[Exacerbation of tonicoclonic seizures in a juvenile myoclonic epileptic taking lamotrigine]. / Accentuation des crises tonico-cloniques sous lamotrigine dans l'épilepsie myoclonique juvénile.

INTRODUCTION: Lamotrigine is an anti-epileptic drug considered as a first-line therapy in idiopathic generalised epilepsy. Lamotrigine is well-tolerated and secondary aggravation of epileptic syndromes has rarely been reported. CASE REPORT: We report the case of a 19 year-old man with juvenile myoclonic epilepsy in whom lamotrigine lead to the exacerbation of generalised tonico-clonic seizures, reversible when lamotrigine was stopped and substituted by valproic acid. CONCLUSION: Lamotrogine may induce exacerbation of generalised tonico-clonic seizures and myoclonic jerks in juvenile myoclonic epilepsy.

Sleep organization in children at risk for sudden infant death syndrome.

The organization of sleep was studied in four groups of 6-month-old babies: monitored near-miss babies (NM), monitored siblings (HR), nonmonitored siblings (LR), and siblings considered at low risk but monitored because of marked parental anxiety (PA). It was studied using the method of cumulated occurrences and orthogonal polynomial fitting introduced for the analysis of sleep by Gaillard and Martinoli in 1976. No monitoring effect was found. We also found no difference between the groups when the usual sleep scores were used. However, differences were found with the polynomial adjustment method: there was more quiet sleep stage 3 in NM than in any other group. There was less waking state and more paradoxical sleep at the end of the night in PA and NM than in HR or LR babies. This suggests that the differences may not be related so much to real risk as to parental comportment.

Delta, theta, alpha and beta power spectrum of sleep electroencephalogram in infants aged two to eleven months.

Automatic sleep EEG analysis was performed on infants from 2 to 11 months of age. Partial power spectra of delta, theta, alpha, and beta 1 bands were studied as function of sleep stages, age, and time of the night. beta 1, alpha, and delta power spectra are significantly lower in paradoxical sleep (PS) than in quiet sleep (QS) whatever the age; but theta is lower in PS than in QS only after 5 months of age. delta, theta, and alpha power increase with age in QS. Only delta and theta are greater in the first half of the night than in the second half. beta 1 power does not differ significantly in stages 2 and 3 of QS, during the course of the night or as a function of age. Thus delta, theta, alpha may be the best spectral parameters for the maturation of quiet sleep EEGs during the first year of life.

[Evolution of gross body movements during sleep in healthy infants aged from 1 to 4 months]. / Evolution des mouvements corporels globaux au cours du sommeil chez des nourrissons témoins, âgés de 1 à 4 mois.

To assess the evolution of body motility according to sleep states and age in young children, we performed day-sleep polygraphic recordings in 45 normal and full-term newborn infants, grouped according to age: 5 to 7 weeks, 9 to 11 weeks, 13 to 15 weeks of age. Generalized gross body movements were only studied. Our results showed that generalized movements varied according to sleep states and also according to age. The number of movements, in each age-group was significantly higher in active (AS) and indeterminate (IS) sleep than in quiet sleep (QS). This work also found that the distribution of the number of movements differed between sleep states. In AS, movements were equally distributed whereas in quiet sleep 40% of movements occurred during the last three minutes of a stage. Our results also showed that the mean number of movements per sleep hour, the mean duration of body movements and the percentage of time spent with movements significantly decreased with age. The distribution of the number of movements as a function of duration, showed that most of them lasted from 5 to 10 sec in each age-group of infants, whatever the sleep state; however, the number of the longest movements, lasting more than 10 sec, significantly decreased with age in IS and AS. These results were difficult to compare with those already published in the literature because of the different techniques for recording body movements; so it seemed impossible to use normal values established by other authors.

[Automatic analysis of sleep-wake states during the first year of life]. / Apport de l'analyse automatique des états veille-sommeil au cours de la première année de la vie.

Automatic analysis on infant sleep tracing was first considered as an aid to the rapid construction of hypnograms. It has long been thought more complicated than in adults, because of the significant changes in electrogenesis during the first year of life, resulting in difficulty to adapt to the criteria of Rechtschaffen and Kales (1968), even if modified, or to those of Anders et al (1971). In fact, these studies have shown that automatic analysis of sleep EEG tracings permit an easier analysis of the changes in electrogenesis according to subject age, sleep stage and time of night. Moreover, automatic analysis of parameters which change with the sleep-wake stages shows the continuity of these changes, and therefore the somewhat arbitrary nature of conventional hypnogram classification. The mathematical treatment of this information facilitates their visualisation, and permits a better analysis of circadian and ultradian variations that could scarcely be formalized by classical hypnogram analysis. In the study of maturation occurring during the first months of life, automatic signal processing will require adaptation that will lead to new forms of reasoning.

