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Korinthenberg R, Bast T, Haberlandt E, Stephani U, Strzelczyk A, Rücker G. Efficacy and safety of corticosteroids and ACTH in epileptic syndromes beyond Infantile Epileptic Spasms Syndrome (IESS): A systematic review and meta-analysis. Epilepsia 2024; 65:1155-1175. [PMID: 38411568 DOI: 10.1111/epi.17918] [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: 12/06/2023] [Revised: 02/02/2024] [Accepted: 02/02/2024] [Indexed: 02/28/2024]
Abstract
We conducted a systematic review investigating the efficacy and tolerability of adrenocorticotropic hormone (ACTH) and corticosteroids in children with epilepsies other than infantile epileptic spasm syndrome (IESS) that are resistant to anti-seizure medication (ASM). We included retrospective and prospective studies reporting on more than five patients and with clear case definitions and descriptions of treatment and outcome measures. We searched multiple databases and registries, and we assessed the risk of bias in the selected studies using a questionnaire based on published templates. Results were summarized with meta-analyses that pooled logit-transformed proportions or rates. Subgroup analyses and univariable and multivariable meta-regressions were performed to examine the influence of covariates. We included 38 studies (2 controlled and 5 uncontrolled prospective; 31 retrospective) involving 1152 patients. Meta-analysis of aggregate data for the primary outcomes of seizure response and reduction of electroencephalography (EEG) spikes at the end of treatment yielded pooled proportions (PPs) of 0.60 (95% confidence interval [CI] 0.52-0.67) and 0.56 (95% CI 0.43-0.68). The relapse rate was high (PP 0.33, 95% CI 0.27-0.40). Group analyses and meta-regression showed a small benefit of ACTH and no difference between all other corticosteroids, a slightly better effect in electric status epilepticus in slow sleep (ESES) and a weaker effect in patients with cognitive impairment and "symptomatic" etiology. Obesity and Cushing's syndrome were the most common adverse effects, occurring more frequently in trials addressing continuous ACTH (PP 0.73, 95% CI 0.48-0.89) or corticosteroids (PP 0.72, 95% CI 0.54-0.85) than intermittent intravenous or oral corticosteroid administration (PP 0.05, 95% CI 0.02-0.10). The validity of these results is limited by the high risk of bias in most included studies and large heterogeneity among study results. This report was registered under International Prospective Register of Systematic Reviews (PROSPERO) number CRD42022313846. We received no financial support.
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Affiliation(s)
- Rudolf Korinthenberg
- Division of Neuropediatrics and Muscular Disorders, Faculty of Medicine, University Medical Center (UMC), University of Freiburg, Freiburg, Germany
| | | | - Edda Haberlandt
- Department of Pediatrics and Adolescent Medicine, Dornbirn Hospital, Dornbirn, Austria
| | - Ulrich Stephani
- Clinic for Children and Adolescents II (Neuropediatrics, Social Pediatrics), University Hospital Schleswig Holstein (UKSH), Kiel, Germany
| | - Adam Strzelczyk
- Epilepsy Center Frankfurt Rhine-Main, Department of Neurology, Goethe University and University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Gerta Rücker
- Medical Faculty and Medical Center, Institute for Medical Biometry and Statistics, University of Freiburg, Freiburg, Germany
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Falsaperla R, Collotta AD, Marino SD, Sortino V, Leonardi R, Privitera GF, Pulvirenti A, Suppiej A, Vecchi M, Verrotti A, Farello G, Spalice A, Elia M, Spitaleri O, Micale M, Mailo J, Ruggieri M. Drug resistant epilepsies: A multicentre case series of steroid therapy. Seizure 2024; 117:115-125. [PMID: 38394725 DOI: 10.1016/j.seizure.2024.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Revised: 02/12/2024] [Accepted: 02/12/2024] [Indexed: 02/25/2024] Open
Abstract
PURPOSE Our study aimed to evaluate the effectiveness of corticosteroids on seizure control in drug-resistant epilepsies (DREs). Our primary goal was to assess the response to steroids for various underlying etiologies, interictal electroencephalographic (EEG) patterns and electroclinical seizure descriptions. Our second goal was to compare steroid responsiveness to different treatment protocols. METHODS This is a retrospective multicentre cohort study conducted according to the STROBE guidelines (Strengthening the Reporting of Observational Studies in Epidemiology). The following data were collected for each patient: epilepsy etiology, interictal EEG pattern, seizure types and type of steroid treatment protocol administered. RESULTS Thirty patients with DRE were included in the study. After 6 months of therapy, 62.7 % of patients experienced reduced seizure frequency by 50 %, and 6.6 % of patients experienced complete seizure cessation. Findings associated with favourable response to steroids included structural/lesional etiology of epilepsy, immune/infectious etiology and focal interictal abnormalities on EEG. Comparing four different steroid treatment protocols, the most effective for seizure control was treatment with methylprednisolone at the dose of 30 mg/kg/day administered for 3 days, leading to greater than 50 % seizure reduction at 6 months in 85.7 % of patients. Treatment with dexamethasone 6 mg/day for 5 days decreased seizure frequency in 71.4 % of patients. Hydrocortisone 10 mg/kg administered for 3 months showed a good response to treatment in 71 %. CONCLUSIONS In our study, two-thirds of patients with DRE experienced a significant seizure reduction following treatment with steroids. We suggest considering steroids as a potential therapeutic option in children with epilepsy not responding to conventional antiseizure medicines (ASM).
