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Mitra AK, Dodge J, Van Ness J, Sokeye I, Van Ness B. A de novo splice site mutation in EHMT1 resulting in Kleefstra syndrome with pharmacogenomics screening and behavior therapy for regressive behaviors. Mol Genet Genomic Med 2016; 5:130-140. [PMID: 28361099 PMCID: PMC5370220 DOI: 10.1002/mgg3.265] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2016] [Revised: 10/24/2016] [Accepted: 11/01/2016] [Indexed: 12/18/2022] Open
Abstract
Background Kleefstra syndrome (KS) is a rare autosomal dominant developmental disability, caused by microdeletions or intragenic mutations within the epigenetic regulator gene EHMT1 (euchromatic histone lysine N‐methyltransferase 1). In addition to common features of autism, young adult regressive behaviors have been reported. However, the genetic downstream effects of the reported deletions or mutations on KS phenotype have not yet been completely explored. While genetic backgrounds affecting drug metabolism can have a profound effect on therapeutic interventions, pharmacogenomic variations are seldom considered in directing psychotropic therapies. Methods In this report, we used next‐generation sequencing (exome sequencing and high‐throughput RNA sequencing) in a patient and his parents to identify causative genetic variants followed by pharmacogenomics‐guided clinical decision‐making for making positive changes toward his treatment strategies. The patient had an early autism diagnosis and showed significant regressive behaviors and physical aberrations at age 23. Results Exome sequencing identified a novel, de novo splice site variant NM_024757.4: c.2750‐1G>T in EHMT1, a candidate gene for Kleefstra syndrome, in the patient that results in exon skipping and downstream frameshift and termination. Gene expression results from the patient showed, when compared to his parents, there was a significant decreased expression of several reported gene variants associated with autism risk. Further, using a pharmacogenomics genotyping panel, we discovered that the patient had the CYP2D6 nonfunctioning variant genotype *4/*4 that results in very low metabolic activity on a number of psychotropic drugs, including fluvoxamine which he was prescribed. As reported here, a change in psychotropic drugs and intense behavior therapies resulted in a significant reversal of the regressive behaviors and physical aberrations. Conclusion These results demonstrate an individualized approach that integrated genetic information and behavior therapies, resulting in a dramatic improvement in regressive behaviors associated with KS.
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Affiliation(s)
- Amit Kumar Mitra
- Department of Genetics, Cell Biology & Development University of Minnesota Minneapolis Minnesota
| | | | - Jody Van Ness
- Eyebox Tools, Inc.MinneapolisMinnesota; Present address: Jody Van Ness, Institute for Community IntegrationUniversity of MinnesotaMinneapolisMinnesota
| | | | - Brian Van Ness
- Department of Genetics, Cell Biology & Development University of Minnesota Minneapolis Minnesota
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152
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Parrini E, Marini C, Mei D, Galuppi A, Cellini E, Pucatti D, Chiti L, Rutigliano D, Bianchini C, Virdò S, De Vita D, Bigoni S, Barba C, Mari F, Montomoli M, Pisano T, Rosati A, Guerrini R. Diagnostic Targeted Resequencing in 349 Patients with Drug-Resistant Pediatric Epilepsies Identifies Causative Mutations in 30 Different Genes. Hum Mutat 2016; 38:216-225. [DOI: 10.1002/humu.23149] [Citation(s) in RCA: 117] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Accepted: 11/13/2016] [Indexed: 12/17/2022]
Affiliation(s)
- Elena Parrini
- Pediatric Neurology, Neurogenetics and Neurobiology Unit and Laboratories, Neuroscience Department; A Meyer Children's Hospital; University of Florence; Florence Italy
| | - Carla Marini
- Pediatric Neurology, Neurogenetics and Neurobiology Unit and Laboratories, Neuroscience Department; A Meyer Children's Hospital; University of Florence; Florence Italy
| | - Davide Mei
