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Febrile seizures, early onset of temporal epilepsy and mesial temporal sclerosis

D. Schmidt et a1 (1) commenting on the peculiar incidence of febrile convulsions (FC) among intractable temporal epileptics suggest that such a figure may arise “possibly through the development of mesial temporal sclerosis” (MTS). A close look at the scarce clinical series in the literature certainly gives the same impression. The cumulative incidence of FC in the general population in the USA and Europe can be estimated as between 2.4% (2) and 3.6% (3). In the sub-population of epileptic patients this figure is increased to 19% (4) to 40% (5). In various selected groups of temporal lobe epileptics this incidence might even be higher, since Falconer and his colleagues reported in three successive operative series 23% (6, 7, 8), 17% (9) and 50% (lo) of FC lasting more than 30 min (without mentioning the others) whereas Ounsted et a1 described 32% of their patients starting in status associated with fever (11). When taking into account FC of any duration the incidence was 38% in the surgical series operated by Paillas (12) as well as in the medical series described by Hassan et a1 (13). Finally the incidence of initial febrile seizures among patients whose pathologic examination discloses mesial temporal sclerosis is as high as 40%, 30% and 82% for Falconer’s series (and pertaining only to prolonged FC). Falconer’s patients were intractable and since a major part of his three series was formed by mesial temporal sclerosis patients (47%, 47% and 55%) it is likely that this pathological subgroup represents the bias through which FC are overrepresented in intractable temporal epileptic groups. When febrile convulsions amidst temporal epileptics are acknowledged as a clinical clue for mesial temporal sclerosis it is indeed to be expected that, on a statistical basis, Schmidt’s patient, with such antecedents had an earlier onset of epilepsy. Cavanagh & Meyer (14) stated as early as 1956 that patients with “Ammon’s horn sclerosis” had an earlier onset of seizures than those without this histological feature. Taylor & Ounsted (15) stated that “the age of onset in cases proven to have mesial temporal sclerosis was almost entirely limited to the first decade of life and largely to the first quinquennium”, whereas onsets in other pathology groups were more or less randomly distributed over five decades. These authors (I]) , commenting on Cavanagh & Meyer’s study, report that “the group with Ammon’s horn sclerosis showed a remarkably high incidence (64%) of status epilepticus in the first few years of life, whereas the group without a history of status were generally of late onset and were not found to have Ammon’s horn sclerosis. Cavanagh & Meyer state that the initial status epilepticus was commonly in the setting of an acute febrile episode that is to say, it was a severe febrile convulsion”. These data, and others, tend to delineate a nosological entity closely associating antecedents of febrile convulsions, early onset of complex partial seizures and mesial temporal sclerosis eventually disclosed after temporal lobectomy or autopsy. This could be of some relevance in the preoperative evaluation of intractable temporal epileptics, since MTS patients are known to benefit on a large scale from surgery.