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Affiliation(s)
- Raffaele Falsaperla
- Paediatric and Paediatric Emergency Department, University Hospital "Policlinico-San Marco", Catania, Italy; Unit of Intensive Care and Neonatology, University Hospital "Policlinico-San Marco", Catania, Italy.
| | - Ausilia Desiree Collotta
- Paediatric and Paediatric Emergency Department, University Hospital "Policlinico-San Marco", Catania, Italy; Department of Clinical and Experimental Medicine, Postgraduate Training Program in Pediatrics, University of Catania, Catania, Italy.
| | - Simona D Marino
- Paediatric and Paediatric Emergency Department, University Hospital "Policlinico-San Marco", Catania, Italy
| | - Vincenzo Sortino
- Paediatric and Paediatric Emergency Department, University Hospital "Policlinico-San Marco", Catania, Italy; Department of Clinical and Experimental Medicine, Postgraduate Training Program in Pediatrics, University of Catania, Catania, Italy
| | - Roberta Leonardi
- Department of Clinical and Experimental Medicine, Postgraduate Training Program in Pediatrics, University of Catania, Catania, Italy
| | - Grete Francesca Privitera
- Department of Mathematics and Computer Science, Department of Clinical and Experimental Medicine, University of Catania, c/o Viale A. Doria, 6, Catania 95125, Italy
| | - Alfredo Pulvirenti
- Department of Mathematics and Computer Science, Department of Clinical and Experimental Medicine, University of Catania, c/o Viale A. Doria, 6, Catania 95125, Italy
| | - Agnese Suppiej
- Medical Science Department (D.O.), Maternal and Child Department, Ferrara University Hospital, University of Ferrara, Italy
| | - Marilena Vecchi
- Paediatric Neurology and Neurophysiology Unit, Department of Women's and Children's Health, Padova University Hospital, Padova, Italy
| | - Alberto Verrotti
- Clinical Paediatric, University of Perugia, Hospital SM Della Misericordia, Perugia, Italy
| | - Giovanni Farello
- Clinical Paediatric, University of Perugia, Hospital SM Della Misericordia, Perugia, Italy
| | - Alberto Spalice
- Department of Paediatrics, Child Neurology and Psychiatry, Sapienza University of Rome, Rome, Italy
| | - Maurizio Elia
- Unit of Neurology and Clinical Neurophysiopathology, Oasi Research Institute, IRCCS, Troina, Italy
| | - Orazio Spitaleri
- Paediatric Neuropsychiatry Unit, Hospital " S.Marta e S.Venera", Acireale, Italy
| | - Marco Micale
- Paediatric Neuropsychiatry Unit, Maternal and Child Department, Arnas Civico, Palermo, Italy
| | - Janette Mailo
- Division of Paediatric Neurology, University of Alberta, Canada
| | - Martino Ruggieri
- Department of Clinical and Experimental Medicine, Unit of Clinical Pediatrics, Section of Pediatrics and Child Neuropsychiatry, University of Catania, Catania 95124, Italy
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Tripathi S, Nathan CL, Tate MC, Horbinski CM, Templer JW, Rosenow JM, Sita TL, James CD, Deneen B, Miller SD, Heimberger AB. The immune system and metabolic products in epilepsy and glioma-associated epilepsy: emerging therapeutic directions. JCI Insight 2024; 9:e174753. [PMID: 38193532 PMCID: PMC10906461 DOI: 10.1172/jci.insight.174753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2024] Open
Abstract
Epilepsy has a profound impact on quality of life. Despite the development of new antiseizure medications (ASMs), approximately one-third of affected patients have drug-refractory epilepsy and are nonresponsive to medical treatment. Nearly all currently approved ASMs target neuronal activity through ion channel modulation. Recent human and animal model studies have implicated new immunotherapeutic and metabolomic approaches that may benefit patients with epilepsy. In this Review, we detail the proinflammatory immune landscape of epilepsy and contrast this with the immunosuppressive microenvironment in patients with glioma-related epilepsy. In the tumor setting, excessive neuronal activity facilitates immunosuppression, thereby contributing to subsequent glioma progression. Metabolic modulation of the IDH1-mutant pathway provides a dual pathway for reversing immune suppression and dampening seizure activity. Elucidating the relationship between neurons and immunoreactivity is an area for the prioritization and development of the next era of ASMs.
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Affiliation(s)
- Shashwat Tripathi
- Department of Neurological Surgery
- Malnati Brain Tumor Institute of the Robert H. Lurie Comprehensive Cancer Center
| | | | | | - Craig M. Horbinski
- Malnati Brain Tumor Institute of the Robert H. Lurie Comprehensive Cancer Center
- Department of Pathology, and
| | | | | | - Timothy L. Sita
- Department of Neurological Surgery
- Department of Radiation Oncology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Charles D. James
- Department of Neurological Surgery
- Malnati Brain Tumor Institute of the Robert H. Lurie Comprehensive Cancer Center
| | - Benjamin Deneen
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Stephen D. Miller
- Department of Microbiology-Immunology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Amy B. Heimberger
- Department of Neurological Surgery
- Malnati Brain Tumor Institute of the Robert H. Lurie Comprehensive Cancer Center
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Becker LL, Kaindl AM. Corticosteroids in childhood epilepsies: A systematic review. Front Neurol 2023; 14:1142253. [PMID: 36970534 PMCID: PMC10036579 DOI: 10.3389/fneur.2023.1142253] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Accepted: 02/15/2023] [Indexed: 03/12/2023] Open
Abstract
Corticosteroids have been used for the treatment of patients with epilepsy for more than 6 decades, based on the hypothesis of inflammation in the genesis and/or promotion of epilepsy. We, therefore, aimed to provide a systematic overview of the use of corticosteroid regimes in childhood epilepsies in line with the PRISMA guidelines. We performed a structured literature search via PubMed and identified 160 papers with only three randomized controlled trials excluding the substantial trials on epileptic spasms. Corticosteroid regimes, duration of treatment (days to several months), and dosage protocols were highly variable in these studies. Evidence supports the use of steroids in epileptic spasms; however, there is only limited evidence for a positive effect for other epilepsy syndromes, e.g., epileptic encephalopathy with spike-and-wave activity in sleep [(D)EE-SWAS] or drug-resistant epilepsies (DREs). In (D)EE-SWAS (nine studies, 126 patients), 64% of patients showed an improvement either in the EEG or in their language/cognition following various steroid treatment regimes. In DRE (15 studies, 436 patients), a positive effect with a seizure reduction in 50% of pediatric and adult patients and seizure freedom in 15% was identified; however, no recommendation can be drawn due to the heterozygous cohort. This review highlights the immense need for controlled studies using steroids, especially in DRE, to offer patients new treatment options.
