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Deckard E, Sathe R, Tabibzadeh D, Terango A, Groves A, Rajaraman RR, Nariai H, Hussain SA. Epileptic spasms relapse is associated with response latency but not conventional attributes of post-treatment EEG. Epilepsia Open 2024; 9:1034-1041. [PMID: 38588009 PMCID: PMC11145600 DOI: 10.1002/epi4.12931] [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: 09/20/2023] [Revised: 02/06/2024] [Accepted: 03/09/2024] [Indexed: 04/10/2024] Open
Abstract
OBJECTIVE Relapse of epileptic spasms after initial treatment of infantile epileptic spasms syndrome (IESS) is common. However, past studies of small cohorts have inconsistently linked relapse risk to etiology, treatment modality, and EEG features upon response. Using a large single-center IESS cohort, we set out to quantify the risk of epileptic spasms relapse and identify specific risk factors. METHODS We identified all children with epileptic spasms at our center using a clinical EEG database. Using the electronic medical record, we confirmed IESS syndrome classification and ascertained treatment, response, time to relapse, etiology, EEG features, and other demographic factors. Relapse-free survival analysis was carried out using Cox proportional hazards regression. RESULTS Among 599 children with IESS, 197 specifically responded to hormonal therapy and/or vigabatrin (as opposed to surgery or other second-line treatments). In this study, 41 (21%) subjects exhibited relapse of epileptic spasms within 12 months of response. Longer duration of IESS prior to response (>3 months) was strongly associated with shorter latency to relapse (hazard ratio = 3.11; 95% CI 1.59-6.10; p = 0.001). Relapse was not associated with etiology, developmental status, or any post-treatment EEG feature. SIGNIFICANCE This study suggests that long duration of IESS before response is the single largest clinical predictor of relapse risk, and therefore underscores the importance of prompt and successful initial treatment. Further study is needed to evaluate candidate biomarkers of epileptic spasms relapse and identify treatments to mitigate this risk. PLAIN LANGUAGE SUMMARY Relapse of infantile spasms is common after initially successful treatment. With study of a large group of children with infantile spasms, we determined that relapse is linked to long duration of infantile spasms. In contrast, relapse was not associated with the cause of infantile spasms, developmental measures, or EEG features at the time of initial response. Further study is needed to identify tools to predict impending relapse of infantile spasms.
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Affiliation(s)
- Emmi Deckard
- Department of PediatricsDivision of NeurologyUniversity of California Los Angeles and UCLA Mattel Children's HospitalCaliforniaLos AngelesUSA
| | - Rujuta Sathe
- Department of PediatricsDivision of NeurologyUniversity of California Los Angeles and UCLA Mattel Children's HospitalCaliforniaLos AngelesUSA
| | - David Tabibzadeh
- Department of PediatricsDivision of NeurologyUniversity of California Los Angeles and UCLA Mattel Children's HospitalCaliforniaLos AngelesUSA
| | - Aria Terango
- Department of PediatricsDivision of NeurologyUniversity of California Los Angeles and UCLA Mattel Children's HospitalCaliforniaLos AngelesUSA
| | - Aran Groves
- Department of PediatricsDivision of NeurologyUniversity of California Los Angeles and UCLA Mattel Children's HospitalCaliforniaLos AngelesUSA
| | - Rajsekar R. Rajaraman
- Department of PediatricsDivision of NeurologyUniversity of California Los Angeles and UCLA Mattel Children's HospitalCaliforniaLos AngelesUSA
| | - Hiroki Nariai
- Department of PediatricsDivision of NeurologyUniversity of California Los Angeles and UCLA Mattel Children's HospitalCaliforniaLos AngelesUSA
| | - Shaun A. Hussain
- Department of PediatricsDivision of NeurologyUniversity of California Los Angeles and UCLA Mattel Children's HospitalCaliforniaLos AngelesUSA
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Vitale G, Terrone G, Vitale S, Vitulli F, Aiello S, Bravaccio C, Pisano S, Bove I, Rizzo F, Seetahal-Maraj P, Wiese T. The Evolving Landscape of Therapeutics for Epilepsy in Tuberous Sclerosis Complex. Biomedicines 2023; 11:3241. [PMID: 38137462 PMCID: PMC10741146 DOI: 10.3390/biomedicines11123241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Revised: 10/30/2023] [Accepted: 11/27/2023] [Indexed: 12/24/2023] Open
Abstract
Tuberous sclerosis complex (TSC) is a rare multisystem genetic disorder characterized by benign tumor growth in multiple organs, including the brain, kidneys, heart, eyes, lungs, and skin. Pathogenesis stems from mutations in either the TSC1 or TSC2 gene, which encode the proteins hamartin and tuberin, respectively. These proteins form a complex that inhibits the mTOR pathway, a critical regulator of cell growth and proliferation. Disruption of the tuberin-hamartin complex leads to overactivation of mTOR signaling and uncontrolled cell growth, resulting in hamartoma formation. Neurological manifestations are common in TSC, with epilepsy developing in up to 90% of patients. Seizures tend to be refractory to medical treatment with anti-seizure medications. Infantile spasms and focal seizures are the predominant seizure types, often arising in early childhood. Drug-resistant epilepsy contributes significantly to morbidity and mortality. This review provides a comprehensive overview of the current state of knowledge regarding the pathogenesis, clinical manifestations, and treatment approaches for epilepsy and other neurological features of TSC. While narrative reviews on TSC exist, this review uniquely synthesizes key advancements across the areas of TSC neuropathology, conventional and emerging pharmacological therapies, and targeted treatments. The review is narrative in nature, without any date restrictions, and summarizes the most relevant literature on the neurological aspects and management of TSC. By consolidating the current understanding of TSC neurobiology and evidence-based treatment strategies, this review provides an invaluable reference that highlights progress made while also emphasizing areas requiring further research to optimize care and outcomes for TSC patients.