- Pediatric Neurology, Neurogenetics and Neurobiology Unit and Laboratories, Neuroscience Department; A Meyer Children's Hospital; University of Florence; Florence Italy
| | - Anna Galuppi
- Pediatric Neurology, Neurogenetics and Neurobiology Unit and Laboratories, Neuroscience Department; A Meyer Children's Hospital; University of Florence; Florence Italy
| | - Elena Cellini
- Pediatric Neurology, Neurogenetics and Neurobiology Unit and Laboratories, Neuroscience Department; A Meyer Children's Hospital; University of Florence; Florence Italy
| | - Daniela Pucatti
- Pediatric Neurology, Neurogenetics and Neurobiology Unit and Laboratories, Neuroscience Department; A Meyer Children's Hospital; University of Florence; Florence Italy
| | - Laura Chiti
- Pediatric Neurology, Neurogenetics and Neurobiology Unit and Laboratories, Neuroscience Department; A Meyer Children's Hospital; University of Florence; Florence Italy
| | - Domenico Rutigliano
- Pediatric Neurology, Neurogenetics and Neurobiology Unit and Laboratories, Neuroscience Department; A Meyer Children's Hospital; University of Florence; Florence Italy
| | - Claudia Bianchini
- Pediatric Neurology, Neurogenetics and Neurobiology Unit and Laboratories, Neuroscience Department; A Meyer Children's Hospital; University of Florence; Florence Italy
| | - Simona Virdò
- Pediatric Neurology, Neurogenetics and Neurobiology Unit and Laboratories, Neuroscience Department; A Meyer Children's Hospital; University of Florence; Florence Italy
| | - Dalila De Vita
- Pediatric Neurology, Neurogenetics and Neurobiology Unit and Laboratories, Neuroscience Department; A Meyer Children's Hospital; University of Florence; Florence Italy
| | - Stefania Bigoni
- UOL of Medical Genetics; Ferrara University Hospital; Ferrara Italy
| | - Carmen Barba
- Pediatric Neurology, Neurogenetics and Neurobiology Unit and Laboratories, Neuroscience Department; A Meyer Children's Hospital; University of Florence; Florence Italy
| | - Francesco Mari
- Pediatric Neurology, Neurogenetics and Neurobiology Unit and Laboratories, Neuroscience Department; A Meyer Children's Hospital; University of Florence; Florence Italy
| | - Martino Montomoli
- Pediatric Neurology, Neurogenetics and Neurobiology Unit and Laboratories, Neuroscience Department; A Meyer Children's Hospital; University of Florence; Florence Italy
| | - Tiziana Pisano
- Pediatric Neurology, Neurogenetics and Neurobiology Unit and Laboratories, Neuroscience Department; A Meyer Children's Hospital; University of Florence; Florence Italy
| | - Anna Rosati
- Pediatric Neurology, Neurogenetics and Neurobiology Unit and Laboratories, Neuroscience Department; A Meyer Children's Hospital; University of Florence; Florence Italy
| | - Renzo Guerrini
- Pediatric Neurology, Neurogenetics and Neurobiology Unit and Laboratories, Neuroscience Department; A Meyer Children's Hospital; University of Florence; Florence Italy
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153
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Sands TT, Balestri M, Bellini G, Mulkey SB, Danhaive O, Bakken EH, Taglialatela M, Oldham MS, Vigevano F, Holmes GL, Cilio MR. Rapid and safe response to low-dose carbamazepine in neonatal epilepsy. Epilepsia 2016; 57:2019-2030. [DOI: 10.1111/epi.13596] [Citation(s) in RCA: 65] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/10/2016] [Indexed: 12/24/2022]
Affiliation(s)
- Tristan T. Sands
- Department of Neurology; University of California San Francisco; San Francisco California U.S.A
| | - Martina Balestri
- Department of Neurology; Bambino Gesú Children's Hospital and Research Institute; Rome Italy
| | - Giulia Bellini
- Department of Experimental Medicine; Second University of Naples; Naples Italy
| | - Sarah B. Mulkey
- Department of Pediatrics; University of Arkansas for Medical Sciences; Little Rock Arkansas U.S.A
| | - Olivier Danhaive
- Department of Pediatrics; University of California San Francisco; San Francisco California U.S.A
| | - Eliza Hayes Bakken
- Department of Pediatrics; University of California San Francisco; San Francisco California U.S.A
| | | | - Michael S. Oldham
- Department of Neurology; University of California San Francisco; San Francisco California U.S.A
| | - Federico Vigevano
