Biomedical subjects
C Ounsted
Publications and source records attributed to C Ounsted.
Hemispherectomy for childhood epilepsy: a 36-year study.
Between 1950 and the present day 17 patients who had been treated for hemiplegic epilepsy by hemispherectomy were followed up. The outcomes of surgery in terms of survival, arrest of dementia, relief from gross disorders of behaviour and from habitual epilepsy were uniformly good. It is concluded that hemispherectomy has an enduring rôle in the treatment of hemiplegic epilepsy for patients who are carefully selected, prepared and postoperatively rehabilitated.
Focal epilepsy with mesial temporal sclerosis after acute meningitis.
Following acute meningitis associated with severe convulsions in childhood, two patients had chronic, drug-resistant, temporal lobe epilepsy. This disorder was preceded by an entirely natural development, in one case extending for nine years and in the other case for eight years. Each patient was treated with right anterior temporal lobectomy. Classic mesial temporal sclerosis (Ammon's horn sclerosis) was found in both patients. Relief of the epilepsy was associated with remission of the concomitant social and psychiatric handicaps. At least ten years of follow-up are required in the evaluation of the treatment of early brain infections. Chronic focal epilepsy after childhood meningitis with febrile convulsions merits neurosurgical consideration.
Long-term outcome in children with temporal lobe seizures. V: Indications and contra-indications for neurosurgery.
One hundred unselected children with temporal lobe epilepsy were followed up between 1948 and 1982. The series was a personal one. None was lost to observation. For 42 patients, contra-indications for surgery had emerged before the end of their schooldays. 29 cases were considered for surgery. 16 were rejected on technical grounds, and none of these made an epileptic, social, psychiatric or personality recovery. 13 patients were operated on, none of whom continued to have habitual epilepsy: all their biographies were remarkably improved, though several years postoperative care sometimes was needed. The authors conclude that surgery plays a major rôle in the treatment of temporal lobe epilepsy of childhood, and those who would benefit usually can be recognised before leaving school.
Developmental aspects of focal epilepsies of childhood treated by neurosurgery.
Data on 50 patients treated surgically for intractable focal epilepsy were analysed. There were 10 hemispherectomies, 32 temporal lobectomies and eight operations to other areas of the brain. The median age at operation was 14 years. 29 patients were found to have mesial temporal sclerosis or sclerotic hemispheres and 17 had alien tissue and one sclerosis with heterotopia. No lesion was found in three cases. The nature of the first seizure was found to relate significantly to pathology. 30 patients had suffered an early convulsion. Between the convulsive insult and the onset of focal epilepsy there was a silent interval, the duration of which was biased by sex and side of lesion. The remaining 20 patients, of whom a highly significant number had alien tissue, had not had an early convulsion before the onset of focal epilepsy. The importance of accurate clinical histories is stressed. Clinical considerations alone predicted the pathology and laterality of the lesion in more than half the series. Regular EEG recordings and repeat scanning were found to be important investigations. Major disorders of behaviour had occurred in 44 patients. As adults, the series were free of severe psychiatric symptoms, but many required years of careful rehabilitation. 31 children had been excluded from normal schools before operation. Postoperatively, many patients continued their education in normal schools. Some required basic remedial teaching, others successfully undertook higher education and training. 49 patients benefited over-all from neurosurgical treatment. 34 had no more habitual epilepsy at all. Full global gains often took at least five years to achieve.
Late language development in a child unable to recognize or produce speech sounds.
A boy with severe quadriplegia who neither recognized nor uttered speech sounds acquired language. Until the age of 6 years he was considered to be of severely subnormal intelligence. At age 6 years 9 months he was introduced to a manual sign system. Subsequently he was able to read, write, converse, and produce imaginative stories. Attention and memory were unimpaired and affective and social responsiveness developed appropriately. The case history demonstrates the selective effects of brain lesions that, despite extensive damage, may spare functional systems necessary for cognitive and linguistic development. It highlights the difficulty in diagnosing and evaluating the intellectual and affective potential of a multihandicapped child without functional hearing or speech and emphasizes the importance of sign language as a communication channel and prerequisite for the acquisition of reading and writing skills.
Fourth goal of perinatal medicine.
Reduction in maternal mortality, infant mortality, and infant morbidity have been successively the goals of perinatal medicine. The fourth is to reduce bonding failure. In July 1978 a preventive service was started in the John Radcliffe Maternity Hospital. A twice-weekly round is made. Midwives refer families who cause them concern. In the first year the referral rate ws 20.5 per 1000 liveborn babies. The referred sample differed from the hospital population in terms of maternal psychiatric history, marital state and babies' admission to special care. The main reasons for referral were: doubt about parenting ability (27%), psychiatric history (15%), disturbed behaviour in hospital (14%), and diffuse social and medical problems (17%). Long-term care was needed for only 14% of families. At their first birthdays, six babies were placed away from their natural parents; the sample had had a slightly higher than expected admission rate to hospital; the distribution of weights did not differ from the expected; doctors and health visitors were still concerned about one-quarter of the families. Seven cases of screening failure were found among those not referred to our service, but only one was seriously abused. No child referred in the first year has been seriously neglected or abused.
