Khartoum Medical Journal (2010) Vol. 03, No. 02, pp. 444 - 447
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The profile of childhood epilepsy in Sudan Inaam N Mohammed1*, Maha Abdel Moneim2,Ahlam A. Rahman1 1Department of Paediatrics and Child Health, Faculty of Medicine, University of Khartoum, Khartoum. 2 Soba University Hospital, Khartoum
Abstract Objective:The objective of this study was to highlight the spectrum of childhood epilepsy in Sudan. Methods: This retrospective hospital based study was carried out over a two year period at the pediatric epilepsy clinic at Saad Abu Al Ellah University Hospital. All records of patients were reviewed and information including detailed history, clinical examination, investigation and management were tabulated. The types of epilepsy were classified according to ILEA classification. Results:The study included 109 males and 73 females.The mean age at onset of seizures was [3.48(+ 1.337 years.Eighty seven patients (47.8%) were classified as generalized epilepsy of whom 58 (31.8%) had generalized tonic clonic seizures, followed by myoclonic 15(08.2%) and absent seizures 08(04.4%).Eighty one patients (44.5%) were classified as focal epilepsy of whom the most common subtype was focal evolving into generalized seizures comprising 36(19.8%) patients, followed by complex focal 31(17.0%) and simple focal 14(07.7%) cases.Fourteen patients (7.7%) were classified as specific epilepsy syndromes of whom the commonest were West syndrome 6 (03.72%). Conclusion: The spectrum of seizure and the peak age of presentation in early childhood are comparable to those described in the literature. *Corresponding author: Department of Pediatrics and Child Health, Faculty of Medicine, University of Khartoum, PO Box 102 Khartoum, Sudan
[email protected]. Introduction There are about 50 million people with epilepsy worldwide, of whom about two-thirds are children, with the majority presenting during infancy or early childhood (1,2). The frequency of the disease, coupled with difficulties in classification, therapeutic management of patients and the myths attached to the condition in various cultures makes it a major public health problem. Little is known about the situation of childhood epilepsy in Sudan. In 1978-1979 Younis estimated the prevalence of childhood epilepsy in Khartoum as 0.9/1000 (3). A recent study was carried out in Southern Sudan by Perenchio et al, the generalized tonic clonic seizure was the commonest type,however it included both children and adultsand no diagnostic investigations were performed(4).The aim of the present study was to highlight the spectrum of childhood epilepsy in Sudan.
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24 hours apart(5). Generalized seizure: A seizure whose initial semilogy indicates, or is consistent with more than minimal involvement of both cerebral hemispheres.(5) Focal seizure:A seizure whose initial semiology indicates, or is consistent with initial activation of only part of one cerebral hemisphere.5 Epilepsy syndrome: A complex of signs and symptoms that define a unique epilepsy condition(6)
Study design: This was a descriptive, retrospective hospital based study.
Study area The study was conducted at the paediatric epilepsy clinic at Saad Abu Al Ellah University Hospital which is one of Khartoum University Teaching Hospitals. It was the first epilepsy clinic devoted to children with epilepsy and other neurodisabilities in Khartoum State. It was established in 2007 by the authors. The clinic is run once weekly, covering around 30-40 patients perclinic. The patients attending the clinic are mostly referred from other hospitals and clinics within Khartoum for seizure control. A small proportion of patients from outside the capital are also seen.
