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Dilena R, Molisso MT, De Carli A, Mauri E, Circiello A, Di Benedetto A, Pisoni S, Bassi L, Bana C, Cappellari AM, Consonni D, Mastrangelo M, Granata T, La Briola F, Peruzzi C, Raviglione F, Striano P, Barbieri S, Mosca F, Fumagalli M. Retrospective study on neonatal seizures in a tertiary center of northern Italy after ILAE classification: Incidence, seizure type, EEG and etiology. Epilepsy Behav 2024; 159:109971. [PMID: 39094245 DOI: 10.1016/j.yebeh.2024.109971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2024] [Revised: 07/22/2024] [Accepted: 07/23/2024] [Indexed: 08/04/2024]
Abstract
OBJECTIVE We aimed to evaluate epidemiology, seizure type, EEG, and etiology of neonatal seizures (NS) in a tertiary neonatal intensive care unit. METHODS Data on infants with a neurophysiological confirmation of NS were collected between 2009 and 2022. Seizure types and epileptic syndromes were classified by the ILAE classification and EEG by the Italian Neonatal Seizure Collaborative Network (INNESCO) score. RESULTS Out of 91,253 neonates, 145 presented with NS; 69.7 % were born at term and 30.3 % were preterm infants. The incidence of NS in neonates born at our center was 1.2 per 1,000 live newborns (96/80697 neonates) while in the entire neonatal population admitted to our center it was 1.6 per 1,000 live births, increasing with lower preterm age. Compared to previous studies, we found a lower proportion of hypoxic-ischemic encephalopathy (HIE) (23.4 %) and a higher rate of genetic contribution (26.2 %). The infection rate was higher in preterm (31.8 %) than in full term (9.9 %) infants. Electrographic seizures were associated with acute provoked seizures (35.9 %), preterm age (52.3 %), and HIE (52.9 %). Vascular etiology was associated with focal clonic seizures (56.8 %). Non-structural neonatal genetic epilepsy was associated with sequential seizures (68.2 %), particularly KCNQ2 and SCN2A epilepsy. Background EEG was abnormal in all HIE, infections (85.7 %) and metabolic NS (83.3 %). In genetic epilepsy, background EEG depended on the epileptic syndrome: normal in 80 % of self-limited neonatal epilepsy and abnormal in 77.8 % of developmental and epileptic encephalopathy. Electroclinical seizures were associated with focal onset, while electrographic seizures correlated with a multifocal onset. CONCLUSIONS A low incidence of HIE and a high incidence of genetic etiology were observed in our cohort of NS. Seizure type and EEG features are fundamental to address etiology.
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Affiliation(s)
- Robertino Dilena
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Neurophysiopathology Unit, Department of Neuroscience and Mental Health, Milan, Italy.
| | - Maria T Molisso
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Neurophysiopathology Unit, Department of Neuroscience and Mental Health, Milan, Italy.
| | - Agnese De Carli
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, NICU, Milan, Italy.
| | - Eleonora Mauri
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Neurophysiopathology Unit, Department of Neuroscience and Mental Health, Milan, Italy.
| | - Alberta Circiello
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, NICU, Milan, Italy; University of Milan, Department of Clinical Sciences and Community Health, Milan, Italy.
| | - Alessia Di Benedetto
- University of Milan, Department of Clinical Sciences and Community Health, Milan, Italy.
| | - Silvia Pisoni
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, NICU, Milan, Italy.
| | - Laura Bassi
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, NICU, Milan, Italy.
| | - Cristina Bana
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Neurophysiopathology Unit, Department of Neuroscience and Mental Health, Milan, Italy.
| | - Alberto M Cappellari
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Neurophysiopathology Unit, Department of Neuroscience and Mental Health, Milan, Italy.
| | - Dario Consonni
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Epidemiology Unit, Milan, Italy.
| | | | - Tiziana Granata
- Fondazione IRCCS Istituto Neurologico Carlo Besta, Dipartimento di Neuroscienze Pediatriche, Child Neuropsychiatry Unit - Epilepsy Center, Milan, Italy.
| | - Francesca La Briola
- University of Milan, Department of Clinical Sciences and Community Health, Milan, Italy; A.S.S.T. Santi Paolo e Carlo, Epilepsy Center - Child Neuropsychiatry Unit, Milan, Italy.
| | - Cinzia Peruzzi
- Fondazione IRCCS San Gerardo dei Tintori, Unità di Neuropsichiatria Infantile, Monza, Italy; Università degli Studi di Milano Bicocca, Dipartimento di Medicina e Chirurgia, Milan, Italy.
| | | | - Pasquale Striano
- IRCCS G. Gaslini, Pediatric Neurology and Muscular Diseases Unit, Genova, Italy; University of Genova, Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, Genova, Italy.
| | - Sergio Barbieri
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Neurophysiopathology Unit, Department of Neuroscience and Mental Health, Milan, Italy.
| | - Fabio Mosca
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, NICU, Milan, Italy; University of Milan, Department of Clinical Sciences and Community Health, Milan, Italy.
| | - Monica Fumagalli
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, NICU, Milan, Italy; University of Milan, Department of Clinical Sciences and Community Health, Milan, Italy.
