Доклад на международной конференции в Риме 31.08.11

14.10.2011

Mental impairment during the formation of BEDC (Benign Epileptiform Discharges of Childhood). True or false?
D.E. Zaytsev, N.A. Titov, L.V. Eletskova, D.V. Lyutin
D.E. Zaytev’s Psychoneurological center.
St. Petersburg, Russian Federation.

Actuality: in addition to various forms of epilepsy, the BEDC (benign epileptiform discharges of childhood) pattern can be accompanied by stress headaches, migraines, childhood cerebral palsy, behavioral disorders such as hyperactivity and attention deficit (ADHD), tumors, and organic affectations of the brain of varying origin.

Objective: the objective of the given study is to examine the connections between cognitive damage and the appearance of BEDC.

Goals:

Examine the particulars of psychological disorders in children with manifest morphological changes of varying etiology in the brain in connection with an appearance of BEDC.
Examine the particulars of the reduction of psychological disorders in children without brain lesions in connection with an appearance of BEDC.
Compare the particulars of the mitigation in these disorders.

Materials and Methods: Our study included 14 children between the ages of 2 years 3 months and 13 years (mean age 6 years 8 months) with brain lesions identified via neuroimaging techniques (NSG, MRI, CT) (group 1) and without such lesions (group II). Eight patients were affected by documented forms of focal epilepsy. All patients were found to have some level of cognitive deficit. Among these deficits were disturbances in the development of the prerequisites for intellect (disturbances in attention, memory, and cognition). Behavioral abnormalities taking the form of pathological impulsive actions and affective fluctuations in 5 children were not subject to evaluation due to the children's severe cognitive deficits and delays in motor development. All children were examined by a neurologist and a psychiatrist, and the dynamic of their condition observed and traced. EEGs were recorded several times over the course of observation, on average once a month, as antiepileptic therapy was administered. Speech pathologists/therapists, psycogists, and parents also evaluated the dynamics of the children's cognitive capacities and emotional changes.

Results: We observed a group of patients consisting of children between the ages of 2 years 3 months and 13 years (mean age 6 years 8 months) with cognitive deficits of varying degrees.

The majority of the patients were boys (11 patients, 75,5%). Nine of the 14 patients (64,3%) were diagnosed with focal epilepsy.

Patients were divided into two groups: group I comprised children confirmed via neurovisualization techniques to have brain lesions (n=7, 50%); group II comprised children without brain lesions (n=7, 50%).

The neurological status of the children in the first group was characterized by focalized neurological symptoms (one or two-sided pyramidal syndrome, ataxia, tremors), which were evidence of brain lesions.

Examination by a psychiatrist revealed deficits of attention, cognition, intellect, and emotion in all children in the first group.
All children diagnosed with epilepsy received antiepilepctic therapy in the form of valproic acid.

At the beginning of the investigation, the EEGs of all children included in the trial revealed the following deviations from the norm:

Delays in the formation of a baseline activity EEG rhythm
Slow focal activity
Epileptiform complexes
Sharp wave-slow wave
Peak-slow wave

EEGs made to document the dynamics of the conditions of all children in the study revealed complexes characteristic of benign epileptiform discharges of childhood (BEDC) that did not register during control examinations 1 —2 — 3 months later.

We also remarked that the appearance of the above pattern in the EEG coincided with a clinically observed improvement in cognition across a range of criteria (attention, hyperactivity, speech production). The dynamics of resto-

Table 1 (Dynamics of restoration of cognitive functions in children with and without brain lesions)

Thus, we can see that group I experienced first an improvement in emotional state, then in memory and attention, which in turn led to an improvement in educability.

In the second group, the order of restoration of cognitive function was somewhat different, which nonetheless led to an analogous result – to increased educability.

When EEG changes characteristic of BEDC were discovered in children included in the study, their therapy was expanded to include the drug topiramate (topamax®), which led to a reduction in the described EEG patterns.

Clinical examples

Case 1.
Child's name: S.N., diagnosis: brain lesions of prenatal origin. Childhood cerebral palsy syndrome complex, spastic diplegia, delays in mental, speech, and motor development. Age at start of observation: 2 years 2 months.

