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Epilepsy in Children With Cerebral Palsy

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Arq Neuropsiquiatr 2001;59(1):35-39

EPILEPSY IN CHILDREN WITH CEREBRAL PALSY

Isac Bruck1, Sérgio Antônio Antoniuk1, Adriane Spessatto2,
Ricardo Schmitt de Bem3, Romeu Hausberger3, Carlos Gustavo Pacheco3

ABSTRACT - Objective: To describe the prevalence and characteristics of epilepsy in patients with cerebral
palsy in a tertiary center. Methods: a total of 100 consecutive patients with cerebral palsy were retrospectively
studied. Criteria for inclusion were follow-up period for at least 2 years. Types and incidence of epilepsy
were correlated with the different forms of cerebral palsy. Other factors associated with epilepsy such as
age of first seizure, neonatal seizures and family history of epilepsy were also analysed. Results: follow-up
ranged between 24 and 151 months (mean 57 months). The overall prevalence of epilepsy was 62%.
Incidence of epilepsy was predominant in patients with hemiplegic and tetraplegic palsies: 70.6% and
66.1%, respectively. First seizure occurred during the first year of life in 74.2% of patients with epilepsy.
Generalized and partial were the predominant types of epilepsy (61.3% and 27.4%, respectively). Thirty-
three (53.2%) of 62 patients were seizure free for at least 1 year. Neonatal seizures and family history of
epilepsy were associated with a higher incidence of epilepsy. Conclusions: epilepsy in cerebral palsy can be
predicted if seizures occur in the first year of life, in neonatal period and if there is family history of epilepsy.
KEY WORDS: epilepsy, cerebral palsy, neonatal seizures.

Epilepsia em crianças com paralisia cerebral

RESUMO - Objetivo: descrever sobre a prevalência e características da epilepsia em crianças com paralisia
cerebral atendidas num serviço terciário. Método: um total de 100 pacientes com paralisia cerebral foi
estudado retrospectivamente, tendo como critérios de inclusão o seguimento regular por pelo menos 2
anos. Os tipos e a incidência de epilepsia foram correlacionados com as diferentes formas de paralisia
cerebral. Outros fatores associados com a ocorrência de epilepsia como idade da primeira crise, crises
neonatais e história familiar de epilepsia também foram analisados. Resultados: o tempo de seguimento
variou de 24 a 151 meses (média 57 meses). A prevalência total de epilepsia foi 62%. Os pacientes com as
formas hemiplégicas e tetraplégicas de paralisia cerebral tiveram a maior incidência de epilepsia: 70,6% e
66,1%, respectivamente. A primeira crise ocorreu durante o primeiro ano de vida em 74,2% dos pacientes
com epilepsia. As epilepsias do tipo generalizada e parcial foram as predominantes (61,3% e 27,4%,
respectivamente). Trinta e três (53,2%) de 62 pacientes permaneciam há pelo menos um ano livres das
crises. Crises neonatais e história familiar de epilepsia estiveram associadas com maior incidência de epilepsia.
Conclusões: epilepsia na paralisia cerebral pode ser prevista se ocorrerem crises no primeiro ano de vida e
no período neonatal, e se existe história familiar de epilepsia.
PALAVRAS-CHAVE: epilepsia, paralisia cerebral, crises neonatais.

Cerebral palsy (CP) is a chronic disorder of move- is discussed controversially in the literature. There
ment and posture. It is the result of a non-progres- are studies showing that epilepsy varies from 12 to
sive damage of the immature nervous system caused ninety percent in children with CP7-11. Some authors
by several factors1 that have occurred in prenatal, argue that in certain types of CP occur higher rate
perinatal or postnatal periods2-5. It can manifest itself of epilepsy6 and has been seen that about one third
in several ways, mainly as spastic, athetoid and ataxic of the patients with CP exhibit seizures and this
palsies; moreover, it is one of the most common figure is proportional to the degree of motor and
causes of motor disability in children and frequently cognitive disabilities12,13.
is associated with other problems, such as mental The present study aimed to describe the preva-
retardation, sensory defects and epilepsy 6. lence and characteristics of epilepsy in a population
The significance of epilepsy in patients with CP of patients with cerebral palsy.

Center of Pediatric Neurology (CENEP) Pediatric Department Clinical Hospital, Federal University of Parana (UFPR); 1Assistant Professor;
2
Medical Resident in Pediatric Neurology; 3Academic Medicine UFPR.
Received 20 July 2000, received in final form 16 October 2000. Accepted 20 October 2000.
Dr. Isak Bruck - CENEP – Rua Floriano Essenfelder 81 - 80060-270 Curitiba PR - Brasil. Fax: (41) 264 9101 / 362 9380
36 Arq Neuropsiquiatr 2001;59(1)

