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Oliger A, Nerison C, Tan H, Raslan A, Ernst L, Datta P, Kellogg M. Responsive neurostimulation as a therapy for epilepsy following new-onset refractory status epilepticus: Case series and review of the literature. Clin Neurophysiol 2024; 162:151-158. [PMID: 38640819 DOI: 10.1016/j.clinph.2024.03.032] [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: 09/06/2023] [Revised: 03/07/2024] [Accepted: 03/24/2024] [Indexed: 04/21/2024]
Abstract
OBJECTIVE To report clinical outcomes of patients who presented with new-onset refractory status epilepticus (NORSE), developed drug-resistant epilepsy (DRE), and were treated with responsive neurostimulation (RNS). METHODS We performed a retrospective review of patients implanted with RNS at our institution and identified three who originally presented with NORSE. Through chart review, we retrieved objective and subjective information related to their presentation, workup, and outcomes including patient-reported seizure frequency. We reviewed electrocorticography (ECoG) data to estimate seizure burden at 3, 6, 12, and 24 months following RNS implantation. We performed a review of literature concerning neurostimulation in NORSE. RESULTS Use of RNS to treat DRE following NORSE was associated with reduced seizure burden and informed care by differentiating epileptic from non-epileptic events. CONCLUSIONS Our single-center experience of three cases suggests that RNS is a safe and potentially effective treatment for DRE following NORSE. SIGNIFICANCE This article reports outcomes of the largest case series of NORSE patients treated with RNS. Since patients with NORSE are at high risk of adverse neuropsychiatric and cognitive sequelae beyond seizures, a unique strength of RNS over other surgical options is the ability to distinguish ictal or peri-ictal from non-epileptic events.
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Affiliation(s)
- Audrey Oliger
- Departments of Neurology, Oregon Health and Science University, Portland, OR, USA.
| | - Caleb Nerison
- Neurological Surgery, Oregon Health and Science University, Portland, OR, USA
| | - Hao Tan
- Neurological Surgery, Oregon Health and Science University, Portland, OR, USA
| | - Ahmed Raslan
- Neurological Surgery, Oregon Health and Science University, Portland, OR, USA
| | - Lia Ernst
- Departments of Neurology, Oregon Health and Science University, Portland, OR, USA
| | - Proleta Datta
- Departments of Neurology, Oregon Health and Science University, Portland, OR, USA
| | - Marissa Kellogg
- Departments of Neurology, Oregon Health and Science University, Portland, OR, USA
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2
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Jha R, Blitz SE, Chua MMJ, Warren AEL, Lee JW, Rolston JD. Surgical management of status epilepticus: A systematic review. Epilepsia Open 2024; 9:850-864. [PMID: 38456595 PMCID: PMC11145616 DOI: 10.1002/epi4.12924] [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: 08/11/2023] [Revised: 11/07/2023] [Accepted: 02/09/2024] [Indexed: 03/09/2024] Open
Abstract
Status Epilepticus (SE), unresponsive to medical management, is associated with high morbidity and mortality. Surgical management is typically considered in these refractory cases. The best surgical approach for affected patients remains unclear; however, given the lack of controlled trials exploring the role of surgery. We performed a systematic review according to PRIMSA guidelines, including case reports and series describing surgical interventions for patients in SE. Cases (157 patients, median age 12.9 years) were followed for a median of 12 months. Patients were in SE for a median of 21 days before undergoing procedures including: focal resection (36.9%), functional hemispherectomy (21%), lobar resection (12.7%), vagus nerve stimulation (VNS) (12.7%), deep brain stimulation (DBS) (6.4%), multiple subpial transection (MST) (3.8%), responsive neurostimulation (RNS) (1.9%), and cortical stimulator placement (1.27%), with 24 patients undergoing multiple procedures. Multiple SE semiologies were identified. 47.8% of patients had focal seizures, and 65% of patients had focal structural abnormalities on MRI. SE persisted for 36.8 ± 47.7 days prior to surgical intervention. SE terminated following surgery in 81.5%, terminated with additional adjuncts in 10.2%, continued in 1.9%, and was not specified in 6.4% of patients. Long-term seizure outcomes were favorable, with the majority improved and 51% seizure-free. Eight patients passed away in follow-up, of which three were in SE. Seizures emerging from one hemisphere were both more likely to immediately terminate (OR 4.7) and lead to long-term seizure-free status (OR 3.9) compared to nonunilateral seizures. No other predictors, including seizure focality, SE duration, or choice of surgical procedure, were predictors of SE termination. Surgical treatment of SE can be effective in terminating SE and leading to sustained seizure freedom, with many different procedures showing efficacy if matched appropriately with SE semiology and etiology. PLAIN LANGUAGE SUMMARY: Patients with persistent seizures (Status Epilepticus) that do not stop following medications can be treated effectively with surgery. Here, we systematically review the entirety of existing literature on surgery for treating status epilepticus to better identify how and when surgery is used and what patients do after surgery.
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Affiliation(s)
- Rohan Jha
- Harvard Medical SchoolBostonMassachusettsUSA
- Department of Neurosurgery, Harvard Medical SchoolBrigham and Women's HospitalBostonMassachusettsUSA
| | - Sarah E. Blitz
- Harvard Medical SchoolBostonMassachusettsUSA
- Department of Neurosurgery, Harvard Medical SchoolBrigham and Women's HospitalBostonMassachusettsUSA
| | - Melissa M. J. Chua
- Department of Neurosurgery, Harvard Medical SchoolBrigham and Women's HospitalBostonMassachusettsUSA
| | - Aaron E. L. Warren
- Department of Neurosurgery, Harvard Medical SchoolBrigham and Women's HospitalBostonMassachusettsUSA
| | - Jong Woo Lee
- Department of Neurology, Harvard Medical SchoolBrigham and Women's HospitalBostonMassachusettsUSA
| | - John D. Rolston
- Department of Neurosurgery, Harvard Medical SchoolBrigham and Women's HospitalBostonMassachusettsUSA
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Niazi F, Han A, Stamm L, Shlobin NA, Korman C, Hoang TS, Kielian A, Du Pont-Thibodeau G, Ducharme Crevier L, Major P, Nguyen DK, Bouthillier A, Ibrahim GM, Fallah A, Hadjinicolaou A, Weil AG. Outcome of emergency neurosurgery in patients with refractory and super-refractory status epilepticus: a systematic review and individual participant data meta-analysis. Front Neurol 2024; 15:1403266. [PMID: 38863514 PMCID: PMC11165020 DOI: 10.3389/fneur.2024.1403266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2024] [Accepted: 04/23/2024] [Indexed: 06/13/2024] Open
Abstract
Background Refractory (RSE) and super-refractory status epilepticus (SRSE) are serious neurological conditions requiring aggressive management. Beyond anesthetic agents, there is a lack of evidence guiding management in these patients. This systematic review and individual participant data meta-analysis (IPDMA) seeks to evaluate and compare the currently available surgical techniques for the acute treatment of RSE and SRSE. Methods A systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Individual Participant Data (PRISMA-IPD). Only patients who underwent surgery while in RSE and SRSE were included. Descriptive statistics were used to compare various subgroups. Multivariable logistic regression models were constructed to identify predictors of status epilepticus (SE) cessation, long-term overall seizure freedom, and favorable functional outcome (i.e., modified Rankin score of 0-2) at last follow-up. Results A total of 87 studies including 161 participants were included. Resective surgery tended to achieve better SE cessation rate (93.9%) compared to non-resective techniques (83.9%), but this did not reach significance (p = 0.071). Resective techniques were also more likely to achieve seizure freedom (69.1% vs. 34.4%, p = <0.0001). Older age at SE (OR = 1.384[1.046-1.832], p = 0.023) was associated with increased likelihood of SE cessation, while longer duration of SE (OR = 0.603[0.362-1.003], p = 0.051) and new-onset seizures (OR = 0.244[0.069-0.860], p = 0.028) were associated with lower likelihood of SE cessation, but this did not reach significance for SE duration. Only shorter duration of SE prior to surgery (OR = 1.675[1.168-2.404], p = 0.0060) and immediate termination of SE (OR = 3.736 [1.323-10.548], p = 0.014) were independently associated with long-term seizure status. Rates of favorable functional outcomes (mRS of 0-2) were comparable between resective (44.4%) and non-resective (44.1%) techniques, and no independent predictors of outcome were identified. Conclusion Our findings suggest that emergency neurosurgery may be a safe and effective alternative in patients with RSE/SRSE and may be considered earlier during the disease course. However, the current literature is limited exclusively to small case series and case reports with high risk of publication bias. Larger clinical trials assessing long-term seizure and functional outcomes are warranted to establish robust management guidelines.
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Affiliation(s)
- Farbod Niazi
- Department of Medicine, Université de Montréal, Montreal, QC, Canada
- Brain and Development Research Axis, CHU Sainte-Justine Research Centre, Montreal, QC, Canada
| | - Aline Han
- Department of Medicine, Université de Montréal, Montreal, QC, Canada
- Brain and Development Research Axis, CHU Sainte-Justine Research Centre, Montreal, QC, Canada
| | - Lauren Stamm
- Brain and Development Research Axis, CHU Sainte-Justine Research Centre, Montreal, QC, Canada
- Department of Medicine, McGill University, Montreal, QC, Canada
| | - Nathan A. Shlobin
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Catherine Korman
- Brain and Development Research Axis, CHU Sainte-Justine Research Centre, Montreal, QC, Canada
- Department of Medicine, McGill University, Montreal, QC, Canada
| | - Thien S. Hoang
- Department of Health Sciences, Université de Montréal, Montreal, QC, Canada
| | - Agnieszka Kielian
- Department of Neurology, Boston Children’s Hospital, Boston, MA, United States
- Harvard Medical School, Boston, MA, United States
| | - Genevieve Du Pont-Thibodeau
- Division of Pediatric Intensive Care, Department of Pediatrics, Sainte-Justine University Hospital Centre, Montreal, QC, Canada
| | - Laurence Ducharme Crevier
- Division of Pediatric Intensive Care, Department of Pediatrics, Sainte-Justine University Hospital Centre, Montreal, QC, Canada
| | - Philippe Major
- Brain and Development Research Axis, CHU Sainte-Justine Research Centre, Montreal, QC, Canada
- Division of Neurology, Department of Pediatrics, Sainte-Justine University Hospital Centre, Montreal, QC, Canada
- Department of Neuroscience, Université de Montréal, Montreal, QC, Canada
| | - Dang K. Nguyen
- Department of Neuroscience, Université de Montréal, Montreal, QC, Canada
- Division of Neurology, University of Montreal Hospital Center (CHUM), Montreal, QC, Canada
| | - Alain Bouthillier
- Division of Neurosurgery, Department of Surgery, University of Montreal Hospital Center (CHUM), Montreal, QC, Canada
| | - George M. Ibrahim
- Division of Neurosurgery, Hospital for Sick Children, Toronto, ON, Canada
- Neurosciences and Mental Health, SickKids Research Institute, Toronto, ON, Canada
| | - Aria Fallah
- Department of Neurosurgery, David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles, CA, United States
| | - Aristides Hadjinicolaou
- Brain and Development Research Axis, CHU Sainte-Justine Research Centre, Montreal, QC, Canada
- Division of Neurology, Department of Pediatrics, Sainte-Justine University Hospital Centre, Montreal, QC, Canada
- Department of Neuroscience, Université de Montréal, Montreal, QC, Canada
| | - Alexander G. Weil
- Brain and Development Research Axis, CHU Sainte-Justine Research Centre, Montreal, QC, Canada
- Department of Neuroscience, Université de Montréal, Montreal, QC, Canada
- Division of Neurosurgery, Department of Surgery, University of Montreal Hospital Center (CHUM), Montreal, QC, Canada
- Division of Neurosurgery, Department of Surgery, Sainte-Justine University Hospital Centre, Montreal, QC, Canada
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4
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Hanin A, Muscal E, Hirsch LJ. Second-line immunotherapy in new onset refractory status epilepticus. Epilepsia 2024; 65:1203-1223. [PMID: 38430119 DOI: 10.1111/epi.17933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Revised: 02/06/2024] [Accepted: 02/12/2024] [Indexed: 03/03/2024]
Abstract
Several pieces of evidence suggest immune dysregulation could trigger the onset and modulate sequelae of new onset refractory status epilepticus (NORSE), including its subtype with prior fever known as febrile infection-related epilepsy syndrome (FIRES). Consensus-driven recommendations have been established to guide the initiation of first- and second-line immunotherapies in these patients. Here, we review the literature to date on second-line immunotherapy for NORSE/FIRES, presenting results from 28 case reports and series describing the use of anakinra, tocilizumab, or intrathecal dexamethasone in 75 patients with NORSE. Among them, 52 patients were managed with anakinra, 21 with tocilizumab, and eight with intrathecal dexamethasone. Most had elevated serum or cerebrospinal fluid cytokine levels at treatment initiation. Treatments were predominantly initiated during the acute phase of the disease (92%) and resulted, within the first 2 weeks, in seizure control for up to 73% of patients with anakinra, 70% with tocilizumab, and 50% with intrathecal dexamethasone. Cytokine levels decreased after treatment for most patients. Anakinra and intrathecal dexamethasone were mainly initiated in children with FIRES, whereas tocilizumab was more frequently prescribed for adults, with or without a prior febrile infection. There was no clear correlation between the response to treatment and the time to initiate the treatment. Most patients experienced long-term disability and drug-resistant post-NORSE epilepsy. Initiation of second-line immunotherapies during status epilepticus (SE) had no clear effect on the emergence of post-NORSE epilepsy or long-term functional outcomes. In a small number of cases, the initiation of anakinra or tocilizumab several years after SE onset resulted in a reduction of seizure frequency for 67% of patients. These data highlight the potential utility of anakinra, tocilizumab, and intrathecal dexamethasone in patients with NORSE. There continues to be interest in the utilization of early cytokine measurements to guide treatment selection and response. Prospective studies are necessary to understand the role of early immunomodulation and its associations with epilepsy and functional outcomes.
