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EpilepsyEpilepsy
In children with Cerebral In children with Cerebral
PalsyPalsy
EpilepsyEpilepsy
In children with Cerebral In children with Cerebral
PalsyPalsyBy Dr. Asia Mulhi
IntroductionIntroduction
Cerebral palsy is a term that define a group of Cerebral palsy is a term that define a group of non progressive but often changing syndromesnon progressive but often changing syndromes
of motor impairment secondary to a lesionsof motor impairment secondary to a lesions
or anomalies of the brain often arising in the or anomalies of the brain often arising in the
early stages of its development .early stages of its development . The incidence of CP range from 1.5- 2.5 perThe incidence of CP range from 1.5- 2.5 per
1000 live births 1000 live births
A range of 15-60 % of CP having epilepsy .A range of 15-60 % of CP having epilepsy . Their epilepsies tend to be persistent .Their epilepsies tend to be persistent . Cerebral palsy who have mental retardation Cerebral palsy who have mental retardation
tend to have higher incidence of epilepsy .tend to have higher incidence of epilepsy . Higher risk of seizure relapse have been Higher risk of seizure relapse have been
observed in children with cerebral palsy . observed in children with cerebral palsy .
ObjectivesObjectivesGeneral :General :
To evaluate the epilepsy in children with Cerebral Palsy To evaluate the epilepsy in children with Cerebral Palsy
SpecificSpecific ; ; TTo determine the frequency of epilepsy in relation to types of CP.o determine the frequency of epilepsy in relation to types of CP.
To identify : - To identify : - -factors associated with epilepsy in -factors associated with epilepsy in children with cp children with cp
- children with cp in relation to age at seizure onset. - children with cp in relation to age at seizure onset.
- types of seizures in children with cp. - types of seizures in children with cp.
- Seizure outcome in children with cp. - Seizure outcome in children with cp.
MethodsMethods Prospective and analytic study reviewed Prospective and analytic study reviewed
epilepsy in children with cerebral palsyepilepsy in children with cerebral palsy Setting : study was conducted in Alwahda Setting : study was conducted in Alwahda
teaching hospital / ADENteaching hospital / ADEN Period of study : January 2000 to Dec. 2003 Period of study : January 2000 to Dec. 2003
Study population : 100 children with CP Study population : 100 children with CP
were seen in neurology out-patient 50 of CP were seen in neurology out-patient 50 of CP with seizures were studied ( group 1)with seizures were studied ( group 1)
A control group of 50 epileptic children A control group of 50 epileptic children with normal neurodevelopment studied with normal neurodevelopment studied during the same period (group 2).during the same period (group 2).
Period of follow up was at least two years.Period of follow up was at least two years. Data were obtained from parents , patients Data were obtained from parents , patients
as: type of CP, type of epilepsy, age of as: type of CP, type of epilepsy, age of epilepsy onset, family history of seizure, epilepsy onset, family history of seizure, history of neonatal seizures, history of history of neonatal seizures, history of status epilepticus, presence of mental status epilepticus, presence of mental retardation, brain C T scan findings, retardation, brain C T scan findings, interictal EEG data, use of anti epileptic interictal EEG data, use of anti epileptic drugs and seizure outcome .drugs and seizure outcome .
Evaluation of mental subnormality based on Evaluation of mental subnormality based on clinical assessment ,neurological exam. Speech, clinical assessment ,neurological exam. Speech, or need for special educationor need for special education
Seizure outcome was defined as good if patient Seizure outcome was defined as good if patient was seizure free for 2 years or morewas seizure free for 2 years or more
and poor for seizure recurrence daily ,weeklyand poor for seizure recurrence daily ,weekly
or monthly .or monthly . Intractable epilepsy was defined as 2 seizures Intractable epilepsy was defined as 2 seizures
per month in spite of appropriate therapy withper month in spite of appropriate therapy with
maximal tolerable dose maximal tolerable dose
Statistical analysisStatistical analysis Data was processed by computer Data was processed by computer
facilities, using percentage as facilities, using percentage as summary measure, Xsummary measure, X2 2 test was test was applied to relate variables among applied to relate variables among groups and Odd Ratio was groups and Odd Ratio was calculated with a significant level calculated with a significant level of 0.05.of 0.05.
ResultsResults
Table ( 1) frequency of epilepsy by cerebral palsy typesTable ( 1) frequency of epilepsy by cerebral palsy types
Type of CpType of Cp TotalTotal CP with CP with epilepsyepilepsy
NO.NO. %%
Sp tetreplegiaSp tetreplegia 4646 2828 6060
Sp hemiplegiaSp hemiplegia 1313 66 4646
Sp DiplegiaSp Diplegia 99 44 4444
DyskineticDyskinetic 1717 77 4141
MixedMixed 1515 55 3333
TotalTotal 100100 5050
Table ( 2) Children by groups and associated factors .Table ( 2) Children by groups and associated factors .Table ( 2) Children by groups and associated factors .Table ( 2) Children by groups and associated factors .