Long-term outcome in children with temporal lobe seizures. IV: Genetic factors, febrile convulsions and the remission of seizures.
Three groups of children are considered: 100 children with temporal lobe epilepsy, 59 of whom had also had febrile convulsions; their 214 sibs; and an unselected coeval sample of 438 children with febrile convulsions. When the family history is positive for seizures, the adverse factors described in previous papers in this series do not discriminate between those who remit their epilepsy and those who do not. Interactions between age of onset, family history and outcome are displayed. In the absence of an affected relative, none of 26 children with an onset below four years remitted. Six had their first seizure at a later age, of whom three remitted. In the presence of a first-degree affected relative, 10 out of 19 remitted: age of onset was cut off at 2 years 9 months. Eight children had second-degree affected relatives; there were four remissions, all with onset after three years. The authors compared the proportion of simple benign febrile convulsions in 438 unselected children who had fits with fever, with the same ration in the probands' affected siblings. The two ratios were the same. They conclude that one gene promoting febrile seizures was common to both groups. The siblings of those probands who remitted their seizures had a 38 per cent risk of seizures: the siblings of non-remitters had an 11 per cent risk. A new genetic theory is proposed to account for these data. Practical considerations include genetic advice, the necessity of weaning some patients from anticonvulsants, and early discrimination of those likely to need neurosurgical relief of their epilepsy.
Long-term outcome in children with temporal lobe seizures. I: Social outcome and childhood factors.
One-hundred children, diagnosed as having temporal lobe epilepsy and reported on in 1966, have been followed into adult life. In this 1977 survey they have been coded into four social outcome categories, A, B, C and D. A: 33 per cent are found to be seizure-free and independent; B: 21 per cent are socially and economically independent but are receiving anticonvulsant treatment and are not necessarily seizure-free; C: O9 per cent are dependent either on their parents or in institutions; D: 5 per cent died under the age of 15. Biological factors ascertained and coded in childhood are related to adult outcome. Eight adverse factors emerged: an IQ below 90, onset of seizures before 2 years 4 months, five or more grand mal attacks, temporal lobe seizure frequency of one per day or more, a left-sided focus, the hyperkinetic syndrome, catastrophic rage and special schooling. The presence of first-degree relatives with seizure disorders was a good prognostic sign. Disorderly homes in childhood did not significantly affect adult outcome. All but one of those achieving Group A status had received normal schooling. In general, the prognosis for children with limbic seizures is clear before the end of adolescence. A simple count of the number of childhood adverse factors predicts adult outcome at a high level of significance.
Long-term outcome in children with temporal lobe seizures. II: Marriage, parenthood and sexual indifference.
One-hundred unselected children with clinical and EEG evidence of temporal lobe seizures were followed into adult life. Data related to marriage and reproduction are analysed. Female survivors, if not totally handicapped, are nearly all married; surviving males who are not totally handicapped more often remain single. Early remission of seizures in males is associated with marriage: seizures continuing through adolescence are associated with sexual appetitive indifference. The female probands have produced children at a rate three times greater than the male probands. The findings have implications for understanding the development of male secual appetite. The epidemiology and genetics of these forms of seizures must take account of much greater fitness on the distaff side of the pedigree. The likelihood of marriage and parenthood would appear to rest on a few biological factors usually recognisable before the end of childhood.
Long-term outcome in children with temporal lobe seizures. III: Psychiatric aspects in childhood and adult life.
One hundred children with temporal lobe epilepsy were followed into adult life. 85 per cent had had psychiatric problems in childhood. The occurrence of overt psychiatric disorder in adult life was low: of those survivors who were not gravely mentally retarded, 70 per cent were regarded as psychiatrically healthy. Overt schizophreniform psychosis has developed in 10 per cent of survivors. Males with continuing epilepsy and left-sided foci were at special risk: 30 per cent of such patients had become psychotic. No patient coded as having a right-sided focus in 1964 had become psychotic by 1977. Though 26 patients had had grossly disordered childhood homes, this factor had no significant relation to adult psychiatric disorder. Antisocial conduct marked the adult life of 12 patients. Their childhood codes showed that male sex, a focus contralateral to the preferred hand, and unremittent epilepsy marked this group. Low intelligence and childhood rages were also prominent. Treated neurotic and depressive illness was quite uncommon. Only five survivors have fallen into this category. Those patients escaping psychiatric ill-health are often notably extraverted and successful.
Myotonic dystrophy and bonding failure.
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Preventing febrile convulsions.
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Sex and histocompatibility testing.
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Family unit in a children's psychiatric hospital.
The need for effective management of disorders of parent/child relationships is repeatedly stressed. Despite the bulk of theoretical work on the subject there is little information on the practical management of the clinical problems that arise. We describe a unit designed and staffed for the management of such disorders. In our view it meets a need in a way that could be difficult or impossible for most paediatric, psychiatric, and social services as they are at present organized.
Aspects of bonding failure: the psychopathology and psychotherapeutic treatment of families of battered children.
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Letter: "High activity and hyperactivity'.
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