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Affiliation(s)
- Giovanni Vitale
- Neuroscience and Rare Diseases, Discovery and Translational Area, Roche Pharma Research and Early Development (pRED), F. Hoffmann–La Roche, 4070 Basel, Switzerland
| | - Gaetano Terrone
- Department of Translational Medical Sciences, Child and Adolescent Neuropsychiatry, University of Naples Federico II, 80138 Naples, Italy; (G.T.); (C.B.)
| | - Samuel Vitale
- School of Medicine and Surgery, University of Naples Federico II, 80138 Naples, Italy;
| | - Francesca Vitulli
- Department of Neurosciences and Reproductive and Dental Sciences, Division of Neurosurgery, University of Naples Federico II, 80138 Naples, Italy (I.B.)
| | - Salvatore Aiello
- Department of Translational Medical Sciences, Child and Adolescent Neuropsychiatry, University of Naples Federico II, 80138 Naples, Italy; (G.T.); (C.B.)
| | - Carmela Bravaccio
- Department of Translational Medical Sciences, Child and Adolescent Neuropsychiatry, University of Naples Federico II, 80138 Naples, Italy; (G.T.); (C.B.)
| | - Simone Pisano
- Department of Translational Medical Sciences, Child and Adolescent Neuropsychiatry, University of Naples Federico II, 80138 Naples, Italy; (G.T.); (C.B.)
| | - Ilaria Bove
- Department of Neurosciences and Reproductive and Dental Sciences, Division of Neurosurgery, University of Naples Federico II, 80138 Naples, Italy (I.B.)
| | - Francesca Rizzo
- Department of Neuroscience “Rita Levi Montalcini”, University of Turin, 10126 Turin, Italy;
| | | | - Thomas Wiese
- Neuroscience and Rare Diseases, Discovery and Translational Area, Roche Pharma Research and Early Development (pRED), F. Hoffmann–La Roche, 4070 Basel, Switzerland
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Sampaio LPDB, Henriques-Souza AMDM, Silveira MRMD, Seguti L, Santos MLSF, Montenegro MA, Antoniuk S, Manreza MLGD. Brazilian experts' consensus on the treatment of infantile epileptic spasm syndrome in infants. ARQUIVOS DE NEURO-PSIQUIATRIA 2023; 81:844-856. [PMID: 37793406 PMCID: PMC10550353 DOI: 10.1055/s-0043-1772835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 07/09/2023] [Indexed: 10/06/2023]
Abstract
BACKGROUND Infantile epileptic spasms syndrome (IESS) is a rare but severe condition affecting children early and is usually secondary to an identifiable brain disorder. It is related to psychomotor deterioration in childhood and epilepsy in adult life. Treatment is challenging as infantile spasms may not respond to most antiseizure medication, and relapse is frequent. OBJECTIVE To evaluate the literature regarding treatment of IESS and provide a practical guidance to a healthcare system with limited resources. METHODS An expert committee from the Brazilian Society of Child Neurology reviewed and discussed relevant scientific evidence in the treatment of IESS regarding the drugs available in Brazil. RESULTS Oral prednisolone and vigabatrin are the most common drugs used as first-line therapy; they are efficient and affordable therapy as both are available in the Brazilian unified health system (SUS, in the Portuguese acronym). Intramuscular adrenocorticotropic hormone (ACTH) presents similar efficacy as oral prednisolone but has a higher cost and is not available in Brazil. Other antiseizure medications such as topiramate, levetiracetam, or benzodiazepines have limited response and are prescribed as adjuvant therapy. If the health service has nutritionists, a ketogenic diet should be implemented for those not responding to hormonal and vigabatrin treatment. Epilepsy surgery is mainly indicated for patients with focal lesions that do not respond to pharmacological therapy. CONCLUSION Early treatment of IESS with efficient drugs is feasible in our country. Using standard protocols increases the odds of achieving complete cessation in a shorter time and decreases relapse.
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Affiliation(s)
| | | | | | - Lisiane Seguti
- Universidade de Brasília, Faculdade de Medicina, Área da Medicina da Criança e do Adolescente, Brasília DF, Brazil.
| | | | | | - Sérgio Antoniuk
- Universidade Federal do Paraná, Departamento de Pediatria, Curitiba PR, Brazil.
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Prezioso G, Chiarelli F, Matricardi S. Efficacy and safety of vigabatrin in patients with tuberous sclerosis complex and infantile epileptic spasm syndrome: a systematic review. Expert Rev Neurother 2023; 23:661-671. [PMID: 37243682 DOI: 10.1080/14737175.2023.2216385] [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: 02/14/2023] [Accepted: 05/17/2023] [Indexed: 05/29/2023]
Abstract
INTRODUCTION Tuberous sclerosis complex (TSC) is a common genetic cause of epilepsy. Infantile epileptic spasm syndrome (IESS) is often the presenting neurologic feature, progressively evolving into refractory epilepsy. Vigabatrin (VGB) is often used in clinical practice as a first-line therapy in TSC with IESS. This systematic review aims to collect and analyze the efficacy data about VGB in TSC cases with IESS, in order to evaluate the strength of evidence in the literature. METHODS A systematic search of trials, observational studies, and case series involving patients with TSC and IESS treated with VGB was performed using MEDLINE, CENTRAL, and the US NIH Clinical Trials Registry. Single case studies, animal and non-English language studies were excluded. Seventeen studies were selected, of which 3 were RCTs and 14 were observational studies. RESULTS An overall response rate of 67% (231/343 responders) resulted from the analysis, with a spasm-free rate restricted to RCTs of 88% (29/33 subjects). CONCLUSIONS Although all the studies analyzed reported beneficial effects of VGB in TSC patients with IESS, with higher response rates in comparison to non-TSC subjects with IESS, a low level of evidence and high heterogeneity do not guarantee sufficient strength for therapeutic recommendations.