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Affiliation(s)
- Lena-Luise Becker
- Department of Pediatric Neurology, Charité – Universitätsmedizin Berlin, Berlin, Germany
- Center for Chronically Sick Children, Charité – Universitätsmedizin Berlin, Berlin, Germany
- German Epilepsy Center for Children and Adolescents, Charité – Universitätsmedizin Berlin, Berlin, Germany
- Institute of Cell- and Neurobiology, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Angela M. Kaindl
- Department of Pediatric Neurology, Charité – Universitätsmedizin Berlin, Berlin, Germany
- Center for Chronically Sick Children, Charité – Universitätsmedizin Berlin, Berlin, Germany
- German Epilepsy Center for Children and Adolescents, Charité – Universitätsmedizin Berlin, Berlin, Germany
- Institute of Cell- and Neurobiology, Charité – Universitätsmedizin Berlin, Berlin, Germany
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5
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Neuroinflammation and Proinflammatory Cytokines in Epileptogenesis. Mol Neurobiol 2022; 59:1724-1743. [PMID: 35015252 DOI: 10.1007/s12035-022-02725-6] [Citation(s) in RCA: 71] [Impact Index Per Article: 35.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 12/30/2021] [Indexed: 02/06/2023]
Abstract
Increasing evidence corroborates the fundamental role of neuroinflammation in the development of epilepsy. Proinflammatory cytokines (PICs) are crucial contributors to the inflammatory reactions in the brain. It is evidenced that epileptic seizures are associated with elevated levels of PICs, particularly interleukin-1β (IL-1β), IL-6, and tumor necrosis factor-α (TNF-α), which underscores the impact of neuroinflammation and PICs on hyperexcitability of the brain and epileptogenesis. Since the pathophysiology of epilepsy is unknown, determining the possible roles of PICs in epileptogenesis could facilitate unraveling the pathophysiology of epilepsy. About one-third of epileptic patients are drug-resistant, and existing treatments only resolve symptoms and do not inhibit epileptogenesis; thus, treatment of epilepsy is still challenging. Accordingly, understanding the function of PICs in epilepsy could provide us with promising targets for the treatment of epilepsy, especially drug-resistant type. In this review, we outline the role of neuroinflammation and its primary mediators, including IL-1β, IL-1α, IL-6, IL-17, IL-18, TNF-α, and interferon-γ (IFN-γ) in the pathophysiology of epilepsy. Furthermore, we discuss the potential therapeutic targeting of PICs and cytokine receptors in the treatment of epilepsy.
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Methylprednisolone pulse therapy in 31 patients with refractory epilepsy: A single-center retrospective analysis. Epilepsy Behav 2020; 109:107116. [PMID: 32388139 DOI: 10.1016/j.yebeh.2020.107116] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2020] [Revised: 04/11/2020] [Accepted: 04/12/2020] [Indexed: 11/23/2022]
Abstract
PURPOSE We investigated the efficacy of methylprednisolone pulse therapy (MP) and responder characteristics in patients with refractory epilepsy. METHODS We reviewed medical records of our center to identify patients with refractory epilepsy treated with MP other than continuous spikes and waves during slow sleep (CSWS), Landau-Kleffner syndrome (LKS), or Rasmussen's syndrome (RS) between 2004 and 2015. A course of MP consisted of intravenous methylprednisolone (30 mg/kg/day) on three consecutive days. Patients received multiple courses at intervals of four weeks. We examined seizure outcome, developmental outcome, antibodies to N-methyl-d-aspartate (NMDA)-type glutamate receptors (GluRs), cerebral spinal fluid (CSF)-albumin/serum-albumin ratio, and interictal electroencephalograms (EEGs). Responder to MP was defined as maintaining seizure reduction rate (SRR) ≥50% for three months after the first course of MP. RESULTS Thirty-one consecutive patients treated with MP at our center were studied. Seizure types were focal onset impaired awareness seizure (FIAS) only (n = 23), FIAS with epileptic spasms (ES) (n = 7), and ES only (n = 1). Responder rate was 32.2% (10/31 patients), and seizure-free rate was 9.7% (3/31). Responders constituted 43.5% of patients without ES. No patient with ES was responder. Behavior and cognition also improved in 6 of 10 responders. History of seizure aggravation after inactivated vaccine before MP was found significantly higher rate in responder patients, comparing with nonresponder patients (p = 0.01). CONCLUSION Methylprednisolone pulse therapy may be considered for possible treatment in patients with focal epilepsy with drug-resistant seizures without ES, and it may improve cognitive function and behavioral comorbidities.
