Tuesday, August 31, 2010

Family sleep center order form

  • Pediatric outpatient sleep study request
  • Home sleep testing for adults
  • After hours EEG request

Pediatric Sleep Diary

Please print and fill out to bring to your physician

What is a Seizure Diary?

A seizure diary is a record of when seizures occur, and what happened during the attack. These can be recorded on any diary, spreadsheet or calendar (e.g. Google or a free "Gus' Pet Wash" promotional calendar). I have offered some basic requirements for a diary and links to sites with ready-made templates for seizure diaries. I welcome recommendatons and reviews! Dr. Rotenberg, Houston TX

What to record

In their simplest form, they consist of a "count" of seizures within a day, week, or month, which will let your doctor calculate the seizure frequency. More sophisticated diaries, however, can include information about other factors as well:

http://www.epilepsy.com/seizurediary - links to a FREE iphone app for a seizure diary

http://seizurediary.org/ - Many types of diaries in pdf form. Includes forms for infantile spasms.

http://www.epilepsysociety.org.uk/AboutEpilepsy/Whatisepilepsy/Seizures/Seizurediaries From the UK a pdf formdiary

http://www.growingstrong.org/epilepsy/diary.html - A basic diary in excel form.

Nice sites sponsored by the makers of anticonvulsants -

From UCB there is a site on preparing for a physician visit. There is a detailed history form with a short diary -

From Eisai http://www.banzel.com/Support/SeizureDiary.aspx

http://www.lundbeckshare.com/pg420_seizure_diary.aspx - From Lundbeck

Monday, August 30, 2010

What is Cerebral palsy

Central nervous system


Cerebral palsy is condition, sometimes thought of as a group of disorders that can involve brain and nervous system functions such as movement, learning, hearing, seeing, and thinking.

Ther are several different types of cerebral palsy, including spastic, dyskinetic, ataxic, hypotonic, and mixed.

Alternative Names

Spastic paralysis; Paralysis - spastic; Spastic hemiplegia; Spastic diplegia; Spastic quadriplegia


Cerebral palsy is caused by injuries or abnormalities of the brain. Most of these problems occur as the baby grows in the womb, but they can happen at any time during the first 2 years of life, while the baby's brain is still developing.

In some people with cerebral palsy, parts of the brain are injured due to low levels of oxygen (hypoxia) in the area. It is not known why this occurs.

Premature infants have a slightly higher risk of developing cerebral palsy. Cerebral palsy may also occur during early infancy as a result of several conditions, including:

  • Bleeding in the brain

  • Brain infections (encephalitis, meningitis, herpes simplex infections)

  • Head injury

  • Infections in the mother during pregnancy (rubella)

  • Severe jaundice

In some cases the cause of cerebral palsy is never determined.


Symptoms of cerebral palsy can be very different between people with this group of disorders. Symptoms may:

  • Be very mild or very severe

  • Only involve one side of the body or both sides

  • Be more pronounced in either the arms or legs, or involve both the arms and legs

Symptoms are usually seen before a child is 2 years old, and sometimes begin as early as 3 months. Parents may notice that their child is delayed in reaching, and in developmental stages such as sitting, rolling, crawling, or walking.

There are several different types of cerebral palsy. Some people have a mixture of symptoms.

Symptoms of spastic cerebral palsy, the most common type, include:

  • Muscles that are very tight and do not stretch. They may tighten up even more over time.

  • Abnormal walk (gait): arms tucked in toward the sides, knees crossed or touching, legs make "scissors" movements, walk on the toes

  • Joints are tight and do not open up all the way (called joint contracture)

  • Muscle weakness or loss of movement in a group of muscles (paralysis)

  • The symptoms may affect one arm or leg, one side of the body, both legs, or both arms and legs

The following symptoms may occur in other types of cerebral palsy:

  • Abnormal movements (twisting, jerking, or writhing) of the hands, feet, arms, or legs while awake, which gets worse during periods of stress

  • Tremors

  • Unsteady gait

  • Loss of coordination

  • Floppy muscles, especially at rest, and joints that move around too much

Other brain and nervous system symptoms:

  • Decreased intelligence or learning disabilities are common, but intelligence can be normal

  • Speech problems (dysarthria)

  • Hearing or vision problems

  • Seizures

  • Pain, especially in adults (can be difficult to manage)

Eating and digestive symptoms

  • Difficulty sucking or feeding in infants, or chewing and swallowing in older children and adults

  • Problems swallowing (at all ages)

  • Vomiting or constipation

Other symptoms:

  • Increased drooling

  • Slower than normal growth

  • Irregular breathing

  • Urinary incontinence

Exams and Tests

A full neurological exam is critical. In older people, testing cognitive function is also important.

