comorbidities (cognitive and emotional problems) were observed. Comparing study vs control groups, there was no difference with anxiety (2 [11.8%] vs 8 [9%]), behavioral issues (4 [23.5%] vs 10 [11%]), mood disorders (0 vs 2 [2%]), and attention-deficit hyperactivity disorder (4 [24%] vs 10 [11%]). Significant differences were also observed: more global-developmental (5 [29%] vs 5 [6%], P < .009) and expressive-language (4 [24%] vs 5 [6%], P < .034) delay and more difficulties with school performance (11 [65%] vs 32 [36%], P < .025), especially with language-related tasks (6 [35%] vs 5 [6%], P < .001).

CONCLUSION

Our results confirm the presence of additional epilepsy comorbidities in patients with absence epilepsy when rolandic spikes are present. Rolandic spikes in patients with absence epilepsy may be a marker of additional cognitive challenges that physicians should be aware of.

Co-existence of Rolandic and 3 Hz Spike-Wave Discharges on EEG in Children with Epilepsy

OBJECTIVE

Benign epilepsy of childhood with central temporal spikes (BECTS) and absence epilepsy are common epilepsy syndromes in children with similar age of onset and favorable prognosis. However, the co-existence of the electrocardiogram (EEG) findings of rolandic spike and 3 Hz generalized spike-wave (GSW) discharges is extremely rare, with few cases reported in the literature. Our objective was to characterize the EEG findings of these syndromes in children in our center and review the electro-clinical features.

METHODS

All EEGs at BC Children's Hospital are entered in a database, which include EEG findings and clinical data. Patients with both centro-temporal spikes and 3 Hz GSW discharges were identified from the database and clinical data were reviewed.

RESULTS

Among the 43,061 patients in the database from 1992 to 2017, 1426 with isolated rolandic discharges and 528 patients with isolated 3 Hz GSW discharges were identified, and 20 (0.05%) patients had both findings: 3/20 had BECTS, and subsequently developed childhood absence epilepsy and 17/20 had no seizures characteristic for BECTS. At follow-up, 17 (85%) were seizure-free, 1 (5%) had rare, and 2 (10%) had frequent seizures.

CONCLUSIONS

This is the largest reported group of patients to our knowledge with the co-existence of rolandic and 3 Hz GSW discharges on EEGs in one institution, not drug-induced. As the presence of both findings is extremely rare, distinct pathophysiological mechanisms are likely. The majority had excellent seizure control at follow-up, similar to what would be expected for each type of epilepsy alone.

Benign rolandic epilepsy and generalized paroxysms: A study of 13 patients

PURPOSE

To present a retrospective study of 13 children with benign epilepsy with centrotemporal spikes (BECTS), also known as benign rolandic epilepsy (BRE), associated with generalized spikes and waves as the only EEG manifestation at onset.

METHOD

Charts of children with typical clinical criteria of BRE electroclinically followed-up between February 2000 and February 2015 were reviewed.

RESULTS

Among 309 patients who met the electroclinical criteria of BRE, we identified 13 children who presented with the typical clinical manifestations but who, on the EEG, only had generalized paroxysms at onset that continued along the course of the syndrome. Generalized spike-and-wave discharges were observed in all patients when awake and during sleep (100%). During the evolution no particular electroclinical pattern was observed. The patients responded well to antiepileptic drugs, such as valproic acid and levetiracetam. Outcome was good in all patients.

CONCLUSIONS

We found evidence that patients with BRE may have generalized EEG discharges at onset as the sole manifestation lasting throughout the course of the syndrome. In some, focal paroxysms developed later. The course was benign. In our group of patients, clinical features and evolution were similar to those of typical cases of BRE. Response to valproic acid and levetiracetam was found to be particularly good.

Coexistence of childhood absence epilepsy and benign epilepsy with centrotemporal spikes: A case series

AIM

Childhood absence epilepsy (CAE) and benign childhood epilepsy with centrotemporal spikes (BECTS) are the most common forms of childhood epilepsy. Recent studies in animal models suggest that the two phenotypes may represent a neurobiological continuum. Although the coexistence of CAE and BECTS has been reported, this issue remains controversial. The purpose of this study was to analyse the electro-clinical characteristics of a group of children with contemporary or subsequent features of absence seizures and focal seizures consistent with BECTS.