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Lugli L, Bariola MC, Guidotti I, Pugliese M, Roversi MF, Bedetti L, Della Casa Muttini E, Miselli F, Ori L, Lucaccioni L, Bertoncelli N, Rossi K, Crestani S, Bergonzini P, Iughetti L, Ferrari F, Berardi A. Neurodevelopmental outcome of neonatal seizures: A longitudinal study. Eur J Paediatr Neurol 2024; 49:17-26. [PMID: 38324990 DOI: 10.1016/j.ejpn.2024.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 01/26/2024] [Accepted: 01/26/2024] [Indexed: 02/09/2024]
Abstract
INTRODUCTION Neonatal seizures (NS) are the most common neurological emergency in the neonatal period. The International League Against Epilepsy (ILAE) proposed a new classification of NS based on semiology and highlighted the correlation between semiology and aetiology. However, neurodevelopmental outcomes have not been comprehensively evaluated based on this new classification. AIMS To evaluate neurodevelopmental outcomes and potential risk factors for severe outcomes in NS. METHODS Patients with video electroencephalogram confirmed NS were evaluated. Seizure aetiology, cerebral magnetic resonance imaging (MRI) data, background electroencephalograms data, general movements, and neurodevelopmental outcomes were analysed. Severe outcomes were one of the following: death, cerebral palsy, Griffiths developmental quotient <70, epilepsy, deafness, or blindness. RESULTS A total of 74 neonates were evaluated: 62 (83.8 %) with acute provoked NS (primarily hypoxic-ischaemic encephalopathy), and 12 (16.2 %) with neonatal-onset epilepsies (self-limited neonatal epilepsy, developmental and epileptic encephalopathy, cerebral malformations). Of these, 32 (43.2 %) had electrographic seizures, while 42 (56.7 %) had electroclinical seizures - 38 (90.5 %) were motor (42.1 % clonic) and 4 (9.5 %) were non-motor phenomena. Severe outcomes occurred in 33 of the 74 (44.6 %) participants. In multivariate analysis, neonatal-onset epilepsies (odds ratio [OR]: 1.3; 95 % confidence interval [CI]: 1.1-1.6), status epilepticus (OR: 5.4; 95 % CI: 1.5-19.9), and abnormal general movements (OR: 3.4; 95 % CI: 1.9-7.6) were associated with severe outcomes. CONCLUSIONS At present, hypoxic-ischaemic encephalopathy remains the most frequent aetiology of NS. The prognosis of neonatal-onset epilepsies was worse than that of acute provoked NS, and status epilepticus was the most predictive factor for adverse outcomes.
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Affiliation(s)
- Licia Lugli
- Neonatology Unit, Mother-Child Department, University Hospital of Modena, Italy.
| | | | - Isotta Guidotti
- Neonatology Unit, Mother-Child Department, University Hospital of Modena, Italy
| | | | | | - Luca Bedetti
- Neonatology Unit, Mother-Child Department, University Hospital of Modena, Italy
| | | | - Francesca Miselli
- Neonatology Unit, Mother-Child Department, University Hospital of Modena, Italy; PhD Program in Clinical and Experimental Medicine, University of Modena and Reggio Emilia, Italy
| | - Luca Ori
- Neonatology Unit, Mother-Child Department, University Hospital of Modena, Italy
| | - Laura Lucaccioni
- Pediatric Unit, Mother-Child Department, University Hospital of Modena, Italy
| | | | - Katia Rossi
- Neonatology Unit, Mother-Child Department, University Hospital of Modena, Italy
| | - Sara Crestani
- Postgraduate School of Pediatrics, Department of Medical and Surgical Sciences for Mother, Children and Adults, University of Modena and Reggio Emilia, Italy
| | - Patrizia Bergonzini
- Pediatric Unit, Mother-Child Department, University Hospital of Modena, Italy
| | - Lorenzo Iughetti
- Pediatric Unit, Mother-Child Department, University Hospital of Modena, Italy; Postgraduate School of Pediatrics, Department of Medical and Surgical Sciences for Mother, Children and Adults, University of Modena and Reggio Emilia, Italy
| | - Fabrizio Ferrari
- Neonatology Unit, Mother-Child Department, University Hospital of Modena, Italy
| | - Alberto Berardi
- Neonatology Unit, Mother-Child Department, University Hospital of Modena, Italy
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Vilan A, Grangeia A, Ribeiro JM, Cilio MR, de Vries LS. Distinctive Amplitude-Integrated EEG Ictal Pattern and Targeted Therapy with Carbamazepine in KCNQ2 and KCNQ3 Neonatal Epilepsy: A Case Series. Neuropediatrics 2024; 55:32-41. [PMID: 37827512 DOI: 10.1055/a-2190-9521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/14/2023]
Abstract
BACKGROUND Carbamazepine (CBZ) is effective in treating KCNQ2/3-related seizures, which may present with a distinctive amplitude-integrated electroencephalography (aEEG) pattern. OBJECTIVE To assess how improved recognition of the distinctive aEEG ictal pattern associated with KCNQ2/3 variants has enabled early and effective targeted therapy with CBZ. METHODS Retrospective descriptive study of five neonates with KCNQ2/3 pathogenic gene variants admitted at a level 3 neonatal intensive care unit (NICU) over an 8-year period. RESULTS The distinctive ictal aEEG pattern was recognized in four neonates after an average of 61.5 hours (minimum 12 hours, maximum 120 hours) from the first electroclinical seizure and prompted the use of CBZ that was effective in all. The two most recently diagnosed patients could avoid polytherapy as they received CBZ as the first and second antiseizure medication, respectively. Three out of five patients with continuous normal voltage (CNV), sleep-wake cycling (SWC), and shorter postictal suppression had normal neurodevelopmental outcome. Regarding the remaining two infants, one was not trialed with CBZ and had a high seizure burden, both presented with a prolonged postictal suppression, no SWC, and had moderate-to-severe developmental delay. Genetic results became available after the neonatal period in all but one of the infants, who had a prenatal diagnosis. CONCLUSION Recognition of the distinctive ictal aEEG pattern in the NICU allowed early and effective targeted therapy with CBZ in four neonates, well before genetic results became available. Furthermore, a CNV background pattern with SWC and short postictal suppression were associated with normal developmental outcomes.
