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