Divya K P

Abstract

Aim: To highlight the clinical and electroencephalographic features, treatment strategies and outcome in atypical variant of benign childhood epilepsy with centrotemporal spikes (BECTS). Materials and Methods: Subject underwent video electroencephalograph (EEG), high-resolution magnetic resonance imaging (MRI), neuropsychological evaluation and language assessment and response to medication was followed up. In addition to sodium valproate, treatment with intravenous methylprednisolone (given as monthly bolus doses) was given as the seizures remained refractory to anti-seizure medications (ASM) alone. Results: Earlier onset, increased frequency and duration of focal seizures compared to prototype Rolandic epilepsy are cardinal features suggestive of atypical variant of BECTS. Head drop and truncal sway due to axial or axiorhizomelic atonia occurring several times per day or week was the key manifestation. When the atypical seizures commenced, one or more of the following problems can occur: hyperactivity, attention deficit, and mild cognitive or language dysfunction. Child became seizure free on a combination of intravenous methylprednisolone, with sodium valproate and his hyperactivity reversed. Conclusion: BECTS in children with an early age of onset, frequent and prolonged seizures and scholastic decline pari passu with seizure onset are more likely to evolve into atonic-BECTS. Carbamazepine, oxcarbazepine and some benzodiazepines may worsen these seizures. They can become seizure free with immunomodulatory therapy, namely methylprednisolone (given as monthly bolus doses) or intravenous immunoglobulin (IVIG), and have complete resolution of the transient motor and cognitive impairment. Atonic-BECTS needs to be differentiated from Lennox–Gastaut syndrome since it is potentially treatable and children recover with no sequel.   Keywords: Benign Rolandic epilepsy, Mental retardation, Atypical benign epilepsy, CSWS

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Abstract

A patient with known epilepsy who has had a single, habitual seizure and whose mental status has returned to baseline need not be transported to the emergency department (ED) unless other injuries require so, whereas a patient with no history of epilepsy who has returned to baseline following a seizure should be evaluated. The evaluation should include basic biochemical parameters, toxicology screening and a brain imaging. One should investigate circumstances that may have precipitated a seizure, such as alcohol withdrawal, stimulant use, or head injury. Risk of recurrence of seizures is more likely in those with a history of significant brain injury or infection. If the patient has a normal magnetic resonance imaging (MRI) and electroencephalograph (EEG), the likelihood of a second seizure is approximately 1 in 3; if either test result is abnormal, the chances are approximately 1 in 2; if both are abnormal, the probability rises to 2 in 3. Computed tomography (CT) scan head is very useful in the evaluation of first seizure in infants less than six months of age. The clinical characteristics predictive of an abnormal CT scan for patients presenting with seizures were age less than 6 months or age greater than 65 years, history of cysticercosis, altered mentation, closed head injury, recent cerebrospinal fluid (CSF) shunt revision, malignancy, neurocutaneous disorder and seizures with focal onset or duration longer than 15 minutes. MRI has been shown to be superior to CT for the detection of cerebral lesions associated with epilepsy.   Keywords: Epilepsy, Antiepileptic drugs, Psychogenic seizures, Syncope, First seizure

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Abstract

Introduction: Clobazam, one of the newer benzodiazepines, is now used extensively as first add on therapy in focal epilepsy. Materials and Methods: A 67-year-old diabetic and hypertensive gentleman with a history of frontal contusion one year ago, presented with clustering of seizures. He was started on clobazam 20 mg, and levetiracetam 1000 mg/day. Recurrence of seizures prompted a dose escalation of clobazam to 40 mg/day. The patient developed hepatic encephalopathy and his decompensation was probably precipitated by the use of high dose of clobazam. Clobazam was thus gradually tapered off along with hepatic precoma regimen, and other supportive measures leading to an uneventful recovery. Results and Conclusion: Caution must be taken while administering clobazam to elderly and debilitated patients or those with organic brain syndrome as they are more prone to the central nervous system (CNS) depressant activity of benzodiazepines. Since clobazam requires dealkylation and hydroxylation prior to conjugation, it should be used with caution in patients with hepatic involvement. Keywords: Central nervous system (CNS), Antiseizure medication (ASM), Arterial blood gas (ABG)

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