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Bosetti C, Ferrini L, Ferrari AR, Bartolini E, Calderoni S. Children with Autism Spectrum Disorder and Abnormalities of Clinical EEG: A Qualitative Review. J Clin Med 2024; 13:279. [PMID: 38202286 PMCID: PMC10779511 DOI: 10.3390/jcm13010279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Revised: 12/22/2023] [Accepted: 12/31/2023] [Indexed: 01/12/2024] Open
Abstract
Over the last decade, the comorbidity between Autism Spectrum Disorder (ASD) and epilepsy has been widely demonstrated, and many hypotheses regarding the common neurobiological bases of these disorders have been put forward. A variable, but significant, prevalence of abnormalities on electroencephalogram (EEG) has been documented in non-epileptic children with ASD; therefore, several scientific studies have recently tried to demonstrate the role of these abnormalities as a possible biomarker of altered neural connectivity in ASD individuals. This narrative review intends to summarize the main findings of the recent scientific literature regarding abnormalities detected with standard EEG in children/adolescents with idiopathic ASD. Research using three different databases (PubMed, Scopus and Google Scholar) was conducted, resulting in the selection of 10 original articles. Despite an important lack of studies on preschoolers and a deep heterogeneity in results, some authors speculated on a possible association between EEG abnormalities and ASD characteristics, in particular, the severity of symptoms. Although this correlation needs to be more strongly elucidated, these findings may encourage future studies aimed at demonstrating the role of electrical brain abnormalities as an early biomarker of neural circuit alterations in ASD, highlighting the potential diagnostic, prognostic and therapeutic value of EEG in this field.
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Affiliation(s)
- Chiara Bosetti
- Department of Developmental Neuroscience, IRCCS Stella Maris Foundation, 56128 Pisa, Italy; (C.B.); (L.F.); (A.R.F.); (S.C.)
- Department of Clinical and Experimental Medicine, University of Pisa, 56126 Pisa, Italy
| | - Luca Ferrini
- Department of Developmental Neuroscience, IRCCS Stella Maris Foundation, 56128 Pisa, Italy; (C.B.); (L.F.); (A.R.F.); (S.C.)
- Department of Translational Research and of New Surgical and Medical Technologies, University of Pisa, 56126 Pisa, Italy
| | - Anna Rita Ferrari
- Department of Developmental Neuroscience, IRCCS Stella Maris Foundation, 56128 Pisa, Italy; (C.B.); (L.F.); (A.R.F.); (S.C.)
| | - Emanuele Bartolini
- Department of Developmental Neuroscience, IRCCS Stella Maris Foundation, 56128 Pisa, Italy; (C.B.); (L.F.); (A.R.F.); (S.C.)
- Tuscany PhD Programme in Neurosciences, 50139 Florence, Italy
| | - Sara Calderoni
- Department of Developmental Neuroscience, IRCCS Stella Maris Foundation, 56128 Pisa, Italy; (C.B.); (L.F.); (A.R.F.); (S.C.)
- Department of Clinical and Experimental Medicine, University of Pisa, 56126 Pisa, Italy
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Dhamne SC, Modi ME, Gray A, Bonazzi S, Craig L, Bainbridge E, Lalani L, Super CE, Schaeffer S, Capre K, Lubicka D, Liang G, Burdette D, McTighe SM, Gurnani S, Vermudez SAD, Curtis D, Wilson CJ, Hameed MQ, D'Amore A, Rotenberg A, Sahin M. Seizure reduction in TSC2-mutant mouse model by an mTOR catalytic inhibitor. Ann Clin Transl Neurol 2023; 10:1790-1801. [PMID: 37545094 PMCID: PMC10578885 DOI: 10.1002/acn3.51868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 07/14/2023] [Accepted: 07/23/2023] [Indexed: 08/08/2023] Open
Abstract
OBJECTIVE Tuberous sclerosis complex (TSC) is a neurodevelopmental disorder caused by autosomal-dominant pathogenic variants in either the TSC1 or TSC2 gene, and it is characterized by hamartomas in multiple organs, such as skin, kidney, lung, and brain. These changes can result in epilepsy, learning disabilities, and behavioral complications, among others. The mechanistic link between TSC and the mechanistic target of the rapamycin (mTOR) pathway is well established, thus mTOR inhibitors can potentially be used to treat the clinical manifestations of the disorder, including epilepsy. METHODS In this study, we tested the efficacy of a novel mTOR catalytic inhibitor (here named Tool Compound 1 or TC1) previously reported to be more brain-penetrant compared with other mTOR inhibitors. Using a well-characterized hypomorphic Tsc2 mouse model, which displays a translationally relevant seizure phenotype, we tested the efficacy of TC1. RESULTS Our results show that chronic treatment with this novel mTOR catalytic inhibitor (TC1), which affects both the mTORC1 and mTORC2 signaling complexes, reduces seizure burden, and extends the survival of Tsc2 hypomorphic mice, restoring species typical weight gain over development. INTERPRETATION Novel mTOR catalytic inhibitor TC1 exhibits a promising therapeutic option in the treatment of TSC.
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Affiliation(s)
- Sameer C. Dhamne
- F.M. Kirby Neurobiology Center, Rosamund Stone Zander Translational Neuroscience Center, Department of Neurology, Boston Children's Hospital, Harvard Medical SchoolBostonMassachusettsUSA
| | - Meera E. Modi
- F.M. Kirby Neurobiology Center, Rosamund Stone Zander Translational Neuroscience Center, Department of Neurology, Boston Children's Hospital, Harvard Medical SchoolBostonMassachusettsUSA
| | - Audrey Gray
- Novartis Institutes for Biomedical ResearchCambridgeMassachusettsUSA
| | - Simone Bonazzi
- Novartis Institutes for Biomedical ResearchCambridgeMassachusettsUSA
| | - Lucas Craig
- Novartis Institutes for Biomedical ResearchCambridgeMassachusettsUSA
| | - Elizabeth Bainbridge
- F.M. Kirby Neurobiology Center, Rosamund Stone Zander Translational Neuroscience Center, Department of Neurology, Boston Children's Hospital, Harvard Medical SchoolBostonMassachusettsUSA
| | - Lahin Lalani
- F.M. Kirby Neurobiology Center, Rosamund Stone Zander Translational Neuroscience Center, Department of Neurology, Boston Children's Hospital, Harvard Medical SchoolBostonMassachusettsUSA
| | - Chloe E. Super
- F.M. Kirby Neurobiology Center, Rosamund Stone Zander Translational Neuroscience Center, Department of Neurology, Boston Children's Hospital, Harvard Medical SchoolBostonMassachusettsUSA
| | - Samantha Schaeffer
- F.M. Kirby Neurobiology Center, Rosamund Stone Zander Translational Neuroscience Center, Department of Neurology, Boston Children's Hospital, Harvard Medical SchoolBostonMassachusettsUSA
| | - Ketthsy Capre
- Novartis Institutes for Biomedical ResearchCambridgeMassachusettsUSA
| | - Danuta Lubicka
- Novartis Institutes for Biomedical ResearchCambridgeMassachusettsUSA
| | - Guiqing Liang
- Novartis Institutes for Biomedical ResearchCambridgeMassachusettsUSA
| | - Doug Burdette
- Novartis Institutes for Biomedical ResearchCambridgeMassachusettsUSA
| | | | - Sarika Gurnani
- F.M. Kirby Neurobiology Center, Rosamund Stone Zander Translational Neuroscience Center, Department of Neurology, Boston Children's Hospital, Harvard Medical SchoolBostonMassachusettsUSA
| | - Sheryl Anne D. Vermudez
- F.M. Kirby Neurobiology Center, Rosamund Stone Zander Translational Neuroscience Center, Department of Neurology, Boston Children's Hospital, Harvard Medical SchoolBostonMassachusettsUSA
| | - Daniel Curtis
- Novartis Institutes for Biomedical ResearchCambridgeMassachusettsUSA
| | | | - Mustafa Q. Hameed
- F.M. Kirby Neurobiology Center, Rosamund Stone Zander Translational Neuroscience Center, Department of Neurology, Boston Children's Hospital, Harvard Medical SchoolBostonMassachusettsUSA
| | - Angelica D'Amore
- F.M. Kirby Neurobiology Center, Rosamund Stone Zander Translational Neuroscience Center, Department of Neurology, Boston Children's Hospital, Harvard Medical SchoolBostonMassachusettsUSA
| | - Alexander Rotenberg
- F.M. Kirby Neurobiology Center, Rosamund Stone Zander Translational Neuroscience Center, Department of Neurology, Boston Children's Hospital, Harvard Medical SchoolBostonMassachusettsUSA
| | - Mustafa Sahin
- F.M. Kirby Neurobiology Center, Rosamund Stone Zander Translational Neuroscience Center, Department of Neurology, Boston Children's Hospital, Harvard Medical SchoolBostonMassachusettsUSA
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Śmiałek D, Kotulska K, Duda A, Jóźwiak S. Effect of mTOR Inhibitors in Epilepsy Treatment in Children with Tuberous Sclerosis Complex Under 2 Years of Age. Neurol Ther 2023; 12:931-946. [PMID: 37085686 DOI: 10.1007/s40120-023-00476-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 03/28/2023] [Indexed: 04/23/2023] Open
Abstract
INTRODUCTION Mechanistic target of rapamycin (mTOR) inhibitors sirolimus and everolimus are an effective therapy for subependymal giant cell astrocytomas, cardiac rhabdomyomas, renal angiomyolipomas, and lymphangioleiomyomatosis associated with tuberous sclerosis complex (TSC). Everolimus was recently approved in the EU and the USA for the treatment of refractory focal-onset seizures. Despite frequent use of mTOR inhibitors, there are only a few studies on their effect on epilepsy control in children under 2 years of age. This study aims to assess the effect of adjunctive mTOR inhibitor treatment on seizure frequency in this age group. METHODS We performed retrospective data analysis of medical records of patients with TSC who initiated sirolimus or everolimus under the age of 2 years. Participants' antiseizure medication was adjusted according to their epilepsy control independently from mTOR inhibitor administration. The data was assessed separately for patients treated with mTOR inhibitors before and after the onset of seizures. We also compared the treatment group with a matched control group. The follow-up duration was up to 24 months. RESULTS Twenty-one patients with TSC from two clinical centers were included in the study. Nine participants had no history of seizures before mTOR inhibitor initiation. Twelve reported active epilepsy in the month prior to treatment initiation. Most patients treated preventively with mTOR inhibitors did not report active epilepsy at the end of their follow-up. In the second group, the mean frequency of seizures decreased with time. According to the comparative analysis, seizure control was better in the groups treated with mTOR inhibitors. CONCLUSION Patients with TSC treated with mTOR inhibitors demonstrated better seizure control than individuals without this treatment. Adjunctive pharmacotherapy with mTOR inhibitors appears to have a beneficial effect on epilepsy outcome in young children. Further prospective clinical trials should be conducted to determine the efficacy of mTOR inhibitors on epilepsy in patients with TSC under the age of 2 years.
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Affiliation(s)
- Dominika Śmiałek
- Department of Pediatric Neurology, Medical University of Warsaw, Warsaw, Poland.
| | - Katarzyna Kotulska
- Department of Neurology and Epileptology, The Children's Memorial Health Institute, Warsaw, Poland
| | | | - Sergiusz Jóźwiak
- Department of Pediatric Neurology, Medical University of Warsaw, Warsaw, Poland
- Research Department, The Children's Memorial Health Institute, Warsaw, Poland
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Lynch M, Smith K, Riney K. Clinical seizure semiology is subtle and identification of seizures by parents is unreliable in infants with tuberous sclerosis complex. Epilepsia 2023; 64:386-395. [PMID: 36318046 PMCID: PMC10107460 DOI: 10.1111/epi.17454] [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: 08/17/2022] [Revised: 10/28/2022] [Accepted: 10/31/2022] [Indexed: 12/07/2022]
Abstract
OBJECTIVE The objectives of this study were to assess the accuracy of parental seizure detection in infants with antenatally diagnosed tuberous sclerosis complex (TSC), and to document the total seizure burden (clinical and subclinical) in those patients who met criteria for prolonged electroencephalography (EEG) recording. METHODS Consecutive infants at a single institution with antenatally diagnosed TSC who met criteria for prolonged video-EEG (vEEG) were recruited to this study. The vEEG data were reviewed and when a seizure was identified on EEG, the video and audio recording was assessed for evidence of clinical seizure and, if present, whether there was evidence of parent seizure identification. RESULTS Nine infants were enrolled, for whom 674 focal seizures were identified in eight of nine patients across 24 prolonged vEEG recordings, with vEEG total duration of 634 h 49 min (average seizure frequency of 1 focal seizure/h). Only 220 of 674 (32.6%) were clinical seizures, 395 of 674 (58.6%) were subclinical seizures, and 59 of 674 seizures could not be classified. Only 63 of 220 clinical seizures (28.6%) were identified by parents, with 157 of 220 (71.4%) not identified. Thirty clusters of epileptic spasms were detected in one patient. At least one clinical epileptic spasm occurred in 2 of 30 clusters (6.7%), 24 of 30 clusters of epileptic spasms (80%) were electrographic only, and classification was uncertain for 4 of 30 clusters (13.3%). No clinical epileptic spasms were detected by parents. Clinical seizure frequency was significantly underestimated by parents for all patients. SIGNIFICANCE This study demonstrates that in infants with TSC who met criteria for prolonged vEEG, (1) parents significantly under recognize total clinical seizure count, (2) parents fail to identify epileptic spasms, and (3) seizure frequency is high. This highlights that epilepsy treatment decisions should not be based solely on parental clinical seizure identification. Prolonged vEEG monitoring may have an important role in the routine epilepsy care of infants with TSC, as demonstrating undetected high clinical seizure frequency may allow improved epilepsy management decisions.
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Affiliation(s)
- Matthew Lynch
- Neurosciences Unit, Queensland Children's Hospital, South Brisbane, Queensland, Australia
| | - Kirsty Smith
- Neurosciences Unit, Queensland Children's Hospital, South Brisbane, Queensland, Australia
| | - Kate Riney
- Neurosciences Unit, Queensland Children's Hospital, South Brisbane, Queensland, Australia
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
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Singh A, Hadjinicolaou A, Peters JM, Salussolia CL. Treatment-Resistant Epilepsy and Tuberous Sclerosis Complex: Treatment, Maintenance, and Future Directions. Neuropsychiatr Dis Treat 2023; 19:733-748. [PMID: 37041855 PMCID: PMC10083014 DOI: 10.2147/ndt.s347327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Accepted: 03/22/2023] [Indexed: 04/13/2023] Open
Abstract
Tuberous sclerosis complex (TSC) is a neurogenetic disorder that affects multiple organ systems, including the heart, kidneys, eyes, skin, and central nervous system. The neurologic manifestations have the highest morbidity and mortality, in particular in children. Clinically, patients with TSC often present with new-onset seizures within the first year of life. TSC-associated epilepsy is often difficult to treat and refractory to multiple antiseizure medications. Refractory TSC-associated epilepsy is associated with increased risk of neurodevelopmental comorbidities, including developmental delay, intellectual disability, autism spectrum disorder, and attention hyperactivity disorder. An increasing body of research suggests that early, effective treatment of TSC-associated epilepsy during critical neurodevelopmental periods can potentially improve cognitive outcomes. Therefore, it is important to treat TSC-associated epilepsy aggressively, whether it be with pharmacological therapy, surgical intervention, and/or neuromodulation. This review discusses current and future pharmacological treatments for TSC-associated epilepsy, as well as the importance of early surgical evaluation for refractory epilepsy in children with TSC and consideration of neuromodulatory interventions in young adults.
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Affiliation(s)
- Avantika Singh
- Division of Epilepsy and Neurophysiology, Department of Neurology, Boston Children’s Hospital and Harvard Medical School, Boston, MA, USA
| | - Aristides Hadjinicolaou
- Division of Epilepsy and Neurophysiology, Department of Neurology, Boston Children’s Hospital and Harvard Medical School, Boston, MA, USA
| | - Jurriaan M Peters
- Division of Epilepsy and Neurophysiology, Department of Neurology, Boston Children’s Hospital and Harvard Medical School, Boston, MA, USA
| | - Catherine L Salussolia
- Division of Epilepsy and Neurophysiology, Department of Neurology, Boston Children’s Hospital and Harvard Medical School, Boston, MA, USA
- F.M. Kirby Neurobiology Center, Department of Neurology, Boston Children’s Hospital and Harvard Medical School, Boston, MA, USA
- Correspondence: Catherine L Salussolia, 3 Blackfan Circle, Center for Life Sciences 14060, Boston, MA, 02115, USA, Tel +617-355-7970, Email
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Whitney R, Zak M, Haile D, Nabavi Nouri M. The state of pediatric tuberous sclerosis complex epilepsy care: Results from a national survey. Epilepsia Open 2022; 7:718-728. [PMID: 36161285 PMCID: PMC9712483 DOI: 10.1002/epi4.12652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Accepted: 09/21/2022] [Indexed: 01/01/2023] Open
Abstract
OBJECTIVE Epilepsy associated with tuberous sclerosis complex (TSC) can be challenging to treat and is associated with significant disease burden. Our objective was to better understand the state of epilepsy care of TSC amongst pediatric neurologists in Canada, identify gaps in care and determine whether access to a dedicated TSC clinic has an impact on epilepsy management. METHODS A survey was developed after a literature review and discussion amongst two pediatric epileptologists and one nurse practitioner with expertise in TSC about the state of epilepsy care of TSC patients in Canada. Canadian pediatric neurologists were asked to participate in sharing their experiences via an anonymous web-based survey through the Canadian League Against Epilepsy (CLAE) and the Canadian Neurological Sciences Federation (CNSF). RESULTS Fifty-seven responses were received. Access to a dedicated TSC clinic was reported by 25% (n = 14). Sixty percent (n = 34) reported performing serial EEG monitoring in infants with TSC and 57% (n = 33) started prophylactic antiseizure therapy when EEG abnormalities were detected, regardless of whether there was access to a TSC clinic (P = .06 and P = .29, respectively). While 52% (n = 29) did not feel comfortable prescribing mTORi for epilepsy, 65% (n = 36) indicated they would consider it with additional training. Epilepsy surgery was offered in 93% (n = 13) of centers with a dedicated TSC clinic but only 45% of centers without a TSC clinic (n = 19) (P = .002). SIGNIFICANCE Our findings demonstrate the variability in neurological care of pediatric patients with TSC as it pertains to epilepsy management. There is a need for the establishment of epilepsy practice guidelines and a national network to support clinical practice, research, and education.
