Chapters Transcript Video Common Childhood Epilepsy Syndromes, and Some Unique Ones Too Thank you, Maria. Welcome, everybody. Um, I've been with UCSF Pediatric Neurology for about 8 years. Prior to that, I was in private practice. So I understand the value of lunch hour and so I do appreciate you guys joining me today. Um, I'm going to be talking about epilepsy. Which is something that we commonly see in our practice. Um, I wanted to share some common syndrome as well as some unique interesting ones. So hopefully, um, you will enjoy this and we'll also talk about some logistics things as well. So I'm gonna go ahead and share my talk to. Here we go. OK. So just a note, my first name is Virgina, not Virginia, which I do get a lot. Um, I will share my email at the end. Um, if you email me, make sure that you don't get that to include that extra I, otherwise, I will not be responding to you. OK, I have nothing to disclose. OK, today's objectives, as I discussed earlier, we'll talk about some common epilepsy types. We'll talk about how to differentiate between seizures and their mimics. We'll talk about how to um use our diagnostic tools, um, and also briefly discuss epilepsy comorbidities. First, I think it's important to know a definition of epilepsy. Um, it is considered two or more unprovoked seizures more than 24 hours apart. Um, there's also an alternative definition is if you have one unprovoked seizure and an abnormal EEG. Now, there is a caveat to that. Um, we do know that children, for example, on the autism spectrum or even ADHD can by themselves have abnormal EEG. So, it's typically more um considered for children who are otherwise neurotypical and had their first um um Provoke seizure, then EEG may be beneficial. Um, to show that, I do wanna share a website, um, that is epilepsy prediction tool that can give you an idea of when a person presented with first-time seizure, what is the risk for having epilepsy. So I'm gonna go ahead and stop share this. And then go to the website that I wanna share with you. This is developed by Um, University of Netherlands. Um, it's helpful for me because it also has, um, risk stratification for when we stop seizure medication for individuals who've gone through epilepsy surgery. But for a purpose of our talk, I do wanna share this with you. Before, um, first consultation. So we're gonna use an example of a 10 year old boy who had bilateral shaking, jerking movements, stiffening tonic posturing, so that's a generalized tonic-clonic seizure. No lateralization, no weakness, no automatism, neuro neurotypical. Um, and let's say the EEG came back normal, and your risk of epilepsy is 13%. If we were to go back and just change one thing, Which is the EEG abnormality, let's say it's generalized epileptic-form discharges that increase your risk to 87%. Um, so, when a child with a first-time seizure and everything else being normal, the EEG may be helpful, um, if it's abnormal. If it's normal, it actually does not rule out, um, diagnosis of epilepsy. I'm gonna go ahead and stop sharing that and then go back to my slides. Bear with me here. OK. So what are some provoking factors? You know, very commonly known fever, as we know, children who have febrile seizures are most commonly present as 6 months to 6 years. Um, sometimes fever can, um, lower seizure threshold for those who have epilepsy. Um, but this definition is, um, what are some of the seizures that provoked and not considered epilepsy. Metabolic disturbances, low, high sodium, calcium, for example, head injury, inflammation, infection of the brain, or structural changes such as from stroke or hemorrhages. Those can also be con you know, kids can have seizures based on that and they don't have a definition of epilepsy. OK, let's dive into um common um important um seizure types, you know, for children, infantile spasms. I do think things have really changed in the last 10 years. Um, I think a lot of pediatricians are a lot more aware of infantile spasms, a lot of parents are more aware of infantile spasms, and so we do tend to get now more referrals for funny baby movements to rule out infantile spasm, which is important and the right thing to do because it is Developmental emergency. And when this happens, the earlier we recognize, the earlier we treat, um, the prognosis is better. Um, they typically happen between 3 to 8 months of age. They, the, the, um, how it looks, it's, it's like a startle reflex without being startled. Um, I do wanna again share um a video so that you are familiar with what it looks like. Let me just go here. This is from the um tuberculosis um Alliance website. But we have to make it so tell me. To see, you know, very sudden extension of the arms, um, flexion of the abdomen. That's a, that's another very classic example. And the reason I I share the EEG background here is to really just highlight the chaotic nature during