- Department of Neurology; Bambino Gesú Children's Hospital and Research Institute; Rome Italy
| | - Gregory L. Holmes
- Department of Neurological Sciences; University of Vermont; College of Medicine; Burlington Vermont U.S.A
| | - Maria Roberta Cilio
- Department of Neurology; University of California San Francisco; San Francisco California U.S.A
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154
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Reif PS, Tsai MH, Helbig I, Rosenow F, Klein KM. Precision medicine in genetic epilepsies: break of dawn? Expert Rev Neurother 2016; 17:381-392. [DOI: 10.1080/14737175.2017.1253476] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Affiliation(s)
- Philipp Sebastian Reif
- Epilepsy Center Frankfurt Rhine-Main, Department of Neurology, Center of Neurology and Neurosurgery, University Hospital, Goethe-University Frankfurt, Frankfurt, Germany
| | - Meng-Han Tsai
- Division of Brain Function & Epilepsy, Department of Neurology, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Ingo Helbig
- Division of Neurology, The Children’s Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Neuropediatrics, Christian-Albrechts-University of Kiel and University Medical Center Schleswig-Holstein, Kiel, Germany
- Departments of Brain and Cognitive Sciences, Physiology and Cell Biology, Zlotowski Center for Neuroscience, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Felix Rosenow
- Epilepsy Center Frankfurt Rhine-Main, Department of Neurology, Center of Neurology and Neurosurgery, University Hospital, Goethe-University Frankfurt, Frankfurt, Germany
- Epilepsy Center Hessen, Department of Neurology, University Hospitals Giessen & Marburg, and Philipps-University Marburg, Marburg, Germany
| | - Karl Martin Klein
- Epilepsy Center Frankfurt Rhine-Main, Department of Neurology, Center of Neurology and Neurosurgery, University Hospital, Goethe-University Frankfurt, Frankfurt, Germany
- Epilepsy Center Hessen, Department of Neurology, University Hospitals Giessen & Marburg, and Philipps-University Marburg, Marburg, Germany
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155
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Millichap JJ, Miceli F, De Maria M, Keator C, Joshi N, Tran B, Soldovieri MV, Ambrosino P, Shashi V, Mikati MA, Cooper EC, Taglialatela M. Infantile spasms and encephalopathy without preceding neonatal seizures caused by KCNQ2 R198Q, a gain-of-function variant. Epilepsia 2016; 58:e10-e15. [PMID: 27861786 DOI: 10.1111/epi.13601] [Citation(s) in RCA: 67] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/07/2016] [Indexed: 02/04/2023]
Abstract
Variants in KCNQ2 encoding for Kv 7.2 neuronal K+ channel subunits lead to a spectrum of neonatal-onset epilepsies, ranging from self-limiting forms to severe epileptic encephalopathy. Most KCNQ2 pathogenic variants cause loss-of-function, whereas few increase channel activity (gain-of-function). We herein provide evidence for a new phenotypic and functional profile in KCNQ2-related epilepsy: infantile spasms without prior neonatal seizures associated with a gain-of-function gene variant. With use of an international registry, we identified four unrelated patients with the same de novo heterozygous KCNQ2 c.593G>A, p.Arg198Gln (R198Q) variant. All were born at term and discharged home without seizures or concern of encephalopathy, but developed infantile spasms with hypsarrhythmia (or modified hypsarrhythmia) between the ages of 4 and 6 months. At last follow-up (ages 3-11 years), all patients were seizure-free and had severe developmental delay. In vitro experiments showed that Kv7.2 R198Q subunits shifted current activation gating to hyperpolarized potentials, indicative of gain-of-function; in neurons, Kv 7.2 and Kv 7.2 R198Q subunits similarly populated the axon initial segment, suggesting that gating changes rather than altered subcellular distribution contribute to disease molecular pathogenesis. We conclude that KCNQ2 R198Q is a model for a new subclass of KCNQ2 variants causing infantile spasms and encephalopathy, without preceding neonatal seizures. A PowerPoint slide summarizing this article is available for download in the Supporting Information section here.
