Abstracts

Rationale: We report 3 cases of reflex seizures induced by diaper-changing, tooth-brushing, and reading. Diaper-changing has not been previously reported as a trigger for reflex seizures. Methods: History, physical examination, neuroimaging, and EEG data were reviewed for each patient. Results: Patient 1 was a 5-year-old boy with a history of refractory infantile spasms that were eventually controlled with ACTH. MRI and an extensive genetic and metabolic evaluation were normal. After initial control of spasms, he had had occasional clusters of spasms that were refractory to treatment with valproic acid, levetiracetam, and clonazepam. He presented with a 5-month history of clusters of extensor spasms occurring only when his parents fastened his diapers closed. Video-EEG established them to be seizures, with a hallmark diffuse slow wave or a slow wave followed by an electrodecrement and beta activity at the onset of each spasm. After the use of absorbent undergarments that could be pulled up without applying pressure to his anterior hip regions, the clusters of spasms stopped completely. Patient 2 was a 3-year-old girl with intractable epilepsy due to a congenital brain malformation consisting of a large left parietal cortical dysplasia as well as a small region of periventricular heterotopia of the right lateral ventricle. Her seizures consisted of drop seizures as well as episodes of unresponsiveness and cyanosis, all of which were refractory to multiple medications, IVIG, the ketogenic diet, and two resections of the left parietal lesion. Her baseline EEG showed voltage attenuation in the left hemisphere and very frequent spikes in the right frontopolar, frontal, temporal, and centro-parietal regions. At three years of age, she developed head drop seizures induced exclusively by tooth-brushing. Patient 3 was a 13-year-old boy who presented with three episodes of confusion, drooling, staring, and pupillary dilatation, each lasting five minutes. All three episodes occurred at school while he was reading. He also had a history of spontaneous seizures. MRI showed a slightly enlarged left temporal horn. Baseline EEG showed left temporal spikes that were activated by sleep. Silent reading was used as an activation procedure and was associated with an increase in epileptiform activity on EEG. Thus, while the seizures have not been established by video-EEG, there was a suggestion that the patient has reading-induced epilepsy. Conclusions: We present three cases of reflex seizures in patients with epilepsy. A careful history may suggest specific activation procedures during EEG that may lend support to the diagnosis of reflex epilepsy. The diagnosis of reflex seizures can be made most definitively by video-EEG. While reading and tooth-brushing have been reported as stimuli for reflex epilepsy, epileptic spasms induced by diaper-changing and treated by the cessation of the use of diapers have not been previously reported. We highlight this case in part to point out the excellent response to simple avoidance of the stimulus.