an infantile spasm. You have all the leads having very high amplitude, very disorganized EEG and um if you turn this, this image upside down, it looks pretty much the same. So it's just all out of chaos. So, um, typically we do see this when the child hooked up to EEG during an infantile spasm. And in between spasms, they can also be very highly disorganized background as well. Um, infantile spasms typically are very frequent, and they can even occur up to, you know, 30, 40s, even 100 during the day. And they tend to cluster, um, meaning they can have several or more within a very short period of time. As you can see from the videos before, the babies may or may not be distressed. Sometimes they just, it just happens and then they just, you know, go on as if nothing has happened. But sometimes the babies do cry. Um, and so that alone is not um helpful, but it's really the, the semiology, how sort of the sudden onset movement and repetitiveness of it. Um, it can happen in any children, but I do think that it is important to think about this as a higher prevalence in children who are, who have trisomy 21 or tuberculosis complex. Um, because of that, it is often helpful for me when I see babies with seizures, particularly infantile spasms, to really check their skin and, and check for any birthmarks that may give us a clue as to the underlying etiology. As I mentioned earlier, prognosis is better um if we don't have any genetic um component to it, and if we caught it early and treat early. See if I can move on to the next slide. OK. The next common childhood epilepsy is childhood epsons epilepsy. This typically happens between the age 4 to 8 years of age, um, typically disappear by about mid-adolescence. However, about 10% of children with childhood epsons epilepsy can develop generalized tonic-clonic seizure. This EEG, it's um intended to share with you the 3 Hz, 3 little spikes within a second um during um an absence seizure. Now, I'm sure many of you have gotten this question, um, probably more than I have, you know, Johnny loves to just stare in space, when I call his name, he doesn't answer. So how do we know whether Johnny is having absence seizures or not? And the clue again is the frequency and the context. Similar to infantile spasm, epsilon's epilepsy do tend to be very frequent, um, and, um, they can happen in more than one context. So if mom notices it and then school notices it, um, they are unable to be distracted, um, and they can happen when they're walking, they happen when they're in the middle of a conversation. Um, a note about distractibility, you know, when you and I daydream, sometimes we don't. Really answer to anybody calling your names and that's normal um for these kids though typically what I would say what I would ask parents to do is clap really loud in front of their face as if to startle them and see if you get that startle reaction try even blowing air in their eyes and see if they sort of flicker and sort of move away and then lastly um maybe a slight pinch rather than just sort of shaking their shoulders and see if they respond we need a little bit more of a trigger to really know. Um, whether or not they can be, um, pulled out of it. Cause I definitely have patients who, um, have, have, have some seizures and no one necessarily noticed them. And, you know, when we do think about doing EEG to, to look at how their seizure burden is, if no one is there to challenge them, it's also really hard to know whether or not they're having seizures as well. So, more vigorous distractibility techniques is needed to try to tease out whether or not every scare is a seizure or not. The other thing that I think is really cool is when we think about absence seizures, they can actually be triggered by hyperventilation. We do that as part of our EEG, but that's something that you can do at your office as well. What I usually do is I take a tissue paper, I put it in front of me, and then I blow it slowly. The reason for the tissue paper is that it gives the kids some a goal to really move the tissue paper, and then I can actually see that they're actually doing the right way. You can do this for about 3 minutes. Majority of the time with very typical childhood absence epilepsy, I tend to trigger seizures within 1 minute or 2 minutes. And then you have your diagnosis. So, if childhood absence epilepsy is something that is benign, that we know children outgrow, a lot of times parents do ask me, why do I wanna give my kid daily medication to prevent that? And a few reasons, because when they're having seizures, particularly during this very important learning period, then they do lose attention that they're not learning well. Um, and so that's a major reason why we do want to start medication on kids with childhood sons epilepsy. Another reason is injury prevention. I've definitely had many of my patients who do have the absence