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Affiliation(s)
- Aurélie Hanin
- Comprehensive Epilepsy Center, Department of Neurology, Yale University School of Medicine, New Haven, Connecticut, USA
- Sorbonne Université, Institut du Cerveau-Paris Brain Institute-ICM, Inserm, CNRS, Assistance Publique - Hôpitaux de Paris, Hôpital de la Pitié-Salpêtrière, Paris, France
- Epilepsy Unit and Clinical Neurophysiology Department, DMU Neurosciences 6, Assistance Publique - Hôpitaux de Paris, Hôpital de la Pitié-Salpêtrière, Paris, France
| | - Eyal Muscal
- Department of Pediatrics, Section of Rheumatology, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas, USA
| | - Lawrence J Hirsch
- Comprehensive Epilepsy Center, Department of Neurology, Yale University School of Medicine, New Haven, Connecticut, USA
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5
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McLaren JR, Kahle KT, Richardson RM, Chu CJ. Epilepsy Surgery for Cognitive Improvement in Epileptic Encephalopathy. Neurosurg Clin N Am 2024; 35:49-59. [PMID: 38000841 DOI: 10.1016/j.nec.2023.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2023]
Abstract
Epileptic encephalopathies are defined by the presence of frequent epileptiform activity that causes neurodevelopmental slowing or regression. Here, we review evidence that epilepsy surgery improves neurodevelopment in children with epileptic encephalopathies. We describe an example patient with epileptic encephalopathy without drug refractory seizures, who underwent successful diagnostic and therapeutic surgeries. In patients with epileptic encephalopathy, cognitive improvement alone is a sufficient indication to recommend surgical intervention in experienced centers.
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Affiliation(s)
- John R McLaren
- Department of Neurology, Massachusetts General Hospital, Boston, MA 02114, USA; Harvard Medical School
| | - Kristopher T Kahle
- Harvard Medical School; Department of Neurosurgery, Massachusetts General Hospital, 55 Fruit Street, Wang Building Room 333, Boston, MA 02114, USA
| | - R Mark Richardson
- Harvard Medical School; Department of Neurosurgery, Massachusetts General Hospital, 55 Fruit Street, Their Building, 4th Floor, Boston, MA 02114, USA
| | - Catherine J Chu
- Department of Neurology, Massachusetts General Hospital, Boston, MA 02114, USA; Harvard Medical School.
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6
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Stavropoulos I, Pak HL, Alarcon G, Valentin A. Neuromodulation Techniques in Children with Super-Refractory Status Epilepticus. Brain Sci 2023; 13:1527. [PMID: 38002487 PMCID: PMC10670094 DOI: 10.3390/brainsci13111527] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Revised: 10/18/2023] [Accepted: 10/24/2023] [Indexed: 11/26/2023] Open
Abstract
Status epilepticus (SE) is a life-threatening condition and medical emergency which can have lifelong consequences, including neuronal death and alteration of neuronal networks, resulting in long-term neurologic and cognitive deficits in children. When standard pharmacological treatment for SE is not successful in controlling seizures, the condition evolves to refractory SE (rSE) and finally to super-refractory SE (srSE) if it exceeds 24 h despite using anaesthetics. In this systematic review, we present literature data on the potential uses of clinical neuromodulation techniques for the management of srSE in children, including electroconvulsive therapy, vagus nerve stimulation, and deep brain stimulation. The evaluation of these techniques is limited by the small number of published paediatric cases (n = 25, one with two techniques) in peer-reviewed articles (n = 18). Although neuromodulation strategies have not been tested through randomised, prospective controlled clinical trials, this review presents the existing data and the potential benefits of neuromodulation therapy, suggesting that these techniques, when available, could be considered at earlier stages within the course of srSE intending to prevent long-term neurologic complications. Clinical trials aiming to establish whether early intervention can prevent long-term sequelae are necessary in order to establish the potential clinical value of neuromodulation techniques for the treatment of srSE in children.
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Affiliation(s)
- Ioannis Stavropoulos
- Department of Clinical Neurophysiology, King’s College Hospital, London SE5 9RS, UK;
- Department of Basic and Clinical Neuroscience, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London SE5 8AB, UK
| | - Ho Lim Pak
- Faculty of Life Sciences and Medicine, King’s College London, London SE1 1UL, UK;
| | - Gonzalo Alarcon
- Royal Manchester Children’s Hospital, Manchester M13 9WL, UK;
- Alder Hey Children’s Hospital, Liverpool L12 2AP, UK
| | - Antonio Valentin
- Department of Clinical Neurophysiology, King’s College Hospital, London SE5 9RS, UK;
- Department of Basic and Clinical Neuroscience, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London SE5 8AB, UK
- Alder Hey Children’s Hospital, Liverpool L12 2AP, UK
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7
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Nagase H, Yamaguchi H, Tokumoto S, Ishida Y, Tomioka K, Nishiyama M, Nozu K, Maruyama A. Timing of therapeutic interventions against infection-triggered encephalopathy syndrome: a scoping review of the pediatric literature. Front Neurosci 2023; 17:1150868. [PMID: 37674514 PMCID: PMC10477367 DOI: 10.3389/fnins.2023.1150868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 08/07/2023] [Indexed: 09/08/2023] Open
Abstract
Our goal was to conduct a scoping review of the literature on the treatment of infection-triggered encephalopathy syndrome/acute encephalopathy in children, focusing on treatment targets and treatment initiation timing. We performed literature searches using PubMed for articles reporting treatments of infection-triggered encephalopathy syndrome/acute encephalopathy. We included articles describing specific treatments for acute encephalopathy with control groups. For the purpose of searching new therapies only experimentally tried in the case series, we also included case series studies without control groups in this review, if the studies contained at least two cases with clear treatment goals. Therapies were classified based on their mechanisms of action into brain protection therapy, immunotherapy, and other therapies. We operationally categorized the timing of treatment initiation as T1 (6-12 h), T2 (12-24 h), T3 (24-48 h), and T4 (>48 h) after the onset of seizures and/or impaired consciousness. Thirty articles were included in this review; no randomized control study was found. Eleven retrospective/historical cohort studies and five case-control studies included control groups with or without specific therapies or outcomes. The targeted conditions and treatment timing varied widely across studies. However, the following three points were suggested to be effective in multiple studies: (1) Careful seizure management and targeted temperature management within 12 h (T1) of onset of febrile seizure/prolonged impaired consciousness without multiple organ failure may reduce the development of acute encephalopathy with biphasic seizures and late reduced diffusion; (2) immunotherapy using corticosteroids, tocilizumab, or plasma exchange within 24 h (T1-T2) of onset of acute necrotizing encephalopathy may reduce sequelae; and (3) anakinra therapy and ketogenic diet demonstrate little evidence of neurologic sequelae reduction, but may reduce seizure frequency and allow for weaning from barbiturates, even when administered weeks (T4) after onset in children with febrile infection-related epilepsy syndrome. Although available studies have no solid evidence in the treatment of infection-triggered encephalopathy syndrome/acute encephalopathy, this scoping review lays the groundwork for future prospective clinical trials.
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Affiliation(s)
- Hiroaki Nagase
- Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Hiroshi Yamaguchi
- Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Shoichi Tokumoto
- Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Yusuke Ishida
- Department of Neurology, Hyogo Prefectural Kobe Children’s Hospital, Kobe, Japan
- Department of Emergency and General Pediatrics, Hyogo Prefectural Kobe Children’s Hospital, Kobe, Japan
| | - Kazumi Tomioka
- Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Masahiro Nishiyama
- Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan
- Department of Neurology, Hyogo Prefectural Kobe Children’s Hospital, Kobe, Japan
| | - Kandai Nozu
- Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Azusa Maruyama
- Department of Neurology, Hyogo Prefectural Kobe Children’s Hospital, Kobe, Japan
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8
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Stavropoulos I, Khaw JH, Valentin A. Neuromodulation in new-onset refractory status epilepticus. Front Neurol 2023; 14:1195844. [PMID: 37388544 PMCID: PMC10301751 DOI: 10.3389/fneur.2023.1195844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 05/17/2023] [Indexed: 07/01/2023] Open
Abstract
Background New-onset refractory status epilepticus (NORSE) and its subset of febrile infection-related epilepsy syndrome (FIRES) are devastating clinical presentations with high rates of mortality and morbidity. The recently published consensus on the treatment of these conditions includes anesthetics, antiseizure drugs, antivirals, antibiotics, and immune therapies. Despite the internationally accepted treatment, the outcome remains poor for a significant percentage of patients. Methods We conducted a systematic review of the use of neuromodulation techniques in the treatment of the acute phase of NORSE/FIRES using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Results Our search strategy brought up 74 articles of which 15 met our inclusion criteria. A total of 20 patients were treated with neuromodulation. Thirteen cases represented FIRES and in 17 cases the NORSE remained cryptogenic. Ten had electroconvulsive therapy (ECT), seven had vagal nerve stimulation (VNS), and four had deep brain stimulation (DBS); one patient had initially VNS and later DBS. Eight patients were female and nine were children. In 17 out of 20 patients, the status epilepticus was resolved after neuromodulation, while three patients died. Conclusion NORSE can have a catastrophic course and the first treatment goal should be the fastest possible termination of status epilepticus. The data presented are limited by the small number of published cases and the variability of neuromodulation protocols used. However, they show some potential clinical benefits of early neuromodulation therapy, suggesting that these techniques could be considered within the course of FIRES/NORSE.
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Affiliation(s)
- Ioannis Stavropoulos
- Department of Basic and Clinical Neuroscience, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom
- Department of Clinical Neurophysiology, King's College Hospital, London, United Kingdom
| | - Jin Han Khaw
- Faculty of Life Sciences and Medicine, King's College London, London, United Kingdom
| | - Antonio Valentin
- Department of Basic and Clinical Neuroscience, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom
- Department of Clinical Neurophysiology, King's College Hospital, London, United Kingdom
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9
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Fisher RS. Deep brain stimulation of thalamus for epilepsy. Neurobiol Dis 2023; 179:106045. [PMID: 36809846 DOI: 10.1016/j.nbd.2023.106045] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2022] [Revised: 02/10/2023] [Accepted: 02/13/2023] [Indexed: 02/22/2023] Open
Abstract
Neuromodulation (neurostimulation) is a relatively new and rapidly growing treatment for refractory epilepsy. Three varieties are approved in the US: vagus nerve stimulation (VNS), deep brain stimulation (DBS) and responsive neurostimulation (RNS). This article reviews thalamic DBS for epilepsy. Among many thalamic sub-nuclei, DBS for epilepsy has been targeted to the anterior nucleus (ANT), centromedian nucleus (CM), dorsomedial nucleus (DM) and pulvinar (PULV). Only ANT is FDA-approved, based upon a controlled clinical trial. Bilateral stimulation of ANT reduced seizures by 40.5% at three months in the controlled phase (p = .038) and 75% by 5 years in the uncontrolled phase. Side effects related to paresthesias, acute hemorrhage, infection, occasional increased seizures, and usually transient effects on mood and memory. Efficacy was best documented for focal onset seizures in temporal or frontal lobe. CM stimulation may be useful for generalized or multifocal seizures and PULV for posterior limbic seizures. Mechanisms of DBS for epilepsy are largely unknown, but animal work points to changes in receptors, channels, neurotransmitters, synapses, network connectivity and neurogenesis. Personalization of therapies, in terms of connectivity of the seizure onset zone to the thalamic sub- nucleus and individual characteristics of the seizures, might lead to improved efficacy. Many questions remain about DBS, including the best candidates for different types of neuromodulation, the best targets, the best stimulation parameters, how to minimize side effects and how to deliver current noninvasively. Despite the questions, neuromodulation provides useful new opportunities to treat people with refractory seizures not responding to medicines and not amenable to resective surgery.
