Hemiconvulsion-hemiplegia epilepsy syndrome (HHE) is a clinical syndrome of infancy or early childhood that is associated with seizures, cerebral hemiatrophy and transient or permanent epilepsy.
It refers to the characteristic holohemispheric global atrophy of one hemisphere, that is independent of any vascular territory and subsequently follows a causative episode of prolonged clonic seizures in the course of a febrile disease. The prolonged unilateral predominant seizure(s) in the initial episode occurs in children usually younger than 4 years of age and are referred to as hemiconvulsion-hemiplegia syndrome (HH).
The exact incidence of this uncommon syndrome is unknown. Overall there has been decreasing incidence in the industrialized countries over the past decades.
Classic patient history is that of initial prolonged hemiconvulsion in infancy or early childhood in a febrile context with immediate flaccid hemiplegia (HH episode), subsequently followed by focal seizures after a seizure-free interval of months to years.
The mechanisms underlying the syndrome are not clarified.
Several factors might contribute to the pathogenesis of HH/HHE syndrome 1:
- prolonged seizure of long duration (possibly unnoticed) impairing metabolism of neuronal cells and leading to excitotoxic cell damage
- prolonged febrile seizure with an aggravation of cell injury by co-existent inflammation
- impairment of blood-brain-barrier permeability by both inflammatory changes and prolonged seizure
- predisposing genetic factors and/or focal epileptogenic lesion allowing for prolonged seizure
Late stage may demonstrate 6:
- slight, moderate or marked hemispheric atrophy
- focal atrophy or porencephaly
- no abnormalities at all
In late stage may additionally depict 5:
- subcortical cavitations in the affected hemisphere
- reduced calibre of ACA, MCA or PCA on the affected side
- small corpus callosum
- ipsilateral hemispheric volume loss with a shift of midline structures
- usually lack haemosiderin on T2*/SWI
Treatment and prognosis
Prevention is better than cure and early and aggressive termination of seizures is considered the most effective way to prevent post-convulsive hemiplegia 9.
In the failure of conservative treatment with anticonvulsants, epilepsy surgery may be indicated 7.
History and etymology
It was first described by the French neurologist Henri Jean Pascal Gastaut (1915-1995) et al. in 1960 4.
For cerebral hemiatrophy include 8:
- congenital disorders
- post-traumatic changes
- infections/inflammatory changes
- clinics: shorter or no symptom-free interval at all
- unihemispheric cerebral vasculitis
- Rasmussen encephalitis
- cerebral infarction
- hemiplegic migraine
- 1. Auvin S, Bellavoine V, Merdariu D et-al. Hemiconvulsion-hemiplegia-epilepsy syndrome: current understandings. Eur. J. Paediatr. Neurol. 2012;16 (5): 413-21. doi:10.1016/j.ejpn.2012.01.007 - Pubmed citation
- 2. Tenney JR, Schapiro MB. Child neurology: hemiconvulsion-hemiplegia-epilepsy syndrome. Neurology. 2012;79 (1): e1-4. doi:10.1212/WNL.0b013e31825dce5f - Pubmed citation
- 3. Oe H, Yuasa R, Tsuchiyama M et-al. Neuroimaging findings of hemiconvulsions, hemiplegia, epilepsy (HHE) syndrome. Rinsho Shinkeigaku. 1999;39 (4): 485-8. Pubmed citation
- 4. Gastaut H., Poirier F., Payan H.,et al, H.H.E. syndrome; hemiconvulsions, hemiplegia, epilepsy. Eksp Khirurgiia 1960 Jun; 1: 418-447
- 5. Salih MA, Kabiraj M, Al-Jarallah AS et-al. Hemiconvulsion-hemiplegia-epilepsy syndrome. A clinical, electroencephalographic and neuroradiological study. Childs Nerv Syst. 1997;13 (5): 257-63. Pubmed citation
- 6. Kataoka K, Okuno T, Mikawa H et-al. Cranial computed tomographic and electroencephalographic abnormalities in children with post-hemiconvulsive hemiplegia. Eur. Neurol. 1989;28 (5): 279-84. Pubmed citation
- 7. van Toorn R, Janse van Rensburg P, Solomons R et-al. Hemiconvulsion-hemiplegia-epilepsy syndrome in South African children: insights from a retrospective case series. Eur. J. Paediatr. Neurol. 2012;16 (2): 142-8. doi:10.1016/j.ejpn.2011.06.009 - Pubmed citation
- 8. Moritani T, Smoker WR, Lee HK et-al. Differential diagnosis of cerebral hemispheric pathology: multimodal approach. Clin Neuroradiol. 2011;21 (2): 53-63. doi:10.1007/s00062-011-0072-7 - Pubmed citation
- 9. Bhat RY, Kakkar S, Prakashini K. Hemiconvulsion-hemiplegia-epilepsy syndrome: clinical course and neuroradiological features in a 20-month-old girl. BMJ Case Rep. 2014;2014 (mar10 1): . doi:10.1136/bcr-2013-203482 - Pubmed citation