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Affiliation(s)
- Robyn Whitney
- Division of Neurology, Department of PaediatricsMcMaster UniversityHamiltonOntarioCanada
| | - Maria Zak
- Division of Neurology, Department of PaediatricsThe Hospital for Sick ChildrenTorontoOntarioCanada
| | - Denait Haile
- Department of Paediatrics, Schulich School of Dentistry and MedicineWestern UniversityLondonOntarioCanada
| | - Maryam Nabavi Nouri
- Department of Paediatrics, Schulich School of Dentistry and MedicineWestern UniversityLondonOntarioCanada
- Children's Health Research InstituteLawson Health Research InstituteLondonOntarioCanada
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Foryś-Basiejko M, Kotulska K, Maryniak A, Siłuszyk A, Szkop M, Borkowska J, Sugalska M, Głowacka-Walas J, Jóźwiak S. Epilepsy and Language Development in 8–36-Month-Old Toddlers with Tuberous Sclerosis Complex. J Clin Med 2022; 11:jcm11154564. [PMID: 35956179 PMCID: PMC9369686 DOI: 10.3390/jcm11154564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 07/21/2022] [Accepted: 07/26/2022] [Indexed: 02/04/2023] Open
Abstract
This paper aimed to assess language development in infants and toddlers with tuberous sclerosis complex (TSC) and epilepsy, which increase the risk of autism spectrum disorder. We assessed language development in 61 patients with TSC at 8–36 months using a standardized Speech Development and Communication Inventory tool. The results showed differences in outcomes due to the duration of the seizures and the number of drugs (pFDR = 0.007 **—pFDR = 0.037 *). Children with TSC with longer epilepsy duration and receiving more antiepileptic drugs have a greater risk of language development delay.
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Affiliation(s)
- Małgorzata Foryś-Basiejko
- Department of Child Clinical Psychology and Family, Faculty of Psychology, University of Warsaw, 00-183 Warszawa, Poland
- Department of Neurology and Epileptology, The Children’s Memorial Health Institute, 04-736 Warszawa, Poland
- Department of Pediatric Neurology, Medical University of Warsaw, 02-091 Warszawa, Poland
- Correspondence:
| | - Katarzyna Kotulska
- Department of Neurology and Epileptology, The Children’s Memorial Health Institute, 04-736 Warszawa, Poland
| | - Agnieszka Maryniak
- Department of Child Clinical Psychology and Family, Faculty of Psychology, University of Warsaw, 00-183 Warszawa, Poland
| | - Agata Siłuszyk
- Department of Pediatric Neurology, Medical University of Warsaw, 02-091 Warszawa, Poland
| | - Monika Szkop
- Department of Neurology and Epileptology, The Children’s Memorial Health Institute, 04-736 Warszawa, Poland
| | - Julita Borkowska
- Department of Neurology and Epileptology, The Children’s Memorial Health Institute, 04-736 Warszawa, Poland
| | - Monika Sugalska
- Department of Pediatric Neurology, Medical University of Warsaw, 02-091 Warszawa, Poland
| | - Jagoda Głowacka-Walas
- Institute of Computer Science, Warsaw University of Technology, 00-665 Warszawa, Poland
- Transition Technologies Science, 01-030 Warsaw, Poland
| | - Sergiusz Jóźwiak
- Department of Pediatric Neurology, Medical University of Warsaw, 02-091 Warszawa, Poland
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Hulshof HM, Kuijf HJ, Kotulska K, Curatolo P, Weschke B, Riney K, Krsek P, Feucht M, Nabbout R, Lagae L, Jansen A, Otte WM, Lequin MH, Sijko K, Benvenuto A, Hertzberg C, Benova B, Scholl T, De Ridder J, Aronica EA, Kwiatkowski DJ, Jozwiak S, Jurkiewicz E, Braun K, Jansen FE. Association of Early MRI Characteristics With Subsequent Epilepsy and Neurodevelopmental Outcomes in Children With Tuberous Sclerosis Complex. Neurology 2022; 98:e1216-e1225. [PMID: 35101906 DOI: 10.1212/wnl.0000000000200027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Accepted: 01/03/2022] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Multiple factors have been found to contribute to the high risk of epilepsy in infants with Tuberous Sclerosis Complex (TSC), including evolution of EEG abnormalities, TSC gene mutation and MRI characteristics. The aim of the present prospective multi-center study was to: 1) identify early MRI biomarkers of epilepsy in infants with TSC aged < 6 months and before seizure onset, and 2) associate these MRI biomarkers with neurodevelopmental outcomes at 2 years of age. The study was part of the EPISTOP project. METHODS We evaluated brain MRIs performed in infants with TSC younger than 6 months of age. We used harmonized MRI-protocols across centers and children were monitored closely with neuropsychological evaluation, and serial video EEG. MRI characteristics defined as tubers, radial migration lines, white matter abnormalities, cysts, calcifications, subependymal nodules (SEN) and subependymal giant cell astrocytoma (SEGA) were visually evaluated and lesions were detected semi-automatically. Lesion to brain volume ratios were calculated and associated with epilepsy and neurodevelopmental outcomes at two years. RESULTS Lesions were assessed on MRIs from 77 TSC infants, 62 MRIs were sufficient for volume analysis. The presence of tubers and higher tuber-brain ratios were associated with the development of clinical seizures, independently of TSC gene mutation and preventive treatment. Furthermore, higher tuber-brain ratios were associated with lower cognitive and motor development quotients at two years, independently of TSC gene mutation and presence of epilepsy. DISCUSSION In infants with TSC, there is a significant association between characteristic TSC lesions detected on early brain MRI and development of clinical seizures, as well as neurodevelopmental outcomes in the first two years of life. According to our results, early brain MRI findings may guide clinical care for young children with TSC. CLASSIFICATION OF EVIDENCE This study provides Class I evidence that in infants with TSC, there is a significant association between characteristic TSC lesions on early brain MRI and the development of clinical seizures and neurodevelopmental outcomes in the first two years of life.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | - Wim M Otte
- Biomedical MR Imaging and Spectroscopy Group, Center for Image Sciences, University Medical Center Utrecht and Utrecht University, Utrecht, The Netherlands
| | - Maarten H Lequin
- Department of Radiology, University Medical Center, Utrecht, the Netherlands
| | - Kamil Sijko
- Instytut Pomnik-Centrum Zdrowia Dziecka, The Children's Memorial Health Institute, Warsaw, Poland, Member of the European Reference Network EpiCARE
| | | | | | | | | | | | - EleonoraM A Aronica
- Stichting Epilepsie Instellingen Nederland (SEIN), Hoofddorp, the Netherlands
| | | | - Sergiusz Jozwiak
- Department of Child Neurology, Medical University of Warsaw, Warsaw, Poland
| | - Elzbieta Jurkiewicz
- Instytut Pomnik-Centrum Zdrowia Dziecka, The Children's Memorial Health Institute, Warsaw, Poland, Member of the European Reference Network EpiCARE
| | - Kees Braun
- Department of Pediatric Neurology, Brain Center UMC Utrecht, The Netherlands, Member of the European Reference Network EpiCARE
| | - Floor E Jansen
- Department of Pediatric Neurology, Brain Center UMC Utrecht, The Netherlands, Member of the European Reference Network EpiCARE
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Nabavi Nouri M, Zak M, Jain P, Whitney R. Epilepsy Management in Tuberous Sclerosis Complex: Existing and Evolving Therapies and Future Considerations. Pediatr Neurol 2022; 126:11-19. [PMID: 34740132 DOI: 10.1016/j.pediatrneurol.2021.09.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Revised: 09/22/2021] [Accepted: 09/25/2021] [Indexed: 10/20/2022]
Abstract
Tuberous sclerosis complex (TSC) is a rare autosomal dominant condition that affects multiple body systems. Disruption of the mammalian target of rapamycin (mTOR) pathway results in abnormal cell growth, proliferation, protein synthesis, and cell differentiation and migration in TSC. In the central nervous system, mTOR disruption is also believed to influence neuronal excitability and promote epileptogenesis. Epilepsy is the most common neurological manifestation of TSC and affects 80% to 90% of individuals with high rates of treatment resistance (up to 75%). The onset of epilepsy in the majority of individuals with TSC occurs before the age of two years, which is a critical time in neurodevelopment. Both medically refractory epilepsy and early-onset epilepsy are associated with intellectual disability in TSC, while seizure control and remission are associated with lower rates of cognitive impairment. Our current knowledge of the treatment of epilepsy in TSC has expanded immensely over the last decade. Several new therapies such as preemptive vigabatrin therapy in infants, cannabidiol, and mTOR inhibitors have emerged in recent years for the treatment of epilepsy in TSC. This review will provide clinicians with a comprehensive overview of the pharmacological and nonpharmacological therapies available for the treatment of epilepsy related to TSC.
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Affiliation(s)
- Maryam Nabavi Nouri
- Division of Neurology, Department of Pediatrics, Western University, London, Ontario, Canada
| | - Maria Zak
- Division of Neurology, Department of Paediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Puneet Jain
- Division of Neurology, Department of Paediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Robyn Whitney
- Division of Neurology, Department of Paediatrics, McMaster University, Hamilton, Ontario, Canada.
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Miszewska D, Sugalska M, Jóźwiak S. Risk Factors Associated with Refractory Epilepsy in Patients with Tuberous Sclerosis Complex: A Systematic Review. J Clin Med 2021; 10:jcm10235495. [PMID: 34884198 PMCID: PMC8658289 DOI: 10.3390/jcm10235495] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Revised: 11/22/2021] [Accepted: 11/23/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Epilepsy affects 70-90% of patients with tuberous sclerosis complex (TSC). In one-third of them, the seizures become refractory to treatment. Drug-resistant epilepsy (DRE) carries a significant educational, social, cognitive, and economic burden. Therefore, determining risk factors that increase the odds of refractory seizures is needed. We reviewed current data on risk factors associated with DRE in patients with tuberous sclerosis. METHODS The review was performed according to the PRISMA guidelines. Embase, Cochrane Library, MEDLINE, and ClinicalTrial.gov databases were searched. Only full-text journal articles on patients with TSC which defined risk factors related to DRE were included. RESULTS Twenty articles were identified, with a cohort size between 6 and 1546. Seven studies were prospective. Three factors appear to significantly increase DRE risk: TSC2 mutation, infantile spasms, and a high number of cortical tubers. CONCLUSIONS A proper MRI and EEG monitoring, along with genetic testing, and close observation of individuals with early onset of seizures, allow identification of the patients at risk of DRE.
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Riikonen R. Could prevention of infantile spasms have been possible in a historical cohort of 31 tuberous sclerosis patients? Eur J Paediatr Neurol 2021; 35:153-157. [PMID: 34731702 DOI: 10.1016/j.ejpn.2021.10.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 10/07/2021] [Accepted: 10/23/2021] [Indexed: 10/20/2022]
Abstract
UNLABELLED Efforts to prevent epilepsy in infants with tuberous sclerosis complex (TSC) has been the focus of EPISTOP. PURPOSE The present study was carried out to evaluate whether prevention could have been realistic. METHODS A retrospective analysis by hospital chart review of 31 patients with TSC and infantile spasms (practically all patients) admitted to two tertiary hospitals, Children's Hospital, University of Helsinki and Kuopio in 1980-2000. Clinical history, early cognitive development, early clinical signs of TSC, clinical signs of suspicious seizures, first seizures and EEG, response to adrenocorticotropic hormone (ACTH) therapy, EEG and brain imaging were evaluated. RESULTS Early development prior the spasms was apparently normal in 25 (80%). The first EEG ever performed for a child showed hypsarrhythmia in 16 (51%) or modified hypsarrhythmia in 10 (32%). Treatment lag was short (0-4, mean 2 weeks) and the primary response to ACTH favorable in 19 (64%). Etiological diagnostic workup of IS revealed TSC. In one single case (3%) the diagnosis of TSC could be made at birth due to a congenital cardiac rhabdomyoma. Three other rhabomyomas were diagnosed later. In brain imaging, subependymal periventricular calcifications or hypodense areas were seen in every patient at onset of IS. Other organ manifestations of TSC were retinal phakomas (6), polycystic kidneys (2), and renal angiolipomatosis (1). CONCLUSIONS Preventive treatment of epileptic discharges could have been possible in a single case of neonatal rhabdomyoma suggesting that preventive treatment is challenging in everyday practice. The main obstacle is the delay of TSC diagnosis.
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Affiliation(s)
- Raili Riikonen
- University of Eastern Finland and Kuopio University Hospital, Kuopio, Finland, Postal Address: Yliopistonranta 1, FI-70110, Kuopio, Finland.
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Stuart C, Fladrowski C, Flinn J, Öberg B, Peron A, Rozenberg M, Smith CA. Beyond the Guidelines: How We Can Improve Healthcare for People With Tuberous Sclerosis Complex Around the World. Pediatr Neurol 2021; 123:77-84. [PMID: 34416612 DOI: 10.1016/j.pediatrneurol.2021.07.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Accepted: 07/20/2021] [Indexed: 01/07/2023]
Abstract
BACKGROUND Tuberous Sclerosis Complex International (TSCi) is a consortium of organizations that supports individuals with tuberous sclerosis complex (TSC) around the world. To improve care for TSC on a global level, TSCi identified the need to expand understanding about existing resources available in other countries, what individuals and caregivers value in TSC care, key gaps between needs and reality in each country, and ways these gaps can be addressed by advocacy organizations around the world. METHODS An iterative, mixed methods approach (the Improving Care project) was adopted to incorporate views from diverse members of TSCi. Through idea generation, a collection of qualitative open-ended responses and concept elicitation, we were able to build consensus where shared experiences and opinions were identified. RESULTS The research performed as a part of the Improving Care project revealed a significant gap between the guidelines and what is actually available to people with TSC worldwide. Three key priority areas of action to improve this gap were identified: (1) implementation of the guidelines; (2) access to TSC expertise, and (3) coordinated and integrated health care. CONCLUSIONS There are significant opportunities for key stakeholders, including organizations, clinicians, and researchers to improve care for individuals with TSC on both local and global levels. Working across stakeholder groups and utilizing TSC organizations are essential to ensure that the advances in TSC research benefit people living with TSC around the world.
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Affiliation(s)
- Clare Stuart
- Tuberous Sclerosis Australia, Sydney, New South Wales, Australia
| | - Carla Fladrowski
- Associazione Sclerosi Tuberosa ASP, Rome, Italy; European Tuberous Sclerosis Complex Association, Wiesbaden, Germany
| | - Jennifer Flinn
- Tuberous Sclerosis Canada Sclérose Tubéreuse, Ontario, Canada
| | | | - Angela Peron
- Child Neuropsychiatry Unit - Epilepsy Center, San Paolo Hospital, Department of Health Sciences, Università degli Studi di Milano, Milan, Italy; Human Pathology and Medical Genetics, ASST Santi Paolo e Carlo, San Paolo Hospital, Milan, Italy; Division of Medical Genetics, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah
| | - Micaela Rozenberg
- European Tuberous Sclerosis Complex Association, Wiesbaden, Germany; Associação de Esclerose Tuberosa em Portugal, Lisbon, Portugal
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13
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French JA, Bebin M, Dichter MA, Engel J, Hartman AL, Jóźwiak S, Klein P, McNamara J, Twyman R, Vespa P. Antiepileptogenesis and disease modification: Clinical and regulatory issues. Epilepsia Open 2021; 6:483-492. [PMID: 34270884 PMCID: PMC8408600 DOI: 10.1002/epi4.12526] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Revised: 07/05/2021] [Accepted: 07/13/2021] [Indexed: 12/13/2022] Open
Abstract
This is a summary report of clinical and regulatory issues discussed at the 2018 NINDS workshop, entitled “Accelerating Therapies for Antiepileptogenesis and Disease Modification.” The intent of the workshop was to optimize and accelerate development of therapies for antiepileptogenesis (AEG) and disease modification in the epilepsies. The working group discussed nomenclature for antiepileptogenic therapies, subdividing them into “antiepileptogenic therapies” and “disease modifying therapies,” both of which are urgently needed. We use the example of traumatic brain injury to explain issues and complexities in designing a trial for disease‐preventing antiepileptogenic therapies, including identifying timing of intervention, selecting the appropriate dose, and the need for biomarkers. We discuss the recent trials of vigabatrin to prevent onset and modify epilepsy outcome in children with tuberous sclerosis (Epistop and PreVeNT). We describe a potential approach to a disease modification trial in adults, using patients with temporal lobe epilepsy. Finally, we discuss regulatory hurdles for antiepileptogenesis and disease‐modifying trials.
