Cerebral palsy, a neurological disease of the young developing brain, is accompanied by a plethora of side effects. As an extension of general poverty of motor control, those with cerebral palsy show deficient hand function. Patients also present with various cognitive deficits, including reduced intellectual ability, and linguistic deficits, such as impaired language comprehension. There are concomitant sensory deficits, especially concerning tactile sensibility. Additionally, people with cerebral palsy often have impairments related to oral processes, such as swallowing. Other comorbid conditions include mental retardation and epilepsy.
EPILEPSY
The prevalence of epilepsy – a neurological disorder characterized by the occurrence of seizures – is much higher among the cerebral palsied than it is among the normally developing population. This is especially true in the cases of spastic quadraplegic and hemiplegic cerebral palsy. Generalized seizures are among the most commonly reported. Since both cerebral palsy and epilepsy are associated with lesions to the brain, under current investigation is whether identification of a specific cerebral palsy etiology may shed light on the prognosis of epilepsy. Neuroimaging methods can aid in this endeavor.
1. Control of epilepsy in children and adolescents suffering from cerebral palsy, with respect to their etiology and cerebral lesion background
INTRODUCTION: Epilepsy in children with cerebral palsy is a very important problem of public health, with a prevalence 750/1,000. AIM. To describe the relationship between cerebral palsy-etiologies and the cerebral injuries in the epilepsy control. PATIENTS AND METHODS: Retrospective study included 398 subjects, both genders, subjects under 18 years old with evidence of epilepsy related to infantile cerebral palsy (ICP). For comparison analysis purposes the entire population was studied on two principally aspects: ICP based on its etiology, and ICP based on cerebral injury background by means of computer tomography (CT). The etiology was subdivided into: hypoxic-ischemic encephalopathy (HIE), cerebral malformation (CM), and others causes (O). Cerebral lesions were classified into: diffuse cerebral injury (DCI), focal location injury (FLI), basal ganglia injury (BGI), cerebral dysgenesia (CD), hydrocephaly (H) and non-CT evidence (N). The impact of the epileptic seizures was determined according to the cerebral injury background and its etiology. RESULTS: The findings after clinical surveillance and statistical analysis were able to affirm that seizures control with respect to etiology was: HIE: 77.9%, CM: 72%, O: 86% without statistical significance (p < 0.28). We found in the cerebral lesion: DCI: 70.7 %, FLI: 82.4%, BGI: 87.5%, CD: 79.3%, H: 77.8%, N: 83.3%, statistical significance was found in these subgroups (p < 0.04). CONCLUSION: Cerebral injury in children suffering from cerebral has a prognostic reliance value in the control of epilepsy, regardless its etiology.
[Rolon-Lacarriere, O. G., Hernandez-Cruz, H., Tableros-Alcantara, C. M. & Perez-Moreno, J. C. (2006). Control of epilepsy in children and adolescents suffering from cerebral palsy, with respect to their etiology and cerebral lesion background [Spanish]. Revista de Neurologia, 43(9), 526-30.]
2. Behaviour in children with cerebral palsy with and without epilepsy
The aim of the study was to describe behavioural problems in children with cerebral palsy (CP) with and without epilepsy. The children were sampled from the Western Sweden CP register and were part of a European Union project. The Strength and Difficulties Questionnaire and questions on epilepsy were answered by one parent of each child. Medical records were reviewed. Parents of 83 children (44 males, 39 females) age range participated: 30 at Gross Motor Function Classification System levels I and II, and 53 at levels III to V; 60 had spastic age range 8 to 12 years (bilateral 42, unilateral 18) and 23 dyskinetic CP; 34 children had active epilepsy. The proportion of children with normal behaviour on the total difficulties score (TDS) of the Strength and Difficulties Questionnaire was significantly lower than normative data (57% vs 80%, p<0.001). Parents of 21 children (25%) considered their child's behaviour to be abnormal. Children with CP and epilepsy had a significantly higher median TDS (p=0.03) than seizure-free children. In children with aided or no walking ability, the TDS was significantly higher in those with epilepsy (p=0.04). Parents of 32 children (39%) considered their children's behaviour to have an impact on themselves and others. We conclude that behavioural problems are common in children with CP, and even more when epilepsy is present. Parents identify these problems, and professionals need to address them.