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Affiliation(s)
- John J Millichap
- Epilepsy Center and Division of Neurology, Departments of Pediatrics and Neurology, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois, U.S.A
| | - Francesco Miceli
- Department of Neuroscience, University of Naples "Federico II", Naples, Italy
| | - Michela De Maria
- Department of Medicine and Health Science, University of Molise, Campobasso, Italy
| | - Cynthia Keator
- Jane and John Justin Neurosciences Center, Cook Children's Hospital, Fort Worth, Texas, U.S.A
| | - Nishtha Joshi
- Departments of Neurology, Neuroscience, Molecular, and Human Genetics, Baylor College of Medicine, Houston, Texas, U.S.A
| | - Baouyen Tran
- Departments of Neurology, Neuroscience, Molecular, and Human Genetics, Baylor College of Medicine, Houston, Texas, U.S.A
| | | | - Paolo Ambrosino
- Department of Medicine and Health Science, University of Molise, Campobasso, Italy
| | - Vandana Shashi
- Division of Neurology, Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina, U.S.A
| | - Mohamad A Mikati
- Division of Neurology, Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina, U.S.A
| | - Edward C Cooper
- Departments of Neurology, Neuroscience, Molecular, and Human Genetics, Baylor College of Medicine, Houston, Texas, U.S.A
| | - Maurizio Taglialatela
- Department of Neuroscience, University of Naples "Federico II", Naples, Italy.,Department of Medicine and Health Science, University of Molise, Campobasso, Italy
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156
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157
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Millichap JJ, Park KL, Tsuchida T, Ben-Zeev B, Carmant L, Flamini R, Joshi N, Levisohn PM, Marsh E, Nangia S, Narayanan V, Ortiz-Gonzalez XR, Patterson MC, Pearl PL, Porter B, Ramsey K, McGinnis EL, Taglialatela M, Tracy M, Tran B, Venkatesan C, Weckhuysen S, Cooper EC. KCNQ2 encephalopathy: Features, mutational hot spots, and ezogabine treatment of 11 patients. NEUROLOGY-GENETICS 2016; 2:e96. [PMID: 27602407 PMCID: PMC4995058 DOI: 10.1212/nxg.0000000000000096] [Citation(s) in RCA: 147] [Impact Index Per Article: 18.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/24/2016] [Accepted: 07/06/2016] [Indexed: 11/15/2022]
Abstract
Objective: To advance the understanding of KCNQ2 encephalopathy genotype–phenotype relationships and to begin to assess the potential of selective KCNQ channel openers as targeted treatments. Methods: We retrospectively studied 23 patients with KCNQ2 encephalopathy, including 11 treated with ezogabine (EZO). We analyzed the genotype–phenotype relationships in these and 70 previously described patients. Results: The mean seizure onset age was 1.8 ± 1.6 (SD) days. Of the 20 EEGs obtained within a week of birth, 11 showed burst suppression. When new seizure types appeared in infancy (15 patients), the most common were epileptic spasms (n = 8). At last follow-up, seizures persisted in 9 patients. Development was delayed in all, severely in 14. The KCNQ2 variants identified introduced amino acid missense changes or, in one instance, a single residue deletion. They were clustered in 4 protein subdomains predicted to poison tetrameric channel functions. EZO use (assessed by the treating physicians and parents) was associated with improvement in seizures and/or development in 3 of the 4 treated before 6 months of age, and 2 of the 7 treated later; no serious side effects were observed. Conclusions: KCNQ2 variants cause neonatal-onset epileptic encephalopathy of widely varying severity. Pathogenic variants in epileptic encephalopathy are clustered in “hot spots” known to be critical for channel activity. For variants causing KCNQ2 channel loss of function, EZO appeared well tolerated and potentially beneficial against refractory seizures when started early. Larger, prospective studies are needed to enable better definition of prognostic categories and more robust testing of novel interventions. Classification of evidence: This study provides Class IV evidence that EZO is effective for refractory seizures in patients with epilepsy due to KCNQ2 encephalopathy.
