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January2009 Vol.46 Issue:      1 Table of Contents
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Infantile and Childhood Epilepsies in Middle Delta: Types, Risk Factors and Etiology

Mohamed Y. El-Senousey1, Wael F. El-Beshlawy1, Ehab El-Seidy1,

Hazem Fayed1, Mohamed H. El-Shafey2

 

Departments of Neuropsychiatry1, Radiology2, Tanta University

 



ABSTRACT

Background and Purpose: Types, Risks and etiology of epilepsies among children are widely different from those among adults. This study was carried out to highlight types,  risks, etiology of  different epilepsies among infants and children in Tanta city and its surrounding rural areas. Moreover, different EEG and MRI abnormalities among studied patients were recorded  to be correlated with clinical data. Patients and Methods: Two hundred eighty epileptic infants and children were subjected to: 1- thorough history taking and clinical neurological examination, 2- neuroimaging by brain MRI, 3- EEG recording and video EEG in some cases. According to the etiology of epilepsy, patients were categorized into two groups: group I (idiopathic epileptic patients); group II (symptomatic- cryptogenic epileptic patients). Moreover, patients were divided into three groups according to the age of epilepsy onset; infantile group (before one year), early childhood group (between one and twelve years) and late childhood group (between twelve and eighteen years). Results: Most of the patients belonging to group II had a home delivery (53.96%) and instrumented labor(31.75%) and significantly higher incidence of perinatal insults (59.52%) compared to those in group I in whom perinatal insults occurred in 7.14%. EEG abnormalities were recorded in 88.1%  and brain MRI abnormalities in 92% of group II patients which were significantly higher compared to those  in group I in whom no MRI abnormalities were recorded  and EEG abnormalities were detected in 73.3%. No significant difference regarding incidence of epileptic  types was detected between group I and group II. On stratification of  the patients according to the age of epilepsy onset; parental consanguinity and family history of epilepsy were significantly higher in the late childhood group (39.62%) compared to the infantile and early childhood groups (18.18% and 26.85% respectively) whereas perinatal insults were significantly higher in the infantile age group (90.9%) compared to that of early childhood (29.16%) and late childhood (3.77%). Conclusion: This study showed that symptomatic epilepsy was prominent among infantile age group (73%) and early childhood group (41.2%) and this reflect the role of perinatal insults for developing symptomatic epilepsy in these age group while idiopathic epilepsy was prominent among late childhood epilepsy group (60%) and this reflect  the role  of genetic factor among this group. Recommendations: From this study it is recommended  that  paying more attention to the importance of premarietal counseling in familial marriage, especially with positive family history of epilepsy, and hospital delivery under supervision of skilled medical personnel might offer a good chance to reduce epilepsy incidence in the paediatric age group. (Egypt J. Neurol. Psychiat. Neurosurg., 2009, 46(1): 151-160)

 

Correspondence to Mohamed El-Senousey,  e-mail: senousey@yahoo.com. Contact number: +20105104857





INTRODUCTION

 

About 65% of  the epilepsies are idiopathic and  presumed to be genetically determined. In 35% of childhood epilepsy, a neuropathologic lesion has been identified1. The causes of symptomatic epilepsy are numerous and include all broad groups of abnormality, such as vascular, neoplastic, degenerative, traumatic, post-infective and metabolic causes.2

Although the majority of patients with epilepsy show interictal epileptiform activity at repeated routine electroencephalographic (EEG) recordings, this is not the case in about 15%3. Ictal recordings can sometimes be quite decisive, especially when combined with a simultaneous video recording4.

The lack of sensitivity for the detection of subtle parenchymal abnormalities renders CT inadequate for evaluating seizure patients. High resolution magnetic resonance imaging (MRI) now allows for diagnosis of previously undetected pathology which is not revealed on computed tomography (CT) scan  or even conventional MRI5.

This study has been undertaken to throw light on risks, etiology, different types, different EEG and brain MRI abnormalities among Egyptian children in both urban and rural areas.

 

SUBJECTS AND METHODS

 

This study was carried out on 280 epileptic infants and children (142 males and 138 females) attended the Neuropsychiatry Department, Tanta University Hospital over a period of one year. The patients’ age ranged between 4 to 215 months  with a mean of 107.6±60.5 months. 

 

Patients were categorized as follows:

A)     According to the etiology of epilepsy into two groups (ILAE,1989).

                Group I: Patients with idiopathic epilepsy .

         Group II: Patients with cryptogenic or symptomatic.

B)     According to the age of epilepsy onset based on Robert6:

-        Infantile group: Patients who developed epilepsy before the age of one year.