[The frequency of respiratory variations during daytime and nighttime sleep in 35 normal 2-month-old infants]. / Variations de la fréquence respiratoire au cours du sommeil de jour et de nuit chez 35 nourrissons normaux âgés de 2 mois.

Daytime and nighttime polygraphic recordings were made of 35 normal 2-month-old infants. Respiratory rate was calculated every minute in active (AS) and quiet (QS) sleep states. The study indicates a difference in mean rate between the 2 states and also shows that mean respiratory rate was lower at night than during the day (P less than 0.0001 for both states) and that there was a marked increase in rate during the first cycle. Infants with episodes of periodic breathing had a lower mean respiratory rate throughout the recordings. For each QS phase, both day and night, a marked decrease in mean respiratory rate occurred, especially during the first part of the sleep state, which was not found in AS. Intrasleep spontaneous awakening led to a marked increase in respiratory rate after sleep was resumed both in QS and AS. However, differences were only statistically significant when the awakened infant was fed. There was less difference between respiratory rates after spontaneous awakening without feeding since the pre-awakening rate was more elevated than when the infant was subsequently fed.

Positive temporal sharp waves in electroencephalograms of the premature newborn.

Positive temporal sharp waves (PTS) were studied in electroencephalograms (EEG) of 92 premature infants born either at 31 and 32 weeks of gestational age, recorded during the first week of life. The infants were assigned either to a reference group (asymptomatic) or to one of three pathologic groups (neonatal asphyxia, hypoglycemia or hypocalcemia, or periventricular leukomalacia with rolandic positive sharp waves). Regardless of the group, no significant differences in PTS criteria (morphology, frequency, amplitude, duration and lateralization) were found between 31- and 32-week infants. The PTS observed in 55% of the asymptomatic infants were characterized by low frequency (0.13 +/- 0.12/min), a mean amplitude of 109.8 +/- 25.8 microV and a mean duration of 148.7 +/- 35.4 ms. For PTS recorded in 72 to 75% of pathologic infants, mean duration and amplitude were significantly greater in all groups than in asymptomatic infants, whereas frequency was significantly greater only in the group presenting with asphyxia. Discriminant analysis based on the three PTS criteria (frequency, amplitude and duration) allowed correct classification for only 30 to 54% of infants in the four groups. The frequency of PTS decreased rapidly during the second week of life in asymptomatic infants, but persisted in a larger number of infants in the pathologic groups. This study shows that PTS have no negative significance when they are few in number, short in duration, moderate in amplitude and rapidly regressive, thus probably reflecting the vulnerability of the temporal lobe during the traumatic period of birth. However, they require attention when they are abundant and/or slow, ample or tend to persist. They may thus constitute a nonspecific response to injury to an immature brain.

Heart rate changes during sleep in normal two-month-old infants.

Thirty-five normal two-month-old infants had nighttime followed by daytime polygraphic recordings. Heart rates were calculated every minute in active and quiet sleep states. A difference in mean heart rates was found between the two states and between the two recordings. Rates were lower at night than during the day (P < 0.0001), regardless of the sleep state. During nighttime or daytime recordings as a function of sleep cycles or during sustained sleep episodes, heart rates were minimal in the middle of recordings, but differences were statistically significant for only a few results (mainly in QS). Intrasleep awakening led to a marked increase in heart rate after sleep was resumed, although differences were only statistically significant when the awakened infant was fed. Infants with episodes of periodic breathing had lower mean heart rates throughout the recordings, but differences were not statistically significant. Respiratory and heart rates showed similar changes during the recordings, and a statistically significant correlation was found between the two measurements.

[Maturation of generalized motility, spontaneous during sleep, from birth at term to the age of 6 months]. / Maturation de la motilité généralisée, spontanée au cours du sommeil, de la naissance à terme à l'âge de 6 mois.

