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Operto FF, Pastorino GMG, Viggiano A, Dell’Isola GB, Dini G, Verrotti A, Coppola G. Epilepsy and Cognitive Impairment in Childhood and Adolescence: A Mini-Review. Curr Neuropharmacol 2023; 21:1646-1665. [PMID: 35794776 PMCID: PMC10514538 DOI: 10.2174/1570159x20666220706102708] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Revised: 02/28/2022] [Accepted: 04/26/2022] [Indexed: 11/22/2022] Open
Abstract
Managing epilepsy in people with an intellectual disability remains a therapeutic challenge and must take into account additional issues such as diagnostic difficulties and frequent drug resistance. Advances in genomic technologies improved our understanding of epilepsy and raised the possibility to develop patients-tailored treatments acting on the key molecular mechanisms involved in the development of the disease. In addition to conventional antiseizure medications (ASMs), ketogenic diet, hormone therapy and epilepsy surgery play an important role, especially in cases of drugresistance. This review aims to provide a comprehensive overview of the mainfactors influencing cognition in children and adolescents with epilepsy and the main therapeutic options available for the epilepsies associated with intellectual disability.
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Affiliation(s)
- Francesca Felicia Operto
- Child and Adolescent Neuropsychiatry Unit, Department of Medicine, Surgery and Dentistry, University of Salerno, Baronissi, SA, Italy
| | - Grazia Maria Giovanna Pastorino
- Child and Adolescent Neuropsychiatry Unit, Department of Medicine, Surgery and Dentistry, University of Salerno, Baronissi, SA, Italy
| | - Andrea Viggiano
- Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, University of Salerno, Baronissi, SA, Italy
| | | | - Gianluca Dini
- Department of Pediatrics, University of Perugia, Giorgio Menghini Square, 06129 Perugia, Italy
| | - Alberto Verrotti
- Department of Pediatrics, University of Perugia, Giorgio Menghini Square, 06129 Perugia, Italy
| | - Giangennaro Coppola
- Child and Adolescent Neuropsychiatry Unit, Department of Medicine, Surgery and Dentistry, University of Salerno, Baronissi, SA, Italy
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2
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Celik H, Ozdemir FMA, Aksoy E, Oztoprak U, Kilic M, Yuksel D. Evaluation of clinical and electroencephalographic findings in patients with early childhood epilepsy and inborn errors of metabolism. Acta Neurol Belg 2022; 122:1575-1581. [DOI: 10.1007/s13760-022-02066-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Accepted: 08/11/2022] [Indexed: 11/01/2022]
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3
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Abstract
Inborn errors of metabolism have been considered as an infrequent cause of epilepsy. Improvement in diagnostics has improved the detection of a metabolic basis of recurrent seizures in neonates and children. The term 'metabolic epilepsy' is used to suggest inherited metabolic disorders with predominant epileptic manifestations as well as those where epilepsy is part of the overall neurological phenotype. Several of these disorders are treatable, and the physician should bear in mind the classical ages of presentation. As there are no specific clinical or electrographic features suggestive of metabolic epilepsies, an early suspicion is based on clinical and laboratory clues. Fortunately, with the advancement of gene sequencing technology, a diagnosis of these rare conditions is more straightforward and may not require invasive procedures such as biopsies, multiple metabolic stress-induced testing for abnormalities, and cerebrospinal fluid analysis. A gene panel may suffice in most cases and can be done from a blood sample. In many countries, many treatable metabolic disorders are now part of the neonatal screen. Early diagnosis and treatment of these disorders can result in the prevention of a full-scale metabolic crisis and improvement of neurological outcomes. Long-term neurological outcomes are variable and additional therapies may be required.
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4
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Poothrikovil RP, Al Thihli K, Al Futaisi A. EEG Pattern in Neonatal Maple Syrup Urine Disease: Description and Clinical Significance. Neurodiagn J 2021; 61:123-131. [PMID: 34449278 DOI: 10.1080/21646821.2021.1935628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Maple Syrup Urine Disease (MSUD) is a rare autosomal recessive disorder characterized by deficiency of branched-chain keto acid dehydrogenase complex, which is required to metabolize the three branched chain amino acids (BCAAs), leucine, isoleucine and valine. This metabolic dysfunction results in progressive encephalopathy manifesting with lethargy, vomiting, posturing and abnormal movements during the neonatal period in the classic form of the disease. If untreated, progressive brain damage causes coma, seizures and death usually within a few weeks. EEG is an essential investigation in a neonate with progressive encephalopathy and seizures. EEG abnormalities in neonatal encephalopathies due to inborn error of metabolism (IEM) are widely variable depending on the severity. Central comb-like rhythm is an EEG marker of neonatal MSUD in appropriate clinical context. This pattern should not be mistaken for epileptic abnormalities, sleep spindles or other similar nonspecific activities. We describe a patient with classic MSUD who presented with an EEG pattern of comb-like rhythm. Background abnormalities and epileptic discharges are common along comb-like rhythm in MSUD patients. EEG technologists and interpreters should be able to identify this pattern to support the early diagnosis and treatment of MSUD.
