Population study of benign rolandic epilepsy:
Is treatment needed?

We thank Verrotti et al for their comments. BECT is indeed a complicated disorder and the diagnosis is not straightforward in many cases. We only included children with typical findings to avoid the ambiguities mentioned by Verrotti. We apologize that the short text permitted for a "Brief Communication" did not allow us to emphasize this properly. Therefore, our findings apply to children with typical BECT and should be applied cautiously to a wider spectrum of patients – nonetheless, children with typical BECT certainly outnumber those with major atypical features. So our conclusions can be applied to most children with BECT.

We are aware that it is possible to measure a transient cognitive deficit at the time of interictal EEG spike discharge in BECT. We are not aware of any study that has demonstrated in BECT that treatment with AEDs improves cognitive function. A randomized trial with cognitive ability as an outcome measure is needed before treatment recommendations can be based on this indication. After all, AEDs may have cognitive side effects that last all day and are not restricted to the tiny fraction of the day occupied by spike discharge in typical BECT.

We don't doubt the heterogeneity of BECT. The point of our paper is that in typical cases, AED treatment is OFTEN not necessary. Treatment decisions can be individualized.

We read with great interest the article by Peters et al [1] about benign rolandic epilepsy (BECT); the authors reported their experience on 79 children suffering with this type of epilepsy; forty-three of 79 children were treated with different antiepileptic drugs while 36 were not treated. The authors conclude that anticonvulsant therapy is not necessary because all patients achieved the expected remission. Despite the fact that, by definition, this type of epilepsy is considered a benign situation, recently atypical evolution have been repeatedly recognised. In some large studies, the percentage of atypical features (including diurnal seizures, screaming as a seizure component, aura and Todd's paralysis) ranged from 10 to 50%. [2, 3, 4]. Our experience [5], in agreement with these authors, suggests that among patients with atypical BECT a small proportion might have learning disabilities and/or behavioral disturbances. In fact, it seems a little strange to us that Peters et al. did not observe any atypical case.

It is important to remember that, at the present time, there are no established clinical signs or EEG pattern useful to identify, at the onset of seizures, the patients who will show an atypical course of disease. Moreover, the real frequency of these atypical features is still unknown. Nevertheless, although children with BECT have a normal cognitive function and behavior, it is increasingly suggested that transient cognitive impairment may accompany interictal spike discharges, especially when they are frequent; for example, a small series of children with BECT showed a trend toward higher error rate in short-term memory tests for trials that had accompanying EEG discharges [6]. It is possible that also in typical form of BECT, a high number of seizures might play an important role in the development of mild cognitive impairment and/or behavior disturbances.

Probably, BECT is a heterogeneous condition, which includes a large spectrum of clinical features, and there are no clear criteria for the definition of benignity of this type of epilepsy. Therefore, we suggest that the decision to treat these children must take into consideration these aspects.

References:

1.Peters JM, Camfield CS, Camfield PR. Population study of benign rolandic epilepsy: is treatment needed? Neurology 2001; 57: 537-539.

2.Bouma PAD, Bovenkerk AC, Westendorp RGJ, Brouwer OF. The course of benign partial epilepsy of childhood with centrotemporal spikes: a meta- analysis. Neurology 1997; 48: 430-437.

3.Fejerman N, Caraballo R, Tenembaum S. Atypical evolutions of benign -localization-related epilepsies in children: are they predictable? Epilepsia 2000; 4: 380-390.

4.Wirrel EC, Camfield PR, Gordon KE, Dooley JM, Camfield CS. Benign rolandic epilepsy: atypical features are very common. J Child Neurol 1995; 10: 455-458.

5.Verrotti A, Latini G, Trotta D, Giannuzzi R, Cutarella R, Morgese G, Chiarelli F. Typical and atypical rolandic epilepsy in childhood: a long term follow-up study. Pediatr Neurol 2002; 26: 26-29.

6.Binnie CD, Marston D. Cognitive correlates of interictal discharges. Epilepsia 1992; 33: s11-s17.