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Affiliation(s)
| | - Kristen L Park
- Authors' affiliations are listed at the end of the article
| | - Tammy Tsuchida
- Authors' affiliations are listed at the end of the article
| | | | - Lionel Carmant
- Authors' affiliations are listed at the end of the article
| | - Robert Flamini
- Authors' affiliations are listed at the end of the article
| | - Nishtha Joshi
- Authors' affiliations are listed at the end of the article
| | | | - Eric Marsh
- Authors' affiliations are listed at the end of the article
| | - Srishti Nangia
- Authors' affiliations are listed at the end of the article
| | | | | | | | | | - Brenda Porter
- Authors' affiliations are listed at the end of the article
| | - Keri Ramsey
- Authors' affiliations are listed at the end of the article
| | | | | | - Molly Tracy
- Authors' affiliations are listed at the end of the article
| | - Baouyen Tran
- Authors' affiliations are listed at the end of the article
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158
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Abstract
OPINION STATEMENT The mainstay of treatment of epilepsy has been antiepileptic drugs; however, despite the emergence of new agents, a consistent proportion remain drug-resistant. Newer AEDs show promise. However, as it becomes clear that the epilepsies are a group of diseases rather than a single disorder the prospect of targeted treatment in some may become a reality.
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Affiliation(s)
- Katharina Vezyroglou
- Great Ormond Street Hospital for Children NHS Trust, Great Ormond Street, London, WC1N 3JH, UK
| | - J Helen Cross
- Clinical Neurosciences, 30 Guilford St, London, WC1N 1EH, UK. .,Great Ormond Street Hospital for Children NHS Trust, Great Ormond Street, London, WC1N 3JH, UK.
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159
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A Clinician's perspective on clinical exome sequencing. Hum Genet 2016; 135:643-54. [PMID: 27126233 DOI: 10.1007/s00439-016-1662-x] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2016] [Accepted: 03/23/2016] [Indexed: 12/22/2022]
Abstract
Clinical exome sequencing has clearly improved our ability as clinicians to identify the cause of a wide variety of disorders. Prior to exome sequencing, a majority of patients with apparent syndromes never received a specific molecular genetic diagnosis despite extensive diagnostic odysseys. Even for those receiving an answer to the question of what caused their disorder, the diagnostic odyssey often spanned years to decades. Determining the particular genetic cause in an individual patient can be challenging due to inherent phenotypic and genetic heterogeneity of disease, technical limitations of testing or both. Blended phenotypes, due to multiple monogenic disorders in the same patient, are true dilemmas for traditional genetic evaluations, but are increasingly being diagnosed through clinical exome sequencing. New sequencing technologies have increased the proportion of patients receiving molecular diagnoses, while significantly shortening the time scale, providing multiple benefits for the health-care team, patient and family.