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Affiliation(s)
- Rajesh P Poothrikovil
- Department of Clinical Physiology Sultan Qaboos University Hospital Muscat, Sultanate of Oman
| | - Khalid Al Thihli
- Department of Clinical Genetics, Sultan Qaboos University Hospital Muscat, Sultanate of Oman
| | - Amna Al Futaisi
- Department of Child Health, College of Medicine and Health SciencesSultan Qaboos University Muscat, Sultanate of Oman
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5
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Almannai M, Al Mahmoud RA, Mekki M, El-Hattab AW. Metabolic Seizures. Front Neurol 2021; 12:640371. [PMID: 34295297 PMCID: PMC8290068 DOI: 10.3389/fneur.2021.640371] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Accepted: 05/21/2021] [Indexed: 12/13/2022] Open
Abstract
Metabolic diseases should always be considered when evaluating children presenting with seizures. This is because many metabolic disorders are potentially treatable and seizure control can be achieved when these diseases are appropriately treated. Seizures caused by underlying metabolic diseases (metabolic seizures) should be particularly considered in unexplained neonatal seizures, refractory seizures, seizures related to fasting or food intake, seizures associated with other systemic or neurologic features, parental consanguinity, and family history of epilepsy. Metabolic seizures can be caused by various amino acids metabolic disorders, disorders of energy metabolism, cofactor-related metabolic diseases, purine and pyrimidine metabolic diseases, congenital disorders of glycosylation, and lysosomal and peroxisomal disorders. Diagnosing metabolic seizures without delay is essential because the immediate initiation of appropriate therapy for many metabolic diseases can prevent or minimize complications.
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Affiliation(s)
- Mohammed Almannai
- Section of Medical Genetics, Children's Hospital, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Rabah A Al Mahmoud
- Department of Clinical Sciences, College of Medicine, University of Sharjah, Sharjah, United Arab Emirates.,Department of Pediatrics, University Hospital Sharjah, Sharjah, United Arab Emirates
| | - Mohammed Mekki
- Department of Clinical Sciences, College of Medicine, University of Sharjah, Sharjah, United Arab Emirates.,Department of Pediatrics, Al Qassimi Women's and Children's Hospital, Sharjah, United Arab Emirates
| | - Ayman W El-Hattab
- Department of Clinical Sciences, College of Medicine, University of Sharjah, Sharjah, United Arab Emirates.,Clinical Genetics, University Hospital Sharjah, Sharjah, United Arab Emirates
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6
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Impact of predictive, preventive and precision medicine strategies in epilepsy. Nat Rev Neurol 2020; 16:674-688. [PMID: 33077944 DOI: 10.1038/s41582-020-0409-4] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/01/2020] [Indexed: 12/15/2022]
Abstract
Over the last decade, advances in genetics, neuroimaging and EEG have enabled the aetiology of epilepsy to be identified earlier in the disease course than ever before. At the same time, progress in the study of experimental models of epilepsy has provided a better understanding of the mechanisms underlying the condition and has enabled the identification of therapies that target specific aetiologies. We are now witnessing the impact of these advances in our daily clinical practice. Thus, now is the time for a paradigm shift in epilepsy treatment from a reactive attitude, treating patients after the onset of epilepsy and the initiation of seizures, to a proactive attitude that is more broadly integrated into a 'P4 medicine' approach. This P4 approach, which is personalized, predictive, preventive and participatory, puts patients at the centre of their own care and, ultimately, aims to prevent the onset of epilepsy. This aim will be achieved by adapting epilepsy treatments not only to a given syndrome but also to a given patient and moving from the usual anti-seizure treatments to personalized treatments designed to target specific aetiologies. In this Review, we present the current state of this ongoing revolution, emphasizing the impact on clinical practice.