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Affiliation(s)
- Giovanni Prezioso
- Pediatric Neurologist, Department of Pediatrics, G. D'Annunzio University, Chieti, Italy
| | - Francesco Chiarelli
- Department of Pediatrics, Department of Pediatrics, G. D'Annunzio University, Chieti, Italy
| | - Sara Matricardi
- Pediatric Neurologist, Department of Pediatrics, G. D'Annunzio University, Chieti, Italy
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Wang J, Zhang YY, Guo HL, Hu YH, Lu XP, Wang SS, Wu CF, Chen F. Rapid determination of plasma vigabatrin by LC-ESI-MS/MS supporting therapeutic drug monitoring in children with infantile spasms. ANALYTICAL METHODS : ADVANCING METHODS AND APPLICATIONS 2023; 15:1365-1377. [PMID: 36847418 DOI: 10.1039/d2ay02017c] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/18/2023]
Abstract
Vigabatrin is one of the second-generation anti-seizure medications (ASMs) designated orphan drugs by the FDA for monotherapy for pediatric patients with infantile spasms from 1 month to 2 years of age. Vigabatrin is also indicated as the adjunctive therapy for adults and pediatric patients 10 years of age and older with refractory complex partial seizures. Ideally, the vigabatrin treatment entails achieving complete seizure freedom without significant adverse effects, and the therapeutic drug monitoring (TDM) will make a significant contribution to this aim, which provides a pragmatic approach to such epilepsy care in that the dose tailoring can be undertaken for uncontrollable seizures and in cases of clinical toxicity guided by the drug concentrations. Thus, reliable assays are mandatory for TDM to be valuable, and blood, plasma, or serum are the matrixes of choice. In this study, a simple, rapid, and sensitive LC-ESI-MS/MS method for the measurement of plasma vigabatrin was developed and validated. The sample clean-up was performed by an easy-to-use method, i.e., protein precipitation using acetonitrile (ACN). Chromatographic separation of vigabatrin and vigabatrin-13C,d2 (internal standard) was achieved on the Waters symmetry C18 column (4.6 mm × 50 mm, 3.5 μm) with isocratic elution at a flow rate of 0.35 mL min-1. The target analyte was completely separated by elution with a highly aqueous mobile phase for 5 min, without any endogenous interference. The method showed good linearity over the 0.010-50.0 μg mL-1 concentration range with a correlation coefficient r2 = 0.9982. The intra-batch and inter-batch precision and accuracy, recovery, and stability of the method were all within the acceptable parameters. Moreover, the method was successfully used in pediatric patients treated with vigabatrin and also provided valuable information for clinicians by monitoring plasma vigabatrin levels in our hospital.
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Affiliation(s)
- Jie Wang
- Pharmaceutical Sciences Research Center, Department of Pharmacy, Children's Hospital of Nanjing Medical University, Nanjing, China.
| | - Yuan-Yuan Zhang
- Pharmaceutical Sciences Research Center, Department of Pharmacy, Children's Hospital of Nanjing Medical University, Nanjing, China.
| | - Hong-Li Guo
- Pharmaceutical Sciences Research Center, Department of Pharmacy, Children's Hospital of Nanjing Medical University, Nanjing, China.
| | - Ya-Hui Hu
- Pharmaceutical Sciences Research Center, Department of Pharmacy, Children's Hospital of Nanjing Medical University, Nanjing, China.
| | - Xiao-Peng Lu
- Department of Neurology, Children's Hospital of Nanjing Medical University, Nanjing, China.
| | - Shan-Shan Wang
- Pharmaceutical Sciences Research Center, Department of Pharmacy, Children's Hospital of Nanjing Medical University, Nanjing, China.
| | - Chun-Feng Wu
- Department of Neurology, Children's Hospital of Nanjing Medical University, Nanjing, China.
| | - Feng Chen
- Pharmaceutical Sciences Research Center, Department of Pharmacy, Children's Hospital of Nanjing Medical University, Nanjing, China.
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Singh A, Hadjinicolaou A, Peters JM, Salussolia CL. Treatment-Resistant Epilepsy and Tuberous Sclerosis Complex: Treatment, Maintenance, and Future Directions. Neuropsychiatr Dis Treat 2023; 19:733-748. [PMID: 37041855 PMCID: PMC10083014 DOI: 10.2147/ndt.s347327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Accepted: 03/22/2023] [Indexed: 04/13/2023] Open
Abstract
Tuberous sclerosis complex (TSC) is a neurogenetic disorder that affects multiple organ systems, including the heart, kidneys, eyes, skin, and central nervous system. The neurologic manifestations have the highest morbidity and mortality, in particular in children. Clinically, patients with TSC often present with new-onset seizures within the first year of life. TSC-associated epilepsy is often difficult to treat and refractory to multiple antiseizure medications. Refractory TSC-associated epilepsy is associated with increased risk of neurodevelopmental comorbidities, including developmental delay, intellectual disability, autism spectrum disorder, and attention hyperactivity disorder. An increasing body of research suggests that early, effective treatment of TSC-associated epilepsy during critical neurodevelopmental periods can potentially improve cognitive outcomes. Therefore, it is important to treat TSC-associated epilepsy aggressively, whether it be with pharmacological therapy, surgical intervention, and/or neuromodulation. This review discusses current and future pharmacological treatments for TSC-associated epilepsy, as well as the importance of early surgical evaluation for refractory epilepsy in children with TSC and consideration of neuromodulatory interventions in young adults.
