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Canpolat M, Gumus H, Kumandas S, Coskun A, Per H. The use of rapamycin in patients with tuberous sclerosis complex: Long-term results. Epilepsy Behav 2018; 88:357-364. [PMID: 30305233 DOI: 10.1016/j.yebeh.2018.09.020] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Accepted: 09/16/2018] [Indexed: 10/28/2022]
Abstract
PURPOSE The purpose of this study was to evaluate the long-term results of eight cases diagnosed with tuberous sclerosis complex (TSC) and receiving rapamycin therapy because of epileptic seizures and/or accompanying TSC findings. METHOD Rapamycin therapy was initiated at a dose of 1.5 mg/m2. Seizure frequency, electroencephalographic (EEG) findings, renal and cranial imaging findings, and cutaneous lesions over 3- to 6-month periods during follow-up and treatment were evaluated. RESULTS Four girls and four boys aged 4-16 years at the start of rapamycin therapy and now aged 9-24 years were evaluated. Duration of rapamycin therapy was 1-5 years, and the monitoring period after commencement of rapamycin therapy lasted 5-8 years. Positive effects were observed at 9-12 months in three out of six cases of renal angiomyolipoma (AML) and in the second year of treatment in one. An increase in AML dimensions was observed in three cases after treatment was stopped. Seizure control was established in the first year of rapamycin therapy in all cases. An increased frequency of seizures was observed in three cases after the second year of treatment. No seizure recurrence was determined in the second year of treatment with rapamycin in five out of eight cases. Recurrence of seizure was observed in 6-12 months after the discontinuation of rapamycin in three cases. CONCLUSION Rapamycin therapy exhibits positive effects on epileptic seizures in cases of TSC in 1-2 years but these positive effects on seizure control of rapamycin therapy decline after the second year. Larger case series are still needed to determine the duration and effectiveness of treatment in childhood.
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Affiliation(s)
- Mehmet Canpolat
- Erciyes University Medical School, Department of Pediatrics, Division of Pediatric Neurology, Talas, Kayseri, Turkey.
| | - Hakan Gumus
- Erciyes University Medical School, Department of Pediatrics, Division of Pediatric Neurology, Talas, Kayseri, Turkey
| | - Sefer Kumandas
- Erciyes University Medical School, Department of Pediatrics, Division of Pediatric Neurology, Talas, Kayseri, Turkey
| | - Abdulhakim Coskun
- Erciyes University Medical School, Department of Radiology and Pediatric Radiology, Talas, Kayseri, Turkey
| | - Huseyin Per
- Erciyes University Medical School, Department of Pediatrics, Division of Pediatric Neurology, Talas, Kayseri, Turkey.
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Canevini MP, Kotulska-Jozwiak K, Curatolo P, La Briola F, Peron A, Słowińska M, Strzelecka J, Vignoli A, Jóźwiak S. Current concepts on epilepsy management in tuberous sclerosis complex. AMERICAN JOURNAL OF MEDICAL GENETICS PART C-SEMINARS IN MEDICAL GENETICS 2018; 178:299-308. [PMID: 30255982 DOI: 10.1002/ajmg.c.31652] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/08/2018] [Revised: 08/21/2018] [Accepted: 08/23/2018] [Indexed: 12/12/2022]
Abstract
Tuberous sclerosis complex (TSC) is an autosomal dominant neurocutaneous disease affecting approximately 1 in 6,000 people, and represents one of the most common genetic causes of epilepsy. Epilepsy affects 90% of the patients and appears in the first 2 years of life in the majority of them. Early onset of epilepsy in the first 12 months of life is associated with high risk of cognitive decline and neuropsychiatric problems including autism. Prenatal or early infantile diagnosis of TSC, before the onset of epilepsy, provides a unique opportunity to monitor EEG before the onset of clinical seizures, thus enabling early intervention in the process of epileptogenesis. In this review, we discuss the current status of knowledge on epileptogenesis in TSC, and present recommendations of American and European experts in the field of epilepsy.
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Affiliation(s)
- Maria Paola Canevini
- Child Neuropsychiatry Unit - Epilepsy Center, San Paolo Hospital, Department of Health Sciences, Università degli Studi di Milano, Milan, Italy
| | | | - Paolo Curatolo
- Department of Pediatric Neuropsychiatry, Tor Vergata University, Rome, Italy
| | - Francesca La Briola
- Child Neuropsychiatry Unit - Epilepsy Center, San Paolo Hospital, Department of Health Sciences, Università degli Studi di Milano, Milan, Italy
| | - Angela Peron
- Child Neuropsychiatry Unit - Epilepsy Center, San Paolo Hospital, Department of Health Sciences, Università degli Studi di Milano, Milan, Italy.,Division of Medical Genetics, Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Monika Słowińska
- Department of Neurology and Epileptology, The Children's Memorial Health Institute, Warsaw, Poland.,Department of Pediatric Neurology, Warsaw Medical University, Warsaw, Poland
| | - Jolanta Strzelecka
- Department of Pediatric Neurology, Warsaw Medical University, Warsaw, Poland
| | - Aglaia Vignoli
- Child Neuropsychiatry Unit - Epilepsy Center, San Paolo Hospital, Department of Health Sciences, Università degli Studi di Milano, Milan, Italy
| | - Sergiusz Jóźwiak
- Department of Neurology and Epileptology, The Children's Memorial Health Institute, Warsaw, Poland.,Department of Pediatric Neurology, Warsaw Medical University, Warsaw, Poland
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53
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Challenges in managing epilepsy associated with focal cortical dysplasia in children. Epilepsy Res 2018; 145:1-17. [DOI: 10.1016/j.eplepsyres.2018.05.006] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2017] [Revised: 04/30/2018] [Accepted: 05/12/2018] [Indexed: 12/15/2022]
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Management of epilepsy associated with tuberous sclerosis complex: Updated clinical recommendations. Eur J Paediatr Neurol 2018; 22:738-748. [PMID: 29880258 DOI: 10.1016/j.ejpn.2018.05.006] [Citation(s) in RCA: 120] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2017] [Revised: 04/12/2018] [Accepted: 05/20/2018] [Indexed: 11/23/2022]
Abstract
Patients with tuberous sclerosis complex (TSC) are at very high risk for developing epilepsy, and the majority experience seizure onset during the first year of life. Early targeted interventions increase the probability of seizure-freedom and may protect neurodevelopment. In 2012, clinical recommendations for the management of epilepsy in patients with TSC were published by a panel of European experts. Since that time novel studies, reports, and expert opinions in preclinical and clinical TSC-related sciences prompted the need for updated recommendations, including epileptogenesis in TSC, the potential role of predictive biomarkers, the possible benefits of presymptomatic diagnosis and preventive treatment, and new treatment options including mTOR inhibitors. A reconvened panel reviewed the current literature to answer specific questions and five panelists discussed the findings, followed by a general discussion during which all issues were debated to achieve consensus regarding recommendations. A draft manuscript based on these discussions and recommendations was then circulated several times among the panelists, who added their own comments. All the panelists/authors agreed with the final manuscript, which was then submitted for publication. The panel concluded that the need for early diagnosis of TSC-associated seizures is now established, electroencephalographic monitoring has good predictive value for epilepsy before seizure onset in TSC, and, until conclusive data from the EPISTOP trial are available, administration of vigabatrin may be considered in children with subclinical epileptiform EEG discharges. The panel also supported the role of adjunctive everolimus for TSC-associated drug-refractory seizures and emphasized the necessity of early surgical evaluation.
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55
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de Vries PJ, Wilde L, de Vries MC, Moavero R, Pearson DA, Curatolo P. A clinical update on tuberous sclerosis complex-associated neuropsychiatric disorders (TAND). AMERICAN JOURNAL OF MEDICAL GENETICS PART C-SEMINARS IN MEDICAL GENETICS 2018; 178:309-320. [PMID: 30117265 DOI: 10.1002/ajmg.c.31637] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/06/2018] [Revised: 05/29/2018] [Accepted: 05/29/2018] [Indexed: 12/18/2022]
Abstract
Tuberous sclerosis complex (TSC) is associated with a wide range of behavioral, psychiatric, intellectual, academic, neuropsychological, and psychosocial difficulties, which are often underdiagnosed and undertreated. Here, we present a clinical update on TSC-associated neuropsychiatric disorders, abbreviated as "TAND," to guide screening, diagnosis, and treatment in practice. The review is aimed at clinical geneticists, genetic counselors, pediatricians, and all generalists involved in the assessment and treatment of children, adolescents and adults with TSC, and related disorders. The review starts with a summary of the construct and levels of TAND, before presenting up-to-date information about each level of investigation. The review concludes with a synopsis of current and future TAND research.
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Affiliation(s)
- Petrus J de Vries
- Division of Child and Adolescent Psychiatry, University of Cape Town, Cape Town, South Africa
| | - Lucy Wilde
- Cerebra Centre for Neurodevelopmental Disorders, School of Psychology, University of Birmingham, Birmingham, United Kingdom
| | - Magdalena C de Vries
- Division of Child and Adolescent Psychiatry, University of Cape Town, Cape Town, South Africa
| | - Romina Moavero
- Child Neurology and Psychiatry Unit, Systems Medicine Department, University of Rome Tor Vergata, Rome, Italy.,Child Neurology Unit, Neuroscience and Neurorehabilitation Department, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Deborah A Pearson
- Department of Psychiatry & Behavioral Sciences, McGovern Medical School, University of Texas Health Centre, Houston, Texas
| | - Paolo Curatolo
- Child Neurology and Psychiatry Unit, Systems Medicine Department, University of Rome Tor Vergata, Rome, Italy
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Song J, Swallow E, Said Q, Peeples M, Meiselbach M, Signorovitch J, Kohrman M, Korf B, Krueger D, Wong M, Sparagana S. Epilepsy treatment patterns among patients with tuberous sclerosis complex. J Neurol Sci 2018; 391:104-108. [DOI: 10.1016/j.jns.2018.06.011] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Revised: 06/01/2018] [Accepted: 06/13/2018] [Indexed: 12/24/2022]
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van der Poest Clement EA, Sahin M, Peters JM. Vigabatrin for Epileptic Spasms and Tonic Seizures in Tuberous Sclerosis Complex. J Child Neurol 2018; 33:519-524. [PMID: 29687739 DOI: 10.1177/0883073818768309] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Vigabatrin is recommended as first-line treatment for infantile spasms in tuberous sclerosis complex (TSC), but other indications in children with tuberous sclerosis complex are less known. We retrospectively reviewed 201 children with tuberous sclerosis complex, and identified 21 children older than 1 year started on vigabatrin for any indication and with sufficient follow-up data. The indication for vigabatrin was epileptic spasms (n = 13), tonic seizures (n = 5), both (n = 2), and status epilepticus (n = 1). Mean age of treatment onset was 4.0 years (range 1.1-18.3). All but 1 patient had a reduction in seizures. Ten patients became seizure free and 4 had an improvement of >90%. In 9 patients, vigabatrin was tapered successfully after 8 to 33 months. Side effects reported included rash (n = 1) and behavioral decline (n = 1). No retinal toxicity was detected in 14 of 21 patients with adequate ophthalmologic surveillance data. In conclusion, vigabatrin may be an effective treatment for epileptic spasms and tonic seizures beyond the infantile age.
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Affiliation(s)
- Emma A van der Poest Clement
- 1 Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital and Harvard Medical, School, Boston, MA, USA
| | - Mustafa Sahin
- 2 Department of Neurology, Translational Neuroscience Center, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | - Jurriaan M Peters
- 1 Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital and Harvard Medical, School, Boston, MA, USA
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Wirrell EC, Vanderwiel AJ, Nickels L, Vanderwiel SL, Nickels KC. Impact of Prior Authorization of Antiepileptic Drugs in Children With Epilepsy. Pediatr Neurol 2018; 83:38-41. [PMID: 29753573 DOI: 10.1016/j.pediatrneurol.2018.03.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Accepted: 03/16/2018] [Indexed: 11/18/2022]
Abstract
OBJECTIVE We assessed how commonly prior authorization results in treatment delay or missed doses in children with epilepsy. METHODS Parents of 462 children followed in a pediatric epilepsy clinic were surveyed regarding prior authorization in the preceding year. Epilepsy and insurance details were collected. If prior authorization was required, parents were asked whether it resulted in (1) delayed initiation of a newly-prescribed antiepileptic drug, and/or (2) lapse in coverage of a current medication. Prior authorization was defined as smooth if there was a less than seven day delay in starting a new antiepileptic drug and no lapse in coverage of a current medication. RESULTS A total of 164 families (35%) returned completed surveys. Mean age of the children was 11.2 (S.D. 5.3) years and 67.4% experienced seizures more than every three months despite trials of two or more antiepileptic drugs. Primary insurance was private in 82.9% and Medicaid in 15.2%. Prior authorization was required in 63 (38.4%) cases, and proceeded smoothly in only 31 (49.2%). Twenty-three children experienced a delay of seven days or more in starting a new drug, and 24 experienced a lapse in coverage of their current medication, 11 of whom missed doses. Of these 11, seven had increased seizures, and one required hospital admission for status epilepticus. CONCLUSIONS Prior authorization of antiepileptic drugs is common but problematic, often resulting in either a delay of initiation of a new antiepileptic drug or a lapse in coverage of a currently-used antiepileptic drug, with a negative impact on seizure control.