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7
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Mathis D, Beese K, Rüegg C, Plecko B, Hersberger M. LC-MS/MS method for the differential diagnosis of treatable early onset inherited metabolic epilepsies. J Inherit Metab Dis 2020; 43:1102-1111. [PMID: 32319100 DOI: 10.1002/jimd.12244] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2020] [Revised: 03/25/2020] [Accepted: 04/17/2020] [Indexed: 12/12/2022]
Abstract
Rapid diagnosis and early specific treatment of metabolic epilepsies due to inborn errors of metabolism (IEMs) is crucial to avoid irreversible sequalae. Nowadays, besides the profile analysis of amino- and organic acids, a range of additional targeted assays is used for the selective screening of those diseases. This strategy can lead to long turn-around times, repeated sampling and diagnostic delays. To replace those individual targeted assays, we developed a new liquid chromatography mass spectrometry method (LC-MS/MS) for the differential diagnosis of inherited metabolic epilepsies that are potentially treatable. The method was developed to simultaneously quantify 12 metabolites (sulfocysteine, guanidinoacetate, creatine, pipecolic acid, Δ1 -piperideine-6-carboxylate (P6C), proline, Δ1 -pyrroline-5-carboxylate (P5C), and the B6 -vitamers) enabling the diagnosis of nine different treatable IEMs presenting primarily with early-onset epilepsy. Plasma and urine samples were mixed with internal standards, precipitated and the supernatants were analyzed by LC-MS/MS. In comparison with previous assays, no derivatization of the metabolites is necessary for analysis. This LC-MS method was validated for quantitative results for all metabolites except P6C and P5C for which semiquantitative results were obtained due to the absence of commercially available standards. Coefficients of variation for all analytes were below 15% and recovery rates range between 80% and 120%. Analysis of patient samples with known IEMs demonstrated the diagnostic value of the method. The presented assay covers a selected panel of biochemical markers, improves the efficiency in the laboratory, and potentially leads to faster diagnoses and earlier treatment avoiding irreversible damage in patients affected with IEMs.
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Affiliation(s)
- Déborah Mathis
- Division of Clinical Chemistry and Biochemistry, University Children's Hospital Zurich, Zurich, Switzerland
- Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland
| | - Karin Beese
- Division of Clinical Chemistry and Biochemistry, University Children's Hospital Zurich, Zurich, Switzerland
| | - Carmen Rüegg
- Division of Clinical Chemistry and Biochemistry, University Children's Hospital Zurich, Zurich, Switzerland
| | - Barbara Plecko
- Department of Pediatrics and Adolescent Medicine, Division of General Pediatrics, Medical University of Graz, Graz, Austria
| | - Martin Hersberger
- Division of Clinical Chemistry and Biochemistry, University Children's Hospital Zurich, Zurich, Switzerland
- Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland
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8
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Dechandt CRP, Vicentini TM, Lanfredi GP, Silva-Jr RMP, Espreafico EM, de Oliveira JAC, Faça VM, Garcia-Cairasco N, Alberici LC. The highly efficient powerhouse in the Wistar audiogenic rat, an epileptic rat strain. Am J Physiol Regul Integr Comp Physiol 2018; 316:R243-R254. [PMID: 30517024 DOI: 10.1152/ajpregu.00254.2018] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
The Wistar audiogenic rat (WAR) is an animal model of tonic-clonic epileptic seizures, developed after genetic selection by sister × brother inbreeding of Wistar rats susceptible to sound stimuli. Although metabolic changes have been described in this strain, nothing is known about its mitochondrial metabolism. Here, we addressed mitochondrial aspects of oxidative phosphorylation, oxidative stress, biogenesis, and dynamics in liver, skeletal muscle, and heart of male WARs and correlating them with physiological aspects of body metabolism. The results showed higher mitochondrial content, respiration rates in phosphorylation and noncoupled states, and H2O2 production in WARs. Liver presented higher content of peroxisome proliferator-activated receptor-γ coactivator 1α (PGC1α) and mammalian target of rapamycin, proteins related to mitochondrial biogenesis. In agreement, isolated liver mitochondria from WARs showed higher respiration rates in phosphorylation state and ADP-to-O ratio, as well as higher content of proteins related to electron transport chain ATP synthase, TCA cycle, and mitochondrial fusion and fission compared with their Wistar counterparts. Mitochondria with higher area and perimeter and more variable shapes were found in liver and soleus from WARs in addition to lower reduced-to-oxidized glutathione ratio. In vivo, WARs demonstrated lower body mass and energy expenditure but higher food and water intake and amino acid oxidation. When exposed to a running test, WARs reached higher speed and resisted for a longer time and distance than their Wistar controls. In conclusion, the WAR strain has mitochondrial changes in liver, skeletal muscle, and heart that improve its mitochondrial capacity of ATP production, making it an excellent rat model to study PGC1α overexpression and mitochondrial function in different physiological conditions or facing pathological challenges.