-        Early childhood group : Patients developed epilepsy at age of one year up to twelve years .

-        Late childhood group : Patients developed epilepsy at the age of twelve years and up to eighteen years.

 

In order to subserve the above categorization each patient was subjected to the following: 

I.       Careful history taking with special emphasis on: (i) perinatal history including prenatal history (premature rupture of membrane “PROM”, drug intake, hemorrhage, infection), natal history (place of labour “hospital or home”, type of labour “normal, instrumented by forceps, ventose or cesarean section”, onset of labour “pre-term, full-term, post-term” and  condition of the baby “injury, asphyxia, weight”). Postnatal history inquiries included: infection, trauma, ischemia or hemorrhage to the baby. (ii) developmental history they were categorized as having a " major disability " when their activities of daily living (such as toileting, dressing or feeding) were impaired to the extent that they could not function independently or appropriately for their age; a "minor disability" implied that the children had signs of motor deficits but were functioning independently. The assessment was independent of cognitive status7. (iii) family history  of epilepsy  or other CNS disease. (iv) history of seizure.

 

II.            Thorough neurological examination.

 

III.   Electrophysiological studies: Interictal awake or sleep EEG was done for each patient using digital paperless multi-channels EEG equipment (PL-270 WINSOR).   

 

IV.          Video EEG monitoring.

It was done for selected patients according to the following indications:

1-   Differential diagnosis between epileptics and non epileptic attacks.

2-   Seizure classification

3-   Evaluation  of seizure precipitating factors.

 

IV.          Neuroimaging (MRI).

The Brain MRI scans were  performed using the General Electric (GE) medical system 1.5 Tesla. MRI of the brain  were obtained for all patients aiming at:8

1-   Identification of underlying pathologies, in patients with neurological signs.

2-   Assisting the formulation of syndrome-based on etiological diagnosis.

3-   Getting neuroimaging data in patients with complicated and intractable epilepsies.

 

VI.          Statistical analysis: The statistical analysis was done through SPSS for Windows, version 7.5.


 

Results

 

Table 1. Demographic data of patients in both groups, paternal consanguinity and family history among  patients and perinatal history of the patients.

 

Demographic data

Group I (n=154)

Group II (n=126)

Statistics

Mean±SD/No

%

Mean±SD/No.

%

X2 or T

P-value

Age (months)

           - Range

           - Mean ±SD

10-204

105.9±57.2

 

 

 

4-214

78.3±57.9

 

 

 

t=8.33

<0.001*

           Sex

          - Male

          - Female

67

87

 

43.50

56.50

 

 

75

51

 

 

59.52

40.48

 

X2= 21.93

<0.001*

Residence

           - Urban

           - Rural

70

84

 

45.46

54.54

 

26

100

 

20.63

79.37

 

X2= 18.94

<0.001*

Family history of epilepsy and/or neurologic illness

          - Positive

          - Negative

 

 

45

109

 

 

29.23

70.77

 

 

13

113

 

 

10.31

89.69

 

1.34

 

0.24

Parental consanguinity

        - Positive

        - Negative

 

51

103

 

33.11

66.89

 

30

96

 

23.80

76.20

1.62

0.20

Labor site

       - Home

       - Hospital

 

58

96

 

37.66

62.34

 

68

58

 

53.96

46.04

14.35

<0.001*

Labor Type

       - Normal

       - Instrumented

       - Caesarean section

 

114

21

19

 

74.02

13.64

12.34

 

68

40

18

 

53.96

31.75

14.29

14.92

<0.001*

Perinatal insults

      -  Positive

      -  Negative

 

11

143

 

 

7.14

92.58

 

 

75

51

 

 

59.52

40.48

 

19.52

<0.001*

*=Significant

 

Table 2. Different seizure types in both groups.

 

 

Seizure types

 

 

 

 

 

Group I

(n=154)

Group II

(n=126)

Total

 

No.

%

No.

%

No

%

Generalized seizure

110

71.43

83

65.88

193

68.93

        - Tonic-clonic

66

42.85

67

53.18

133

47.7

       - Tonic

0

0

2

1.58

2

0.71

       - Typical absence

21

13.63

0

0

21

7.50

       - Atypical absence

0

0

10

7.93

10

3.57

       - Myoclonic

15

9.75

0

0

15

5.35

       - Mixed seizure types

8

5.20

4

3.19

12

4.28

Partial seizures

44

28.57

43

34.12

87

31.07

    - Simple partial

20

12.99

21

16.67

41

14.65

    - Complex partial

12

7.79

10

7.93

22

7.85

    - Partial with secondary generalization

12

7.79

12

9.52

24

8.57

X2

0.19

P

0.90

 

 

Table 3. Neurological deficits in both groups.