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Affiliation(s)
- Ana Vilan
- Department of Neonatology, Centro Hospitalar São João, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Ana Grangeia
- Department of Genetics, Centro Hospitalar São João, Faculty of Medicine, University of Porto, Porto, Portugal
| | - José Mendes Ribeiro
- Laboratory of Clinical Neurophysiology, Department of Neurology, Centro Hospitalar Vila Nova de Gaia e Espinho, Porto, Portugal
| | - Maria Roberta Cilio
- Division of Pediatric Neurology, Department of Pediatrics, Catholic University of Louvain, Brussels, Belgium
| | - Linda S de Vries
- Department of Neonatology, Leiden University Medical Center, Leiden, The Netherlands
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Soto-Perez J, Cleary CM, Sobrinho CR, Mulkey SB, Carroll JL, Tzingounis AV, Mulkey DK. Phox2b-expressing neurons contribute to breathing problems in Kcnq2 loss- and gain-of-function encephalopathy models. Nat Commun 2023; 14:8059. [PMID: 38052789 PMCID: PMC10698053 DOI: 10.1038/s41467-023-43834-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Accepted: 11/21/2023] [Indexed: 12/07/2023] Open
Abstract
Loss- and gain-of-function variants in the gene encoding KCNQ2 channels are a common cause of developmental and epileptic encephalopathy, a condition characterized by seizures, developmental delays, breathing problems, and early mortality. To understand how KCNQ2 dysfunction impacts behavior in a mouse model, we focus on the control of breathing by neurons expressing the transcription factor Phox2b which includes respiratory neurons in the ventral parafacial region. We find Phox2b-expressing ventral parafacial neurons express Kcnq2 in the absence of other Kcnq isoforms, thus clarifying why disruption of Kcnq2 but not other channel isoforms results in breathing problems. We also find that Kcnq2 deletion or expression of a recurrent gain-of-function variant R201C in Phox2b-expressing neurons increases baseline breathing or decreases the central chemoreflex, respectively, in mice during the light/inactive state. These results uncover mechanisms underlying breathing abnormalities in KCNQ2 encephalopathy and highlight an unappreciated vulnerability of Phox2b-expressing ventral parafacial neurons to KCNQ2 pathogenic variants.
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Affiliation(s)
- J Soto-Perez
- Dept of Physiology and Neurobiology, University of Connecticut, Storrs, CT, USA
| | - C M Cleary
- Dept of Physiology and Neurobiology, University of Connecticut, Storrs, CT, USA
| | - C R Sobrinho
- Dept of Physiology and Neurobiology, University of Connecticut, Storrs, CT, USA
| | - S B Mulkey
- Prenatal Pediatrics Institute, Children's National Hospital, Departments of Neurology and Pediatrics, The George Washington Univ. School of Medicine and Health Sciences, Washington, DC, USA
| | - J L Carroll
- Dept. of Pediatrics, Univ. Arkansas for Medical Sciences, Little Rock, AR, USA
| | - A V Tzingounis
- Dept of Physiology and Neurobiology, University of Connecticut, Storrs, CT, USA.
| | - D K Mulkey
- Dept of Physiology and Neurobiology, University of Connecticut, Storrs, CT, USA.
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Millevert C, Weckhuysen S. ILAE Genetic Literacy Series: Self-limited familial epilepsy syndromes with onset in neonatal age and infancy. Epileptic Disord 2023; 25:445-453. [PMID: 36939707 DOI: 10.1002/epd2.20026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 12/13/2022] [Accepted: 12/22/2022] [Indexed: 03/21/2023]
Abstract
The self-limited (familial) epilepsies with onset in neonates or infants, formerly called benign familial neonatal and/or infantile epilepsies, are autosomal dominant disorders characterized by neonatal- or infantile-onset focal motor seizures and the absence of neurodevelopmental complications. Seizures tend to remit during infancy or early childhood and are therefore called "self-limited". A positive family history for epilepsy usually suggests the genetic etiology, but incomplete penetrance and de novo inheritance occur. Here, we review the phenotypic spectrum and the genetic architecture of self-limited (familial) epilepsies with onset in neonates or infants. Using an illustrative case study, we describe important clues in recognition of these syndromes, diagnostic steps including genetic testing, management, and genetic counseling.