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Affiliation(s)
- Elaine C Wirrell
- Divisions of Child and Adolescent Neurology and Epilepsy, Mayo Clinic, Rochester, Minnesota.
| | - Alexander J Vanderwiel
- Divisions of Child and Adolescent Neurology and Epilepsy, Mayo Clinic, Rochester, Minnesota
| | - Lauren Nickels
- Divisions of Child and Adolescent Neurology and Epilepsy, Mayo Clinic, Rochester, Minnesota
| | - Saskia L Vanderwiel
- Divisions of Child and Adolescent Neurology and Epilepsy, Mayo Clinic, Rochester, Minnesota
| | - Katherine C Nickels
- Divisions of Child and Adolescent Neurology and Epilepsy, Mayo Clinic, Rochester, Minnesota
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Adjunctive everolimus for children and adolescents with treatment-refractory seizures associated with tuberous sclerosis complex: post-hoc analysis of the phase 3 EXIST-3 trial. THE LANCET CHILD & ADOLESCENT HEALTH 2018; 2:495-504. [PMID: 30169322 DOI: 10.1016/s2352-4642(18)30099-3] [Citation(s) in RCA: 68] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Revised: 03/01/2018] [Accepted: 03/09/2018] [Indexed: 01/01/2023]
Abstract
BACKGROUND Epilepsy occurs in 70-90% of patients with tuberous sclerosis complex. We aimed to assess the efficacy and safety of adjunctive everolimus for treatment-refractory seizures associated with tuberous sclerosis complex in paediatric patients enrolled in the EXIST-3 trial, a double-blind, placebo-controlled, randomised, phase 3 study. METHODS This post-hoc analysis focused on paediatric patients (age <18 years) in the EXIST-3 trial, which consisted of baseline (8 weeks), core (18 weeks), and extension phases (≥48 weeks) and was done at 99 centres in 25 countries worldwide. Briefly, patients with tuberous sclerosis complex-associated treatment-refractory seizures, who were receiving a stable dose of one to three antiepileptic drugs, were randomly assigned (1:1:1) to receive placebo, low-exposure everolimus (3-7 ng/mL), or high-exposure everolimus (9-15 ng/mL). Following the core phase, patients could enter the extension phase to receive everolimus at a targeted exposure range of 3-15 ng/mL up to 48 weeks after the last patient had completed the core phase. Efficacy endpoints were response rate (≥50% of reduction from baseline in average weekly seizure frequency) and median percentage reduction in seizure frequency during the 12-week maintenance period of the core phase, and at 12-week intervals throughout the extension phase. This study is registered with ClinicalTrials.gov, number NCT01713946. FINDINGS Between July 3, 2013, and May 29, 2015, 299 paediatric patients enrolled in the trial. In the younger subgroup (<6 years; n=104), 34 received placebo, 33 low-exposure everolimus, and 37 high-exposure everolimus; in the older subgroup (≥6 years to <18 years; n=195), 62 received placebo, 63 low-exposure everolimus, and 70 high-exposure everolimus. At the end of the core phase, response rate was higher in the treatment groups than placebo in both the younger subgroup (17·6% [6·8-34·5] for placebo vs 30·3% [95% CI 15·6-48·7; p=0·2245] for low-exposure everolimus vs 59·5% [42·1-75·2; p=0·0003] for high-exposure everolimus) and the older subgroup (12·9% [5·7-23·9] vs 27·0% [16·6-39·7; p=0·0491] vs 30·0% [19·6-42·1; p=0·0179]), as were median reduction in seizure frequency (12·3% [95% CI -10·1 to 24·8] vs 29·3% [95% CI 13·4 to 46·3; p=0·0474] vs 54·7% [43·5 to 73·1; p<0·0001] in younger patients; 13·5% [-3·0 to 26·8] vs 31·0% [16·1 to 42·9; p=0·0128] vs 34·8% [26·7 to 41·3; p=0·0006] in older patients). The efficacy persisted, with sustained seizure reduction after 1 year of treatment across both paediatric subgroups (response rate 48·9% [95% CI 38·1-59·8] for the younger subgroup vs 47·2% [39·3-55·2] for the older subgroup; median percentage reduction in seizure frequency 48·4% [95% CI 34·3-73·6] vs 48·0% [38·2-57·5]). At the cutoff date for the extension phase, grade 3 or 4 adverse events were reported in 45 (45%) younger patients (commonly pneumonia [n=16]) and 74 (38%) older patients (commonly pneumonia [n=8] and stomatitis [n=6]). Two deaths (pneumonia, which was suspected to be treatment-related, and sudden unexplained death due to epilepsy) were reported. INTERPRETATION Adjunctive everolimus resulted in sustained reductions in seizure frequency after 1 year and was well tolerated in paediatric patients with treatment-refractory seizures associated with tuberous sclerosis complex. FUNDING Novartis Pharmaceuticals Corporation.
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Tye C, Thomas LE, Sampson JR, Lewis J, O'Callaghan F, Yates JRW, Bolton PF. Secular changes in severity of intellectual disability in tuberous sclerosis complex: A reflection of improved identification and treatment of epileptic spasms? Epilepsia Open 2018; 3:276-280. [PMID: 29881807 PMCID: PMC5983114 DOI: 10.1002/epi4.12111] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/15/2018] [Indexed: 11/10/2022] Open
Abstract
Tuberous sclerosis complex (TSC) is a multisystem genetic disorder caused by mutations in TSC1 or TSC2. Epilepsy occurs in 80%-90% of affected individuals during their lifetime, and up to one-third of children with TSC will develop epileptic (infantile) spasms, for which vigabatrin has been shown to be particularly effective. Epilepsy severity and epileptic spasms are consistent markers of risk for the development of intellectual impairment in TSC. Although previous studies demonstrate a bimodal distribution of intellectual ability in TSC, recent findings suggest a unimodal distribution, which may reflect a change in IQ distribution over time. We compared 3 large historical UK cohorts of TSC (n = 331) that show varied distributions of intellectual ability, first ruling out differences in study methodology. Later-born individuals had a higher frequency of reported spasms and higher likelihood of vigabatrin administration, but were less likely to have profound intellectual impairment, compared to the earlier-born individuals. Our findings suggest that epileptic spasms went undetected in the older patients and therefore were not treated, leading to a higher occurrence of profound impairment, whereas the later born cohort had better access to treatment. These findings support the importance of early identification and treatment of seizures in TSC.
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Affiliation(s)
- Charlotte Tye
- Department of Child & Adolescent Psychiatry and MRC Social Genetic & Developmental Psychiatry Centre Institute of Psychiatry, Psychology & Neuroscience King's College London London United Kingdom
| | - Laura E Thomas
- Division of Cancer and Genetics Institute of Medical Genetics Cardiff University School of Medicine Cardiff United Kingdom
| | - Julian R Sampson
- Division of Cancer and Genetics Institute of Medical Genetics Cardiff University School of Medicine Cardiff United Kingdom
| | - Julia Lewis
- Mental Health and Learning Disabilities Division Anuerin Bevan University Health Board Newport United Kingdom
| | - Finbar O'Callaghan
- Institute of Child Health University College London London United Kingdom
| | - John R W Yates
- Department of Medical Genetics University of Cambridge Cambridge United Kingdom
| | - Patrick F Bolton
- Department of Child & Adolescent Psychiatry and MRC Social Genetic & Developmental Psychiatry Centre Institute of Psychiatry, Psychology & Neuroscience King's College London London United Kingdom
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Słowińska M, Jóźwiak S, Peron A, Borkowska J, Chmielewski D, Sadowski K, Jurkiewicz E, Vignoli A, La Briola F, Canevini MP, Kotulska-Jóźwiak K. Early diagnosis of tuberous sclerosis complex: a race against time. How to make the diagnosis before seizures? Orphanet J Rare Dis 2018; 13:25. [PMID: 29378663 PMCID: PMC5789613 DOI: 10.1186/s13023-018-0764-z] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2017] [Accepted: 01/10/2018] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Tuberous sclerosis complex (TSC) is a genetic disorder with an incidence of 1:6000 live births and associated with the development of benign tumors in several organs. It is also characterized by high rates of neurological and neuropsychiatric abnormalities, including epilepsy affecting 70-90% of patients and being one of the major risk factors of intellectual disability. The first seizures in TSC patients appear usually between the 4th and the 6th months of life. Recent studies have shown the beneficial role of preventative antiepileptic treatment in TSC patients, with the possibility for improvement of cognitive outcome. Moreover, European recommendations suggest early introduction of Vigabatrin if ictal discharges occur on EEG recordings, with or without clinical manifestation. The aim of this study was to define the most useful approach to make the diagnosis of TSC before seizure onset (before age 4th months), in order to start early EEG monitoring with possible preventative treatment intervention. METHODS We performed a retrospective review of children who were suspected of having TSC due to single or multiple cardiac tumors as the first sign of the disease. We analyzed the medical records in terms of conducted clinical tests and TSC signs, which were observed until the end of the 4th month of age. Subsequently, we described the different clinical scenarios and recommendations for early diagnosis. RESULTS 82/100 children were diagnosed with TSC within the first 4 months of life. Apart from cardiac tumors, the most frequently observed early TSC signs were subependymal nodules (71/100, 71%), cortical dysplasia (66/100, 66%), and hypomelanotic macules (35/100, 35%). The most useful clinical studies for early TSC diagnosis were brain magnetic resonance imaging (MRI), skin examination and echocardiography. Genetic testing was performed in 49/100 of the patients, but the results were obtained within the first 4 months of life in only 3 children. CONCLUSIONS Early diagnosis of TSC, before seizure onset, is feasible and it is becoming pivotal for epilepsy management and improvement of cognitive outcome. Early TSC diagnosis is mostly based on clinical signs. Brain MRI, echocardiography, skin examination and genetic testing should be performed early in every patient suspected of having TSC.
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Affiliation(s)
- Monika Słowińska
- Department of Neurology and Epileptology, The Children’s Memorial Health Institute, Al. Dzieci Polskich 20, 04-730 Warszawa, Poland
- Department of Child Neurology, Medical University of Warsaw, Ul. Żwirki I Wigury 63A, 02-091 Warszawa, Poland
| | - Sergiusz Jóźwiak
- Department of Neurology and Epileptology, The Children’s Memorial Health Institute, Al. Dzieci Polskich 20, 04-730 Warszawa, Poland
- Department of Child Neurology, Medical University of Warsaw, Ul. Żwirki I Wigury 63A, 02-091 Warszawa, Poland
| | - Angela Peron
- Child Neuropsychiatry Unit - Epilepsy Center, San Paolo Hospital, Via Antonio di Rudinì, 8, 20142 Milan, Italy
- Department of Health Sciences, Università degli Studi di Milano, Via Antonio di Rudinì, 8, 20142 Milan, Italy
- Department of Pediatrics, Division of Medical Genetics, University of Utah School of Medicine, Salt Lake City, UT USA
| | - Julita Borkowska
- Department of Neurology and Epileptology, The Children’s Memorial Health Institute, Al. Dzieci Polskich 20, 04-730 Warszawa, Poland
| | - Dariusz Chmielewski
- Department of Neurology and Epileptology, The Children’s Memorial Health Institute, Al. Dzieci Polskich 20, 04-730 Warszawa, Poland
| | - Krzysztof Sadowski
- Department of Neurology and Epileptology, The Children’s Memorial Health Institute, Al. Dzieci Polskich 20, 04-730 Warszawa, Poland
| | - Elżbieta Jurkiewicz
- Department of Radiology, The Children’s Memorial Health Institute, Al. Dzieci Polskich 20, 04-730 Warszawa, Poland
| | - Aglaia Vignoli
- Child Neuropsychiatry Unit - Epilepsy Center, San Paolo Hospital, Via Antonio di Rudinì, 8, 20142 Milan, Italy
- Department of Health Sciences, Università degli Studi di Milano, Via Antonio di Rudinì, 8, 20142 Milan, Italy
| | - Francesca La Briola
- Child Neuropsychiatry Unit - Epilepsy Center, San Paolo Hospital, Via Antonio di Rudinì, 8, 20142 Milan, Italy
| | - Maria Paola Canevini
- Child Neuropsychiatry Unit - Epilepsy Center, San Paolo Hospital, Via Antonio di Rudinì, 8, 20142 Milan, Italy
- Department of Health Sciences, Università degli Studi di Milano, Via Antonio di Rudinì, 8, 20142 Milan, Italy
| | - Katarzyna Kotulska-Jóźwiak
- Department of Neurology and Epileptology, The Children’s Memorial Health Institute, Al. Dzieci Polskich 20, 04-730 Warszawa, Poland
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Curatolo P, Moavero R, van Scheppingen J, Aronica E. mTOR dysregulation and tuberous sclerosis-related epilepsy. Expert Rev Neurother 2018; 18:185-201. [DOI: 10.1080/14737175.2018.1428562] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- Paolo Curatolo
- Child Neurology and Psychiatry Unit, Systems Medicine Department, Tor Vergata University Hospital, Rome, Italy
| | - Romina Moavero
- Child Neurology and Psychiatry Unit, Systems Medicine Department, Tor Vergata University Hospital, Rome, Italy
- Child Neurology Unit, Neuroscience and Neurorehabilitation Department, “Bambino Gesù” Children’s Hospital, IRCCS, Rome, Italy
| | - Jackelien van Scheppingen
- Department of (Neuro)Pathology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Eleonora Aronica
- Department of (Neuro)Pathology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
- Stichting Epilepsie Instellingen Nederland (SEIN), The Netherlands
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Mao S, Long Q, Lin H, Liu J. Rapamycin therapy for neonatal tuberous sclerosis complex with cardiac rhabdomyomas: A case report and review. Exp Ther Med 2017; 14:6159-6163. [PMID: 29285173 PMCID: PMC5740740 DOI: 10.3892/etm.2017.5335] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Accepted: 07/11/2017] [Indexed: 11/19/2022] Open
Abstract
Tuberous sclerosis complex (TSC) is an autosomal dominant genetic disease that varies greatly in its expression. The current study reports a novel case of TSC caused by a TSC2 mutation (TSC2c.1642_1643insA or TSC2p.K549fsX589), in which multiple cardiac rhabdomyomas were detected by fetal echocardiography in week 31 of pregnancy. The infant was delivered successfully; however, seizures began 16 days following birth. Subsequent genetic tests confirmed a diagnosis of TSC. Rapamycin treatment resulted in regression of cardiac rhabdomyomas and controlled seizures. The current study demonstrates the value of fetal echocardiography in the diagnosis of TSC and suggests that inhibition of the mammalian target of the rapamycin (mTOR) signaling pathway may be considered as a potential antiepileptogenic therapy for neonatal TSC. In addition, it was demonstrated that rapamycin treatment was therapeutically beneficial for preventing disorders caused by abnormal mTOR signaling, such as cancer. According to the literature, cardiac rhabdomyomas, seizures and skin lesions are well established markers for TSC in neonates. MRI scans of the brain and genetic screening of TSC1 and TSC2 genes may facilitate an early diagnosis of TSC.
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Affiliation(s)
- Shanshan Mao
- Department of Neurology, The Children's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang 310052, P.R. China
| | - Qi Long
- Department of Clinical Nutrition, The Children's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang 310052, P.R. China
| | - Huijia Lin
- Department of Neonatology, The Children's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang 310052, P.R. China
| | - Jinling Liu
- Department of Pulmonology, The Children's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang 310052, P.R. China
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Abstract
Utilizing the multicenter TSC (tuberous sclerosis complex) Natural History Database including 2034 subjects, this study aimed to identify predictors of drug-resistant epilepsy in TSC. Basic epilepsy data were available for 1965 individuals in the database. Supplemental data were further collected from 1546 of these subjects through directed site queries, addressing additional epilepsy characteristics including the presence of drug-resistant epilepsy, therapies trialed, and outcomes of specific therapies. Epilepsy was reported in 86.4% of individuals with TSC. Infantile spasms were reported in 45.2% of individuals and focal seizures were reported in 84.4% of individuals. In those with focal epilepsy, drug resistance was reported in 59.6%, with focal seizure onset prior to age 1 year (odds ratio [OR] 1.9, confidence interval [CI] 1.4-2.5, P < .001), infantile spasms (OR 2.0, CI 1.5-2.5, P < 0.001), and infantile spasms incompletely responsive to therapy (OR 47.6, CI 6.7-333.3, P < 0.001) being associated with an increased likelihood of drug resistance.