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7
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Dexamethasone after early-life seizures attenuates increased susceptibility to seizures, seizure-induced microglia activation and neuronal injury later in life. Neurosci Lett 2020; 728:134953. [DOI: 10.1016/j.neulet.2020.134953] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Revised: 03/26/2020] [Accepted: 03/31/2020] [Indexed: 12/29/2022]
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8
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Heier CR, Yu Q, Fiorillo AA, Tully CB, Tucker A, Mazala DA, Uaesoontrachoon K, Srinivassane S, Damsker JM, Hoffman EP, Nagaraju K, Spurney CF. Vamorolone targets dual nuclear receptors to treat inflammation and dystrophic cardiomyopathy. Life Sci Alliance 2019; 2:2/1/e201800186. [PMID: 30745312 PMCID: PMC6371196 DOI: 10.26508/lsa.201800186] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Revised: 01/25/2019] [Accepted: 01/28/2019] [Indexed: 12/25/2022] Open
Abstract
Cardiomyopathy is a leading cause of death for Duchenne muscular dystrophy. Here, we find that the mineralocorticoid receptor (MR) and glucocorticoid receptor (GR) can share common ligands but play distinct roles in dystrophic heart and skeletal muscle pathophysiology. Comparisons of their ligand structures indicate that the Δ9,11 modification of the first-in-class drug vamorolone enables it to avoid interaction with a conserved receptor residue (N770/N564), which would otherwise activate transcription factor properties of both receptors. Reporter assays show that vamorolone and eplerenone are MR antagonists, whereas prednisolone is an MR agonist. Macrophages, cardiomyocytes, and CRISPR knockout myoblasts show vamorolone is also a dissociative GR ligand that inhibits inflammation with improved safety over prednisone and GR-specific deflazacort. In mice, hyperaldosteronism activates MR-driven hypertension and kidney phenotypes. We find that genetic dystrophin loss provides a second hit for MR-mediated cardiomyopathy in Duchenne muscular dystrophy model mice, as aldosterone worsens fibrosis, mass and dysfunction phenotypes. Vamorolone successfully prevents MR-activated phenotypes, whereas prednisolone activates negative MR and GR effects. In conclusion, vamorolone targets dual nuclear receptors to treat inflammation and cardiomyopathy with improved safety.
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Affiliation(s)
- Christopher R Heier
- Department of Genomics and Precision Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC, USA .,Center for Genetic Medicine Research, Children's National Medical Center, Washington, DC, USA
| | - Qing Yu
- Center for Genetic Medicine Research, Children's National Medical Center, Washington, DC, USA
| | - Alyson A Fiorillo
- Department of Genomics and Precision Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC, USA.,Center for Genetic Medicine Research, Children's National Medical Center, Washington, DC, USA
| | - Christopher B Tully
- Center for Genetic Medicine Research, Children's National Medical Center, Washington, DC, USA
| | - Asya Tucker
- Center for Genetic Medicine Research, Children's National Medical Center, Washington, DC, USA
| | - Davi A Mazala
- Center for Genetic Medicine Research, Children's National Medical Center, Washington, DC, USA
| | | | | | | | - Eric P Hoffman
- AGADA Biosciences Incorporated, Halifax, Nova Scotia, Canada.,ReveraGen BioPharma, Incorporated, Rockville, MD, USA.,School of Pharmacy and Pharmaceutical Sciences, Binghamton University-State University of New York (SUNY), Binghamton, NY, USA
| | - Kanneboyina Nagaraju
- AGADA Biosciences Incorporated, Halifax, Nova Scotia, Canada.,ReveraGen BioPharma, Incorporated, Rockville, MD, USA.,School of Pharmacy and Pharmaceutical Sciences, Binghamton University-State University of New York (SUNY), Binghamton, NY, USA
| | - Christopher F Spurney
- Department of Genomics and Precision Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC, USA.,Center for Genetic Medicine Research, Children's National Medical Center, Washington, DC, USA.,Division of Cardiology, Children's National Heart Institute, Children's National Medical Center, Washington, DC, USA
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9
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Xu D, Robinson AP, Ishii T, Duncan DS, Alden TD, Goings GE, Ifergan I, Podojil JR, Penaloza-MacMaster P, Kearney JA, Swanson GT, Miller SD, Koh S. Peripherally derived T regulatory and γδ T cells have opposing roles in the pathogenesis of intractable pediatric epilepsy. J Exp Med 2018; 215:1169-1186. [PMID: 29487082 PMCID: PMC5881465 DOI: 10.1084/jem.20171285] [Citation(s) in RCA: 66] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2017] [Revised: 11/08/2017] [Accepted: 01/26/2018] [Indexed: 12/14/2022] Open
Abstract
The pathophysiology of drug-resistant pediatric epilepsy is unknown. Flow cytometric analysis of inflammatory leukocytes in resected brain tissues from 29 pediatric patients with genetic (focal cortical dysplasia) or acquired (encephalomalacia) epilepsy demonstrated significant brain infiltration of blood-borne inflammatory myeloid cells and memory CD4+ and CD8+ T cells. Significantly, proinflammatory (IL-17- and GM-CSF-producing) γδ T cells were concentrated in epileptogenic lesions, and their numbers positively correlated with disease severity. Conversely, numbers of regulatory T (T reg) cells inversely correlated with disease severity. Correspondingly, using the kainic acid model of status epilepticus, we show ameliorated seizure activity in both γδ T cell- and IL-17RA-deficient mice and in recipients of T reg cells, whereas T reg cell depletion heightened seizure severity. Moreover, both IL-17 and GM-CSF induced neuronal hyperexcitability in brain slice cultures. These studies support a major pathological role for peripherally derived innate and adaptive proinflammatory immune responses in the pathogenesis of intractable epilepsy and suggest testing of immunomodulatory therapies.