 

Neurological examination

Group I

(n=154)

Group II

(n=126)

No

%

No

%

 - No neurological deficit

 - Neurological deficit

154

0

 

 

100

0

 

 

7

119

 

5.55

94.45

 

X2

p

280

< 0.001*

*=Significant

 

 

Table 4. Brain MRI abnormality among both groups.

 

MRI findings

Group I (n=154)

Group II (n=126)

No

%

No

%

Normal

154

100

10

8.0

Abnormal

0

0

116

92.0

X2

p

127.94

< 0.001*

*=Significant

 

Table 5. EEG pattern in both groups.

 

Item

Group I (n=154)

Group II (n=126)

Total

No

%

No

%

No

%

·        Normal

·        Abnormal epileptiform activity

 - Focal

 - Focal with secondary generalization

 - Multifocal

 - Subcortical (generalized)

41

113

21

15

0

77

26.7

73.3

13.6

9.7

0

50.0

15

111

19

27

7

58

11.9

88.1

15.1

21.4

5.6

46

56

224

34

66

7

117

20

80

12.2

23.5

2.5

41.8

X2

p

9.38

< 0.001*

*=Significant

 

 

 

 

Fig (1): Distribution of epilepsies and epileptic syndromes in group I and II.

Table 6. Parental consanguinity, family history, perinatal insults and etiology of epilepsy in the three age groups.

 

Age of epilepsy onset

Infancy

(<1 year)

Early childhood

(1-12 years)

Late childhood

(12-18 years)

Statistics

No

%

No

%

No

%

t or X2

P

Number

Total

11

280

3.9

100

216

280

77.14

100

53

280

18.92

100

t=15

0.001*

Residence

                - Urban

                - Rural

                - Total

 

3

8

11

 

27.27

72.73

100

 

69

147

216

 

31.94

68.06

100

 

27

26

53

 

50.90

49.10

100

X2= 12

0.001*

Parental consanguinity

               - Positive

               - Negative

               - Total

 

2

9

11

 

18.18

81.82

100

 

58

158

216

 

26.85

73.15

100

 

21

32

53

 

39.62

60.38

100

X2= 6.1

0.04*

Family history

              - Positive

              - Negative

              - Total

 

1

10

11

 

9.1

90.9

100

 

40

176

216

 

18.51

81.49

100

 

17

36

53

 

32.07

67.93

100

X2= 5.23

0.06

Perinatal insult

              - Positive

              - Negative

              - Total

 

10

1

11

 

90.9

9.1

100

 

63

153

216

 

29.16

70.84

100

 

02

51

53

 

3.77

96.23

100

X2= 12

0.001*

Etiology of epilepsy

          - Idiopathic

          - Cryptogenic

          - Symptomatic

          - Total

 

1

2

8

11

 

9.1

18.18

72.81

100

 

121

6

89

216

 

56.01

2.77

41.22

100

 

32

2

19

53

 

60.40

3.80

35.80

100

 

 

14.40

 

 

0.001*

*=Significant

 

A

B

C

Fig (2): Brain MRI of female child age 12 years presented by severe headache, right side hemiplegia and

recurrent partial seizure with secondary generalization. It shows heterotopia with arachnoid cyst.

T2 Axial

T1 coronal

Fig. (3): Brain MRI of male child age 13-year old presented with uncontrolled complex partial seizures which started at the age of 6 years. T1  weighted coronal section and T2 weighted image axial section (right mesio-temporal  sclerosis).

 

 


DISCUSSION

 

In this study, the patients’ age ranged between 4 to 215 months  with a mean of 107.6±60.5 months. Of the included group of patients, 142 were males and 138 were females with a male to female ratio of 1.1: 1. Also ,we reported predominance of male in symptomatic and cryptogenic group (59.52%) than in idiopathic group (43.5%) of patients and the difference was significant (Table 1). The predominance of male gender was reported by other studies9 among pediatric epileptic patients.   

In the current  study, patients from rural areas were significantly higher in symptomatic group (79.3%) compared to idiopathic group (54.54%) (Table 1). The  predominance of rural areas patients was compatible with that  recorded in other series7,10. This predominance of patients coming from rural area may refer to the location of our hospital near rural areas. Also,  the ratio of rural to urban population  in Tanta region  is about 1.5:1 and this high ratio of rural population was reflected on the predominance  of rural patient in this study. Also, normal labor by non medical personnel  at home is very common  in rural area in this study (45%) in which the infants suffer from bad perinatal care which is important factor for developing epilepsy especially symptomatic and cryptogenic.