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Affiliation(s)
- Avantika Singh
- Division of Epilepsy and Neurophysiology, Department of Neurology, Boston Children’s Hospital and Harvard Medical School, Boston, MA, USA
| | - Aristides Hadjinicolaou
- Division of Epilepsy and Neurophysiology, Department of Neurology, Boston Children’s Hospital and Harvard Medical School, Boston, MA, USA
| | - Jurriaan M Peters
- Division of Epilepsy and Neurophysiology, Department of Neurology, Boston Children’s Hospital and Harvard Medical School, Boston, MA, USA
| | - Catherine L Salussolia
- Division of Epilepsy and Neurophysiology, Department of Neurology, Boston Children’s Hospital and Harvard Medical School, Boston, MA, USA
- F.M. Kirby Neurobiology Center, Department of Neurology, Boston Children’s Hospital and Harvard Medical School, Boston, MA, USA
- Correspondence: Catherine L Salussolia, 3 Blackfan Circle, Center for Life Sciences 14060, Boston, MA, 02115, USA, Tel +617-355-7970, Email
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Whitney R, Zak M, Haile D, Nabavi Nouri M. The state of pediatric tuberous sclerosis complex epilepsy care: Results from a national survey. Epilepsia Open 2022; 7:718-728. [PMID: 36161285 PMCID: PMC9712483 DOI: 10.1002/epi4.12652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Accepted: 09/21/2022] [Indexed: 01/01/2023] Open
Abstract
OBJECTIVE Epilepsy associated with tuberous sclerosis complex (TSC) can be challenging to treat and is associated with significant disease burden. Our objective was to better understand the state of epilepsy care of TSC amongst pediatric neurologists in Canada, identify gaps in care and determine whether access to a dedicated TSC clinic has an impact on epilepsy management. METHODS A survey was developed after a literature review and discussion amongst two pediatric epileptologists and one nurse practitioner with expertise in TSC about the state of epilepsy care of TSC patients in Canada. Canadian pediatric neurologists were asked to participate in sharing their experiences via an anonymous web-based survey through the Canadian League Against Epilepsy (CLAE) and the Canadian Neurological Sciences Federation (CNSF). RESULTS Fifty-seven responses were received. Access to a dedicated TSC clinic was reported by 25% (n = 14). Sixty percent (n = 34) reported performing serial EEG monitoring in infants with TSC and 57% (n = 33) started prophylactic antiseizure therapy when EEG abnormalities were detected, regardless of whether there was access to a TSC clinic (P = .06 and P = .29, respectively). While 52% (n = 29) did not feel comfortable prescribing mTORi for epilepsy, 65% (n = 36) indicated they would consider it with additional training. Epilepsy surgery was offered in 93% (n = 13) of centers with a dedicated TSC clinic but only 45% of centers without a TSC clinic (n = 19) (P = .002). SIGNIFICANCE Our findings demonstrate the variability in neurological care of pediatric patients with TSC as it pertains to epilepsy management. There is a need for the establishment of epilepsy practice guidelines and a national network to support clinical practice, research, and education.
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Affiliation(s)
- Robyn Whitney
- Division of Neurology, Department of PaediatricsMcMaster UniversityHamiltonOntarioCanada
| | - Maria Zak
- Division of Neurology, Department of PaediatricsThe Hospital for Sick ChildrenTorontoOntarioCanada
| | - Denait Haile
- Department of Paediatrics, Schulich School of Dentistry and MedicineWestern UniversityLondonOntarioCanada
| | - Maryam Nabavi Nouri
- Department of Paediatrics, Schulich School of Dentistry and MedicineWestern UniversityLondonOntarioCanada
- Children's Health Research InstituteLawson Health Research InstituteLondonOntarioCanada
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Gataullina S, Galvani G, Touchet S, Nous C, Lemaire E, Laschet J, Chiron C, Dulac O, Dossi E, Brion JD, Messaoudi S, Alami M, Huberfeld G. GluN2C
selective inhibition is a target to develop new antiepileptic compounds. Epilepsia 2022; 63:2911-2924. [PMID: 36054371 DOI: 10.1111/epi.17396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 08/17/2022] [Accepted: 08/17/2022] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Many early-onset epilepsies present as developmental and epileptic encephalopathy associated with refractory seizures, altered psychomotor development, and disorganized interictal cortical activity. Abnormal upregulation of specific N-methyl-d-aspartate receptor (NMDA-R) subunits is being disentangled as one of the mechanisms of severe early-onset epilepsies. In tuberous sclerosis complex (TSC), upregulation of the GluN2C subunit of the NMDA-R with slow deactivation kinetic results in increased neuronal excitation and synchronization. METHODS Starting from an available GluN2C/D antagonist, NMDA-R-modulating compounds were developed and screened using a patch clamp on neuronal culture to select those with the strongest inhibitory effect on glutamatergic NMDA currents. For these selected compounds, blood pharmacokinetics and passage through the blood-brain barrier were studied. We tested the effect of the most promising compounds on epileptic activity in Tsc1+/- mice brain slices with multielectrode array, and then in vivo at postnatal ages P14-P17, comparable with the usual age at epilepsy onset in human TSC. RESULTS Using a double-electrode voltage clamp on isolated NMDA currents, we identified the most prominent antagonists of the GluN2C subunit with no effect on GluN2A as a means of preventing side effects. The best compound passing through the blood-brain barrier was selected. Applied in vivo in six Tsc1+/- mice at P14-P17, this compound reduced or completely stopped spontaneous seizures in four of them, and decreased the background activity disorganization. Furthermore, ictal-like discharges stopped on a human brain sample from an infant with epilepsy due to TSC. INTERPRETATION Subunit-selective inhibition is a valuable target for developing drugs for severe epilepsies resulting from an upregulation of NMDA-R subunit-mediated transmission.
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Affiliation(s)
- S. Gataullina
- Service d’explorations fonctionnelles multidisciplinaires Centre de médecine du sommeil, Antoine Béclère Hospital, APHP, Université Paris Saclay Clamart France
| | - G. Galvani
- AdPueriVitam (APV), Antony France
- Université de Lorraine CNRS, L2CM Nancy France
| | - S. Touchet
- AdPueriVitam (APV), Antony France
- Université de Lorraine CNRS, L2CM Nancy France
| | - C. Nous
- Institut de la Vision, UFR Sciences et Technologies Paris France
| | | | | | - C. Chiron
- Inserm U1141, Paris & APHP, Neuropediatrics, Necker Hospital Paris France
| | - O. Dulac
- AdPueriVitam (APV), Antony France
| | - E. Dossi
- Center for Interdisciplinary Research in Biology, Collège de France, CNRS UMR 7241, INSERM U1050 Université PSL Paris France
| | - J. D. Brion
- Université Paris‐Saclay CNRS UMR 8076, BioCIS Châtenay‐Malabry France
| | - S. Messaoudi
- Université Paris‐Saclay CNRS UMR 8076, BioCIS Châtenay‐Malabry France
| | - M. Alami
- Université Paris‐Saclay CNRS UMR 8076, BioCIS Châtenay‐Malabry France
| | - G. Huberfeld
- Center for Interdisciplinary Research in Biology, Collège de France, CNRS UMR 7241, INSERM U1050 Université PSL Paris France
- Neurology Department, Hôpital Fondation Adolphe de Rothschild Paris France
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Jonsson H, Lehto M, Vanhatalo S, Gaily E, Linnankivi T. Visual field defects after vigabatrin treatment during infancy: retrospective population-based study. Dev Med Child Neurol 2022; 64:641-648. [PMID: 34716587 DOI: 10.1111/dmcn.15099] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/27/2021] [Indexed: 02/02/2023]
Abstract
AIM To investigate the prevalence of vigabatrin-attributed visual field defect (VAVFD) in infantile spasms and the utility of optical coherence tomography (OCT) in detecting vigabatrin-related damage. METHOD We examined visual fields by Goldmann or Octopus perimetry and the thickness of peripapillary retinal nerve fiber layer (RNFL) with spectral-domain OCT at school age or adolescence. RESULTS Out of 88 patients (38 females, mean age at study 15y, SD 4y 3mo, range 6y 4mo-23y 3mo [n=65] or deceased [n=21] or moved abroad [n=2]) exposed to vigabatrin in infancy, 28 were able to perform formal visual field testing. Two had visual field defect from structural causes. We found mild VAVFD in four patients and severe VAVFD in one patient. Median vigabatrin treatment duration for those with normal visual field was 11 months compared to 19 months for those with VAVFD (p=0.04). OCT showed concomitant attenuated RNFL in three children with VAVFD, and was normal in one. The temporal half of the peripapillary RNFL was significantly thinner in the VAVFD group compared to the normal visual field group. INTERPRETATION The overall prevalence of VAVFD is lower after exposure in infancy compared to 52% which has been reported after exposure in adulthood. The risk increases with longer treatment duration. Further studies should identify infants particularly susceptible to VAVFD and clarify the role of OCT.