seizures while they're walking on the street. And imagine if they're swimming, if they're, you know, riding their bike, um, it's important to, from an injury prevention, uh, perspective. We do have a few very effective anti-seizure medications for Epsilon's epilepsy. Ethosepsima is the most common because it does have the lowest side effect profile. However, it does not prevent generalized tonic-clonic seizures. It is still my first line for childhood epsilons epilepsy. If the child develops a generalized tonic-clonic, then we switch to a seizure medication that is more broad spectrum. Moving on to the next one is juvenile myoclonic epilepsy. This typically begins at older age, in your middle school or high school age. Um, and unlike childhood absence epilepsy, juvenile myoclonic epilepsy is considered lifelong. Um, and they do need to maintain on medication. Um, however, they are very, um, manageable with just one anti-seizure medication. Um, it actually encompasses three types of seizures, myoclonic, generalized tonic clonic seizures, and absence. I here show an EEG of a myoclonic seizure. Do you want to share a video, um, with you guys, um, with a myoclonic seizure? Cause I think sometimes it's hard to describe it and ask the question whether that someone is having that type of seizure or not. Wait 1 2nd. And here this patient is connected to EEG. Here's a muscle myoclonic seizure, very brief, very short. Now look at when they're using their hand, objects do fall out because of the twitching. That's the last video I'm gonna show you guys. We're gonna continue on our PowerPoint from now on. Apologize for the constant going back and forth. I'm losing my space. There we go. OK. OK. So, um, the, the myoclonus seizure, um, can be bilateral, can be just one side of the body as well, and they typically happen in the morning. So one thing I ask, um, when I screen patients for myoclonic seizure is when you wake up in the morning and you're brushing your teeth or combing your hair, does the object just fly out of your hand? Um, that is a more, um, indicative of an involuntary movement. Cause if you ask teenagers whether they have shaking, majority of them will say yes. Um, now, we, I mentioned this earlier, um, some children with childhood epsilons epilepsy can evolve over time, develop, um, generalized tonic-clonic seizure, and their epsilons may continue, they may develop myoclonic seizures, so they can change from childhood epsilons epilepsy to juvenile myoclonic epilepsy. Um, and the question is very common, in particular when it comes to teenager, is whether or not driving is allowed. An epilepsy diagnosis does not necessarily preclude someone from driving. You just have to show the DMV that you have good seizure control, and you have no seizures for more than 6 months. And those are typically referring to generalized chronic chronic seizures where you lose consciousness or excellence because you're not physically aware. Um, for a person with juvenile myoclonic epilepsy, if their primary seizure type is myoclonic seizure, um, it is OK for them to drive. According to California law. OK. Um, the next one that is also common, um, which also has a good prognosis, um, has many, many names. Um, the most, uh, historical name is benign rolandic epilepsy. Every few years or so, epileptologists from all over the world get together and decide to change names for epilepsy syndromes that have been known for a while. And so it's something that we do have to keep up with. Um, but I do think this title makes sense because it does really, it's a very descriptive term, self-limiting epilepsy with central temporal spikes. I've included um an EEG picture of where the central temporal spikes are. Typically it's more um one-sided, but it can be bilateral. Um, this type of seizure typically happens in sleep or during transition from sleep to wake cycle. The person who has a seizure may actually know that something is going on. They may have some twitching of the face or drooling because they have trouble with oral motor movements, um, and they're aware that this is happening. Typically, it's they, if, if they have time, they may try to alert their parents or caregiver that something is going on, and then they secondarily generalize this to a full body convulsion. Now, sometimes the The initial part of the seizure, the facial twitching can be very short and not recognized by anybody cause most likely other family members are sleeping and all we see is just a generalized honey-clonic seizure. Because of that, I typically do ask with um the, the, the patients if they're, if they are um aware that there are any prodrome, any, any feeling or symptoms before they have a seizure. And sometimes I get, oh yeah, I was trying to get my dad and mom, but I just couldn't make it. And so um that uh is something that is important to look for. Typically, it's around 7 to 