In this study, 21% of the patients had a family history of epilepsy and/or neurological  illness and about 29% had parental consanguinity. Although these parameters were more common in idiopathic group (33% and 29%, respectively) compared to symptomatic group (24% and 10%, respectively) the difference didn’t reach a statistical significance (Table 1). Actually the symptomatic epilepsies are usually acquired disorders where genetic factors play a minor role11. An Egyptian study12 reported to some extent higher  percentage (40%) of family history of epilepsy among infant and children with idiopathic generalized epilepsies. Also in accordance with data presented in the current study, other studies suggested a strong genetic predisposition for idiopathic epilepsies13 and that inheritance is complex than monogenic14. Parental consanguinity might suggest autosomal recessive disorder15.

In the current study, home delivery mostly by non-medical personnel together with instrumented and cesarean section “C.S.” delivery were significantly higher among symptomatic epilepsy group patients (Table 1). The latter circumstances contributed to the significantly higher incidence of perinatal insults encountered among the symptomatic epilepsy patients in this study (59.52%) compared to that of the idiopathic group (7.14%) (Table 1). These findings are concordant with that reported by other studies7,9,16,17 highlighting the fact that perinatal insults contribute markedly in the etiology of symptomatic epilepsy in pediatric age group.   

In this study, generalized seizures were present in 69% of patients while partial seizure in 31% (Table 2). Nearly similar findings were detected by other studies in which generalized seizures were common than partial seizures7,18. Lower percentage  of generalized seizures, reaching down to 12% and up to 44%, were present in other studies19-23. This low percentage  of generalized seizures among the previous studies may refer to high percentage  of undetermined seizures in these studies. Also, generalized seizures predominate seizure types among patients of this study explained by high percentage of patients who had mixed generalized seizure types (4.3%) and high percentage of generalized epileptic syndromes ; childhood absence epilepsy (13%) and juvenile absence epilepsy (5.9%). 

In this study, 42% of patients had neurological deficit all of them belong to symptomatic and/or cryptogenic group (Table 3). About 66% of neurological deficit was pyramidal sings either unilateral or bilateral. This was nearly compatible with the result of other series24,25, who found that 49% of their patients had neurological deficits. Some authors categorized  the epileptic patients as symptomatic cases when epileptic seizure occurred in the presence of neurological abnormalities or a history of brain insult or a disorder associated with an increased risk of epilepsy and which were presumed to be etiologically related to childhood epilepsy24. 

In this study, 41% of patients had abnormal MRI all of them were of symptomatic epilepsy while all of idiopathic and cryptogenic epilepsy had normal MRI (Table 4). This is in agreement with previous studies24,26, which reported no MRI abnormality in children with EEG confirmed idiopathic epilepsy and only found MRI abnormality in symptomatic epilepsies.

In this study, EEG showed that 80% of all patients had abnormal EEG pattern (Table 5). This result is in accordance with a previous study7, which reported abnormal EEG in 83% of patients. On comparison between symptomatic and idiopathic groups we found that ,abnormal EEG was more common among symptomatic epilepsy groups (88%) compared to idiopathic epilepsy group (73.5%).

In this study , 20% of all the patients could be diagnosed as specific epileptic syndromes. These data are  concordant with another study27, who could diagnose 20.9% of patients as specific epileptic syndromes. On the other hand, other study28, reported much higher percentage (52%) because they did not exclude provoked seizures from their work. In this study (Fig. 1), 31% of all the patients had localized related epilepsies and epileptic syndromes ;16% were idiopathic and 15.3% were symptomatic or cryptogenic epilepsies and epileptic syndromes. Generalized related epilepsy and epileptic syndromes were present in 68% of patients; 39% were idiopathic and 29% were symptomatic or cryptogenic generalized related epilepsies and epileptic syndromes and finally, 1% had syndromes undetermined whether focal or generalized.

After  patients had been categorized  according  to their age of epilepsy onset  , it was apparent that 3.92% of patients developed epilepsy before the age of one year, 77.14% between the age of 1 to 12 years and 18.2% developed  it between 12 -18 years (Table 6). This is in agreement with other series10,25, which reported highest incidence of epilepsies in the early childhood period. Such finding might be attributed to the high percentage of patients in this group exposed  to different perinatal insults.     