The following other tests may be performed:

  • Blood tests

  • CT scan of the head

  • Electroencephalogram (EEG)

  • Hearing screen

  • MRI of the head

  • Vision testing


There is no cure for cerebral palsy. The goal of treatment is to help the person be as independent as possible.

Treatment requires a team approach, including:

  • Primary care doctor

  • Dentist (dental check-ups are recommended around every 6 months)

  • Social worker

  • Nurses

  • Occupational, physical, and speech therapists

  • Other specialists, including a neurologist, rehabilitation physician, pulmonologist, and gastroenterologist

Treatment is based on the person's symptoms and the need to prevent complications.

Self and home care include:

  • Getting enough food and nutrition

  • Keeping the home safe

  • Performing exercises recommended by the health care providers

  • Practicing proper bowel care (stool softeners, fluids, fiber, laxatives, regular bowel habits)

  • Protecting the joints from injury

Putting the child in regular schools is recommended, unless physical disabilities or mental development makes this impossible. Special education or schooling may help.

The following may help with communication and learning:

  • Glasses

  • Hearing aids

  • Muscle and bone braces

  • Walking aids

  • Wheelchairs

Physical therapy, occupational therapy, orthopedic help, or other treatments may also be needed to help with daily activities and care.

Medications may include:

  • Anticonvulsants to prevent or reduce the frequency of seizures

  • Botulinum toxin to help with spasticity and drooling

  • Muscle relaxants (baclofen) to reduce tremors and spasticity

Surgery may be needed in some cases to:

  • Control gastroesophageal reflux

  • Cut certain nerves from the spinal cord to help with pain and spasticity

  • Place feeding tubes

  • Release joint contractures

Stress and burnout among parents and other caregivers of cerebral palsy patients is common, and should be monitored.

Support Groups

For organizations that provide support and additional information, see cerebral palsy resources.

Outlook (Prognosis)

Cerebral palsy is a lifelong disorder. Long-term care may be required. The disorder does not affect expected length of life. The amount of disability varies.

Many adults are able to live in the community, either independently or with different levels of help. In severe cases, the person may need to be placed in an institution.

Possible Complications

  • Bone thinning or osteoporosis

  • Bowel obstruction

  • Hip dislocation and arthritis in the hip joint

  • Injuries from falls

  • Joint contractures

  • Pneumonia caused by choking

  • Poor nutrition

  • Reduced communication skills (sometimes)

  • Reduced intellect (sometimes)

  • Scoliosis

  • Seizures (in about half of patients)

  • Social stigma

When to Contact a Medical Professional

Call your health care provider if symptoms of cerebral palsy develop, especially if you know that an injury occurred during birth or early infancy.


Getting the proper prenatal care may reduce the risk of some rare causes of cerebral palsy. However, dramatic improvements in care over the last 15 years have not reduced the rate of cerebral palsy. In most cases, the injury causing the disorder may not be preventable.

Pregnant mothers with certain medical conditions may need to be followed in a high-risk prenatal clinic.


Johnston MV. Encephalopathies. In: Kliegman RM, Behrman RE, Jenson HB, Stanton BF, eds. Nelson Textbook of Pediatrics. 18th ed. Philadelphia, Pa: Saunders Elsevier; 2007: chap 598.

Whelan MA. Practice parameter: diagnostic assessment of the child with cerebral palsy: report of the Quality Standards Subcommittee of the American Academy of Neurology and the Practice Committee of the Child Neurology Society. Neurology. 2004;63:1985-1986.

Reid SM, Johnstone BR, Westbury C, Rawicki B, Reddihough DS. Randomized trial of botulinum toxin injections into the salivary glands to reduce drooling in children with neurological disorders. Dev Med Child Neurol. 2008;50:123-126.

Sakzewski L, Ziviani J, Boyd R. Systematic review and meta-analysis of therapeutic management of upper-limb dysfunction in children with congenital hemiplegia. Pediatrics. 2009;123:e1111-1122.

Review Date: 9/16/2009
Reviewed By: Daniel B. Hoch, PhD, MD, Assistant Professor of Neurology, Harvard Medical School, Department of Neurology, Massachusetts General Hospital; and Neil K. Kaneshiro, MD, MHA, Clinical Assistant Professor of Pediatrics, University of Washington School of Medicine. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.

EEG (Electroencephalogram)

What It Is

An electroencephalogram (EEG) is a non-painful monitoring test used to detect abnormalities related to electrical activity of the brain. This procedure tracks and records brain wave patterns. Small metal discs with thin wires (electrodes) are placed on the scalp, and then send signals to a computer to record the results. Normal electrical activity in the brain makes a recognizable pattern. Through an EEG, doctors can look for abnormal patterns that indicate seizures and other problems.