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Affiliation(s)
| | - Martina Bebin
- UAB School of Medicine and UAB Epilepsy Center, Birmingham, AL, USA
| | | | - Jerome Engel
- David Geffen School of Medicine at, UCLA and the Brain Research Institute, Los Angeles, CA, USA
| | - Adam L Hartman
- Division of Clinical Research, National Institute of Neurological Disorders and Stroke/NIH, Bethesda, MD, USA
| | - Sergiusz Jóźwiak
- Department of Child Neurology, Medical University of Warsaw, Warsaw, Poland
| | - Pavel Klein
- Mid-Atlantic Epilepsy and Sleep Center, Bethesda, MD, USA
| | - James McNamara
- Department of Neurobiology, Duke University School of Medicine, Durham, NC, USA
| | | | - Paul Vespa
- Departments of Neurology and Neurosurgery, David Geffen School of Medicine UCLA, Los Angeles, CA, USA
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14
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Schubert-Bast S, Strzelczyk A. Review of the treatment options for epilepsy in tuberous sclerosis complex: towards precision medicine. Ther Adv Neurol Disord 2021; 14:17562864211031100. [PMID: 34349839 PMCID: PMC8290505 DOI: 10.1177/17562864211031100] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Accepted: 06/21/2021] [Indexed: 12/24/2022] Open
Abstract
Tuberous sclerosis complex (TSC) is a rare genetic disorder caused by mutations in the TSC1 or TSC2 genes, which encode proteins that antagonise the mammalian isoform of the target of rapamycin complex 1 (mTORC1) - a key mediator of cell growth and metabolism. TSC is characterised by the development of benign tumours in multiple organs, together with neurological manifestations including epilepsy and TSC-associated neuropsychiatric disorders (TAND). Epilepsy occurs frequently and is associated with significant morbidity and mortality; however, the management is challenging due to the intractable nature of the seizures. Preventative epilepsy treatment is a key aim, especially as patients with epilepsy may be at a higher risk of developing severe cognitive and behavioural impairment. Vigabatrin given preventatively reduces the risk and severity of epilepsy although the benefits for TAND are inconclusive. These promising results could pave the way for evaluating other treatments in a preventative capacity, especially those that may address the underlying pathophysiology of TSC, including everolimus, cannabidiol and the ketogenic diet (KD). Everolimus is an mTOR inhibitor approved for the adjunctive treatment of refractory TSC-associated seizures that has demonstrated significant reductions in seizure frequency compared with placebo, improvements that were sustained after 2 years of treatment. Highly purified cannabidiol, recently approved in the US as Epidiolex® for TSC-associated seizures in patients ⩾1 years of age, and the KD, may also participate in the regulation of the mTOR pathway. This review focusses on the pivotal clinical evidence surrounding these potential targeted therapies that may form the foundation of precision medicine for TSC-associated epilepsy, as well as other current treatments including anti-seizure drugs, vagus nerve stimulation and surgery. New future therapies are also discussed, together with the potential for preventative treatment with targeted therapies. Due to advances in understanding the molecular genetics and pathophysiology, TSC represents a prototypic clinical syndrome for studying epileptogenesis and the impact of precision medicine.
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Affiliation(s)
- Susanne Schubert-Bast
- Epilepsy Center Frankfurt Rhine-Main, Center of Neurology and Neurosurgery, Goethe-University Frankfurt, Frankfurt am Main, Germany
| | - Adam Strzelczyk
- Epilepsy Center Frankfurt Rhine-Main, Goethe-University Frankfurt, Schleusenweg 2-16, Frankfurt am Main, 60528, Germany
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15
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Di Napoli C, Gennaro A, Lupica C, Falsaperla R, Leonardi R, Garozzo MT, Polizzi A, Praticò AD, Zanghì A, Ruggieri M. TSC1 and TSC2: Tuberous Sclerosis Complex and Its Related Epilepsy Phenotype. JOURNAL OF PEDIATRIC NEUROLOGY 2021. [DOI: 10.1055/s-0041-1727142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
AbstractTuberous sclerosis complex (TSC) is an autosomal dominant disorder characterized by a multisystemic involvement. In TSC, reduced function of TSC1 and TSC2 genes products (hamartin and tuberin, respectively) leads to an hyperactivation of the mechanistic target of rapamycin (mTOR) pathway and to a consequent cell growth dysregulation. In TSC patients, neurological and neuropsychiatric manifestations, especially epilepsy and neuropsychiatric comorbidities such as autism or intellectual disability, represent the most disabling features. In particular, epilepsy occurrs up to 80% of patients, is often drug resistant and is frequently associated with neurological impairment. Due to the burden of this morbidity, different treatment strategies have been proposed with the purpose to make patients epilepsy free, such as the use of different antiepileptic drugs like vigabatrin, carbamazepine, valproic acid, and levetiracetam. More recently, a mTOR inhibitor (i.e. everolimus) has showed promising results in terms of seizures reduction.
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Affiliation(s)
- Claudia Di Napoli
- Postgraduate Training Program in Genetics, Department of Biomedical and Biotechnological Sciences, Section of Genetics, University of Catania, Catania, Italy
| | - Alessia Gennaro
- Postgraduate Training Program in Genetics, Department of Biomedical and Biotechnological Sciences, Section of Genetics, University of Catania, Catania, Italy
| | - Carmelania Lupica
- Postgraduate Training Program in Genetics, Department of Biomedical and Biotechnological Sciences, Section of Genetics, University of Catania, Catania, Italy
| | - Raffaele Falsaperla
- Unit of Pediatrics and Pediatric Emergency, University Hospital “Policlinico Rodolico-San Marco,” Catania, Italy
- Unit of Neonatal Intenstive Care and Neonatology, University Hospital “Policlinico Rodolico-San Marco,” Catania, Italy
| | - Roberta Leonardi
- Department of Clinical and Experimental Medicine, Section of Pediatrics and Child Neuropsychiatry, Unit of Rare Diseases of the Nervous System in Childhood, University of Catania, Catania, Italy
| | - Maria Teresa Garozzo
- Unit of Pediatrics and Pediatric Emergency, Hospital “Cannizzaro,” Catania, Italy
| | - Agata Polizzi
- Chair of Pediatrics, Department of Educational Sciences, University of Catania, Catania, Italy
| | - Andrea D. Praticò
- Department of Clinical and Experimental Medicine, Section of Pediatrics and Child Neuropsychiatry, Unit of Rare Diseases of the Nervous System in Childhood, University of Catania, Catania, Italy
| | - Antonio Zanghì
- Department of General Surgery and Medical-Surgical Specialty, University of Catania, Catania, Italy
| | - Martino Ruggieri
- Chair of Pediatrics, Department of Educational Sciences, University of Catania, Catania, Italy
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16
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De Ridder J, Verhelle B, Vervisch J, Lemmens K, Kotulska K, Moavero R, Curatolo P, Weschke B, Riney K, Feucht M, Krsek P, Nabbout R, Jansen AC, Wojdan K, Domanska-Pakieła D, Kaczorowska-Frontczak M, Hertzberg C, Ferrier CH, Samueli S, Benova B, Aronica E, Kwiatkowski DJ, Jansen FE, Jóźwiak S, Lagae L. Early epileptiform EEG activity in infants with tuberous sclerosis complex predicts epilepsy and neurodevelopmental outcomes. Epilepsia 2021; 62:1208-1219. [PMID: 33778971 DOI: 10.1111/epi.16892] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2020] [Revised: 03/10/2021] [Accepted: 03/12/2021] [Indexed: 01/24/2023]
Abstract
OBJECTIVE To study the association between timing and characteristics of the first electroencephalography (EEG) with epileptiform discharges (ED-EEG) and epilepsy and neurodevelopment at 24 months in infants with tuberous sclerosis complex (TSC). METHODS Patients enrolled in the prospective Epileptogenesis in a genetic model of epilepsy - Tuberous sclerosis complex (EPISTOP) trial, had serial EEG monitoring until the age of 24 months. The timing and characteristics of the first ED-EEG were studied in relation to clinical outcome. Epilepsy-related outcomes were analyzed separately in a conventionally followed group (initiation of vigabatrin after seizure onset) and a preventive group (initiation of vigabatrin before seizures, but after appearance of interictal epileptiform discharges [IEDs]). RESULTS Eighty-three infants with TSC were enrolled at a median age of 28 days (interquartile range [IQR] 14-54). Seventy-nine of 83 patients (95%) developed epileptiform discharges at a median age of 77 days (IQR 23-111). Patients with a pathogenic TSC2 variant were significantly younger (P-value .009) at first ED-EEG and more frequently had multifocal IED (P-value .042) than patients with a pathogenic TSC1 variant. A younger age at first ED-EEG was significantly associated with lower cognitive (P-value .010), language (P-value .001), and motor (P-value .013) developmental quotients at 24 months. In the conventional group, 48 of 60 developed seizures. In this group, the presence of focal slowing on the first ED-EEG was predictive of earlier seizure onset (P-value .030). Earlier recording of epileptiform discharges (P-value .019), especially when multifocal (P-value .026) was associated with higher risk of drug-resistant epilepsy. In the preventive group, timing, distribution of IED, or focal slowing, was not associated with the epilepsy outcomes. However, when multifocal IEDs were present on the first ED-EEG, preventive treatment delayed the onset of seizures significantly (P-value <.001). SIGNIFICANCE Early EEG findings help to identify TSC infants at risk of severe epilepsy and neurodevelopmental delay and those who may benefit from preventive treatment with vigabatrin.
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Affiliation(s)
- Jessie De Ridder
- Department of Development and Regeneration, Section Pediatric Neurology, Catholic University of Leuven (KU Leuven), Leuven, Belgium
| | - Birgit Verhelle
- Department of Development and Regeneration, Section Pediatric Neurology, Catholic University of Leuven (KU Leuven), Leuven, Belgium
| | - Jan Vervisch
- Department of Development and Regeneration, Section Pediatric Neurology, Catholic University of Leuven (KU Leuven), Leuven, Belgium
| | - Katrien Lemmens
- Department of Development and Regeneration, Section Pediatric Neurology, Catholic University of Leuven (KU Leuven), Leuven, Belgium
| | - Katarzyna Kotulska
- Department of Neurology and Epileptology, The Children's Memorial Health Institute, Warsaw, Poland
| | - Romina Moavero
- Child Neurology and Psychiatry Unit, Systems Medicine Department, Tor Vergata University, Rome, Italy.,Child Neurology Unit, Neuroscience and Neurorehabilitation Department, "Bambino Gesù" Children's Hospital, Rome, Italy
| | - Paolo Curatolo
- Child Neurology and Psychiatry Unit, Systems Medicine Department, Tor Vergata University, Rome, Italy
| | - Bernhard Weschke
- Department of Child Neurology, Charité University Medicine Berlin, Berlin, Germany
| | - Kate Riney
- Neuroscience Unit, Queensland Children's Hospital, Brisbane, Australia.,University of Queensland School of Clinical Medicine, Brisbane, Australia
| | - Martha Feucht
- Department of Pediatrics, Medical University Vienna, Vienna, Austria
| | - Pavel Krsek
- Department of Paediatric Neurology, Second Faculty of Medicine, Motol University Hospital, Charles University, Prague, Czech Republic
| | - Rima Nabbout
- Department of Pediatric Neurology, Reference Centre for Rare Epilepsies, Necker- Enfants Malades Hospital, Imagine Institute, INSERM U1163, University Paris Descartes, Paris, France
| | - Anna C Jansen
- Pediatric Neurology Unit, University Hospital Brussel, Brussels, Belgium
| | - Konrad Wojdan
- Transition Technologies, Warsaw, Poland.,Institute of Heat Engineering, Warsaw University and Technology, Warsaw, Poland
| | - Dorota Domanska-Pakieła
- Department of Neurology and Epileptology, The Children's Memorial Health Institute, Warsaw, Poland
| | | | - Christoph Hertzberg
- Diagnose und Behandlungszentrum für Kinder und Jugendliche, Vivantes Klinikum Neuköln, Berlin, Germany
| | - Cyrille H Ferrier
- Department of Child Neurology, Brain Centre, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Sharon Samueli
- Department of Pediatrics, Medical University Vienna, Vienna, Austria
| | - Barbora Benova
- Department of Paediatric Neurology, Second Faculty of Medicine, Motol University Hospital, Charles University, Prague, Czech Republic
| | - Eleonora Aronica
- Department of (Neuro)Pathology, Amsterdam University Medical Centres (UMC), University of Amsterdam, Amsterdam, The Netherlands.,Stichting Epilepsie Instellingen Nederland (SEIN), Zwolle, The Netherlands
| | - David J Kwiatkowski
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Floor E Jansen
- Department of Child Neurology, Brain Centre, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Sergiusz Jóźwiak
- Department of Neurology and Epileptology, The Children's Memorial Health Institute, Warsaw, Poland.,Department of Child Neurology, Medical University of Warsaw, Warsaw, Poland
| | - Lieven Lagae
- Department of Development and Regeneration, Section Pediatric Neurology, Catholic University of Leuven (KU Leuven), Leuven, Belgium
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17
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Kotulska K, Kwiatkowski DJ, Curatolo P, Weschke B, Riney K, Jansen F, Feucht M, Krsek P, Nabbout R, Jansen AC, Wojdan K, Sijko K, Głowacka‐Walas J, Borkowska J, Sadowski K, Domańska‐Pakieła D, Moavero R, Hertzberg C, Hulshof H, Scholl T, Benova B, Aronica E, de Ridder J, Lagae L, Jóźwiak S. Prevention of Epilepsy in Infants with Tuberous Sclerosis Complex in the EPISTOP Trial. Ann Neurol 2021; 89:304-314. [PMID: 33180985 PMCID: PMC7898885 DOI: 10.1002/ana.25956] [Citation(s) in RCA: 119] [Impact Index Per Article: 39.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Revised: 11/04/2020] [Accepted: 11/06/2020] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Epilepsy develops in 70 to 90% of children with tuberous sclerosis complex (TSC) and is often resistant to medication. Recently, the concept of preventive antiepileptic treatment to modify the natural history of epilepsy has been proposed. EPISTOP was a clinical trial designed to compare preventive versus conventional antiepileptic treatment in TSC infants. METHODS In this multicenter study, 94 infants with TSC without seizure history were followed with monthly video electroencephalography (EEG), and received vigabatrin either as conventional antiepileptic treatment, started after the first electrographic or clinical seizure, or preventively when epileptiform EEG activity before seizures was detected. At 6 sites, subjects were randomly allocated to treatment in a 1:1 ratio in a randomized controlled trial (RCT). At 4 sites, treatment allocation was fixed; this was denoted an open-label trial (OLT). Subjects were followed until 2 years of age. The primary endpoint was the time to first clinical seizure. RESULTS In 54 subjects, epileptiform EEG abnormalities were identified before seizures. Twenty-seven were included in the RCT and 27 in the OLT. The time to the first clinical seizure was significantly longer with preventive than conventional treatment [RCT: 364 days (95% confidence interval [CI] = 223-535) vs 124 days (95% CI = 33-149); OLT: 426 days (95% CI = 258-628) vs 106 days (95% CI = 11-149)]. At 24 months, our pooled analysis showed preventive treatment reduced the risk of clinical seizures (odds ratio [OR] = 0.21, p = 0.032), drug-resistant epilepsy (OR = 0.23, p = 0.022), and infantile spasms (OR = 0, p < 0.001). No adverse events related to preventive treatment were noted. INTERPRETATION Preventive treatment with vigabatrin was safe and modified the natural history of seizures in TSC, reducing the risk and severity of epilepsy. ANN NEUROL 2021;89:304-314.