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Affiliation(s)
- Carlos Roberto Porto Dechandt
- Departamento de Física e Química, Faculdade de Ciências Farmacêuticas de Ribeirão Preto, Universidade de São Paulo , Ribeirão Preto, São Paulo , Brazil
| | - Tatiane M Vicentini
- Departamento de Física e Química, Faculdade de Ciências Farmacêuticas de Ribeirão Preto, Universidade de São Paulo , Ribeirão Preto, São Paulo , Brazil
| | - Guilherme Pauperio Lanfredi
- Departamento de Bioquímica e Imunologia, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo , Ribeirão Preto, São Paulo , Brazil
| | - Rui M P Silva-Jr
- Departamento de Biologia Celular e Molecular, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo , Ribeirão Preto, São Paulo , Brazil
| | - Enilza Maria Espreafico
- Departamento de Biologia Celular e Molecular, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo , Ribeirão Preto, São Paulo , Brazil
| | - José A Cortes de Oliveira
- Departamento de Fisiologia, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Vitor Marcel Faça
- Departamento de Bioquímica e Imunologia, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo , Ribeirão Preto, São Paulo , Brazil
| | - Norberto Garcia-Cairasco
- Departamento de Fisiologia, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Luciane Carla Alberici
- Departamento de Física e Química, Faculdade de Ciências Farmacêuticas de Ribeirão Preto, Universidade de São Paulo , Ribeirão Preto, São Paulo , Brazil
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9
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Almannai M, El-Hattab AW. Inborn Errors of Metabolism with Seizures: Defects of Glycine and Serine Metabolism and Cofactor-Related Disorders. Pediatr Clin North Am 2018; 65:279-299. [PMID: 29502914 DOI: 10.1016/j.pcl.2017.11.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Inborn errors of metabolism (IEM) are relatively uncommon causes for seizures in children; however, they should be considered in the differential diagnosis because several IEM are potentially treatable and seizures can be resolved if appropriate treatment is initiated. Clues from clinical presentation, physical examination, laboratory tests, and brain imaging can raise the possibility of IEM. Several IEM can present with seizures, either as the main presenting finding or as a part of a more complex phenotype. These include cofactor-related disorders, glycine and serine metabolism defects, and other disorders.
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Affiliation(s)
- Mohammed Almannai
- Department of Molecular and Human Genetics, Baylor College of Medicine, Texas Children's Hospital, One Baylor Plaza, Houston, TX 77030, USA
| | - Ayman W El-Hattab
- Division of Clinical Genetics and Metabolic Disorders, Pediatrics Department, Tawam Hospital, Tawam Roundabout, Al-Ain 15258, United Arab Emirates.
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10
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Saudubray JM, Garcia-Cazorla À. Inborn Errors of Metabolism Overview: Pathophysiology, Manifestations, Evaluation, and Management. Pediatr Clin North Am 2018; 65:179-208. [PMID: 29502909 DOI: 10.1016/j.pcl.2017.11.002] [Citation(s) in RCA: 86] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
The specialty of inherited metabolic disease is at the forefront of progress in medicine, with new methods in metabolomics and genomics identifying the molecular basis for a growing number of conditions and syndromes. This review presents an updated pathophysiologic classification of inborn errors of metabolism and a method of clinical screening in neonates, late-onset emergencies, neurologic deterioration, and other common clinical scenarios. When and how to investigate a metabolic disorder is presented to encourage physicians to use sophisticated biochemical investigations and not miss a treatable disorder.
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Affiliation(s)
- Jean-Marie Saudubray
- Department of Neurology, Neurometabolic Unit, Hopital Pitié Salpétrière, 47-83 Boulevard de l'Hopital, Paris 75013, France.
| | - Àngels Garcia-Cazorla
- Neurology Department, Neurometabolic Unit, Hospital Sant Joan de Deu and CIBERER-ISCIII, Passeig Sant Joan de Deu 28950 Esplugues de Llobregat, Barcelona, Spain
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11
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Sharma S, Prasad AN. Inborn Errors of Metabolism and Epilepsy: Current Understanding, Diagnosis, and Treatment Approaches. Int J Mol Sci 2017; 18:ijms18071384. [PMID: 28671587 PMCID: PMC5535877 DOI: 10.3390/ijms18071384] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Revised: 06/21/2017] [Accepted: 06/23/2017] [Indexed: 12/22/2022] Open
Abstract
Inborn errors of metabolism (IEM) are a rare cause of epilepsy, but seizures and epilepsy are frequently encountered in patients with IEM. Since these disorders are related to inherited enzyme deficiencies with resulting effects on metabolic/biochemical pathways, the term “metabolic epilepsy” can be used to include these conditions. These epilepsies can present across the life span, and share features of refractoriness to anti-epileptic drugs, and are often associated with co-morbid developmental delay/regression, intellectual, and behavioral impairments. Some of these disorders are amenable to specific treatment interventions; hence timely and appropriate diagnosis is critical to improve outcomes. In this review, we discuss those disorders in which epilepsy is a dominant feature and present an approach to the clinical recognition, diagnosis, and management of these disorders, with a greater focus on primarily treatable conditions. Finally, we propose a tiered approach that will permit a clinician to systematically investigate, identify, and treat these rare disorders.