METHOD RESULTS
In a retrospective study were reviewed the charts of A total of 100 patients with the diagnosis of CP
100 consecutive patients with cerebral palsy evaluated were included in this study (49 girls and 51 boys).
between 1996 and 1998 in the Pediatric Neurology Unit Ages ranged from 24 to 209 months (mean age 88,4
at Clinical Hospital of Federal University of Parana (HC- months) and the diagnosis of CP from 1 to 96 mon-
UFPR), for at least 2 years. The following data were ob-
ths (mean age 8,2 months). Followed up period
tained: gender, gestational age (prematures, matures, or
ranged from 24 to 151 months (means 57 months).
postmatures newborns), follow-up period in the service,
From them, 19 were prematures, 79 matures and
age at manifestation of CP, types of CP, its etiology (pre-
natal, perinatal, postnatal or unknown)14, its degree of
only 2 postmatures.
severity (very severe: when patients do not have any pos- As far as etiology of CP, 41 were prenatal, 37
tural control; severe: can walk with maximum support perinatal and 10 postnatal. In 12 it could not be
or, in hemiplegic patients it does not have voluntary ma- determined (Table 1). Fifty six were tetraplegic and
nual grasp; moderate: can walk with some support or most of them with very severe and severe disabilities,
when the patient globally used the paretic hand without 17 hemiplegic, 10 hypotonic, 10 mixed and 7
possibility of individual movements of the fingers and; diplegic (Table 2).
mild: can walk independently15. Mental subnormality (that Sixty nine patients had seizures, and 62 (89.9%)
was evaluate through the level of speech: aphasia, mono- of them developed epilepsy. The average age of the
syllable, disyllable, sentences; and school performance:
onset of epilepsy was 12.59 months, with the first
do not attend, special school, special classroom in regular
seizure occurring during the first year of live in
school, normal classroom in regular school16,17 and; age
74.2% of the patients.
at manifestation of epilepsy, types of epilepsy, use of
antiepileptic drugs, neonatal seizures, family history of
The incidence and the types of epilepsy in 100
seizures and findings from electroencephalogram (EEG) patients with cerebral palsy is shown in Figure 1.
and computed tomography (CT) scan of the brain. The only significant difference of incidence of
Patients were included into CP types based upon the epilepsy in the different types of CP was in spastic
classification proposed by Nelson et al.18: spastic tetra- hemiplegia when comparing with spastic diplegia
plegia (spasticity of all four limbs with involvement of since epilepsy occurred in twelve patients (70.6%)
the arms more marked than or equal to that of the legs), with spastic hemiplegia and in only two patients
spastic diplegia (spasticity of the lower extremities with
a variable but a lesser degree of involvement of the upper
limbs), spastic hemiplegia (spasticity of the arm and leg Table 1. Etiology of brain lesion causing cerebral palsy (CP)
on one side), hypotonic and mixed forms (the last one
Causes
encopass a combination of previous types, as well as
athetoid, ataxic and dystonic, due to reduce number of
Perinatal (n= 41) Hypoxia (30)
cases).
Jaundice (8)
Epilepsy was defined as the occurrence of at least two
Hypoxia + jaundice (1)
unprovoked epileptic seizures that were not diagnosed
Prematurity (1)
as neonatal or as febrile seizures19. The diagnosis was
Fetal dystocia (1)
based on history, clinical description and EEG’s findings.
Epilepsies were classified in accordance with the Prenatal (n=37) Maternal
International Classification of Epilepsies and Seizure Disor- Ingestion of alcohol (1)
ders (ILAE - 1989)20, in which are defined four main Profuse bleeding due to
categories: partial (including simple, complex and secon- incomplete abortion (2)
dary generalized), generalized (including absences, tonic, Eclampsia (4)
clonic, tonic-clonics and myoclonics), infantile spasms and Premature disruption of placenta (3)
undeterminate (when it does not fit in any of the previous Fetal placental dysfunction (15)
category). Seizure outcome was defined as good when the Infections: Cytomegalovirus (2)
patients were seizure free during the last year while using Toxoplasmosis (2)
drugs and when they did not have any relapse of seizures Rubella (1)
two years after withdrawal of antiepileptic drugs (AED). Uterus rupture (1)
Results were evaluated by means of a descriptive Fetal
method guided by the Statistic Laboratory of the Federal Malformation (6)
University of Parana, Brazil. Differences among groups
were assessed by non-parametric tests: Fisher’s Exact Test Postnatal (n=10) Meningoencephalitis (10)
or chi-square test when appropriate and using the EPI-
Indeterminate (n=12)
INFO – Version 6.0 epidemiological package21.
 Arq Neuropsiquiatr 2001;59(1) 37

Table 2. Degree of severity in different forms of cerebral palsy Table 3. Factors associated with development of epilepsy in
(CP). cerebral palsy (CP)