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Affiliation(s)
- Charissa Millevert
- Applied & Translational Neurogenomics Group, VIB Center for Molecular Neurology, VIB, Antwerp, Belgium
- Department of Neurology, University Hospital, Antwerp, Belgium
| | - Sarah Weckhuysen
- Applied & Translational Neurogenomics Group, VIB Center for Molecular Neurology, VIB, Antwerp, Belgium
- Department of Neurology, University Hospital, Antwerp, Belgium
- μNEURO Research Centre of Excellence, University of Antwerp, Antwerp, Belgium
- Translational Neurosciences, Faculty of Medicine and Health Science, University of Antwerp, Antwerp, Belgium
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6
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Hou B, Santaniello S, Tzingounis AV. KCNQ2 channels regulate the population activity of neonatal GABAergic neurons ex vivo. Front Neurol 2023; 14:1207539. [PMID: 37409016 PMCID: PMC10318362 DOI: 10.3389/fneur.2023.1207539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Accepted: 05/18/2023] [Indexed: 07/07/2023] Open
Abstract
Over the last decade KCNQ2 channels have arisen as fundamental and indispensable regulators of neonatal brain excitability, with KCNQ2 loss-of-function pathogenic variants being increasingly identified in patients with developmental and epileptic encephalopathy. However, the mechanisms by which KCNQ2 loss-of-function variants lead to network dysfunction are not fully known. An important remaining knowledge gap is whether loss of KCNQ2 function alters GABAergic interneuron activity early in development. To address this question, we applied mesoscale calcium imaging ex vivo in postnatal day 4-7 mice lacking KCNQ2 channels in interneurons (Vgat-ires-cre;Kcnq2f/f;GCamp5). In the presence of elevated extracellular potassium concentrations, ablation of KCNQ2 channels from GABAergic cells increased the interneuron population activity in the hippocampal formation and regions of the neocortex. We found that this increased population activity depends on fast synaptic transmission, with excitatory transmission promoting the activity and GABAergic transmission curtailing it. Together, our data show that loss of function of KCNQ2 channels from interneurons increases the network excitability of the immature GABAergic circuits, revealing a new function of KCNQ2 channels in interneuron physiology in the developing brain.
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Affiliation(s)
- Bowen Hou
- Department of Physiology and Neurobiology, University of Connecticut, Storrs, CT, United States
| | - Sabato Santaniello
- Department of Biomedical Engineering and CT Institute for the Brain and Cognitive Sciences, University of Connecticut, Storrs, CT, United States
| | - Anastasios V. Tzingounis
- Department of Physiology and Neurobiology, University of Connecticut, Storrs, CT, United States
- Department of Biomedical Engineering and CT Institute for the Brain and Cognitive Sciences, University of Connecticut, Storrs, CT, United States
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Miziak B, Czuczwar SJ. Approaches for the discovery of drugs that target K Na 1.1 channels in KCNT1-associated epilepsy. Expert Opin Drug Discov 2022; 17:1313-1328. [PMID: 36408599 DOI: 10.1080/17460441.2023.2150164] [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: 11/22/2022]
Abstract
INTRODUCTION There are approximately 70 million people with epilepsy and about 30% of patients are not satisfactorily treated. A link between gene mutations and epilepsy is well documented. A number of pathological variants of KCNT1 gene (encoding the weakly voltage-dependent sodium-activated potassium channel - KNa 1.1) mutations has been found. For instance, epilepsy of infancy with migrating focal seizures, autosomal sleep-related hypermotor epilepsy or Ohtahara syndrome have been associated with KCNT1 gene mutations. AREAS COVERED Several methods for studies on KNa 1.1 channels have been reviewed - patch clamp analysis, Förster resonance energy transfer spectroscopy and whole-exome sequencing. The authors also review available drugs for the management of KCNT1 epilepsies. EXPERT OPINION The current methods enable deeper insights into electrophysiology of KNa 1.1 channels or its functioning in different activation states. It is also possible to identify a given KCNT1 mutation. Quinidine and cannabidiol show variable efficacy as add-on to baseline antiepileptic drugs so more effective treatments are required. A combined approach with the methods shown above, in silico methods and the animal model of KCNT1 epilepsies seems likely to create personalized treatment of patients with KCNT1 gene mutations.
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Affiliation(s)
- Barbara Miziak
- Department of Pathophysiology, Medical University of Lublin, Lublin, Poland
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Allegaert K. Integrated in a systems pharmacology approach, pharmacogenetics holds the promise for personalized medicine in neonates. Pharmacogenomics 2022; 23:667-670. [PMID: 35929406 DOI: 10.2217/pgs-2022-0100] [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: 11/21/2022] Open
Abstract
Tweetable abstract Integrated in a systems pharmacology approach, pharmacogenetics holds the promise for personalized medicine in neonates. This has been illustrated for some diseases specific to neonates.