9, um, and, and, um, we don't we don't tend to treat because As the, as the um diagnosis name implied, it is self-limiting. Majority of children will have less than 10 lifelong seizures, and many of them do happen around sleep-wake cycle. So no medications um are indicated. Um, this is a pretty fun one, and I, as a neurologist, cannot spell panattopolis. I always have to, um, look it up. But as I said earlier, the epileptologists gathered around and decided that we should call this self-limiting epilepsy with autonomic seizures. So this is sort of going beyond your full body convulsions or just staring. Um, these are autonomic seizures. Um, luckily, this is also very benign, um, and this usually happens in kids who are in preschool, um, and maybe a few years older, um, but they're very self-limiting. Um, they look pale. They vomit. Um, they may or may not have some visual symptoms. They could lose their vision transiently or they could be seeing stars or shapes, um, but they are typically aware that's happening, um, whether or not they can speak, um, that it's, um, some, some kids do and some kids don't. Um, but you, you know, this is something very different. Um, then the other symptom, uh, epilepsy syndromes that we talked about. And I know that many of you have seen kids with vomiting. There's AGE all year round. But this is really episodic vomiting without diarrhea, without any other illnesses. These are very distinct episodes. Again, they are very self-limiting, and we generally don't put kids on seizure medications. Um, once in a while, if these episodes are long, then we do give them rescue medicine to stop them sooner. OK. A few more um to discuss. Um, Dravet syndrome is SCN1A epileptic encephalopathy. Um, SCN1A is a sodium channel um mutation. Um, these kids tend to start having seizures before 7 months of age, um, and their seizures can be triggered by fevers, vaccines, even hot showers. They can quickly have more than 5 total seizures, sometimes And even present as status epilepticus. Um, they do tend to lose development whether their seizures are good control or not. Although there is a wide spectrum. Um, we definitely have children at CM1A who are still able to go to school, maybe slightly low IQ, um, some that are quite devastated and unable to walk or need assistance with all ADLs. So the spectrum is quite, quite wide, um, but their seizures are typically really hard to control. Um, it's important to note that, um, this is the, the sodium channel um blockers are actually contraindicated, particularly in, you know, um, acute setting like status epilepticus. Um, we are actually not able to use bentoin, um, because they can actually make the seizure worse because it does, um, work on sodium channel and SCM1A is a sodium channel. Um, your EEG is, it's generally non-specific. MRI is typically normal cause this is not a structural, um, lesion. Um, but we do need genetic testing to find the SCN1A mutation. Um, we generally use, uh, either gene DX or epilepsy panel. Um, they include many common epilepsy, um, known epilepsy triggering, um, genes, um, and we do find that to be helpful if we have a high probability of an epileptic, um, uh, genetic epilepsy syndrome. OK. Sunflower syndrome, um, it's, it's a type of seizure that happens around age 2 to 8, and the interesting thing is, the child would want to actually raise their hand, put it around a light source, and then wave their hand back and forth as if to create a phenomenon of um light and dark contrast, um, similar to sort of um photic stimulation. So it is a type of photosensitive epilepsy. These type of children do have to the flashing lights in movies that they do sometimes um show a warning sign, you know, any concerts, any, you know, light exhibition that, you know, specific frequency could potentially trigger seizures. Um, what is interesting about this case is it's, there's still controversy as to whether the hand waving, um, maneuver itself is epileptic or not. There have been studies showing that, you know, the EEG is changing about a second before this hand started waving. So, um, tend to think that that is actually part of the epilepsy syndrome. Um, although kids will, you know, it seems like they're voluntarily doing it and there might be some sort of, um, uh, like OCD component to it. Um, this type of epilepsy, unfortunately, is pretty hard to treat. They don't generally really respond to medications. Um, there have been some, um, suggestion that some light tinted glasses may help, um, but overall, seizure burden tends to be high. Yeah, um, this one, Landau-Klaffner, um, syndrome is worth mentioning because these are typically normally developing kids, and then until about 3 to 6, they start to lose language. Um, whereas in contrast, you know, with our, um, children with autism, typically they do have regression, but more than one developmental domain, and that typically