This work analysed the evolution of generalized motility from normal birth (39 to 40 weeks of gestational age) to six months of age, in 73 healthy infants during sleep, according to age. Sleep polygraphic recordings were performed in the morning; body movements were recorded with piezo-electric accelerometers. Our results showed that the number of movements per sleep hour was higher in active sleep (AS) as compared to quiet sleep (QS) whatever the age although the difference was less important in neonates (P < 0.05) than after one month of life (P < 0.001). The number of movements and the percentage of time spent in movements decreased with age; however in QS these parameters decreased sharply from birth to one month and a half but then did not significantly differ; in AS they became progressively lower. There were no statistically significant differences in the duration of body movements between sleep states in each age group; their mean duration became shorter from birth to six months of age (in AS P < 0.0001 and in QS P < 0.05). The distributions of the number of movements throughout the sleep stage were different according to sleep state and age. The movements were equally distributed during AS whatever the age and in the neonate group during QS; in older infants, the number of movements increased at the beginning and at the end of QS stages. During the first six months of life, spontaneous motility during sleep was inhibited, however, this process differed in quiet and active sleep. The relationship between body movements and sleep stages' organisation became closer during maturation.

[Indications of electroencephalogram in the newborn]. / Indications de l'électroencéphalogramme en période néonatale. Recommandations du groupe de neurophysiologie clinique de l'enfant.

The electroencephalogram (EEG), an easy-to-use and non invasive cerebral investigation, is a useful tool for diagnosis and early prognosis in newborn babies. In newborn full term babies manifesting abnormal clinical signs, EEG can point focal lesions or specific aetiology. EEG background activity and sleep organization have a high prognostic value. Tracings recorded over long period can detect seizures, with or without clinical manifestations, and differentiate them from paroxysmal non epileptic movements. The EEG should therefore be recorded at the beginning of the first symptoms, and if possible before any seizure treatment. When used as a neonatal prognostic tool, EEG background activity is classified as normal, abnormal (type A and type B discontinuous and hyperactive rapid tracing) or highly abnormal (inactive, paroxysmal, low voltage plus theta tracing). In such cases, the initial recording must be made between 12 and 48 h after birth, and then between 4 and 8 days of life. Severe EEG abnormalities before 12 h of life have no reliable prognostic value but may help in the choice of early neuroprotective treatment of acute cerebral hypoxia-ischemia. During presumed hypoxic-ischemic encephalopathy, unusual EEG patterns may indicate another diagnosis. In premature newborn babies (29-32 w GA) with neurological abnormalities, EEG use is the same as in term newborns. Without any neurological abnormal sign, EEG requirements depend on GA and the mother's or child's risk factors. Before 28 w GA, when looking for positive rolandic sharp waves (PRSW), EEG records are to be acquired systematically at D2-D3, D7-D8, 31-32 and 36 w GA. It is well known that numerous and persistent PRSW are related to periventricular leukomalacia (PVL) and indicate a bad prognosis. In babies born after 32 GA with clinically severe symptoms, an EEG should be performed before D7. Background activity, organization and maturation of the tracing are valuable diagnosis and prognosis indicators. These recommendations are designed (1) to get a maximum of precise informations from a limited number of tracings and (2) to standardize practices and thus facilitate comparisons and multicenter studies.

[Electroencephalographic changes in patients with cardiopathies, subsequently operated under extracorporeal circulation. Significance and outcome. Evaluation of 679 cases]. / Altérations électroencéphalographiques chez des patients atteints de cardiopathies, opérés ultérieurement sous circulation extracorporelle. Signification et devenir. Bilan de 679 dossiers.

This study analysed the pre-operative electroencephalographic recordings of 679 patients with heart disease, later undergoing surgery under extra-corporeal circulation. The type and the severity of the abnormalities are listed for each heart disease. These results are compared to those already published in the literature on this subject and are discussed in terms of a number of possible aetiological factors: the age of the patients, data provided by the pre-operative cardio-pulmonary assessment. This analysis does not enable us to demonstrate, with any statistical significance, the aetiological factor(s) of these electroencephalographic alterations. Finally, comparison of the pre-, intra- and postoperative EEG in the same patients enables us to evaluate the prognostic value of these electrical abnormalities.

[Sleep apnea syndrome in intensive care]. / Le syndrome d'apnée du sommeil en réanimation.