FactorsFactorsEpilepsyEpilepsy
With cpWith cpGroup 1Group 1
Epilepsy Epilepsy without CPwithout CP
Group 2Group 2 Odd ratioOdd ratio
N=50N=50 %% N=50N=50 %% XX22 PP
Neonatal seizuresNeonatal seizures 1616 3232 22 44 13.2813.28 0.00020.0002 11.311.3
(2.3-76.3)(2.3-76.3)
Positive F/H of Positive F/H of seizuresseizures
1111 2222 33 66 5. 325. 32 0.020.02 4. 44. 4
(1. 03-21 .6)(1. 03-21 .6)
Seizures onset during Seizures onset during the first year of lifethe first year of life
2828 5656 66 1212 21. 5721. 57 0.0000.000 9.33(3.08-9.33(3.08-2.97)2.97)
Mental subnormalityMental subnormality 4545 9090 33 66 70.770.7 0.0000.000 14.1(27.3-14.1(27.3-887.1)887.1)
Status epilpticusStatus epilpticus 1717 3434 22 44 14.6214.62 0.00010.0001 12.4(2.5-12.4(2.5-83.3)83.3)
Need two or more AEDNeed two or more AED 3434 6868 1515 3030 14.4514.45 0.00010.0001 4.96(1.96-4.96(1.96-12.7)12.7)
EEG abnormalitiesEEG abnormalities 4545 9090 4040 8080 1.251.25 0.2626 0.2626 (Ns)(Ns)
2.252.25
Abnormalities on brain Abnormalities on brain imagingimaging
4242 8484 88 3232 29.029.0 0.00000.0000 29.8(6.1-29.8(6.1-169.1)169.1)
Table(3 ) Table(3 ) Children with epilepsy and cerebral palsy by ageChildren with epilepsy and cerebral palsy by age at seizure onsetat seizure onset
Types of CPTypes of CP EpilepsyEpilepsy
With cpWith cp
Group 1Group 1
N=50N=50
Epilepsy Epilepsy without CPwithout CP
Group 2Group 2
N=50N=50AgeAge
(years)(years)
SpasticSpastic
TetraplegiaTetraplegia
Spastic Spastic
HemiplegiHemiplegi
Spastic Spastic
DiplegiaDiplegia
Dysk.Dysk. MixMix
<1<1 2121
75%75%
11
16%16%
00 22
28%28%
44
80%80%
2828 56%56% 66 12%12%
1-61-6 66
21%21%
22
33%33%
33
75%75%
44
57%57%
11
20%20%
1616 32%32% 1919 38%38%
>6>6 11
3.5%3.5%
33
50%50%
11
25%25%
11
14%14%
00 66 12%12% 2525 50%50%
X X 22:26.14 P :0.000:26.14 P :0.000
Seizures TypesSeizures Types EpilepsyEpilepsy
With cpWith cp
Group 1Group 1
Epilepsy without Epilepsy without CPCP
Group 2Group 2
No.No. %% No.No. %%
Generalized T+CGeneralized T+C 1919 3838 1515 3030
Partial /complex, sec general. Partial /complex, sec general. 1111 2222 1818 3636
MyoclonicMyoclonic 88 1616 66 1212
Infantile spasmsInfantile spasms 44 88 22 44
AtonicAtonic 00 00 33 66
Absence (TYPICAL)Absence (TYPICAL) 00 00 44 88
PolymorphicPolymorphic 99 1818 22 44
Table (4) Table (4) Children of epilepsy by types of seizureChildren of epilepsy by types of seizure
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
generalizedT&C
part.&sec.Gen.
myoclonic infantilspasm
polymorphic
Mixed
Dyskinetic
sp.diplegia
sp.hemiplegia
sp. Tetraplegia
Graph(2) children with cerebral palsy by seizure types
Table No. ( 5) Children with CP and Epilepsy and Table No. ( 5) Children with CP and Epilepsy and Epilepsy without CP by Seizure outcome.Epilepsy without CP by Seizure outcome.
Seizure Seizure outcomeoutcome
EpilepsyEpilepsy
With cpWith cp
Group 1Group 1
Epilepsy Epilepsy without CPwithout CP
Group 2Group 2
No.No. %% No.No. %%
GoodGood 1919 3838 3838 7676
PoorPoor 3131 6262 1212 2424
TotalTotal 5050 100100 5050 100100
Seizure Seizure outcomeoutcome
EpilepsyEpilepsy
With cpWith cp
Group 1Group 1
Epilepsy Epilepsy without CP without CP
Group 2Group 2XX22 p-value p-value
IntractableIntractable 3131( 62%)( 62%) 12 ( 24 % )12 ( 24 % ) 14.7 0.00114.7 0.001
ControlledControlled 19 (38%)19 (38%) 38 ( 38 ( 76%76%)) 22.2 0.00022.2 0.000
Discontinuation Discontinuation of AEDsof AEDs
11 (22%)11 (22%) 35 (35 (7070%)%) 14.9 0.000114.9 0.0001
MonotherapyMonotherapy 16 (32%)16 (32%) 35 (70%)35 (70%) 14.50 0.000114.50 0.0001
polytherapypolytherapy 34 (34 (6868%)%) 15 (30%)15 (30%) 14.5 0.000114.5 0.0001
Table (6) Children with epilepsy by seizure outcomeTable (6) Children with epilepsy by seizure outcome
Table (7) seizure outcome in children Table (7) seizure outcome in children with cerebral palsy by types of CPwith cerebral palsy by types of CP
Seizure Seizure outcomeoutcome
..