Happens slightly younger, you know, our typical autism kid presentation about 18 months or even before 2. This group of um patients is older and again it's really just primarily language that is regressed, um, otherwise they're fine. An EEG can show just continuous epilepsy, epileptic discharges throughout sleep. Um, the reason I put that brain picture there is one of the. Treatment is actually spell um resection. So if you cut the peel sort of trans transectionally, um, that could tend to be um a cure. It's pretty dramatic, but it's, it's still shown to be helpful. Um, so I just wanted to really highlight Landau-Kleipner versus um autism because we do get a lot of referrals and, and, you know, some neurologists still screen every single child with autism with an EEG and see if they These are the continuous epileptic form discharges and, and treat that way. Um, but a lot of times, and studies have panned out, um, you know, pretty consistent with, you know, that EEG abnormality in autism is just sort of part of the autism. Um, although autism children do tend to have a high risk for epilepsy, but, you know, we don't generally just do EEG on children autism. Um, unless there's a high suspicion for epileptic seizures. OK. So I wanna move on to talking about um seizure mimics, um, cause I'm sure that this is quite common in general pediatric setting. Um, when I think about seizure, these are things that I also think about, you know, stereotopy or the most typical one is hand flapping in children on the spectrum, although it can also happen in neurotypical children. These are sort of, um, self-stimulating. There's, um, almost like a, a voluntary movement compared to seizures that are not voluntary. Um, breath holding spells, as many of you are familiar, they can lead to seizure if you hold your breath long enough. Sometimes kids do go into a convulsion, um, but they are not considered part of epilepsy. We do get a lot of convulsive syncope, um, and then the next slide or show we'll talk about sort of how to tease those out a little bit more, um, but, you know, when I hear about, um, you know, Sammy getting up too quickly and then get dizzy and then pass out and then shake, and, you know, that may not always be um epilepsy. So the history, um, is, um, important to tease those out. And we'll talk about that in just a minute. Parasomnia, that is, you know, your sleep talking, sleepwalking, um, benign myoclonic, uh, myoclonal sleep that happens in babies as well. Um, and then paroxysmal dyskinesia are typically more sort of, uh, rhythmic movements, but also, um, dystonic posturing, sort of, you know, being stuck in a certain position. Um, that is a movement disorder rather than um epilepsy. And then you have your functional neurological disorder, which used to be called conversion disorder, or in the setting up seizure, um, pseudo-seizures or non-epileptic spells. Um, those are definitely also on the differential. OK. So, um, when it comes to history, as I alluded to earlier, just simply saying shaking is not enough, um, right? I, I would like to know more about what they mean by shaking. Um, you know, for example, when a baby has a, uh, has chills and fevers, they're also shaking too. So typically I would say, can you demonstrate to me what the sha looks like. Is there rhythmic, is there rhythm to it? Is it symmetric? Is it just one side shaking? Is it the entire body shaking? Can you suppress it? If you push on, if you put your hand on the child, does that shaking stops, right? Is it triggered by something, right? And so these are more sort of detailed, um, important questions to help us differentiate uh epileptic seizures versus not. I always ask about the eyes, even with febrile seizures. I'm, I'm so trained to always ask about are the eyes open or closed? Are they looking at a specific direction? Typically, if a focal seizures involving the frontal eye fields, your eyes will tend to move to the opposite side of where the seizures are, and then your head is also turned to one side. And it's typically pretty fixated and then you're unable to really redirect the gaze or the head direction. Um, versus in, um, in FNT or functional neurological disorder or used to be called pseudo seizures, typically the eyes are closed and they're sort of squinted shut. Um, and so it's hard to imagine epileptic seizures with your eyes just really squinted shut because you actually need control, more voluntary movements for that. Um, ask about what happens immediately after. Um, are they confused? Are they sort of immediately bounced back? There are definitely epilepsy syndrome where kids have a seizure and then they immediately bounce back. For example, childhood absence epilepsy does not have, um, any postsicktal period versus if you had a generalized convulsion, you can be postsicktal. You're gonna be in a sort of slowly, um, confused or sleepy state for