The aim of this work was to study the existence of special characteristics in the sleep apnoea syndrome (SAS) discovered following a stay on the Intensive Care Unit. This retrospective study of 25 casenotes of SAS patients who were resuscitated has enabled a comparison with 182 SAS patients who have never had acute respiratory failure. The intensive care consisted of controlled ventilation, following intubation, in a clinical context of acute respiratory failure with major problems of conscious level. The diagnosis of SAS was made using conventional or computerised polysomnography, or a computerised study of transcutaneous SaO2 (SaO2TC) which had been validated before. The results show that patients with SAS in an Intensive Care Unit, differs significantly from other patients with SAS by the permanent presence of alveolar hypoventilation in a stable state, associated with a significant decrease in the FEV1 (VEMS) in relation to the group that had not been in intensive care. However, the FEV1/VC ratio did not differ between the two groups which were expressed in absolute values or as a percentage of the theoretical value defined on the basis of their age. There was no difference on the data from the sleep studies and notably the hypoapnoeic indices, nor on age, the index of body mass or the sex ratio. We conclude that there is a need to look for SAS in the presence of acute respiratory failure in the obese without a recognised cause.

[Predictive factors in maintaining nocturnal continuous positive pressure in patients with sleep apnea syndrome]. / Facteurs prédictifs de l'observance de la pression positive continue nocturne chez les patients porteurs d'un syndrome d'apnées du sommeil.

A retrospective study was carried out on 347 case notes involving 303 men and 44 women who were suffering from a sleep apnea syndrome (SAS). The mean age was 57 plus or minus 10 years, and the diagnosis was made between 1982 and 1992. We have carried out the research to examine if there were clinical factors or factors related to respiratory function which would predict the acceptance in the short or long term and the correct observation in a daily time-table of nocturnal continuous positive pressure (PPC). The diagnosis of SAS was made using conventional polygraphy (35%), computerised cardiorespiratory recording 38%, or limited to transcutaneous saturation 27%. The mean number of respiratory nocturnal events in the three groups were respectively 48 plus or minus 25 per hour during sleep, and 45 plus or minus 23 and 51 plus or minus 20 per hour by the recording techniques. We have suggested a treatment by PPC in 235 patients: 86 patients refused at the outset (37%), 26 stopped secondarily (11%), and 108 (46%) continued until the end point 1992 with a mean duration of treatment of 24 (plus or minus 17), months and a mean duration of nocturnal usage of 6.2 (plus or minus 2.5) hours a mean level of positive pressure of 11 (plus or minus) 2) centimetres. The primary acceptance of PPC is significantly linked to the understanding of the patient of the functional signs (p less than 0.001) and of the severity of diurnal hypersomnolence (p less than 0.001). The acceptance in the long-term is linked in a weakly significant manner to the recognition by the patient of functional signs (p less than 0.04). None of the other 68 criteria used for assessing the severity of the patient and the SAS had any influence on the acceptance of PPC in short or long term. The compliance with a daily time-table is a weakly significant factor to the severity of the SAS judged by the number of nocturnal respiratory events (p less than 0.03).

[First results given by a sleep automatic analysis for 2- to 12-months-old infants (author's transl)]. / Premiers résultats d'une méthode d'analyse automatique de sommeil du nourrisson.

A sleep automatic analysis program was performed for infants older than 2 months. It used spectral analysis of the EEG and polygraphic parameters. Three EEG parameters and three polygraphic parameters are considered to be sufficient to stage babies' sleep with computers. Automatic detection was satisfactory for babies older than 4 1/2 months: agreement was better than 0.8 between automatic and human observation. Results are less satisfactory for the younger infants where there is only between .50 and .60 agreement between machine and human observers. These preliminary results confirm that decision criteria must be age related.

[Body movements during sleep in the infant: comparison between control infants and siblings of infants dying of sudden infant death syndrome]. / Etude des mouvements corporels au cours du sommeil chez le nourrisson: comparison entre nourrissons témoins et nourrissons issus d'une fratrie de mort subite inexpliquée du nourrisson.

Day-sleep polygraphic recordings were performed in 10 normal infants and 10 siblings of infants who died of sudden infant death syndrome. Body movements were studied in both groups of infants during 3 stages of sleep. In controls and siblings, the mean number of body movements per sleep hour, per infant was respectively 7 or 6 in quiet sleep and 22 and 23 in REM sleep; the mean duration of body movement was longer (11.3 sec) in REM sleep than in non-REM sleep (9.4 sec). In both cases, there was no significant difference between the 2 groups. An analysis of the movement duration showed that most of them lasted between 5 and 10 sec and in siblings were statistically more numerous during indeterminate sleep. In both groups, these movements appeared more often at the beginning and at the end of the quiet sleep, but were more equally distributed in the REM sleep. Respectively 15 and 13.7% of these movements in the normal and sibling group were accompanied by a brief respiratory pause. The relation between body movements and sleep is discussed.