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Affiliation(s)
- Katarzyna Kotulska
- Department of Neurology and EpileptologyThe Children's Memorial Health InstituteWarsawPoland
| | | | - Paolo Curatolo
- Child Neurology and Psychiatry Unit, Systems Medicine DepartmentTor Vergata UniversityRomeItaly
| | - Bernhard Weschke
- Department of Child NeurologyCharité University Medicine BerlinBerlinGermany
| | - Kate Riney
- Neurosciences UnitQueensland Children's HospitalSouth BrisbaneQLDAustralia
- School of MedicineUniversity of QueenslandSt LuciaQLDAustralia
| | - Floor Jansen
- Department of Child Neurology, Brain CenterUniversity Medical Center UtrechtUtrechtThe Netherlands
| | - Martha Feucht
- Department of PediatricsUniversity Hospital ViennaViennaAustria
| | - Pavel Krsek
- Motol University Hospital, Charles UniversityPrague 5Czech Republic
| | - Rima Nabbout
- Department of Pediatric Neurology, Reference Centre for Rare Epilepsies, Necker‐ Enfants Malades HospitalUniversity Paris Descartes, Imagine InstituteParisFrance
| | - Anna C. Jansen
- Pediatric Neurology Unit‐UZ BrusselBrusselsBelgium
- Neurogenetics Research GroupVrije Universiteit BrusselBrusselsBelgium
| | - Konrad Wojdan
- Transition TechnologiesWarsawPoland
- Warsaw University of Technology, Institute of Heat EngineeringWarsawPoland
| | - Kamil Sijko
- Department of Neurology and EpileptologyThe Children's Memorial Health InstituteWarsawPoland
- Transition TechnologiesWarsawPoland
| | - Jagoda Głowacka‐Walas
- Department of Neurology and EpileptologyThe Children's Memorial Health InstituteWarsawPoland
- Warsaw University of Technology, The Faculty of Electronics and Information TechnologyWarsawPoland
| | - Julita Borkowska
- Department of Neurology and EpileptologyThe Children's Memorial Health InstituteWarsawPoland
| | - Krzysztof Sadowski
- Department of Neurology and EpileptologyThe Children's Memorial Health InstituteWarsawPoland
| | - Dorota Domańska‐Pakieła
- Department of Neurology and EpileptologyThe Children's Memorial Health InstituteWarsawPoland
| | - Romina Moavero
- Child Neurology Unit, Neuroscience and Neurorehabilitation DepartmentBambino Gesù Children's Hospital, IRCCSRomeItaly
| | - Christoph Hertzberg
- Department of Child NeurologyCharité University Medicine BerlinBerlinGermany
| | - Hanna Hulshof
- Department of Child Neurology, Brain CenterUniversity Medical Center UtrechtUtrechtThe Netherlands
| | - Theresa Scholl
- Department of PediatricsUniversity Hospital ViennaViennaAustria
| | - Barbora Benova
- Motol University Hospital, Charles UniversityPrague 5Czech Republic
| | - Eleonora Aronica
- Amsterdam UMC, University of Amsterdam, Department of (Neuro)Pathology, Amsterdam NeuroscienceAmsterdamThe Netherlands
| | - Jessie de Ridder
- Department of Development and Regeneration‐Section Pediatric NeurologyUniversity Hospitals KU LeuvenLeuvenBelgium
| | - Lieven Lagae
- Department of Development and Regeneration‐Section Pediatric NeurologyUniversity Hospitals KU LeuvenLeuvenBelgium
| | - Sergiusz Jóźwiak
- Department of Neurology and EpileptologyThe Children's Memorial Health InstituteWarsawPoland
- Department of Child NeurologyMedical University of WarsawWarsawPoland
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18
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Słowińska M, Kotulska K, Szymańska S, Roberds SL, Fladrowski C, Jóźwiak S. Approach to Preventive Epilepsy Treatment in Tuberous Sclerosis Complex and Current Clinical Practice in 23 Countries. Pediatr Neurol 2021; 115:21-27. [PMID: 33310533 DOI: 10.1016/j.pediatrneurol.2020.11.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Revised: 10/01/2020] [Accepted: 11/01/2020] [Indexed: 12/24/2022]
Abstract
UNLABELLED Tuberous sclerosis complex (TSC) is associated with a high risk of early-onset epilepsy and developmental delay. Recently, EEG monitoring in infants with TSC and preventive antiepileptogenic treatment have been proposed to improve epilepsy and neurodevelopmental outcome. We explored how recent studies and recommendations regarding EEG monitoring and preventive epilepsy treatment have influenced the clinical practice of epilepsy management among children with TSC. METHODS A survey on the epilepsy management approach in infants with TSC was sent by e-mail to 165 clinicians who actively participated in TSC international research conferences in years 2016 - 2019. Additionally, the e-mail addresses of TSC referral centers were collected from national TSC organizations. The survey was also distributed in the American Epilepsy Society newsletter. Only responses from centers providing neurological care for children with TSC were included in the study. RESULTS Sixty-one responses from 23 countries were analyzed. Sixty respondents answered questions concerning infants, and 57 of 60 respondents (95%) perform at least one EEG study before epilepsy onset and 42 (70.0%) conduct regular EEG monitoring. Most of the clinicians perform video EEG (42/61, 68.8%). Overall, 51.7% of respondents, mostly from Europe, Australia, and South America, endorse preventive antiepileptic treatment in infants with TSC. Vigabatrin is a preferred drug in patients younger than two years old for both focal (61.7%) and generalized (56.7%) seizures. CONCLUSIONS Despite the lack of published results of randomized trials, the concepts of preseizure EEG monitoring and epilepsy prevention are already being implemented in the majority of surveyed centers.
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Affiliation(s)
- Monika Słowińska
- Department of Pediatric Neurology, Medical University of Warsaw, Warsaw, Poland.
| | - Katarzyna Kotulska
- Department of Neurology and Epileptology, The Children's Memorial Health Institute, Warsaw, Poland
| | - Sylwia Szymańska
- Department of Pediatric Neurology, Medical University of Warsaw, Warsaw, Poland
| | | | | | - Sergiusz Jóźwiak
- Department of Pediatric Neurology, Medical University of Warsaw, Warsaw, Poland
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19
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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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20
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De Ridder J, Lavanga M, Verhelle B, Vervisch J, Lemmens K, Kotulska K, Moavero R, Curatolo P, Weschke B, Riney K, Feucht M, Krsek P, Nabbout R, Jansen AC, Wojdan K, Domanska-Pakieła D, Kaczorowska-Frontczak M, Hertzberg C, Ferrier CH, Samueli S, Benova B, Aronica E, Kwiatkowski DJ, Jansen FE, Jóźwiak S, Van Huffel S, Lagae L. Prediction of Neurodevelopment in Infants With Tuberous Sclerosis Complex Using Early EEG Characteristics. Front Neurol 2020; 11:582891. [PMID: 33178126 PMCID: PMC7596378 DOI: 10.3389/fneur.2020.582891] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Accepted: 08/27/2020] [Indexed: 12/31/2022] Open
Abstract
Tuberous Sclerosis Complex (TSC) is a multisystem genetic disorder with a high risk of early-onset epilepsy and a high prevalence of neurodevelopmental comorbidities, including intellectual disability and autism spectrum disorder (ASD). Therefore, TSC is an interesting disease model to investigate early biomarkers of neurodevelopmental comorbidities when interventions are favourable. We investigated whether early EEG characteristics can be used to predict neurodevelopment in infants with TSC. The first recorded EEG of 64 infants with TSC, enrolled in the international prospective EPISTOP trial (recorded at a median gestational age 42 4/7 weeks) was first visually assessed. EEG characteristics were correlated with ASD risk based on the ADOS-2 score, and cognitive, language, and motor developmental quotients (Bayley Scales of Infant and Toddler Development III) at the age of 24 months. Quantitative EEG analysis was used to validate the relationship between EEG background abnormalities and ASD risk. An abnormal first EEG (OR = 4.1, p-value = 0.027) and more specifically a dysmature EEG background (OR = 4.6, p-value = 0.017) was associated with a higher probability of ASD traits at the age of 24 months. This association between an early abnormal EEG and ASD risk remained significant in a multivariable model, adjusting for mutation and treatment (adjusted OR = 4.2, p-value = 0.029). A dysmature EEG background was also associated with lower cognitive (p-value = 0.029), language (p-value = 0.001), and motor (p-value = 0.017) developmental quotients at the age of 24 months. Our findings suggest that early EEG characteristics in newborns and infants with TSC can be used to predict neurodevelopmental comorbidities.
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Affiliation(s)
- Jessie De Ridder
- Pediatric Neurology, Department of Development and Regeneration, University of Leuven KU Leuven, Leuven, Belgium
| | - Mario Lavanga
- Department of Electrical Engineering (ESAT), STADIUS Centre for Dynamical Systems, Signal Processing and Data Analytics, KU Leuven, Leuven, Belgium
| | - Birgit Verhelle
- Pediatric Neurology, Department of Development and Regeneration, University of Leuven KU Leuven, Leuven, Belgium
| | - Jan Vervisch
- Pediatric Neurology, Department of Development and Regeneration, University of Leuven KU Leuven, Leuven, Belgium
| | - Katrien Lemmens
- Pediatric Neurology, Department of Development and Regeneration, University of Leuven KU Leuven, Leuven, Belgium
| | - Katarzyna Kotulska
- Department of Neurology and Epileptology, The Children's Memorial Health Institute, Warsaw, Poland
| | - Romina Moavero
- Child Neurology and Psychiatry Unit, Systems Medicine Department, Tor Vergata University, Rome, Italy.,Child Neurology Unit, Neuroscience and Neurorehabilitation Department, "Bambino Gesù" Children's Hospital, Rome, Italy
| | - Paolo Curatolo
- Child Neurology and Psychiatry Unit, Systems Medicine Department, Tor Vergata University, Rome, Italy
| | - Bernhard Weschke
- Department of Child Neurology, Charité University Medicine Berlin, Berlin, Germany
| | - Kate Riney
- Neuroscience Unit, Queensland Children's Hospital, Brisbane, QLD, Australia.,University of Queensland School of Clinical Medicine, Brisbane, QLD, Australia
| | - Martha Feucht
- Department of Pediatrics, Medical University Vienna, Vienna, Austria
| | - Pavel Krsek
- Department of Paediatric Neurology, Charles University, Second Faculty of Medicine, Motol University Hospital, Prague, Czechia
| | - Rima Nabbout
- Department of Pediatric Neurology, Reference Centre for Rare Epilepsies, Imagine Institute, Necker- Enfants Malades Hospital, University Paris Descartes, Paris, France
| | - Anna C Jansen
- Pediatric Neurology Unit, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - Konrad Wojdan
- Transition Technologies, Warsaw, Poland.,Institute of Heat Engineering, Warsaw University and Technology, Warsaw, Poland
| | - Dorota Domanska-Pakieła
- Department of Neurology and Epileptology, The Children's Memorial Health Institute, Warsaw, Poland
| | | | - Christoph Hertzberg
- Diagnose und Behandlungszentrum für Kinder und Jugendliche, Vivantes Klinikum Neuköln, Berlin, Germany
| | - Cyrille H Ferrier
- Department of Child Neurology, Brain Centre, University Medical Centre Utrecht, Utrecht, Netherlands
| | - Sharon Samueli
- Department of Pediatrics, Medical University Vienna, Vienna, Austria
| | - Barbora Benova
- Department of Paediatric Neurology, Charles University, Second Faculty of Medicine, Motol University Hospital, Prague, Czechia
| | - Eleonora Aronica
- Department of (Neuro)Pathology, Amsterdam Universitair Medisch Centrum, University of Amsterdam, Amsterdam, Netherlands.,Stichting Epilepsie Instellingen Nederland (SEIN), Heemstede, Netherlands
| | - David J Kwiatkowski
- Harvard Medical School, Brigham and Women's Hospital, Boston, MA, United States
| | - Floor E Jansen
- Department of Child Neurology, Brain Centre, University Medical Centre Utrecht, Utrecht, Netherlands
| | - Sergiusz Jóźwiak
- Department of Neurology and Epileptology, The Children's Memorial Health Institute, Warsaw, Poland.,Department of Child Neurology, Medical University of Warsaw, Warsaw, Poland
| | - Sabine Van Huffel
- Department of Electrical Engineering (ESAT), STADIUS Centre for Dynamical Systems, Signal Processing and Data Analytics, KU Leuven, Leuven, Belgium
| | - Lieven Lagae
- Pediatric Neurology, Department of Development and Regeneration, University of Leuven KU Leuven, Leuven, Belgium
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21
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Morka A, Kohut J, Radzymińska-Chruściel B, Mroczek T, Gładki M, Weryński P, Rudziński A, Skalski J, Szydłowski L. Echocardiography and Newer Imaging Techniques in Diagnosis and Long-Term Follow-Up of Primary Heart Tumors in Children. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17155471. [PMID: 32751243 PMCID: PMC7432637 DOI: 10.3390/ijerph17155471] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/21/2020] [Revised: 07/17/2020] [Accepted: 07/24/2020] [Indexed: 11/24/2022]
Abstract
Background: Primary heart tumors (PHTs) in the pediatric population are very rare and do not manifest any characteristic symptoms. Methods: A retrospective analysis of 61 cases was undertaken. Data from three centers for the years 2003–2018 were gathered. The tumors’ clinical course, location, number, hemodynamic, treatment, and follow-up were evaluated. Echocardiography was complemented with magnetic resonance imaging, computer tomography, and histopathological examination. Results: Out of 61 PHT diagnoses, 56 (91.8%) were circumstantial including all 16 (26.2%) prenatal tumors. The reasons for cardiological consultations were arrhythmia, syncopes, lowered physical performance, and murmurs. Only five patients (8.2%) were suspected of tumors based on previous symptoms of sclerosis tuberosa. Rhabdomyoma was the most frequently found PHT (60.7%). The tumors were predominantly located in the ventricles (49.1%) and intraventricular septum (14.9%) and tended to be single (70.5%). About 37.7% of patients suffered from coexistent multi-organ problems, two (3.28%) from congenital heart defects and one (1.64%) from Carney’s syndrome. Tumor resection was performed on 26 (42.7%) patients, of which 16 (61.5%) underwent total and 10 (38.5%) partial tumor resection. During the follow-up (mean 4.3 years), 54 patients (88.5%) have improved or were stable, while seven (11.5%) died. Conclusions: Primary pediatric heart tumors are diagnosed completely circumstantially, and the most common is rhabdomyoma, although arrhythmia may suggest fibroma. Diagnosis of a heart tumor in children is not synonymous with fatal prognosis, and most of them require only constant observation. Life-saving operation allows improvement, while the prognosis for malignant tumors in children is definitely unfavorable.
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Affiliation(s)
- Aleksandra Morka
- Department of Pediatric Cardiac Surgery, University Children’s Hospital, Faculty of Health Sciences, Jagiellonian University Medical College, 30-663 Kraków, Poland
- Correspondence:
| | - Joanna Kohut
- Department of Pediatric Cardiology, Faculty of Medical Sciences, Medical University of Silesia in Katowice, 40-752 Katowice, Poland; (J.K.); (L.S.)
| | | | - Tomasz Mroczek
- Department of Pediatric Cardiac Surgery, University Children’s Hospital, Faculty of Medicine, Jagiellonian University Medical College, 30-663 Kraków, Poland; (T.M.); (J.S.)
| | - Marcin Gładki
- Department of Pediatric Cardiac Surgery, University Children’s Hospital, 30-663 Kraków, Poland;
| | - Piotr Weryński
- Department of Pediatric Cardiology, University Children’s Hospital, Faculty of Medicine, Jagiellonian University Medical College, 30-663 Kraków, Poland; (P.W.); (A.R.)
| | - Andrzej Rudziński
- Department of Pediatric Cardiology, University Children’s Hospital, Faculty of Medicine, Jagiellonian University Medical College, 30-663 Kraków, Poland; (P.W.); (A.R.)
| | - Janusz Skalski
- Department of Pediatric Cardiac Surgery, University Children’s Hospital, Faculty of Medicine, Jagiellonian University Medical College, 30-663 Kraków, Poland; (T.M.); (J.S.)
| | - Lesław Szydłowski
- Department of Pediatric Cardiology, Faculty of Medical Sciences, Medical University of Silesia in Katowice, 40-752 Katowice, Poland; (J.K.); (L.S.)
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22
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Moavero R, Kotulska K, Lagae L, Benvenuto A, Emberti Gialloreti L, Weschke B, Riney K, Feucht M, Krsek P, Nabbout R, Jansen AC, Wojdan K, Borkowska J, Sadowski K, Hertzberg C, Van Schooneveld MM, Samueli S, Maulisovà A, Aronica E, Kwiatkowski DJ, Jansen FE, Jozwiak S, Curatolo P. Is autism driven by epilepsy in infants with Tuberous Sclerosis Complex? Ann Clin Transl Neurol 2020; 7:1371-1381. [PMID: 32705817 PMCID: PMC7448162 DOI: 10.1002/acn3.51128] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 06/16/2020] [Accepted: 06/17/2020] [Indexed: 01/19/2023] Open
Abstract
Objective To evaluate the relationship between age at seizure onset and neurodevelopmental outcome at age 24 months in infants with TSC, as well as the effect on neurodevelopmental outcome of early versus conventional treatment of epileptic seizures with vigabatrin (80–150 mg/kg/day). Methods Infants with TSC, aged ≤4 months and without previous seizures were enrolled in a prospective study and closely followed with monthly video EEG and serial standardized neurodevelopmental testing (Bayley Scales of Infant Development and Autism Diagnostic Observation Schedule). Results Eighty infants were enrolled. At the age of 24 months testing identified risk of Autism Spectrum Disorder (ASD) in 24/80 children (30.0%), and developmental delay (DD) in 26/80 (32.5%). Children with epilepsy (51/80; 63.8%) had a higher risk of ASD (P = 0.02) and DD (P = 0.001). Overall, no child presented with moderate or severe DD at 24 months (developmental quotient < 55). In 20% of children abnormal developmental trajectories were detected before the onset of seizures. Furthermore, 21% of all children with risk of ASD at 24 months had not developed seizures at that timepoint. There was no significant difference between early and conventional treatment with respect to rate of risk of ASD (P = 0.8) or DD (P = 0.9) at 24 months. Interpretation This study confirms a relationship between epilepsy and risk of ASD/DD. However, in this combined randomized/open label study, early treatment with vigabatrin did not alter the risk of ASD or DD at age 2 years.