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Affiliation(s)
- Robert S Fisher
- Department of Neurology and Neurological Sciences and Neurosurgery by Courtesy, Department of Neurology and Neurological Sciences, Stanford University School of Medicine, 213 Quarry Road, Room 4865, Palo Alto, CA 94304, USA.
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10
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Sculier C, Gaspard N. New-onset refractory status epilepticus and febrile infection-related epilepsy syndrome. Curr Opin Neurol 2023; 36:110-116. [PMID: 36762646 DOI: 10.1097/wco.0000000000001137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
PURPOSE OF REVIEW The concept and understanding of new-onset refractory status epilepticus (NORSE), and its subtype with prior fever known as febrile infection-related epilepsy syndrome (FIRES) have evolved in the recent past. This review aims to summarize the recent developments in the pathophysiology, diagnosis and management of these challenging conditions. RECENT FINDINGS NORSE and FIRES can have many different causes. Although the list of possible causes is still growing, they mostly fall in the categories of autoimmune encephalitis and genetic disorders. However, despite extensive investigations, most cases of NORSE and FIRES remain cryptogenic. Recent studies have pointed towards the key role of autoinflammation as a unifying pathophysiological mechanism in these cases. These findings also support the use of immunomodulatory treatment in this setting. Consensus recommendations on the management of NORSE and FIRES have recently been published. SUMMARY NORSE and FIRES remain challenging conditions to diagnose and treat. Recent findings from clinical and basic research and new recommendations, reviewed in this article, contribute to an emerging framework for management and future research.
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Affiliation(s)
- Claudine Sculier
- Service de Neurologie Pédiatrique, Hôpital Universitaire de Bruxelles - Hôpital Erasme
| | - Nicolas Gaspard
- Service de Neurologie, Hôpital Universitaire de Bruxelles - Hôpital Erasme, Bruxelles, Belgique
- Neurology Department, Yale University School of Medicine, New Haven, Connecticut, USA
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11
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Lai YC, Abou-El-Kheir G, Nguyen T, Hanerhoff M, Riviello JJ, Muscal E. Systemic inflammatory markers and EEG features of children with FIRES receiving anakinra. Ann Clin Transl Neurol 2023; 10:440-446. [PMID: 36645080 PMCID: PMC10013998 DOI: 10.1002/acn3.51714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Revised: 11/21/2022] [Accepted: 11/21/2022] [Indexed: 01/17/2023] Open
Abstract
In a retrospective case series of 10 children with cryptogenic FIRES, we sought to describe the early clinical course and potential biomarkers following anakinra initiation. Six children achieved anesthetic withdrawal within 3 weeks of therapy and one in week four. Of the available cEEG (six children), CRP (10 children), and serum cytokine (six children) studies, there were temporal changes in highly epileptiform bursts (observed in three children), CRP, IL-6, and IL-10 levels that might parallel clinical progression. These observations may represent candidate biomarkers for monitoring clinical progression and therapeutic interventions including anakinra, which merits further investigation in future studies.
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Affiliation(s)
- Yi-Chen Lai
- Division of Pediatric Critical Care Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Gabriella Abou-El-Kheir
- Division of Pediatric Critical Care Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Thao Nguyen
- Division of Pediatric Critical Care Medicine, Baylor College of Medicine, Houston, Texas, USA
| | | | - James J Riviello
- Division of Neurology and Developmental Neuroscience, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Eyal Muscal
- Division of Neurology and Developmental Neuroscience, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA.,Division of Pediatric Rheumatology, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
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12
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Stredny C, Rotenberg A, Leviton A, Loddenkemper T. Systemic inflammation as a biomarker of seizure propensity and a target for treatment to reduce seizure propensity. Epilepsia Open 2023; 8:221-234. [PMID: 36524286 PMCID: PMC9978091 DOI: 10.1002/epi4.12684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Accepted: 12/12/2022] [Indexed: 12/23/2022] Open
Abstract
People with diabetes can wear a device that measures blood glucose and delivers just the amount of insulin needed to return the glucose level to within bounds. Currently, people with epilepsy do not have access to an equivalent wearable device that measures a systemic indicator of an impending seizure and delivers a rapidly acting medication or other intervention (e.g., an electrical stimulus) to terminate or prevent a seizure. Given that seizure susceptibility is reliably increased in systemic inflammatory states, we propose a novel closed-loop device where release of a fast-acting therapy is governed by sensors that quantify the magnitude of systemic inflammation. Here, we review the evidence that patients with epilepsy have raised levels of systemic indicators of inflammation than controls, and that some anti-inflammatory drugs have reduced seizure occurrence in animals and humans. We then consider the options of what might be incorporated into a responsive anti-seizure system.
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Affiliation(s)
- Coral Stredny
- Division of Epilepsy and Clinical Neurophysiology, Department of NeurologyBoston Children's HospitalBostonMassachusettsUSA
- Department of NeurologyHarvard Medical SchoolBostonMassachusettsUSA
| | - Alexander Rotenberg
- Division of Epilepsy and Clinical Neurophysiology, Department of NeurologyBoston Children's HospitalBostonMassachusettsUSA
- Department of NeurologyHarvard Medical SchoolBostonMassachusettsUSA
| | - Alan Leviton
- Division of Epilepsy and Clinical Neurophysiology, Department of NeurologyBoston Children's HospitalBostonMassachusettsUSA
- Department of NeurologyHarvard Medical SchoolBostonMassachusettsUSA
| | - Tobias Loddenkemper
- Division of Epilepsy and Clinical Neurophysiology, Department of NeurologyBoston Children's HospitalBostonMassachusettsUSA
- Department of NeurologyHarvard Medical SchoolBostonMassachusettsUSA
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13
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Pavone P, Corsello G, Raucci U, Lubrano R, Parano E, Ruggieri M, Greco F, Marino S, Falsaperla R. Febrile infection-related Epilepsy Syndrome (FIRES): a severe encephalopathy with status epilepticus. Literature review and presentation of two new cases. Ital J Pediatr 2022; 48:199. [PMID: 36527084 PMCID: PMC9756623 DOI: 10.1186/s13052-022-01389-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 11/24/2022] [Indexed: 12/23/2022] Open
Abstract
FIRES is defined as a disorder that requires a prior febrile infection starting between 2 weeks and 24 h before the onset of the refractory status epilepticus with or without fever at the onset of status epilepticus. The patients, previously normal, present in the acute phase recurrent seizures and status epilepticus followed by a severe course with usually persistent seizures and residual cognitive impairment. Boundary with "new onset refractory status epilepticus (NORSE) has not clearly established. Pathogenetic hypothesis includes inflammatory or autoimmune mechanism with a possible genetic predisposition for an immune response dysfunction.Various types of treatment have been proposed for the treatment of the acute phase of the disorder to block the rapid seizures evolution to status epilepticus and to treat status epilepticus itself. Prognosis is usually severe both for control of the seizures and for cognitive involvement.FIRES is an uncommon but severe disorder which must be carefully considered in the differential diagnosis with other epileptic encephalopathy.
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Affiliation(s)
- Piero Pavone
- grid.412844.f0000 0004 1766 6239Department of Clinical and Experimental Medicine, University Hospital “Policlinico-San Marco”, Catania Catania, Italy
| | - Giovanni Corsello
- grid.10776.370000 0004 1762 5517Department of Health Promotion, Mather and Child Care, Internal Medicine and Medical Specialities, University of Palermo, Palermo, Italy
| | - Umberto Raucci
- grid.414603.4Department of Emergency and Clinical Pediatrics, Bambin Gesù Children’s Hospital IRCCS, Rome, Italy
| | - Riccardo Lubrano
- grid.7841.aPediatrics and Neonatology Unit, Maternal-Child Department, Santa Maria Goretti Hospital, Sapienza University of Rome, Latina, Italy
| | - Enrico Parano
- grid.5326.20000 0001 1940 4177Unit of Catania, Institute for Research and Biomedical Innovation (IRIB), National Council of Research, Catania, Italy
| | - Martino Ruggieri
- grid.412844.f0000 0004 1766 6239Department of Clinical and Experimental Medicine, University Hospital “Policlinico-San Marco”, Catania Catania, Italy
| | - Filippo Greco
- grid.412844.f0000 0004 1766 6239Department of Clinical and Experimental Medicine, University Hospital “Policlinico-San Marco”, Catania Catania, Italy
| | - Silvia Marino
- grid.8158.40000 0004 1757 1969Unit of Pediatrics and Pediatric Emergency, AOU “Policlinico”- PO “San Marco”, University of Catania, Catania, Italy
| | - Raffaele Falsaperla
- grid.8158.40000 0004 1757 1969Unit of Pediatrics and Pediatric Emergency, AOU “Policlinico”- PO “San Marco”, University of Catania, Catania, Italy
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14
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Wickstrom R, Taraschenko O, Dilena R, Payne ET, Specchio N, Nabbout R, Koh S, Gaspard N, Hirsch LJ. International consensus recommendations for management of New Onset Refractory Status Epilepticus (NORSE) incl. Febrile Infection-Related Epilepsy Syndrome (FIRES): Statements and Supporting Evidence. Epilepsia 2022; 63:2840-2864. [PMID: 35997591 PMCID: PMC9828002 DOI: 10.1111/epi.17397] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Revised: 07/14/2022] [Accepted: 08/18/2022] [Indexed: 01/12/2023]
Abstract
OBJECTIVE To develop consensus-based recommendations for the management of adult and paediatric patients with NORSE/FIRES based on best evidence and experience. METHODS The Delphi methodology was followed. A facilitator group of 9 experts was established, who defined the scope, users and suggestions for recommendations. Following a review of the current literature, recommendation statements concerning diagnosis, treatment and research directions were generated which were then voted on a scale of 1 (strongly disagree) to 9 (strongly agree) by a panel of 48 experts in the field. Consensus that a statement was appropriate was reached if the median score was greater or equal to 7, and inappropriate if the median score was less than or equal to 3. The analysis of evidence was mapped to the results of each statement included in the Delphi survey. RESULTS Overall, 85 recommendation statements achieved consensus. The recommendations are divided into five sections: 1) disease characteristics, 2) diagnostic testing and sampling, 3) acute treatment, 4) treatment in the post-acute phase, and 5) research, registries and future directions in NORSE/FIRES. The detailed results and discussion of all 85 statements are outlined herein. A corresponding summary of findings and practical flowsheets are presented in a companion article. SIGNIFICANCE This detailed analysis offers insight into the supporting evidence and the current gaps in the literature that are associated with expert consensus statements related to NORSE/FIRES. The recommendations generated by this consensus can be used as a guide for the diagnosis, evaluation, and management of patients with NORSE/FIRES, and for planning of future research.
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Affiliation(s)
- Ronny Wickstrom
- Neuropaediatric UnitDepartment of Women's and Children's HealthKarolinska Institutet and Karolinska University HospitalStockholmSweden
| | - Olga Taraschenko
- Department of Neurological SciencesUniversity of Nebraska Medical CenterOmahaNebraskaUSA
| | - Robertino Dilena
- Neuropathophysiology UnitFoundation IRCCS Ca' Granda Ospedale Maggiore PoliclinicoMilanItaly
| | - Eric T. Payne
- Department of Pediatrics, Section of NeurologyAlberta Children's HospitalCalgaryAlbertaCanada
| | - Nicola Specchio
- Rare and Complex Epilepsy Unit, Department of NeurosciencesBambino Gesù Children's Hospital, IRCCS, Full Member of European Reference Network EpiCARERomeItaly
| | - Rima Nabbout
- Department of Pediatric Neurology, APHP, Member of EPICARE ERN, Centre de Reference Epilepsies RaresUniversite de Paris, Institut Imagine, INSERM 1163ParisFrance
| | - Sookyong Koh
- Department of Pediatrics, Children's Hospital and Medical CenterUniversity of NebraskaOmahaNebraskaUSA
| | | | - Lawrence J. Hirsch
- Department of Neurology, Comprehensive Epilepsy CenterYale UniversityNew HavenConnecticutUSA
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15
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Costagliola G, Depietri G, Michev A, Riva A, Foiadelli T, Savasta S, Bonuccelli A, Peroni D, Consolini R, Marseglia GL, Orsini A, Striano P. Targeting Inflammatory Mediators in Epilepsy: A Systematic Review of Its Molecular Basis and Clinical Applications. Front Neurol 2022; 13:741244. [PMID: 35359659 PMCID: PMC8961811 DOI: 10.3389/fneur.2022.741244] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Accepted: 02/08/2022] [Indexed: 12/12/2022] Open
Abstract
Introduction Recent studies prompted the identification of neuroinflammation as a potential target for the treatment of epilepsy, particularly drug-resistant epilepsy, and refractory status epilepticus. This work provides a systematic review of the clinical experience with anti-cytokine agents and agents targeting lymphocytes and aims to evaluate their efficacy and safety for the treatment of refractory epilepsy. Moreover, the review analyzes the main therapeutic perspectives in this field. Methods A systematic review of the literature was conducted on MEDLINE database. Search terminology was constructed using the name of the specific drug (anakinra, canakinumab, tocilizumab, adalimumab, rituximab, and natalizumab) and the terms “status epilepticus,” “epilepsy,” and “seizure.” The review included clinical trials, prospective studies, case series, and reports published in English between January 2016 and August 2021. The number of patients and their age, study design, specific drugs used, dosage, route, and timing of administration, and patients outcomes were extracted. The data were synthesized through quantitative and qualitative analysis. Results Our search identified 12 articles on anakinra and canakinumab, for a total of 37 patients with epilepsy (86% febrile infection-related epilepsy syndrome), with reduced seizure frequency or seizure arrest in more than 50% of the patients. The search identified nine articles on the use of tocilizumab (16 patients, 75% refractory status epilepticus), with a high response rate. Only one reference on the use of adalimumab in 11 patients with Rasmussen encephalitis showed complete response in 45% of the cases. Eight articles on rituximab employment sowed a reduced seizure burden in 16/26 patients. Finally, one trial concerning natalizumab evidenced a response in 10/32 participants. Conclusion The experience with anti-cytokine agents and drugs targeting lymphocytes in epilepsy derives mostly from case reports or series. The use of anti-IL-1, anti-IL-6, and anti-CD20 agents in patients with drug-resistant epilepsy and refractory status epilepticus has shown promising results and a good safety profile. The experience with TNF inhibitors is limited to Rasmussen encephalitis. The use of anti-α4-integrin agents did not show significant effects in refractory focal seizures. Concerning research perspectives, there is increasing interest in the potential use of anti-chemokine and anti-HMGB-1 agents.