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Affiliation(s)
- Karel Allegaert
- Department of Pharmaceutical & Pharmacological Sciences, KU Leuven, Leuven, Belgium.,Department of Development & Regeneration, KU Leuven, Leuven, Belgium.,Leuven Child & Youth Institute, KU Leuven, Leuven, Belgium.,Department of Hospital Pharmacy, Erasmus MC, Rotterdam, the Netherlands
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9
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Dilena R, Mauri E, Di Fonzo A, Bana C, Ajmone PF, Rigamonti C, Catenio T, Gangi S, Striano P, Fumagalli M. Case Report: Effect of Targeted Therapy With Carbamazepine in KCNQ2 Neonatal Epilepsy. Front Neurol 2022; 13:942582. [PMID: 35911888 PMCID: PMC9329581 DOI: 10.3389/fneur.2022.942582] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Accepted: 06/13/2022] [Indexed: 11/13/2022] Open
Abstract
We present a family case of neonatal-onset KCNQ2-related epilepsy due to a novel intronic mutation. Three members of an Italian family (father and offspring) presented with neonatal-onset asymmetric tonic and clonic seizures with peculiar video-electroencephalography and aEEG features referring to sequential seizures. The father and the first son underwent standard of care treatments in line with current neonatal intensive care unit protocols, with a prolonged hospitalization before reaching full seizure control with carbamazepine. After the experience acquired with her family and the latest advances in the literature, the younger daughter was directly treated with carbamazepine, obtaining rapid seizure control and short hospitalization. They all had normal development. Carbamazepine is rarely administered as a first-line option in neonatal seizures. Recent evidence suggests that neonatal intensive care unit protocols should implement a trial with sodium channel blockers such as carbamazepine as first-option anti-seizure medication and a fast access to genetic testing in neonates with sequential seizures without structural brain injury or acute causes. Moreover, we report and discuss the laboratory studies performed on a novel causative intronic mutation in KCNQ2 (c.1525+5 G>A in IVS13), since pathogenicity may be difficult to prove for intronic variants.
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Affiliation(s)
- Robertino Dilena
- Neurophysiopathology Unit, Department of Neuroscience and Mental Health, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- *Correspondence: Robertino Dilena
| | - Eleonora Mauri
- Neurophysiopathology Unit, Department of Neuroscience and Mental Health, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Alessio Di Fonzo
- Neurology Unit, Department of Neuroscience and Mental Health, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Dino Ferrari Centre, University of Milan, Milan, Italy
| | - Cristina Bana
- Neurophysiopathology Unit, Department of Neuroscience and Mental Health, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Paola Francesca Ajmone
- Child and Adolescent Neuropsychiatic Unit (UONPIA), Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Claudia Rigamonti
- Child and Adolescent Neuropsychiatic Unit (UONPIA), Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | | | - Silvana Gangi
- Foundation IRCCS Cà Granda Ospedale Maggiore Policlinico, University of Milan, Neonatology and NICU, Milan, Italy
| | - Pasquale Striano
- Pediatric Neurology and Muscular Diseases Unit, IRCCS ‘G. Gaslini' Institute, Genoa, Italy
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa, Genoa, Italy
| | - Monica Fumagalli
- Foundation IRCCS Cà Granda Ospedale Maggiore Policlinico, University of Milan, Neonatology and NICU, Milan, Italy
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Aeby A, Ceulemans B, Lagae L. Treatment of Focal-Onset Seizures in Children: Should This Be More Etiology-Driven? Front Neurol 2022; 13:842276. [PMID: 35330806 PMCID: PMC8940242 DOI: 10.3389/fneur.2022.842276] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Accepted: 01/24/2022] [Indexed: 01/22/2023] Open
Abstract
To accelerate the process of licensing antiseizure medication (ASM) in children, extrapolation of efficacy data for focal-onset seizures from adults to children ≥2 or ≥4 years of age is now accepted. We summarized the efficacy evidence from randomized, controlled trials that was used to grant approval for the pediatric indication of focal-onset seizures for the different ASMs available in Europe. Data from high-quality randomized, controlled trials in young children are limited, especially on the use of ASMs in monotherapy. Licensure trials are typically focused on seizure type irrespective of etiology or epilepsy syndrome. We elaborate on the importance of etiology- or syndrome-driven research and treatment, illustrating this with examples of childhood epilepsy syndromes characterized by predominantly focal-onset seizures. Some of these syndromes respond well to standard ASMs used for focal-onset seizures, but others would benefit from a more etiology- or syndrome-driven approach. Advances in molecular genetics and neuroimaging have made it possible to reveal the underlying cause of a child's epilepsy and tailor research and treatment. More high-quality randomized, controlled trials based on etiology or syndrome type are needed, including those assessing effects on cognition and behavior. In addition, study designs such as "N-of-1 trials" could elucidate possible new treatment options in rare epilepsies. Broadening incentives currently in place to stimulate the development and marketing of drugs for rare diseases (applicable to some epilepsy syndromes) to more common pediatric epilepsy types and syndromes might be a means to enable high-quality trials, and ultimately allow more evidence-based treatment in children.