Types of CP Very Severe Moderate Mild Total (n) CP With CP Without

severe Epilepsy Epilepsy
n = 62 n = 38
Tetraplegic 21 15 13 7 56

Hemiplegic 0 0 9 8 17 Girl/boy 29/33 19/19 Ns

Diplegic 0 1 4 2 7 Neonatal seizures 30 3 p < 0.004

Hipotonic 2 1 4 3 10 Positive 18 1 P < 0.02

family history
Mixed 3 1 3 3 10
CT scan 48/57* 15/27** Ns
abnormalities

with spastic diplegia (p<0.03). The distribution of Ns, not significant; *48 of 57 patients with CP and epilepsy showed
computed tomographic scan abnormalities; **15 of 27 patients with CP
types of epilepsy in the different forms of CP is and without epilepsy showed computed tomographic scan abnormalities.
shown in Figure 2. History of neonatal seizures and
family history of epilepsy were correlated with a
higher prevalence of epilepsy (p<0.004 and p<0.02
respectively) (Table 3). Table 4. Relationship between mental subnormality and epilepsy
There was not apparently any relationship bet-
CP With Epilepsy CP Without Epilepsy
ween epilepsy and cognitive level; however, 38 of
Age > 59 months Age > 59 months
46 children with both epilepsy and age above 59
n = 46 n = 25
months were unable to speak and 42 of them were
placed in special schools or did not attend any type Mental subnormality
of school (Table 4). Twenty two (78.6%) of 28 chil-
Language
dren with aphasia and 15 (75%) of 20 patients who
were not attending any type of school carried the Unable to speak 38 (82.6%) 17 (68.0%) Ns
diagnosis of CP tetraplegic. Educational Establishment
Regarding response to anticonvulsant therapy,
Especial school 42 (91.3%) 21 (84.0%) Ns
control of seizures was achieved in 33 cases (53.2%)
or did not attend
and 8 of them are without any antiepileptic drug
(n=29) (Table 5). Ns, Not significant.

Fig 1. Incidence and types of epilepsy in 100 patients with cerebral palsy (CP)
38 Arq Neuropsiquiatr 2001;59(1)

Table 5. Use of antiepileptic drugs (AED) and its success in seizure

control in patients with cerebral palsy (CP).

* Patients that were still taking antiepileptic drugs at the end of this study.

Fig 2. Types of epilepsy in the different forms of cerebral palsy (CP).

complished in children with or without CP12,25,31.

DISCUSSION Niedemayer32 justified this finding saying that the
Epilepsy is one of the most prevalent neuroim- generalized epileptiform activity can be attributed
pairment in childhood and is present in 4.0 – 8.8 either to a genetic predisposition, or to a quick
per 1000 in population-based studies22. When other secondary bilateral synchronization, such as the one
neuroimpairments (i.e., mental retardation and cere- induced sometimes by a frontal focus. On rare occa-
bral palsy) are present, the proportion of epilepsy sions, deep subcortical cerebral lesion can also gene-
in these children is strikingly higher23. Although sei- rate this kind of epileptiform activity.
zures can be controlled by pharmacotherapy, epi- The presence of neonatal seizures has been a use-
lepsy remains a major cause of anxiety for the family ful marker for subsequent epilepsy in CP28. History
who had children with CP. of neonatal seizures were found in 30 (48.4%)
The patients in this sample are not necessarily patients from our population studied.
representative of the population of children and Normal CT findings were recorded in only 9 from
adolescents with CP since the HC-UFPR is a tertiary 57 patients with CP and epilepsy, but this group
institution and for this reason a great number of showed a high degree of motor impairment (2 with
patients coming to the clinic are the most severely very severe, 3 with severe and 4 with moderate
affected. motor disability) and when mental subnormality was
The literature mentioned that there is a straight evaluated all the patients were incapable to
relationship between epilepsy and degree of motor articulate words and do not attend any type of
impairment, as well as their association with mental school and when so did it in especial schools. The
retardation13,24-26. In our study this is also true, since generalized epilepsy was the predominant form in
the majority of tetraplegic patients presented these patients and only 2 were seizure free, one on
epilepsy and intellectual impairment . and the other without AED.

Approximately 74% of the children with CP had From the patients with CP and epilepsy treated
their first seizure under 12 months, which is in with antiepileptic drugs, 33 (53.2%) were free of
accordance with Zafeiriou et al.27, while is in contrast seizures, the majority of them on monotherapy.
with other studies in which the incidence is only Similar results were obtained in other studies 12,30,33.
10%28. Skatvedt34 found a remission of epilepsy in 43.5%
of 46 children with cerebral palsy after 1 year of
The incidence of epilepsy in our sample was grea- follow-up. From the 8 patients without use of antie-
ter when comparing with the literature29,30, perhaps pileptic drugs that are more than 2 years under sei-
related to the higher degree of motor and mental zures control, 6 had the generalized form of epilepsy
disabilities of the patients studied in these popu- and 5 of them had mild degree of motor impair-
lation7,28. ment. From 29 patients with epilepsy could not
The predominant form of epilepsy was genera- achieved a good control, 18 (62.1%) were on poly-
lized, what is in accordance with some studies ac- therapy.
 Arq Neuropsiquiatr 2001;59(1) 39

In this study the majority of patients had a severe 14. Diament A. Encefalopatias crônicas na infância (Paralisia Cerebral).
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