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Affiliation(s)
- Henna Jonsson
- Department of Pediatric Neurology, New Children's Hospital and Pediatric Research Center, Epilepsia Helsinki, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Mikko Lehto
- Department of Ophthalmology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Sampsa Vanhatalo
- Department of Children's Clinical Neurophysiology, BABA Center, Department of Clinical Neurophysiology, Children's Hospital, Helsinki University Hospital, Helsinki, Finland.,Neuroscience Center, Helsinki Institute of Life Science, University of Helsinki, Helsinki, Finland
| | - Eija Gaily
- Department of Pediatric Neurology, New Children's Hospital and Pediatric Research Center, Epilepsia Helsinki, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Tarja Linnankivi
- Department of Pediatric Neurology, New Children's Hospital and Pediatric Research Center, Epilepsia Helsinki, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
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Nabavi Nouri M, Zak M, Jain P, Whitney R. Epilepsy Management in Tuberous Sclerosis Complex: Existing and Evolving Therapies and Future Considerations. Pediatr Neurol 2022; 126:11-19. [PMID: 34740132 DOI: 10.1016/j.pediatrneurol.2021.09.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Revised: 09/22/2021] [Accepted: 09/25/2021] [Indexed: 10/20/2022]
Abstract
Tuberous sclerosis complex (TSC) is a rare autosomal dominant condition that affects multiple body systems. Disruption of the mammalian target of rapamycin (mTOR) pathway results in abnormal cell growth, proliferation, protein synthesis, and cell differentiation and migration in TSC. In the central nervous system, mTOR disruption is also believed to influence neuronal excitability and promote epileptogenesis. Epilepsy is the most common neurological manifestation of TSC and affects 80% to 90% of individuals with high rates of treatment resistance (up to 75%). The onset of epilepsy in the majority of individuals with TSC occurs before the age of two years, which is a critical time in neurodevelopment. Both medically refractory epilepsy and early-onset epilepsy are associated with intellectual disability in TSC, while seizure control and remission are associated with lower rates of cognitive impairment. Our current knowledge of the treatment of epilepsy in TSC has expanded immensely over the last decade. Several new therapies such as preemptive vigabatrin therapy in infants, cannabidiol, and mTOR inhibitors have emerged in recent years for the treatment of epilepsy in TSC. This review will provide clinicians with a comprehensive overview of the pharmacological and nonpharmacological therapies available for the treatment of epilepsy related to TSC.
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Affiliation(s)
- Maryam Nabavi Nouri
- Division of Neurology, Department of Pediatrics, Western University, London, Ontario, Canada
| | - Maria Zak
- Division of Neurology, Department of Paediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Puneet Jain
- Division of Neurology, Department of Paediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Robyn Whitney
- Division of Neurology, Department of Paediatrics, McMaster University, Hamilton, Ontario, Canada.
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Ihnen SKZ, Capal JK, Horn PS, Griffith M, Sahin M, Martina Bebin E, Wu JY, Northrup H, Krueger DA. Epilepsy Is Heterogeneous in Early-Life Tuberous Sclerosis Complex. Pediatr Neurol 2021; 123:1-9. [PMID: 34343869 PMCID: PMC8487620 DOI: 10.1016/j.pediatrneurol.2021.06.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 06/28/2021] [Accepted: 06/29/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND Epilepsy in tuberous sclerosis complex (TSC) typically presents with early onset, multiple seizure types, and intractability. However, variability is observed among individuals. Here, detailed individual data on seizure characteristics collected prospectively during early life were used to define epilepsy profiles in this population. METHODS Children aged zero to 36 months were followed longitudinally. Caregivers kept daily seizure diaries, including onset and daily counts for each seizure type. Patients with >70% seizure diary completion and >365 diary days were included. Developmental outcomes at 36 months were compared between subgroups. RESULTS Epilepsy was seen in 124 of 156 (79%) participants. Seizure onset occurred from zero to 29.5 months; 93% had onset before age 12 months. Focal seizures and epileptic spasms were most common. Number of seizures (for median 897 days) ranged from 1 to 9128. Hierarchical clustering based on six metrics of seizure burden (age of onset, total seizures, ratio of seizure days to nonseizure days, seizures per seizure day, and worst seven- and 30-day stretches) revealed two distinct groups with broadly favorable and unfavorable epilepsy profiles. Subpopulations within each group showed clinically meaningful differences in seizure burden. Groups with higher seizure burden had worse developmental outcomes at 36 months. CONCLUSIONS Although epilepsy is highly prevalent in TSC, not all young children with TSC have the same epilepsy profile. At least two phenotypic subpopulations are discernible based on seizure burden. Early and aggressive treatments for epilepsy in TSC may be best leveraged by targeting specific subgroups based on phenotype severity.