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Affiliation(s)
- Giorgio Costagliola
- Pediatric Immunology, Pediatric University Department, Azienda Ospedaliero Universitaria Pisana, University of Pisa, Pisa, Italy
| | - Greta Depietri
- Pediatric Neurology, Pediatric University Department, Azienda Ospedaliero Universitaria Pisana, University of Pisa, Pisa, Italy
| | - Alexandre Michev
- Pediatric Clinic, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Matteo Foundation, University of Pavia, Pavia, Italy
- *Correspondence: Alexandre Michev
| | - Antonella Riva
- Pediatric Neurology and Muscular Diseases Unit, IRCCS Istituto “Giannina Gaslini”, Genova, Italy
| | - Thomas Foiadelli
- Pediatric Clinic, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Matteo Foundation, University of Pavia, Pavia, Italy
| | - Salvatore Savasta
- Pediatric Clinic, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Matteo Foundation, University of Pavia, Pavia, Italy
| | - Alice Bonuccelli
- Pediatric Neurology, Pediatric University Department, Azienda Ospedaliero Universitaria Pisana, University of Pisa, Pisa, Italy
| | - Diego Peroni
- Pediatric Immunology, Pediatric University Department, Azienda Ospedaliero Universitaria Pisana, University of Pisa, Pisa, Italy
- Pediatric Neurology, Pediatric University Department, Azienda Ospedaliero Universitaria Pisana, University of Pisa, Pisa, Italy
| | - Rita Consolini
- Pediatric Immunology, Pediatric University Department, Azienda Ospedaliero Universitaria Pisana, University of Pisa, Pisa, Italy
| | - Gian Luigi Marseglia
- Pediatric Clinic, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Matteo Foundation, University of Pavia, Pavia, Italy
| | - Alessandro Orsini
- Pediatric Neurology, Pediatric University Department, Azienda Ospedaliero Universitaria Pisana, University of Pisa, Pisa, Italy
| | - Pasquale Striano
- Pediatric Neurology and Muscular Diseases Unit, IRCCS Istituto “Giannina Gaslini”, Genova, Italy
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genova, Genova, Italy
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16
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Khan M, Paktiawal J, Piper RJ, Chari A, Tisdall MM. Intracranial neuromodulation with deep brain stimulation and responsive neurostimulation in children with drug-resistant epilepsy: a systematic review. J Neurosurg Pediatr 2022; 29:208-217. [PMID: 34678764 DOI: 10.3171/2021.8.peds21201] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 08/02/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE In children with drug-resistant epilepsy (DRE), resective, ablative, and disconnective surgery may not be feasible or may fail. Neuromodulation in the form of deep brain stimulation (DBS) and responsive neurostimulation (RNS) may be viable treatment options, however evidence for their efficacies in children is currently limited. This systematic review aimed to summarize the literature on DBS and RNS for the treatment of DRE in the pediatric population. Specifically, the authors focused on currently available data for reported indications, neuromodulation targets, clinical efficacy, and safety outcomes. METHODS PRISMA guidelines were followed throughout this systematic review (PROSPERO no. CRD42020180669). Electronic databases, including PubMed, Embase, Cochrane Library, OpenGrey, and CINAHL Plus, were searched from their inception to February 19, 2021. Inclusion criteria were 1) studies with at least 1 pediatric patient (age < 19 years) who underwent DBS and/or RNS for DRE; and 2) retrospective, prospective, randomized, or nonrandomized controlled studies, case series, and case reports. Exclusion criteria were 1) letters, commentaries, conference abstracts, and reviews; and 2) studies without full text available. Risk of bias of the included studies was assessed using the Cochrane ROBINS-I (Risk of Bias in Non-randomised Studies - of Interventions) tool. RESULTS A total of 35 studies were selected that identified 72 and 46 patients who underwent DBS and RNS, respectively (age range 4-18 years). Various epilepsy etiologies and seizure types were described in both cohorts. Overall, 75% of patients had seizure reduction > 50% after DBS (among whom 6 were seizure free) at a median (range) follow-up of 14 (1-100) months. In an exploratory univariate analysis of factors associated with favorable response, the follow-up duration was shorter in those patients with a favorable response (18 vs 33 months, p < 0.05). In the RNS cohort, 73.2% of patients had seizure reduction > 50% after RNS at a median (range) follow-up of 22 (5-39) months. On closer inspection, 83.3% of patients who had > 50% reduction in seizures actually had > 75% reduction, with 4 patients being seizure free. CONCLUSIONS Overall, both DBS and RNS showed favorable response rates, indicating that both techniques should be considered for pediatric patients with DRE. However, serious risks of overall bias were found in all included studies. Many research needs in this area would be addressed by conducting high-quality clinical trials and establishing an international registry of patients who have undergone pediatric neuromodulation, thereby ensuring robust prospective collection of predictive variables and outcomes.
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Affiliation(s)
- Mehdi Khan
- 1University College London Medical School, London, United Kingdom
- 3Department of Neurosurgery, Great Ormond Street Hospital, London, United Kingdom; and
| | - Jaber Paktiawal
- 2Medical University Pleven, Pleven, Bulgaria
- 3Department of Neurosurgery, Great Ormond Street Hospital, London, United Kingdom; and
| | - Rory J Piper
- 3Department of Neurosurgery, Great Ormond Street Hospital, London, United Kingdom; and
- 4Developmental Neuroscience, Great Ormond Street Institute of Child Health, University College London, London, United Kingdom
| | - Aswin Chari
- 3Department of Neurosurgery, Great Ormond Street Hospital, London, United Kingdom; and
- 4Developmental Neuroscience, Great Ormond Street Institute of Child Health, University College London, London, United Kingdom
| | - Martin M Tisdall
- 3Department of Neurosurgery, Great Ormond Street Hospital, London, United Kingdom; and
- 4Developmental Neuroscience, Great Ormond Street Institute of Child Health, University College London, London, United Kingdom
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17
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Perulli M, Cicala G, Turrini I, Musto E, Quintiliani M, Gambardella ML, Pulitanò SM, Bompard S, Staccioli S, Carmillo L, Di Sante G, Ria F, Veredice C, Contaldo I, Battaglia D. Fighting autoinflammation in FIRES: The role of interleukins and early immunomodulation. Epilepsy Behav Rep 2022; 18:100531. [PMID: 35356746 PMCID: PMC8958320 DOI: 10.1016/j.ebr.2022.100531] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Revised: 02/15/2022] [Accepted: 02/16/2022] [Indexed: 01/11/2023] Open
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18
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Hect JL, Fernandez LD, Welch WP, Abel TJ. Deep brain stimulation of the centromedian thalamic nucleus for the treatment of FIRES. Epilepsia Open 2021; 7:187-193. [PMID: 34862854 PMCID: PMC8886094 DOI: 10.1002/epi4.12568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Revised: 11/16/2021] [Accepted: 11/28/2021] [Indexed: 11/10/2022] Open
Abstract
Febrile infection‐related epilepsy syndrome (FIRES) is a rare, life‐threatening complication of febrile illness in previously healthy individuals followed by super‐refractory status epilepticus. Deep brain stimulation (DBS) has been demonstrated to be a promising therapy for the treatment of intractable epilepsy. Here, we present a pediatric patient with FIRES whose seizures were mitigated by acute DBS of the bilateral centromedian thalamic nucleus (CMTN). This is a previously healthy 11‐year‐old female who presented emergently with altered mental status, fever, and malaise after 1 week of lethargy, anorexia, fever, and abdominal pain. The patient began having seizures shortly after admission. After thorough workup for encephalitis and other potential etiologies, this patient was diagnosed with FIRES due to super‐refractory status epilepticus. Status epilepticus persisted despite pharmacologic management, immunotherapy, and vagus nerve stimulation. DBS of the bilateral CMTN (CM‐DBS) was pursued after 56 days of hospitalization, and she demonstrated considerable improvement in baseline mental status 30 days after DBS insertion. This report highlights application of CM‐DBS for super‐refractory status epilepticus in FIRES. This region is a diffusely connected brain region and has been shown to modulate neural networks contributing to seizure propagation and consciousness; therefore, neurostimulation is a potential therapeutic intervention for patients with super‐refractory status epilepticus.
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Affiliation(s)
- Jasmine L Hect
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Luis D Fernandez
- Division of Pediatric Neurology, Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - William P Welch
- Division of Pediatric Neurology, Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Taylor J Abel
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.,Department of Bioengineering, University of Pittsburgh Swanson School of Engineering, Pittsburgh, Pennsylvania, USA
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19
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Stavropoulos I, Pak HL, Valentin A. Neuromodulation in Super-refractory Status Epilepticus. J Clin Neurophysiol 2021; 38:494-502. [PMID: 34261110 DOI: 10.1097/wnp.0000000000000710] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
SUMMARY Status epilepticus (SE) is a severe condition that needs immediate pharmacological treatment to tackle brain damage and related side effects. In approximately 20% of cases, the standard treatment for SE does not control seizures, and the condition evolves to refractory SE. If refractory status epilepticus lasts more than 24 hours despite the use of anesthetic treatment, the condition is redefined as super-refractory SE (srSE). sRSE is a destructive condition, potentially to cause severe brain damage. In this review, we discuss the clinical neuromodulation techniques for controlling srSE when conventional treatments have failed: electroconvulsive therapy, vagus nerve stimulation, transcranial magnetic stimulation, and deep brain stimulation. Data show that neuromodulation therapies can abort srSE in >80% of patients. However, no randomized, prospective, and controlled trials have been completed, and data are provided only by retrospective small case series and case reports with obvious inclination to publication bias. There is a need for further investigation into the use of neuromodulation techniques as an early treatment of srSE and to address whether an earlier intervention can prevent long-term complications.
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Affiliation(s)
- Ioannis Stavropoulos
- Department of Clinical Neurophysiology, King's College Hospital, London, United Kingdom
- Department of Basic and Clinical Neuroscience, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom; and
| | - Ho Lim Pak
- Faculty of Life Sciences and Medicine, King's College London, London, United Kingdom
| | - Antonio Valentin
- Department of Clinical Neurophysiology, King's College Hospital, London, United Kingdom
- Department of Basic and Clinical Neuroscience, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom; and
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20
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Zamora M, Meller S, Kajin F, Sermon JJ, Toth R, Benjaber M, Dijk DJ, Bogacz R, Worrell GA, Valentin A, Duchet B, Volk HA, Denison T. Case Report: Embedding "Digital Chronotherapy" Into Medical Devices-A Canine Validation for Controlling Status Epilepticus Through Multi-Scale Rhythmic Brain Stimulation. Front Neurosci 2021; 15:734265. [PMID: 34630021 PMCID: PMC8498587 DOI: 10.3389/fnins.2021.734265] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 08/24/2021] [Indexed: 01/15/2023] Open
Abstract
Circadian and other physiological rhythms play a key role in both normal homeostasis and disease processes. Such is the case of circadian and infradian seizure patterns observed in epilepsy. However, these rhythms are not fully exploited in the design of active implantable medical devices. In this paper we explore a new implantable stimulator that implements chronotherapy as a feedforward input to supplement both open-loop and closed-loop methods. This integrated algorithm allows for stimulation to be adjusted to the ultradian, circadian and infradian patterns observed in patients through slowly-varying temporal adjustments of stimulation and algorithm sub-components, while also enabling adaption of stimulation based on immediate physiological needs such as a breakthrough seizure or change of posture. Embedded physiological sensors in the stimulator can be used to refine the baseline stimulation circadian pattern as a "digital zeitgeber," i.e., a source of stimulus that entrains or synchronizes the subject's natural rhythms. This algorithmic approach is tested on a canine with severe drug-resistant idiopathic generalized epilepsy exhibiting a characteristic diurnal pattern correlated with sleep-wake cycles. Prior to implantation, the canine's cluster seizures evolved to status epilepticus (SE) and required emergency pharmacological intervention. The cranially-mounted system was fully-implanted bilaterally into the centromedian nucleus of the thalamus. Using combinations of time-based modulation, thalamocortical rhythm-specific tuning of frequency parameters as well as fast-adaptive modes based on activity, the canine experienced no further SE events post-implant as of the time of writing (7 months). Importantly, no significant cluster seizures have been observed either, allowing the reduction of rescue medication. The use of digitally-enabled chronotherapy as a feedforward signal to augment adaptive neurostimulators could prove a useful algorithmic method in conditions where sensitivity to temporal patterns are characteristics of the disease state, providing a novel mechanism for tailoring a more patient-specific therapy approach.
