Diagnosing and managing childhood absence epilepsy by telemedicine

doi:10.1016/j.yebeh.2020.107404

Epilepsy & Behavior

Volume 115, February 2021, 107404

https://doi.org/10.1016/j.yebeh.2020.107404 Get rights and content

Highlights

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Childhood absence epilepsy (CAE) can be diagnosed via televisit based on spell features and a positive hyperventilation test.
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Hyperventilation can also be used during televisits to assess treatment adequacy and compliance in established CAE.
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Electroencephalography (EEG) can often be deferred if not readily available (e.g., during the current CVID-19 pandemic).

Abstract

The diagnosis of childhood absence epilepsy (CAE) is typically based on history and description of spells, supported by an office-based positive hyperventilation test and confirmed by routine electroencephalography (EEG). In the current coronavirus disease 2019 (COVID-19) pandemic, many pediatric neurologists have switched to telemedicine visits for nonemergent outpatient evaluations. We present a series of children diagnosed as having CAE on the basis of a positive hyperventilation test performed during remote televisits. Several of these children were begun on treatment for CAE prior to obtaining an EEG, with significant seizure reduction. Our series documents the feasibility of CAE diagnosis and management by telemedicine.

Introduction

The diagnosis of childhood absence epilepsy (CAE) is often straightforward. The diagnosis is highly suspected in the appropriate clinical context of a typically developing school-aged child who presents with brief (seconds long), multiple daily episodes of staring or zoning out, without recall or ability of caretakers to interrupt the episode [1]. In the office, a normal neurologic examination and elicitation of a typical episode by a hyperventilation test increases the likelihood of this diagnosis. In fact, with rare exceptions, hyperventilation-induced staring spells are essentially pathognomonic of absence epilepsy [2]. Despite the high sensitivity and specificity of this simple office-based test, the current standard of care is to confirm the diagnosis of CAE by a routine electroencephalography (EEG) before beginning treatment [3].

While telemedicine has been increasing in recent years as a method to evaluate and manage patients, the current coronavirus disease 2019 (COVID-19) pandemic has accelerated its use. Pediatric neurology visits are now conducted routinely via telemedicine, and at many institutions, the ready availability of routine EEGs may be limited. Although prompt diagnosis and treatment of absence epilepsy would be ideal in terms of patient safety and daily function, an EEG for absence epilepsy would probably not qualify as a medical emergency. Therefore, the standard practice of obtaining an EEG prior to initiation of medication may need revision, at least temporarily. Here, we present a small series of patients diagnosed as having CAE during the current COVID-19 pandemic.

Section snippets

Methods

This is a retrospective chart review of patients referred to the Division of Pediatric Neurology at Johns Hopkins Hospital for staring spells or suspected absence seizures during the months of March–June 2020. Data recorded included age, sex, description of spells and their frequency, result and type of hyperventilation procedure, and any treatment if given. Hyperventilation was performed for 3 min. For children who begun on treatment, follow-up data were recorded if available. The timing and

Results

In mid-March 2020, the pediatric neurology division at Johns Hopkins Hospital switched almost entirely to telemedicine for outpatient visits. Over the next three months, several providers diagnosed children as having CAE via remote synchronized 2-way audiovisual televisit. During that time, seven children were referred with classic symptoms of absence epilepsy; these children lacked risk factors or other clinical features of other types of epilepsy, and six of them developed typical episodes in

Conclusions

These cases demonstrate that children with staring spells that are suspected to be seizures continue to present to pediatric neurology clinics for evaluation during the COVID-19 pandemic. Telemedicine has required practitioners to adopt a variety of creative approaches to history taking and neurologic examination [8,9]. In the case of suspected absence epilepsy, provocative tests such as hyperventilation can be utilized successfully. Office-based assessment of staring spells relies on

Financial disclosures

This work did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Declaration of competing interest

None.

Acknowledgments

None.

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Telemedicine in the era of coronavirus disease 2019 (COVID-19): a neurosurgical perspective
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There are more references available in the full text version of this article.