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Affiliation(s)
- Dan Xu
- Department of Microbiology-Immunology, Feinberg School of Medicine, Northwestern University, Chicago, IL
- Department of Interdepartmental Immunobiology Center, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Andrew P Robinson
- Department of Microbiology-Immunology, Feinberg School of Medicine, Northwestern University, Chicago, IL
- Department of Interdepartmental Immunobiology Center, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Toshiyuki Ishii
- Department of Pharmacology, Feinberg School of Medicine, Northwestern University, Chicago, IL
- Department of Physiology, Nippon Medical School, Tokyo, Japan
| | - D'Anne S Duncan
- Department of Microbiology-Immunology, Feinberg School of Medicine, Northwestern University, Chicago, IL
- Department of Interdepartmental Immunobiology Center, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Tord D Alden
- Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Gwendolyn E Goings
- Department of Microbiology-Immunology, Feinberg School of Medicine, Northwestern University, Chicago, IL
- Department of Interdepartmental Immunobiology Center, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Igal Ifergan
- Department of Microbiology-Immunology, Feinberg School of Medicine, Northwestern University, Chicago, IL
- Department of Interdepartmental Immunobiology Center, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Joseph R Podojil
- Department of Microbiology-Immunology, Feinberg School of Medicine, Northwestern University, Chicago, IL
- Department of Interdepartmental Immunobiology Center, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Pablo Penaloza-MacMaster
- Department of Microbiology-Immunology, Feinberg School of Medicine, Northwestern University, Chicago, IL
- Department of Interdepartmental Immunobiology Center, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Jennifer A Kearney
- Department of Pharmacology, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Geoffrey T Swanson
- Department of Pharmacology, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Stephen D Miller
- Department of Microbiology-Immunology, Feinberg School of Medicine, Northwestern University, Chicago, IL
- Department of Interdepartmental Immunobiology Center, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Sookyong Koh
- Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, IL
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Herrera-Vázquez O, Rojas AT, Fleury A. NEUROINFLAMACIÓN Y EPILEPSIA. TIP REVISTA ESPECIALIZADA EN CIENCIAS QUÍMICO-BIOLÓGICAS 2016. [DOI: 10.1016/j.recqb.2016.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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Bakker DP, Catsman-Berrevoets CE, Neuteboom RF. Effectiveness of a hybrid corticosteroid treatment regimen on refractory childhood seizures and a review of other corticosteroid treatments. Eur J Paediatr Neurol 2015; 19:553-60. [PMID: 25976064 DOI: 10.1016/j.ejpn.2015.04.006] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2014] [Revised: 02/20/2015] [Accepted: 04/11/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Many different corticosteroid treatment schedules have been used in order to treat refractory epileptic seizures with encouraging effects on seizure reduction in many epileptic syndromes. OBJECTIVE The objective is to report our experience with a hybrid treatment regimen for refractory seizures in children with epilepsies other than West and Landau-Kleffner syndrome. We hypothesized that a pulse of corticosteroids effectively reduces seizures while low-dosage maintenance treatment reduces side effects. The results are compared with results from a review of reported corticosteroid and ACTH treatments. METHODS In this retrospective observational study, 26 children diagnosed with epilepsy with refractory seizures other than West syndrome and Landau-Kleffner syndrome were eligible for a treatment regimen consisting of three days intravenous methylprednisolone (20 mg per kilogram per day) followed by twelve weeks oral prednisolone (0.5 mg per kilogram on alternate days), concluded with a taper phase. Data on effectiveness and side effects were obtained. End-points were the percentages of patients who became seizure free or responded well. RESULTS Twenty-one patients received the study treatment. Nine (43%) responded well and 6 (29%) became seizure free. All but one patient had a relapse of seizures. Four patients had reversible adverse effects. Data extracted from the literature were consistent with a good response in 48% of 192 children treated with different corticosteroids and in 69% of 103 patients treated with ACTH. CONCLUSION This new hybrid therapy of a pulse of intravenous methylprednisolone and alternate day oral prednisolone is effective with a favourable side effect profile. Results on efficacy and safety justify a randomized controlled trial.
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Affiliation(s)
- Dewi P Bakker
- Erasmus University Hospital-Sophia Children's Hospital, The Netherlands
| | | | - Rinze F Neuteboom
- Erasmus University Hospital-Sophia Children's Hospital, The Netherlands.
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12
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Mehta V, Ferrie CD, Cross JH, Vadlamani G. Corticosteroids including ACTH for childhood epilepsy other than epileptic spasms. Cochrane Database Syst Rev 2015; 2015:CD005222. [PMID: 26086765 PMCID: PMC7390481 DOI: 10.1002/14651858.cd005222.pub3] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND This is an updated version of the original Cochrane review published in Issue 1, 2007.Epilepsy is a disorder with recurrent epileptic seizures. Corticosteroids have been used in the treatment of children with epilepsy and have significant adverse effects. Their efficacy and tolerability have not been clearly established. OBJECTIVES To determine the efficacy, in terms of seizure control, improvements in cognition and in quality of life and tolerability of steroids compared to placebo or other antiepileptic drugs in children with epilepsy, excluding epileptic spasms. SEARCH METHODS We searched the following databases: The Cochrane Epilepsy Group Specialized Register (1 August 2014); CENTRAL, (The Cochrane Library Issue 7, July 2014); MEDLINE (1946 to 1 August 2014); EMBASE (1966 to December 2004); Database of Abstracts of Reviews of Effectiveness (DARE; Issue 3 of the database published in The Cochrane Library Issue 7, July 2014); ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform ICTRP (1 August 2014).We checked the reference lists of retrieved studies for additional reports of relevant studies. SELECTION CRITERIA All randomised controlled trials of administration of corticosteroids to children (less than 16 years) with epilepsy. DATA COLLECTION AND ANALYSIS For this update two review authors independently selected trials for inclusion and extracted data. Outcomes included cessation of seizures, reduction in seizure frequency, improvement in cognition, quality of life and adverse effects of steroids. MAIN RESULTS A single RCT was included that recruited five children in a double blind cross-over trial. One child was withdrawn prematurely from the study and another had infantile spasms and hence was excluded from further analysis. Adrenocorticotrophin hormone (ACTH 4-9) was administered. Of the three children analysed, one showed a reduction in seizures of 25% to 50% at both the low and higher doses of corticosteroids compared to placebo; one child showed a reduction in seizures at the higher dose only and one child showed no reduction in seizures at either dose. No adverse effects were reported. AUTHORS' CONCLUSIONS Since the last version of this review no new evidence has been found for the efficacy of corticosteroids in treating childhood epilepsies. Clinicians using steroids in childhood epilepsies, other than for epileptic spasms, should take this into account before using these agents.