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Affiliation(s)
- Suvasini Sharma
- Department of Pediatrics, Lady Hardinge Medical College, New Delhi 110001, India.
| | - Asuri N Prasad
- Department of Pediatrics and Clinical Neurological Sciences, Schulich School of Medicine and Dentistry, Children's Hospital of Western Ontario and London Health Sciences Centre, London, ON N6A5W9, Canada.
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12
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Patel J, Mercimek-Mahmutoglu S. Epileptic Encephalopathy in Childhood: A Stepwise Approach for Identification of Underlying Genetic Causes. Indian J Pediatr 2016; 83:1164-74. [PMID: 26821542 DOI: 10.1007/s12098-015-1979-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2015] [Accepted: 12/02/2015] [Indexed: 01/29/2023]
Abstract
Epilepsy is one of the most common neurological disorders in childhood. Epilepsy associated with global developmental delay and cognitive dysfunction is defined as epileptic encephalopathy. Certain inherited metabolic disorders presenting with epileptic encephalopathy can be treated with disease specific diet, vitamin, amino acid or cofactor supplementations. In those disorders, disease specific therapy is successful to achieve good seizure control and improve long-term neurodevelopmental outcome. For this reason, intractable epilepsy with global developmental delay or history of developmental regression warrants detailed metabolic investigations for the possibility of an underlying treatable inherited metabolic disorder, which should be undertaken as first line investigations. An underlying genetic etiology in epileptic encephalopathy has been supported by recent studies such as array comparative genomic hybridization, targeted next generation sequencing panels, whole exome and whole genome sequencing. These studies report a diagnostic yield up to 70%, depending on the applied genetic testing as well as number of patients enrolled. In patients with epileptic encephalopathy, a stepwise approach for diagnostic work-up will help to diagnose treatable inherited metabolic disorders quickly. Application of detailed genetic investigations such as targeted next generation sequencing as second line and whole exome sequencing as third line testing will diagnose underlying genetic disease which will help for genetic counseling as well as guide for prenatal diagnosis. Knowledge of underlying genetic cause will provide novel insights into the pathogenesis of epileptic encephalopathy and pave the ground towards the development of targeted neuroprotective treatment strategies to improve the health outcome of children with epileptic encephalopathy.
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Affiliation(s)
- Jaina Patel
- Division of Clinical and Metabolic Genetics, Department of Pediatrics, University of Toronto, The Hospital for Sick Children, 555 University Avenue, Toronto, Ontario, M5G 1X8, Canada
| | - Saadet Mercimek-Mahmutoglu
- Division of Clinical and Metabolic Genetics, Department of Pediatrics, University of Toronto, The Hospital for Sick Children, 555 University Avenue, Toronto, Ontario, M5G 1X8, Canada. .,Genetics and Genome Biology Program, Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada.
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13
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Abstract
Inborn errors of metabolism (IEM) are individually rare but collectively common. Approximately 25% of IEMs can have manifestations in the neonatal period. Neonates with IEM are usually healthy at birth; however, in hours to days after birth they can develop nonspecific signs that are common to several other neonatal conditions. Therefore, maintaining a high index of suspicion is extremely important for early diagnosis and the institution of appropriate therapy, which are mandatory to prevent death and ameliorate complications from many IEMs.
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Affiliation(s)
- Ayman W El-Hattab
- Division of Clinical Genetics and Metabolic Disorders, Pediatric Department, Tawam Hospital, P.O. Box 15258, Al-Ain, United Arab Emirates.
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14
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Abstract
Refractory epilepsy, estimated to affect 10-20% children with epilepsy, can have profound effect on the education, social and cognitive functioning and recreational activities of the child. The definitions are still evolving. A detailed clinical evaluation may reveal an accurate syndromic and etiological diagnosis. The recent advances in neuroimaging and electrophysiology have revolutionized the management of children with refractory epilepsy and supplement the clinical evaluation. Genetic and metabolic evaluation may be indicated in selected cases. The rational use of anti-epileptic drugs, epilepsy surgery and dietary therapies are the mainstay in the management. Various experimental treatment options and pharmacogenetics offer hope for future.
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Affiliation(s)
- Satinder Aneja
- Department of Pediatrics, Lady Hardinge Medical College and Associated Kalawati Saran Children's Hospital, New Delhi, 110001, India,
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15
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Abstract
Magnetic resonance spectroscopy (MRS) is indicated in the imaging protocol of the patient with epilepsy to screen for metabolic derangements such as inborn errors of metabolism and to characterize masses that may be equivocal on conventional magnetic resonance imaging for dysplasia versus neoplasia. Single-voxel MRS with echo time of 35 milliseconds may be used for this purpose as a quick screening tool in the epilepsy imaging protocol. MRS is useful in the evaluation of both focal and generalized epilepsy.