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Affiliation(s)
- S. Katie Z. Ihnen
- Division of Neurology, Cincinnati Children’s Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Jamie K. Capal
- Department of Neurology, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Paul S. Horn
- Division of Neurology, Cincinnati Children’s Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Molly Griffith
- Division of Neurology, Cincinnati Children’s Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Mustafa Sahin
- Department of Neurology and F.M Kirby Neurobiology Center, Boston Children’s Hospital, Harvard Medical School, Harvard University, Boston, MA
| | - E. Martina Bebin
- Department of Neurology, University of Alabama at Birmingham, Birmingham, AL
| | - Joyce Y. Wu
- Division of Neurology, Department of Pediatrics, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Hope Northrup
- Department of Pediatrics, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX
| | - Darcy A. Krueger
- Division of Neurology, Cincinnati Children’s Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
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Updated International Tuberous Sclerosis Complex Diagnostic Criteria and Surveillance and Management Recommendations. Pediatr Neurol 2021; 123:50-66. [PMID: 34399110 DOI: 10.1016/j.pediatrneurol.2021.07.011] [Citation(s) in RCA: 234] [Impact Index Per Article: 78.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Accepted: 07/20/2021] [Indexed: 01/10/2023]
Abstract
BACKGROUND Tuberous sclerosis complex (TSC) is an autosomal dominant genetic disease affecting multiple body systems with wide variability in presentation. In 2013, Pediatric Neurology published articles outlining updated diagnostic criteria and recommendations for surveillance and management of disease manifestations. Advances in knowledge and approvals of new therapies necessitated a revision of those criteria and recommendations. METHODS Chairs and working group cochairs from the 2012 International TSC Consensus Group were invited to meet face-to-face over two days at the 2018 World TSC Conference on July 25 and 26 in Dallas, TX, USA. Before the meeting, working group cochairs worked with group members via e-mail and telephone to (1) review TSC literature since the 2013 publication, (2) confirm or amend prior recommendations, and (3) provide new recommendations as required. RESULTS Only two changes were made to clinical diagnostic criteria reported in 2013: "multiple cortical tubers and/or radial migration lines" replaced the more general term "cortical dysplasias," and sclerotic bone lesions were reinstated as a minor criterion. Genetic diagnostic criteria were reaffirmed, including highlighting recent findings that some individuals with TSC are genetically mosaic for variants in TSC1 or TSC2. Changes to surveillance and management criteria largely reflected increased emphasis on early screening for electroencephalographic abnormalities, enhanced surveillance and management of TSC-associated neuropsychiatric disorders, and new medication approvals. CONCLUSIONS Updated TSC diagnostic criteria and surveillance and management recommendations presented here should provide an improved framework for optimal care of those living with TSC and their families.
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Nabbout R, Kuchenbuch M, Chiron C, Curatolo P. Pharmacotherapy for Seizures in Tuberous Sclerosis Complex. CNS Drugs 2021; 35:965-983. [PMID: 34417984 DOI: 10.1007/s40263-021-00835-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/05/2021] [Indexed: 01/18/2023]
Abstract
Epilepsy is one of the main symptoms affecting the lives of individuals with tuberous sclerosis complex (TSC), causing a high rate of morbidity. Individuals with TSC can present with various types of seizures, epilepsies, and epilepsy syndromes that can coexist or appear in relation to age. Focal epilepsy is the most frequent epilepsy type with two developmental and epileptic encephalopathies: infantile spasms syndrome and Lennox-Gastaut syndrome. Active screening and early management of epilepsy is recommended in individuals with TSC to limit its consequences and its impact on quality of life, cognitive outcome and the economic burden of the disease. The progress in the knowledge of the mechanisms underlying epilepsy in TSC has paved the way for new concepts in the management of epilepsy related to TSC. In addition, we are moving from traditional "reactive" and therapeutic choices with current antiseizure medications used after the onset of seizures, to a proactive approach, aimed at predicting and preventing epileptogenesis and the onset of epilepsy with vigabatrin, and to personalized treatments with mechanistic therapies, namely mechanistic/mammalian target of rapamycin inhibitors. Indeed, epilepsy linked to TSC is one of the only epilepsies for which a predictive and preventive approach can delay seizure onset and improve seizure response. However, the efficacy of such interventions on long-term cognitive and psychiatric outcomes is still under investigation.
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Affiliation(s)
- Rima Nabbout
- Reference Centre for Rare Epilepsies, Department of Pediatric Neurology, Necker Enfants Malades University Hospital, APHP, Université de Paris, 149 rue de Sèvres, 75015, Paris, France.
- UMR 1163, Institut National de la Santé et de la Recherche Médicale (INSERM), Imagine Institute, Université de Paris, Paris, France.