[Carlsson, M., Olsson, I., Hagberg, G. & Beckung, E. (2008). Behaviour in children with cerebral palsy with and without epilepsy. Developmental Medicine and Child Neurology, 50(10), 784-9.]
3. Epilepsy in children with cerebral palsy
The incidence of epilepsy in 110 patients with cerebral palsy (the majority with spastic tetraplegia) was 46,4%. Almost half of the patients with spastic tetraplegia (45%) and hemiplegia (52%) had epilepsy. The incidence was lower in patients with spastic diplegia (32%). Half of epilepsy in spastic hemiplegia were partial seizures and the other half consisted of generalized seizures, while generalized tonic-clonic episodes predominated in all other forms of C.P. A high incidence of West syndrome was observed in patients with spastic tetraplegia. Etiological factors of C.P. were perinatal in 75%. 16,65% had neonatal antecedents of convulsions; most of them had spastic tetraplegia (75%) and a significant mental retardation. A low intelligence quotient (I.Q.) was seen in most of the children with epilepsy, and patients with tetraplegia had significantly lower intelligence quotient than other groups.
[Peduzzi, M., Defontaine, E. & Misson, J. P. (2006). Epilepsy in children with cerebral palsy [French]. Revue Medicale de Liege, 61(4), 237-9.]
4. Epilepsy in patients with cerebral palsy
The incidence of epilepsy in 323 patients with cerebral palsy (CP) was 41.8%. Almost half of the patients with spastic tetraplegia and hemiplegia had epilepsy. The incidence was lower in patients with spastic diplegia. No sex differences were observed. Partial seizures were by far the most common form of epilepsy in spastic hemiplegia, while generalized tonic-clonic episodes predominated in all other forms of CP. A very high incidence of West syndrome was observed in patients with spastic tetraplegia. Most of the patients with spastic tetraplegia had their first seizure in the first year of life. In patients with spastic hemiplegia the onset of epilepsy was often delayed for several years. A high rate of polytherapy was recorded, but two-thirds of the patients remained seizure-free for long periods. In just over one-fifth of the patients successful withdrawal of medication was achieved.
[Hadjipanayis, A., Hadjichristodoulou, C. & Youroukos, S. (1997). Epilepsy in patients with cerebral palsy. Developmental Medicine and Child Neurology, 39(10), 659-63.]
5. Epilepsy in children with cerebral palsy
To study the spectrum of epilepsy in children with cerebral palsy, 105 consecutive children with cerebral palsy and active epilepsy, between 1 and 14 years of age, were studied prospectively. A detailed history and examination, electroencephalography (EEG), and computed tomography (CT) were done in all cases. The social quotient was assessed using the Vineland Social Maturity Scale. A retrospective cohort of 452 cases of cerebral palsy was studied to find the prevalence of epilepsy in cerebral palsy. A control group of 60 age-matched children with cerebral palsy but no epilepsy was also studied for comparison of the social quotient. Of the 105 children, 65 were male, 40 of 105 (38%) had a history of birth asphyxia. The mean age of onset of seizures was 18.9 months; 64 (60.95%) had seizure onset before 1 year of age. Children with myoclonic seizures (P < .05) and infantile spasms (P < .01) had seizure onset significantly early in life. Generalized seizures were the most common, followed by partial seizures, infantile spasms, and other myoclonic seizures. Seizures were controlled in 45 (58.1%) children, and polytherapy was required in 40 children. EEG and CT abnormalities were seen in 70.5% and 61% of the children. Seizure control was achieved in 74% of the patients with a normal to borderline social quotient compared with 48.7% with a social quotient less than 70. Social quotient values had a positive correlation with age of onset of seizures (P < .01) and with better control of seizures (P < .01). Of the cohort of 452 children, 160 (35.4%) had epilepsy. The maximum incidence (66%) was seen in children with spastic hemiplegia, followed by quadriplegia (42.6%) and diplegia (15.8%). Epilepsy in cerebral palsy is seen in about one third of cases; it is often severe and difficult to control particularly in children with mental retardation.
[Singhi, P., Jagirdar, S., Khandelwai, N. & Malhi, P. (2003). Epilepsy in children with cerebral palsy. Journal of Child Neurology, 18(3), 174-9.]