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160
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Hernan AE, Holmes GL. Antiepileptic drug treatment strategies in neonatal epilepsy. PROGRESS IN BRAIN RESEARCH 2016; 226:179-93. [PMID: 27323943 DOI: 10.1016/bs.pbr.2016.03.011] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The highest risk of seizures across the lifespan is in the neonatal period. The enhanced excitability of the immature brain compared to the mature brain is related to the sequential development and expression of essential neurotransmitter signaling pathways. During the neonatal period there is an overabundance of excitatory receptors, and γ-amino-butyric acid (GABA) is potentially depolarizing, as opposed to hyperpolarizing in the older brain. While this enhanced excitability is required for regulation of activity-dependent synapse formation and refining of synaptic connections that are necessary for normal brain development, enhanced excitability predisposes the immature brain to seizures. In addition to being common, neonatal seizures are very difficult to treat; antiepileptic drugs used in older children and adults are less efficacious, and possibly detrimental to brain development. In an effort to target the unique features of neurotransmission in the neonate, bumetanide, an NKCC1 inhibitor which reduces intraneuronal Cl(-) and induces a significant shift of EGABA toward more hyperpolarized values in vitro, has been used to treat neonatal seizures. As the understanding of the pathophysiology of genetic forms of neonatal epilepsy has evolved there have been a few successful attempts to pharmacologically target the mutated protein. This approach, while promising, is challenging due to the findings that the genetic syndromes presenting in infancy demonstrate genetic heterogeneity in regard to both the mutated gene and its function.
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Affiliation(s)
- A E Hernan
- University of Vermont College of Medicine, Burlington, VT, United States
| | - G L Holmes
- University of Vermont College of Medicine, Burlington, VT, United States.
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161
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Abstract
Genetics should now be part of everyday clinical epilepsy practice. Good data exist to provide empiric risks based on epilepsy syndrome diagnosis. Investigation of the molecular basis of some epilepsies is now a practical clinical task and is of clear value to the patient and family. In some cases, specific therapeutic decisions can now be made based on genetic findings, and this scenario of precision therapy is likely to increase in the coming years.
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Affiliation(s)
- Samuel F. Berkovic
- Director, Epilepsy Research Centre, University of Melbourne, Heidelberg, Australia
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162
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Kang SK, Kadam SD. Neonatal Seizures: Impact on Neurodevelopmental Outcomes. Front Pediatr 2015; 3:101. [PMID: 26636052 PMCID: PMC4655485 DOI: 10.3389/fped.2015.00101] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2015] [Accepted: 11/05/2015] [Indexed: 11/24/2022] Open
Abstract
Neonatal period is the most vulnerable time for the occurrence of seizures, and neonatal seizures often pose a clinical challenge both for their acute management and frequency of associated long-term co-morbidities. Etiologies of neonatal seizures are known to play a primary role in the anti-epileptic drug responsiveness and the long-term sequelae. Recent studies have suggested that burden of acute recurrent seizures in neonates may also impact chronic outcomes independent of the etiology. However, not many studies, either clinical or pre-clinical, have addressed the long-term outcomes of neonatal seizures in an etiology-specific manner. In this review, we briefly review the available clinical and pre-clinical research for long-term outcomes following neonatal seizures. As the most frequent cause of acquired neonatal seizures, we focus on the studies evaluating long-term effects of HIE-seizures with the goal to evaluate (1) what parameters evaluated during acute stages of neonatal seizures can reliably be used to predict long-term outcomes? and (2) what available clinical and pre-clinical data are available help determine importance of etiology vs. seizure burdens in long-term sequelae.
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Affiliation(s)
- Seok Kyu Kang
- Neuroscience Laboratory, Hugo Moser Research Institute at Kennedy Krieger , Baltimore, MD , USA
| | - Shilpa D Kadam
- Neuroscience Laboratory, Hugo Moser Research Institute at Kennedy Krieger , Baltimore, MD , USA ; Department of Neurology, Johns Hopkins University School of Medicine , Baltimore, MD , USA
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