| | - Mathieu Kuchenbuch
- Reference Centre for Rare Epilepsies, Department of Pediatric Neurology, Necker Enfants Malades University Hospital, APHP, Université de Paris, 149 rue de Sèvres, 75015, Paris, France
- UMR 1163, Institut National de la Santé et de la Recherche Médicale (INSERM), Imagine Institute, Université de Paris, Paris, France
| | - Catherine Chiron
- Reference Centre for Rare Epilepsies, Department of Pediatric Neurology, Necker Enfants Malades University Hospital, APHP, Université de Paris, 149 rue de Sèvres, 75015, Paris, France
- Institut National de la Santé et de la Recherche Médicale (INSERM), UMR 1141, Neurospin, Gif sur Yvette, France
| | - Paolo Curatolo
- Department of System Medicine, Child Neurology and Psychiatry Unit, Tor Vergata University Hospital, Rome, Italy
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Schubert-Bast S, Strzelczyk A. Review of the treatment options for epilepsy in tuberous sclerosis complex: towards precision medicine. Ther Adv Neurol Disord 2021; 14:17562864211031100. [PMID: 34349839 PMCID: PMC8290505 DOI: 10.1177/17562864211031100] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Accepted: 06/21/2021] [Indexed: 12/24/2022] Open
Abstract
Tuberous sclerosis complex (TSC) is a rare genetic disorder caused by mutations in the TSC1 or TSC2 genes, which encode proteins that antagonise the mammalian isoform of the target of rapamycin complex 1 (mTORC1) - a key mediator of cell growth and metabolism. TSC is characterised by the development of benign tumours in multiple organs, together with neurological manifestations including epilepsy and TSC-associated neuropsychiatric disorders (TAND). Epilepsy occurs frequently and is associated with significant morbidity and mortality; however, the management is challenging due to the intractable nature of the seizures. Preventative epilepsy treatment is a key aim, especially as patients with epilepsy may be at a higher risk of developing severe cognitive and behavioural impairment. Vigabatrin given preventatively reduces the risk and severity of epilepsy although the benefits for TAND are inconclusive. These promising results could pave the way for evaluating other treatments in a preventative capacity, especially those that may address the underlying pathophysiology of TSC, including everolimus, cannabidiol and the ketogenic diet (KD). Everolimus is an mTOR inhibitor approved for the adjunctive treatment of refractory TSC-associated seizures that has demonstrated significant reductions in seizure frequency compared with placebo, improvements that were sustained after 2 years of treatment. Highly purified cannabidiol, recently approved in the US as Epidiolex® for TSC-associated seizures in patients ⩾1 years of age, and the KD, may also participate in the regulation of the mTOR pathway. This review focusses on the pivotal clinical evidence surrounding these potential targeted therapies that may form the foundation of precision medicine for TSC-associated epilepsy, as well as other current treatments including anti-seizure drugs, vagus nerve stimulation and surgery. New future therapies are also discussed, together with the potential for preventative treatment with targeted therapies. Due to advances in understanding the molecular genetics and pathophysiology, TSC represents a prototypic clinical syndrome for studying epileptogenesis and the impact of precision medicine.
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Affiliation(s)
- Susanne Schubert-Bast
- Epilepsy Center Frankfurt Rhine-Main, Center of Neurology and Neurosurgery, Goethe-University Frankfurt, Frankfurt am Main, Germany
| | - Adam Strzelczyk
- Epilepsy Center Frankfurt Rhine-Main, Goethe-University Frankfurt, Schleusenweg 2-16, Frankfurt am Main, 60528, Germany
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Di Napoli C, Gennaro A, Lupica C, Falsaperla R, Leonardi R, Garozzo MT, Polizzi A, Praticò AD, Zanghì A, Ruggieri M. TSC1 and TSC2: Tuberous Sclerosis Complex and Its Related Epilepsy Phenotype. JOURNAL OF PEDIATRIC NEUROLOGY 2021. [DOI: 10.1055/s-0041-1727142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
AbstractTuberous sclerosis complex (TSC) is an autosomal dominant disorder characterized by a multisystemic involvement. In TSC, reduced function of TSC1 and TSC2 genes products (hamartin and tuberin, respectively) leads to an hyperactivation of the mechanistic target of rapamycin (mTOR) pathway and to a consequent cell growth dysregulation. In TSC patients, neurological and neuropsychiatric manifestations, especially epilepsy and neuropsychiatric comorbidities such as autism or intellectual disability, represent the most disabling features. In particular, epilepsy occurrs up to 80% of patients, is often drug resistant and is frequently associated with neurological impairment. Due to the burden of this morbidity, different treatment strategies have been proposed with the purpose to make patients epilepsy free, such as the use of different antiepileptic drugs like vigabatrin, carbamazepine, valproic acid, and levetiracetam. More recently, a mTOR inhibitor (i.e. everolimus) has showed promising results in terms of seizures reduction.
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Affiliation(s)
- Claudia Di Napoli
- Postgraduate Training Program in Genetics, Department of Biomedical and Biotechnological Sciences, Section of Genetics, University of Catania, Catania, Italy
| | - Alessia Gennaro
- Postgraduate Training Program in Genetics, Department of Biomedical and Biotechnological Sciences, Section of Genetics, University of Catania, Catania, Italy
| | - Carmelania Lupica
- Postgraduate Training Program in Genetics, Department of Biomedical and Biotechnological Sciences, Section of Genetics, University of Catania, Catania, Italy
| | - Raffaele Falsaperla
- Unit of Pediatrics and Pediatric Emergency, University Hospital “Policlinico Rodolico-San Marco,” Catania, Italy
- Unit of Neonatal Intenstive Care and Neonatology, University Hospital “Policlinico Rodolico-San Marco,” Catania, Italy
| | - Roberta Leonardi
- Department of Clinical and Experimental Medicine, Section of Pediatrics and Child Neuropsychiatry, Unit of Rare Diseases of the Nervous System in Childhood, University of Catania, Catania, Italy
| | - Maria Teresa Garozzo
- Unit of Pediatrics and Pediatric Emergency, Hospital “Cannizzaro,” Catania, Italy
| | - Agata Polizzi
- Chair of Pediatrics, Department of Educational Sciences, University of Catania, Catania, Italy
| | - Andrea D. Praticò
- Department of Clinical and Experimental Medicine, Section of Pediatrics and Child Neuropsychiatry, Unit of Rare Diseases of the Nervous System in Childhood, University of Catania, Catania, Italy
| | - Antonio Zanghì
- Department of General Surgery and Medical-Surgical Specialty, University of Catania, Catania, Italy
| | - Martino Ruggieri
- Chair of Pediatrics, Department of Educational Sciences, University of Catania, Catania, Italy
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Uematsu M, Numata-Uematsu Y, Aihara Y, Kobayashi T, Fujikawa M, Togashi N, Shiihara T, Ohashi K, Hattori A, Saitoh S, Kure S. Behavioral problems and family distress in tuberous sclerosis complex. Epilepsy Behav 2020; 111:107321. [PMID: 32698109 DOI: 10.1016/j.yebeh.2020.107321] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 06/28/2020] [Accepted: 07/02/2020] [Indexed: 11/16/2022]
Abstract
BACKGROUND Tuberous sclerosis complex (TSC)-associated neuropsychiatric disorders (TAND) have a large impact on patients and their families. Improving intellectual ability outcomes using preventive vigabatrin (VGB) treatment has recently been reported. AIM The aim of this study was to investigate the severity of behavioral problems and degree of distress among families of patients with TSC with and without a history of VGB treatment. METHOD The study enrolled 21 children and adolescents who were patients with TSC from four hospitals: 14 in the VGB group and 7 in the no-VGB group. To evaluate patients' psychiatric and neurological symptoms, we used the TAND Checklist, Aberrant Behavior Checklist (ABC), Social Communication Questionnaire (SCQ), and Social Responsive Scale-2nd edition (SRS-2). RESULTS All VGB-group patients were administered VGB after the onset of epileptic seizures. No obvious differences were observed between the VGB and no-VGB groups in behavioral problem scores on the TAND Checklist, or on the ABC, SCQ, and SRS-2 total scores. Behavioral problem scores were lower in patients with normal intelligence than in those with mild intellectual disability (ID; P = 0.042). Degrees of family distress assessed with the TAND Checklist were not correlated with the intelligence quotient/developmental quotient (IQ/DQ) or seizure frequency but were correlated with the total SRS-2 scores (P = 0.022). For several patients, there were large discrepancies between familial and physician ratings of the TAND impact score. CONCLUSION Children and adolescents with TSC may present with significant behavioral difficulties and family distress, regardless of whether they were treated with VGB or not after the onset of seizures. Difficulties in social communication may have the strongest "TAND impact" on families.