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Affiliation(s)
- Vishal Mehta
- Hull and East Yorkshire Hospitals NHS TrustDepartment of PaediatricsAnlaby RoadHullWest YorkshireUKHU3 2JZ
| | - Colin D Ferrie
- Leeds General InfirmaryDepartment of Paediatric NeurologyClarendon WingBelmont GroveLeedsUKLS2 9NS
| | - J Helen Cross
- UCL Institute of Child Health4/5 Long YardLondonUKWC1N 3LU
- The Neville Childhood Epilepsy CentreSt Piers LaneLingfieldSurreyUKRH7 6PW
| | - Gayatri Vadlamani
- Leeds General InfirmaryDepartment of Paediatric NeurologyClarendon WingBelmont GroveLeedsUKLS2 9NS
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Grosso S, Parisi P, Giordano L, di Bartolo R, Balestri P. Lacosamide efficacy in epileptic syndromes with continuous spike and waves during slow sleep (CSWS). Epilepsy Res 2014; 108:1604-8. [DOI: 10.1016/j.eplepsyres.2014.08.021] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2013] [Revised: 08/09/2014] [Accepted: 08/31/2014] [Indexed: 11/17/2022]
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Frye RE, Rossignol D, Casanova MF, Brown GL, Martin V, Edelson S, Coben R, Lewine J, Slattery JC, Lau C, Hardy P, Fatemi SH, Folsom TD, MacFabe D, Adams JB. A review of traditional and novel treatments for seizures in autism spectrum disorder: findings from a systematic review and expert panel. Front Public Health 2013; 1:31. [PMID: 24350200 PMCID: PMC3859980 DOI: 10.3389/fpubh.2013.00031] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2013] [Accepted: 08/20/2013] [Indexed: 01/20/2023] Open
Abstract
Despite the fact that seizures are commonly associated with autism spectrum disorder (ASD), the effectiveness of treatments for seizures has not been well studied in individuals with ASD. This manuscript reviews both traditional and novel treatments for seizures associated with ASD. Studies were selected by systematically searching major electronic databases and by a panel of experts that treat ASD individuals. Only a few anti-epileptic drugs (AEDs) have undergone carefully controlled trials in ASD, but these trials examined outcomes other than seizures. Several lines of evidence point to valproate, lamotrigine, and levetiracetam as the most effective and tolerable AEDs for individuals with ASD. Limited evidence supports the use of traditional non-AED treatments, such as the ketogenic and modified Atkins diet, multiple subpial transections, immunomodulation, and neurofeedback treatments. Although specific treatments may be more appropriate for specific genetic and metabolic syndromes associated with ASD and seizures, there are few studies which have documented the effectiveness of treatments for seizures for specific syndromes. Limited evidence supports l-carnitine, multivitamins, and N-acetyl-l-cysteine in mitochondrial disease and dysfunction, folinic acid in cerebral folate abnormalities and early treatment with vigabatrin in tuberous sclerosis complex. Finally, there is limited evidence for a number of novel treatments, particularly magnesium with pyridoxine, omega-3 fatty acids, the gluten-free casein-free diet, and low-frequency repetitive transcranial magnetic simulation. Zinc and l-carnosine are potential novel treatments supported by basic research but not clinical studies. This review demonstrates the wide variety of treatments used to treat seizures in individuals with ASD as well as the striking lack of clinical trials performed to support the use of these treatments. Additional studies concerning these treatments for controlling seizures in individuals with ASD are warranted.