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Affiliation(s)
- Anna Jeong
- Department of Neurology, Washington University School of Medicine,
St. Louis, MO 63110
| | | | - Michael Wong
- Department of Neurology, Washington University School of Medicine,
St. Louis, MO 63110
- Hope Center for Neurological Disorders, Washington University School
of Medicine, St. Louis, MO 63110
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Tuchman R. What is the Relationship Between Autism Spectrum Disorders and Epilepsy? Semin Pediatr Neurol 2017; 24:292-300. [PMID: 29249509 DOI: 10.1016/j.spen.2017.10.004] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The association of epilepsy and autism spectrum disorders (ASD) is best understood by examining the relationship between social cognition, nonsocial cognition, and epilepsy. The relationship between ASD and epilepsy is bidirectional and is strongly linked to intellectual disability (ID). The risk of developing ASD in children with epilepsy is highest in children with early onset seizures, with a high prevalence in children with infantile spasms. The risk of developing epilepsy in children first diagnosed with ASD is highest in those with ID. The prevalence of seizures in ASD increases with age. When epilepsy and ASD coexist, they share common pathophysiological mechanisms. In epilepsy with and without ID, social-cognitive deficits are an important determinant of neurodevelopmental outcomes. Early recognition of social deficits is an important aspect of the comprehensive management of children with epilepsy. Treating the seizures in individuals with epilepsy and ASD is crucial but interventions that address social-cognitive deficits are necessary to maximize neurodevelopmental outcomes.
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Affiliation(s)
- Roberto Tuchman
- From the Department of Neurology, Nicklaus Children's Hospital Miami Children's Health System, Miami, FL.
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Nickels KC, Wirrell EC. Cognitive and Social Outcomes of Epileptic Encephalopathies. Semin Pediatr Neurol 2017; 24:264-275. [PMID: 29249506 DOI: 10.1016/j.spen.2017.10.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
The term "epileptic encephalopathy" denotes a disorder in which seizures or frequent interictal discharges exacerbate neurocognitive dysfunction beyond what would be expected on the basis of underlying etiology. However, many underlying causes of epileptic encephalopathy also result in neurocognitive deficits, and it can be challenging to discern to what extent these deficits can be improved with better seizure control. Additionally, as seizures in these conditions are typically refractory, children are often exposed to high doses of multiple antiepileptic drugs which further exacerbate these comorbidities. This review will summarize the neurocognitive and social outcomes in children with various epileptic encephalopathies. Prompt, accurate diagnosis of epilepsy syndrome and etiology allows selection of optimal therapy to maximize seizure control, limiting the impact of ongoing seizures and frequent epileptiform abnormalities on the developing brain. Furthermore, mandatory screening for comorbidities allows early recognition and focused therapy for these commonly associated conditions to maximize neurocognitive outcome.
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Affiliation(s)
- Katherine C Nickels
- Divisions of Child and Adolescent Neurology and Epilepsy, Mayo Clinic, Rochester, MN
| | - Elaine C Wirrell
- Divisions of Child and Adolescent Neurology and Epilepsy, Mayo Clinic, Rochester, MN.
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Capal JK, Horn PS, Murray DS, Byars AW, Bing NM, Kent B, Bucher LA, Williams ME, O’Kelley S, Pearson DA, Sahin M, Krueger DA, Mansour R, Hanson EM, Peters J, Goyal M, Walsh A, Bruns S, Filip-Dhima R, Mitchell T, Cutter G, Northrup H, Wu JY, Bebin M. Utility of the Autism Observation Scale for Infants in Early Identification of Autism in Tuberous Sclerosis Complex. Pediatr Neurol 2017; 75:80-86. [PMID: 28844798 PMCID: PMC5610103 DOI: 10.1016/j.pediatrneurol.2017.06.010] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Revised: 06/19/2017] [Accepted: 06/21/2017] [Indexed: 12/15/2022]
Abstract
BACKGROUND Tuberous sclerosis complex (TSC) is a genetic disorder with high prevalence of associated autism spectrum disorder (ASD). Our primary objectives were to determine early predictors of autism risk to identify children with TSC in most need of early interventions. The Autism Observation Scale for Infants (AOSI) was evaluated as a measure of ASD-associated behaviors in infants with TSC at age 12 months and its ability to predict ASD at 24 months. METHODS Children ages 0 to 36 months with TSC were enrolled in the TSC Autism Center of Excellence Research Network (TACERN), a multicenter, prospective observational study to identify biomarkers of ASD. The AOSI was administered at age 12 months and the Autism Diagnostic Observation Schedule-2 (ADOS-2) and Autism Diagnostic Interview-Revised (ADI-R) at 24 months. Developmental functioning was assessed using the Mullen Scales of Early Learning. Children were classified as ASD or non-ASD according to the ADOS-2. RESULTS Analysis included 79 children who had been administered the AOSI at 12 months and ADOS-2 and ADI-R at 24 months. The ASD group had a mean AOSI total score at 12 months significantly higher than the non-ASD group (11.8 ± 7.4 vs 6.3 ± 4.7; P < 0.001). An AOSI total score cutoff of 13 provided a specificity of 0.89 to detect ASD with the ADOS-2. AOSI total score at 12 months was similarly associated with exceeding cutoff scores on the ADI-R. CONCLUSIONS The AOSI is a useful clinical tool in determining which infants with TSC are at increased risk for developing ASD.
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Affiliation(s)
- Jamie K Capal
- Department of Neurology MLC 2015, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.
| | - Paul S. Horn
- Department of Neurology MLC 2015, Cincinnati Children’s Hospital Medical Center 3333 Burnet Avenue, Cincinnati, OH, 45229, USA
| | - Donna S. Murray
- Department of Developmental and Behavioral Pediatrics, Cincinnati Children’s Hospital Medical Center, 3430 Burnet Avenue, Cincinnati, OH, 45229, USA,Autism Speaks Inc, 85 Devonshire St, Boston, MA 02109, USA
| | - Anna Weber Byars
- Department of Neurology MLC 2015, Cincinnati Children’s Hospital Medical Center 3333 Burnet Avenue, Cincinnati, OH, 45229, USA
| | - Nicole M. Bing
- Department of Developmental and Behavioral Pediatrics, Cincinnati Children’s Hospital Medical Center, 3430 Burnet Avenue, Cincinnati, OH, 45229, USA
| | - Bridget Kent
- Department of Developmental and Behavioral Pediatrics, Cincinnati Children’s Hospital Medical Center, 3430 Burnet Avenue, Cincinnati, OH, 45229, USA
| | - Lindsey A. Bucher
- Department of Developmental and Behavioral Pediatrics, Cincinnati Children’s Hospital Medical Center, 3430 Burnet Avenue, Cincinnati, OH, 45229, USA
| | - Marian E. Williams
- Keck School of Medicine of USC, University of Southern California, Children’s Hospital Los Angeles, 4650 Sunset Blvd., MS#53, Los Angeles, CA 90027, USA
| | - Sarah O’Kelley
- University of Alabama at Birmingham, 1720 2nd Ave S, Birmingham, AL 35233, USA
| | - Deborah A. Pearson
- McGovern Medical School, The University of Texas Health Science Center at Houston, 1941 East Road, Rm. 3.126 BBSB; Houston, TX 77054
| | - Mustafa Sahin
- Department of Neurology, Boston Children’s Hospital, 300 Longwood Avenue, Boston, MA, 02115, USA
| | - Darcy A. Krueger
- Department of Neurology MLC 2015, Cincinnati Children’s Hospital Medical Center 3333 Burnet Avenue, Cincinnati, OH, 45229, USA
| | - Rosleen Mansour
- McGovern Medical School, The University of Texas Health Science Center at Houston, 1941 East Road, Rm. 3.126 BBSB; Houston, TX 77054
| | - Ellen M. Hanson
- Division of Developmental Medicine, Boston Children’s Hospital and Harvard Medical School, Boston, MA, 300 Longwood Avenue, 02115, USA
| | - Jurriaan Peters
- Department of Neurology, Boston Children’s Hospital, 300 Longwood Avenue, Boston, MA, 02115, USA
| | - Monisha Goyal
- University of Alabama at Birmingham, 1720 2nd Ave S, Birmingham, AL 35233, USA
| | - Amy Walsh
- Department of Neurology, Boston Children’s Hospital, 300 Longwood Avenue, Boston, MA, 02115, USA
| | - Stephanie Bruns
- Department of Neurology MLC 2015, Cincinnati Children’s Hospital Medical Center 3333 Burnet Avenue, Cincinnati, OH, 45229, USA
| | - Rajna Filip-Dhima
- Department of Neurology, Boston Children’s Hospital, 300 Longwood Avenue, Boston, MA, 02115, USA
| | - Terry Mitchell
- Department of Developmental and Behavioral Pediatrics, Cincinnati Children’s Hospital Medical Center, 3430 Burnet Avenue, Cincinnati, OH, 45229, USA
| | - Gary Cutter
- McGovern Medical School, The University of Texas Health Science Center at Houston, 1941 East Road, Rm. 3.126 BBSB; Houston, TX 77054
| | - Hope Northrup
- McGovern Medical School, The University of Texas Health Science Center at Houston, 6431 Fannin Street, Houston, TX 77030, USA
| | - Joyce Y. Wu
- Division of Pediatric Neurology, UCLA Mattel Children’s Hospital, David Geffen School of Medicine, University of California Los Angeles, 10833 Le Conte Ave, Los Angeles, CA 90095, USA
| | - Martina Bebin
- University of Alabama at Birmingham, 1720 2nd Ave S, Birmingham, AL 35233, USA
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Jackson MC, Jafarpour S, Klehm J, Thome-Souza S, Coughlin F, Kapur K, Loddenkemper T. Effect of vigabatrin on seizure control and safety profile in different subgroups of children with epilepsy. Epilepsia 2017; 58:1575-1585. [PMID: 28691157 DOI: 10.1111/epi.13836] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/12/2017] [Indexed: 12/01/2022]
Abstract
OBJECTIVE To evaluate the efficacy and safety of vigabatrin in pediatric epilepsy. METHODS We retrospectively reviewed patients with epilepsy treated with vigabatrin over a 2-year period at a pediatric tertiary center. We assessed the relationship between seizure frequency, etiology, vigabatrin dose, adverse events, medication discontinuation reasons, and electroencephalography (EEG) characteristics. RESULTS One hundred three patients followed at Boston Children's Hospital were treated with vigabatrin and had complete medical records. Within the follow-up interval, 69 (67%) of 103 patients had discontinued vigabatrin therapy. Two patients (1.9%) died during therapy for unknown reasons. Median age at vigabatrin initiation was 8 months (interquartile range [IQR] 5-15). Median starting dose was 48.1 mg/kg per day (IQR 29.8-52.3) with a median target of 100 mg/kg (IQR 81.9-107.9). Median treatment duration was 12.1 months (n = 89, IQR 5.0-22.9) overall, and 13.3 months (IQR 5.2-23.2) for patients who discontinued vigabatrin. The most common reasons for discontinuation were controlled seizures in 31 (43.7%) of 71 and unsatisfactory therapeutic effect in 23 (32.4%) of 71. Median percent seizure reduction from baseline to first follow-up was 83.3% (IQR 27.4-99.8) and 96.7% (IQR 43.3-100) to last follow-up. Twenty-four (38.7%) of 62 patients with a follow-up posttreatment remained seizure-free. Four patients who had initially achieved seizure freedom relapsed. Patients with structural/metabolic etiology had greater median percent seizure reduction at first follow-up than patients with genetic etiology (98.7% vs. 61.4%, respectively, p = 0.001). Hypsarrhythmia resolved after therapy in 18 of 20 (90%, 95% confidence interval [CI] 70-97) patients with pretreatment hypsarrhythmia, and 2 patients presented with hypsarrhythmia posttreatment. Risk of having hypsarrhythmia was reduced by 32% (95% CI 14.9-49.1) posttreatment. SIGNIFICANCE Vigabatrin is efficacious in all seizure types and resolved hypsarrhythmia in most patients. In this series with a median treatment duration of 12.1 months, vigabatrin had a good safety profile with a low rate of discontinuation due to nonophthalmologic and ophthalmologic adverse effects.
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Affiliation(s)
- Michele C. Jackson
- Division of Epilepsy and Clinical Neurophysiology; Department of Neurology; Boston Children's Hospital; Harvard Medical School; Boston Massachusetts U.S.A
| | - Saba Jafarpour
- Division of Epilepsy and Clinical Neurophysiology; Department of Neurology; Boston Children's Hospital; Harvard Medical School; Boston Massachusetts U.S.A
| | - Jacquelyn Klehm
- Division of Epilepsy and Clinical Neurophysiology; Department of Neurology; Boston Children's Hospital; Harvard Medical School; Boston Massachusetts U.S.A
| | - Sigride Thome-Souza
- Division of Epilepsy and Clinical Neurophysiology; Department of Neurology; Boston Children's Hospital; Harvard Medical School; Boston Massachusetts U.S.A
- Psychiatry Department; Clinics Hospital-School of Medicine-University of Sao Paulo; Sao Paulo Brazil
| | - Francesca Coughlin
- Division of Epilepsy and Clinical Neurophysiology; Department of Neurology; Boston Children's Hospital; Harvard Medical School; Boston Massachusetts U.S.A
| | - Kush Kapur
- Division of Epilepsy and Clinical Neurophysiology; Department of Neurology; Boston Children's Hospital; Harvard Medical School; Boston Massachusetts U.S.A
| | - Tobias Loddenkemper
- Division of Epilepsy and Clinical Neurophysiology; Department of Neurology; Boston Children's Hospital; Harvard Medical School; Boston Massachusetts U.S.A
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Shehata HS, AbdelGhaffar HM, Nasreldin M, Elmazny A, Abdelalim A, Sabbah A, Shalaby NM. Clinical patterns and outcomes of status epilepticus in patients with tuberous sclerosis complex. Ther Clin Risk Manag 2017; 13:779-785. [PMID: 28721058 PMCID: PMC5501639 DOI: 10.2147/tcrm.s138576] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
INTRODUCTION Refractory epilepsy is a common clinical manifestation in patients with tuberous sclerosis complex (TSC), which can be complicated by many life-threatening conditions, such as status epilepticus (SE). However, very few reports mention the patterns and semiology of SE in those patients. OBJECTIVE To study the clinical characteristics and outcomes of SE in TSC patients. MATERIALS AND METHODS This observational, prospective study was carried out on 36 Egyptian children with definite TSC. Clinical history, general and neurological examination and psychometric evaluation by standard questionnaires were used to explore characteristics of epileptic manifestations and clinical patterns of SE. All included patients were required to have long-term video electroencephalograms (EEGs) and brain MRI performed. RESULTS A total of 32 attacks of SE were recorded in 21 patients (58.3%) in our cohort during a follow-up period of 2.8±1.1 years; of those patients, 15 had convulsive status, 7 had non-convulsive SE, 6 had refractory/super-refractory SE and 14 patients had a history of infantile spasms (epileptic spasms). The duration of status ranged from 40 to 150 min (mean ± standard deviation: 90±15). Fourteen patients with SE had severe mental retardation, 9 had autistic spectrum disorder and 22 had severe epileptogenic EEG findings. Patients with SE had higher tuber numbers (mean: 9.6), 5 patients had subependymal giant cell astrocytomas and 2 patients had their SE after receiving everolimus. CONCLUSIONS The incidence of SE in our patient sample is high (>50%); severe mental retardation, autistic features, history of infantile spasm (epileptic spasms) and high tuber burden are risk factors for developing SE.