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Affiliation(s)
- Alec Aeby
- Pediatric Neurology, Queen Fabiola Children's University Hospital, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Berten Ceulemans
- Department of Pediatric Neurology, Antwerp University Hospital, University of Antwerp, Antwerp, Belgium
| | - Lieven Lagae
- Reference Center for Refractory Epilepsy, Pediatric Neurology, Department of Development and Regeneration, University Hospitals Leuven, Leuven, Belgium
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Yang SM, Cao CD, Ding Y, Wang MJ, Yue SJ. D-bifunctional protein deficiency caused by HSD17B4 gene mutation in a neonate. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2021; 23:1058-1063. [PMID: 34719423 DOI: 10.7499/j.issn.1008-8830.2107158] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
A 15-day-old boy was admitted to the hospital due to repeated convulsions for 14 days. The main clinical manifestations were uncontrolled seizures, hypoergia, feeding difficulties, limb hypotonia, and bilateral hearing impairment. Clinical neurophysiology showed reduced brainstem auditory evoked potential on both sides and burst-suppression pattern on electroencephalogram. Measurement of very-long-chain fatty acids in serum showed that C26:0 was significantly increased. Genetic testing showed a pathogenic compound heterozygous mutation, c.101C>T(p.Ala34Val) and c.1448_1460del(p.Ala483Aspfs*37), in the HSD17B4 gene. This article reports a case of D-bifunctional protein deficiency caused by HSD17B4 gene mutation and summarizes the epidemiological and clinical features, diagnosis, and treatment of this disease, with a focus on the differential diagnosis of this disease from Ohtahara syndrome.
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Affiliation(s)
- Shu-Mei Yang
- Department of Neonatology, Xiangya Hospital, Central South University, Changsha 410008, China (Yue S-J, )
| | - Chuan-Ding Cao
- Department of Neonatology, Xiangya Hospital, Central South University, Changsha 410008, China (Yue S-J, )
| | - Ying Ding
- Department of Neonatology, Xiangya Hospital, Central South University, Changsha 410008, China (Yue S-J, )
| | - Ming-Jie Wang
- Department of Neonatology, Xiangya Hospital, Central South University, Changsha 410008, China (Yue S-J, )
| | - Shao-Jie Yue
- Department of Neonatology, Xiangya Hospital, Central South University, Changsha 410008, China (Yue S-J, )
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Abstract
With the advent of next generation sequencing technology there has been a spurt of papers on genetics in epilepsy in children. Genetic testing has now become an essential part of clinical practice in epilepsy. It helps in reaching an etiological diagnosis, providing prognostic information, guiding therapy precisely indicated for the patient and avoiding drugs that may worsen the seizures. Once the pathogenic variant has been found, this enables determining and counseling the risk of recurrence to the patient and other relatives at risk. It also makes available different reproductive options such as prenatal diagnosis or pre-implantation diagnosis. The authors describe the benefits, the clinical situations that require genetic testing, the types of genetic tests that are available, and how to choose the appropriate test and their likely yields. Genetic counseling, both pre- and post-test that should be provided is described briefly. Two useful tables are included that depict the therapy for variants in different epilepsy genes.
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The relationship between the characteristics of burst suppression pattern and different etiologies in epilepsy. Sci Rep 2021; 11:15903. [PMID: 34354098 PMCID: PMC8342459 DOI: 10.1038/s41598-021-95040-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Accepted: 07/14/2021] [Indexed: 11/08/2022] Open
Abstract
To analyze the relationship between the characteristics of burst suppression (BS) pattern and different etiologies in epilepsy. Patients with a BS pattern who were younger than 6 months old were screened from our electroencephalogram (EEG) database. The synchronized and symmetric BS patterns under different etiologies in epilepsy were analyzed. A total of 32 patients had a BS pattern on EEG. The etiologies included genetic disorders (37.5%), cortical malformations (28.1%), inborn errors of metabolism (12.5%), and unknown (21.9%). Twenty-five patients were diagnosed with Ohtahara syndrome, one as early myoclonic encephalopathy, and one as epilepsy of infancy with migrating focal seizure. Five cases could not be classified into any epileptic syndrome. Asynchronous BS pattern was identified in 18 cases, of which 13 (72%) patients had genetic and/or metabolic etiologies. Synchronous BS pattern was identified in 14 cases, of which 8 (57%) patients had structural etiologies. Twenty-three patients had symmetric BS patterns, of which 15 (65%) patients had genetic etiologies. Nine patients had asymmetric BS patterns, of which 8 (89%) patients had structural etiologies. Patients with genetic epilepsies tended to have asynchronous and symmetric BS patterns, whereas those with structural epilepsies were more likely to have synchronous and asymmetric BS patterns.
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Omer S, Jin SC, Koumangoye R, Robert SM, Duran D, Nelson-Williams C, Huttner A, DiLuna M, Kahle KT, Delpire E. Protein kinase D1 variant associated with human epilepsy and peripheral nerve hypermyelination. Clin Genet 2021; 100:176-186. [PMID: 33904160 DOI: 10.1111/cge.13973] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Revised: 04/19/2021] [Accepted: 04/21/2021] [Indexed: 11/26/2022]
Abstract
We report the case of a patient with severe progressive epilepsy and peripheral neuropathy and a novel de novo inactivating variant (p.E79X) in Protein Kinase D1 (PKD1). Using CRISPR/Cas9, we engineered the homologous variant in mice and showed that in the homozygote mouse, it recapitulated the patient peripheral nerve hypermyelination pathology. The lethality of the homozygote mouse prevented us from performing an assessment of locomotor behavior. The mutant heterozygote mouse; however, exhibited a significant increase in kainate-induced seizure activity over wild-type mice, supporting the hypothesis that the PKD1 variant is a candidate for the cause of the patient epilepsy. Because PKD1 was previously identified in a kinomic screen as an interacting partner of the K-Cl cotransporter 3 (KCC3), and since KCC3 is involved in peripheral nerve disease and brain hyperexcitability, one possible mechanism of action of PKD1 in disease is through KCC3. We show that catalytically inactive PKD1 stimulates KCC3 activity, consistent with tonic relief of inhibitory phosphorylation. Our findings implicate a novel role for PKD1 in the human nervous system, and uncover a mechanism that could serve as a potential target to promote nervous system myelination.