[Localized fast rhythms in EEG tracings following surgery for intracranial meningioma]. / Les rythmes rapides localisés sur les traces EEG après intervention pour méningiome intra-cranien.

Forty-six patients were followed up after removal of an intracranial meningioma. Nine of the 46 patients in their 3rd month postoperative EEG had localised fast rhythms which remained stable. The fast rhythms appeared in small 20-25 Hz and 20-40 microV bursts; they were localised over the craniotomy flap as shown by the control X-ray of the sites of the electrodes; they were unaffected by eye-opening and slightly reduced by fist-clenching. These fast rhythms were sometimes mixed with sharp waves and theta activity and seemed to be equivalent to the 'breach rhythm' described first by Fischgold et al. (1952) and then by Cobb et al. (1979). In our study, these rhythms were more frequently observed in patients with an olfactory or sphenoidal meningioma, in patients with pre-operative seizure and in patients with an extensive post-operative intracranial atrophy (as shown by the scanner). On the other hand, incomplete removal or recurrence of the tumour or post-operative epilepsy did not seem to play a role in the appearance of these rhythms.

[Kidney failure patients undergoing hemodialysis with aluminum poisoning after renal transplantation: electro-clinical aspects]. / Insuffisants rénaux en hémodialyse atteints d'intoxication à l'aluminium et greffe renale: aspects électro-cliniques.

A renal transplantation was performed on 6 dialysis patients using high concentration aluminum water. The post-graft course in 3 patients led to the appearance of worsening or neurological symptoms, with associated deterioration on the EEG. In 3 other patients there was progressive improvement in clinical signs, though with long-term persistance of electrical abnormalities in 1 case. These 6 cases are compared with 10 dialysis patients without aluminum intoxication who underwent renal transplantation in the same conditions. These results are then analyzed with reference to those already published in the literature. Three factors (length of exposure, water aluminum concentration and seizure disorder) seem significant to the prognosis of renal transplantation in patients with aluminum intoxication.

Persistence of distal motor control in the locked in syndrome. Review of 11 patients.

We report 11 patients with the locked in syndrome (LIS). The functional outcome was good in four patients with notable motor recovery, but motor deficit remained seriously disturbed in seven patients. All of the patients regained some distal control of finger and toe movements, often allowing functional use of a digital switch. The independence thereby gained is worthwhile, in some patients allowing environment control, communication by means of a computer, and electric wheelchair ambulation. When motor recovery occurs, the progression is disto-proximal with dramatic axial hypotonia. In five patients clinical insomnia was noted and polysomnography showed a reduction of REM sleep. The implications of systems other than the pyramidal tracts in the physiopathology of LIS are discussed.

[Normal children sleep E.E.Gs from 5 months to 3 years old (author's transl)]. / Electroencéphalogramme du sommeil de l'enfant normal entre 5 mois et 3 ans.

The sleep E.E.G. of the child under 3 years old is characteristic from several points of view: Drowsiness: The hypersynchrony is always observed. It is more continuous in younger children, than in the older one, where only bursts of hypersynchrony are seen. The fast rhythms of low amplitude may exist, during stage 2 sleep, but they are rare. Calm Sleep (C.S.): The vertex humps are more and more acute and sharper from 18 months. The sleep spindles are of high amplitude and frequent at 6 and 8 months. They diminish later. It may be for that reason that III and IV sleep stages seem to be more important after 12 months than before. From 21 months, we have observed an unusual pattern during C.S.: rhythmic and diffuse thêta rhythms of about 6 c/s. Paradoxal sleep (P.S.): If it is possible to observe P.S. during day-naps 8 or 9 months, it is rare later and for recording P.S., it is necessary to record E.E.G.s at night. The E.E.Gs are either a little like stage I E.E.G, or consistent of high and monomorphic delta waves. If it is possible to observe at least 3 complete sleep cycles, the proportion of P.S. is about 20 p. 100 of the total length of the sleep. At least, it is very important, even in medical practice, to record not only E.E.G. but also polygraphic leads: breathing, electro-myogram, electrocardiogram, and to notice also the rapid eyes movements.