Apnoeic attacks as an isolated manifestation of epileptic seizures in infants

doi:10.1016/S1090-3798(98)80018-4

European Journal of Paediatric Neurology

Volume 2, Issue 4, 1998, Pages 187-191

https://doi.org/10.1016/S1090-3798(98)80018-4 Get rights and content

Apnoea as an isolated manifestation of seizures is well described in neonates but is only occasionally observed in infants. We present data from four infants, with apnoea as the sole manifestation of seizures, documented by polygraphic ictal electroencephalogram (EEG) and video recording. The four infants, after normal pregnancy and delivery at term, showed the first apnoea at the age of 2–11 months. The interictal EEG was normal. The ictal EEG and video recording showed in all infants a focal rhythmic alpha or theta activity with or without generalization, which lasted 40–120 seconds. The apnoea appeared a few seconds after the beginning of rhythmic activity and the heart rate remained unchanged during the apnoea. At 2 years' follow-up, three children are seizure-free under anti-epileptic therapy with normal psychomotor development in two, and a slight delay in the third infant. The fourth child has partial seizures and is severely retarded.

References (14)

HashimotoT et al.
A case of lissencephaly (agyria) syndrome with apnea: polygraphic study
Brain Dev
(1984)
SanmartiFX et al.
Episodes d'apnée chez un nourisson: formes inhabituelles de crises comitiales
Rev EEG Neurophysiol
(1985)
KameiA et al.
A case of infantile spasms: epileptic apnea as partial seizures at onset
Brain Dev
(1996)
KellyD et al.
Astrocytoma in an infant with prolonged apnea
Pediatrics
(1980)
WatanabeK et al.
Seizures with apnea in children
Pediatrics
(1982)
CoulterDL
Partial seizures with apnea and bradycardia
Arch Neurol
(1984)
DavisJM et al.
Apnea and seizures
Arch Dis Child
(1986)

There are more references available in the full text version of this article.

Cited by (27)