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Affiliation(s)
- Romina Moavero
- Child Neurology and Psychiatry Unit, Systems Medicine Department, Tor Vergata University, Via Montpellier 1, Rome, 00133, Italy.,Child Neurology Unit, Neuroscience and Neurorehabilitation Department, "Bambino Gesù" Children's Hospital, IRCCS, P.zza S. Onofrio 4, Rome, 00165, Italy
| | - Katarzyna Kotulska
- Department of Neurology and Epileptology, The Children's Memorial Health Institute, Al. Dzieci Polskich 20, Warsaw, 04-730, Poland
| | - Lieven Lagae
- Department of Development and Regeneration-Section Pediatric Neurology, University Hospitals KU Leuven, Leuven, Belgium
| | - Arianna Benvenuto
- Child Neurology and Psychiatry Unit, Systems Medicine Department, Tor Vergata University, Via Montpellier 1, Rome, 00133, Italy
| | - Leonardo Emberti Gialloreti
- Department of Biomedicine and Prevention, Tor Vergata University of Rome, Via Montpellier 1, Rome, 00133, Italy
| | - Bernhard Weschke
- Department of Child Neurology, Charité University Medicine Berlin, Augustenburger Platz 1, Berlin, 13353, Germany
| | - Kate Riney
- Neuroscience Unit, Queensland Children's Hospital, 501 Stanley Street, South Brisbane, QLD, 4101, Australia.,School of Clinical Medicine, University of Queensland, St Lucia, QLD, 4072, Australia
| | - Martha Feucht
- Department of Pediatrics, Medical University Vienna, Vienna, Austria
| | - Pavel Krsek
- Department of Paediatric Neurology, Charles University, Second Faculty of Medicine and Motol University Hospital, Prague, Czech Republic
| | - Rima Nabbout
- Department of Pediatric Neurology, Reference Centre for Rare Epilepsies, Necker- Enfants Malades Hospital, University Paris Descartes, Imagine Institute, Paris, France
| | - Anna C Jansen
- Pediatric Neurology Unit-UZ Brussel, Brussels, Belgium
| | - Konrad Wojdan
- Warsaw University of Technology, Institute of Heat Engineering, Warsaw, Poland.,Transition Technologies, ul. Pawia 5, Warsaw, 01-030, Poland
| | - Julita Borkowska
- Department of Neurology and Epileptology, The Children's Memorial Health Institute, Al. Dzieci Polskich 20, Warsaw, 04-730, Poland
| | - Krzysztof Sadowski
- Department of Neurology and Epileptology, The Children's Memorial Health Institute, Al. Dzieci Polskich 20, Warsaw, 04-730, Poland
| | - Christoph Hertzberg
- Diagnose und Behandlungszentrum für Kinder und Jugendliche, Vivantes Klinikum Neuköln, Berlin, Germany
| | - Monique M Van Schooneveld
- Department of Child Neurology, Brain Center University Medical Center Utrecht, Utrecht, The Netherlands
| | - Sharon Samueli
- Department of Pediatrics, Medical University Vienna, Vienna, Austria
| | - Alice Maulisovà
- Department of Paediatric Neurology, Charles University, Second Faculty of Medicine and Motol University Hospital, Prague, Czech Republic
| | - Eleonora Aronica
- Department of (Neuro)Pathology, Amsterdam UMC, University of Amsterdam, Amsterdam Neuroscience, Meibergdreef 9, Amsterdam, The Netherlands.,Stichting Epilepsie Instellingen Nederland (SEIN), Heemstede, The Netherlands
| | | | - Floor E Jansen
- Department of Child Neurology, Brain Center University Medical Center Utrecht, Utrecht, The Netherlands
| | - Sergiusz Jozwiak
- Department of Neurology and Epileptology, The Children's Memorial Health Institute, Al. Dzieci Polskich 20, Warsaw, 04-730, Poland.,Department of Child Neurology, Medical University of Warsaw, Warsaw, Poland
| | - Paolo Curatolo
- Child Neurology and Psychiatry Unit, Systems Medicine Department, Tor Vergata University, Via Montpellier 1, Rome, 00133, Italy
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23
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Abstract
Children with infantile spasms are likely to have a poor outcome. Outcome measures for infantile spasms include primary response to treatment, relapse of spasms, neurological development, death, and progression to another type of epilepsy (Consensus Statements of the WEST Delphi Group 2004). This review is based mainly on prospective studies and emphasizes data about the current first-line drugs, adrenocorticotropic hormone, vigabatrin, and prednisolone, taking into account the proportion of patients with known and unknown etiology, which has a very strong effect on seizure outcome. In most studies, hormonal treatment (adrenocorticotropic hormone or prednisolone) is the optimal monotherapy, except for patients with tuberous sclerosis complex, in whom vigabatrin appears superior. Combination therapy (hormones plus vigabatrin) may well be more effective than either agent alone. The underlying etiology is the most important prognostic factor. In studies with a long follow-up (up to 50 years), a favorable cognitive outcome has been observed in approximately one quarter of patients and complete seizure freedom in one-third. Autism is relatively frequent, and premature mortality is high throughout life. Modifiable prognostic factors include early recognition of the spasms with prompt treatment, short duration of hypsarrhythmia, prompt treatment of relapses of spasms and multifocal epileptic discharges, and early treatment of adverse effects. It is hoped that eventually advanced genetics and molecular data will allow an understanding of the pathogenetic mechanisms of many specific etiologies to allow disease-specific treatment such as is emerging for tuberous sclerosis.
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Affiliation(s)
- Raili Riikonen
- Children's Hospital, University of Eastern Finland and Kuopio University Hospital, Kuopio, Finland.
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24
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Savini MN, Mingarelli A, Peron A, La Briola F, Cervi F, Alfano RM, Canevini MP, Vignoli A. Electro-clinical and neurodevelopmental outcome in six children with early diagnosis of tuberous sclerosis complex and role of the genetic background. Ital J Pediatr 2020; 46:36. [PMID: 32216820 PMCID: PMC7099780 DOI: 10.1186/s13052-020-0801-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Accepted: 03/17/2020] [Indexed: 11/10/2022] Open
Abstract
Background Seizures in individuals affected by tuberous sclerosis complex (TSC) commonly develop in the first year of life, are often preceded by a progressive deterioration of the electroencephalogram (EEG), and likely influence developmental outcome. Although early diagnosis of TSC has offered a tremendous opportunity to monitor affected patients before seizure onset, reports of the neurological manifestations of TSC in infants before seizure onset are still scarce. Here we describe early EEG activity, clinical and genetic data and developmental assessment in a group of TSC infants, with the aim of identifying possible prognostic factors for neurodevelopmental outcome. Methods We report on six infants diagnosed with TSC pre- or perinatally, who underwent serial Video-EEG recordings during the first two years of life. EEGs were classified based on distribution and intensity of interictal epileptiform discharges, and Vigabatrin was introduced in case of ictal discharges. Psychomotor development, cognitive functioning and behavioral problems were assessed through standardized scales. Molecular testing included analysis for point mutations and deletions/duplications in TSC1 and TSC2. Results EEG abnormalities appeared at a mean age of 4 months. Four of the six patients developed seizures. EEG abnormalities preceded the onset of clinical seizures in all of them. The two individuals with good seizure control showed normal development, while the other two exhibited psychomotor delays. The patients who did not develop seizures had normal development. A pathogenic variant in the TSC2 gene was detected in all patients but one. The one without a mutation identified did not develop seizures and showed normal neurodevelopment. Of note, the two patients presenting with the worst outcome (that is, poor seizure control and intellectual/behavioral disability) both carried pathogenic variants in the GAP domain of TSC2. Conclusion Our report supports the importance of EEG monitoring before seizure onset in patients with TSC, and the correlation between prompt seizure control and positive neurodevelopmental outcome, regardless of seizure type. Our results also indicate a possible role of the genetic background in influencing the outcome.
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Affiliation(s)
- M N Savini
- Child Neuropsychiatric Unit - Epilepsy Center, San Paolo Hospital, Department of Health Sciences, Università degli Studi di Milano, Via di Rudinì 8, 20142, Milan, Italy
| | - A Mingarelli
- Child Neuropsychiatric Unit - Epilepsy Center, San Paolo Hospital, Milan, Italy
| | - A Peron
- Child Neuropsychiatric Unit - Epilepsy Center, San Paolo Hospital, Department of Health Sciences, Università degli Studi di Milano, Via di Rudinì 8, 20142, Milan, Italy. .,Department of Pediatrics, Division of Medical Genetics, University of Utah School of Medicine, Salt Lake City, UT, USA. .,Human Pathology and Molecular Pathology Unit, San Paolo Hospital, Milan, Italy.
| | - F La Briola
- Child Neuropsychiatric Unit - Epilepsy Center, San Paolo Hospital, Milan, Italy
| | - F Cervi
- Child Neuropsychiatric Unit - Epilepsy Center, San Paolo Hospital, Milan, Italy
| | - R M Alfano
- Human Pathology and Molecular Pathology Unit, San Paolo Hospital, Milan, Italy
| | - M P Canevini
- Child Neuropsychiatric Unit - Epilepsy Center, San Paolo Hospital, Department of Health Sciences, Università degli Studi di Milano, Via di Rudinì 8, 20142, Milan, Italy
| | - A Vignoli
- Child Neuropsychiatric Unit - Epilepsy Center, San Paolo Hospital, Department of Health Sciences, Università degli Studi di Milano, Via di Rudinì 8, 20142, Milan, Italy
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25
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Kim D, Kim HJ, You SJ, Yum MS, Ko TS. Diagnosis of Tuberous Sclerosis Complex and Epilepsy Outcomes in Children with Fetal Cardiac Rhabdomyoma: A Long Term Follow-up Study. ANNALS OF CHILD NEUROLOGY 2019. [DOI: 10.26815/acn.2019.00185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
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26
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Modifying genetic epilepsies - Results from studies on tuberous sclerosis complex. Neuropharmacology 2019; 166:107908. [PMID: 31962286 DOI: 10.1016/j.neuropharm.2019.107908] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2019] [Revised: 12/03/2019] [Accepted: 12/05/2019] [Indexed: 12/12/2022]
Abstract
Tuberous sclerosis complex (TSC) is an autosomal dominant neurocutaneous disorder affecting approximately 1 in 6,000 in general population and represents one of the most common genetic causes of epilepsy. Epilepsy affects 90% of the patients and appears in the first 2 years of life in the majority of them. Early onset of epilepsy in the first year of life is associated with high risk of cognitive decline and neuropsychiatric problems including autism. Recently TSC has been recognized as a model of genetic epilepsies. TSC is a genetic condition with known dysregulated mTOR pathway and is increasingly viewed as a model for human epileptogenesis. Moreover, TSC is characterized by a hyperactivation of mTOR (mammalian target of rapamycin) pathway, and mTOR activation was showed to be implicated in epileptogenesis in many animal models and human epilepsies. Recently published studies documented positive effect of preventive or disease modifying treatment of epilepsy in infants with high risk of epilepsy with significantly lower incidence of epilepsy and better cognitive outcome. Further studies on preventive treatment of epilepsy in other genetic epilepsies of early childhood are considered. This article is part of the special issue entitled 'New Epilepsy Therapies for the 21st Century - From Antiseizure Drugs to Prevention, Modification and Cure of Epilepsy'.
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27
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Jozwiak S, Słowińska M, Borkowska J, Sadowski K, Łojszczyk B, Domańska-Pakieła D, Chmielewski D, Kaczorowska-Frontczak M, Głowacka J, Sijko K, Kotulska K. Preventive Antiepileptic Treatment in Tuberous Sclerosis Complex: A Long-Term, Prospective Trial. Pediatr Neurol 2019; 101:18-25. [PMID: 31481332 DOI: 10.1016/j.pediatrneurol.2019.07.008] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Revised: 07/15/2019] [Accepted: 07/16/2019] [Indexed: 01/02/2023]
Abstract
BACKGROUD Drug-resistant epilepsy is the main risk factor for future intellectual disability in patients with tuberous sclerosis complex. Clinical epileptic seizures are often preceded by electroencephalographic changes, which provide an opportunity for preventive treatment. We evaluated the neuropsychologic and epilepsy outcomes at school age in children with tuberous sclerosis complex who received preventive antiepileptic treatment in infancy. METHODS We performed a prospective, nonrandomized clinical trial with 14 infants diagnosed with tuberous sclerosis complex in whom serial electroencephalographic recordings were performed and preventive treatment with vigabatrin initiated when active epileptic discharges were detected. An age-matched control group consisted of 31 infants with tuberous sclerosis complex in whom treatment with vigabatrin was given only after onset of clinical seizures. Results of clinical assessment of epilepsy and cognitive outcomes were analyzed. RESULTS All patients in the preventive group (n = 14) and 25 of 31 patients in the standard treatment group were followed through minimum age five years, median 8.8 and 8.0 years in the preventive and standard groups, respectively. The median intelligence quotient was 94 for the preventive group when compared with 46 for the standard group (P < 0.03). Seven of 14 patients (50%) in the preventive group never had a clinical seizure when compared with one of 25 patients (5%) in the standard treatment group (P = 0.001). CONCLUSIONS This study provides evidence that preventive antiepileptic treatment in infants with tuberous sclerosis complex improves long-term epilepsy control and cognitive outcome at school age.
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Affiliation(s)
- Sergiusz Jozwiak
- Department of Child Neurology, Warsaw Medical University, Warsaw, Poland; Department of Neurology and Epileptology, The Children's Memorial Health Institute, Warsaw, Poland.
| | - Monika Słowińska
- Department of Child Neurology, Warsaw Medical University, Warsaw, Poland
| | - Julita Borkowska
- Department of Neurology and Epileptology, The Children's Memorial Health Institute, Warsaw, Poland
| | - Krzysztof Sadowski
- Department of Neurology and Epileptology, The Children's Memorial Health Institute, Warsaw, Poland
| | - Barbara Łojszczyk
- Department of Neurology and Epileptology, The Children's Memorial Health Institute, Warsaw, Poland
| | - Dorota Domańska-Pakieła
- Department of Neurology and Epileptology, The Children's Memorial Health Institute, Warsaw, Poland
| | - Dariusz Chmielewski
- Department of Neurology and Epileptology, The Children's Memorial Health Institute, Warsaw, Poland
| | | | - Jagoda Głowacka
- Department of Neurology and Epileptology, The Children's Memorial Health Institute, Warsaw, Poland; Transition Technologies, Warsaw, Poland
| | - Kamil Sijko
- Department of Neurology and Epileptology, The Children's Memorial Health Institute, Warsaw, Poland; Transition Technologies, Warsaw, Poland
| | - Katarzyna Kotulska
- Department of Neurology and Epileptology, The Children's Memorial Health Institute, Warsaw, Poland
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28
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Słowińska M, Jóźwiak S. Emerging treatments and therapeutic targets for tuberous sclerosis complex in children. Expert Opin Orphan Drugs 2019. [DOI: 10.1080/21678707.2019.1662295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- Monika Słowińska
- Department of Pediatric Neurology, Medical University of Warsaw, Warsaw, Poland
| | - Sergiusz Jóźwiak
- Department of Pediatric Neurology, Medical University of Warsaw, Warsaw, Poland
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29
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Abt M, Dinklo T, Rothfuss A, Husar E, Dannecker R, Kallivroussis K, Peck R, Doessegger L, Wandel C. A Framework Proposal to Follow-Up on Preclinical Convulsive Signals of a New Molecular Entity in First-in-Human Studies Using Electroencephalographic Monitoring. Clin Pharmacol Ther 2019; 106:968-980. [PMID: 30993670 PMCID: PMC6851537 DOI: 10.1002/cpt.1455] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Accepted: 03/18/2019] [Indexed: 01/11/2023]
Abstract
Traditionally, in dose-escalating first-in-human (FiH) studies, a dose cap with a 10-fold safety margin to the no observed effect level in animals is implemented if convulsive events are observed in animals. However, the convulsive risk seen in animals does not generally translate to humans. Several lines of evidence are summarized indicating that in a dose-escalating setting, electroencephalographic epileptiform abnormalities occur at lower doses than clinical convulsive events. Therefore, we propose to consider the occurrence of epileptiform abnormalities in toxicology studies as premonitory signals for convulsions in dose-escalating FiH studies. Compared with the traditional dose-cap approach, this may allow the exploration of higher doses in FiH and, subsequently, phase II studies without compromising human safety. Similarly, the presence or absence of electroencephalographic epileptiform abnormalities may also aid the assessment of proconvulsive risk in situations of increased perpetrator burden as potentially present in pharmacokinetic and/or pharmacodynamic drug-drug interactions.