6. Risk factors and prognosis of epilepsy in children with cerebral palsy in north-eastern Poland
Though epilepsy occurs in 15-90% of children with cerebral palsy (CP) its clinical course is not well defined. We therefore conducted studies of 198 children with CP seen in Pediatric Neurology Department of the Medical Academy in Białystok between 1994 and, 2001. The aim was to evaluate the risk factors, incidence and prognosis of epilepsy in CP. The overall epilepsy incidence was 41.4%. Epilepsy most commonly affected children with spastic tetraplegia 65.6%. Low birth weight, neonatal seizures, seizures during the first year of life, family history of epilepsy, severity of CP and computer tomography findings were found to be related to significantly increased risk of epilepsy in children with CP in the logistic regression analysis. Intractable epilepsy occurred in 51.2%, while in spastic tetraplegia it was even higher (60%). Controlled epilepsy was observed in 83.3% of spastic diplegia and in 72.7% of spastic hemiplegia. Polytherapy was commonly used in children with spastic tetraplegia 59.5%. Partial seizures secondarily generalized, infantile spasms and Lennox-Gastaut syndrome were the most frequently observed seizures in epileptic children with CP. Epilepsy is common in children with CP and has poor prognosis.
[Kulak, W. & Sobaniec, W. (2003). Risk factors and prognosis of epilepsy in children with cerebral palsy in north-eastern Poland. Brain & Development, 25(7), 499-506.]
7. Epilepsy in children with cerebral palsy
Epilepsy occurs in 15-60% of children with cerebral palsy; however, its clinical course is not well defined. This retrospective study reviewed the prevalence, nature, and prognosis of epilepsy in cerebral palsy. Thirty-two of 85 children with cerebral palsy seen in the Neurodevelopmental Clinic in Tuen Mun Hospital between 1990 and 1995 had epilepsy. A control group of 59 epileptic children with normal neurodevelopment status was seen during the same period. Epilepsy most commonly affected patients with spastic tetraplegia and those with mental subnormality. When compared with controls, children with cerebral palsy had a higher incidence of epilepsy with onset within the first year of age (47% vs 10%), history of neonatal seizures (19% vs 3%), status epilepticus (16% vs 1.7%), polytherapy (25% vs 3%), and treatment with second-line antiepileptic drugs (31% vs 6.7%). They had a lower incidence of generalized seizures (28% vs 59%) and remaining seizure free (37% vs 90%). Factors associated with a seizure-free period of 1 year or more in epileptic children with cerebral palsy were normal intelligence, single seizure type, monotherapy, and spastic diplegia. Epilepsy was common in children with cerebral palsy. Further larger studies are required to delineate other prognostic factors.
[Kwong, K. L., Wong, S. N. & So, K. T. (1998). Epilepsy in children with cerebral palsy. Pediatric Neurology, 19(1), 31-6.]
8. Epilepsy and intrathecal baclofen therapy in children with cerebral palsy
The objective of this study was to analyze the relationship between epilepsy and intrathecal baclofen by investigating a consecutive sample of 150 children with cerebral palsy or spasticity of cerebral origin who underwent intrathecal baclofen. The medical charts of the 150 children were retrospectively reviewed. A series of 100 children with cerebral palsy, operated on other procedures, was reviewed as a control group. Forty percent of the 150 children had epilepsy before intrathecal baclofen pump implantation; 13.3% had a decrease in seizure frequency after intrathecal baclofen, while two children worsened and one child had seizures ex novo. We conclude that in children with spasticity of cerebral origin, intrathecal baclofen does not seem to aggravate or induce seizure activity.
[Buonagura, V., Scelsa, B., Curci, D., Monforte, S., Iuorno, T. & Motta, F. (2005). Epilepsy and intrathecal baclofen therapy in children with cerebral palsy. Pediatric Neurology, 33(2), 110-3.]