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Affiliation(s)
- Mayela Zamora
- Institute of Biomedical Engineering, Department of Engineering Science, University of Oxford, Oxford, United Kingdom
| | - Sebastian Meller
- Department of Small Animal Medicine and Surgery, University of Veterinary Medicine Hannover, Hanover, Germany
| | - Filip Kajin
- Department of Small Animal Medicine and Surgery, University of Veterinary Medicine Hannover, Hanover, Germany
| | - James J. Sermon
- Institute of Biomedical Engineering, Department of Engineering Science, University of Oxford, Oxford, United Kingdom
- MRC Brain Network Dynamics Unit, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
| | - Robert Toth
- MRC Brain Network Dynamics Unit, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
| | - Moaad Benjaber
- Institute of Biomedical Engineering, Department of Engineering Science, University of Oxford, Oxford, United Kingdom
- MRC Brain Network Dynamics Unit, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
| | - Derk-Jan Dijk
- Surrey Sleep Research Centre, University of Surrey, Guildford, United Kingdom
- UK Dementia Research Institute, Care Research and Technology Centre, Imperial College London and The University of Surrey, Guildford, United Kingdom
| | - Rafal Bogacz
- MRC Brain Network Dynamics Unit, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
| | | | - Antonio Valentin
- Department of Clinical Neurophysiology, King's College Hospital NHS Trust, London, United Kingdom
| | - Benoit Duchet
- MRC Brain Network Dynamics Unit, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
| | - Holger A. Volk
- Department of Small Animal Medicine and Surgery, University of Veterinary Medicine Hannover, Hanover, Germany
| | - Timothy Denison
- Institute of Biomedical Engineering, Department of Engineering Science, University of Oxford, Oxford, United Kingdom
- MRC Brain Network Dynamics Unit, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
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21
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Nass RD, Taube J, Bauer T, Rüber T, Surges R, Helmstaedter C. Permanent loss of independence in adult febrile-infection-related epilepsy syndrome survivors: an underestimated and unsolved challenge. Eur J Neurol 2021; 28:3061-3071. [PMID: 34091969 DOI: 10.1111/ene.14958] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Revised: 04/27/2021] [Accepted: 06/02/2021] [Indexed: 12/23/2022]
Abstract
BACKGROUND AND PURPOSE Febrile-infection-related epilepsy syndrome (FIRES) is an exceedingly rare and devastating subtype of new-onset refractory status epilepticus, which causes refractory epilepsy and permanent neurocognitive impairment. METHODS This was a long-term follow-up of adult FIRES survivors treated between 2005 and 2018 as part of the EpiCARE initiative, a European Reference Network for rare and complex epilepsies. Clinical, electroencephalography, imaging and functional outcome measures are described using the Scores of Independence for Neurologic and Geriatric Rehabilitation, the modified Rankin Scale and the Global Assessment of Severity of Epilepsy Scale. RESULTS Six patients with refractory epilepsy following FIRES were evaluated. Despite general improvement after intensive care unit discharge, disease severity was still high at follow-up in all patients. The functional outcome, as assessed by the modified Rankin Scale, was moderately impaired in 2/6 patients. In contrast, the Scores of Independence for Neurologic and Geriatric Rehabilitation indicated a loss of independence in 5/6, serious problems in memory and planning/problem-solving in 4/6 and serious attentional problems in 3/6 patients. CONCLUSIONS Febrile-infection-related epilepsy syndrome survivors may regain vital functions and mobility but experience a significant loss of independence and participation due to recurring seizures, structural brain damage and neurocognitive decline. Minimization of disastrous outcomes through the systematic evaluation of rescue therapies within a network of specialized centres is crucial.
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Affiliation(s)
| | - Julia Taube
- Department of Epileptology, University Hospital Bonn, Bonn, Germany
| | - Tobias Bauer
- Department of Epileptology, University Hospital Bonn, Bonn, Germany
| | - Theodor Rüber
- Department of Epileptology, University Hospital Bonn, Bonn, Germany
| | - Rainer Surges
- Department of Epileptology, University Hospital Bonn, Bonn, Germany
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22
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Lin WS, Hsu TR. Hypothesis: Febrile infection-related epilepsy syndrome is a microglial NLRP3 inflammasome/IL-1 axis-driven autoinflammatory syndrome. Clin Transl Immunology 2021; 10:e1299. [PMID: 34141434 PMCID: PMC8204115 DOI: 10.1002/cti2.1299] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Revised: 05/22/2021] [Accepted: 05/27/2021] [Indexed: 11/08/2022] Open
Abstract
FIRES (febrile infection-related epilepsy syndrome) is a protracted neuroinflammatory condition of obscure cause. It mainly afflicts school-age children and often leads to permanent neurological sequelae. Most treatments to date have been of limited efficacy, while ketogenic diet and anti-interleukin-1 therapy appear beneficial for some patients. Research into this clinical entity is hampered by its rarity and complexity. Nonetheless, accumulating evidence derived from basic investigations and clinical observations converges to implicate the autoinflammatory nature of this syndrome. A closer analysis of current literature suggests that microglia and the NLRP3 inflammasome might be the pivotal cellular and molecular players in FIRES pathogenesis, respectively. Through evidence synthesis, herein we formulate the working hypothesis of overactivation of microglial NLRP3 inflammasome/interleukin-1 axis as the driving event in FIRES by creating a proinflammatory and proconvulsive milieu. The reverberation between neuroinflammation and seizure forms a vicious cycle. The unique properties of microglia might also contribute to unopposed IL-1 signalling and incessant sterile neuroinflammation in this context. The potential therapeutic relevance of the proposed conceptual framework is discussed.
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Affiliation(s)
- Wei-Sheng Lin
- Department of Pediatrics Taipei Veterans General Hospital Taipei Taiwan.,Institute of Clinical Medicine and Faculty of Medicine National Yang Ming Chiao Tung University Taipei Taiwan
| | - Ting-Rong Hsu
- Department of Pediatrics Taipei Veterans General Hospital Taipei Taiwan.,Institute of Clinical Medicine and Faculty of Medicine National Yang Ming Chiao Tung University Taipei Taiwan
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23
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Towards a Treatment for Neuroinflammation in Epilepsy: Interleukin-1 Receptor Antagonist, Anakinra, as a Potential Treatment in Intractable Epilepsy. Int J Mol Sci 2021; 22:ijms22126282. [PMID: 34208064 PMCID: PMC8230637 DOI: 10.3390/ijms22126282] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Revised: 06/09/2021] [Accepted: 06/10/2021] [Indexed: 12/26/2022] Open
Abstract
Febrile Infection-Related Epilepsy Syndrome (FIRES) is a unique catastrophic epilepsy syndrome, and the development of drug-resistant epilepsy (DRE) is inevitable. Recently, anakinra, an interleukin-1 receptor antagonist (IL-1RA), has been increasingly used to treat DRE due to its potent anticonvulsant activity. We here summarized its effects in 38 patients (32 patients with FIRES and six with DRE). Of the 22 patients with FIRES, 16 (73%) had at least short-term seizure control 1 week after starting anakinra, while the remaining six suspected anakinra-refractory cases were male and had poor prognoses. Due to the small sample size, an explanation for anakinra refractoriness was not evident. In all DRE patients, seizures disappeared or improved, and cognitive function improved in five of the six patients following treatment. Patients showed no serious side effects, although drug reactions with eosinophilia and systemic symptoms, cytopenia, and infections were observed. Thus, anakinra has led to a marked improvement in some cases, and functional deficiency of IL-1RA was indicated, supporting a direct mechanism for its therapeutic effect. This review first discusses the effectiveness of anakinra for intractable epileptic syndromes. Anakinra could become a new tool for intractable epilepsy treatment. However, it does not currently have a solid evidence base.
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24
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Jain S, Potschka H, Chandra PP, Tripathi M, Vohora D. Management of COVID-19 in patients with seizures: Mechanisms of action of potential COVID-19 drug treatments and consideration for potential drug-drug interactions with anti-seizure medications. Epilepsy Res 2021; 174:106675. [PMID: 34044300 PMCID: PMC8132550 DOI: 10.1016/j.eplepsyres.2021.106675] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 04/29/2021] [Accepted: 05/14/2021] [Indexed: 12/19/2022]
Abstract
In regard to the global pandemic of COVID-19, it seems that persons with epilepsy (PWE) are not more vulnerable to get infected by SARS-CoV-2, nor are they more susceptible to a critical course of the disease. However, management of acute seizures in patients with COVID-19 as well as management of PWE and COVID-19 needs to consider potential drug-drug interactions between antiseizure drugs and candidate drugs currently assessed as therapeutic options for COVID-19. Repurposing of several licensed and investigational drugs is discussed for therapeutic management of COVID-19. While for none of these approaches, efficacy and tolerability has been confirmed yet in sufficiently powered and controlled clinical studies, testing is ongoing with multiple clinical trials worldwide. Here, we have summarized the possible mechanisms of action of drugs currently considered as potential therapeutic options for COVID-19 management along with possible and confirmed drug-drug interactions that should be considered for a combination of antiseizure drugs and COVID-19 candidate drugs. Our review suggests that potential drug-drug interactions should be taken into account with drugs such as chloroquine/hydroxychloroquine and lopinavir/ritonavir while remdesivir and tocilizumab may be less prone to clinically relevant interactions with ASMs.
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Affiliation(s)
- Shreshta Jain
- Department of Pharmacology, School of Pharmaceutical Education and Research, Jamia Hamdard, New Delhi, India
| | - Heidrun Potschka
- Institute of Pharmacology, Toxicology, and Pharmacy, Ludwig-Maximilians-University (LMU), Königinstr. 16, D-80539, Munich, Germany
| | | | - Manjari Tripathi
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - Divya Vohora
- Department of Pharmacology, School of Pharmaceutical Education and Research, Jamia Hamdard, New Delhi, India.
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25
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Yang JC, Harid NM, Nascimento FA, Kokkinos V, Shaughnessy A, Lam AD, Westover MB, Leslie-Mazwi TM, Hochberg LR, Rosenthal ES, Cole AJ, Richardson RM, Cash SS. Responsive neurostimulation for focal motor status epilepticus. Ann Clin Transl Neurol 2021; 8:1353-1361. [PMID: 33955717 PMCID: PMC8164849 DOI: 10.1002/acn3.51318] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Revised: 01/09/2021] [Accepted: 01/25/2021] [Indexed: 12/12/2022] Open
Abstract
No clear evidence‐based treatment paradigm currently exists for refractory and super‐refractory status epilepticus, which can result in significant mortality and morbidity. While patients are typically treated with antiepileptic drugs and anesthetics, neurosurgical neuromodulation techniques can also be considered. We present a novel case in which responsive neurostimulation was used to effectively treat a patient who had developed super‐refractory status epilepticus, later consistent with epilepsia partialis continua, that was refractory to antiepileptic drugs, immunomodulatory therapies, and transcranial magnetic stimulation. This case demonstrates how regional therapy provided by responsive neurostimulation can be effective in treating super‐refractory status epilepticus through neuromodulation of seizure networks.