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Affiliation(s)
- Markus Abt
- Department of Biometrics, F. Hoffmann-La Roche AG, Basel, Switzerland
| | - Theo Dinklo
- Roche Pharma Research and Early Development, Roche Innovation Center Basel, F. Hoffmann-La Roche AG, Basel, Switzerland
| | - Andreas Rothfuss
- Roche Pharma Research and Early Development, Roche Innovation Center Basel, F. Hoffmann-La Roche AG, Basel, Switzerland
| | - Elisabeth Husar
- Roche Pharma Research and Early Development, Roche Innovation Center Basel, F. Hoffmann-La Roche AG, Basel, Switzerland
| | | | | | - Richard Peck
- Roche Pharma Research and Early Development, Roche Innovation Center Basel, F. Hoffmann-La Roche AG, Basel, Switzerland
| | | | - Christoph Wandel
- Department of Safety & Risk Management, F. Hoffmann-La Roche AG, Basel, Switzerland
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李 青. Neurofibromatosis Type I with Infantile Spasm as Initial Symptom: A Case Report and Literature Review. ACTA ACUST UNITED AC 2019. [DOI: 10.12677/acrp.2019.73004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
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Canevini MP, Kotulska-Jozwiak K, Curatolo P, La Briola F, Peron A, Słowińska M, Strzelecka J, Vignoli A, Jóźwiak S. Current concepts on epilepsy management in tuberous sclerosis complex. AMERICAN JOURNAL OF MEDICAL GENETICS PART C-SEMINARS IN MEDICAL GENETICS 2018; 178:299-308. [PMID: 30255982 DOI: 10.1002/ajmg.c.31652] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/08/2018] [Revised: 08/21/2018] [Accepted: 08/23/2018] [Indexed: 12/12/2022]
Abstract
Tuberous sclerosis complex (TSC) is an autosomal dominant neurocutaneous disease affecting approximately 1 in 6,000 people, and represents one of the most common genetic causes of epilepsy. Epilepsy affects 90% of the patients and appears in the first 2 years of life in the majority of them. Early onset of epilepsy in the first 12 months of life is associated with high risk of cognitive decline and neuropsychiatric problems including autism. Prenatal or early infantile diagnosis of TSC, before the onset of epilepsy, provides a unique opportunity to monitor EEG before the onset of clinical seizures, thus enabling early intervention in the process of epileptogenesis. In this review, we discuss the current status of knowledge on epileptogenesis in TSC, and present recommendations of American and European experts in the field of epilepsy.
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Affiliation(s)
- Maria Paola Canevini
- Child Neuropsychiatry Unit - Epilepsy Center, San Paolo Hospital, Department of Health Sciences, Università degli Studi di Milano, Milan, Italy
| | | | - Paolo Curatolo
- Department of Pediatric Neuropsychiatry, Tor Vergata University, Rome, Italy
| | - Francesca La Briola
- Child Neuropsychiatry Unit - Epilepsy Center, San Paolo Hospital, Department of Health Sciences, Università degli Studi di Milano, Milan, Italy
| | - Angela Peron
- Child Neuropsychiatry Unit - Epilepsy Center, San Paolo Hospital, Department of Health Sciences, Università degli Studi di Milano, Milan, Italy.,Division of Medical Genetics, Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Monika Słowińska
- Department of Neurology and Epileptology, The Children's Memorial Health Institute, Warsaw, Poland.,Department of Pediatric Neurology, Warsaw Medical University, Warsaw, Poland
| | - Jolanta Strzelecka
- Department of Pediatric Neurology, Warsaw Medical University, Warsaw, Poland
| | - Aglaia Vignoli
- Child Neuropsychiatry Unit - Epilepsy Center, San Paolo Hospital, Department of Health Sciences, Università degli Studi di Milano, Milan, Italy
| | - Sergiusz Jóźwiak
- Department of Neurology and Epileptology, The Children's Memorial Health Institute, Warsaw, Poland.,Department of Pediatric Neurology, Warsaw Medical University, Warsaw, Poland
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Management of epilepsy associated with tuberous sclerosis complex: Updated clinical recommendations. Eur J Paediatr Neurol 2018; 22:738-748. [PMID: 29880258 DOI: 10.1016/j.ejpn.2018.05.006] [Citation(s) in RCA: 120] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2017] [Revised: 04/12/2018] [Accepted: 05/20/2018] [Indexed: 11/23/2022]
Abstract
Patients with tuberous sclerosis complex (TSC) are at very high risk for developing epilepsy, and the majority experience seizure onset during the first year of life. Early targeted interventions increase the probability of seizure-freedom and may protect neurodevelopment. In 2012, clinical recommendations for the management of epilepsy in patients with TSC were published by a panel of European experts. Since that time novel studies, reports, and expert opinions in preclinical and clinical TSC-related sciences prompted the need for updated recommendations, including epileptogenesis in TSC, the potential role of predictive biomarkers, the possible benefits of presymptomatic diagnosis and preventive treatment, and new treatment options including mTOR inhibitors. A reconvened panel reviewed the current literature to answer specific questions and five panelists discussed the findings, followed by a general discussion during which all issues were debated to achieve consensus regarding recommendations. A draft manuscript based on these discussions and recommendations was then circulated several times among the panelists, who added their own comments. All the panelists/authors agreed with the final manuscript, which was then submitted for publication. The panel concluded that the need for early diagnosis of TSC-associated seizures is now established, electroencephalographic monitoring has good predictive value for epilepsy before seizure onset in TSC, and, until conclusive data from the EPISTOP trial are available, administration of vigabatrin may be considered in children with subclinical epileptiform EEG discharges. The panel also supported the role of adjunctive everolimus for TSC-associated drug-refractory seizures and emphasized the necessity of early surgical evaluation.
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Benova B, Petrak B, Kyncl M, Jezdik P, Maulisova A, Jahodova A, Komarek V, Krsek P. Early predictors of clinical and mental outcome in tuberous sclerosis complex: A prospective study. Eur J Paediatr Neurol 2018; 22:632-641. [PMID: 29636221 DOI: 10.1016/j.ejpn.2018.03.001] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Revised: 02/15/2018] [Accepted: 03/07/2018] [Indexed: 02/06/2023]
Abstract
AIM We aimed to identify early predictors of intractable epilepsy, intellectual disability (ID) and autism spectrum disorders (ASD) in the cohort of TSC patients initially diagnosed with cardiac rhabdomyomas (CR). METHOD Over the period of twelve years we prospectively obtained clinical, neuropsychological, electrophysiological and neuroimaging data in a group of 22 TSC patients (9 females, 13 males) with the pre/perinatal diagnosis of CR, included to the study at the time of diagnosis. Afterwards, we statistically determined variables associated with ID, ASD and intractable epilepsy. RESULTS Development of ID was predicted by severe epilepsy (a higher number of anti-epileptic drugs used), a higher number of dysplastic lesions on MRI, and abnormal background activity on EEG (p < 0.05). Predictors of ASD included early developmental delay, abnormal background activity on EEG at the end of follow-up and a higher number of areas with dysplastic features on MRI (p < 0.05). Intractable epilepsy was associated with a higher number of areas with dysplastic features on MRI, ID and with TSC2 genotype. CONCLUSION Adverse mental and clinical outcome was associated with intractable epilepsy and the severe anatomical brain involvement; therefore, our centre developed a tailored protocol for early identification of TSC patients at a higher risk of developing intractable epilepsy with its deleterious effect on cognitive outcome.
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Affiliation(s)
- Barbora Benova
- Department of Paediatric Neurology, 2nd Faculty of Medicine, Charles University and Motol University Hospital, V Úvalu 84, Praha 5, 150 06, Czech Republic; 2nd Faculty of Medicine, Charles University, V Úvalu 84, Praha 5, 150 06, Czech Republic
| | - Borivoj Petrak
- Department of Paediatric Neurology, 2nd Faculty of Medicine, Charles University and Motol University Hospital, V Úvalu 84, Praha 5, 150 06, Czech Republic
| | - Martin Kyncl
- 2nd Faculty of Medicine, Charles University, V Úvalu 84, Praha 5, 150 06, Czech Republic; Department of Radiology, 2nd Faculty of Medicine, Charles University and Motol University Hospital, V Úvalu 84, Praha 5, 150 06, Czech Republic
| | - Petr Jezdik
- Department of Paediatric Neurology, 2nd Faculty of Medicine, Charles University and Motol University Hospital, V Úvalu 84, Praha 5, 150 06, Czech Republic; Department of Measurement, Czech Technical University in Prague, Faculty of Electrical Engineering, Technická 2, Praha 6, 166 27, Czech Republic
| | - Alice Maulisova
- Department of Clinical Psychology, Motol University Hospital, V Úvalu 84, Praha 5, 150 06, Czech Republic; Charles University, Faculty of Arts, Department of Psychology, Prague, Nám. Jana Palacha 1/2, Praha 1-Staré Město, 116 38, Czech Republic
| | - Alena Jahodova
- Department of Paediatric Neurology, 2nd Faculty of Medicine, Charles University and Motol University Hospital, V Úvalu 84, Praha 5, 150 06, Czech Republic; 2nd Faculty of Medicine, Charles University, V Úvalu 84, Praha 5, 150 06, Czech Republic
| | - Vladimir Komarek
- Department of Paediatric Neurology, 2nd Faculty of Medicine, Charles University and Motol University Hospital, V Úvalu 84, Praha 5, 150 06, Czech Republic; 2nd Faculty of Medicine, Charles University, V Úvalu 84, Praha 5, 150 06, Czech Republic
| | - Pavel Krsek
- Department of Paediatric Neurology, 2nd Faculty of Medicine, Charles University and Motol University Hospital, V Úvalu 84, Praha 5, 150 06, Czech Republic; 2nd Faculty of Medicine, Charles University, V Úvalu 84, Praha 5, 150 06, Czech Republic.
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Bar C, Kaminska A, Nabbout R. Spikes might precede seizures and predict epilepsy in children with Sturge-Weber syndrome: A pilot study. Epilepsy Res 2018; 143:75-78. [PMID: 29674168 DOI: 10.1016/j.eplepsyres.2018.03.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Revised: 03/20/2018] [Accepted: 03/27/2018] [Indexed: 11/16/2022]
Abstract
PURPOSE Sturge-Weber syndrome (SWS) is a neurocutaneous disorder characterized by a facial port-wine stain, a glaucoma, and a leptomeningeal angioma. Epilepsy occurs in more than 75% of affected children, and seizures occurring in the first year of life are associated with a poor neurological prognosis. The aim of this study was to identify possible predictive markers of epilepsy on electroencephalogram (EEG) performed prior to seizure onset in children with SWS. METHODS This study included children with a diagnosis of SWS who had an EEG performed prior to seizure onset. Patients who did not develop epilepsy had a minimum follow-up of 3-years. We compared EEG characteristics of patients who developed epilepsy with patients who did not develop epilepsy by the time of their follow-up. RESULTS Eleven children were included in this study. EEG was performed at the median age of 2.1 months (range 1.0-22.1). Six children developed seizures with a time interval between EEG and seizure onset ranging from 2 days to 21 months. EEG background activity was asymmetric in 8 patients, 5 of whom later developed epilepsy. Focal interictal spikes or sharp waves were exclusively recorded in patients who developed later epilepsy (4 out of 6). One of these patients had a supposed false positive EEG as he did not developed epilepsy until 21 months later and one patient had a false negative EEG with seizures occurring 2 days after a normal EEG. CONCLUSION Spikes on EEG might be a useful marker to identify patients with SWS at risk of developing epilepsy. Their predictive value should be assessed in larger prospective studies.
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Affiliation(s)
- Claire Bar
- Reference Centre for Rare Epilepsies, Department of Pediatric Neurology, Hôpital Necker-Enfants Malades, APHP, Paris, France
| | - Anna Kaminska
- Reference centre for rare epilepsies, Department of Clinical Neurophysiology, Hôpital Necker-Enfants Malades, AP-HP, Paris, France; INSERM U1129, Paris, France; Paris Descartes University, Sorbonne Paris Cité, CEA, Gif sur Yvette, France
| | - Rima Nabbout
- Reference Centre for Rare Epilepsies, Department of Pediatric Neurology, Hôpital Necker-Enfants Malades, APHP, Paris, France; INSERM U1129, Paris, France; Paris Descartes University, Sorbonne Paris Cité, CEA, Gif sur Yvette, France.
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Słowińska M, Jóźwiak S, Peron A, Borkowska J, Chmielewski D, Sadowski K, Jurkiewicz E, Vignoli A, La Briola F, Canevini MP, Kotulska-Jóźwiak K. Early diagnosis of tuberous sclerosis complex: a race against time. How to make the diagnosis before seizures? Orphanet J Rare Dis 2018; 13:25. [PMID: 29378663 PMCID: PMC5789613 DOI: 10.1186/s13023-018-0764-z] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2017] [Accepted: 01/10/2018] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Tuberous sclerosis complex (TSC) is a genetic disorder with an incidence of 1:6000 live births and associated with the development of benign tumors in several organs. It is also characterized by high rates of neurological and neuropsychiatric abnormalities, including epilepsy affecting 70-90% of patients and being one of the major risk factors of intellectual disability. The first seizures in TSC patients appear usually between the 4th and the 6th months of life. Recent studies have shown the beneficial role of preventative antiepileptic treatment in TSC patients, with the possibility for improvement of cognitive outcome. Moreover, European recommendations suggest early introduction of Vigabatrin if ictal discharges occur on EEG recordings, with or without clinical manifestation. The aim of this study was to define the most useful approach to make the diagnosis of TSC before seizure onset (before age 4th months), in order to start early EEG monitoring with possible preventative treatment intervention. METHODS We performed a retrospective review of children who were suspected of having TSC due to single or multiple cardiac tumors as the first sign of the disease. We analyzed the medical records in terms of conducted clinical tests and TSC signs, which were observed until the end of the 4th month of age. Subsequently, we described the different clinical scenarios and recommendations for early diagnosis. RESULTS 82/100 children were diagnosed with TSC within the first 4 months of life. Apart from cardiac tumors, the most frequently observed early TSC signs were subependymal nodules (71/100, 71%), cortical dysplasia (66/100, 66%), and hypomelanotic macules (35/100, 35%). The most useful clinical studies for early TSC diagnosis were brain magnetic resonance imaging (MRI), skin examination and echocardiography. Genetic testing was performed in 49/100 of the patients, but the results were obtained within the first 4 months of life in only 3 children. CONCLUSIONS Early diagnosis of TSC, before seizure onset, is feasible and it is becoming pivotal for epilepsy management and improvement of cognitive outcome. Early TSC diagnosis is mostly based on clinical signs. Brain MRI, echocardiography, skin examination and genetic testing should be performed early in every patient suspected of having TSC.
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Affiliation(s)
- Monika Słowińska
- Department of Neurology and Epileptology, The Children’s Memorial Health Institute, Al. Dzieci Polskich 20, 04-730 Warszawa, Poland
- Department of Child Neurology, Medical University of Warsaw, Ul. Żwirki I Wigury 63A, 02-091 Warszawa, Poland
| | - Sergiusz Jóźwiak
- Department of Neurology and Epileptology, The Children’s Memorial Health Institute, Al. Dzieci Polskich 20, 04-730 Warszawa, Poland
- Department of Child Neurology, Medical University of Warsaw, Ul. Żwirki I Wigury 63A, 02-091 Warszawa, Poland
| | - Angela Peron
- Child Neuropsychiatry Unit - Epilepsy Center, San Paolo Hospital, Via Antonio di Rudinì, 8, 20142 Milan, Italy
- Department of Health Sciences, Università degli Studi di Milano, Via Antonio di Rudinì, 8, 20142 Milan, Italy
- Department of Pediatrics, Division of Medical Genetics, University of Utah School of Medicine, Salt Lake City, UT USA
| | - Julita Borkowska
- Department of Neurology and Epileptology, The Children’s Memorial Health Institute, Al. Dzieci Polskich 20, 04-730 Warszawa, Poland
| | - Dariusz Chmielewski
- Department of Neurology and Epileptology, The Children’s Memorial Health Institute, Al. Dzieci Polskich 20, 04-730 Warszawa, Poland
| | - Krzysztof Sadowski
- Department of Neurology and Epileptology, The Children’s Memorial Health Institute, Al. Dzieci Polskich 20, 04-730 Warszawa, Poland
| | - Elżbieta Jurkiewicz
- Department of Radiology, The Children’s Memorial Health Institute, Al. Dzieci Polskich 20, 04-730 Warszawa, Poland
| | - Aglaia Vignoli
- Child Neuropsychiatry Unit - Epilepsy Center, San Paolo Hospital, Via Antonio di Rudinì, 8, 20142 Milan, Italy
- Department of Health Sciences, Università degli Studi di Milano, Via Antonio di Rudinì, 8, 20142 Milan, Italy
| | - Francesca La Briola
- Child Neuropsychiatry Unit - Epilepsy Center, San Paolo Hospital, Via Antonio di Rudinì, 8, 20142 Milan, Italy
| | - Maria Paola Canevini
- Child Neuropsychiatry Unit - Epilepsy Center, San Paolo Hospital, Via Antonio di Rudinì, 8, 20142 Milan, Italy
- Department of Health Sciences, Università degli Studi di Milano, Via Antonio di Rudinì, 8, 20142 Milan, Italy
| | - Katarzyna Kotulska-Jóźwiak
- Department of Neurology and Epileptology, The Children’s Memorial Health Institute, Al. Dzieci Polskich 20, 04-730 Warszawa, Poland
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Chung CWT, Lawson JA, Sarkozy V, Riney K, Wargon O, Shand AW, Cooper S, King H, Kennedy SE, Mowat D. Early Detection of Tuberous Sclerosis Complex: An Opportunity for Improved Neurodevelopmental Outcome. Pediatr Neurol 2017; 76:20-26. [PMID: 28811058 DOI: 10.1016/j.pediatrneurol.2017.05.014] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Revised: 05/16/2017] [Accepted: 05/17/2017] [Indexed: 11/15/2022]
Abstract
BACKGROUND Tuberous sclerosis complex (TSC) is an autosomal dominant condition associated with epilepsy, benign tumors, and variable neurodevelopmental outcomes. The diagnosis is most commonly made after epilepsy onset, although a proportion are diagnosed prenatally. Presymptomatic or early treatment with agents such as vigabatrin offers the hope of improved neurodevelopmental outcome. Therefore early diagnosis, before the onset of seizures, is important. In a cohort of children with TSC, we evaluated the age and mode of initial presentation, assessed the neurocognitive and epilepsy outcome, and analyzed whether those diagnosed before the onset of seizures have a different outcome compared with those diagnosed postseizures. METHODS We reviewed patients at the TSC clinic at Sydney Children's Hospital who were born between 2001 and 2015. RESULTS A total of 74 patients were identified: 34 (46%) diagnosed preseizure (21 prenatally) and 40 (54%) postseizure. In the preseizure cohort, 77% presented with cardiac rhabdomyoma(s) and 72% developed seizures. The postseizure cohort had more severe epilepsy, requiring more antiepileptic drugs for seizure control (median five, compared with three in the preseizure cohort [P = 0.01]). Developmental disability occurred in 65% of the preseizure cohort compared with 72% of the postseizure cohort. Severe developmental disability most often occurred in children who had their first seizure before age 12 months. CONCLUSION Children who are diagnosed with TSC before the onset of seizures have less severe epilepsy and better developmental outcome.