Definitions: • Epilepsy was diagnosed if the patient had two or more unprovoked seizures occurring more than
Study population Inclusion Criteria: This study included all patients with active epilepsy within the age range from 2
Patients and Methods
Inaam N Mohammed, Maha Abdel Moneim, Ahlam A. Rahman
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months to 18 years, recruited over a period of 2 years (1st Jan 2008 – 30th December 2009). Exclusion criteria: • Incomplete data. • Age less than two months Sample size: A total of 182 children were fulfilling the criteria for the study. Method: The records of all these patients were reviewed and information including; the Sociodemographic data, history, clinical examination, investigations and management were tabulated. All patients had EEGs which were reported by different adult neurophysiologists. EEG findings were considered as abnormal if there were interictal or ictal epileptiform discharges and/or the presence of abnormal background activity with focal or generalized slow waves, abnormal for the age and state of the child. The patients were classified using International League Against Epilepsy classification (ILAE 1981, 1989) into: (a) generalized epilepsy, which included myoclonic seizures, absence seizures,atonic, generalized tonic–clonic, clonic and tonic seizures; (b) partial epilepsy, which included simple or complex partial seizures, or secondarily generalized seizures; and (c) unclassifiable seizures, which were atypical or those in which the patients were not sure whether they were focal or generalized in presentation. Infantile spasms, early infantile myoclonic encephalopathy, Lennox–Gastaut syndrome, and Landau–Kleffner syndrome were separately classified as specific epilepsy syndromes, taking into consideration the specific form of seizure presentation and the associated characteristic EEG patterns. Data analysis: The data were analyzed using SPSS software for windows version 13.0. Results The study included 109 males and 73females with a male to female ratio of 1.5:1. The mean age at seizure onset was [3.48 (+ 1.337)] years. Eighty eight (48.3%) patients were less than one year of age at the onset of epilepsy. The major types of epilepsy are shown in Table (1) the generalized seizures are slightly higher than focal seizures. Table1:Major types of epilepsy (n= 182) Types
No (%)
Generalized seizures Focal seizures Specific epilepsy syndrome Total
87(47.8) 81(44.5) 14(7.7) 182(100)
The subtypes of generalized epilepsy are shown in Table (2), the tonic clonic subtype was the commonest. The subtypes of focal epilepsy are shown in Table
(3), the commonest subtype was focal evolving into generalized and the epilepsy syndromes are shown in Table (4). Eleven patients were excluded because they proved to be non-epilepsy, 3 with breathholding attacks, 3 with psychogenic non-epileptic seizures2with hypocalcaemia, 2 with tics and one patient with night terrors. Table2;Subtypes of generalized epilepsy (n=87) Subtype Number (%) Tonic-clonic 58 (66.7) Myoclonic 15 (17.2) Absence 8 (09.3) Atonic 03 (03.4) Clonic 03 (03.4) Total 87 (100.0) Table 3:Subtypes of focal epilepsy (n=81) Subtype No (%) Partial evolving into generalized 36(44.4) Complex 31(38.3) Simple 14(17.3) Total
81(100)
Table4 : Specific Epileptic Syndromes (n=14) Subtypes No (%) West Syndrome 06 (42.9) Lennox Gastaut Syndrome 05( 35.7) LandauKleffener Syndrome 02(14.3) Dravet syndrome 01( 07.1) Total 14(100) Discussion In this study, eighty eight patients (48.3%) were less than one year of age at the onset of epilepsy, with a steady decline with increasing age. This is in agreement with what had been reported from other parts of the world (7 – 9). Classification of epilepsy and epileptic syndromes is useful for proper diagnosis and helps to outline management and predict prognosis.The International League against Epilepsy (ILAE) used the seizure semiology, interictal electroencephalogram (EEG) to classify seizuresinto, Generalized, Focal, Unclassified and Others (5).However the same patient may have more than one type of seizure, either together or in sequence. Many patients’ seizures also change over the course of their illness. These problems paved the way for another system of classification-the ILAE Classification of Epilepsies and Epileptic Syndromes 1989 (6). According to this system, epilepsies are divided into four broad groups: Localization-related, Generalized, Undetermined and Special syndromes. Using ILAE classification our results were similar to that from India, China and Sweden (10-12) where the proportion of generalized seizures is slightly higher
The profile of childhood epilepsy in Sudan
than that of focal seizures. A higher proportion of generalized seizures were reported from other countries including Bangladesh, China, Kenya and Turkey.(13-16) However, studies from Vietnam, Lithuania and Japan reported a higher proportion of focal seizure (17,19). Generalized tonic-clonic seizures were the predominant subtype of generalized seizures similar to that reported by Younis and Perenchio et al (3, 4) , from Sudan and also from Ghana, Nigeria and Egypt (20-23).The commonest subtype of focal seizures in patients in this study was focal evolving into generalized seizures, this is similar to reports from Kenya (24), and however other studies from Ghana and Nigeria found that complex focal seizures were the commonest type of focal seizures (20-22).The proportion of specific epilepsy syndromes was low in our series comprising 14 (7.7%)of patientswhich is similar to the figure of 6% reported fromColombia(25), whereas Vianiet al from Italy reported a much higher figure of 27.2% (26). Conclusion The age at onset of epilepsy was less than one year in almost half of the patients. There was equal proportion of generalized and focal seizures while the noumber of the specific epilepsy syndromes was small. Acknowledgement We are grateful to all the staff of the pediatric epilepsy clinic at Saad Abu Alellah University Hospital for their cooperation. Thanks to Prof. Mohammed Ahmed Abdullah for his help and advice. References 1. Hauser WA. Epidemiology of epilepsy in children. In: Pellock JM, Dodson WE, Bourgeois BFD, eds. Pediatric Epilepsy Diagnosis and Therapy, 2nd ed.New York: Demos Medical Publishing; 2001. p. 81–96. 2. Jain S. Priority of epilepsy research in Asia. Epilepsia 2005; 46:46–7. 3. Younis Y. Epidemiology of epilepsy among school populations in Khartoum Province, Sudan. J Trop Med Hyg1983; 86:213-6. 4. Perenchio M, Caldognetto M, Makender E, Qasim S. Epilepsy in a remote area of southern Sudan. Trop Doct 2004; 34:229-30. 5. Commission on Classification and Terminology of the International League Against Epilepsy. Proposal for revised clinical and electroencephalographic classification of epileptic seizures. Epilepsia 1981; 22:489-501. 6. Commission on Classification and Terminology of the International League Against Epilepsy. Proposal for revised classification of epilepsies and epileptic syndromes. Epilepsia 1989; 30:389-99. 7. Abdul Salam A, Al-Sulaiman A, Ismail H. Clinical pattern of newly-diagnosed seizures
446
8. 9.