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Affiliation(s)
- Jimmy C Yang
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.,Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Nitish M Harid
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Fábio A Nascimento
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Vasileios Kokkinos
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Abigail Shaughnessy
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Alice D Lam
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.,Center for Neurotechnology and Neurorecovery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - M Brandon Westover
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Thabele M Leslie-Mazwi
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.,Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Leigh R Hochberg
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.,Center for Neurotechnology and Neurorecovery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Eric S Rosenthal
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.,Center for Neurotechnology and Neurorecovery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Andrew J Cole
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Robert M Richardson
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.,Center for Neurotechnology and Neurorecovery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Sydney S Cash
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.,Center for Neurotechnology and Neurorecovery, Massachusetts General Hospital, Boston, Massachusetts, USA
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26
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Mantoan Ritter L, Nashef L. New-onset refractory status epilepticus (NORSE). Pract Neurol 2021; 21:practneurol-2020-002534. [PMID: 33674412 DOI: 10.1136/practneurol-2020-002534] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/24/2021] [Indexed: 11/04/2022]
Abstract
New-onset refractory status epilepticus and its subcategory febrile infection-related epilepsy syndrome are rare devastating clinical presentations in those without pre-existing relevant history, often in schoolchildren or young adults, without a clear cause on initial investigations. A cause is later identified in up to half of adults, but in many fewer children. Patients often require protracted intensive care and are at significant risk of dying. Functional disability is common and subsequent chronic epilepsy is the norm, but some people do have good outcomes, even after prolonged status epilepticus. Patients need prompt investigations and treatment. Anaesthetic and antiseizure medications are supplemented by other treatment modalities, including the ketogenic diet. Despite limited evidence, it is appropriate to try to modify the presumed underlying pathogenesis with immune modulation early, with a more recent focus on using interleukin inhibitors. Optimising management will require concerted multicentre international efforts.
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Affiliation(s)
- Laura Mantoan Ritter
- Department of Neurology, King's College Hospital, London, UK
- Maurice Wohl Clinical Neuroscience Institute, King's College London, London, UK
| | - Lina Nashef
- Department of Neurology, King's College Hospital, London, UK
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27
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Koh S, Wirrell E, Vezzani A, Nabbout R, Muscal E, Kaliakatsos M, Wickström R, Riviello JJ, Brunklaus A, Payne E, Valentin A, Wells E, Carpenter JL, Lee K, Lai Y, Eschbach K, Press CA, Gorman M, Stredny CM, Roche W, Mangum T. Proposal to optimize evaluation and treatment of Febrile infection-related epilepsy syndrome (FIRES): A Report from FIRES workshop. Epilepsia Open 2021; 6:62-72. [PMID: 33681649 PMCID: PMC7918329 DOI: 10.1002/epi4.12447] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Revised: 11/03/2020] [Accepted: 11/13/2020] [Indexed: 12/23/2022] Open
Abstract
Febrile infection-related epilepsy syndrome (FIRES) is a rare catastrophic epileptic encephalopathy that presents suddenly in otherwise normal children and young adults causing significant neurological disability, chronic epilepsy, and high rates of mortality. To suggest a therapy protocol to improve outcome of FIRES, workshops were held in conjunction with American Epilepsy Society annual meeting between 2017 and 2019. An international group of pediatric epileptologists, pediatric neurointensivists, rheumatologists and basic scientists with interest and expertise in FIRES convened to propose an algorithm for a standardized approach to the diagnosis and treatment of FIRES. The broad differential for refractory status epilepticus (RSE) should include FIRES, to allow empiric therapies to be started early in the clinical course. FIRES should be considered in all previously healthy patients older than two years of age who present with explosive onset of seizures rapidly progressing to RSE, following a febrile illness in the preceding two weeks. Once FIRES is suspected, early administrations of ketogenic diet and anakinra (the IL-1 receptor antagonist that blocks biologic activity of IL-1β) are recommended.
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Affiliation(s)
- Sookyong Koh
- Department of PediatricsEmory University School of MedicineAtlantaGAUSA
| | - Elaine Wirrell
- Child and Adolescent Neurology and EpilepsyMayo ClinicRochesterMNUSA
| | - Annamaria Vezzani
- Department of NeuroscienceInstituto di Ricerche Farmacologiche Mario Negri IRCCSMilanItaly
| | - Rima Nabbout
- Reference Centre for Rare EpilepsiesDepartment of Pediatric NeurologyNecker Enfants Malades Hospital, APHPImagine InstituteParis Descartes UniversityParisFrance
| | - Eyal Muscal
- Department of PediatricsSection of Pediatric, RheumatologyBaylor College of MedicineHoustonTXUSA
| | - Marios Kaliakatsos
- Department of NeurologyGreat Ormond Street Hospital for ChildrenLondonUK
| | - Ronny Wickström
- Neuropediatric UnitDepartment of Women's and Children's HealthKarolinska InstituteStockholmSweden
| | | | - Andreas Brunklaus
- Paediatric Neurosciences Research GroupRoyal Hospital for ChildrenGlasgowUK
| | - Eric Payne
- Child and Adolescent Neurology and EpilepsyMayo ClinicRochesterMNUSA
| | - Antonio Valentin
- Department of Basic and Clinical Neuroscience, Psychology and NeuroscienceDepartment of Clinical NeurophysiologyKing's College Hospital NHS TrustLondonUK
| | - Elizabeth Wells
- Center for Neuroscience and Behavioral MedicineChildren’s National Health SystemWashingtonDCUSA
| | - Jessica L. Carpenter
- Center for Neuroscience and Behavioral MedicineChildren’s National Health SystemWashingtonDCUSA
| | - Kihyeong Lee
- Comprehensive Epilepsy CenterAdvent Health for ChildrenOrlandoFLUSA
| | - Yi‐Chen Lai
- Jan and Dan Duncan Neurological Research InstituteBaylor College of MedicineHoustonTXUSA
| | - Krista Eschbach
- Department of PediatricsSection of NeurologyUniversity of Colorado DenverDenverCOUSA
| | - Craig A. Press
- Department of PediatricsSection of NeurologyUniversity of Colorado DenverDenverCOUSA
| | - Mark Gorman
- Department of NeurologyBoston Children’s HospitalBostonMAUSA
| | | | - William Roche
- Department of PediatricsEmory University School of MedicineAtlantaGAUSA
| | - Tara Mangum
- Department of PediatricsPhoenix Children’s HospitalPhoenixAZUSA
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28
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Johannessen Landmark C, Potschka H, Auvin S, Wilmshurst JM, Johannessen SI, Kasteleijn-Nolst Trenité D, Wirrell EC. The role of new medical treatments for the management of developmental and epileptic encephalopathies: Novel concepts and results. Epilepsia 2021; 62:857-873. [PMID: 33638459 DOI: 10.1111/epi.16849] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 01/28/2021] [Accepted: 01/30/2021] [Indexed: 12/20/2022]
Abstract
Developmental and epileptic encephalopathies (DEEs) are among the most challenging of all epilepsies to manage, given the exceedingly frequent and often severe seizure types, pharmacoresistance to conventional antiseizure medications, and numerous comorbidities. During the past decade, efforts have focused on development of new treatment options for DEEs, with several recently approved in the United States or Europe, including cannabidiol as an orphan drug in Dravet and Lennox-Gastaut syndromes and everolimus as a possible antiepileptogenic and precision drug for tuberous sclerosis complex, with its impact on the mammalian target of rapamycin pathway. Furthermore, fenfluramine, an old drug, was repurposed as a novel therapy in the treatment of Dravet syndrome. The evolution of new insights into pathophysiological processes of various DEEs provides possibilities to investigate novel and repurposed drugs and to place them into the context of their role in future management of these patients. The purpose of this review is to provide an overview of these new medical treatment options for the DEEs and to discuss the clinical implications of these results for improved treatment.
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Affiliation(s)
- Cecilie Johannessen Landmark
- Program for Pharmacy, Department of Life Sciences and Health, Faculty of Health Sciences, Oslo Metropolitan University, Oslo, Norway.,National Center for Epilepsy, Oslo University Hospital, Oslo, Norway.,Section for Clinical Pharmacology, Department of Pharmacology, Oslo University Hospital, Oslo, Norway
| | - Heidrun Potschka
- Institute of Pharmacology, Toxicology, and Pharmacy, Ludwig Maximilian University of Munich, Munich, Germany
| | - Stéphane Auvin
- Pediatric Neurology Department, Robert Debré Hospital, Public Hospital Network of Paris, Paris, France.,Mixed Unit of Research NeuroDiderot U1141, University of Paris, Paris, France
| | - Jo M Wilmshurst
- Paediatric Neurology Department, Red Cross War Memorial Children's Hospital, Neuroscience Institute, University of Cape Town, Cape Town, South Africa
| | - Svein I Johannessen
- National Center for Epilepsy, Oslo University Hospital, Oslo, Norway.,Section for Clinical Pharmacology, Department of Pharmacology, Oslo University Hospital, Oslo, Norway
| | | | - Elaine C Wirrell
- Divisions of Child and Adolescent Neurology and Epilepsy, Mayo Clinic, Rochester, Minnesota, USA
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29
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The role of inflammatory mediators in epilepsy: Focus on developmental and epileptic encephalopathies and therapeutic implications. Epilepsy Res 2021; 172:106588. [PMID: 33721708 DOI: 10.1016/j.eplepsyres.2021.106588] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 01/28/2021] [Accepted: 02/16/2021] [Indexed: 02/06/2023]
Abstract
In recent years, there has been an increasing interest in the potential involvement of neuroinflammation in the pathogenesis of epilepsy. Specifically, the role of innate immunity (that includes cytokines and chemokines) has been extensively investigated either in animal models of epilepsy and in clinical settings. Developmental and epileptic encephalopathies (DEE) are a heterogeneous group of epileptic disorders, in which uncontrolled epileptic activity results in cognitive, motor and behavioral impairment. By definition, epilepsy in DEE is poorly controlled by common antiepileptic drugs but may respond to alternative treatments, including steroids and immunomodulatory drugs. In this review, we will focus on how cytokines and chemokines play a role in the pathogenesis of DEE and why expanding our knowledge about the role of neuroinflammation in DEE may be crucial to develop new and effective targeted therapeutic strategies to prevent seizure recurrence and developmental regression.
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30
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Low frequency centromedian thalamic nuclei deep brain stimulation for the treatment of super refractory status epilepticus: A case report and a review of the literature. Brain Stimul 2020; 14:226-229. [PMID: 33388465 DOI: 10.1016/j.brs.2020.12.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Revised: 11/26/2020] [Accepted: 12/28/2020] [Indexed: 11/21/2022] Open
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31
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Lai Y, Muscal E, Wells E, Shukla N, Eschbach K, Hyeong Lee K, Kaliakatsos M, Desai N, Wickström R, Viri M, Freri E, Granata T, Nangia S, Dilena R, Brunklaus A, Wainwright MS, Gorman MP, Stredny CM, Asiri A, Hundallah K, Doja A, Payne E, Wirrell E, Koh S, Carpenter JL, Riviello J. Anakinra usage in febrile infection related epilepsy syndrome: an international cohort. Ann Clin Transl Neurol 2020; 7:2467-2474. [PMID: 33506622 PMCID: PMC7732241 DOI: 10.1002/acn3.51229] [Citation(s) in RCA: 72] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 10/02/2020] [Accepted: 10/04/2020] [Indexed: 12/31/2022] Open
Abstract
Febrile-infection related epilepsy syndrome (FIRES) is a devastating neurological condition characterized by a febrile illness preceding new onset refractory status epilepticus (NORSE). Increasing evidence suggests innate immune dysfunction as a potential pathological mechanism. We report an international retrospective cohort of 25 children treated with anakinra, a recombinant interleukin-1 receptor antagonist, as an immunomodulator for FIRES. Anakinra was potentially safe with only one child discontinuing therapy due to infection. Earlier anakinra initiation was associated with shorter duration of mechanical ventilation, ICU and hospital length of stay. Our retrospective data lay the groundwork for prospective consensus-driven cohort studies of anakinra in FIRES.
