Midline Spikes in Children and Clinical Correlations
Version of Record online: 8 NOV 2002
Volume 43, Issue 11, pages 1436–1440, 2002
How to Cite
Sanders, S., Rowlinson, S., Koutroumanidis, M., Ferrie, C. D. and Panayiotopoulos, C. P. (2002), Midline Spikes in Children and Clinical Correlations. Epilepsia, 43: 1436–1440. doi: 10.1046/j.1528-1157.2002.33601_2.x
- Issue online: 8 NOV 2002
- Version of Record online: 8 NOV 2002
To the Editor:
Kutluay et al. (1) highlighted midline spikes and associated seizure semiology, a subject that has previously received little attention, as reviewed elsewhere (2). Midline spikes alone were found in 35 (0.2%) of 20,000 EEGs. These commonly occurred in children and were significantly associated with heterogeneous types of focal and generalized seizures of idiopathic (16 cases), symptomatic (13), or undetermined cause (6). Onset of seizures was mainly between ages 1 and 6 years (21 of 35 cases) (1). Midline spikes were facilitated by sleep or occasionally seen only during sleep (1).
We supplement these observations with our results from an ongoing prospective study from 1998 (3,4). At the end of the first 3 years, we had recorded 424 EEGs in 308 children aged 1–14 years; 228 (74%) had one or more epileptic seizures. All EEGs were recorded digitally, which allows optimal study of midline and other spike locations; in old paper EEGs, midline spikes are not detected in montages that do not include midline electrodes. Of 228 patients with seizures, 21 (9.2%) had at least one EEG with midline spikes alone (six, or 2.6%) or together with spikes in other, usually multiple, locations (15, or 6.6%). Midline spikes were frequently of high amplitude and in clusters but could also be small, singular, and sparse (Fig. 1). For comparison, occipital spikes alone or with other, including midline, spikes were found in 36 (16%) cases. Centrotemporal spikes alone or with other, including midline, spikes were found in 48 (21%) cases.
Five of the six patients with at least one EEG having midline spikes only had normal development. These had febrile seizures (one case), rolandic epilepsy (one), Panayiotopoulos syndrome (one), occipital and a single complex partial seizure (one), and brief seizures with loss of consciousness only (one). The only symptomatic case had generalised convulsions. In follow-up EEGs of these 6 children, none of them had only midline spikes alone (fig). Instead, midline spikes occurred together with centrotemporal, occipital or other spikes in various combinations (3 patients), disappeared but spikes were seen in other locations (1) or EEGs were normalised (2).
Significantly, of the 21 patients with midline spikes alone or in combination with other spikes, six had definite Panayiotopoulos syndrome (another four were possible cases of the same syndrome) manifesting with single or infrequent autonomic seizures, autonomic status epilepticus, or both (4,5). Conversely, midline spikes were present in 15% of patients with this syndrome (4).
Our results are generally in agreement with those of Kutluay et al. (1), but it appears that midline spikes (a) are much more frequent than previously appreciated (which is attributed to improved detection with digital EEGs); (b) usually occur together with spikes in other locations; more rarely, they occur alone, but this is not a consistent localisation in serial EEGs of the same patient; and (c) are significantly associated with benign childhood focal seizures and particularly with Panayiotopoulos syndrome.
From a practical point of view, an EEG with midline and multifocal spikes in a normal child with a single or a few seizures should raise the possibility of benign childhood seizures and particularly of Panayiotopoulos syndrome of autonomic seizures and autonomic status epilepticus (2,4,5).
- 2Benign childhood partial seizures and related epileptic syndromes. London: John Libbey, 1999: 325–9..
- 3Panayiotopoulos syndrome of early onset benign childhood seizures: EEG variability and management issues. Clin Neurophysiol 2001;112: 1269., , , et al.
- 4Panayiotopoulos syndrome: a common and benign childhood epileptic syndrome. London: John Libbey, 2002..