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BRIEF COMMUNICATIONS: K. A. McVicar, K. Ballaban-Gil, I. Rapin, S. L. Moshé, and S. Shinnar Epileptiform EEG abnormalities in children with language regression Neurology 2005; 65: 129-131 [Abstract] [Full text] [PDF]

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Epileptiform EEG abnormalities in children with language regression

Ingrid E. Scheffer, Bronwyn Parry-Fielder, Saul A Mullen, and Kerryn Saunders   (22 May 2006)

Reply from the editorialist

Edwin Trevathan   (22 May 2006)

Reply from the author

Kathryn A. McVicar   (22 May 2006)

Epileptiform EEG abnormalities in children with language regression 22 May 2006
Ingrid E. Scheffer, University of Melbourne, Royal Children's Hospital Austin Health, Heidelberg 3081, Australia, Bronwyn Parry-Fielder, Saul A Mullen, and Kerryn Saunders Send Correspondence to journal: Re: Epileptiform EEG abnormalities in children with language regression scheffer{at}unimelb.edu.au Ingrid E. Scheffer, et al.	The value of the sleep EEG in language disorders is a controversial topic in pediatic epileptology. The arguments were recently fueled by the data of McVicar et al [1] and the accompanying editorial by Trevethan which criticized the utility of this test in children with autistic regression in addition to language regression.[2] This interpretation of the data is already transforming clinical practice in some centers but may not be appropriate. While the McVicar study showed the yield of epileptiform abnormalities in children with isolated language regression (56%) was higher than that in those with language regression associated with autistic regression (28%), the latter finding should not be discounted. The two boys with autism subsequently had Landau-Kleffner syndrome showing that at least 2 of 105 patients had a diagnostic sleep study with treatment implications influencing outcome; this is not dissimilar from the yield of many other diagnostic investigations. Concerning the other 28% of children with language regression in the context of autistic regression, the significance of this finding is uncertain. It was unclear how frequently discharges occurred nor whether bilaterally synchronous activity was prevalent in sleep. The finding of epileptiform activity in children with autistic regression may be informing us about etiology but, just as importantly, could highlight children whose outcome may be modified by antiepileptic medication such as traditional anticonvulsants or steroids. While many believe that treatment is never of value, good studies are lacking and the possibility of an important treatable subset, in addition to rare cases with florid continuous spike wave in sleep, has not been ruled out. More information is needed before we can be dogmatic about the utility of sleep EEG studies in autistic regression. This is a separate argument from the conclusion drawn by McVicar et al that the language regression group is distinct from the autistic-language regression group rather than forming a spectrum as previously thought. Once the etiologies of these disorders are understood, then this question can be definitively answered. Trevathan dismisses the utility of sleep EEG in autistic regression because of the low yield compared with language regression. It can be argued that even a low pick up in children with severe autism may be worthwhile and treatment could affect their outcome. The concern is the conclusion regarding the lack of utility of the EEG in the autistic regression group – it is simply a matter of interpretation – is the cup half full or half empty? References 1. McVicar, KA, Ballaban-Gil, K, Rapin, I, Moshé, Shinnar, S. Epileptiform EEG abnormalities in children with language regression. Neurology 2005; 65:129-131. 2.Trevathan, E. To sleep, perchance to speak. The search for epileptic language regression. Neurology 2005; 65: 11-12. Disclosure: The authors report no conflicts of interest.
Reply from the editorialist 22 May 2006
Edwin Trevathan, Washington University in St. Louis 660 South Euclid Avenue, Campus Box 8111, St. Louis, MO 63110-1093 Send Correspondence to journal: Re: Reply from the editorialist Trevathan{at}WUSTL.EDU Edwin Trevathan	Dr. Scheffer et al incorrectly state that I “dismissed” the utility of all-night EEG among children with autistic regression. In my editorial [2] that accompanied the article by McVicar et al, [1] I stated that “It is unlikely that early referral of children with autistic regression will result in the diagnosis of a treatable epileptic encephalopathy, but prospective studies of children referred early in the course of language regression with autistic regression for all-night EEG studies are needed to resolve this issue." [2] This statement is consistent with the data reported by McVicar et al [1] and with our experience. I agree with Scheffer et al that additional studies are indicated. However, if Dr. Scheffer and her colleagues are suggesting that mass screening of children with autistic regression with all-night EEG is currently indicated as part of routine medical care, then I disagree. Screening all children with autistic regression for acquired epileptic aphasia with 24- hour EEG has a low yield has not been shown to improve outcomes. If 24- hour EEG screening of young children with autistic regression is proven to lead to effective treatment, then I’ll join Dr. Scheffer and her colleagues as a supporter of 24-hour EEG as a screening tool for these children. Meanwhile, pediatricians and neurologists should use judgment in the selection of children for 24-hour EEG studies in search of acquired epileptic aphasia. Children with autistic regression plus a history of clinical seizures have higher odds of having electrographic evidence of acquired epileptic aphasia and they may be better candidates for all-night EEG-video monitoring. Children with isolated language regression who do not have associated autistic features are more likely to have electrographic evidence of acquired epileptic aphasia; early screening of all children with isolated language regression using all- night EEG-video monitoring may be indicated based upon currently available data. Disclosure: The author reports no conflicts of interest.
Reply from the author 22 May 2006
Kathryn A. McVicar, Albert Einstein College of Medicine Montefiore Medical Center, Hoff 1 EEG, 111 East 210th Street, Bronx, NY 10467 Send Correspondence to journal: Re: Reply from the author kmcvicar1{at}optonline.net Kathryn A. McVicar	Controversy has continued to surround the question of whether or not language regression occurs on a spectrum or not. The spectrum of language regression includes those with and without autistic regression. Our paper is a retrospective chart review of the experience of a single epilepsy center. It is premature to suggest that clinical practice be altered as a result of this study alone. This study attempted to characterize the clinical and electroencephalographic phenotype of language regression [1]. Our findings suggest two clinical phenotypes. The questions raised by Scheffer et al concerning the specific electroencephalographic findings in children with autistic regression and their laterality are of interest. This study was not designed to address this concern specifically. We are able to state only that language regression in isolation and language regression in the setting of a more global autistic regression are different in terms of age of onset, seizure frequency and electroencephalographic findings. This suggests differences in etiology but retrospective chart review clearly has limitations. Preliminary work from an ongoing prospective study of these children suggests that the presence of brain endothelial antibodies in children with language regression has a much higher frequency [3] than has been previously reported for children with autism. [4,5] There is no difference between the frequency in those with language regression in isolation compared with those with language regression in the setting of autistic regression. Further research needs to be done. In the meantime, while new research raises provocative questions, one should be cautious about changing current clinical evaluation and treatment paradigms as a result of preliminary data based on retrospective reviews, no matter how interesting the results. References 3. McVicar KA, Valicenti-McDermott MR, Moshé SL, Shinnar S. Brain Endothelial Antibodies in Children with Language Regression. Scientific Abstract Listing and Annual Meeting Information, American Academy of Neurology. 2006:58. 4. Connolly AM, Chez MG, Pestronk A, et al. Serum autoantibodies to brain in Landau-Kleffner variant, autism, and other neurologic disorders. J Pediatr. 1999 May;134:607-13. 5. Connolly AM, Chez M, Streif EM, et al. Brain-derived neurotrophic factor and autoantibodies to neural antigens in sera of children with autistic spectrum disorders, Landau-Kleffner syndrome, and epilepsy. Biol Psychiatry. 2006 Feb 15;59:354-63. Epub 2005 Sep 21. Disclosure: The author reports no conflicts of interest.