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Affiliation(s)
- Yi‐Chen Lai
- Baylor College of Medicine/Texas Children's HospitalHoustonTexasUSA
| | - Eyal Muscal
- Baylor College of Medicine/Texas Children's HospitalHoustonTexasUSA
| | - Elizabeth Wells
- Children's National Health SystemWashingtonDistrict of ColumbiaUSA
| | - Nikita Shukla
- Baylor College of Medicine/Texas Children's HospitalHoustonTexasUSA
| | - Krista Eschbach
- Department of PediatricsSection of NeurologyChildren's Hospital ColoradoUniversity of ColoradoAuroraColoradoUSA
| | - Ki Hyeong Lee
- AdventHealthChild Neurology and Comprehensive Epilepsy CenterOrlandoFloridaUSA
| | | | - Nevedita Desai
- Neurosciences DepartmentGreat Ormond Street HospitalLondonUK
| | - Ronny Wickström
- Department of Women's and Children's HealthKarolinska University HospitalNeuropediatric UnitStockholmSweden
| | - Maurizio Viri
- Childhood Neuropsychiatric DepartmentUniversity Hospital Maggiore della CaritàNovaraItaly
| | - Elena Freri
- Department of Pediatric NeuroscienceFONDAZIONE IRCCS ISTITUTO NEUROLOGICO "CARLO BESTA"MilanItaly
| | - Tiziana Granata
- Department of Pediatric NeuroscienceFONDAZIONE IRCCS ISTITUTO NEUROLOGICO "CARLO BESTA"MilanItaly
| | - Srishti Nangia
- New York Presbyterian Hospital‐Weill Cornell Medical CollegeNYCNew YorkNew YorkUSA
| | - Robertino Dilena
- Clinical NeurophysiologyFondazione IRCCS Ca' Granda Ospedale Maggiore PoliclinicoMilanItaly
- Department of NeurosciencesRehabilitation, Ophthalmology, Genetics, Maternal and Child HealthUniversity of GenovaGenovaItaly
| | - Andreas Brunklaus
- Fraser of Allander Neurosciences UnitRoyal Hospital for ChildrenGlasgowUK
| | | | - Mark P. Gorman
- Department of NeurologyPediatric Multiple Sclerosis and Related Disorders ProgramBoston Children's HospitalHarvard Medical SchoolBostonMassachusettsUSA
| | - Coral M. Stredny
- Department of NeurologyPediatric Multiple Sclerosis and Related Disorders ProgramBoston Children's HospitalHarvard Medical SchoolBostonMassachusettsUSA
| | - Abdurhman Asiri
- Prince Sultan Medical Military City (PSMMC)RiyadhSaudi Arabia
| | | | - Asif Doja
- Division of NeurologyCHEO Research InstituteFaculty of MedicineUniversity of OttawaOttawaCanada
| | - Eric Payne
- Divisions of NeurologyDepartment of PediatricsAlberta Children’s HospitalCalgaryAlbertaCanada
| | - Elaine Wirrell
- Divisions of Child and Adolescent Neurology and EpilepsyDepartment of Pediatric NeurologyMayo ClinicRochesterMinnesotaUSA
| | - Sookyong Koh
- Division of NeurologyDepartment of PediatricsEmory University School of MedicineAtlantaGeorgiaUSA
| | | | - James Riviello
- Baylor College of Medicine/Texas Children's HospitalHoustonTexasUSA
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32
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Bialer M, Johannessen SI, Koepp MJ, Levy RH, Perucca E, Perucca P, Tomson T, White HS. Progress report on new antiepileptic drugs: A summary of the Fifteenth Eilat Conference on New Antiepileptic Drugs and Devices (EILAT XV). II. Drugs in more advanced clinical development. Epilepsia 2020; 61:2365-2385. [PMID: 33165915 DOI: 10.1111/epi.16726] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 09/20/2020] [Accepted: 09/21/2020] [Indexed: 12/16/2022]
Abstract
The Fifteenth Eilat Conference on New Antiepileptic Drugs and Devices (EILAT XV) was held as a fully virtual conference from July 27 to July 30, 2020 for the sessions on drugs, and on August 3, 2020 for the sessions on devices. A total of 534 delegates from 63 countries attended lectures and interactive discussions, representing a broad range of disciplines from basic science, clinical research, and clinical care. This progress report provides summaries of recent findings on investigational compounds for which preclinical data as well as data from patient studies were presented. The report includes the following five compounds: anakinra, cenobamate, CVL-865, fenfluramine, and ganaxolone, all with novel modes of action compared to more established antiepileptic drugs. Some of these compounds demonstrated promising results in placebo-controlled phase 3 trials, and two have recently received approval from the US Food and Drug Administration (FDA). These include cenobamate, which was approved by the FDA on November 21, 2019 for the treatment of partial onset (focal) seizures in adults, and fenfluramine oral solution, which was approved by the FDA on June 25, 2020 for the treatment of seizures associated with Dravet syndrome in patients 2 years and older.
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Affiliation(s)
- Meir Bialer
- Faculty of Medicine, School of Pharmacy and David R. Bloom Center for Pharmacy, Institute for Drug Research, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Svein I Johannessen
- National Center for Epilepsy, Sandvika, Norway.,Department of Pharmacology, Oslo University Hospital, Oslo, Norway
| | - Matthias J Koepp
- Department of Clinical and Experimental Epilepsy, UCL Institute of Neurology, London, UK
| | - René H Levy
- Department of Pharmaceutics and Neurological Surgery, University of Washington, Seattle, WA, USA
| | - Emilio Perucca
- Department of Internal Medicine and Therapeutics, University of Pavia, Pavia, Italy.,IRCCS Mondino Foundation, Pavia, Italy
| | - Piero Perucca
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia.,Department of Medicine and Neurology, Royal Melbourne Hospital, University of Melbourne, Melbourne, Victoria, Australia.,Department of Neurology, Alfred Health, Melbourne, Victoria, Australia
| | - Torbjörn Tomson
- Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
| | - H Steve White
- Department of Pharmacy, School of Pharmacy, University of Washington, Seattle, WA, USA
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Koh S, Dupuis N, Auvin S. Ketogenic diet and Neuroinflammation. Epilepsy Res 2020; 167:106454. [DOI: 10.1016/j.eplepsyres.2020.106454] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 07/26/2020] [Accepted: 09/01/2020] [Indexed: 12/13/2022]
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Maniscalco V, Abu-Rumeileh S, Mastrolia MV, Marrani E, Maccora I, Pagnini I, Simonini G. The off-label use of anakinra in pediatric systemic autoinflammatory diseases. Ther Adv Musculoskelet Dis 2020; 12:1759720X20959575. [PMID: 33149772 PMCID: PMC7580132 DOI: 10.1177/1759720x20959575] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 08/26/2020] [Indexed: 12/19/2022] Open
Abstract
Interleukin 1 (IL-1), a central mediator of innate immunity, is considered a master cytokine of local and systemic inflammation. IL-1 has emerged as pivotal in the pathogenesis of autoinflammatory diseases (AIDs), and blockade of its pathway has become a crucial target for therapy. Anakinra (ANA), a recombinant IL-1β receptor antagonist, was the first anti-IL-1 agent employed in clinical practice. ANA is currently approved for the treatment of rheumatoid arthritis, systemic juvenile idiopathic arthritis, adult-onset Still’s disease, and cryopyrin-associated autoinflammatory syndrome. It has also been successfully used for off-label treatment of various monogenic, polygenic, or undefined etiology systemic AIDs. This review describes currently available evidence for the off-label use of ANA in pediatric rheumatologic diseases. Specifically, the use of ANA in Kawasaki disease, idiopathic recurrent pericarditis, Behçet disease, monogenic AIDs, undifferentiated AIDs, chronic non-bacterial osteomyelitis, macrophage activation syndrome, and febrile infection-related epilepsy, in terms of its safety and efficacy. In selected pediatric rheumatic disorders, the off-label administration of ANA appears to be effective and safe. In order to control severe and/or relapsing disease, ANA should be considered as a valuable treatment option in children suffering from rare inflammatory diseases. However, currently available data consist of retrospective studies and short case series; thus, randomized controlled trials and larger series with long-term follow up are mandatory to better assess the efficacy and cost effectiveness of ANA in these challenging patients.
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Affiliation(s)
- Valerio Maniscalco
- Rheumatology Unit, Meyer Children's University Hospital, Florence, Italy
| | - Sarah Abu-Rumeileh
- Rheumatology Unit, Meyer Children's University Hospital, Florence, Italy
| | | | - Edoardo Marrani
- Rheumatology Unit, Meyer Children's University Hospital, Florence, Italy
| | - Ilaria Maccora
- Rheumatology Unit, Meyer Children's University Hospital, Florence, Italy
| | - Ilaria Pagnini
- Rheumatology Unit, Meyer Children's University Hospital, Florence, Italy
| | - Gabriele Simonini
- Rheumatology Unit, Meyer Children's University Hospital, Viale Gaetano Pieraccini, 24, Firenze, Toscana 50139, Italy
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Löscher W, Potschka H, Sisodiya SM, Vezzani A. Drug Resistance in Epilepsy: Clinical Impact, Potential Mechanisms, and New Innovative Treatment Options. Pharmacol Rev 2020; 72:606-638. [PMID: 32540959 PMCID: PMC7300324 DOI: 10.1124/pr.120.019539] [Citation(s) in RCA: 334] [Impact Index Per Article: 83.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Epilepsy is a chronic neurologic disorder that affects over 70 million people worldwide. Despite the availability of over 20 antiseizure drugs (ASDs) for symptomatic treatment of epileptic seizures, about one-third of patients with epilepsy have seizures refractory to pharmacotherapy. Patients with such drug-resistant epilepsy (DRE) have increased risks of premature death, injuries, psychosocial dysfunction, and a reduced quality of life, so development of more effective therapies is an urgent clinical need. However, the various types of epilepsy and seizures and the complex temporal patterns of refractoriness complicate the issue. Furthermore, the underlying mechanisms of DRE are not fully understood, though recent work has begun to shape our understanding more clearly. Experimental models of DRE offer opportunities to discover, characterize, and challenge putative mechanisms of drug resistance. Furthermore, such preclinical models are important in developing therapies that may overcome drug resistance. Here, we will review the current understanding of the molecular, genetic, and structural mechanisms of ASD resistance and discuss how to overcome this problem. Encouragingly, better elucidation of the pathophysiological mechanisms underpinning epilepsies and drug resistance by concerted preclinical and clinical efforts have recently enabled a revised approach to the development of more promising therapies, including numerous potential etiology-specific drugs (“precision medicine”) for severe pediatric (monogenetic) epilepsies and novel multitargeted ASDs for acquired partial epilepsies, suggesting that the long hoped-for breakthrough in therapy for as-yet ASD-resistant patients is a feasible goal.
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Affiliation(s)
- Wolfgang Löscher
- Department of Pharmacology, Toxicology, and Pharmacy, University of Veterinary Medicine, Hannover, Germany (W.L.); Center for Systems Neuroscience, Hannover, Germany (W.L.); Institute of Pharmacology, Toxicology and Pharmacy, Ludwig-Maximilians-University, Munich, Germany (H.P.); Department of Clinical and Experimental Epilepsy, UCL Queen Square Institute of Neurology, London, United Kingdom (S.S); and Department of Neuroscience, Mario Negri Institute for Pharmacological Research Istituto di Ricovero e Cura a Carattere Scientifico, Milano, Italy (A.V.)
| | - Heidrun Potschka
- Department of Pharmacology, Toxicology, and Pharmacy, University of Veterinary Medicine, Hannover, Germany (W.L.); Center for Systems Neuroscience, Hannover, Germany (W.L.); Institute of Pharmacology, Toxicology and Pharmacy, Ludwig-Maximilians-University, Munich, Germany (H.P.); Department of Clinical and Experimental Epilepsy, UCL Queen Square Institute of Neurology, London, United Kingdom (S.S); and Department of Neuroscience, Mario Negri Institute for Pharmacological Research Istituto di Ricovero e Cura a Carattere Scientifico, Milano, Italy (A.V.)
| | - Sanjay M Sisodiya
- Department of Pharmacology, Toxicology, and Pharmacy, University of Veterinary Medicine, Hannover, Germany (W.L.); Center for Systems Neuroscience, Hannover, Germany (W.L.); Institute of Pharmacology, Toxicology and Pharmacy, Ludwig-Maximilians-University, Munich, Germany (H.P.); Department of Clinical and Experimental Epilepsy, UCL Queen Square Institute of Neurology, London, United Kingdom (S.S); and Department of Neuroscience, Mario Negri Institute for Pharmacological Research Istituto di Ricovero e Cura a Carattere Scientifico, Milano, Italy (A.V.)
| | - Annamaria Vezzani
- Department of Pharmacology, Toxicology, and Pharmacy, University of Veterinary Medicine, Hannover, Germany (W.L.); Center for Systems Neuroscience, Hannover, Germany (W.L.); Institute of Pharmacology, Toxicology and Pharmacy, Ludwig-Maximilians-University, Munich, Germany (H.P.); Department of Clinical and Experimental Epilepsy, UCL Queen Square Institute of Neurology, London, United Kingdom (S.S); and Department of Neuroscience, Mario Negri Institute for Pharmacological Research Istituto di Ricovero e Cura a Carattere Scientifico, Milano, Italy (A.V.)