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Park S, Lee EJ, Eom S, Kang HC, Lee JS, Kim HD. Ketogenic Diet for the Management of Epilepsy Associated with Tuberous Sclerosis Complex in Children. J Epilepsy Res 2017; 7:45-49. [PMID: 28775955 PMCID: PMC5540690 DOI: 10.14581/jer.17008] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2017] [Accepted: 05/17/2017] [Indexed: 11/21/2022] Open
Abstract
Background and Purpose In the present study, we reviewed the outcome of ketogenic diet (KD) use for the management of epilepsy in children with tuberous sclerosis complex (TSC). Methods A total of 12 children with intractable epilepsy associated with TSC who were treated with KD at our hospital between March 1, 2008 and February 28, 2015 were retrospectively enrolled. Results The mean age at the time of KD initiation was 73.1 ± 38.0 months. Patients were medically refractory to a mean of 4.8 ± 1.7 antiepileptic drugs. Nine patients (75.0%) had a history of infantile spasms. At 3 months after KD initiation, 10 patients (83.3%) had > 50% seizure reduction. Moreover, 7 patients (58.3%) exhibited qualitative improvements in cognition and behavior after KD initiation, as reported by caregivers/parents. The mean duration of dietary therapy was 14.8 ± 12.8 months. Half of the patients in this study eventually underwent epilepsy surgery due to persistent seizures or seizure relapse. Conclusion KD is an important non-pharmacological treatment option for patients with intractable epilepsy associated with TSC. KD may improve cognition and behavior in addition to reducing seizure frequency.
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Affiliation(s)
- Soyoung Park
- Department of Pediatrics, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, Bucheon, Korea
| | - Eun Joo Lee
- Division of Dietetics, Severance Children's Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Soyong Eom
- Epilepsy Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Hoon-Chul Kang
- Division of Pediatric Neurology, Epilepsy Research Institute, Severance Children's Hospital, Department of Pediatrics, Yonsei University College of Medicine, Seoul, Korea
| | - Joon Soo Lee
- Division of Pediatric Neurology, Epilepsy Research Institute, Severance Children's Hospital, Department of Pediatrics, Yonsei University College of Medicine, Seoul, Korea
| | - Heung Dong Kim
- Division of Pediatric Neurology, Epilepsy Research Institute, Severance Children's Hospital, Department of Pediatrics, Yonsei University College of Medicine, Seoul, Korea
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Gaetz W, Jurkiewicz MT, Kessler SK, Blaskey L, Schwartz ES, Roberts TP. Neuromagnetic responses to tactile stimulation of the fingers: Evidence for reduced cortical inhibition for children with Autism Spectrum Disorder and children with epilepsy. Neuroimage Clin 2017; 16:624-633. [PMID: 28971012 PMCID: PMC5619996 DOI: 10.1016/j.nicl.2017.06.026] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2016] [Revised: 05/30/2017] [Accepted: 06/16/2017] [Indexed: 12/04/2022]
Abstract
The purpose of this study was to compare somatosensory responses from a group of children with epilepsy and a group of children with autism spectrum disorder (ASD), with age matched TD controls. We hypothesized that the magnitude of the tactile "P50m" somatosensory response would be reduced in both patient groups, possibly due to reduced GABAergic signaling as has been implicated in a variety of previous animal models and in vivo human MRS studies. We observed significant (~ 25%) decreases in tactile P50m dipole moment values from the source localized tactile P50m response, both for children with epilepsy and for children with ASD. In addition, the latency of the tactile P50m peak was observed to be equivalent between TD and ASD groups but was significantly delayed in children with epilepsy by ~ 6 ms. Our data support the hypothesis of impaired GABAergic signaling in both children with ASD and children with epilepsy. Further work is needed to replicate these findings and directly relate them to both in vivo measures of GABA via e.g. magnetic resonance spectroscopy and psychophysical assessments of somatosensory function, and behavioral indices.
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Affiliation(s)
- William Gaetz
- Lurie Family Foundations MEG Imaging Center, Department of Radiology, Children's Hospital of Philadelphia, United States
- Department of Radiology, Children’s Hospital of Philadelphia and Perelman School of Medicine, University of Pennsylvania, United States
| | - Michael T. Jurkiewicz
- Department of Radiology, Children’s Hospital of Philadelphia and Perelman School of Medicine, University of Pennsylvania, United States
| | - Sudha Kilaru Kessler
- Department of Neurology, Children's Hospital of Philadelphia and Perelman School of Medicine, University of Pennsylvania, United States
- Department of Pediatrics, Children's Hospital of Philadelphia and Perelman School of Medicine, University of Pennsylvania, United States
| | - Lisa Blaskey
- Lurie Family Foundations MEG Imaging Center, Department of Radiology, Children's Hospital of Philadelphia, United States
- Children's Hospital of Philadelphia, Department of Radiology and Center for Autism Research, United States
| | - Erin S. Schwartz
- Lurie Family Foundations MEG Imaging Center, Department of Radiology, Children's Hospital of Philadelphia, United States
- Department of Radiology, Children’s Hospital of Philadelphia and Perelman School of Medicine, University of Pennsylvania, United States
| | - Timothy P.L. Roberts
- Lurie Family Foundations MEG Imaging Center, Department of Radiology, Children's Hospital of Philadelphia, United States
- Department of Radiology, Children’s Hospital of Philadelphia and Perelman School of Medicine, University of Pennsylvania, United States
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Moavero R, Santarone ME, Galasso C, Curatolo P. Cognitive and behavioral effects of new antiepileptic drugs in pediatric epilepsy. Brain Dev 2017; 39:464-469. [PMID: 28202262 DOI: 10.1016/j.braindev.2017.01.006] [Citation(s) in RCA: 78] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2016] [Revised: 12/28/2016] [Accepted: 01/16/2017] [Indexed: 01/31/2023]
Abstract
BACKGROUND In pediatric epilepsy, neurodevelopmental comorbidities could be sometimes even more disabling than seizures themselves, therefore it is crucial for the clinicians to understand how to benefit these children, and to choose the proper antiepileptic drug for the treatment of epilepsy associated to a specific neurodevelopmental disorder. Aim of this paper is to discuss the potential impact on cognition and behavior of new and newest AEDs and to guide the choice of the clinicians for a targeted use in epilepsy associated with specific neurodevelopmental disorders. METHODS Information in this review is mainly based on peer-reviewed medical publications from 2002 until October 2016 (PubMed). We choose to include in our review only the AEDs of second and third generation approved for pediatric population. RESULTS Vigabatrin, lamotrigine, topiramate, levetiracetam, oxcarbazepine, zonisamide, rufinamide, lacosamide, eslicarbazepine, and perampanel have been included in this review. The most tolerated AEDs from a cognitive and behavioral point of view are lamotrigine and rufinamide, thus representing optimal drugs for children with cognitive and/or attention problems. DISCUSSION Most of the new AEDs are initially licensed for adult patients. Data on children are usually very limited, both in terms of efficacy and safety, and the use standardized cognitive and behavioral outcome measures are very limited in pediatric clinical trials. CONCLUSION Several factors including polytherapy, administration of AEDs with the same mechanism of action and the dose and titration of the drug, should be considered as important in the development of cognitive and behavioral side effects.
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Affiliation(s)
- Romina Moavero
- Child Neurology and Psychiatry Unit, Tor Vergata University of Rome, Italy; Child Neurology Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy.
| | | | - Cinzia Galasso
- Child Neurology and Psychiatry Unit, Tor Vergata University of Rome, Italy
| | - Paolo Curatolo
- Child Neurology and Psychiatry Unit, Tor Vergata University of Rome, Italy
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Mitchell R, Barton S, Harvey AS, Williams K. Risk factors for the development of autism spectrum disorder in children with tuberous sclerosis complex: protocol for a systematic review. Syst Rev 2017; 6:49. [PMID: 28270230 PMCID: PMC5341363 DOI: 10.1186/s13643-017-0448-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2016] [Accepted: 02/28/2017] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Tuberous sclerosis complex (TSC) is an autosomal dominant condition, caused by mutations in either the TSC1 or TSC2 gene. It has widespread systemic manifestations and is associated with significant neurological morbidity. In addition to seizures and cerebral pathology including cortical tubers, subependymal nodules, subependymal giant cell astrocytoma and abnormal white matter, there are recognised neuropsychiatric difficulties including intellectual disability, autism spectrum disorder (ASD) and a range of learning and behaviour problems, recently conceptualised as "tuberous sclerosis-associated neuropsychiatric disorders", or "TAND". ASD in TSC is of particular importance because (1) it affects up to 50% of people with TSC and is a source of considerable difficulty for them and their families and (2) it provides a model for considering neurobiological pathways involved in ASD. Multiple factors are implicated in the development of ASD in TSC, including (1) seizures and related electrophysiological factors, (2) cerebral pathology, (3) genotype and (4) child characteristics. However, the neurobiological pathway remains unclear. We will conduct a systematic review to investigate and synthesise existing evidence about the role of these risk factors, individually and in combination, in leading to the development of ASD. METHODS Our review will report on all studies that include one or more of four predefined risk factors in the development of ASD in children with TSC. We will search five databases: MEDLINE, EMBASE, PubMed, The Cochrane Library and Web of Science (Conference Proceedings Citation Index). Studies will be selected for reporting after two authors independently (1) review all titles and abstracts, (2) read full text of all appropriate papers and (3) assess for bias using the Newcastle-Ottawa Scale recommended by the Guidelines for Meta-Analysis and Systematic Reviews of Observational Studies (MOOSE guidelines) and the ROBINS-I. DISCUSSION To our knowledge, this is the first systematic review investigating multiple risk factors in the development of ASD in children with TSC. Clarifying the evidence in this area will be important to researchers in the field and to clinicians providing prognostic information to families. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42016042841.
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Affiliation(s)
- Rebecca Mitchell
- Developmental Medicine, The Royal Children's Hospital, 50 Flemington Road, Parkville, Victoria, 3052, Australia.
| | - Sarah Barton
- Department of Neurology, The Royal Children's Hospital, 50 Flemington Road, Parkville, Victoria, 3052, Australia
| | - A Simon Harvey
- Department of Neurology, The Royal Children's Hospital, 50 Flemington Road, Parkville, Victoria, 3052, Australia
| | - Katrina Williams
- Developmental Medicine, The Royal Children's Hospital, 50 Flemington Road, Parkville, Victoria, 3052, Australia
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Abstract
BACKGROUND Tuberous sclerosis complex (TSC) is a neurocutaneous disorder with a wide spectrum of manifestations. Recent consensus recommendations stress the importance of multidisciplinary management of children with TSC. The objective of this study was to examine the manifestations of TSC at a large referral centre to determine the care needs of this population. METHODS A retrospective, systematic chart review was performed of children with TSC managed at British Columbia Children's Hospital. Patients were identified through epilepsy and clinical neurophysiology databases. RESULTS The study population comprised 81 patients, born between 1987 and 2014, who were a median of 10 years (range, 0.2-23.2) at most recent follow-up. Epilepsy occurred in 91% of patients, including 32% with a history of infantile spasms. Nineteen patients underwent epilepsy surgery, nine (47%) of whom were seizure-free at most recent follow-up. Overall, 61% of epilepsy patients had been seizure-free for at least 1 year at the time of last follow-up. Neuropsychiatric disorders were diagnosed in 49% of children, with autism (25%), attention deficit hyperactivity order (19%) and anxiety (16%) being the most common. Cardiac rhabdomyomata occurred in 35% of children and renal angiomyolipomas were seen in 43%. A total of 91% had skin manifestations. CONCLUSION This study outlines the multisystem manifestations of TSC, observed through a large pediatric referral center. Epilepsy and neuropsychiatric disorders are the major source of morbidity in this age group and provide many challenges to the treating clinician. Because a subset of the study population is still quite young, the prevalence of neuropsychiatric disorders is likely underestimated.
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75
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Ismail FY, Fatemi A, Johnston MV. Cerebral plasticity: Windows of opportunity in the developing brain. Eur J Paediatr Neurol 2017; 21:23-48. [PMID: 27567276 DOI: 10.1016/j.ejpn.2016.07.007] [Citation(s) in RCA: 268] [Impact Index Per Article: 38.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2016] [Accepted: 07/06/2016] [Indexed: 12/31/2022]
Abstract
BACKGROUND Neuroplasticity refers to the inherently dynamic biological capacity of the central nervous system (CNS) to undergo maturation, change structurally and functionally in response to experience and to adapt following injury. This malleability is achieved by modulating subsets of genetic, molecular and cellular mechanisms that influence the dynamics of synaptic connections and neural circuitry formation culminating in gain or loss of behavior or function. Neuroplasticity in the healthy developing brain exhibits a heterochronus cortex-specific developmental profile and is heightened during "critical and sensitive periods" of pre and postnatal brain development that enable the construction and consolidation of experience-dependent structural and functional brain connections. PURPOSE In this review, our primary goal is to highlight the essential role of neuroplasticity in brain development, and to draw attention to the complex relationship between different levels of the developing nervous system that are subjected to plasticity in health and disease. Another goal of this review is to explore the relationship between plasticity responses of the developing brain and how they are influenced by critical and sensitive periods of brain development. Finally, we aim to motivate researchers in the pediatric neuromodulation field to build on the current knowledge of normal and abnormal neuroplasticity, especially synaptic plasticity, and their dependence on "critical or sensitive periods" of neural development to inform the design, timing and sequencing of neuromodulatory interventions in order to enhance and optimize their translational applications in childhood disorders of the brain. METHODS literature review. RESULTS We discuss in details five patterns of neuroplasticity expressed by the developing brain: 1) developmental plasticity which is further classified into normal and impaired developmental plasticity as seen in syndromic autism spectrum disorders, 2) adaptive (experience-dependent) plasticity following intense motor skill training, 3) reactive plasticity to pre and post natal CNS injury or sensory deprivation, 4) excessive plasticity (loss of homeostatic regulation) as seen in dystonia and refractory epilepsy, 6) and finally, plasticity as the brain's "Achilles tendon" which induces brain vulnerability under certain conditions such as hypoxic ischemic encephalopathy and epileptic encephalopathy syndromes. We then explore the unique feature of "time-sensitive heightened plasticity responses" in the developing brain in the in the context of neuromodulation. CONCLUSION The different patterns of neuroplasticity and the unique feature of heightened plasticity during critical and sensitive periods are important concepts for researchers and clinicians in the field of pediatric neurology and neurodevelopmental disabilities. These concepts need to be examined systematically in the context of pediatric neuromodulation. We propose that critical and sensitive periods of brain development in health and disease can create "windows of opportunity" for neuromodulatory interventions that are not commonly seen in adult brain and probably augment plasticity responses and improve clinical outcomes.
