Children and adolescents with epilepsy in rehabilitation centers: A French prospective transversal study.

INTRODUCTION: The reason why some children and adolescent with epilepsy (CAWE) still challenge the "inclusive" educative policy needs to be explored. METHODS/PATIENTS: We conducted a transversal study in French medical, social, and educative rehab centers (MSERCs) dedicated to CAWE to describe the profile of 263 centers-involved (CI)-CAWE. Centers-involved CAWE were prospectively followed from September 2012 to August 2013. Medical, social, and educative rehab centers were dichotomized according to their care-provider agreement (i.e., CAWE of "moderate" (M) vs. "severe" (S) conditions). Clinical factors known to impact clinical outcome and quality of life (QoL) in epilepsy and four disabling conditions at risk to impact school life (i.e., cognitive and psychiatric/behavioral disorders, risk of physical hazards (i.e., refractory seizures with unpredictable loss of tone and/or awareness), and one or more seizure/week) were evaluated. The electronic chart of the French collaborative database (namely GRENAT) was used for data collection allowing comparison with the profile of 731 "normally integrated and schooled" (NIS)-CAWE extracted from GRENAT and matching for generation (i.e., born between 1988 and 2006). RESULTS: Centers-involved CAWE's profile was found, after adjustment, to be associated with clinical factors and disabling conditions reflecting the poorest clinical outcome and health-related quality of life (HR-QoL) (all p < 0.001). A cutoff of two disabilities/child highly discriminated NIS-CAWE vs. CI-CAWE. Centers-involved CAWE of S-MSERCs were the most severe (all p < 0.001), and the type of cognitive disability (i.e., intellectual disability (ID) vs. specific learning disorders (SLD)) highly paralleled the types of MSERCs (S vs. M). Using a parent-informant questionnaire, the number of disabilities/child was found to correlate with both the evaluation of the impact of epilepsy (r = 0.47, p < 0.001) and the HR-QoL (r = 0.37, p < 0.001). A satisfactory social life was reported (83.8%) even after S vs. M dichotomization (77.2% vs. 94.7%; p < 0.001). CONCLUSION: Multiple disabilities rather than epilepsy per se challenge the inclusive educative policy. Evaluation of disabilities could be the missing bridge to optimize this policy and understand its limits.

Epileptogenicity and surgical outcome in post stroke drug resistant epilepsy in children and adults.

OBJECTIVE Post-stroke epilepsy (PSE) represents a rare etiology in patients undergoing pre-surgical evaluation for epilepsy. Refractory PSE has been traditionally surgically treated with hemispherotomy. The aim of this study was to define the electrophysiological features of epileptogenic zone (EZ) using stereoelectroencephalography (SEEG) recordings in patients with refractory PSE. METHODS We analyzed ictal SEEG recordings from 21 consecutive patients. Epileptogenicity was quantified using the "epileptogenicity index" (EI) method in distant and perilesional cortical structures. We identified different seizure onset patterns (SOP) through a visual and time-frequency analysis. RESULTS We found that 81% of patients showed a complex organization of EZ, involving remote and perilesional structures. EZ involved a significantly (p < 0.01) higher number of distant regions displaying a high epileptogenicity (EI ≥ 0.3). Low voltage fast activity (LFA) and high amplitude slow activity (HAS) patterns were observed respectively in 85.7% and 14.3% of patients. Surgery was proposed in 12/21 patients. Good surgical outcome (Engel Class I or II) was observed for all patients who underwent tailored functional disconnection based on SEEG results. Shorter epilepsy duration to surgery was found in the seizure-free group. SIGNIFICANCE Refractory PSE may present a complex organization of EZ. SEEG recordings are warranted to guide tailored hemispherectomy.

Intraoperative spinal cord monitoring in children under 4 years old.

PURPOSE: The purpose was to study intraoperative spinal cord monitoring (IOM) particularities and performances in children under 4 years old with congenital spinal deformities. IOM is characterized by specific difficulties due to the immaturity of sensory-motor pathways in such young patients. To the best of our knowledge, this study is the largest dedicated to IOM in this challenging population. METHODS: This study was retrospective and monocentric. 78 IOM in children under 4 years old were analyzed. Somatosensory evoked potentials (SSEP), neurogenic mixed evoked potentials (NMEP) and D waves were performed. Patients were classified into one of four categories with respect to IOM data and clinical outcome: true positive, false positive, true negative and false negative. Sensitivity and specificity were then calculated accordingly. RESULTS: There were 6 true positive, 3 false positive, 67 true negative and 1 false negative outcomes. One patient was characterized by unreliable baseline IOM data. IOM sensitivity was 86 %. IOM specificity was 96 %. The false negative case was monitored using SSEP alone. IOM was difficult in 10/77 cases, being unilateral because of a planned fibular graft harvest. NMEP were characterized by higher signal-to-noise ratio than SSEP. CONCLUSIONS: Immaturity of sensory-motor pathways predominates in the central rather than the peripheral nervous system in young children. MEP and D waves could thus be difficult to obtain. Although non-specific to motor pathways, it could be useful to "by-pass" the brain, using NMEP. In regard to maturational particularities, IOM in children under 4 years old should be performed by experienced neurophysiologists, avoiding in these cases surgeon-guided devices.