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Since the beginning of coronavirus disease (COVID-19) epidemic in Israel in early 2020, follow-up visits through phone consultations were available only for patients treated in our outpatient epilepsy clinic.
To assess the potential feasibility of phone consultation instead of in-person first visit in the outpatient epilepsy clinic.
The computerized database and medical records of all the patients who had an in-person first visit in our outpatient epilepsy clinic during a 4-year period (2018-2021) were retrospectively reviewed. Potential feasibility of a remote visit was assessed for all visits and was deemed possible when physical examination or vagal nerve stimulator (VNS) examination or parameter adjustment was not reported in the visit summary.
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A remote visit may be potentially feasible for most patients who are scheduled for a first visit in the epilepsy clinic. An in-person visit may remain the preferred option for patients with additional neurological symptoms or a VNS, and may also be considered in older patients and those with longer disease duration or antiseizure medication polytherapy.
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Providers used WhatsApp to help families manage their epilepsy symptoms following the diet, and families felt that video calls helped them understand how to prepare a ketogenic diet. Telemedicine was used in the United States to diagnose childhood focal epilepsy.30,31 Through telemedicine, children were able to be diagnosed by remote video with EEG and hyperventilation studies to receive their treatment, resulting in a significant reduction in their seizures.
COVID-19 pandemic influence on epilepsy course in pediatric patients
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Previous studies support those statements as telemedicine consultations were successfully utilized as an important tool for epilepsy management regardless of epilepsy type, etiology, seizure frequency, comorbidities, and patients' residential areas [28]. It was also used with a success in diagnosis and managing childhood absence epilepsy [29]. Telemedicine may also provide high satisfaction and economic benefits in the future, after the pandemic [30].
In 2020, Coronavirus Disease 2019 (COVID-19) was declared as a global pandemic. Self-reported stress, anxiety, and insomnia, which are believed to be common triggers for epilepsy, are more likely to occur. We aimed to establish the influence of COVID-19 pandemic itself on changes in the daily life routine related to pandemic on epilepsy course in pediatric patients. The unique form of clinical care which is telemedicine was also taken into consideration. We wanted to evaluate patients' satisfaction with telemedicine and if changing stationary visits into telemedicine influenced epilepsy course in our patients.
Patients, who attended developmental neurology outpatient clinic in the period March–December 2020 were collected. As patients were minors, legal guardians were asked to fill out the questionnaire. Patients were divided according to the outcome into three groups: those with a worsened, stable, or improved course of epilepsy during the pandemic. Appropriate statistical tests for two-group and multi-group comparisons have been implemented. Post hoc p values were also calculated.
Four hundred and two questionnaires were collected. Most of the patients had a stable course of epilepsy during the pandemic; in 13% of participants an improvement has been observed, worsening of the disease was seen in 16% of patients. Age, sex, type of epilepsy, number of seizure incidents before pandemic, and duration of the disease had no statistically significant connection with changes in the course of the disease. Behavioral changes and altered sleep patterns were found to be more common in the worsened group.
Fifty-eight percent of patients were satisfied with telemedicine. Poorer satisfaction was connected with less frequent visits, cancellation of scheduled appointments, and lack of help in case of need in an emergency situation.
Epilepsy course in pediatric patients seems to be stable during COVID-19 pandemic. Sleep disturbances and changes in a child’s behavior may be related to increase in seizure frequency. Telemedicine is an effective tool for supervising children with epilepsy. Patients should be informed about possible ways of getting help in urgent cases.
Physician and patient satisfaction with the switch to remote outpatient encounters in epilepsy clinics during the Covid-19 pandemic
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The strict use of families’ description of seizures without EEGs reinstated seizure semiology as a reliable indicator that should be used by physicians in countries with limited resources to classify seizure and epilepsy types [25]. Some syndromes such as childhood absence epilepsy can be efficiently identified and can allow initiation of ASM therapy [26]. Most difficulties arose with first encounters, physicians stated that they would have needed a physical examination and were less comfortable answering the parents’ questions.
Analyzing parents’ and physicians’ opinions regarding phone-based encounters in emergency shifts of a French pediatric epilepsy center compared to traditional face-to-face encounters during the first lockdown of the COVID-19 pandemic
Prospective monocentric study on remote encounters at Necker rare epilepsy reference center from March 20th, 2020 to April 23rd, 2020 due to lockdown measures. This study was conducted with a survey based on 5-point Likert scales (LS_-2/2) designed for both parents and physicians. We compared first versus follow-up encounters as well as physicians’ and parents’ opinions.
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Brief CommunicationDiagnosing and managing childhood absence epilepsy by telemedicine

Highlights

Abstract

Introduction

Section snippets

Methods

Results

Conclusions

Financial disclosures

Declaration of competing interest

Acknowledgments

Brain Res

Pediatr Neurol

World Neurosurg

Epilepsy Behav

Brief Communication
Diagnosing and managing childhood absence epilepsy by telemedicine