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Affiliation(s)
- Richard E. Frye
- Arkansas Children’s Hospital Research Institute, Little Rock, AR, USA
| | | | | | - Gregory L. Brown
- Autism Recovery and Comprehensive Health Medical Center, Franklin, WI, USA
| | - Victoria Martin
- Autism Recovery and Comprehensive Health Medical Center, Franklin, WI, USA
| | | | - Robert Coben
- New York University Brain Research Laboratory, New York, NY, USA
| | - Jeffrey Lewine
- MIND Research Network, University of New Mexico, Albuquerque, NM, USA
| | - John C. Slattery
- Arkansas Children’s Hospital Research Institute, Little Rock, AR, USA
| | - Chrystal Lau
- Arkansas Children’s Hospital Research Institute, Little Rock, AR, USA
| | - Paul Hardy
- Hardy Healthcare Associates, Hingham, MA, USA
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Yu N, Liu H, Di Q. Modulation of Immunity and the Inflammatory Response: A New Target for Treating Drug-resistant Epilepsy. Curr Neuropharmacol 2013; 11:114-27. [PMID: 23814544 PMCID: PMC3580785 DOI: 10.2174/157015913804999540] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2012] [Revised: 07/16/2012] [Accepted: 11/17/2012] [Indexed: 12/11/2022] Open
Abstract
Until recently, epilepsy medical therapy is usually limited to anti-epileptic drugs (AEDs). However, approximately 1/3 of epilepsy patients, described as drug-resistant epilepsy (DRE) patients, still suffer from continuous frequent seizures despite receiving adequate AEDs treatment of sufficient duration. More recently, with the remarkable progress of immunology, immunity and inflammation are considered to be key elements of the pathobiology of epilepsy. Activation of inflammatory processes in brain tissue has been observed in both experimental seizure animal models and epilepsy patients. Anti-inflammatory and immunotherapies also showed significant anticonvulsant properties both in clinical and in experimental settings. The above emerging evidence indicates that modulation of immunity and inflammatory processes could serve as novel specific targets to achieve potential anticonvulsant effects for the patients with epilepsy, especially DRE. Herein we review the recent evidence supporting the role of inflammation in the development and perpetuation of seizures, and also discuss the recent achievements in modulation of inflammation and immunotherapy applied to the treatment of epilepsy. Apart from medical therapy, we also discuss the influences of surgery, ketogenic diet, and electroconvulsive therapy on immunity and inflammation in DRE patients. Taken together, a promising perspective is suggested for future immunomodulatory therapies in the treatment of patients with DRE.
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Affiliation(s)
- Nian Yu
- Department of Neurology, Nanjing Brain Hospital affiliated to Nanjing Medical University, Nanjing, Jiangsu, China
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Abstract
Patients with nephrotic syndrome require steroids for long time and sometimes repeatedly resulting in various adverse effects. Deflazacort (DFZ) had been described as equally effective and with fewer side effects as compared with other steroids. This review evaluates the literature on efficacy and toxicity of DFZ as compared with other therapies for nephrotic syndrome. A systematic review of Pubmed database and Cochrane Central Register of Controlled Trials with last search date of 20(th) April 2011. Search terms included "nephrotic AND deflazacort" without any limitations. Randomized control trials comparing DFZ vs placebo or other therapies in subjects with nephrotic syndrome were included. Two authors extracted data independently. Three studies meet inclusion criteria and data were synthesized qualitatively. The limited evidence suggested that DFZ appeared to be equally effective in inducing remission or decreasing proteinuria in patients with nephrotic syndrome. It caused significantly less decrease in bone mineral content (BMC) in spine as compared with prednisolone. The results related to weight change, blood pressure change, Cushingoid symptoms, and urinary calcium excretion were inconsistent between included studies. By reviewing the available limited evidence, DFZ appears to be of similar efficacy for nephrotic patients, but there were inconsistent results regarding side effect profile of DFZ as compared with other steroids except for decrease in BMC where DFZ was better. There is need for larger randomized controlled trials to evaluate effectiveness and adverse effect profile of DFZ as compared with other steroids in nephrotic syndrome.
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Affiliation(s)
- K R Jat
- Department of Pediatrics, Government Medical College and Hospital, Sector-32, Chandigarh, India
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Marchi N, Granata T, Ghosh C, Janigro D. Blood-brain barrier dysfunction and epilepsy: pathophysiologic role and therapeutic approaches. Epilepsia 2012; 53:1877-86. [PMID: 22905812 DOI: 10.1111/j.1528-1167.2012.03637.x] [Citation(s) in RCA: 166] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
The blood-brain barrier (BBB) is located within a unique anatomic interface and has functional ramifications to most of the brain and blood cells. In the past, the BBB was considered a pharmacokinetic impediment to antiepileptic drug penetration into the brain; nowadays it is becoming increasingly evident that targeting of the damaged or dysfunctional BBB may represent a therapeutic approach to reduce seizure burden. Several studies have investigated the mechanisms linking the onset and sustainment of seizures to BBB dysfunction. These studies have shown that the BBB is at the crossroad of a multifactorial pathophysiologic process that involves changes in brain milieu, altered neuroglial physiology, development of brain inflammation, leukocyte-endothelial interactions, faulty angiogenesis, and hemodynamic changes leading to energy mismatch. A number of knowledge gaps, conflicting points of view, and discordance between clinical and experimental data currently characterize this field of neuroscience. As more pieces are added to this puzzle, it is apparent that each mechanism needs to be validated in an appropriate clinical context. We now offer a BBB-centric view of seizure disorders, linking several aspects of seizures and epilepsy physiopathology to BBB dysfunction. We have reviewed the therapeutic, antiseizure effect of drugs that promote BBB repair. We also present BBB neuroimaging as a tool to correlate BBB restoration to seizure mitigation. Add-on cerebrovascular drug could be of efficacy in reducing seizure burden when used in association with neuronal antiepileptic drugs.
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Affiliation(s)
- Nicola Marchi
- Departments of Molecular Medicine Cell Biology, Cleveland Clinic Foundation, 9500 Euclid Ave, Cleveland, OH 44195, U.S.A.