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Affiliation(s)
- Clara W T Chung
- Department of Medical Genetics, Sydney Children's Hospital, Randwick, NSW, Australia
| | - John A Lawson
- Department of Neurology, Sydney Children's Hospital, Randwick, NSW, Australia; School of Women's and Children's Health, UNSW Medicine, The University of New South Wales, Kensington, NSW, Australia
| | - Vanessa Sarkozy
- School of Women's and Children's Health, UNSW Medicine, The University of New South Wales, Kensington, NSW, Australia; Child Development Services (Tumbatin), Sydney Children's Hospital, Randwick, NSW, Australia
| | - Kate Riney
- Department of Neurology, Lady Cilento Children's Hospital, South Brisbane, QLD, Australia
| | - Orli Wargon
- Department of Dermatology, Sydney Children's Hospital, Randwick, NSW, Australia
| | - Antonia W Shand
- School of Women's and Children's Health, UNSW Medicine, The University of New South Wales, Kensington, NSW, Australia; Maternal Fetal Medicine Unit, The Royal Hospital for Women, Randwick, NSW, Australia; Menzies Centre for Health Policy, School of Public Health, University of Sydney, Sydney, NSW, Australia
| | - Stephen Cooper
- Department of Cardiology, Sydney Children's Hospital, Randwick, NSW, Australia
| | - Harrison King
- Department of Medical Genetics, Sydney Children's Hospital, Randwick, NSW, Australia
| | - Sean E Kennedy
- School of Women's and Children's Health, UNSW Medicine, The University of New South Wales, Kensington, NSW, Australia; Department of Nephrology, Sydney Children's Hospital, Randwick, NSW, Australia
| | - David Mowat
- Department of Medical Genetics, Sydney Children's Hospital, Randwick, NSW, Australia; School of Women's and Children's Health, UNSW Medicine, The University of New South Wales, Kensington, NSW, Australia.
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Whitney R, Jan S, Zak M, McCoy B. The Utility of Surveillance Electroencephalography to Guide Early Antiepileptic Drug Therapy in Infants With Tuberous Sclerosis Complex. Pediatr Neurol 2017; 72:76-80. [PMID: 28506505 DOI: 10.1016/j.pediatrneurol.2017.04.009] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Revised: 04/07/2017] [Accepted: 04/08/2017] [Indexed: 12/21/2022]
Abstract
BACKGROUND Seizures are a common early presentation in infants with tuberous sclerosis complex (TSC) and can be preceded by electrographic changes on electroencephalography (EEG) before clinical seizure onset. A limited number of studies have addressed the initial EEG findings in TSC and the outcome of early treatment with antiepileptic medication prior to clinical seizure onset. METHODS We describe two infants with tuberous sclerosis complex whose surveillance EEG showed focal seizures that were not previously recognized by caregivers. We review previously reported patients with TSC with early EEG findings. Our patients were started on vigabatrin after the onset of focal seizures with the aim of preventing seizure recurrence, halting the possible progression to infantile spasms or focal seizures, and preventing neurodevelopmental decline. RESULTS Both patients remain seizure free and have reached appropriate developmental milestones. CONCLUSIONS We recommend early serial EEG monitoring once a diagnosis of TSC is suspected or confirmed in infants. Additional prospective studies are needed to assess the long-term outcome of early antiepileptic drug initiation as soon as electrographic seizure activity is detected.
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Affiliation(s)
- Robyn Whitney
- Division of Pediatric Neurology, Department of Pediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Saber Jan
- Division of Pediatric Neurology, Department of Pediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada; Department of Pediatrics, Taibah University, Medina, Saudi Arabia
| | - Maria Zak
- Division of Pediatric Neurology, Department of Pediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Bláthnaid McCoy
- Division of Pediatric Neurology, Department of Pediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada; Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada.
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Abstract
Epileptic encephalopathies represent a particularly severe form of epilepsy, associated with cognitive and behavioral deficits, including impaired social-communication and restricted, repetitive behaviors that are the hallmarks of autism spectrum disorder (ASD). With the advent of next-generation sequencing, the genetic landscape of epileptic encephalopathies is growing and demonstrates overlap with genes separately implicated in ASD. However, many questions remain about this connection, including whether epileptiform activity itself contributes to the development of ASD symptomatology. In this review, we compiled a database of genes associated with both epileptic encephalopathy and ASD, limiting our purview to Mendelian disorders not including inborn errors of metabolism, and we focused on the connection between ASD and epileptic encephalopathy rather than epilepsy broadly. Our review has four goals: to (1) discuss the overlapping presentations of ASD and monogenic epileptic encephalopathies; (2) examine the impact of the epilepsy itself on neurocognitive features, including ASD, in monogenic epileptic encephalopathies; (3) outline many of the genetic causes responsible for both ASD and epileptic encephalopathy; (4) provide an illustrative example of a final common pathway that may be implicated in both ASD and epileptic encephalopathy. We demonstrate that autistic features are a common association with monogenic epileptic encephalopathies. Certain epileptic encephalopathy syndromes, like infantile spasms, are especially linked to the development of ASD. The connection between seizures themselves and neurobehavioral deficits in these monogenic encephalopathies remains open to debate. Finally, advances in genetics have revealed many genes that overlap in ties to both ASD and epileptic encephalopathy and that play a role in diverse central nervous system processes. Increased attention to the autistic features of monogenic epileptic encephalopathies is warranted for both researchers and clinicians alike.
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Affiliation(s)
- Siddharth Srivastava
- Department of Neurology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115 USA
| | - Mustafa Sahin
- Department of Neurology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115 USA
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Jozwiak S, Becker A, Cepeda C, Engel J, Gnatkovsky V, Huberfeld G, Kaya M, Kobow K, Simonato M, Loeb JA. WONOEP appraisal: Development of epilepsy biomarkers-What we can learn from our patients? Epilepsia 2017; 58:951-961. [PMID: 28387933 PMCID: PMC5806696 DOI: 10.1111/epi.13728] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/20/2017] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Current medications for patients with epilepsy work in only two of three patients. For those medications that do work, they only suppress seizures. They treat the symptoms, but do not modify the underlying disease, forcing patients to take these drugs with significant side effects, often for the rest of their lives. A major limitation in our ability to advance new therapeutics that permanently prevent, reduce the frequency of, or cure epilepsy comes from a lack of understanding of the disease coupled with a lack of reliable biomarkers that can predict who has or who will get epilepsy. METHODS The main goal of this report is to present a number of approaches for identifying reliable biomarkers from observing patients with brain disorders that have a high probability of producing epilepsy. RESULTS A given biomarker, or more likely a profile of biomarkers, will have both a quantity and a time course during epileptogenesis that can be used to predict who will get the disease, to confirm epilepsy as a diagnosis, to identify coexisting pathologies, and to monitor the course of treatments. SIGNIFICANCE Additional studies in patients and animal models could identify common and clinically valuable biomarkers to successfully translate animal studies into new and effective clinical trials.
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Affiliation(s)
- Sergiusz Jozwiak
- Department of Child Neurology, Medical University of Warsaw, Poland
- Department of Child Neurology, The Children’s Memorial Health Institute, Warsaw, Poland
| | - Albert Becker
- Section for Translational Epilepsy Research, Department of Neuropathology, University of Bonn Medical Center, Bonn, Germany
| | - Carlos Cepeda
- IDDRC, Semel Institute for Neuroscience & Human Behavior, University of California Los Angeles, Los Angeles, CA, USA
| | - Jerome Engel
- Departments of Neurology, Neurobiology, and Psychiatry & Biobehavioral Sciences and the Brain Research Institute, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Vadym Gnatkovsky
- Unit of Epilepsy and Experimental Neurophysiology, Fondazione Istituto Neurologico Carlo Besta, Milan, Italy
| | - Gilles Huberfeld
- Sorbonne and UPMC University, AP-HP, Department of Neurophysiology, UPMC and La Pitié-Salpêtrière Hospital, Paris, France
- INSERM U1129, Paris Descartes University, PRES Sorbonne Paris, Cité, Paris, CEA, France
| | - Mehmet Kaya
- Department of Physiology, Koc University School of Medicine, Rumelifeneri Yolu, Sariver, Istanbul, Turkey
| | - Katja Kobow
- Department of Neuropathology, University Hospital Erlangen, Erlangen, Germany
| | - Michele Simonato
- Department of Medical Sciences, University of Ferrara and Division of Neuroscience, University Vita-Salute San Raffaele, Milan, Italy
| | - Jeffrey A. Loeb
- Department of Neurology and Rehabilitation, The University of Illinois at Chicago, Chicago, IL
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Curatolo P, Bjørnvold M, Dill PE, Ferreira JC, Feucht M, Hertzberg C, Jansen A, Jóźwiak S, Kingswood JC, Kotulska K, Macaya A, Moavero R, Nabbout R, Zonnenberg BA. The Role of mTOR Inhibitors in the Treatment of Patients with Tuberous Sclerosis Complex: Evidence-based and Expert Opinions. Drugs 2016; 76:551-65. [PMID: 26927950 DOI: 10.1007/s40265-016-0552-9] [Citation(s) in RCA: 58] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Tuberous sclerosis complex (TSC) is a genetic disorder arising from mutations in the TSC1 or TSC2 genes. The resulting over-activation of the mammalian target of rapamycin (mTOR) signalling pathway leaves patients with TSC susceptible to the growth of non-malignant tumours in multiple organs. Previously, surgery was the main therapeutic option for TSC. However, pharmacological therapy with mTOR inhibitors such as everolimus and sirolimus is now emerging as an alternate approach. Everolimus and sirolimus have already been shown to be effective in treating subependymal giant cell astrocytoma (SEGA) and renal angiomyolipoma (AML), and everolimus is currently being evaluated in treating TSC-related epilepsy. In November 2013 a group of European experts convened to discuss the current options and practical considerations for treating various manifestations of TSC. This article provides evidence-based recommendations for the treatment of SEGA, TSC-related epilepsy and renal AML, with a focus on where mTOR inhibitor therapy may be considered alongside other treatment options. Safety considerations regarding mTOR inhibitor therapy are also reviewed. With evidence of beneficial effects in neurological and non-neurological TSC manifestations, mTOR inhibitors may represent a systemic treatment for TSC.
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Affiliation(s)
- Paolo Curatolo
- Department of Neurosciences, Child Neurology and Psychiatry Unit, Tor Vergata University Hospital of Rome, Rome, Italy.
| | - Marit Bjørnvold
- National Center for Rare Epilepsy-related Disorders, National Center of Epilepsy, Oslo University Hospital, Oslo, Norway
| | - Patricia E Dill
- Department of Pediatric Neurology and Developmental Medicine, University Children's Hospital Basel, University of Basel, Basel, Switzerland.,INSERM Unité 1511, Paris, France
| | - José Carlos Ferreira
- Neuro Pediatra, Centro Hospitalar Lisboa Ocidental, Hospital São Francisco Xavier, Lisbon, Portugal
| | - Martha Feucht
- Department of Paediatrics, University Hospital Vienna, Vienna, Austria
| | - Christoph Hertzberg
- Diagnose und Behandlungszentrum für Kinder und Jugendliche, Vivantes Klinikum Neukölln, Berlin, Germany
| | - Anna Jansen
- Pediatric Neurology Unit-UZ Brussel, Brussels, Belgium
| | - Sergiusz Jóźwiak
- Department of Child Neurology, Medical University of Warsaw, Warsaw, Poland
| | - J Christopher Kingswood
- Sussex Renal Unit, Royal Sussex County Hospital, Brighton, UK.,The Trafford Department of Renal Medicine, Royal Sussex County Hospital, Brighton, UK
| | - Katarzyna Kotulska
- Department of Neurology and Epileptology, The Children's Memorial Health Institute, Warsaw, Poland
| | - Alfons Macaya
- Servei de Neurologia Pediàtrica, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Romina Moavero
- Department of Neurosciences, Child Neurology and Psychiatry Unit, Tor Vergata University Hospital of Rome, Rome, Italy.,Pediatric Neurology Unit, Department of Neuroscience and Neurorehabilitation, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Rima Nabbout
- Department of Pediatric Neurology, Reference Centre for Rare Epilepsies and Tuberous Sclerosis Complex, Necker-Enfants Malades Hospital, University Paris Descartes, Paris, France
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41
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Kharoshankaya L, Murray DM, Bogue C, Ahearne C, Murphy BP, Boylan GB. Early EEG findings in tuberous sclerosis complex presenting with apneic seizures soon after birth. Clin Neurophysiol 2016; 127:3265-7. [DOI: 10.1016/j.clinph.2016.07.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2016] [Revised: 07/28/2016] [Accepted: 07/29/2016] [Indexed: 10/21/2022]
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Abstract
Tuberous sclerosis complex (TSC) is an autosomal dominant disorder that affects multiple organ systems and is caused by loss-of-function mutations in one of two genes: TSC1 or TSC2. The disorder can affect both adults and children. First described in depth by Bourneville in 1880, it is now estimated that nearly 2 million people are affected by the disease worldwide. The clinical features of TSC are distinctive and can vary widely between individuals, even within one family. Major features of the disease include tumours of the brain, skin, heart, lungs and kidneys, seizures and TSC-associated neuropsychiatric disorders, which can include autism spectrum disorder and cognitive disability. TSC1 (also known as hamartin) and TSC2 (also known as tuberin) form the TSC protein complex that acts as an inhibitor of the mechanistic target of rapamycin (mTOR) signalling pathway, which in turn plays a pivotal part in regulating cell growth, proliferation, autophagy and protein and lipid synthesis. Remarkable progress in basic and translational research, in addition to several randomized controlled trials worldwide, has led to regulatory approval of the use of mTOR inhibitors for the treatment of renal angiomyolipomas, brain subependymal giant cell astrocytomas and pulmonary lymphangioleiomyomatosis, but further research is needed to establish full indications of therapeutic treatment. In this Primer, we review the state-of-the-art knowledge in the TSC field, including the molecular and cellular basis of the disease, medical management, major knowledge gaps and ongoing research towards a cure.
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Affiliation(s)
- Elizabeth P Henske
- Pulmonary and Critical Care Medicine Division, Brigham and Women's Hospital, Harvard Medical School, 15 Francis Street, Boston, Massachusetts 02115, USA
| | - Sergiusz Jóźwiak
- Department of Pediatric Neurology, Medical University of Warsaw, Warsaw, Poland.,Children's Memorial Health Institute, Warsaw, Poland
| | | | - Julian R Sampson
- Institute of Medical Genetics, Division of Cancer and Genetics, Cardiff University School of Medicine, Cardiff, UK
| | - Elizabeth A Thiele
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Citraro R, Leo A, Constanti A, Russo E, De Sarro G. mTOR pathway inhibition as a new therapeutic strategy in epilepsy and epileptogenesis. Pharmacol Res 2016; 107:333-343. [DOI: 10.1016/j.phrs.2016.03.039] [Citation(s) in RCA: 115] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2016] [Revised: 03/23/2016] [Accepted: 03/31/2016] [Indexed: 12/24/2022]
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Early onset epileptic encephalopathy or genetically determined encephalopathy with early onset epilepsy? Lessons learned from TSC. Eur J Paediatr Neurol 2016; 20:203-211. [PMID: 26758984 DOI: 10.1016/j.ejpn.2015.12.005] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2015] [Revised: 12/01/2015] [Accepted: 12/13/2015] [Indexed: 01/12/2023]
Abstract
BACKGROUND In tuberous sclerosis complex (TSC) a relationship has been shown between early and refractory seizures and intellectual disability. However, it is uncertain whether epilepsy in TSC is simply a marker in infants who are destined to develop an encephalopathic process or if seizures play a causal role in developing an encephalopathy. METHODS This paper summarizes the key points discussed during a European TSC workshop held in Rome, and reviews the experimental and clinical evidence in support of the two theories. RESULTS/CONCLUSION There are many factors that influence the appearance of both early seizure onset and the encephalopathy resulting in neurodevelopmental deficits. Experimental studies show that as a consequence of the TSC genes mutation, mammalian target of Rapamycin (mTOR) overactivation determines an alteration in cellular morphology with cytomegalic neurons, altered synaptogenesis and an imbalance between excitation/inhibition, thus providing a likely neuroanatomical substrate for the early appearance of refractory seizures and for the encephalopathic process. At the clinical level, early signs of altered developmental trajectories are often unrecognized before 12 months of age. Evidence from experimental research shows that encephalopathy in TSC might have a genetic cause, and mTOR activation caused by TSC gene mutation can be directly responsible for the early appearance of seizures and encephalopathy.