In this study, Most of patients belong to infantile age group (73%) or early childhood group (68%) were from rural area while 49% of patients in late childhood group were from rural area (Table 6). This finding is in accordance with other study7, which found 70% of patients at infantile age group and 61% of early childhood group were from rural area. This high percentage of patients from rural area in both groups reflect the major role of home delivery under supervision of non medical personnel, which is common in rural area, for developing symptomatic epilepsy as a result of poor perinatal care. 

In the current study, parental consanguinity was more prevalent (39.62%) among late childhood group and also family history of epilepsy (32.07%) compared to both infantile and early childhood groups (Table 6). These results agree with a previous study29, who found parental consanguinity in 36% of patients who developed epilepsy at late childhood period. This can explain the high percentage of idiopathic epilepsies among the late childhood grouping where  genetic factor plays an important role. Consequently, paying more attention and awareness of young individuals about the increased risk of epilepsy after familial marriage, as well as pre-marital counseling for couples who have a family history of epilepsy are necessarily as an effective protective program.

About 91% of infant and 29% of early childhood age group had history  of perinatal troubles (Table 6) and this agree with previous series7,30 which reported that perinatal insults among  patients who developed epilepsy at infant (<1 year) and from (1-12 years) were 80% and 35% respectively. This indicate the importance of perinatal  insults  in developing symptomatic epilepsy at these age groups. This was evident  in this study where symptomatic epilepsy was prominent among infantile age group (72.81%) and early childhood group (41.22%) compared to late childhood group (35.8%).

 

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الملخص العربي

 

مرض الصرع لدي الرضع والأطفال في وسط الدلتا: الأنواع، عوامل الخطورة والأسباب

 

يعتبر مرض الصرع من أكثر الأمراض العصبية شيوعا حول العالم حيث   الصرع وتزداد نسبة حدوثه بين الأطفال وكبار السن وتعتبر إصابات لرأس ومخاطر ما حول الولادة والتهابات الجهاز العصبي من أكثر المسببات لهذا المرض فى الأطفال. وعلي ذلك قد هدف هذا البحث إلي دراسة  الأنواع، عوامل الخطورة والأسباب التي قد تؤدي إلى ظهور مرض الصرع عند الأطفال في منطقة وسط الدلتا. وقد أجري هذا البحث علي مائتان وثمانون طفلا من المصابين بمرض الصرع المترددين على العيادة الخارجية بقسم الأمراض العصبية والنفسية بمستشفى طنطا الجامعي  في خلال سنة واحدة من تاريخ البحث. وقد أشتمل فحص المرضي علي أخذ التاريخ المرضى لهم، فحص الجهاز العصبي بدقة، عمل رسم مخ كهربائي لكل المرضى، متابعة رسم المخ بالفيديو لبعض المرضى المحتاجين لها و كذلك أشعة بالرنين المغناطيسي على المخ لكل المرضى. وقد تم تقسيم المرضى إلى مجموعتين حسب سبب مرضى الصرع: مجموعة فيها الصرع ذاتي السبب ومجموعة فيها صرع خفي المنشأ أو معلوم المنشأ ثم تم تقسيمهم مرة أخرى حسب سن بدء المرض إلى ثلاث مجموعات: المجموعة الأولى بدأ فيها المرض في اقل من عام والمجموعة الثانية من عمر عام  إلى أثني عشر عام والمجموعة الثالثة من أثني عشر إلى ثمانية عشر عاما .وقد وجد من خلال التحليل الإحصائي لنتائج هذا البحث أن مرض الصرع أكثر شيوعا ما بين أطفال الريف خاصة التشنجات الصرعية الشاملة وأن الولادة الطبيعية على أيدي غير الأطباء من أكثر العوامل التي تؤدي إلى ظهور مرض الصرع. وقد تبين أيضا أن مشاكل ما حول الولادة من أكثر الأسباب المؤدية إلى الصرع خصوصا في الأطفال الأقل من أثني عشر عاما. كذلك اظهر البحث أن درجة القرابة ووجود تاريخ أسري لمرض الصرع من العوامل لتي تساعد على ظهور الصرع بعد سن أثني عشر عاما. وقد تبين أيضا أن مرض الصرع معلوم المنشأ أكثر شيوعا بين الأطفال صغار السن منذ الولادة وإلى أثني عشر عاما في حين أن مرض الصرع ذاتي المنشأ هو الأكثر شيوعا بين الأطفال الأكبر من أثني عشر عاما. لذا يوصي هذا البحث إلي أن الاستشارة الطبية قبل زواج الأقارب خاصة في وجود تاريخ عائلي لمرض الصرع وكذلك الولادة تحت إشراف طبي دقيق قد يعطي إمكانية جيده لتقليل فرص الإصابة بمرض الصرع مابين الرضع والأطفال.



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