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Who receives home-based perinatal palliative care: experience from Poland. BIOMED RESEARCH INTERNATIONAL 2013; 2013:652321. [PMID: 24083234 PMCID: PMC3776364 DOI: 10.1155/2013/652321] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/12/2013] [Revised: 06/28/2013] [Accepted: 08/04/2013] [Indexed: 11/17/2022]
Abstract
Context. The current literature suggests that perinatal palliative care (PPC) programs should be comprehensive, initiated early, and integrative. So far there have been very few publications on the subject of home-based PC of newborns and neonates. Most publications focus on hospital-based care, mainly in the neonatal intensive care units. Objective. To describe the neonates and infants who received home-based palliative care in Lodz Region between 2005 and 2011. Methods. A retrospective review of medical records. Results. 53 neonates and infants were admitted to a home hospice in Lodz Region between 2005 and 2011. In general, they are a growing group of patients referred to palliative care. Congenital diseases (41%) were the primary diagnoses; out of 53 patients 16 died, 20 were discharged home, and 17 stayed under hospice care until 2011. The most common cause of death (56%) was cardiac insufficiency. Neurological symptoms (72%) and dysphagia (58%) were the most common clinical problems. The majority of children (45%) had a feeding tube inserted and were oxygen dependent (45%); 39 families received psychological care and 31 social supports. Conclusions. For terminally ill neonates and infants, perinatal palliative care is an option which improves the quality of their lives and provides the family with an opportunity to say goodbye.
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Papetti L, Parisi P, Leuzzi V, Nardecchia F, Nicita F, Ursitti F, Marra F, Paolino MC, Spalice A. Metabolic epilepsy: an update. Brain Dev 2013; 35:827-41. [PMID: 23273990 DOI: 10.1016/j.braindev.2012.11.010] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2011] [Revised: 10/23/2012] [Accepted: 11/25/2012] [Indexed: 10/27/2022]
Abstract
Inborn errors of metabolism comprise a large class of genetic diseases involving disorders of metabolism. Presentation is usually in the neonatal period or infancy but can occur at any time, even in adulthood. Seizures are frequent symptom in inborn errors of metabolism, with no specific seizure types or EEG signatures. The diagnosis of a genetic defect or an inborn error of metabolism often results in requests for a vast array of biochemical and molecular tests leading to an expensive workup. However a specific diagnosis of metabolic disorders in epileptic patients may provide the possibility of specific treatments that can improve seizures. In a few metabolic diseases, epilepsy responds to specific treatments based on diet or supplementation of cofactors (vitamin-responsive epilepsies), but for most of them specific treatment is unfortunately not available, and conventional antiepileptic drugs must be used, often with no satisfactory success. In this review we present an overview of metabolic epilepsies based on various criteria such as treatability, age of onset, seizure type, and pathogenetic background.
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Affiliation(s)
- Laura Papetti
- Department of Pediatrics, Child Neurology Division, Sapienza University of Rome, Italy
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18
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Masri A, Wahsh SA. Manifestations and treatment of epilepsy in children with neurometabolic disorders: a series from Jordan. Seizure 2013; 23:10-5. [PMID: 23998926 DOI: 10.1016/j.seizure.2013.08.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2013] [Revised: 07/15/2013] [Accepted: 08/09/2013] [Indexed: 11/29/2022] Open
Abstract
PURPOSE To examine the characteristics of epilepsy in children with neurometabolic disorders to reveal co morbidities and optimal treatment. METHODS We retrospectively reviewed the files of children diagnosed with a neurometabolic disorder and treated at Jordan University Hospital between 2001 and 2012. We examined the incidence, age at onset, clinical characteristics, and medical control of epilepsy. RESULTS Cases treated (40 boys, 30 girls) included the different categories of neurometabolic diseases. Twenty-nine patients (41.4%) were also diagnosed with epilepsy, with age at seizure onset ranging from 3 days to 7 years. All types of seizures were reported, but generalized tonic-clonic and mixed types were most common (16/29 patients, 55.2%). Patients were on either a single antiepileptic drug (16/29, 55.2%) or multiple drugs (13/29, 44.7%), and most drugs prescribed were older generation anticonvulsants. Complete seizure control was achieved in 19/29 patients (65.5%), partial control in 7/29 (24.1%), and poor or no control in 3/29 (10.3%). EEG recordings were missing from the medical files of 10/29 patients. The first EEG revealed epileptiform activity in 12/19 patients (63.2%) and was normal in 7/19 patients (36.8%). CONCLUSIONS Epilepsy was diagnosed in about half of pediatric neurometabolic disease patients, with the majority of seizure cases well controlled.