Why It's Done

The most common reason an EEG is performed is to diagnose and monitor seizure disorders. EEGs can also help to identify causes of other problems such as sleep disorders and changes in behavior. EEGs are sometimes used to evaluate brain activity after a severe head injury or before heart or liver transplantation.


If your child is having an EEG, preparation is minimal. Your child's hair should be clean and free of oils, sprays, and conditioner to help the electrodes stick to the scalp.

Your doctor may recommend that your child stop taking certain medications before the test that can alter results.

It's often recommended that kids avoid caffeine up to 8 hours before the test. If it's necessary for your child to sleep during the EEG, the doctor will suggest ways to help make this easier including sleep deprivation.

The Procedure

An EEG can either be performed in an area near the doctor's office or at a hospital. Your child will be asked to lie on a bed or sit in a chair. The EEG technician will attach electrodes to different locations on the scalp using adhesive paste. Each electrode is connected to an amplifier and EEG recording machine.

The electrical signals from the brain are converted into wavy lines on a computer screen. Your child will be asked to lie still because movement can alter the results.

If the goal of the EEG is to mimic or produce the problem your child is experiencing, he or she may be asked to look at a bright flickering light or breathe a certain way. The health care provider performing the EEG will know your child's medical history and will be prepared for any issues that may arise during the test.

Most EEGs take about an hour to perform. If your child is required to sleep during it, the test will take longer. You might be able to stay in the room with your child, or you can step outside to a waiting area

What to Expect – No Pain, No Pain

An EEG isn't uncomfortable and patients do not feel any shocks on the scalp or elsewhere; however, having electrodes pasted to the scalp can be a little stressful for kids, as can lying still during the test.

Getting the Results

A neurologist (a doctor trained in nervous system disorders) will read and interpret the results. Though EEGs vary in complexity and duration, results are typically available in several days.


EEGs are very safe. If your child has a seizure disorder, your doctor might want to stimulate and record a seizure during the EEG. A seizure can be triggered by flashing lights or a change in breathing pattern.

Helping Your Child – Tap into their imagination

You can best ease your child through this procedure by “joining them” on an adventure of their choice. Perhaps they are going to the moon? The hair salon?

You can also help prepare your child for an EEG by explaining that the test won't be uncomfortable. You can describe the room and the equipment that will be used, and reassure your child that you'll be right there for support. Bring their favorite books or toys.

For older kids, be sure to explain the importance of keeping still while the EEG is done so it won't have to be repeated.

If You Have Questions

If you have questions about the EEG procedure, speak with your doctor. You can also talk to the EEG technician before the exam.


Sunday, August 29, 2010


J Child Neurol. 2010 Jul 20. [Epub ahead of print]

Do Patients With Absence Epilepsy Respond to Ketogenic Diets?

Groomes LB, Pyzik PL, Turner Z, Dorward JL, Goode VH, Kossoff EH.

The John M. Freeman Pediatric Epilepsy Center, The Johns Hopkins Hospital, Baltimore, MD, USA.


Dietary therapies are established as beneficial for symptomatic generalized epilepsies such as Lennox-Gastaut syndrome; however, the outcome for idiopathic generalized epilepsy has never been specifically reported. The efficacy of the ketogenic and modified Atkins diet for childhood and juvenile absence epilepsy was evaluated from both historical literature review and patients treated at Johns Hopkins Hospital. Upon review of 17 published studies in which absence epilepsy was included as a patient subpopulation, approximately 69% of 133 with clear outcomes patients who received the ketogenic diet had a >50% seizure reduction, and 34% of these patients became seizure free. At Johns Hopkins Hospital, the ketogenic diet (n = 8) and modified Atkins diet (n = 13) led to similar outcomes, with 18 (82%) having a >50% seizure reduction, of which 10 (48%) had a >90% seizure reduction and 4 (19%) were seizure free. Neither age at diet onset, number of anticonvulsants used previously, particular diet used, nor gender correlated with success.

PMID: 20647578 [PubMed - as supplied by publisher]

Thursday, August 26, 2010

Symptoms of a seizure can be subtle...
Symptoms of a Seizure

A seizure is usually defined as a sudden alteration of behavior due to a temporary change in the electrical functioning of the brain, in particular the outside rim of the brain called the cortex. Below you will find some of the symptoms people with epilepsy may experience before, during and after a seizure. Seizures can take on many different forms and seizures affect different people in different ways. It is not implied that every person with seizures will experience every symptom described below.