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Affiliation(s)
- Fatima Yousif Ismail
- Department of neurology and developmental medicine, The Kennedy Krieger Institute, Johns Hopkins Medical Institutions, MD, USA; Department of pediatrics, College of Medicine and Health Sciences, United Arab Emirates University, Al- Ain, UAE.
| | - Ali Fatemi
- Departments of Neurology and Pediatrics, The Kennedy Krieger Institute, and Johns Hopkins University School of Medicine, MD, USA
| | - Michael V Johnston
- Departments of Neurology and Pediatrics, The Kennedy Krieger Institute, and Johns Hopkins University School of Medicine, MD, USA
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76
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Curatolo P, Bjørnvold M, Dill PE, Ferreira JC, Feucht M, Hertzberg C, Jansen A, Jóźwiak S, Kingswood JC, Kotulska K, Macaya A, Moavero R, Nabbout R, Zonnenberg BA. The Role of mTOR Inhibitors in the Treatment of Patients with Tuberous Sclerosis Complex: Evidence-based and Expert Opinions. Drugs 2016; 76:551-65. [PMID: 26927950 DOI: 10.1007/s40265-016-0552-9] [Citation(s) in RCA: 58] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Tuberous sclerosis complex (TSC) is a genetic disorder arising from mutations in the TSC1 or TSC2 genes. The resulting over-activation of the mammalian target of rapamycin (mTOR) signalling pathway leaves patients with TSC susceptible to the growth of non-malignant tumours in multiple organs. Previously, surgery was the main therapeutic option for TSC. However, pharmacological therapy with mTOR inhibitors such as everolimus and sirolimus is now emerging as an alternate approach. Everolimus and sirolimus have already been shown to be effective in treating subependymal giant cell astrocytoma (SEGA) and renal angiomyolipoma (AML), and everolimus is currently being evaluated in treating TSC-related epilepsy. In November 2013 a group of European experts convened to discuss the current options and practical considerations for treating various manifestations of TSC. This article provides evidence-based recommendations for the treatment of SEGA, TSC-related epilepsy and renal AML, with a focus on where mTOR inhibitor therapy may be considered alongside other treatment options. Safety considerations regarding mTOR inhibitor therapy are also reviewed. With evidence of beneficial effects in neurological and non-neurological TSC manifestations, mTOR inhibitors may represent a systemic treatment for TSC.
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Affiliation(s)
- Paolo Curatolo
- Department of Neurosciences, Child Neurology and Psychiatry Unit, Tor Vergata University Hospital of Rome, Rome, Italy.
| | - Marit Bjørnvold
- National Center for Rare Epilepsy-related Disorders, National Center of Epilepsy, Oslo University Hospital, Oslo, Norway
| | - Patricia E Dill
- Department of Pediatric Neurology and Developmental Medicine, University Children's Hospital Basel, University of Basel, Basel, Switzerland.,INSERM Unité 1511, Paris, France
| | - José Carlos Ferreira
- Neuro Pediatra, Centro Hospitalar Lisboa Ocidental, Hospital São Francisco Xavier, Lisbon, Portugal
| | - Martha Feucht
- Department of Paediatrics, University Hospital Vienna, Vienna, Austria
| | - Christoph Hertzberg
- Diagnose und Behandlungszentrum für Kinder und Jugendliche, Vivantes Klinikum Neukölln, Berlin, Germany
| | - Anna Jansen
- Pediatric Neurology Unit-UZ Brussel, Brussels, Belgium
| | - Sergiusz Jóźwiak
- Department of Child Neurology, Medical University of Warsaw, Warsaw, Poland
| | - J Christopher Kingswood
- Sussex Renal Unit, Royal Sussex County Hospital, Brighton, UK.,The Trafford Department of Renal Medicine, Royal Sussex County Hospital, Brighton, UK
| | - Katarzyna Kotulska
- Department of Neurology and Epileptology, The Children's Memorial Health Institute, Warsaw, Poland
| | - Alfons Macaya
- Servei de Neurologia Pediàtrica, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Romina Moavero
- Department of Neurosciences, Child Neurology and Psychiatry Unit, Tor Vergata University Hospital of Rome, Rome, Italy.,Pediatric Neurology Unit, Department of Neuroscience and Neurorehabilitation, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Rima Nabbout
- Department of Pediatric Neurology, Reference Centre for Rare Epilepsies and Tuberous Sclerosis Complex, Necker-Enfants Malades Hospital, University Paris Descartes, Paris, France
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77
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Interdependence of clinical factors predicting cognition in children with tuberous sclerosis complex. J Neurol 2016; 264:161-167. [PMID: 27878438 PMCID: PMC5225189 DOI: 10.1007/s00415-016-8335-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2016] [Revised: 10/27/2016] [Accepted: 11/04/2016] [Indexed: 12/24/2022]
Abstract
Cognitive development in patients with tuberous sclerosis complex is highly variable. Predictors in the infant years would be valuable to counsel parents and to support development. The aim of this study was to confirm factors that have been reported to be independently correlated with cognitive development. 102 patients included in this study were treated at the ENCORE-TSC expertise center of the Erasmus Medical Center-Sophia Children’s Hospital. Data from the first 24 months of life were used, including details on epilepsy, motor development and mutation status. Outcome was defined as cognitive development (intellectual equivalent, IE) as measured using tests appropriate to the patients age and cognitive abilities (median age at testing 8.2 years, IQR 4.7–12.0). Univariable and multivariable regression analyses were used. In a univariable analysis, predictors of lower IE were: the presence of infantile spasms (β = −18.3, p = 0.000), a larger number of antiepileptic drugs used (β = −6.3, p = 0.000), vigabatrin not used as first drug (β = −14.6, p = 0.020), corticosteroid treatment (β = −33.2, p = 0.005), and a later age at which the child could walk independently (β = −2.1, p = 0.000). An older age at seizure onset predicted higher IE (β = 1.7, p = 0.000). In a multivariable analysis, only age at seizure onset was significantly correlated to IE (β = 1.2, p = 0.005), contributing to 28% of the variation in IE. In our cohort, age at seizure onset was the only variable that independently predicted IE. Factors predicting cognitive development could aid parents and physicians in finding the appropriate support and schooling for these patients.
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78
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Switon K, Kotulska K, Janusz-Kaminska A, Zmorzynska J, Jaworski J. Tuberous sclerosis complex: From molecular biology to novel therapeutic approaches. IUBMB Life 2016; 68:955-962. [PMID: 27797139 DOI: 10.1002/iub.1579] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2016] [Accepted: 10/09/2016] [Indexed: 12/20/2022]
Abstract
Tuberous sclerosis complex (TSC) is a rare multi-system disorder, primary manifestations of which are benign tumors and lesions in various organs of the body, including the brain. TSC patients often suffer from epilepsy, mental retardation, and autism spectrum disorder (ASD). Therefore, TSC serves as a model of epilepsy, ASD, and tumorigenesis. TSC is caused by the lack of functional Tsc1-Tsc2 complex, which serves as a major cellular inhibitor of mammalian Target of Rapamycin Complex 1 (mTORC1). mTORC1 is a kinase controlling most of anabolic processes in eukaryotic cells. Consequently, mTORC1 inhibitors, such as rapamycin, serve as experimental or already approved drugs for several TSC symptoms. However, rapalogs, although quite effective, need to be administered chronically and likely for a lifetime, since therapy discontinuation results in tumor regrowth and epilepsy recurrence. Recent studies revealed that metabolism and excitability (in the case of neurons) of cells lacking Tsc1-Tsc2 complex are changed, and these features may potentially be used to treat some of TSC symptoms. In this review, we first provide basic facts about TSC and its molecular background, to next discuss the newest findings in TSC cell biology that can be used to improve existing therapies of TSC and other diseases linked to mTORC1 hyperactivation. © 2016 IUBMB Life, 68(12):955-962, 2016.
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Affiliation(s)
- Katarzyna Switon
- Laboratory of Molecular and Cellular Neurobiology, International Institute of Molecular and Cell Biology, Warsaw, Poland
| | - Katarzyna Kotulska
- Department of Neurology and Epileptology, Children's Memorial Health Institute, Warsaw, Poland
| | - Aleksandra Janusz-Kaminska
- Laboratory of Molecular and Cellular Neurobiology, International Institute of Molecular and Cell Biology, Warsaw, Poland
| | - Justyna Zmorzynska
- Laboratory of Molecular and Cellular Neurobiology, International Institute of Molecular and Cell Biology, Warsaw, Poland
| | - Jacek Jaworski
- Laboratory of Molecular and Cellular Neurobiology, International Institute of Molecular and Cell Biology, Warsaw, Poland
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79
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Nickels KC, Zaccariello MJ, Hamiwka LD, Wirrell EC. Cognitive and neurodevelopmental comorbidities in paediatric epilepsy. Nat Rev Neurol 2016; 12:465-76. [PMID: 27448186 DOI: 10.1038/nrneurol.2016.98] [Citation(s) in RCA: 133] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Cognitive and behavioural comorbidities are often seen in children with epilepsy, and are more common and severe in refractory epilepsy. These comorbidities are associated with worse quality of life, increased behavioural and language problems and worse social skills, all of which adversely affect long-term psychosocial functioning. To enable early intervention and therapy, children and teens with epilepsy should be periodically screened for cognitive comorbidities. The location of the epileptic focus can, to a certain degree, predict the type(s) of comorbidity; however, the spectrum of disability is often broad, presumably because focal perturbations can cause network dysfunction. Comorbidities often result from underlying structural or functional pathology that has led to seizures. In selected cases, therapy targeting the underlying cause, such as the ketogenic diet for GLUT1 deficiency syndromes, may be remarkably effective in ameliorating both seizures and cognitive concerns. In many cases, however, cognitive impairment persists despite seizure control. In epileptic encephalopathies, frequent seizures and/or interictal epileptiform abnormalities exacerbate neurocognitive dysfunction, owing to synaptic reorganization or impaired neurogenesis, or to other effects on developing neural circuits, and prompt initiation of effective antiepileptic therapy is essential to limit cognitive comorbidities.
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Affiliation(s)
- Katherine C Nickels
- Child and Adolescent Neurology and Epilepsy, Mayo Clinic, 200 First Street SW, Rochester, Minnesota 55905, USA
| | - Michael J Zaccariello
- Child and Adolescent Neurology and Epilepsy, Mayo Clinic, 200 First Street SW, Rochester, Minnesota 55905, USA
| | - Lorie D Hamiwka
- Seattle Children's Hospital, MB.7.420 - Neurology, 4800 Sand Point Way NE, Seattle, Washington 98105, USA
| | - Elaine C Wirrell
- Child and Adolescent Neurology and Epilepsy, Mayo Clinic, 200 First Street SW, Rochester, Minnesota 55905, USA
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80
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Moavero R, Napolitano A, Cusmai R, Vigevano F, Figà-Talamanca L, Calbi G, Curatolo P, Bernardi B. White matter disruption is associated with persistent seizures in tuberous sclerosis complex. Epilepsy Behav 2016; 60:63-67. [PMID: 27179194 DOI: 10.1016/j.yebeh.2016.04.026] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2016] [Revised: 04/10/2016] [Accepted: 04/11/2016] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND AIMS White matter is diffusely altered in tuberous sclerosis complex (TSC), and these alterations appear to be more evident in subjects with a more severe neurologic phenotype. However, little is known on the correlation between white matter alterations and epilepsy in TSC. The aims of this study were to evaluate the effects of early onset and refractory seizures on white matter by using diffusion tensor imaging (DTI). METHODS We enrolled 20 children with TSC and epilepsy onset in the first 3years of life and grouped them according to seizure persistence or freedom. All patients underwent brain MRI with DTI. Specific ROIs have were placed to generate tracks to calculate fractional anisotropy (FA) and apparent diffusion coefficient (ADC). Statistical analysis was performed by ANOVA. RESULTS Children with persistent seizures presented an overall reduced FA, with statistically significant differences on the cingulum (right p=0.003, left p=0.016), the left cerebral peduncle (p=0.020), the superior cerebellar peduncles (right p=0.008, left p=0.002), the posterior limbs of internal capsule (right p=0.037, left p=0.015), the external capsule (right p=0.018, left p=0.031), the inferior frontooccipital fasciculus (right p=0.010, left p=0.026), and the temporal trunk (right p=0.017, left p=0.001). CONCLUSIONS Our study demonstrated that children with persistent seizures present more significant alterations of brain connectivity in areas crucial for global cognitive maturation, executive functions, and verbal abilities, implying a higher risk of cognitive impairment, attention-deficit hyperactivity disorder, and autism.
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Affiliation(s)
- Romina Moavero
- Systems Medicine Department, Child Neurology and Psychiatry Unit, Tor Vergata University Hospital of Rome, Viale Oxford 81, 00133 Rome, Italy; Neuroscience Department, Neurology Unit, "Bambino Gesù" Children's Hospital, IRCCS, Piazza S. Onofrio 4, 00165 Rome, Italy.
| | - Antonio Napolitano
- Enterprise Risk Management, Medical Physics Department, "Bambino Gesù" Children's Hospital, IRCCS, Piazza S. Onofrio 4, 00165 Rome, Italy
| | - Raffaella Cusmai
- Neuroscience Department, Neurology Unit, "Bambino Gesù" Children's Hospital, IRCCS, Piazza S. Onofrio 4, 00165 Rome, Italy
| | - Federico Vigevano
- Neuroscience Department, Neurology Unit, "Bambino Gesù" Children's Hospital, IRCCS, Piazza S. Onofrio 4, 00165 Rome, Italy
| | - Lorenzo Figà-Talamanca
- Neuroradiology Unit, Imaging Department, "Bambino Gesù" Children's Hospital, IRCCS, Piazza S. Onofrio 4, 00165 Rome, Italy
| | - Giuseppe Calbi
- Anesthesiology Unit, DEA-ARCO "Bambino Gesù" Children's Hospital, IRCCS, Piazza S. Onofrio 4, 00165 Rome, Italy
| | - Paolo Curatolo
- Systems Medicine Department, Child Neurology and Psychiatry Unit, Tor Vergata University Hospital of Rome, Viale Oxford 81, 00133 Rome, Italy
| | - Bruno Bernardi
- Neuroradiology Unit, Imaging Department, "Bambino Gesù" Children's Hospital, IRCCS, Piazza S. Onofrio 4, 00165 Rome, Italy
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81
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Tye C, Varcin K, Bolton P, Jeste SS. Early developmental pathways to autism spectrum disorder in tuberous sclerosis complex. ADVANCES IN AUTISM 2016. [DOI: 10.1108/aia-01-2016-0004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose
– Tuberous sclerosis complex (TSC) is a genetic disorder with a high prevalence of autism spectrum disorder (ASD), yet no single genetic, neurological or neurophysiological risk marker is necessary or sufficient to increase risk for ASD. This paper aims to discuss the utility of adopting a developmental perspective.
Design/methodology/approach
– The increasing number of TSC infants presenting with abnormalities prenatally provides a unique opportunity to study risk pathways to ASD from birth. Here, the authors review findings to date that support the investigation of infants with TSC to further our understanding of typical and atypical development.
Findings
– Evidence has accumulated from studies of infants at familial risk for ASD (“baby siblings”) to suggest that early markers of ASD are present in the first year of life. The early waves of prospective studies of infants with TSC indicate dynamic changes in developmental trajectories to ASD and are likely to provide insight into cascading effects of brain “insult” early in development. Emerging evidence of phenotypic and biological homology between syndromic and idiopathic cases of ASD supports the notion of a convergence of risk factors on a final common pathway in ASD.
Originality/value
– The delineation of brain-based biomarkers of risk, prediction and treatment response in TSC will be critical in aiding the development of targeted intervention and prevention strategies for those infants at high risk of poorer developmental outcomes.