Subtle temporal lobe epilepsy with headache as the major complaint: What can we learn from the long-delayed diagnosis?
2013, Seizure
Infantile Ictal apneas in a child with Williams-Beuren syndrome
2013, Pediatric Neurology
Citation Excerpt :
This case report emphasizes the importance of prolonged video EEG monitoring in the evaluation of suspected ictal apnea. A review of the literature found three case series, each describing four or more infants presenting with apneic episodes found to be coincident with, and preceded by, epileptiform activity on EEG [6-8]. Of the 20 total infants described in these case series, 14 had normal interictal EEG results.
Williams-Beuren syndrome is a genetic disorder rarely associated with seizures. The few described cases of Williams-Beuren syndrome and epilepsy have primarily involved infantile spasms and deletions extending beyond the common deletion region for this disorder. We present the case of a 5-week-old child with ictal apneas and typical Williams-Beuren syndrome deletion. Diagnosis was challenging, because the child had cardiac, respiratory, and gastrointestinal abnormalities typically associated with Williams-Beuren syndrome, which are also associated with cyanotic episodes. The results of interictal electroencephalography were normal, illustrating that prolonged electroencephalography is often essential in evaluation of suspected ictal apneas. Seizure freedom was achieved with carbamazepine. Sudden death is seen in Williams-Beuren syndrome, and this case raises the question whether some of these cases may be related to ictal apneas and could potentially be preventable with appropriate pharmaceutical intervention.
The Grocery Store Blues: Recognizing a Toxic Syndrome When History Fails
2012, Clinical Pediatric Emergency Medicine
Citation Excerpt :
Patients may experience shallow breathing patterns during these times. Apnea as the sole presenting feature of seizure is rare but has been reported in infants.6 Increased intracranial pressure (ICP) may lead to altered mental status and an irregular Cheyne-Stokes breathing pattern that can include periods of apnea or hypopnea.
Altered mental status and decreased respiratory effort are potentially life-threatening symptoms that encompass a wide variety of etiologies including toxic ingestions. We report a case of methadone toxicity in a 34-month-old girl with Noonan syndrome who presented to the emergency department with episodes of altered mental status, bradypnea/apnea, and miosis. Initial history and comprehensive evaluation including urine drug screen did not reveal a diagnosis; however, response to naloxone indicated that her presentation was likely caused by opioid toxicity. This diagnosis was later confirmed with toxicologic testing, which demonstrated an elevated serum methadone concentration. This case illustrates the need for a high index of suspicion for ingestions in children presenting with altered mental status and respiratory depression without an obvious pulmonary or central nervous system cause as well as the importance of recognizing a toxidrome, despite a lack of history of a toxic exposure.
Effects of acetazolamide on epileptic apnea in migrating partial seizures in infancy
2011, Epilepsy Research
Citation Excerpt :
Apnea as a manifestation of epileptic seizures is also observed in patients with localization-related epilepsy (Watanabe et al., 1982; Akaike et al., 2008). This type of seizure can appear during sleep or wakefulness, can necessitate resuscitation and can also be lethal (Ramelli et al., 1998), and has been assumed to be partly responsible for sudden unexpected death in epilepsy. Within these seizures, ictal activity usually consists of rhythmic focal alpha to theta activity originating in the temporal lobes (Watanabe et al., 1982).
We report two cases of migrating partial seizures in infancy complicated with intractable epileptic apnea with severe desaturation. Ictal electroencephalography revealed migrating foci of epileptiform discharges, which spread to bilateral temporal areas resulting in the onset of apnea. Magnetoencephalography detected dipole sources at bilateral perisylvian areas. Single photon emission tomography revealed a significant ictal change in perfusion at bilateral anterior temporal lobes in one patient. Addition of acetazolamide to the regimen resulted in complete disappearance of epileptic seizures.
Epileptic Apnea in a Trisomy 18 Infant
2010, Pediatric Neurology
Citation Excerpt :
Consequently, a misdiagnosis of the cause of apnea can be harmful to infants with epileptic apnea. Several reports suggested that during apneic spells, an unchanged heart rate, as in our patient, indicates epileptic apnea, whereas the occurrence of bradycardia indicates nonepileptic apnea [15]. However, an exceptional case of bradycardia occurring during epileptic apnea was also reported [9].
Trisomy 18 is frequently associated with neurologic abnormalities, including hypotonia in infancy, mental retardation, central apnea, and epilepsy. Although central apnea and epilepsy are common complications in children with trisomy 18, epileptic apnea in these children was not previously reported. We describe an infant with trisomy 18 who developed epileptic apnea. Her apneic episodes began at age 10 months, occurring in clusters over several days each month. According to ictal electroencephalogram, interictal [¹¹C] flumazenil-positron emission tomography, and [¹⁸F] fluorodeoxyglucose-positron emission tomography, the apneic episodes represented complex partial seizures (autonomic seizures), probably originating in the left frontotemporal area, probably related to cortical microdysgenesis. The condition was successfully treated with zonisamide. In infants with trisomy 18, differentiation of epileptic apnea from central apnea is crucial, because medications used to treat central apnea, including caffeine and theophylline, can be harmful to children with epileptic apnea.
Apnoea in relation to neonatal temporal lobe haemorrhage
2009, European Journal of Paediatric Neurology
Six term newborns presented with apnoea and temporal lobe haemorrhage.
In this observational study, we described involvement of the limbic system in apnoeic term newborns with temporal lobe injury.
Six term newborns presented to the neonatal care unit with apnoea within the first 2 days of life. Ultrasound (US) and MRI of the brain were obtained in the first week of life.
Apnoea was related to temporal lobe haemorrhage in all. During apnoeic periods four had focal epileptic activity on EEG. All lesions were detected first with US. On MRI, haemorrhages were located in the parenchyma, the subdural and/or subarachnoid space. Three haemorrhages were surrounded by infarction in the temporal lobe. In three infants hippocampus and mesial temporal cortex were affected. In two basal temporal cortex only was involved. Vascular anomalies were excluded by MRA, serial MRI or serial US with Doppler imaging.
Term infants with seizure associated apnoea may present with haemorrhage and/or infarction to hippocampus, mesial and basal temporal cortex. This study supports the existence and possible disruption of descending influences from the temporal cortex and/or amygdala on brainstem breathing centres in the term newborn.

View all citing articles on Scopus

View full text

Original articleApnoeic attacks as an isolated manifestation of epileptic seizures in infants

Brain Dev

Rev EEG Neurophysiol

Brain Dev

Astrocytoma in an infant with prolonged apnea

Pediatrics

Seizures with apnea in children

Pediatrics

Partial seizures with apnea and bradycardia

Arch Neurol

Apnea and seizures

Arch Dis Child

Original article
Apnoeic attacks as an isolated manifestation of epileptic seizures in infants