Seizures have a beginning, middle, and end
When an individual is aware of the beginning, it may be thought of as a warning or aura. On the other hand, an individual may not be aware of the beginning and therefore have no warning.
Sometimes, the warning or aura is not followed by any other symptoms. It may be considered a simple partial seizure by the doctor.

The middle of the seizure may take several different forms. For people who have warnings, the aura may simply continue or it may turn into a complex partial seizure or a convulsion. For those who do not have a warning, the seizure may continue as a complex partial seizure or it may evolve into a convulsion.

The end to a seizure represents a transition from the seizure back to the individual’s normal state. This period is referred to as the “post-ictal period” (an ictus is a seizure) and signifies the recovery period for the brain. It may last from seconds to minutes to hours, depending on several factors including which part(s) of the brain were affected by the seizure and whether the individual was on anti-seizure medication. If a person has a complex partial seizure or a convulsion, their level of awareness gradually improves during the post-ictal period, much like a person waking up from anesthesia after an operation. There are other symptoms that occur during the post-ictal period and are detailed below.

Please note: Below is only a partial list, some people may experience other symptoms not listed below. These lists are meant to help patients communicate with their physicians.

Early seizure symptoms (warnings)
Deja vu/ Jamais vu
Visual loss or blurring
Racing thoughts
Stomach feelings
Strange feelings
Tingling feeling
Pleasant feeling
No warning:
Sometimes seizures come with no warning
Seizure symptoms
Black out
Electric Shock Feeling
Loss of consciousness
Spacing out
Out of body experience
Visual loss or blurring
Chewing movements
Difficulty talking
Eyelid fluttering
Eyes rolling up
Falling down
Foot stomping
Hand waving
Inability to move
Lip smacking
Making sounds
Teeth clenching/grinding
Tongue biting
Twitching movements
Breathing difficulty
Heart racing
After-seizure symptoms (post-ictal)
Memory loss
Writing difficulty
Depression and sadness
Difficulty talking
Urge to urinate/defecate

If you or someone you know has the symptoms listed above -- you are not alone. Below are personal stories by people who have either experienced or witnessed seizure symptoms.


Adapated from: Schachter SC, editor. Brainstorms: epilepsy in our words. New York: Raven Press; 1993; and Schachter SC, editor.The brainstorms companion: epilepsy in our view. New York: Raven Press; 1995.
What is a Seizure

A seizure is a sudden surge of electrical activity in the brain that usually affects how a person feels or acts for a short time. Seizures are not a disease in themselves. Instead, they are a symptom of many different disorders that can affect the brain. Some seizures can hardly be noticed, while others are totally disabling.
The seizures in epilepsy may be related to a brain injury or a family tendency, but often the cause is completely unknown. The word "epilepsy" does not indicate anything about the cause or severity of the person's seizures.

If I have one seizure, does that mean I will get epilepsy?

About half of the people who have one seizure without a clear cause will have another one, usually within 6 months. You are twice as likely to have another seizure if you have a known brain injury or other type of brain abnormality. If you do have two seizures, there's about an 80% chance that you'll have more....

Suicide-Related Events in Patients Treated With Antiepileptic Drugs
Arana A, Wentworth CE, Ayuso-Mateos JL, Arellano FM N Engl J Med. 2010;363:542-551

Based on a meta-analysis of clinical trial data, use of antiepileptic drugs has previously been linked to suicidal ideation and/or behavior. Using observational data collected during clinical care of 5,130,795 patients representative of the general UK population, this study looked at the association between the use or nonuse of antiepileptic drugs and suicide-related events, which were defined as attempted or completed suicides in patients with epilepsy, depression, or bipolar disorder. ...
Adjustment using logistic regression analysis showed that the use of antiepileptic drugs was not associated with an increased risk for suicide-related events among patients with epilepsy (odds ratio [OR], 0.59; 95% CI, 0.35-0.98) or bipolar disorder (OR, 1.13; 95% CI, 0.35-3.61). However, the use of antiepileptic drugs was associated with a significantly increased risk for suicide-related events in patients with depression (OR, 1.65; 95% CI, 1.24-2.19), as well as in patients without epilepsy, depression, or bipolar disorder (OR, 2.57; 95% CI, 1.78-3.71).


From Dr. Rotenberg - This is exciting news for people who have to take anti-convulsants for epilepsy. The article did not find an association between suicide-related events and the use of anti-seizure medications. On the other hand, I would caution readers from infering that there is a protective efffect of anti-convulsant use. The odds ratio of .59 might lead one to conclude that the risk of suicide was lower and that the medications are protective. Despite the indications of this number, please recall that this is a single statistic and that the study was not designed to show this inverse relationship.