10.
11. 12. 13.
14. 15.
16.
17. 18. 19. 20. 21. 22. 23.
24.
in Saudi Arabia: a prospective study of 263 children. Child Nerv Syst 1999; 15:468-71. Cowan Ld, Bodenstiener J, Levinton A, Doherty L. Prevalence of epilepsies in children and adolescents. Epilepsia 1989;30:94-106. Kramer U, Nevo Y, Neufeld M, Fatal A, Leitner Y, Harel S. Epidemiology of epilepsy in childhood: a cohort of 440 consecutive patients. Pediatr Neurol. 1998; 18:46-50. Shah KN, Rajadhyaksha SB, ShahNS, Desai VG. Experience withthe International League Against Epilepsy. Classifications of epilepticsei zures (1981) and epilepsies and epileptic syndromes (1989) in epileptic children in a developing country. Epilepsia 1992; 33:1072-7. Kwong K, Chak W, Wong S, So K. Epidemiology of childhood epilepsy in a cohort of 309 Chinese children. Pediatr Neurol 2001; 24:276-82. Larsson K, Eeg-Olofsson O. A population based study of epilepsy in children from a Swedish county. Eur J Paediatr Neurol 2006; 10:107-13. Banu S, Khan N, Hossain M, Jahan A, Parveen M, Rahman N, et al. Profile of childhood epilepsy in Bangladesh. Dev Med Child Neurol 2003 Jul; 45(7):477-82. Wong V. Study of seizure and epilepsy in Chinese children in Hong Kong: period prevalence and patterns. J Child Neurol 2004; 19:19-25. Mung’ala-Odera V, White S, Meehan R, , et al. Prevalence, incidence and risk factors of epilepsy in older children in rural Kenya. Seizure 2008; 17:396-404. Serdaroğlu A, Ozkan S, Aydin K, Gücüyener K, Tezcan S, Aycan S. Prevalence of epilepsy in Turkish children between the ages of 0 and 16 years. J Child Neurol2004; 19:271-74. Shirasaka Y, Hinh lD, Minh P, Sato W. Causes of childhood epilepsy in Vietnam: cases in BachMaiHospital. Pediatr Int 2007; 49:584-88. Endziniene M, Pauza V, Miseviciene I. Prevalence of childhood epilepsy in Kaunas, Lithuania. Brain Dev1997; 19:379-87. Oka E. Childhood epilepsy in Okayama Prefecture, Japan--a neuroepidemiological study. No To Hattatsu2002; 34:95-102. Commey J. Neurodevelopmental problems in Ghanaian children: Part I. Convulsive disorder. West Afr J Med 1995; 14:189-93. Ogunlesi T, Ogundeyi M, Olowu A. Pattern of childhood epilepsies in Sagumu, Nigeria. Indian J Pediatr2009; 76:385-89. Ojuawo A, Joiner K. Childhood epilepsy in Ilorin, Nigeria. East Afr Med J 1997; 74:72-5. Bassili A, Omar T, Zaki A, Abdel-Fattah M, Tognoni G. Pattern of diagnostic and therapeutic care of childhood epilepsy in Alexandria, Egypt. Int J Qual Hlth Care 2002; 14:277-84. El Sharkawy G, Newton C, Hartley S. Attitudes and practices of families and health care personnel
447
Inaam N Mohammed, Maha Abdel Moneim, Ahlam A. Rahman
toward children with epilepsy in Kilifi, Kenya. Epilepsy Behav 2006; 8:201-12. 25. Eslava-Cobos J, Narino D. Experience with the International League Against Epilepsy Proposals for Classification of Epileptic Seizures and the Epilepsies and Epileptic Syndromes in a pediatric outpatient epilepsy clinic. Epilepsia1989; 30: 112-15. 26. Viani F, Beghi E, Atza MG, Gulotta MP. Classifications of epileptic syndromes. Advantages and limitations for evaluation of childhood epileptic syndromes in clinical practice. Epilepsia1988; 29:44&5.