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Affiliation(s)
- Salma Omer
- Department of Anesthesiology, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
- Neuroscience Graduate Program, Vanderbilt University Nashville, Nashville, Tennessee, USA
| | - Sheng Chih Jin
- Department of Genetics, Yale University School of Medicine, New Haven, Connecticut, USA
- Department of Genetics and the McDonnell Genome Institute, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Rainelli Koumangoye
- Department of Anesthesiology, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Stephanie M Robert
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Daniel Duran
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Carol Nelson-Williams
- Department of Genetics, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Anita Huttner
- Department of Pathology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Michael DiLuna
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Kristopher T Kahle
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Eric Delpire
- Department of Anesthesiology, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
- Neuroscience Graduate Program, Vanderbilt University Nashville, Nashville, Tennessee, USA
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Cornet MC, Morabito V, Lederer D, Glass HC, Ferrao Santos S, Numis AL, Ferriero DM, Sands TT, Cilio MR. Neonatal presentation of genetic epilepsies: Early differentiation from acute provoked seizures. Epilepsia 2021; 62:1907-1920. [PMID: 34153113 DOI: 10.1111/epi.16957] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 05/21/2021] [Accepted: 05/23/2021] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Although most seizures in neonates are due to acute brain injury, some represent the first sign of neonatal onset genetic epilepsies. Delay in recognition and lack of expert assessment of neonates with epilepsy may result in worse developmental outcomes. As in older children and adults, seizure semiology in neonates is an essential determinant in diagnosis. We aimed to establish whether seizure type at presentation in neonates can suggest a genetic etiology. METHODS We retrospectively analyzed the clinical and electroencephalographic (EEG) characteristics of seizures in neonates admitted in two Level IV neonatal intensive care units, diagnosed with genetic epilepsy, for whom a video-EEG recording at presentation was available for review, and compared them on a 1:2 ratio with neonates with seizures due to stroke or hypoxic-ischemic encephalopathy. RESULTS Twenty neonates with genetic epilepsy were identified and compared to 40 neonates with acute provoked seizures. Genetic epilepsies were associated with pathogenic variants in KCNQ2 (n = 12), KCNQ3 (n = 2), SCN2A (n = 2), KCNT1 (n = 1), PRRT2 (n = 1), and BRAT1 (n = 2). All neonates with genetic epilepsy had seizures with clinical correlates that were either tonic (18/20) or myoclonic (2/20). In contrast, 17 of 40 (42%) neonates with acute provoked seizures had electrographic only seizures, and the majority of the remainder had clonic seizures. Time to first seizure was longer in neonates with genetic epilepsies (median = 60 h of life) compared to neonates with acute provoked seizures (median = 15 h of life, p < .001). Sodium channel-blocking antiseizure medications were effective in 13 of 14 (92%) neonates with tonic seizures who were trialed at onset or during the course of the epilepsy. SIGNIFICANCE Seizure semiology is an easily accessible sign of genetic epilepsies in neonates. Early identification of the seizure type can prompt appropriate workup and treatment. Tonic seizures are associated with channelopathies and are often controlled by sodium channel-blocking antiseizure medications.
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Affiliation(s)
- Marie-Coralie Cornet
- Department of Pediatrics, University of California, San Francisco, San Francisco, California, USA
| | - Valeria Morabito
- Department of Pediatrics, Saint-Luc University Hospital, Catholic University of Louvain, Brussels, Belgium
| | | | - Hannah C Glass
- Department of Pediatrics, University of California, San Francisco, San Francisco, California, USA.,Department of Neurology, University of California, San Francisco, San Francisco, California, USA
| | - Susana Ferrao Santos
- Department of Neurology, Saint-Luc University Hospital, Catholic University of Louvain, Brussels, Belgium
| | - Adam L Numis
- Department of Neurology, University of California, San Francisco, San Francisco, California, USA
| | - Donna M Ferriero
- Department of Pediatrics, University of California, San Francisco, San Francisco, California, USA.,Department of Neurology, University of California, San Francisco, San Francisco, California, USA
| | - Tristan T Sands
- Department of Neurology, Columbia University, New York, New York, USA
| | - Maria Roberta Cilio
- Department of Pediatrics, Saint-Luc University Hospital, Catholic University of Louvain, Brussels, Belgium
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Okumura A. Electroencephalography in neonatal epilepsies. Pediatr Int 2020; 62:1019-1028. [PMID: 32153072 DOI: 10.1111/ped.14227] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Revised: 03/01/2020] [Accepted: 03/06/2020] [Indexed: 12/22/2022]
Abstract
Neonatal epilepsies - neonatal seizures caused by remote symptomatic etiologies - are infrequent compared with those caused by acute symptomatic etiologies. The etiologies of neonatal epilepsies are classified into structural, genetic, and metabolic. Electroencephalography (EEG) and amplitude-integrated EEG (aEEG) are essential for the diagnosis and monitoring of neonatal epilepsies. Electroencephalography / aEEG findings may differ substantially among infants, even within infants with variants in a single gene. Unusual EEG/aEEG findings, such as downward seizure patterns on aEEG, can be found. Neonatal seizures are exclusively of focal onset. An International League Against Epilepsy task force proposed that the seizure type is typically determined by the predominant clinical feature and is classified into motor or non-motor presentations. Ictal EEG usually demonstrates a sudden, repetitive, evolving, and stereotyped activities with a minimum duration of 10 s. In epileptic spasms and myoclonic seizures, the cut-off point of 10 s cannot be applied. One must always be aware of electro-clinical dissociation in neonates suspected to have seizures. Amplitude-integrated EEG is also useful for the diagnosis and monitoring of neonatal epilepsies but aEEG cannot be recommended as the mainstay because of its relatively low sensitivity and specificity. At present, EEG findings are not pathognomonic, although some characteristic ictal or interictal EEG findings have been reported in several neonatal epilepsies. Deep learning will be expected to be introduced into EEG interpretation in near future. Objective EEG classification derived from deep learning may help to clarify EEG characteristics in some specific cases of neonatal epilepsy.