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82
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Abstract
Epilepsy and autistic spectrum disorder frequently coexist in the same individual. Electroencephalogram (EEG) epileptiform activity is also present at a substantially higher rate in children with autism than normally developing children. As with epilepsy, there are a multitude of genetic and environmental factors that can result in autistic spectrum disorder. There is growing consensus from both animal and clinical studies that autism is a disorder of aberrant connectivity. As measured with functional magnetic resonance imaging (MRI) and EEG, the brain in autistic spectrum disorder may be under- or overconnected or have a mixture of over- and underconnectivity. In the case of comorbid epilepsy and autism, an imbalance of the excitatory/inhibitory (E/I) ratio in selected regions of the brain may drive overconnectivity. Understanding the mechanism by which altered connectivity in individuals with comorbid epilepsy and autistic spectrum disorder results in the behaviors specific to the autistic spectrum disorder remains a challenge.
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Affiliation(s)
| | - Gregory L Holmes
- Department of Neurological Sciences, University of Vermont College of Medicine, Burlington, Vermont 05405
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83
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Early onset epileptic encephalopathy or genetically determined encephalopathy with early onset epilepsy? Lessons learned from TSC. Eur J Paediatr Neurol 2016; 20:203-211. [PMID: 26758984 DOI: 10.1016/j.ejpn.2015.12.005] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2015] [Revised: 12/01/2015] [Accepted: 12/13/2015] [Indexed: 01/12/2023]
Abstract
BACKGROUND In tuberous sclerosis complex (TSC) a relationship has been shown between early and refractory seizures and intellectual disability. However, it is uncertain whether epilepsy in TSC is simply a marker in infants who are destined to develop an encephalopathic process or if seizures play a causal role in developing an encephalopathy. METHODS This paper summarizes the key points discussed during a European TSC workshop held in Rome, and reviews the experimental and clinical evidence in support of the two theories. RESULTS/CONCLUSION There are many factors that influence the appearance of both early seizure onset and the encephalopathy resulting in neurodevelopmental deficits. Experimental studies show that as a consequence of the TSC genes mutation, mammalian target of Rapamycin (mTOR) overactivation determines an alteration in cellular morphology with cytomegalic neurons, altered synaptogenesis and an imbalance between excitation/inhibition, thus providing a likely neuroanatomical substrate for the early appearance of refractory seizures and for the encephalopathic process. At the clinical level, early signs of altered developmental trajectories are often unrecognized before 12 months of age. Evidence from experimental research shows that encephalopathy in TSC might have a genetic cause, and mTOR activation caused by TSC gene mutation can be directly responsible for the early appearance of seizures and encephalopathy.
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84
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Moavero R, Marciano S, Graziola F, Curatolo P. Combined targeted treatment in early onset epilepsy associated with tuberous sclerosis. EPILEPSY & BEHAVIOR CASE REPORTS 2016; 5:13-6. [PMID: 27330989 PMCID: PMC4907789 DOI: 10.1016/j.ebcr.2015.12.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/17/2015] [Revised: 11/26/2015] [Accepted: 12/12/2015] [Indexed: 11/23/2022]
Abstract
Tuberous sclerosis is associated with epilepsy in up to 85% of cases, and in 2/3, the onset is within the first year of life. An early antiepileptic treatment is crucial to minimize the consequences of epilepsy on cognition and behavior. We present a case report of a child with tuberous sclerosis who presented with infantile spasms at the age of 6 months, immediately treated with vigabatrin. Because of the presence of a subependymal giant cell astrocytoma, he also received everolimus since 18 months of age. We might wonder if an earlier treatment could have produced a better outcome; in fact, despite a targeted combined treatment, he continues to suffer from sporadic focal motor seizures, and at the age of 40 months, he presents severe developmental delay with autism-like behavior.
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Affiliation(s)
- Romina Moavero
- Child Neurology and Psychiatry Unit, Systems Medicine Department, Tor Vergata University of Rome, Italy
- Neurology Unit, Neuroscience and Neurorehabilitation Department, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Sara Marciano
- Child Neurology and Psychiatry Unit, Systems Medicine Department, Tor Vergata University of Rome, Italy
| | - Federica Graziola
- Child Neurology and Psychiatry Unit, Systems Medicine Department, Tor Vergata University of Rome, Italy
| | - Paolo Curatolo
- Child Neurology and Psychiatry Unit, Systems Medicine Department, Tor Vergata University of Rome, Italy
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85
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Moavero R, Romagnoli G, Graziola F, Curatolo P. Mammalian Target of Rapamycin Inhibitors and Life-Threatening Conditions in Tuberous Sclerosis Complex. Semin Pediatr Neurol 2015; 22:282-94. [PMID: 26706015 DOI: 10.1016/j.spen.2015.10.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Tuberous sclerosis complex (TSC) is a multisystem disease associated with an overall reduction in life expectancy due to the possible occurrence of different life-threatening conditions. Subjects affected by TSC are, in fact, at risk of hydrocephalus secondary to the growth of subependymal giant cell astrocytomas, or of sudden unexpected death in epilepsy. Other nonneurological life-threatening conditions include abdominal bleeding owing to renal angiomyolipomas rupture, renal insufficiency due to progressive parenchymal destruction by multiple cysts, pulmonary complications due to lymphangioleiomyomatosis, and cardiac failure or arrhythmias secondary to rhabdomyomas. In the last decades, there has been a great progress in understanding the pathophysiology of TSC-related manifestations, which are mainly linked to the hyperactivation of the so-called mammalian target of rapamycin (mTOR) pathway, as a consequence of the mutation in 1 of the 2 genes TSC1 or TSC2. This led to the development of new treatment strategies for this disease. In fact, it is now available as a biologically targeted therapy with everolimus, a selective mTOR inhibitor, which has been licensed in Europe and USA for the treatment of subependymal giant cell astrocytomas and angiomyolipomas in subjects with TSC. This drug also proved to benefit other TSC-related manifestations, including pulmonary lymphangioleiomyomatosis, cardiac rhabdomyomas, and presumably epileptic seizures. mTOR inhibitors are thus proving to be a systemic therapy able to simultaneously address different and potentially life-threatening complications, giving the hope of improving life expectation in individuals with TSC.
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Affiliation(s)
- Romina Moavero
- Child Neurology and Psychiatry Unit, Tor Vergata University Hospital of Rome, Rome, Italy; Child Neurology Unit, Neuroscience and Neurorehabilitation Department, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy.
| | - Gloria Romagnoli
- Child Neurology and Psychiatry Unit, Tor Vergata University Hospital of Rome, Rome, Italy
| | - Federica Graziola
- Child Neurology and Psychiatry Unit, Tor Vergata University Hospital of Rome, Rome, Italy
| | - Paolo Curatolo
- Child Neurology and Psychiatry Unit, Tor Vergata University Hospital of Rome, Rome, Italy
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86
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Curatolo P, Moavero R, de Vries PJ. Neurological and neuropsychiatric aspects of tuberous sclerosis complex. Lancet Neurol 2015; 14:733-45. [PMID: 26067126 DOI: 10.1016/s1474-4422(15)00069-1] [Citation(s) in RCA: 365] [Impact Index Per Article: 40.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2014] [Revised: 04/21/2015] [Accepted: 04/27/2015] [Indexed: 01/22/2023]
Abstract
Tuberous sclerosis (also known as tuberous sclerosis complex [TSC]) is a multisystem genetic disorder that affects almost every organ in the body. Mutations in the TSC1 or TSC2 genes lead to disruption of the TSC1-TSC2 intracellular protein complex, causing overactivation of the mammalian target of rapamycin (mTOR) protein complex. The surveillance and management guidelines and clinical criteria for tuberous sclerosis were revised in 2012, and mTOR inhibitors are now recommended as treatment options for subependymal giant cell astrocytomas and renal angiomyolipomas-two common features of the disease. However, most morbidity and mortality caused by tuberous sclerosis is associated with neurological and neuropsychiatric manifestations. Treatment of epilepsy associated with tuberous sclerosis remains a major challenge, with more than 60% of patients having ongoing seizures. Tuberous-sclerosis-associated neuropsychiatric disorders (TAND) are multilevel and occur in most individuals with the disorder, but are rarely assessed and treated. Clinical trials of mTOR inhibitors to treat seizures and TAND are underway. Management of the neurological and neuropsychiatric manifestations of the disorder should be coordinated with treatment of other organ systems. In view of the age-related expression of manifestations from infancy to adulthood, continuity of clinical care and ongoing monitoring is paramount, and particular attention is needed to plan transition of patient care from childhood to adult services.
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Affiliation(s)
- Paolo Curatolo
- Neuroscience Department, Child Neurology and Psychiatry Division, University Hospital of Tor Vergata, Rome, Italy.
| | - Romina Moavero
- Neuroscience Department, Child Neurology and Psychiatry Division, University Hospital of Tor Vergata, Rome, Italy; Neuroscience Department, Child Neurology Division, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Petrus J de Vries
- Division of Child and Adolescent Psychiatry, University of Cape Town, Cape Town, South Africa
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Fountain NB, Van Ness PC, Bennett A, Absher J, Patel AD, Sheth KN, Gloss DS, Morita DA, Stecker M. Quality improvement in neurology: Epilepsy Update Quality Measurement Set. Neurology 2015; 84:1483-7. [PMID: 25846995 DOI: 10.1212/wnl.0000000000001448] [Citation(s) in RCA: 73] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Nathan B Fountain
- From the Neurology Department (N.B.F.), Comprehensive Epilepsy Program, University of Virginia, Charlottesville; the Department of Neurology and Neurotherapeutics (P.C.V.N.), University of Texas Southwestern Medical Center, Dallas; the American Academy of Neurology (A.B.), Minneapolis, MN; Absher Neurology (J.A.), Greenville, SC; the Division of Neurology and Pediatrics (A.D.P.), Nationwide Children's Hospital and The Ohio State University College of Medicine, Columbus; the Division of Neurocritical Care & Emergency Neurology, Department of Neurology (K.N.S.), Yale University School of Medicine, New Haven, CT; the Department of Neurology (D.S.G.), Geisinger Health System, Danville, PA; the Department of Pediatrics, Division of Neurology (D.A.M.), Cincinnati Children's Hospital Medical Center, OH; and the Department of Patient Safety, Quality and Innovation (M.S.), Winthrop University Hospital, Mineola, NY
| | - Paul C Van Ness
- From the Neurology Department (N.B.F.), Comprehensive Epilepsy Program, University of Virginia, Charlottesville; the Department of Neurology and Neurotherapeutics (P.C.V.N.), University of Texas Southwestern Medical Center, Dallas; the American Academy of Neurology (A.B.), Minneapolis, MN; Absher Neurology (J.A.), Greenville, SC; the Division of Neurology and Pediatrics (A.D.P.), Nationwide Children's Hospital and The Ohio State University College of Medicine, Columbus; the Division of Neurocritical Care & Emergency Neurology, Department of Neurology (K.N.S.), Yale University School of Medicine, New Haven, CT; the Department of Neurology (D.S.G.), Geisinger Health System, Danville, PA; the Department of Pediatrics, Division of Neurology (D.A.M.), Cincinnati Children's Hospital Medical Center, OH; and the Department of Patient Safety, Quality and Innovation (M.S.), Winthrop University Hospital, Mineola, NY
| | - Amy Bennett
- From the Neurology Department (N.B.F.), Comprehensive Epilepsy Program, University of Virginia, Charlottesville; the Department of Neurology and Neurotherapeutics (P.C.V.N.), University of Texas Southwestern Medical Center, Dallas; the American Academy of Neurology (A.B.), Minneapolis, MN; Absher Neurology (J.A.), Greenville, SC; the Division of Neurology and Pediatrics (A.D.P.), Nationwide Children's Hospital and The Ohio State University College of Medicine, Columbus; the Division of Neurocritical Care & Emergency Neurology, Department of Neurology (K.N.S.), Yale University School of Medicine, New Haven, CT; the Department of Neurology (D.S.G.), Geisinger Health System, Danville, PA; the Department of Pediatrics, Division of Neurology (D.A.M.), Cincinnati Children's Hospital Medical Center, OH; and the Department of Patient Safety, Quality and Innovation (M.S.), Winthrop University Hospital, Mineola, NY
| | - John Absher
- From the Neurology Department (N.B.F.), Comprehensive Epilepsy Program, University of Virginia, Charlottesville; the Department of Neurology and Neurotherapeutics (P.C.V.N.), University of Texas Southwestern Medical Center, Dallas; the American Academy of Neurology (A.B.), Minneapolis, MN; Absher Neurology (J.A.), Greenville, SC; the Division of Neurology and Pediatrics (A.D.P.), Nationwide Children's Hospital and The Ohio State University College of Medicine, Columbus; the Division of Neurocritical Care & Emergency Neurology, Department of Neurology (K.N.S.), Yale University School of Medicine, New Haven, CT; the Department of Neurology (D.S.G.), Geisinger Health System, Danville, PA; the Department of Pediatrics, Division of Neurology (D.A.M.), Cincinnati Children's Hospital Medical Center, OH; and the Department of Patient Safety, Quality and Innovation (M.S.), Winthrop University Hospital, Mineola, NY
| | - Anup D Patel
- From the Neurology Department (N.B.F.), Comprehensive Epilepsy Program, University of Virginia, Charlottesville; the Department of Neurology and Neurotherapeutics (P.C.V.N.), University of Texas Southwestern Medical Center, Dallas; the American Academy of Neurology (A.B.), Minneapolis, MN; Absher Neurology (J.A.), Greenville, SC; the Division of Neurology and Pediatrics (A.D.P.), Nationwide Children's Hospital and The Ohio State University College of Medicine, Columbus; the Division of Neurocritical Care & Emergency Neurology, Department of Neurology (K.N.S.), Yale University School of Medicine, New Haven, CT; the Department of Neurology (D.S.G.), Geisinger Health System, Danville, PA; the Department of Pediatrics, Division of Neurology (D.A.M.), Cincinnati Children's Hospital Medical Center, OH; and the Department of Patient Safety, Quality and Innovation (M.S.), Winthrop University Hospital, Mineola, NY
| | - Kevin N Sheth
- From the Neurology Department (N.B.F.), Comprehensive Epilepsy Program, University of Virginia, Charlottesville; the Department of Neurology and Neurotherapeutics (P.C.V.N.), University of Texas Southwestern Medical Center, Dallas; the American Academy of Neurology (A.B.), Minneapolis, MN; Absher Neurology (J.A.), Greenville, SC; the Division of Neurology and Pediatrics (A.D.P.), Nationwide Children's Hospital and The Ohio State University College of Medicine, Columbus; the Division of Neurocritical Care & Emergency Neurology, Department of Neurology (K.N.S.), Yale University School of Medicine, New Haven, CT; the Department of Neurology (D.S.G.), Geisinger Health System, Danville, PA; the Department of Pediatrics, Division of Neurology (D.A.M.), Cincinnati Children's Hospital Medical Center, OH; and the Department of Patient Safety, Quality and Innovation (M.S.), Winthrop University Hospital, Mineola, NY
| | - David S Gloss
- From the Neurology Department (N.B.F.), Comprehensive Epilepsy Program, University of Virginia, Charlottesville; the Department of Neurology and Neurotherapeutics (P.C.V.N.), University of Texas Southwestern Medical Center, Dallas; the American Academy of Neurology (A.B.), Minneapolis, MN; Absher Neurology (J.A.), Greenville, SC; the Division of Neurology and Pediatrics (A.D.P.), Nationwide Children's Hospital and The Ohio State University College of Medicine, Columbus; the Division of Neurocritical Care & Emergency Neurology, Department of Neurology (K.N.S.), Yale University School of Medicine, New Haven, CT; the Department of Neurology (D.S.G.), Geisinger Health System, Danville, PA; the Department of Pediatrics, Division of Neurology (D.A.M.), Cincinnati Children's Hospital Medical Center, OH; and the Department of Patient Safety, Quality and Innovation (M.S.), Winthrop University Hospital, Mineola, NY
| | - Diego A Morita
- From the Neurology Department (N.B.F.), Comprehensive Epilepsy Program, University of Virginia, Charlottesville; the Department of Neurology and Neurotherapeutics (P.C.V.N.), University of Texas Southwestern Medical Center, Dallas; the American Academy of Neurology (A.B.), Minneapolis, MN; Absher Neurology (J.A.), Greenville, SC; the Division of Neurology and Pediatrics (A.D.P.), Nationwide Children's Hospital and The Ohio State University College of Medicine, Columbus; the Division of Neurocritical Care & Emergency Neurology, Department of Neurology (K.N.S.), Yale University School of Medicine, New Haven, CT; the Department of Neurology (D.S.G.), Geisinger Health System, Danville, PA; the Department of Pediatrics, Division of Neurology (D.A.M.), Cincinnati Children's Hospital Medical Center, OH; and the Department of Patient Safety, Quality and Innovation (M.S.), Winthrop University Hospital, Mineola, NY