even up to 24 hours. Um, the other key question is, are they stereotypical? Does it look exactly the same each time? Um, there are a few epilepsy syndrome where kids can have multiple different seizure types. For example, juvenile myoclonic epilepsy, right? You can have the convulsion, the myoclonic seizure, and the absom seizures. Um, but in, in otherwise healthy neurotypical Child, if I start hearing story like, oh, this one time the right hand shakes a little bit and then the other time it was the left leg. And so, um, you know, the difficulty to really localize or, or being very consistently stereotypical will make seizure diagnosis less likely. OK. We kind of talked about this earlier already, but um there are um things there, there are limited things that we can really do uh in terms of diagnostic evaluation. But the most common ones we talked about, you know, hyperventilation at in clinic, during EEG, um, MRI is typically not very helpful because epilepsy is an electrical abnormality, not a structural abnormality majority of the time. However, if we do EEG and we do find more focal epileptic, epilepsy focus, um, then the MRI would be helpful. Um, we often have to, uh, think about other considerations such as the age of the child. At, um, at UCSF we, um, have, um, we don't have open MRI. It's a closed MRI, um, and we often have to think about whether or not children need to be put under general anesthesia for MRI. Um, we, um, think about MRI if it's focal EEG or, um, you know, it's, it's, if it's really gonna be helpful in terms of thinking about, um, for example, epilepsy surgery. So, um, if someone who has really refractory seizures and really try multiple different medications, even if it's still generalized seizure, we could potentially do MRI or even other advanced imaging, um, to look and see whether they're surgical candidate. Um, and then EEG, there are many different types of EEG offered, um, at, uh, at UCSF. We have a routine EEG. We can also do a two-hour, um, it is important to try to capture sleep, um, in, you know, in particular some specific forms of epilepsy such as, um, the self-limiting select, uh, epilepsy with central temporal spikes. Cause some sometimes those central temporal spikes can occur um around sleep with Cycle or during sleep. And so if we do like a thirty-minute EEG on a child who no longer naps during the day, we may be missing um critical information that the EEG can provide for us. Um, we also have ambulatory EEG where patients come into our clinic to get connected, um, get wrapped up really nicely, have a little um purse that where the battery is for the EEG, um, portable machine. They go home. They come back the next day or in 2 days to get disconnected and the patologist will review the data. Um, the good thing is that we can really limit exposure to the hospital. Um, and so, um, some some families that are locally do appreciate that option. The challenge is, um, we don't have video component to that. And, um, if one of the EEG leads is off, we won't know until the ophthaltologist look at the results, and at that time, it may be too late. Um, we are, uh, improving our, um, EEG monitoring unit at, um, Banioff Hospital. Um, we are, um, extending a few more beds. Um, so the availability for overnight EEG at the hospital is definitely improving. And with that, we do have video monitoring. We have text 24 hours. If anything comes up, they can. Fix it right away. And typically, people, um, families will get a preliminary report in the, in the morning before they discharge. Um, so that there could be a plan in place, um, for that. And again, um, we have, uh, increased, uh, availability starting in July, um, for the EMU option. The challenge is, is still more insurance approval. I've definitely had Issues with um insurances requiring a just a routine EEG first um before we can move on to more prolonged monitoring. Although I've been surprised that some uh more than, more than I expected uh situations that I was able to get a more overnight EEG whether it's ambulatory or um uh uh an admission to the hospital. But EEG itself, you know, depending on how long, depending on um how compliant, um, can give you more information. But again, a normal EEG does not necessarily rule out epilepsy. It really depends on how high our pre-test probability is for seizures. OK. I wanna spend a few minutes um to talk about comorbidities. Um, when I was um reviewing literature for this talk, um, I did find that 80% of school-age children with epilepsy will have some form of comorbidities from, um, From epilepsy. So on the left, you have depression, autism, ADHD, learning disability, um, anxiety, and pseudo. And I wanna spend some time talking about those. Um, so, Uh, and a study has also found that um 40% of children with epilepsy may have 3 or more of these comorbidities. Um, ADHD is quite common. It's about 20 to 30% of