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Affiliation(s)
- Amira Masri
- Department of Pediatrics, Division of Child Neurology, Faculty of Medicine, The University of Jordan, P.O. Box 1612, 11941 Amman, Jordan.
| | - Shourouk Al Wahsh
- Department of Pediatrics, Faculty of Medicine, The University of Jordan, Jordan
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Abstract
Most genetic causes of neurodegenerative disorders in childhood are due to neurometabolic disease. There are over 200 disorders, including aminoacidopathies, creatine disorders, mitochondrial cytopathies, peroxisomal disorders and lysosomal storage disorders. However, diagnosis can pose a challenge to the clinician when patients present with non-specific problems like epilepsy, developmental delay, autism, dystonia and ataxia. The variety of specialist tests involved can also be daunting. This review aims to give a practical approach to the investigation and diagnosis of neurometabolic disease from the neonatal period to late childhood while prioritising disorders where there are therapeutic options. In particular, patients who have a complex clinical picture of several neurological and non-neurological features should be investigated.
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Affiliation(s)
- Germaine Pierre
- Division of Women’s and Children’s Services, Bristol Royal Hospital for Children, Level 6, UHBT, Education Centre, Upper Maudlin Street, Bristol BS2 8AE, UK.
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Nassogne MC, Hertz-Pannier L. Metabolic diagnostic work-up in chronic conditions. HANDBOOK OF CLINICAL NEUROLOGY 2013; 113:1563-1580. [PMID: 23622379 DOI: 10.1016/b978-0-444-59565-2.00026-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
Neurological symptoms are very frequent in inborn errors of metabolism. This chapter presents a general approach to investigate inborn errors of metabolism in chronic neurological conditions. A diagnostic work-up has been designed to evaluate progressive neurological conditions with motor, cognitive, and/or behavioral signs in early infancy, late infancy to early childhood, and late childhood to adolescence. Inborn errors of metabolism associated with peripheral neuropathies, microcephaly, or macrocephaly are also reviewed.
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Affiliation(s)
- Marie-Cécile Nassogne
- Pediatric Neurology and Metabolism, Université Catholique de Louvain, Cliniques Universitaires Saint-Luc, Brussels, Belgium.
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Kamien BA, Cardamone M, Lawson JA, Sachdev R. A genetic diagnostic approach to infantile epileptic encephalopathies. J Clin Neurosci 2012; 19:934-41. [PMID: 22617547 DOI: 10.1016/j.jocn.2012.01.017] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2011] [Revised: 01/12/2012] [Accepted: 01/19/2012] [Indexed: 12/29/2022]
Abstract
Epileptic encephalopathies are characterized by frequent severe seizures, and/or prominent interictal epileptiform discharges on the electroencephalogram, developmental delay or deterioration, and usually a poor prognosis. The epileptiform abnormalities themselves are believed to contribute to the progressive disturbance in cerebral function. Determining the underlying aetiology responsible for infantile epileptic encephalopathy is a clinical challenge worth undertaking to facilitate advice on the recurrence risk and to allow for the option of prenatal testing, as often this category of epilepsy is associated with devastating hardship for families. This review takes advantage of recently published studies that have identified new genes associated with epilepsy and focuses on known monogenic causes where detection is useful for the process of genetic counselling. Based on the review, we present a diagnostic work-up in order to triage specific genetic testing for infants presenting with an epileptic encephalopathy.
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Affiliation(s)
- Benjamin A Kamien
- Department of Medical Genetics, Sydney Children's Hospital, High St., Randwick, New South Wales 2031, Australia.
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Mastrangelo M, Celato A, Leuzzi V. A diagnostic algorithm for the evaluation of early onset genetic-metabolic epileptic encephalopathies. Eur J Paediatr Neurol 2012; 16:179-91. [PMID: 21940184 DOI: 10.1016/j.ejpn.2011.07.015] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2011] [Revised: 07/13/2011] [Accepted: 07/24/2011] [Indexed: 02/03/2023]
Abstract
Early onset epileptic encephalopathies represent a struggling challenge in neurological clinical practice, mostly in infants and very young children, partly due to an unclear and still debated cathegorization. In this scenario genetic and metabolic epileptic encephalopathies play a central role, with new entries still needing an arrangement. In this Paper we present a brief overview on genes, metabolic disorders and syndromes picturing the pathogenesis of genetic and metabolic epileptic encephalopathies with onset under one year of age. These forms will be classified, according to a combined clinical and genetic-metabolic criterion, into two main groups including seizures as prominent/unique symptom and seizures associated with a syndromic phenotype. Starting from this classification we suggest a possible simplified diagnostic algorithm, discussing main decision making nodes in practical patients management. The aim of the proposed algorithm is to guide through metabolic and molecular-genetic work up and to clarify "where" and "what" to search in biochemical, electroencephalographic and neuroimaging investigations.
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Affiliation(s)
- Mario Mastrangelo
- Division of Child Neurology, Department of Pediatrics, Child Neurology and Psychiatry, Sapienza University of Rome, via dei Sabelli 108, 00185 Roma, Italy
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24
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Affiliation(s)
- Tiziana Granata
- Department of Pediatric Neuroscience, Fondazione IRCCS Instituto Neurologico Carlo Besta, Milan, Italy.