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Affiliation(s)
- Akihisa Okumura
- Department of Pediatrics, Aichi Medical University, Aichi, Japan
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Lee IC, Chang MY, Liang JS, Chang TM. Ictal and interictal electroencephalographic findings can contribute to early diagnosis and prompt treatment in KCNQ2-associated epileptic encephalopathy. J Formos Med Assoc 2020; 120:744-754. [PMID: 32863083 DOI: 10.1016/j.jfma.2020.08.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Accepted: 08/12/2020] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND KCNQ2-associated epilepsy is most common in neonatal genetic epilepsy. A prompt diagnosis to initialize early treatment is important. METHODS We studied the electroencephalographic (EEG) changes including automated EEGs and conventional EEGs monitoring of 10 nonconsanguineous cases with KCNQ2 mutations, identified among 162 (6%) childhood epilepsy. We compared 11 (25%) non-KCNQ2 seizures videoed from 44 automated EEG and EEG monitoring. RESULTS Patients with KCNQ2 seizures had received more antiepileptic treatments than patients in non-KCNQ2 group. Seizures were detected in all patients with KCNQ2 epileptic encephalopathy (EE); the detection rate in KCNQ2 group was more than in patients with non-KCNQ2. The ictal recordings showed 3 newborns presented with initial lower amplitudes (<15 μV) and fast activity (>20 Hz), evolving into higher-amplitude theta-delta waves. Two patient's ictal seizures showed recurrent focal tonic movements of the unilateral limbs associated with slowly continuous spikes in the contralateral hemisphere. The interictal EEGs in 5 KCNQ2 EE were burst-suppression. In 5 patients with familial KCNQ2 mutations, the interictal EEGs showed focal paroxysmal activity. Compared with 11 non-KCNQ2 EEG of ictal seizures, the differences are ictal EEGs initially appeared manifesting theta-delta waves without fast activities. In KCNQ2 seizures, patients with mutations locating in the selectivity filter controlling K+ permeability had severe EEG patterns and poor neurodevelopmental outcomes. CONCLUSION Ictal EEGs in KCNQ2 seizures are unique and different from the EEGs of seizures with other etiologies. An EEG monitoring can be a valuable tool for early diagnosing KCNQ2-associated seizures and for supporting prompt treatments.
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Affiliation(s)
- Inn-Chi Lee
- Division of Pediatric Neurology, Department of Pediatrics, Chung Shan Medical University Hospital, Taichung, Taiwan; Institute of Medicine, School of Medicine, Chung Shan Medical University, Taichung, Taiwan.
| | - Ming-Yuh Chang
- Department of Pediatric Neurology, Changhua Christian Children's Hospital Changhua, Taiwan
| | - Jao-Shwann Liang
- Department of Pediatrics, Far Eastern Memorial Hospital, New Taipei City, Taiwan
| | - Tung-Ming Chang
- Department of Pediatric Neurology, Changhua Christian Children's Hospital Changhua, Taiwan; School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
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Santarone ME, Pietrafusa N, Fusco L. Neonatal seizures: When semiology points to etiology. Seizure 2020; 80:161-165. [DOI: 10.1016/j.seizure.2020.06.025] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 06/02/2020] [Accepted: 06/03/2020] [Indexed: 12/20/2022] Open
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Abstract
PURPOSE OF REVIEW Although differentiating neonatal-onset epilepsies from acute symptomatic neonatal seizures has been increasingly recognized as crucial, existing guidelines, and recommendations on EEG monitoring are mainly based on acute symptomatic seizures, especially secondary to hypoxic-ischemic encephalopathy. We aimed to narratively review current knowledge on neonatal-onset epilepsies of genetic, metabolic, and structural non-acquired origin, with special emphasis on EEG features and monitoring. RECENT FINDINGS A wide range of rare conditions are increasingly described, reducing undiagnosed cases. Although distinguishing features are identifiable in some, how to best monitor and detect less described etiologies is still an issue. A comprehensive approach considering onset, seizure evolution, ictal semiology, clinical, laboratory, EEG, and neuroimaging data is key to diagnosis. Phenotypic variability prevents precise recommendations, but a solid, consistent method moving from existing published guidelines helps in correctly assessing these newborns in order to provide better care, especially in view of expanding precision therapies.
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