children with epilepsy will have ADHD. And I just really want to emphasize that um stimulants are not contraindicated. So if you have a child with epilepsy on medication, you can still start Even, you know, alpha 2 agonist. The only medication, and that's why I put it there, that we have to be careful is Wellbutrin because greater than 300 mg daily can lower your seizure threshold. And I have had kids where that did um trigger more seizures. So other than that, your um medications, your SSRI SNRI, they're all safe and sometimes really important for children who have um epilepsy. Um, and what I do find interesting is that with the mood disorders such as depression and anxiety, sometimes they tend to happen even before the onset of epilepsy. Um, you know, I've had a few teenagers where they came to see me for first on first time seizure, but You know, they've already been um struggling with anxiety. And so, uh definitely something that we do see um commonly and, and I think in general, just maybe the recognition um that, you know, thoughts um anxiety and depression are quite common um in, in, in children. Um, and so, you know, it's something definitely that we want to look at and screen for and um with my stable epilepsy patient, I often still ask about whether or not they have any mood, um, uh, disorders or um any issues going on with their mental health. If if you think about it, it's actually a, um, it's, it's very anxiety provoking to have epilepsy because you never know, truly know when you have another seizure. By definition, seizures are unpredictable. So that alone can definitely be very anxiety provoking and can be socially isolating as well. Um, and so, it's, it's understandable. That's something that we want to also focus on treating. Um, that, um, I, I spoke a little bit about autism before. Um, I think about autism and epilepsy and intellectual disability are are sort of equal parts in the Venn diagram. They are all sort of, um, comorbidities of each other, um, and so, um. A lot of times, my patients with autism and epilepsy, define epilepsy, um, and, and, and, you know, confirmed epilepsy, I should say, um, not sort of, you know, a lot of spacing out. I'm not sure whether they're seizures or not. Um, but they, they do need a lot of, of support. Um, and then I also just wanna spend a few minutes talking about Sudep. It stands for sudden unexplained death in epilepsy. Um, and, and that's something really scary because, um, you can't recover from that. And so there's a lot of vigorous research going on, um, identifying the risk factors and understanding pseudap a little bit more. Um, there's some theory into as to that, um, the sudden death could be caused by arrhythmia, um. And or um suffocation because, you know, someone may have a seizure while laying down prone and not recognized um you know, in the middle of the night until the next morning. Um, so that's also a theory. What we do know about um increased risk factors for pseudap are um patients who have very intractable epilepsy. Those who have frequent Generalized tonic-clonic seizures, um, that are very intractable, so more than, you know, being on two or more seizure medications that are still having very frequent seizures, um, those tend to be the one that we worry most about pseudo. Um, And, um, and the, and the uh prevalence is about 0.22 per 1000 patient years. So, it's, it's uh it's a very small group, but it's definitely something that many parents um do worry about. Um, and a um comment about sort of how we approach that is um there are um devices that are available for seizure monitoring. Um, they can be found on Danny Did Foundation website, um, but they are all, they're not FDA approved. Some of them are FDA cleared, and they're generally helpful for convulsions. So they basically detect heart rate, um, and also movement. So, um, Irregular movement, uh, you know, more than expected. And so, they are good at detecting full body convulsions because those are unusual movements. However, if there are children who are just really restless in their sleep, um, they are gonna get a lot of false positive. Um, and so sometimes I recommend maybe just even a baby monitor so that, you know, parents can Listen to noises, can listen to, um, you know, other sounds that are made, um, rather than these devices. But, you know, in, in patients who I worry about lots of seizures, worry about missing seizures, and for example, I'm titrating the medication, but yet they're still sometimes these devices um do have a role in, in helping family to identify seizures, um, and to be able to count seizures more accurately. Um, so, Those are all my uh information. Here's my um email here. Um, if you guys have questions after, I'm happy to respond via email. Um, and I have some references here that I'm gonna go back so um my email address is available. Thank you for your attention. Created by