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Olischar M, Shany E, Aygün C, Azzopardi D, Hunt RW, Toet MC, Hamosh A, de Vries LS, Hellström-Westas L, Theda C. Amplitude-integrated electroencephalography in newborns with inborn errors of metabolism. Neonatology 2012; 102:203-11. [PMID: 22797054 DOI: 10.1159/000339567] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2012] [Accepted: 05/17/2012] [Indexed: 12/13/2022]
Abstract
BACKGROUND The utility of amplitude-integrated electroencephalography (aEEG) monitoring has been established for patients with neonatal hypoxic-ischemic encephalopathy. OBJECTIVE To evaluate the role of aEEG in the diagnostic process and treatment of patients with encephalopathy due to inborn errors of metabolism. METHODS Cases collected through an international registry were divided into 5 groups of metabolic disorders. Common aEEG features were sought for each group. RESULTS In total, 21/30 (70%) cases had abnormal aEEG background patterns, 18/30 (60%) showed seizure activity. Patients with disorders of energy metabolism, hyperammonemia, and organic/amino acidopathies often showed marked aEEG depression with seizure activity. In contrast, aEEGs of patients with peroxisomal disorders did not show major background abnormalities but seizures were present in 5/6 subjects. We report two features of interest: firstly, two tracings displayed an unusual upward shift of the lower aEEG amplitude margin. Secondly, aEEGs of infants with non-ketotic hyperglycinemia showed a pattern we refer to as 'high-frequency burst-suppression pattern'. CONCLUSIONS aEEG in patients with inborn errors of metabolism frequently reveals abnormalities and assists clinicians in the clinical assessment, management and monitoring of these patients.
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Affiliation(s)
- Monika Olischar
- Department of Neonatology, University Children's Hospital Vienna, Vienna, Austria
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Van Hove JLK, Lohr NJ. Metabolic and monogenic causes of seizures in neonates and young infants. Mol Genet Metab 2011; 104:214-30. [PMID: 21839663 DOI: 10.1016/j.ymgme.2011.04.020] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2011] [Revised: 04/20/2011] [Accepted: 04/20/2011] [Indexed: 11/22/2022]
Abstract
Seizures in neonates or young infants present a frequent diagnostic challenge. After exclusion of acquired causes, disturbances of the internal homeostasis and brain malformations, the physician must evaluate for inborn errors of metabolism and for other non-malformative genetic disorders as the cause of seizures. The metabolic causes can be categorized into disorders of neurotransmitter metabolism, disorders of energy production, and synthetic or catabolic disorders associated with brain malformation, dysfunction and degeneration. Other genetic conditions involve channelopathies, and disorders resulting in abnormal growth, differentiation and formation of neuronal populations. These conditions are important given their potential for treatment and the risk for recurrence in the family. In this paper, we will succinctly review the metabolic and genetic non-malformative causes of seizures in neonates and infants less than 6 months of age. We will then provide differential diagnostic clues and a practical paradigm for their evaluation.
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Affiliation(s)
- Johan L K Van Hove
- Department of Pediatrics, University of Colorado, Clinical Genetics, Aurora, CO 80045, USA.
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Abstract
Inherited biochemical defects may present with acute life-threatening illness with a high mortality and morbidity. Some are treatable and have a good outcome with early appropriate intervention. However, because of their rarity, diagnosis is often delayed; they are not considered or investigated appropriately. This is especially likely in those presenting in previously healthy adults. The collection of acute samples is crucial. There are numerous disorders, and front-line tests must cast a wide net. A small core of emergency tests generally indicates which metabolic pathway is defective and provides a working diagnosis and basis for treatment. Later confirmation and identification of the precise defect are essential for long-term management and for genetic counselling and prenatal diagnosis of future pregnancies. An escalating number of specialist tests and mutation analyses are undertaken by metabolic laboratories worldwide, but they are not widely available, are expensive, and must be requested selectively. Guidelines are presented here for the front-line investigation of acutely ill children with hypoglycaemia, metabolic acidosis, encephalopathy and intractable seizures, and for a dying child with a suspected, undiagnosed, inherited metabolic defect. With modification, these are also applicable to adults with a metabolic defect. In order to guide further investigation, selected disorders are described briefly along with their diagnostic work-up. Information about sample collection and processing is provided.
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28
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Affiliation(s)
- Jean-Marie Saudubray
- Departement des maladies métaboliques, Federation des maladies du système nerveux Hôpital Pitié-Salpêtrière, Assistance Publique Hôpitaux de Paris et Université Pierre et Marie Curie (Paris VI), Paris, France.
- , 22 rue Juliette Lamber, Paris, 75017, France.
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