Types of CPTypes of CP
EpilepsyEpilepsy
With CPWith CP
Group 1Group 1
EpilepsyEpilepsy
withoutwithout
CPCP
Group 2 Group 2
SpasticSpastic
TetraplegiTetraplegia.a.
DyskineticDyskinetic Mixed.Mixed. spasticspasticHemiplegiaHemiplegia
SpasticSpastic
DiplegiDiplegiaa
GoodGood 66
35%35%
33
42%42%
22
40%40%
44
66.7%66.7%
44
100%100%
1919
38 %38 %
3838
76%76%
poorpoor 2222
78.6%78.6%
44
57.1%57.1%
33
60%60%
22
33.3%33.3%
00 3131
62%62% 1212
24%24%X X 2 2 14.7 P :0.000114.7 P :0.0001
Table (8 ) Table (8 ) Intractable epilepsy in children with Intractable epilepsy in children with cerebral palsy and Antiepileptic drugs (AEDcerebral palsy and Antiepileptic drugs (AED).).
Type of CPType of CP TotalTotalIntractableIntractable
epilepsyepilepsyControlled Controlled epilepsyepilepsy
DiscontinuaDiscontinua-tion of -tion of AEDsAEDs
Mono-Mono-therapytherapy
Poly-Poly-therapytherapy
SpasticSpasticTetraplegiaTetraplegia
2828 22 22 (78%)(78%) 6 (35%)6 (35%) 4 (14% )4 (14% ) 7(25%)7(25%) 21(21(7575%)%)
DyskineticDyskinetic77 4 (57%)4 (57%) 3 (42 %)3 (42 %) 0 (0.0 %)0 (0.0 %) 1(14 %)1(14 %) 6(85% )6(85% )
MixedMixed55 3 (60%)3 (60%) 2 (40%)2 (40%) 0 (0.0 %)0 (0.0 %) 00 5(5(100100% )% )
Spastic Spastic
HemiplegiaHemiplegia
66 2 ( 33%)2 ( 33%) 4(66%)4(66%) 4 (66% )4 (66% ) 5(83% )5(83% ) 1( 16%)1( 16%)
Spastic Spastic DiplegiaDiplegia
44 00 4 (4 (100%)100%) 3 (3 (75%75%)) 3(75% )3(75% ) 1(25%)1(25%)
TotalTotal 5050 31 (62%)31 (62%) 19 (38%)19 (38%) 11 (22%)11 (22%) 16 (32%)16 (32%) 34 (70%)34 (70%)
ConclusionConclusion
The incidence of epilepsy was higher in The incidence of epilepsy was higher in tetraplegic cerebral palsy.tetraplegic cerebral palsy.
Intellectual impairment, history of neonatal Intellectual impairment, history of neonatal seizures, earlier age of seizure onset, status seizures, earlier age of seizure onset, status epilepticus ,abnormal brain imaging finding and epilepticus ,abnormal brain imaging finding and need for polytherapy were associated factors in need for polytherapy were associated factors in cerebral palsy.cerebral palsy.
Epilepsy in CP was associated with earlier age Epilepsy in CP was associated with earlier age of seizure onset than that in control group.of seizure onset than that in control group.
Generalized seizure was predominant formGeneralized seizure was predominant form of seizures in children with CP , and all infantile of seizures in children with CP , and all infantile
spasms were observed among tetraplegic patients.spasms were observed among tetraplegic patients.
Better seizure outcome was associated with normal Better seizure outcome was associated with normal intelligence, single seizure type,monotherapy, intelligence, single seizure type,monotherapy, spastic diplegia . spastic diplegia .
Fewer children with CP were able to discontinue Fewer children with CP were able to discontinue Anti-epileptic drugs, and non of children with Anti-epileptic drugs, and non of children with infantile spasms or polymorphic seizure achieved a infantile spasms or polymorphic seizure achieved a seizure free period of more than one year .seizure free period of more than one year .
RecommendationsRecommendations
Further studies concerning risks of epilepsy Further studies concerning risks of epilepsy development and its relations with the EEG and development and its relations with the EEG and brain imaging are needed .brain imaging are needed .
Trial of AEDs discontinuation after at least two Trial of AEDs discontinuation after at least two years free of seizures should be practiced in CP years free of seizures should be practiced in CP patient when possible.patient when possible.
Early treatment for epilepsy in patients with Early treatment for epilepsy in patients with cerebral palsy recommended to avoid further cerebral palsy recommended to avoid further brain damage and more cognitive dysfunction.brain damage and more cognitive dysfunction.
Thank youThank you
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