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Fusco C, Ucchino V, Frattini D, Pisani F, Della Giustina E. Acute and chronic corticosteroid treatment of ten patients with paralytic form of Sydenham's chorea. Eur J Paediatr Neurol 2012; 16:373-8. [PMID: 22197452 DOI: 10.1016/j.ejpn.2011.12.005] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2011] [Revised: 11/26/2011] [Accepted: 12/03/2011] [Indexed: 10/14/2022]
Abstract
AIMS To determine efficacy and safety of corticosteroid treatment in patients with severe Sydenham's chorea paralytic form. METHODS This is a 4 years observational study on ten patient with severe paralytic form of Sydenham's chorea unresponsive to neuroleptics and antiepileptics agents, treated with intravenous methylprednisolone followed by oral deflazacort therapy. Chorea paralytica patients were bedridden, unable to take independent steps, showed severe generalized hypotonia and were hospitalized for 3-4 weeks. Additional clinical evaluations were undertaken at 1, 3 and 6 months and 1, 2 and 4 years from onset of chorea. Severity chorea at the onset and during follow up was rated according to Universidade Federal de Minas Gerais (UFMG) Sydenham's Chorea Rating Scale (USCRS). In all children video-recording was performing at onset and during clinical follow-up. RESULTS We reported a significant improvement in swallowing and chewing with partial recovery of language 2-3 days after starting intravenous methylprednisolone treatment and complete disappearance of movement disorders after 3-4 weeks of treatment. All our patients were followed for 4 years from onset and none experienced relapse of chorea, other movement disorders or psychiatric disturbances. The treatment with deflazacort was well-tolerated in all children with no significant side effects reported. CONCLUSION Our data showed that high dose of methylprednisolone intravenously followed by deflazacort therapy may be effective and well-tolerated in children with severe paralytic form of Sydenham's chorea.
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Affiliation(s)
- Carlo Fusco
- Pediatric Neurology Unit, Arcispedale Santa Maria Nuova, V.le Risorgimento 80, 42123 Reggio Emilia, Italy.
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Heyman E, Lahat E, Gandelman-Marton R. Interictal encephalography can influence patient selection for methylprednisolone therapy in pediatric refractory epilepsy. J Child Neurol 2012; 27:162-7. [PMID: 21881006 DOI: 10.1177/0883073811414905] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
We describe our experience with intravenous methylprednisolone pulse therapy in older children with refractory epilepsy. Patients with refractory epilepsy, who were treated with steroids between 2005 and 2010, were retrospectively selected from the database of the pediatric epilepsy clinic at Assaf Harofeh Medical Center. Eight patients (5 boys) aged 1.1 to 9 years (5.2 ± 2.6) were identified. Intravenous methylprednisolone 30 mg/kg/d was given to all patients for 5 days in addition to a stable dosage of the regular antiepileptic drugs. Transient side effects were reported in 4 of the patients during pulse therapy. Significant clinical improvement was noted in 4 patients, accompanied by a significant reduction of the amplitude of the spike-slow wave discharges on the electroencephalogram (EEG). Children with refractory epilepsy, abnormal EEG background, and high-amplitude spike-slow wave discharges appear to be the best candidates for intravenous methylprednisolone pulse therapy.
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Affiliation(s)
- Eli Heyman
- Department of Pediatric Neurology, Assaf Harofeh Medical Center, Zerifin, Israel
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Abstract
Several experimental and clinical studies demonstrated an immunologic basis for different forms of epilepsy. A wide range of immune abnormalities have been reported suggesting the existence of various subtypes of epileptic syndromes with different immunopathogenetic mechanisms. This evidence gives rise to the development of immunologic and immunomodulatory treatments such as usage of steroids, plasmapheresis, and intravenous immunoglobulins, which will be discussed briefly in this article.
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Affiliation(s)
- Çiğdem Özkara
- Department of Neurology, Cerrahpasa Medical Faculty, Istanbul University, Istanbul, Turkey.
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Efficacy of anti-inflammatory therapy in a model of acute seizures and in a population of pediatric drug resistant epileptics. PLoS One 2011; 6:e18200. [PMID: 21464890 PMCID: PMC3065475 DOI: 10.1371/journal.pone.0018200] [Citation(s) in RCA: 117] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2010] [Accepted: 02/23/2011] [Indexed: 12/02/2022] Open
Abstract
Targeting pro-inflammatory events to reduce seizures is gaining momentum. Experimentally, antagonism of inflammatory processes and of blood-brain barrier (BBB) damage has been demonstrated to be beneficial in reducing status epilepticus (SE). Clinically, a role of inflammation in the pathophysiology of drug resistant epilepsies is suspected. However, the use anti-inflammatory drug such as glucocorticosteroids (GCs) is limited to selected pediatric epileptic syndromes and spasms. Lack of animal data may be one of the reasons for the limited use of GCs in epilepsy. We evaluated the effect of the CG dexamethasone in reducing the onset and the severity of pilocarpine SE in rats. We assessed BBB integrity by measuring serum S100β and Evans Blue brain extravasation. Electrophysiological monitoring and hematologic measurements (WBCs and IL-1β) were performed. We reviewed the effect of add on dexamethasone treatment on a population of pediatric patients affected by drug resistant epilepsy. We excluded subjects affected by West, Landau-Kleffner or Lennox-Gastaut syndromes and Rasmussen encephalitis, known to respond to GCs or adrenocorticotropic hormone (ACTH). The effect of two additional GCs, methylprednisolone and hydrocortisone, was also reviewed in this population. When dexamethasone treatment preceded exposure to the convulsive agent pilocarpine, the number of rats developing status epilepticus (SE) was reduced. When SE developed, the time-to-onset was significantly delayed compared to pilocarpine alone and mortality associated with pilocarpine-SE was abolished. Dexamethasone significantly protected the BBB from damage. The clinical study included pediatric drug resistant epileptic subjects receiving add on GC treatments. Decreased seizure frequency (≥50%) or interruption of status epilepticus was observed in the majority of the subjects, regardless of the underlying pathology. Our experimental results point to a seizure-reducing effect of dexamethasone. The mechanism encompasses improvement of BBB integrity. Our results also suggest that add on GCs could be of efficacy in controlling pediatric drug resistant seizures.
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