Case history reveals that the child was the product of a first pregnancy, delivery was expedited. Apgar score 5/6 points. Serious condition during the first few days of life, child placed on artificial respirator for the first 5 days.

“Twitching” observed from the first few days of life. Said twitching was initially judged to be myoclonic, and valproic acid administered to the child at a dose of 30 mg/kg/day. Objective observations upon examination at age 2 years 2 months: Neurological status: The child is conscious. Skull nerves: eye slits (D=S), symmetrical pupils, responsiveness to light retained. Mild convergent alternating strabismus OU. Muscle tone high, more so in the legs, in a fashion characteristic of lesions in the pyramidal tract. Deep tendon reflexes animated,
more so in the legs, D=S. No speech produced.

EEG (2 years 2 months) (Figure 1) — The waking EEG recording reveals diffuse changes in bioelectic activity of the large hemispheres of the cerebral cortex. There is evidence of a slight delay in electrogenesis, as the weakly demarcated distinctions between regions suggest. Typical epileptiform activity is not observed. The child continued to receive valproic
acid therapy, epileptic seizures did not take place

Control EEG at age 2Control EEG at age 2 years 8 months (Figure 3) – The background EEG recording during an active waking state reveals diffuse dysregularing changes in the bioelectric activity of the brain within the framework of an agedependent electrogenesis dynamic, with changes of the BEDC variety in the central and frontal region.Objective observations at age 2 years 8 months:2 years 6 months + short phrases.

Control EEG at age 2 years 6 months (Figure 2) – The background EEG recording during an active waking state reveals diffuse dysregularing changes in the bioelectric activity of the brain within the framework of an age-dependent electrogenesis dynamic, with changes of the BEDC variety in the central region occurring bilaterally and asynchronically. Topiramate introduced into the therapy regimen, tapering down of valproic acid beg

Objective observations at age 2 years 6 months: Understands speech addressed to him, approachable, emotional. Follows directions. Speech produced consists of syllables, phrases absent. Neurological status: manifestations of spastic diplegia retained.

Control EEG at age 3 years (Figure 4) – The background activity of an EEG recorded during an active waking state reveals diffuse changes in the bioelectrical activity of the brain within the framework of an age-dependent dynamic of electrogenesis. Typical paroxysmal and/or epileptiform activity is not found.

Figure 5: EEG at 3 years 4 months (nowadays) – the returning of BEDC in central region. The therapy is the same.

Case 2.
Child's name: D.A., diagnosis: epileptiform autistic disintegration. Age at start of observation: 4 years. Case history reveals that the child was the product of a fourth pregnancy, concomitant with that a chronic case of pyelonephritis in the mother, and 2 expedited previous births. Apgar score: 8/8 points, left the hospital with a diagnosis of “healthy”.

Objective observations at 4 years of age: child is conscious, engages in social contact reluctantly. Speech is characterized by babbling, follows simple directions. Indifferent to toys, does not make eye contact. Neurological status: lacks focalized neurological symptoms. Motor clumsiness observed. EEG at age 4 years (figure 6) – an EEG recorded during both waking and sleep reveal diffuse changes in the bioelectric activity of the large hemispheres of the cerebral cortex in the form of a low functional activity and low stability of the cortex, as well as an irritation of central structures. A delay in electrogenesis is noted. Typical paroxysmal and/or epileptiform activity is not observed.

Conclusions:

Our investigation has shown that:

Regardless of the presence or absence of brain lesions in children in conjunction with adequately selected anti-epileptic therapy, a robust improvement in cognitive function is observed.
BEDC had a transient character (in our investigation they appeared on average within the 1st to 2nd month of observation and became reduced by the 3rd to 4th month after the initial incidence).
According to our data, the observed dynamic changes in bioelectric BEDC activity in brains of children with and without brain lesions are accompanied by a clinically observable improvement in cognitive function.
It can be supposed that in our study BEDC does not have a deleterious effect on a child's cognitive functions, but can serve as a predictor of a recovery from a hereditary impairment of brain maturation.