9. Epilepsy in children with cerebral palsy
OBJECTIVES: To study the occurrence, associated factors, nature and prognosis of seizures in children with cerebral palsy (CP). DESIGN: A prospective, descriptive, hospital-based, case-control study. SETTING: Tertiary level University Teaching Hospitals in the Al Ain Medical District, United Arab Emirates. PATIENTS: Fifty-six children with CP and seizures seen in the neurodevelopmental clinics at Al Ain and Tawam University Hospitals during the period of 1997-1999 were studied (group 1). Two control groups of 35 children with CP without seizures (group 2) and 50 children with seizures but no CP (group 3) were also studied. RESULTS: Spastic tetraplegia was the commonest type of CP associated with seizures whereas spastic diplegia was the commonest variety of CP in group 2. Most children with CP had an early onset of seizures within the first year of life as against those without CP. The children in group 1 had a higher incidence of neonatal seizures (42.9% vs. 29.4% in group 2 and 0% in group 3), presence of significant developmental delay (98.2% vs. 20.0% in group 3), occurrence of significant abnormalities on brain imaging (94.6% vs. 19.6% in group 3) and a need for use of more than 1 antiepileptic drug (66.1% vs. 30.0% in group 3). Over half of children in the study group presented with generalized tonic clonic seizures; the electroencephalogram (EEG) showed focal epileptic discharges with or without secondary generalization in 39.3%. The overall outcome of seizures in children with CP was poor needing prolonged course of anticonvulsant medications, polytherapy and higher incidence of refractory seizures and admissions for status epilepticus compared to the control group. CONCLUSIONS: Cerebral palsy is associated with a higher incidence of seizure disorders, which, in a majority, has its onset in the neonatal period; brain imaging showed abnormal pathology in most affected children, which possibly accounts for the tendency to more refractory seizures in these children.
[Gururaj, A. K., Sztriha, L., Bener, A., Dawodu, A. & Eapen, V. (2003). Epilepsy in children with cerebral palsy. Seizure, 12(2), 110-4.]
10. Epilepsy in Saudi children with cerebral palsy
OBJECTIVE: To study the clinical characteristics, electroencephalographic and computerized axial tomography profile in Saudi children with cerebral palsy who suffer epilepsy in a university referral center. METHODS: A total of 113 patients with cerebral palsy and epilepsy was seen (67 boys, 46 girls) with an over all mean age 5.3 years (range.2-12 years) during the study period (January 1998 - December 1999). They all had clinical evaluation and standardized electroencephalographic studies interpreted by the same examiner. RESULTS: The main clinical features were language delay (61%), hypotonia (45%), hypertonia (38%), and behavioral abnormalities (41%). Seizure types included generalized in 96 (85%), and partial and complex partial with or without secondary generalization in 17 (15%). None of the patients had simple partial seizures. The generalized seizures were non-convulsive in 4 patients (3.5%), tonic/clonic 73 (65%), atonic 3 (3%), myoclonic 16 (14%), and mixed 2 (2%). Inter-ictal electroencephalographic abnormalities were epileptiform activity, generalized in 65 (57.5%) and focal 18 (16%), slow-wave activity in 58 (51%) and hypsarrythmia pattern in 6 (5%). Only 9 patients had normal electroencephalogram. The cranial computerized tomography findings were normal in 11.5%. The main abnormalities were cerebral atrophy (65%), hydrocephalus (8%) and agenesis of the corpus callosum (8%). CONCLUSION: The pattern of seizure type in patients with cerebral palsy and types of electroencephalogram abnormalities electroencephalogram and cranial computerized tomography are comparable to the results from studies in other clinical settings and environments.
[Al-Sulaiman, A. A. (2001). Epilepsy in Saudi children with cerebral palsy. Saudi Medical Journal, 22(1), 19-21.]
11. Epilepsy in patients with cerebral palsy--analysis of frequency and clinical prognosis
This study was designed to investigate the incidence and prognosis of epilepsy in 109 patients with cerebral palsy and to attempt to correlate these clinical data with the type of palsy. The incidence of epilepsy, the onset of age and the type of first seizure were associated with the regions affected by palsy. A good association exists between tetraplegia and age-dependent epileptic encephalopathy. In patients with cerebral cortical lesions demonstrated by radiological examination, the incidence of epilepsy was significantly increased. The prognosis of epilepsy is not related to the type of palsy. In spastic palsy, the patients with epilepsy showed more severe intellectual disabilities.