MATERIAL AND METHODS

A systematic record review from 8 epilepsy centres was used to identify 11 subjects, 5 females and 6 males, with electro-clinical documented consecutive or contemporary coexistence of CAE and BECTS.

RESULTS

Patient's age ranged between 7.8 and 17.3 years. Four out of 11 patients presented concomitant features of both syndromes, whereas the remaining 7 experienced the two syndromes at different times.

CONCLUSIONS

Although CAE and BECTS are clearly defined syndromes and considered very different in terms of their pathophysiology, they share some features (such as similar age of onset, overall good prognosis), and can occur in the same patient. The long term prognosis of these patients seems to be good with an excellent response to anticonvulsant therapy.

Childhood absence epilepsy and benign epilepsy with centro-temporal spikes: a narrative review analysis

BACKGROUND

Recent studies have shown a possible coexistence of absence seizures with other forms of epilepsy. The purpose of this study was to ascertain the possible contemporary or subsequent presence of childhood absence epilepsy (CAE) and benign epilepsy with centro-temporal spikes (BECTS) in pediatric epileptic patients.

DATA SOURCES

A PubMed systematic search indexed for MEDLINE, PubMed and EMBASE was undertaken to identify studies in children including articles written between 1996 and 2015. Retrospective studies, meta-analysis and case reports were included. The list of references of all the relevant articles was also studied. The date of our last search was December 2015.

RESULTS

Review of the literature revealed 19 cases, 8 females and 11 males, reporting a consecutive or contemporary coexistence of CAE and BECTS within the same patients. Patient's age ranged between 4 and 12 years. Three out of 19 patients presented concomitant features of both syndromes, whereas 16 patients experienced the two syndromes at different times.

CONCLUSIONS

BECTS and CAE may be pathophysiologically related, and the two epileptic phenotypes may indicate a neurobiological continuum. Further studies are needed to elucidate a probable genetic or functional link between partial and primarily generalized electro-clinical patterns in idiopathic childhood epilepsies.

Ethosuximide-induced conversion of typical childhood absence to Rolandic spikes

Coexistence of 2 idiopathic epilepsy syndromes (ie, childhood absence and Rolandic epilepsy), as evidenced by electroencephalographic (EEG) findings with or without clinical features of the 2 conditions, is uncommon and remains controversial. Few case reports support this coexistence either as a continuum or drug-induced conversion, whereas a large sample case review did not find such co-occurrence. The authors report a case of conversion of typical absence to Rolandic spikes after treatment with ethosuximide. An 11-year-old girl was diagnosed with typical childhood absence epilepsy at the age of 6 years with classic clinical and EEG features. She became seizure-free on ethosuximide but her follow-up EEGs consistently recorded right centrotemporal and centroparietal spikes without associated clinical seizures. This case may suggest simultaneous presence of these 2 common childhood idiopathic epilepsies either as a continuum or a drug-induced conversion.

Two epileptic syndromes, one brain: childhood absence epilepsy and benign childhood epilepsy with centrotemporal spikes

Childhood absence epilepsy (CAE) and benign childhood epilepsy with centrotemporal spikes (BCECTS), or benign rolandic epilepsy (BRE), are the most common forms of childhood epilepsy. CAE and BCECTS are well-known and clearly defined syndromes; although they are strongly dissimilar in terms of their pathophysiology, these functional epileptic disturbances share many features such as similar age at onset, overall good prognosis, and inheritance factors. Few reports are available on the concomitance of CAE and BCECTS in the same patients or the later occurrence of generalized epilepsy in patients with a history of partial epilepsy. In most cases described in the literature, absence seizures always started after the onset of benign focal epilepsy but the contrary has never occurred yet. We describe two patients affected by idiopathic generalized epileptic syndrome with typical absences, who experienced BCECTS after remission of seizures and normalization of EEG recordings. While the coexistence of different seizure types within an epileptic syndrome is not uncommon, the occurrence of childhood absence and BCECTS in the same child appears to be extremely rare, and this extraordinary event supports the hypothesis that CAE and BCECTS are two distinct epileptic conditions. However, recent interesting observations in animal models suggest that BCECTS and CAE could be pathophysiologically related and that genetic links could play a large role.