| | - Mona Stecker
- From the Neurology Department (N.B.F.), Comprehensive Epilepsy Program, University of Virginia, Charlottesville; the Department of Neurology and Neurotherapeutics (P.C.V.N.), University of Texas Southwestern Medical Center, Dallas; the American Academy of Neurology (A.B.), Minneapolis, MN; Absher Neurology (J.A.), Greenville, SC; the Division of Neurology and Pediatrics (A.D.P.), Nationwide Children's Hospital and The Ohio State University College of Medicine, Columbus; the Division of Neurocritical Care & Emergency Neurology, Department of Neurology (K.N.S.), Yale University School of Medicine, New Haven, CT; the Department of Neurology (D.S.G.), Geisinger Health System, Danville, PA; the Department of Pediatrics, Division of Neurology (D.A.M.), Cincinnati Children's Hospital Medical Center, OH; and the Department of Patient Safety, Quality and Innovation (M.S.), Winthrop University Hospital, Mineola, NY
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Overwater IE, Bindels-de Heus K, Rietman AB, ten Hoopen LW, Vergouwe Y, Moll HA, de Wit MCY. Epilepsy in children with tuberous sclerosis complex: Chance of remission and response to antiepileptic drugs. Epilepsia 2015; 56:1239-45. [DOI: 10.1111/epi.13050] [Citation(s) in RCA: 74] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/04/2015] [Indexed: 01/16/2023]
Affiliation(s)
- Iris E. Overwater
- Department of Neurology; Erasmus MC-Sophia Children's Hospital; Rotterdam The Netherlands
- ENCORE TSC Expertise Center; Erasmus MC-Sophia Children's Hospital; Rotterdam The Netherlands
| | - Karen Bindels-de Heus
- ENCORE TSC Expertise Center; Erasmus MC-Sophia Children's Hospital; Rotterdam The Netherlands
- Department of Pediatrics; Erasmus MC-Sophia Children's Hospital; Rotterdam The Netherlands
| | - André B. Rietman
- Department of Neurology; Erasmus MC-Sophia Children's Hospital; Rotterdam The Netherlands
- ENCORE TSC Expertise Center; Erasmus MC-Sophia Children's Hospital; Rotterdam The Netherlands
| | - Leontine W. ten Hoopen
- ENCORE TSC Expertise Center; Erasmus MC-Sophia Children's Hospital; Rotterdam The Netherlands
- Department of Child and Adolescent Psychiatry/Psychology; Erasmus MC-Sophia Children's Hospital; Rotterdam The Netherlands
| | - Yvonne Vergouwe
- Department of Public Health; Erasmus MC Rotterdam; Rotterdam The Netherlands
| | - Henriette A. Moll
- Department of Pediatrics; Erasmus MC-Sophia Children's Hospital; Rotterdam The Netherlands
| | - Marie-Claire Y. de Wit
- Department of Neurology; Erasmus MC-Sophia Children's Hospital; Rotterdam The Netherlands
- ENCORE TSC Expertise Center; Erasmus MC-Sophia Children's Hospital; Rotterdam The Netherlands
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89
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Samueli S, Abraham K, Dressler A, Groeppel G, Jonak C, Muehlebner A, Prayer D, Reitner A, Feucht M. Tuberous Sclerosis Complex: new criteria for diagnostic work-up and management. Wien Klin Wochenschr 2015; 127:619-30. [PMID: 25860851 DOI: 10.1007/s00508-015-0758-y] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2014] [Accepted: 01/27/2015] [Indexed: 12/24/2022]
Abstract
Tuberous sclerosis complex (TSC) is a rare genetic multisystem disorder, characterized by predominantly benign tumors in potentially all organ systems. System involvement, severity of clinical symptoms and the response to treatment are age-dependent and heterogeneous. Consequently, the disorder is still not recognized in a considerable number of patients. The diagnostic criteria and the guidelines for surveillance and management of patients with TSC were revised, and the establishment of specialized TSC-centers was strongly recommended during an International Consensus Conference in 2012. TOSCA (TuberOus SClerosis registry to increase disease Awareness), an international patient registry, was started to allow new insights into the causes of different courses. Finally, there are-since the approval of the mTOR inhibitor Everolimus-promising new therapeutic approaches.This review focuses on the various TSC related symptoms occurring at different ages, the novel recommendations for diagnosis and treatment as well as the need for multidisciplinary follow-up.
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Affiliation(s)
- Sharon Samueli
- Universitätsklinik für Kinder- und Jugendheilkunde, AKH Wien, Wien, Österreich
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90
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Widjaja E, Go C, McCoy B, Snead OC. Neurodevelopmental outcome of infantile spasms: A systematic review and meta-analysis. Epilepsy Res 2014; 109:155-62. [PMID: 25524855 DOI: 10.1016/j.eplepsyres.2014.11.012] [Citation(s) in RCA: 77] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2014] [Revised: 11/03/2014] [Accepted: 11/11/2014] [Indexed: 11/25/2022]
Abstract
BACKGROUND The aims of this systematic review and meta-analysis were to assess (i) estimates of good neurodevelopmental outcome in infantile spasms (IS), (ii) if neurodevelopmental outcome has changed since the publication of the first guideline on medical treatment of IS in 2004 and (iii) effect of lead time to treatment (LTTT). METHODS The Medline, Embase, Cochrane, PsycINFO, Web of Science and Scopus databases, and reference lists of retrieved articles were searched. Studies inclusion criteria were: (i) >5 patients with IS, (ii) mean/median follow-up of >6 months, (iii) neurodevelopmental outcome, and (iv) randomized and observational studies. The data extracted included proportion of good neurodevelopmental outcome, year of publication, cryptogenic or symptomatic IS and LTTT. RESULTS Of the 1436 citations screened, 55 articles were included in final analysis, with a total of 2967 patients. The pooled estimate for good neurodevelopmental outcome was 0.236 (95% CI: 0.193-0.286). There was no difference between the proportions of good neurodevelopmental outcome for the 21 studies published after 2004 [0.264 (95% CI: 0.197-0.344)] compared to the 34 studies published before 2004 [0.220 (95% CI: 0.168-0.283)] (Q value=0.862, p=0.353). The pooled estimate of good neurodevelopmental outcome for cryptogenic IS [0.543 (95% CI: 0.458-0.625)] was higher than symptomatic IS [0.125 (95% CI: 0.09-0.171)] (Q value=69.724, p<0.001). Risk ratio of LTTT <4weeks relative to >4weeks for good neurodevelopmental outcome of 8 studies was 1.519 (95% CI: 1.064-2.169). CONCLUSION Neurodevelopmental outcome was overall poor in patients with IS and has not changed since the publication of first guideline on IS. Although cryptogenic IS has better prognosis than symptomatic IS, the outcome for cryptogenic IS remained poor. There was heterogeneity in neurodevelopmental outcome ascertainment methods, highlighting the need for a more standardized and comprehensive assessment of cognitive, behavioural, emotional and functional outcomes.
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Affiliation(s)
- Elysa Widjaja
- Diagnostic Imaging, The Hospital for Sick Children, Toronto, Ontario, Canada; Division of Neurology, The Hospital for Sick Children, Toronto, Ontario, Canada.
| | - Cristina Go
- Division of Neurology, The Hospital for Sick Children, Toronto, Ontario, Canada.
| | - Blathnaid McCoy
- Division of Neurology, The Hospital for Sick Children, Toronto, Ontario, Canada.
| | - O Carter Snead
- Division of Neurology, The Hospital for Sick Children, Toronto, Ontario, Canada.
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91
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Spurling Jeste S, Wu JY, Senturk D, Varcin K, Ko J, McCarthy B, Shimizu C, Dies K, Vogel-Farley V, Sahin M, Nelson CA. Early developmental trajectories associated with ASD in infants with tuberous sclerosis complex. Neurology 2014; 83:160-8. [PMID: 24920850 DOI: 10.1212/wnl.0000000000000568] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE We performed a longitudinal cohort study of infants with tuberous sclerosis complex (TSC), with the overarching goal of defining early clinical, behavioral, and biological markers of autism spectrum disorder (ASD) in this high-risk population. METHODS Infants with TSC and typically developing controls were recruited as early as 3 months of age and followed longitudinally until 36 months of age. Data gathered at each time point included detailed seizure history, developmental testing using the Mullen Scales of Early Learning, and social-communication assessments using the Autism Observation Scale for Infants. At 18 to 36 months, a diagnostic evaluation for ASD was performed using the Autism Diagnostic Observation Schedule. RESULTS Infants with TSC demonstrated delays confined to nonverbal abilities, particularly in the visual domain, which then generalized to more global delays by age 9 months. Twenty-two of 40 infants with TSC were diagnosed with ASD. Both 12-month cognitive ability and developmental trajectories over the second and third years of life differentiated the groups. By 12 months of age, the ASD group demonstrated significantly greater cognitive delays and a significant decline in nonverbal IQ from 12 to 36 months. CONCLUSIONS This prospective study characterizes early developmental markers of ASD in infants with TSC. The early delay in visual reception and fine motor ability in the TSC group as a whole, coupled with the decline in nonverbal ability in infants diagnosed with ASD, suggests a domain-specific pathway to ASD that can inform more targeted interventions for these high-risk infants.
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Affiliation(s)
- Shafali Spurling Jeste
- From the Departments of Psychiatry and Neurology (S.S.J.), and Department of Psychiatry (J.K., B.M., C.S.), UCLA Semel Institute of Neuroscience and Human Behavior, Los Angeles, CA; Division of Pediatric Neurology (J.Y.W.), Mattel Children's Hospital, UCLA, Los Angeles; Department of Biostatistics (D.S.), School of Public Health, UCLA, Los Angeles; and Laboratories of Cognitive Neuroscience (K.V., V.V.-F., C.A.N.), Division of Developmental Medicine, Department of Neurology (K.D.), F.M. Kirby Neurobiology Center (M.S.), Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA.
| | - Joyce Y Wu
- From the Departments of Psychiatry and Neurology (S.S.J.), and Department of Psychiatry (J.K., B.M., C.S.), UCLA Semel Institute of Neuroscience and Human Behavior, Los Angeles, CA; Division of Pediatric Neurology (J.Y.W.), Mattel Children's Hospital, UCLA, Los Angeles; Department of Biostatistics (D.S.), School of Public Health, UCLA, Los Angeles; and Laboratories of Cognitive Neuroscience (K.V., V.V.-F., C.A.N.), Division of Developmental Medicine, Department of Neurology (K.D.), F.M. Kirby Neurobiology Center (M.S.), Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Damla Senturk
- From the Departments of Psychiatry and Neurology (S.S.J.), and Department of Psychiatry (J.K., B.M., C.S.), UCLA Semel Institute of Neuroscience and Human Behavior, Los Angeles, CA; Division of Pediatric Neurology (J.Y.W.), Mattel Children's Hospital, UCLA, Los Angeles; Department of Biostatistics (D.S.), School of Public Health, UCLA, Los Angeles; and Laboratories of Cognitive Neuroscience (K.V., V.V.-F., C.A.N.), Division of Developmental Medicine, Department of Neurology (K.D.), F.M. Kirby Neurobiology Center (M.S.), Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Kandice Varcin
- From the Departments of Psychiatry and Neurology (S.S.J.), and Department of Psychiatry (J.K., B.M., C.S.), UCLA Semel Institute of Neuroscience and Human Behavior, Los Angeles, CA; Division of Pediatric Neurology (J.Y.W.), Mattel Children's Hospital, UCLA, Los Angeles; Department of Biostatistics (D.S.), School of Public Health, UCLA, Los Angeles; and Laboratories of Cognitive Neuroscience (K.V., V.V.-F., C.A.N.), Division of Developmental Medicine, Department of Neurology (K.D.), F.M. Kirby Neurobiology Center (M.S.), Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Jordan Ko
- From the Departments of Psychiatry and Neurology (S.S.J.), and Department of Psychiatry (J.K., B.M., C.S.), UCLA Semel Institute of Neuroscience and Human Behavior, Los Angeles, CA; Division of Pediatric Neurology (J.Y.W.), Mattel Children's Hospital, UCLA, Los Angeles; Department of Biostatistics (D.S.), School of Public Health, UCLA, Los Angeles; and Laboratories of Cognitive Neuroscience (K.V., V.V.-F., C.A.N.), Division of Developmental Medicine, Department of Neurology (K.D.), F.M. Kirby Neurobiology Center (M.S.), Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Brigid McCarthy
- From the Departments of Psychiatry and Neurology (S.S.J.), and Department of Psychiatry (J.K., B.M., C.S.), UCLA Semel Institute of Neuroscience and Human Behavior, Los Angeles, CA; Division of Pediatric Neurology (J.Y.W.), Mattel Children's Hospital, UCLA, Los Angeles; Department of Biostatistics (D.S.), School of Public Health, UCLA, Los Angeles; and Laboratories of Cognitive Neuroscience (K.V., V.V.-F., C.A.N.), Division of Developmental Medicine, Department of Neurology (K.D.), F.M. Kirby Neurobiology Center (M.S.), Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Christina Shimizu
- From the Departments of Psychiatry and Neurology (S.S.J.), and Department of Psychiatry (J.K., B.M., C.S.), UCLA Semel Institute of Neuroscience and Human Behavior, Los Angeles, CA; Division of Pediatric Neurology (J.Y.W.), Mattel Children's Hospital, UCLA, Los Angeles; Department of Biostatistics (D.S.), School of Public Health, UCLA, Los Angeles; and Laboratories of Cognitive Neuroscience (K.V., V.V.-F., C.A.N.), Division of Developmental Medicine, Department of Neurology (K.D.), F.M. Kirby Neurobiology Center (M.S.), Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Kira Dies
- From the Departments of Psychiatry and Neurology (S.S.J.), and Department of Psychiatry (J.K., B.M., C.S.), UCLA Semel Institute of Neuroscience and Human Behavior, Los Angeles, CA; Division of Pediatric Neurology (J.Y.W.), Mattel Children's Hospital, UCLA, Los Angeles; Department of Biostatistics (D.S.), School of Public Health, UCLA, Los Angeles; and Laboratories of Cognitive Neuroscience (K.V., V.V.-F., C.A.N.), Division of Developmental Medicine, Department of Neurology (K.D.), F.M. Kirby Neurobiology Center (M.S.), Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Vanessa Vogel-Farley
- From the Departments of Psychiatry and Neurology (S.S.J.), and Department of Psychiatry (J.K., B.M., C.S.), UCLA Semel Institute of Neuroscience and Human Behavior, Los Angeles, CA; Division of Pediatric Neurology (J.Y.W.), Mattel Children's Hospital, UCLA, Los Angeles; Department of Biostatistics (D.S.), School of Public Health, UCLA, Los Angeles; and Laboratories of Cognitive Neuroscience (K.V., V.V.-F., C.A.N.), Division of Developmental Medicine, Department of Neurology (K.D.), F.M. Kirby Neurobiology Center (M.S.), Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Mustafa Sahin
- From the Departments of Psychiatry and Neurology (S.S.J.), and Department of Psychiatry (J.K., B.M., C.S.), UCLA Semel Institute of Neuroscience and Human Behavior, Los Angeles, CA; Division of Pediatric Neurology (J.Y.W.), Mattel Children's Hospital, UCLA, Los Angeles; Department of Biostatistics (D.S.), School of Public Health, UCLA, Los Angeles; and Laboratories of Cognitive Neuroscience (K.V., V.V.-F., C.A.N.), Division of Developmental Medicine, Department of Neurology (K.D.), F.M. Kirby Neurobiology Center (M.S.), Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Charles A Nelson
- From the Departments of Psychiatry and Neurology (S.S.J.), and Department of Psychiatry (J.K., B.M., C.S.), UCLA Semel Institute of Neuroscience and Human Behavior, Los Angeles, CA; Division of Pediatric Neurology (J.Y.W.), Mattel Children's Hospital, UCLA, Los Angeles; Department of Biostatistics (D.S.), School of Public Health, UCLA, Los Angeles; and Laboratories of Cognitive Neuroscience (K.V., V.V.-F., C.A.N.), Division of Developmental Medicine, Department of Neurology (K.D.), F.M. Kirby Neurobiology Center (M.S.), Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA
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Curatolo P, Moavero R. mTOR inhibitors as a new therapeutic option for epilepsy. Expert Rev Neurother 2014; 13:627-38. [PMID: 23739000 DOI: 10.1586/ern.13.49] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Dysregulation of the mTOR signaling pathway is associated with highly epileptogenic conditions such as tuberous sclerosis, focal cortical dysplasia, hemimegalencephaly and ganglioglioma, grouped under the term of 'mTORopathies'. Brain abnormalities associated with mTOR overactivation include enlarged and dysplastic neurons, abnormal cortical organization and astrogliosis. mTOR signaling intervenes in several molecular/biochemical processes leading to epileptogenesis. Animal models demonstrated that mTOR inhibitors could exert both an anticonvulsant action and an antiepileptogenic effect in models of genetic and acquired epilepsy. Preliminary studies in patients affected by tuberous sclerosis and treated with rapamycin or everolimus demonstrated potential benefits in seizure frequency reduction, suggesting that mTOR inhibition could be a promising treatment option for mTORopathies-related epilepsy. The authors reviewed the current knowledge of mTOR overactivation in different forms of epilepsy, and discuss the potential clinical use of mTOR inhibitors.