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Deep brain stimulation for the treatment of refractory and super-refractory status epilepticus. Seizure 2020; 81:58-62. [DOI: 10.1016/j.seizure.2020.07.022] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Revised: 07/21/2020] [Accepted: 07/23/2020] [Indexed: 02/06/2023] Open
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Cukiert A, Cukiert CM, Burattini JA, Mariani PP. Seizure outcome during bilateral, continuous, thalamic centromedian nuclei deep brain stimulation in patients with generalized epilepsy: a prospective, open-label study. Seizure 2020; 81:304-309. [PMID: 32947179 DOI: 10.1016/j.seizure.2020.08.028] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 08/22/2020] [Accepted: 08/25/2020] [Indexed: 12/28/2022] Open
Abstract
OBJECTIVE We report on the seizure frequency and attention outcome during thalamic centromedian stimulation (CM-DBS) in patients with refractory generalized epilepsy (GE). METHODS Twenty consecutive patients with GE who were submitted to CM-DBS and had at least one year of follow-up were prospectively studied. The CM was targeted bilaterally. Stimulation intensity was ramped up (bipolar, continuous, 130 Hz; 300μsec) until 4.5 V or until side effects developed. Contacts` position was determined on postoperative volumetric MRI scans. Attention was qualitatively evaluated using the SNAP-IV (Swanson, Nolan, and Pelham) questionnaire. Patients were considered responders during CM-DBS if an at least 50% seizure frequency reduction was obtained compared to baseline. RESULTS Median age was 15.5 years (13 males). Median follow-up time was 2.55 years. EEG disclosed generalized spike-and wave discharges in all patients. MRI was normal in 10 patients, showed diffuse atrophy in 6 patients, and showed abnormalities in 4 patients (3 patients had bilateral cortical development abnormalities and one had unilateral hemispheric atrophy). Patients presented with daily multiple seizure types (8 to 66 per day; median: 37), including tonic, atonic, myoclonic, atypical absence and generalized tonic-clonic seizures. Mean DBS intensity was 4.3 V. An insertional effect was noted in 14 patients. CM-DBS was able to significantly reduce the frequency of tonic (p < 0.001), atypical absence seizures (p < 0.001), atonic seizures (p = 0.001) and bilateral generalized tonic-clonic seizures (p = 0.004). One patient became seizure-free. Ninety percent of the patients were considered responders (>50% seizure frequency reduction). All patients showed some improvement in attention. The mean number of items in which improvement was noted in the SNAP-IV questionnaire was 4.8. There was a significant relationship between overall seizure frequency reduction and improvement of attention (p = 0.033). DISCUSSION This prospective, open label study included a large, homogeneous cohort and provided evidence on the efficacy of CM-DBS in reducing the seizure burden and increasing attention in patients with refractory generalized epilepsy.
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Specchio N, Pietrafusa N. New-onset refractory status epilepticus and febrile infection-related epilepsy syndrome. Dev Med Child Neurol 2020; 62:897-905. [PMID: 32372459 DOI: 10.1111/dmcn.14553] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/19/2020] [Indexed: 12/11/2022]
Abstract
New-onset refractory status epilepticus (NORSE) and febrile infection-related epilepsy syndrome (FIRES) are relatively rare clinical presentations. They are characterized by de novo onset of refractory status epilepticus (RSE) without clearly identifiable acute or active cause (structural, toxic, or metabolic). We reviewed the literature using PubMed reports published between 2003 and 2019 and summarized the clinical, neurophysiological, imaging, and treatment findings. Focal motor seizures, which tend to evolve into status epilepticus, characterize the typical presentation. Disease course is biphasic: acute phase followed by chronic phase with refractory epilepsy and neurological impairment. Aetiology is unknown, but immune-inflammatory-mediated epileptic encephalopathy is suspected. Electroencephalograms show variety in discharges (sporadic or periodic, focal, generalized, or more frequently bilateral), sometimes with a multifocal pattern. About 70% of adult NORSE have abnormal magnetic resonance imaging (MRI); in paediatric series of FIRES, 61.2% of patients have a normal brain MRI at the beginning and only 18.5% during the chronic phase. No specific therapy for FIRES and NORSE currently exists; high doses of barbiturates and ketogenic diet can be used with some effectiveness. Recently, anakinra and tocilizumab, targeting interleukin pathways, have emerged as potential specific therapies. Mortality rate is around 12% in children and even higher in adults (16-27%).
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Affiliation(s)
- Nicola Specchio
- Rare and Complex Epilepsy Unit, Department of Neuroscience and Neurorehabilitation, Bambino Gesù Children Hospital, Rome, Italy.,European Reference Network EpiCARE, Rome, Italy
| | - Nicola Pietrafusa
- Rare and Complex Epilepsy Unit, Department of Neuroscience and Neurorehabilitation, Bambino Gesù Children Hospital, Rome, Italy
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Helbig I, Barcia G, Pendziwiat M, Ganesan S, Mueller SH, Helbig KL, Vaidiswaran P, Xian J, Galer PD, Afawi Z, Specchio N, Kluger G, Kuhlenbäumer G, Appenzeller S, Wittig M, Kramer U, van Baalen A, Nabbout R. Whole-exome and HLA sequencing in Febrile infection-related epilepsy syndrome. Ann Clin Transl Neurol 2020; 7:1429-1435. [PMID: 32666661 PMCID: PMC7448193 DOI: 10.1002/acn3.51062] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 04/23/2020] [Accepted: 04/26/2020] [Indexed: 12/12/2022] Open
Abstract
Febrile infection‐related epilepsy syndrome (FIRES) is a devastating epilepsy characterized by new‐onset refractory status epilepticus with a prior febrile infection. We performed exome sequencing in 50 individuals with FIRES, including 27 patient–parent trios and 23 single probands, none of whom had pathogenic variants in established genes for epilepsies or neurodevelopmental disorders. We also performed HLA sequencing in 29 individuals with FIRES and 529 controls, which failed to identify prominent HLA alleles. The genetic architecture of FIRES is substantially different from other developmental and epileptic encephalopathies, and the underlying etiology remains elusive, requiring novel approaches to identify the underlying causative factors.
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Affiliation(s)
- Ingo Helbig
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,The Epilepsy NeuroGenetics Initiative (ENGIN), Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Department of Neurology, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Giulia Barcia
- Reference Centre for Rare Epilepsies, Department of Pediatric Neurology, Necker Enfants Malades Hospital, Paris Descartes University, Paris, France.,Laboratory of Translational Research for Neurological Disorders, Institute Imagine, Paris, France.,Department of Genetics, Necker Enfants Malades Hospital, Imagine Institute, Paris, France
| | - Manuela Pendziwiat
- Department of Neuropediatrics, University Medical Center Schleswig-Holstein, Christian-Albrechts University, Kiel, Germany
| | - Shiva Ganesan
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,The Epilepsy NeuroGenetics Initiative (ENGIN), Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Stefanie H Mueller
- Institute of Health Informatics, UCL, London, UK.,Department of Neurology, University Hospital Schleswig Holstein, Kiel, Germany
| | - Katherine L Helbig
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,The Epilepsy NeuroGenetics Initiative (ENGIN), Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Priya Vaidiswaran
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,The Epilepsy NeuroGenetics Initiative (ENGIN), Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Department of Neurology, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Julie Xian
- Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Peter D Galer
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,The Epilepsy NeuroGenetics Initiative (ENGIN), Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Zaid Afawi
- Sackler School of Medicine, Tel-Aviv University, Ramat Aviv, Israel.,Department of Psychiatry, Tel-Aviv University, Ramat Aviv, Israel.,Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Nicola Specchio
- Neurology Unit, Department of Neuroscience, Bambino Gesù Children's Hospital, IRCCS, Roma, Italy
| | - Gerhard Kluger
- Neuropediatric Clinic and Clinic for Neurorehabilitation, Epilepsy Center for Children and Adolescents, Vogtareuth, Germany.,Research Institute Rehabilitation/Transition/Palliation, PMU Salzburg, Salzburg, Austria
| | - Gregor Kuhlenbäumer
- Department of Neurology, University Hospital Schleswig Holstein, Kiel, Germany
| | - Silke Appenzeller
- Comprehensive Cancer Center Mainfranken, University Hospital Würzburg, Würzburg, Germany
| | - Michael Wittig
- Institute of Clinical Molecular Biology, Christian-Albrechts-University of Kiel, Kiel, Germany
| | - Uri Kramer
- Pediatric Neurology Center, Dana-Dwek Children's Hospital, Tel Aviv Medical Center, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Andreas van Baalen
- Department of Neuropediatrics, University Medical Center Schleswig-Holstein, Christian-Albrechts University, Kiel, Germany
| | - Rima Nabbout
- Reference Centre for Rare Epilepsies, Department of Pediatric Neurology, Necker Enfants Malades Hospital, Paris Descartes University, Paris, France.,Laboratory of Translational Research for Neurological Disorders, Institute Imagine, Paris, France.,Universite Paris Descartes -Sorbonne Paris City, Imagine Institute, Paris, France
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Klein P, Friedman A, Hameed MQ, Kaminski RM, Bar-Klein G, Klitgaard H, Koepp M, Jozwiak S, Prince DA, Rotenberg A, Twyman R, Vezzani A, Wong M, Löscher W. Repurposed molecules for antiepileptogenesis: Missing an opportunity to prevent epilepsy? Epilepsia 2020; 61:359-386. [PMID: 32196665 PMCID: PMC8317585 DOI: 10.1111/epi.16450] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Revised: 01/26/2020] [Accepted: 01/27/2020] [Indexed: 12/11/2022]
Abstract
Prevention of epilepsy is a great unmet need. Acute central nervous system (CNS) insults such as traumatic brain injury (TBI), cerebrovascular accidents (CVA), and CNS infections account for 15%-20% of all epilepsy. Following TBI and CVA, there is a latency of days to years before epilepsy develops. This allows treatment to prevent or modify postinjury epilepsy. No such treatment exists. In animal models of acquired epilepsy, a number of medications in clinical use for diverse indications have been shown to have antiepileptogenic or disease-modifying effects, including medications with excellent side effect profiles. These include atorvastatin, ceftriaxone, losartan, isoflurane, N-acetylcysteine, and the antiseizure medications levetiracetam, brivaracetam, topiramate, gabapentin, pregabalin, vigabatrin, and eslicarbazepine acetate. In addition, there are preclinical antiepileptogenic data for anakinra, rapamycin, fingolimod, and erythropoietin, although these medications have potential for more serious side effects. However, except for vigabatrin, there have been almost no translation studies to prevent or modify epilepsy using these potentially "repurposable" medications. We may be missing an opportunity to develop preventive treatment for epilepsy by not evaluating these medications clinically. One reason for the lack of translation studies is that the preclinical data for most of these medications are disparate in terms of types of injury, models within different injury type, dosing, injury-treatment initiation latencies, treatment duration, and epilepsy outcome evaluation mode and duration. This makes it difficult to compare the relative strength of antiepileptogenic evidence across the molecules, and difficult to determine which drug(s) would be the best to evaluate clinically. Furthermore, most preclinical antiepileptogenic studies lack information needed for translation, such as dose-blood level relationship, brain target engagement, and dose-response, and many use treatment parameters that cannot be applied clinically, for example, treatment initiation before or at the time of injury and dosing higher than tolerated human equivalent dosing. Here, we review animal and human antiepileptogenic evidence for these medications. We highlight the gaps in our knowledge for each molecule that need to be filled in order to consider clinical translation, and we suggest a platform of preclinical antiepileptogenesis evaluation of potentially repurposable molecules or their combinations going forward.
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Affiliation(s)
- Pavel Klein
- Mid-Atlantic Epilepsy and Sleep Center, Bethesda, Maryland
| | - Alon Friedman
- Departments of Physiology and Cell Biology, and Brain and Cognitive Science, Zlotowski Center for Neuroscience, Ben-Gurion University of the Negev, Beer-Sheva, Israel
- Departments of Medical Neuroscience and Brain Repair Center, Dalhousie University, Halifax, Canada
| | - Mustafa Q. Hameed
- Neuromodulation Program, Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Rafal M. Kaminski
- Neurosymptomatic Domains Section, Roche Pharma Research & Early Development, Roche Innovation Center, Basel, Switzerland
| | - Guy Bar-Klein
- McKusick-Nathans Institute of Genetic Medicine, Howard Hughes Medical Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Henrik Klitgaard
- Neurosciences Therapeutic Area, UCB Pharma, Braine-l’Alleud, Belgium
| | - Mathias Koepp
- Department of Clinical and Experimental Epilepsy, University College London Institute of Neurology, London, UK
| | - Sergiusz Jozwiak
- Department of Pediatric Neurology, Warsaw Medical University, Warsaw, Poland
| | - David A. Prince
- Neurology and the Neurological Sciences, Stanford University School of Medicine, Stanford, California
| | - Alexander Rotenberg
- Neuromodulation Program, Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
| | | | - Annamaria Vezzani
- Department of Neuroscience, Mario Negri Institute for Pharmacological Research, Scientific Institute for Research and Health Care, Milan, Italy
| | - Michael Wong
- Department of Neurology, Washington University School of Medicine, St Louis, Missouri
| | - Wolfgang Löscher
- Department of Pharmacology, Toxicology, and Pharmacy, University of Veterinary Medicine, Hannover, Germany
- Center for Systems Neuroscience, Hannover, Germany
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Wickström R. Strategies for extinguishing FIRES. Eur J Paediatr Neurol 2019; 23:669. [PMID: 31530449 DOI: 10.1016/j.ejpn.2019.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Ronny Wickström
- Neuropaediatric Unit, Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden.
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