Electroencephalographic generalized features in idiopathic childhood focal epilepsies

PURPOSE

Idiopathic focal epilepsies in childhood including benign childhood epilepsy with occipital paroxysms (BEOP) or benign childhood epilepsy with centro-temporal spikes (BCECTS) are characterized by specific focal electrographic patterns as the name indicates. Generalized spike-wave discharges in children with idiopathic focal epilepsy can suggest a neurobiological continuum with the idiopathic generalized epilepsies. We assessed the prevalence of generalized epileptiform discharges and generalized seizures in BEOP/BCECTS patients.

METHODS

Between August 2005 and November 2008, we identified 220 cases with electroclinical features typical of idiopathic focal epilepsies, 172 patients with BCECTS and 48 patients with BEOP, excluding patients whose neurological examinations or brain MRI were abnormal. We analyzed gender, age at onset, manifestation of generalized seizures, and serial EEG records to detect generalized abnormalities.

RESULTS

Of our population, 42 patients (19.1%, 22 boys), 30 (17.4%) of 172 BCECTS patients and 12 (25.0%) of 48 BEOP patients, showed generalized spike-wave discharges once or more during follow-up. The typical 3-Hz generalized spike wave discharge was noticed in 7 patients and concurrence with clinical generalized seizure was observed in 11.

CONCLUSION

A relatively high incidence of generalized spike-wave discharge and concurrence with generalized seizure were observed in patients with BEOP/BCECTS, with the incidence being higher in BEOP patients than in those with BCECTS. It may be inferred that idiopathic focal epilepsy is not a fixed syndrome but is a part of a broad, age-related, benign, seizure susceptibility syndrome.

Childhood absence epilepsy in patients with benign focal epileptiform discharges

Few reports are available of ictal recordings in patients with benign focal epileptiform discharges. The study objective was to estimate the frequency of such recordings and to describe their clinical and electrophysiologic presentation. We performed a retrospective chart review of all patients undergoing routine electroencephalography (EEG) with video during a 10-year period. Among 214 patients with benign focal epileptiform discharges, 5 patients were identified with recorded EEG seizures (2.3%). Epilepsy syndromes included one case of benign focal epilepsy of childhood, three cases of childhood absence epilepsy, and in one case the patient presented with both. Only 1 of the 214 patients (0.4%) had a seizure characteristic of benign focal epilepsy of childhood. A literature review revealed the coexistence of childhood absence and benign focal epilepsy of childhood or benign focal epileptiform discharges within the same patient. These findings suggest that benign focal epilepsy of childhood seizures are rarely recorded during routine EEG, probably because seizures occur during the early morning part of the sleep cycle, which may differ from the brief nap during routine EEG. There was concurrence of generalized spike and wave discharges in these patients. It is unclear whether this is related to a common pathophysiologic factor.

Benign myoclonic epilepsy in infancy (BMEI): a longitudinal electroclinical study of 22 cases

PURPOSE

Benign myoclonic epilepsy in infancy (BMEI) is a nosologically well-defined entity, characterized by myoclonic seizures (MS) in normal children younger than 3 years and by a good long term prognosis. In some cases the seizures are reflex. We studied 22 cases to better define the electroclinical semeiology and evolution of the disorder.

METHODS

Serial electroclinical and neuropsychological assessments, both during wakefulness and during sleep, were performed in 22 otherwise healthy children with spontaneous (17) or reflex (5) MS, recorded by video-EEG-polygraphy since clinical onset.