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Affiliation(s)
- Paolo Curatolo
- Child Neurology and Psychiatry Unit, Systems Medicine Department, Tor Vergata University Hospital, Rome, Italy.
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93
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Wang S, Fallah A. Optimal management of seizures associated with tuberous sclerosis complex: current and emerging options. Neuropsychiatr Dis Treat 2014; 10:2021-30. [PMID: 25364257 PMCID: PMC4211915 DOI: 10.2147/ndt.s51789] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Seizures are clinically significant manifestations associated with 79%-90% of patients with tuberous sclerosis complex. Often occurring within the first year of life in the form of infantile spasms, seizures interfere with neuropsychiatric, social, and cognitive development and carry significant individual and societal consequences. Prompt identification and treatment of seizures is an important focus in the overall management of tuberous sclerosis complex patients. Medical management, either after seizure onset or prophylactically in infants with electroencephalographic abnormalities, is considered first-line therapy. Vigabatrin and adrenocorticotropic hormone have emerged over the past few decades as mainstay pharmacologic modalities. Furthermore, emerging research on mammalian target of rapamycin inhibitors demonstrated promise for the management of seizures and subependymal giant cell astrocytoma. For appropriate surgical candidates with an epileptogenic zone associated with one or more glioneuronal hamartomas, ideally in noneloquent cortex, resective surgery can be considered, which provides a cure in 56% of patients. For medically refractory patients who do not meet criteria for curative surgery, palliative surgical approaches focused on reducing seizure burden, in the form of corpus callosotomy and vagus nerve stimulation, are alternative management options. Lastly, the ketogenic diet, a reemerging therapy based on the anticonvulsant effects of ketone bodies, can be utilized independently or in conjunction with other treatment modalities for the management of difficult-to-treat seizures.
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Affiliation(s)
- Shelly Wang
- Department of Neurosurgery, University of Toronto, Toronto, ON, Canada
| | - Aria Fallah
- Department of Neurosurgery, Miami Children's Hospital, Miami, FL, USA ; Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada
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Vignoli A, La Briola F, Turner K, Scornavacca G, Chiesa V, Zambrelli E, Piazzini A, Savini MN, Alfano RM, Canevini MP. Epilepsy in TSC: certain etiology does not mean certain prognosis. Epilepsia 2013; 54:2134-42. [PMID: 24304436 DOI: 10.1111/epi.12430] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/20/2013] [Indexed: 01/03/2023]
Abstract
PURPOSE Prevalence and long-term outcome of epilepsy in tuberous sclerosis complex (TSC) is reported to be variable, and the reasons for this variability are still controversial. METHODS We reviewed the clinical characteristics of patients with TSC who were regularly followed since 2000 at the San Paolo Multidisciplinary Tuberous Sclerosis Centre in Milan, Italy. From patient charts we collected data about age at epilepsy onset, seizure frequency and seizure type, history of infantile spasms (IS), epileptic syndrome, evolution to refractory epilepsy or to seizure freedom and/or medication freedom, electroencephalography (EEG) features, magnetic resonance imaging (MRI) findings, cognitive outcome, and genetic background. KEY FINDINGS Among the 160 subjects (120 adults and 40 children), 116 (72.5%) had epilepsy: 57 (35.6%) were seizure-free, and 59 (36.9%) had drug-resistant epilepsy. Most seizure-free patients had a focal epilepsy (89.5%), with 54.4% of them drug resistant for a period of their lives. Epilepsy onset in the first year of life with IS and/or focal seizures was characteristic of the drug-resistant group of patients, as well as cognitive impairment and TSC2 mutation (p < 0.05). A small group of patients (7 patients, 4.4%) experienced a seizure only once; all of them had normal cognition. SIGNIFICANCE Although epilepsy management can be challenging in TSC, more than one third of patients had their seizures controlled: through monotherapy in 56% and by polytherapy in 32%. Moreover, 12% of the patients became seizure-free and were off medication. Identifying predictive features of epilepsy and cognitive outcome can ensure better management for patients with TSC and delineate genotype-phenotype correlations.
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Affiliation(s)
- Aglaia Vignoli
- Neurology Unit, Epilepsy Center - Neurology Unit 2, San Paolo Hospital, DISS University of Milan, Milan, Italy
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Moavero R, Coniglio A, Garaci F, Curatolo P. Is mTOR inhibition a systemic treatment for tuberous sclerosis? Ital J Pediatr 2013; 39:57. [PMID: 24044547 PMCID: PMC3848592 DOI: 10.1186/1824-7288-39-57] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2013] [Accepted: 09/03/2013] [Indexed: 12/02/2022] Open
Abstract
Tuberous sclerosis complex (TSC) is a genetic multisystem disorder characterized by the development of hamartomas in several organs. Mutations in the TSC1 and TSC2 tumor suppressor genes determin overactivation of the mammalian target of rapamycin (mTOR) signaling pathway and subsequent abnormalities in numerous cell processes. As a result, mTOR inhibitors such as sirolimus and everolimus have the potential to provide targeted therapy for TSC patients. Everolimus has been recently approved as a pharmacotherapy option for TSC patients with subependymal giant-cell astrocytomas (SEGAs) or renal angiomyolipomas (AMLs). However, clinical evidence suggests that this treatment can benefit other TSC-associated disease manifestations, such as skin manifestations, pulmonary lymphangioleiomyomatosis, cardiac rhabdomyomas, and epilepsy. Therefore, the positive effects that mTOR inhibition have on a wide variety of TSC disease manifestations make this a potential systemic treatment option for this genetic multifaceted disorder.
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Affiliation(s)
- Romina Moavero
- Systems Medicine Department, Child Neurology and Psychiatry Unit, Tor Vergata University Hospital of Rome, Via Montpellier 1, 00133, Rome, Italy.
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96
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Frye RE, Rossignol D, Casanova MF, Brown GL, Martin V, Edelson S, Coben R, Lewine J, Slattery JC, Lau C, Hardy P, Fatemi SH, Folsom TD, MacFabe D, Adams JB. A review of traditional and novel treatments for seizures in autism spectrum disorder: findings from a systematic review and expert panel. Front Public Health 2013; 1:31. [PMID: 24350200 PMCID: PMC3859980 DOI: 10.3389/fpubh.2013.00031] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2013] [Accepted: 08/20/2013] [Indexed: 01/20/2023] Open
Abstract
Despite the fact that seizures are commonly associated with autism spectrum disorder (ASD), the effectiveness of treatments for seizures has not been well studied in individuals with ASD. This manuscript reviews both traditional and novel treatments for seizures associated with ASD. Studies were selected by systematically searching major electronic databases and by a panel of experts that treat ASD individuals. Only a few anti-epileptic drugs (AEDs) have undergone carefully controlled trials in ASD, but these trials examined outcomes other than seizures. Several lines of evidence point to valproate, lamotrigine, and levetiracetam as the most effective and tolerable AEDs for individuals with ASD. Limited evidence supports the use of traditional non-AED treatments, such as the ketogenic and modified Atkins diet, multiple subpial transections, immunomodulation, and neurofeedback treatments. Although specific treatments may be more appropriate for specific genetic and metabolic syndromes associated with ASD and seizures, there are few studies which have documented the effectiveness of treatments for seizures for specific syndromes. Limited evidence supports l-carnitine, multivitamins, and N-acetyl-l-cysteine in mitochondrial disease and dysfunction, folinic acid in cerebral folate abnormalities and early treatment with vigabatrin in tuberous sclerosis complex. Finally, there is limited evidence for a number of novel treatments, particularly magnesium with pyridoxine, omega-3 fatty acids, the gluten-free casein-free diet, and low-frequency repetitive transcranial magnetic simulation. Zinc and l-carnosine are potential novel treatments supported by basic research but not clinical studies. This review demonstrates the wide variety of treatments used to treat seizures in individuals with ASD as well as the striking lack of clinical trials performed to support the use of these treatments. Additional studies concerning these treatments for controlling seizures in individuals with ASD are warranted.
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Affiliation(s)
- Richard E. Frye
- Arkansas Children’s Hospital Research Institute, Little Rock, AR, USA
| | | | | | - Gregory L. Brown
- Autism Recovery and Comprehensive Health Medical Center, Franklin, WI, USA
| | - Victoria Martin
- Autism Recovery and Comprehensive Health Medical Center, Franklin, WI, USA
| | | | - Robert Coben
- New York University Brain Research Laboratory, New York, NY, USA
| | - Jeffrey Lewine
- MIND Research Network, University of New Mexico, Albuquerque, NM, USA
| | - John C. Slattery
- Arkansas Children’s Hospital Research Institute, Little Rock, AR, USA
| | - Chrystal Lau
- Arkansas Children’s Hospital Research Institute, Little Rock, AR, USA
| | - Paul Hardy
- Hardy Healthcare Associates, Hingham, MA, USA
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97
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Abstract
Autism is a neurodevelopmental disorder whose diagnosis is based on three behavioral criteria: unusual reciprocal social interactions, deficits in communication, and stereotyped repetitive behaviors with restricted interests. A large number of de novo single gene mutations and chromosomal deletions are associated with autism spectrum disorders. Based on the strong genetic evidence, mice with targeted mutations in homologous genes have been generated as translational research tools. Mouse models of autism have revealed behavioral and biological outcomes of mutations in risk genes. The field is now poised to employ the most robust phenotypes in the most replicable mouse models for preclinical screening of novel therapeutics.
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Affiliation(s)
- Jacqueline N Crawley
- Robert Chason Chair in Translational Research, M.I.N.D. Institute Professor of Psychiatry and Behavioral Sciences, School of Medicine, University of California, Davis, Sacramento, CA 95817, USA.
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98
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Ehninger D. From genes to cognition in tuberous sclerosis: Implications for mTOR inhibitor-based treatment approaches. Neuropharmacology 2013; 68:97-105. [DOI: 10.1016/j.neuropharm.2012.05.015] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2012] [Revised: 05/03/2012] [Accepted: 05/13/2012] [Indexed: 01/27/2023]
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99
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Yum MS, Lee EH, Ko TS. Vigabatrin and mental retardation in tuberous sclerosis: infantile spasms versus focal seizures. J Child Neurol 2013; 28:308-13. [PMID: 22752486 PMCID: PMC3695701 DOI: 10.1177/0883073812446485] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Tuberous sclerosis complex is a genetic disorder resulting in epilepsy and mental retardation. Vigabatrin has shown efficacy in the treatment of infantile spasms caused by tuberous sclerosis complex, but its effects on focal seizures caused by tuberous sclerosis complex have not been determined. We compared the efficacy of vigabatrin in patients with tuberous sclerosis complex-induced focal seizures and infantile spasms and assessed the mental outcomes in both groups. We retrospectively evaluated 31 children with tuberous sclerosis complex and epilepsy, who were treated with vigabatrin in a single tertiary center in Seoul, Korea. Vigabatrin treatment resulted in spasms cessation in 16 of 18 (88.9%) patients with infantile spasms, whereas 6 of 13 (46.2%) patients with focal seizures became seizure free. Initial response to vigabatrin had no effect on intellectual disability. Vigabatrin was highly effective in eliminating infantile spasms caused by tuberous sclerosis complex but was less effective in patients with focal seizures.
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Affiliation(s)
- Mi-Sun Yum
- Department of Pediatrics, Asan Medical Center, Children’s Hospital, University of Ulsan College of Medicine, Seoul, Korea
| | - Eun Hye Lee
- Department of Pediatrics, Asan Medical Center, Children’s Hospital, University of Ulsan College of Medicine, Seoul, Korea,Department of Pediatrics, College of Medicine, Kyung Hee University, Seoul, Korea
| | - Tae-Sung Ko
- Department of Pediatrics, Asan Medical Center, Children’s Hospital, University of Ulsan College of Medicine, Seoul, Korea
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