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Gataullina S, Lemaire E, Wendling F, Kaminska A, Watrin F, Riquet A, Ville D, Moutard ML, de Saint Martin A, Napuri S, Pedespan JM, Eisermann M, Bahi-Buisson N, Nabbout R, Chiron C, Dulac O, Huberfeld G. Epilepsy in young Tsc1(+/-) mice exhibits age-dependent expression that mimics that of human tuberous sclerosis complex. Epilepsia 2016; 57:648-59. [PMID: 26873267 DOI: 10.1111/epi.13325] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/04/2016] [Indexed: 01/09/2023]
Abstract
OBJECTIVE To describe the epileptic phenotype of Tsc1(+/-) mice pups in comparison with age-related seizures in human tuberous sclerosis complex (TSC). METHODS Tsc1(+/-) and control mice underwent intracranial electroencephalography (EEG) recording at postnatal ages (P)8 to P33, with linear silicon probe implanted in the somatosensory cortex of one or both hemispheres for 8-24 h. Ictal events were classified visually by independent analyzers; distinct EEG patterns were related to age and analyzed to quantify field potential characteristics and signal dynamics between hemispheres. We collected retrospectively 20 infants with prenatally diagnosed TSC and EEG before seizure onset, and analyzed the electroclinical course of epilepsy, taking into account a first-line treatment by vigabatrin. RESULTS Spontaneous seizures were disclosed in 55% of Tsc1(+/-) mice at P9-18. Three ictal patterns were identified: from P9 to P12 "spike clusters" consisted of recurring large spikes without clinical correlate; "spasm-like" discharges dominated from P13 to P16 consisting of high amplitude large field potential superimposed with or followed by fast activity repeated every 2-10 s for at least 20 s, accompanied by rhythmic limb contractions; from P14 to P18 a "tonic-clonic like" pattern comprised rhythmic spikes of increasing amplitude with tonic-clonic movements. Early onset "spike clusters" were mainly unilateral, whereas "spasm-like" and "tonic-clonic like" patterns were bilateral. Interhemispheric propagation was significantly faster for "tonic-clonic like" than for "spasm-like" events. In infants diagnosed prenatally with TSC, clusters of sharp waves or spikes preceded the first seizure, and vigabatrin prevented the development of seizures. Patients treated after seizure onset developed spasms or focal seizures that were pharmacoresistant in 66.7% of cases. SIGNIFICANCE Tsc1(+/-) mice pups exhibit an age-dependent seizure pattern sequence mimicking early human TSC epilepsy features. Spike clusters before seizure onset in TSC should be considered as a first stage of epilepsy reinforcing the concept of preventive antiepileptic therapy.
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Affiliation(s)
- Svetlana Gataullina
- INSERM U1129 "Infantile Epilepsies and Brain Plasticity", Paris, France.,Paris Descartes University, PRES Sorbonne Paris Cité, Paris, France.,CEA, Gif sur Yvette, France.,Neurology Department, Mignot Hospital, CH Versailles, Le Chesnay, France
| | - Eric Lemaire
- Innovations and Industrial Development, Activsoft, Antony, France.,Adpuerivitam, Antony, France
| | - Fabrice Wendling
- INSERM, U1099, Rennes, France.,LTSI, Rennes 1 University, Rennes, France
| | - Anna Kaminska
- INSERM U1129 "Infantile Epilepsies and Brain Plasticity", Paris, France.,Paris Descartes University, PRES Sorbonne Paris Cité, Paris, France.,CEA, Gif sur Yvette, France.,Clinical Neurophysiology, Necker-Enfants Malades Hospital, APHP, Paris, France.,Reference Center for Rare Epilepsies, Necker-Enfants Malades Hospital, APHP, Paris, France
| | | | - Audrey Riquet
- Pediatric Neurology Department and Reference Center for Tuberous Sclerosis and Rare Epilepsies, University Hospital of Lille, France
| | - Dorothée Ville
- Pediatric Neurology Department and Center of Reference for Rare Intellectual Disorders, Tuberous Sclerosis, and Rare Epileptic Disorders, University Hospital of Lyon, Lyon, France
| | - Marie-Laure Moutard
- Neuropediatric Department, Developmental Pathology, Trousseau Hospital, APHP, Paris, France
| | - Anne de Saint Martin
- Pediatric Neurology, Department of Pediatrics, University Hospital of Strasbourg, Strasbourg, France.,Reference Center for Rare Epilepsies, Strasbourg, France
| | | | | | - Monika Eisermann
- INSERM U1129 "Infantile Epilepsies and Brain Plasticity", Paris, France.,Paris Descartes University, PRES Sorbonne Paris Cité, Paris, France.,CEA, Gif sur Yvette, France.,Clinical Neurophysiology, Necker-Enfants Malades Hospital, APHP, Paris, France.,Reference Center for Rare Epilepsies, Necker-Enfants Malades Hospital, APHP, Paris, France
| | - Nadia Bahi-Buisson
- Pediatric Neurology Department, Necker-Enfants Malades Hospital, APHP, Paris, France.,INSERM UMR1163, Embryology and Genetics of Congenital Malformations, Paris, France.,Paris Descartes University, Paris, France
| | - Rima Nabbout
- INSERM U1129 "Infantile Epilepsies and Brain Plasticity", Paris, France.,Paris Descartes University, PRES Sorbonne Paris Cité, Paris, France.,CEA, Gif sur Yvette, France.,Reference Center for Rare Epilepsies, Necker-Enfants Malades Hospital, APHP, Paris, France.,Pediatric Neurology Department, Necker-Enfants Malades Hospital, APHP, Paris, France
| | - Catherine Chiron
- INSERM U1129 "Infantile Epilepsies and Brain Plasticity", Paris, France.,Paris Descartes University, PRES Sorbonne Paris Cité, Paris, France.,CEA, Gif sur Yvette, France.,Reference Center for Rare Epilepsies, Necker-Enfants Malades Hospital, APHP, Paris, France
| | - Olivier Dulac
- INSERM U1129 "Infantile Epilepsies and Brain Plasticity", Paris, France.,Paris Descartes University, PRES Sorbonne Paris Cité, Paris, France.,CEA, Gif sur Yvette, France.,Reference Center for Rare Epilepsies, Necker-Enfants Malades Hospital, APHP, Paris, France
| | - Gilles Huberfeld
- INSERM U1129 "Infantile Epilepsies and Brain Plasticity", Paris, France.,Paris Descartes University, PRES Sorbonne Paris Cité, Paris, France.,CEA, Gif sur Yvette, France.,Sorbonne University, UPMC University Paris 06, Paris, France.,Neurophysiology Department, UPMC, CHU Pitié-Salpêtrière, APHP, Paris, France
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46
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Moavero R, Marciano S, Graziola F, Curatolo P. Combined targeted treatment in early onset epilepsy associated with tuberous sclerosis. EPILEPSY & BEHAVIOR CASE REPORTS 2016; 5:13-6. [PMID: 27330989 PMCID: PMC4907789 DOI: 10.1016/j.ebcr.2015.12.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/17/2015] [Revised: 11/26/2015] [Accepted: 12/12/2015] [Indexed: 11/23/2022]
Abstract
Tuberous sclerosis is associated with epilepsy in up to 85% of cases, and in 2/3, the onset is within the first year of life. An early antiepileptic treatment is crucial to minimize the consequences of epilepsy on cognition and behavior. We present a case report of a child with tuberous sclerosis who presented with infantile spasms at the age of 6 months, immediately treated with vigabatrin. Because of the presence of a subependymal giant cell astrocytoma, he also received everolimus since 18 months of age. We might wonder if an earlier treatment could have produced a better outcome; in fact, despite a targeted combined treatment, he continues to suffer from sporadic focal motor seizures, and at the age of 40 months, he presents severe developmental delay with autism-like behavior.
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Affiliation(s)
- Romina Moavero
- Child Neurology and Psychiatry Unit, Systems Medicine Department, Tor Vergata University of Rome, Italy
- Neurology Unit, Neuroscience and Neurorehabilitation Department, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Sara Marciano
- Child Neurology and Psychiatry Unit, Systems Medicine Department, Tor Vergata University of Rome, Italy
| | - Federica Graziola
- Child Neurology and Psychiatry Unit, Systems Medicine Department, Tor Vergata University of Rome, Italy
| | - Paolo Curatolo
- Child Neurology and Psychiatry Unit, Systems Medicine Department, Tor Vergata University of Rome, Italy
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47
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Ikeno M, Okumura A, Abe S, Igarashi A, Hisata K, Shoji H, Shimizu T. Clinically silent seizures in a neonate with tuberous sclerosis. Pediatr Int 2016; 58:58-61. [PMID: 26712128 DOI: 10.1111/ped.12738] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2015] [Revised: 05/08/2015] [Accepted: 06/15/2015] [Indexed: 01/05/2023]
Abstract
Although seizures during infancy in patients with tuberous sclerosis complex are common, seizures in neonates are infrequent. Here, we report the clinical course and electroencephalography (EEG) findings of a neonate with tuberous sclerosis complex associated with clinically silent seizures. The patient was a girl in whom cardiac tumors were detected on fetal ultrasonography. Brain magnetic resonance imaging during the neonatal period showed subependymal and cortical tubers. Routine EEG indicated unexpected ictal changes with no noticeable clinical symptoms. Ictal EEG was associated with a subtle increase in heart rate and a brief increase in chin electromyogram. These changes were difficult to identify clinically. The patient later developed focal seizures and epileptic spasms and had severe psychomotor delay. The present case suggests the occurrence of clinically silent seizures before the appearance of epileptic spasms in infants with tuberous sclerosis, and that EEG is an option for neonates with a prenatal diagnosis.
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Affiliation(s)
- Mitsuru Ikeno
- Department of Pediatrics, Juntendo University Faculty of Medicine, Tokyo, Japan
| | - Akihisa Okumura
- Department of Pediatrics, Juntendo University Faculty of Medicine, Tokyo, Japan.,Department of Pediatrics, Aichi Medical University, Nagakute, Aichi, Japan
| | - Shinpei Abe
- Department of Pediatrics, Juntendo University Faculty of Medicine, Tokyo, Japan
| | - Ayuko Igarashi
- Department of Pediatrics, Juntendo University Faculty of Medicine, Tokyo, Japan
| | - Ken Hisata
- Department of Pediatrics, Juntendo University Faculty of Medicine, Tokyo, Japan
| | - Hiromichi Shoji
- Department of Pediatrics, Juntendo University Faculty of Medicine, Tokyo, Japan
| | - Toshiaki Shimizu
- Department of Pediatrics, Juntendo University Faculty of Medicine, Tokyo, Japan
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48
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Wu JY, Peters JM, Goyal M, Krueger D, Sahin M, Northrup H, Au KS, Cutter G, Bebin EM. Clinical Electroencephalographic Biomarker for Impending Epilepsy in Asymptomatic Tuberous Sclerosis Complex Infants. Pediatr Neurol 2016; 54:29-34. [PMID: 26498039 PMCID: PMC4691569 DOI: 10.1016/j.pediatrneurol.2015.09.013] [Citation(s) in RCA: 85] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2015] [Accepted: 09/06/2015] [Indexed: 11/18/2022]
Abstract
BACKGROUND We assessed the clinical utility of routine electroencephalography (EEG) in the prediction of epilepsy onset in asymptomatic infants with tuberous sclerosis complex. METHODS This multicenter prospective observational study recruited infants younger than 7 months, seizure-free and on no antiepileptic drugs at enrollment, who all underwent serial physical examinations and video EEGs throughout the study. Parental education on seizure recognition was completed at the time of initial enrollment. Once seizure onset occurred, standard of care was applied, and subjects were followed up until 24 months. RESULTS Forty patients were enrolled, 28 older than 12 months with completed EEG evaluation at the time of this interim analysis. Of those, 19 (67.8%) developed seizures. Epileptic spasms occurred in 10 (52.6%), focal seizures in five (26.3%), generalized tonic-clonic seizure in one (5.3%), and a combination of epileptic spasms and focal seizures in three (15.7%). Fourteen infants (73.6%) had the first emergence of epileptiform abnormalities on EEG at an average age 4.2 months, preceding seizure onset by a median of 1.9 months. Hypsarrhythmia or modified hypsarrhythmia was not found in any infant before onset of epileptic spasms. All children with epileptiform discharges subsequently developed epilepsy (100% positive predictive value), and the negative predictive value for not developing epilepsy after a normal EEG was 64%. CONCLUSIONS Serial routine EEGs in infants with tuberous sclerosis complex is a feasible strategy to identify individuals at high risk for epilepsy. The most frequent clinical presentation was epileptic spasms followed by focal seizures, and then a combination of both seizure types.
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Affiliation(s)
- Joyce Y Wu
- Division of Pediatric Neurology, Mattel Children's Hospital at UCLA, Los Angeles, California
| | - Jurriaan M Peters
- Department of Neurology, Boston Children's Hospital, Boston, Massachusetts
| | - Monisha Goyal
- Department of Neurology, University of Alabama Birmingham, Birmingham, Alabama
| | | | - Mustafa Sahin
- Department of Neurology, Boston Children's Hospital, Boston, Massachusetts
| | | | | | - Gary Cutter
- Department of Neurology, University of Alabama Birmingham, Birmingham, Alabama
| | - E Martina Bebin
- Department of Neurology, University of Alabama Birmingham, Birmingham, Alabama.
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49
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Davis PE, Peters JM, Krueger DA, Sahin M. Tuberous Sclerosis: A New Frontier in Targeted Treatment of Autism. Neurotherapeutics 2015; 12:572-83. [PMID: 25986747 PMCID: PMC4489948 DOI: 10.1007/s13311-015-0359-5] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Tuberous sclerosis complex (TSC) is a genetic disorder with a high prevalence of autism spectrum disorder (ASD). Tremendous progress in understanding the pathogenesis of TSC has been made in recent years, along with initial trials of medical treatment aimed specifically at the underlying mechanism of the disorder. At the cellular level, loss of TSC1 or TSC2 results in upregulation of the mechanistic target of rapamycin (mTOR) pathway. At the circuitry level, TSC and mTOR play crucial roles in axonal, dendritic, and synaptic development and function. In this review, we discuss the molecular mechanism underlying TSC, and how this disease results in aberrant neural connectivity at multiple levels in the central nervous system, leading to ASD symptoms. We then review recent advances in mechanism-based treatments of TSC, and the promise that these treatments provide for future mechanism-based treatment of ASD. Because of these recent advances, TSC represents an ideal model for how to make progress in understanding and treating the mechanisms that underlie ASD in general.
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Affiliation(s)
- Peter E. Davis
- />Department of Neurology, Boston Children’s Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, 02115 MA USA
| | - Jurriaan M. Peters
- />Department of Neurology, Boston Children’s Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, 02115 MA USA
| | - Darcy A. Krueger
- />Division of Neurology, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH USA
| | - Mustafa Sahin
- />Department of Neurology, Boston Children’s Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, 02115 MA USA
- />F.M. Kirby Neurobiology Center, Boston Children’s Hospital, Harvard Medical School, Boston, MA USA
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50
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Overwater IE, Bindels-de Heus K, Rietman AB, ten Hoopen LW, Vergouwe Y, Moll HA, de Wit MCY. Epilepsy in children with tuberous sclerosis complex: Chance of remission and response to antiepileptic drugs. Epilepsia 2015; 56:1239-45. [DOI: 10.1111/epi.13050] [Citation(s) in RCA: 74] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/04/2015] [Indexed: 01/16/2023]
Affiliation(s)
- Iris E. Overwater
- Department of Neurology; Erasmus MC-Sophia Children's Hospital; Rotterdam The Netherlands
- ENCORE TSC Expertise Center; Erasmus MC-Sophia Children's Hospital; Rotterdam The Netherlands
| | - Karen Bindels-de Heus
- ENCORE TSC Expertise Center; Erasmus MC-Sophia Children's Hospital; Rotterdam The Netherlands
- Department of Pediatrics; Erasmus MC-Sophia Children's Hospital; Rotterdam The Netherlands
| | - André B. Rietman
- Department of Neurology; Erasmus MC-Sophia Children's Hospital; Rotterdam The Netherlands
- ENCORE TSC Expertise Center; Erasmus MC-Sophia Children's Hospital; Rotterdam The Netherlands
| | - Leontine W. ten Hoopen
- ENCORE TSC Expertise Center; Erasmus MC-Sophia Children's Hospital; Rotterdam The Netherlands
- Department of Child and Adolescent Psychiatry/Psychology; Erasmus MC-Sophia Children's Hospital; Rotterdam The Netherlands
| | - Yvonne Vergouwe
- Department of Public Health; Erasmus MC Rotterdam; Rotterdam The Netherlands
| | - Henriette A. Moll
- Department of Pediatrics; Erasmus MC-Sophia Children's Hospital; Rotterdam The Netherlands
| | - Marie-Claire Y. de Wit
- Department of Neurology; Erasmus MC-Sophia Children's Hospital; Rotterdam The Netherlands
- ENCORE TSC Expertise Center; Erasmus MC-Sophia Children's Hospital; Rotterdam The Netherlands
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