Response to Koutroumanidis

Abstract

To the Editors: We appreciate the comments from Dr. Koutroumanidis about our article on autonomic symptoms (AS's) during partial seizures in children. Dr. Koutroumanidis raises some important questions, and we will try to address them briefly below. Regarding the predominant (most important) ictal manifestations seen in our population of children – Typical psychomotor or motor seizures were predominant. Autonomic symptoms occurred frequently, but were not the predominant feature of these seizures. Regarding the timing (early or late in the seizure sequence) of AS's – Most of the AS's appeared later in the seizures. Some of them were typically postictal (or occurred at the end of the ictal episode) – e.g., nose-wiping, vomiting, coughing, hiccupping. Other signs occurred within the ictal period, but late in the session – e.g., genital automatisms, flushing, pallor, hypersalivation. Only a few AS's appeared at an early stage – e.g., epigastric aura and apnea. In short, the occurrence of AS's in these children followed the typical adult pattern of late-appearing AS's, as cited by Dr. Koutroumanidis. Regarding the duration of seizures with and without AS's – The duration of the AS's was usually short and constituted a minor part of the seizure. We did not see any seizures with autonomic status epilepticus, and none of the seizures were characterized exclusively by AS's. Rather, the AS period appeared as part of the whole psychomotor or motor seizure attack. We did not measure the exact length of seizures (an enormous undertaking for 514 attacks), and therefore cannot compare statistically the length of seizures with and without AS's. Regarding signs typical of Panayiotopoulos syndrome (PS) – Loss of muscle tone or awareness, a typical sign of PS, was noted in our semiological seizure classification of “atonic seizure.” Only 4 of 514 seizures (<1%) contained atonic components, so loss of muscle tone was clearly not a characteristic symptom of this patient group. We believe that the differences of our seizure with AS's, as compared to the longer autonomic seizures of PS, result from our special patient population. In our study, all the children had focal, well-localized, therapy-resistant epilepsy – a group very much different from the idiopathic childhood epilepsy population.