[Sugiura, C., Shiota, M., Ieshima, A. & Ohno, K. (2003). Epilepsy in patients with cerebral palsy--analysis of frequency and clinical prognosis [Japanese]. No To Hattatsu. Brain and Development, 35(6), 478-83.]
12. Epilepsy in children with cerebral palsy
This was a prospective analytical study done from October '99 through December 2000 to observe the clinical profile of epilepsy in children with cerebral palsy. Sixty epileptic children with cerebral palsy were studied and their results were compared with the results of epilepsy in 30 developmentally normal children. Ages of all children studied were 1-15 years. Majority were below five years of age and male out numbered female. Spastic quadriplegia (60%) was the commonest type of cerebral palsy. Generalized tonic-clonic seizure (66%) was the commonest seizure type in both groups. Second most common type of seizure was partial (13%) and myoclonic (29%) in developmentally normal and cerebral palsy children respectively. Mental retardation (63%) and speech delay (58%) were the two common associated problems in cerebral palsy patients. Ventriculomegaly (55%) was the commonest computed tomographic findings in cerebral palsy patients. In electro encephalography generalized epileptiform activity was the commonest finding in both groups. Clinical pattern is different in many ways when epilepsy is associated with cerebral palsy.
[Rahman, M. M., Akhter, S. & Karim, B. A. (2004). Epilepsy in children with cerebral palsy. Mymensingh Medical Journal: MMJ, 13(1), 67-70.]
13. Clinical and aetiological aspects of epilepsy in children with cerebral palsy
The aims of this retrospective and population-based study were to describe the frequency and characteristics of epilepsy in 146 children (82 males and 64 females) with cerebral palsy (CP) born from 1987 to 1994 in the Göteborg area of Sweden. The frequency of epilepsy was found to be 38% (55 children). All children with tetraplegic CP and about one-third of the children with other CP types developed epilepsy. Age at onset of epilepsy varied with type of CP: children with tetraplegic CP tended to have an earlier onset of epilepsy than children with other CP types. Partial seizures were the most common seizure type; all children with hemiplegic CP had partial seizures. Children with cognitive impairment had a higher frequency of epilepsy than those without cognitive impairment. CP aetiology may predict the development and outcome of epilepsy, as children with CP caused by CNS malformation, CNS infection, and grey matter damage all showed a higher frequency of epilepsy than children with CP of other aetiology, and also had less chance of becoming seizure-free.
[Carlsson, M., Hagberg, G. & Olsson, I. (2003). Clinical and aetiological aspects of epilepsy in children with cerebral palsy. Developmental Medicine and Child Neurology, 45(6), 371-6.]
14. Epilepsy in children with cerebral palsy
This article deals with the clinical profile of children with cerebral palsy and epilepsy, and to study the clinical predictors of response to anti-epileptic drugs. It is a prospective hospital based follow-up study. All the children who presented with cerebral palsy and history of seizure (other than neonatal seizures) over a period of one year were included. Seizures were classified according to ILAE classification. An EEG was obtained in all cases. Neuroimaging was done in all patients. Eighty-five patients were studied and followed for minimum of 12 months. Perinatal factors accounted for 62 (72.3%) cases. The motor deficits seen were quadriparesis (n = 64), hemiplegia (n = 12) and diplegia (n = 9). Associated mental retardation was seen in 80.9% patients with quadriparesis. A predominance of generalised epilepsy was seen with generalised tonic clonic seizures (32.9%) followed by mycolonic seizures (30.6%) and localisation related epilepsy (24.7%). The patients with quadriparesis were more likely to have generalised epilepsy and 52.4% of them required two or more anti-epileptic drugs for control of seizures. Patients with hemiplegia had localisation related epilepsy in 83.3% of cases. On multivariate analysis presence of quadriparesis, microcephaly, mental retardation and myoclonic epilepsy were found to predict the poor response to AED. Epilepsy in patients with cerebral palsy is of severe nature and difficult to control. Presence of quadriparesis, mental retardation and myoclonic seizures was predictive of poor response to anti-epileptic drugs.
[Aneja, S., Ahuja, B., Taluja, V. & Bhatia, V. K. (2001). Epilepsy in children with cerebral palsy. Indian Journal of Pediatrics, 68(2), 111-5.]