RESULTS

Seizure onset was between 3 months and 4 years 10 months (50% during first year, 86% before the third year); in reflex cases onset, was earlier than the 14th month. MS recurred during wakefulness and slow sleep in all cases and during REM sleep in reflex cases. MS and related EEG discharges were synchronous or asynchronous. Often ictal EEG discharges were limited to the rolandic and vertex regions (falsely focal paroxysms). Several seizures were subtle and could have escaped recognition. Unusually frequent sleep startles were recorded mostly in reflex cases. MS were well controlled by treatment. At follow-up, between ages 3 and 19 years, four patients had occasional seizures; two had cognitive impairment and three had learning difficulties. No other seizures or cognitive deficits were observed in reflex cases.

CONCLUSIONS

Seizures associated with BMEI are rarely truly generalized and are often so subtle and related to falsely focal paroxysms that their frequency can be underestimated. The reflex form is a well-defined variant with an early onset, peculiar electroclinical features, and a good prognosis.

Coexistence of childhood absence and rolandic epilepsy

The coexistence of absence and rolandic epilepsy is extremely rare. This coexistence has been attributed to either the treatment or an atypical course of the disease. However, for some authors, this issue remains controversial. We report the case of a 9-year-old girl presenting with both absence seizures and focal seizures consistent with rolandic epilepsy.

Absence seizures in patients with localization-related epilepsy

We studied the clinical features of 12 patients with localization-related epilepsy (LRE) associated with absence seizures (AS). AS did not appear in any patients before partial seizures (PS) were first observed. The interval between the onset of PS and AS ranged from 1 month to 7.2 years (mean 2.11 years). The duration of AS (mean 5 months) was short compared with that of PS (mean 3.8 years). Carbamazepine (CBZ) was used in seven patients at the onset of AS. It was discontinued in five but continued in the other two. AS was initially treated with valproate in ten patients. Three of them needed additional antiepileptic drugs: clonazepam in two patients and ethosuximide in one. All patients became free from AS after treatment for AS was started, whereas PS was relatively intractable. Generalized spike-and-waves were often observed before the onset of AS. The interval between the first appearance of generalized spike-and-waves and the onset of AS ranged from 1 to 53 months (mean 20 months). AS in patients with LRE will be relatively benign and transient, and will respond well to antiepileptic drugs.

Coincidence of rolandic and absence features: rare, but not impossible

The purpose of the study was to evaluate the incidence of a possible combination of rolandic and absence signs in epileptic children, which remains a subject of controversy. The medical files and electroencephalographic (EEG) records of children with rolandic, childhood absence, and juvenile absence epilepsy were retrospectively analyzed. During the antiepilepsy treatment, 6 of 66 patients with rolandic epilepsy, most of them with initial carbamazepine therapy, had absences and generalized spike-wave discharges of a secondarily generalized type. Five cases of 34 children with childhood absence epilepsy and 3 of 11 patients with juvenile absence epilepsy were identified with an EEG focus of the rolandic type. We considered the likely relation of absence features in rolandic epilepsy to the treatment or to an atypical course. The presence of a rolandic focus in absence epilepsies, however, makes the coincidence of these entirely distinct phenomena, even if very rare, not excluded. Further studies are required to elucidate a probable genetic or functional link between partial and primarily generalized EEG discharges in the idiopathic childhood epilepsies.

Time-related configuration change in benign focal epileptiform discharges of childhood: from a dipole to a negative monopole in a patient with generalized epilepsy

The case of a 6-year-old child with generalized epilepsy and benign focal epileptiform discharges (BFEDs) of childhood is presented. During his first EEG, performed when he was 6 years old, the patient had three staring episodes accompanied by bursts of 3-Hz spike-and-wave complexes. Interictally, frequent BFEDs were seen, configured as dipoles with a right temporal negativity and a right frontal positivity. The patient was administered ethosuximide and the staring spells disappeared. On follow-up EEG performed 2 years later, no generalized discharges were seen. However, the EEG again showed frequent spikes with a characteristic morphology of BFEDs. This time they were not configured as dipoles, but as monopoles with a maximum negativity over the right frontal region. The change in the generator's orientation over time (from a horizontal to a vertical dipole) is discussed, as well as the prognostic implications of the morphology and configuration of focal spikes. In addition, the authors review the coexistence of BFEDs and 3-Hz spike-and-wave complexes in their patient database.