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Affiliation(s)
- Mitsugu Uematsu
- Department of Pediatrics, Tohoku University School of Medicine, 980-8574, Japan.
| | | | - Yu Aihara
- Department of Pediatrics, Tohoku University School of Medicine, 980-8574, Japan
| | - Tomoko Kobayashi
- Department of Pediatrics, Tohoku University School of Medicine, 980-8574, Japan
| | - Mayu Fujikawa
- Department of Neuropsychiatry, Keio University School of Medicine, 160-8582, Japan; Department of Epileptology, Tohoku University School of Medicine, 980-8574, Japan
| | - Noriko Togashi
- Department of Pediatric Neurology, Miyagi Children's Hospital, 989-3126, Japan
| | - Takashi Shiihara
- Department of Neurology, Gunma Children's Medical Center, 377-8577, Japan
| | - Kei Ohashi
- Department of Neonatology and Pediatrics, Nagoya City University Graduate School of Medical Sciences, 467-8602, Japan
| | - Ayako Hattori
- Department of Neonatology and Pediatrics, Nagoya City University Graduate School of Medical Sciences, 467-8602, Japan
| | - Shinji Saitoh
- Department of Neonatology and Pediatrics, Nagoya City University Graduate School of Medical Sciences, 467-8602, Japan
| | - Shigeo Kure
- Department of Pediatrics, Tohoku University School of Medicine, 980-8574, Japan
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Velíšek L, Velíšková J. Modeling epileptic spasms during infancy: Are we heading for the treatment yet? Pharmacol Ther 2020; 212:107578. [PMID: 32417271 PMCID: PMC7299814 DOI: 10.1016/j.pharmthera.2020.107578] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Accepted: 05/07/2020] [Indexed: 12/22/2022]
Abstract
Infantile spasms (IS or epileptic spasms during infancy) were first described by Dr. William James West (aka West syndrome) in his own son in 1841. While rare by definition (occurring in 1 per 3200-3400 live births), IS represent a major social and treatment burden. The etiology of IS varies - there are many (>200) different known pathologies resulting in IS and still in about one third of cases there is no obvious reason. With the advancement of genetic analysis, role of certain genes (such as ARX or CDKL5 and others) in IS appears to be important. Current treatment strategies with incomplete efficacy and serious potential adverse effects include adrenocorticotropin (ACTH), corticosteroids (prednisone, prednisolone) and vigabatrin, more recently also a combination of hormones and vigabatrin. Second line treatments include pyridoxine (vitamin B6) and ketogenic diet. Additional treatment approaches use rapamycin, cannabidiol, valproic acid and other anti-seizure medications. Efficacy of these second line medications is variable but usually inferior to hormonal treatments and vigabatrin. Thus, new and effective models of this devastating condition are required for the search of additional treatment options as well as for better understanding the mechanisms of IS. Currently, eight models of IS are reviewed along with the ideas and mechanisms behind these models, drugs tested using the models and their efficacy and usefulness. Etiological variety of IS is somewhat reflected in the variety of the models. However, it seems that for finding precise personalized approaches, this variety is necessary as there is no "one-size-fits-all" approach possible for both IS in particular and epilepsy in general.
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Affiliation(s)
- Libor Velíšek
- Departments of Cell Biology & Anatomy, New York Medical College, Valhalla, NY, USA; Departments of Pediatrics, New York Medical College, Valhalla, NY, USA; Departments of Neurology, New York Medical College, Valhalla, NY, USA.
| | - Jana Velíšková
- Departments of Cell Biology & Anatomy, New York Medical College, Valhalla, NY, USA; Departments of Neurology, New York Medical College, Valhalla, NY, USA; Departments of Obstetrics & Gynecology, New York Medical College, Valhalla, NY, USA
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18
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Specchio N, Pietrafusa N, Ferretti A, De Palma L, Santarone ME, Pepi C, Trivisano M, Vigevano F, Curatolo P. Treatment of infantile spasms: why do we know so little? Expert Rev Neurother 2020; 20:551-566. [PMID: 32316776 DOI: 10.1080/14737175.2020.1759423] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
INTRODUCTION Infantile spasm (IS) is an epileptic syndrome with typical onset within the first 2 years of life. This condition might be caused by several etiologies. IS is associated with pathological neuronal networks; however, definite hypotheses on neurobiological processes are awaited. AREAS COVERED Changes in NMDA and GABAB receptors and increase of Ca2+ conductance are some of the possible pathophysiological mechanisms. Animal models can help, but most have only some features of IS. Outcome is strongly affected by etiology and the timing of treatment, which relies still on ACTH, oral steroids, and vigabatrin. No significant differences in terms of efficacy have been documented, though a combination of ACTH and vigabatrin seems to be associated with better long-term outcomes. Despite the increasing knowledge about the etiology and pathophysiology of IS, in the last years, no new treatment approaches have been recognized to be able to modify the neurobiological process underlying IS. Precision medicine has far to come in IS. EXPERT OPINION Recently, no new therapeutic options for IS have emerged, probably due to the lack of reliable animal models and to the extreme variability in etiologies. Consequently, the outlook for patients and families is poor and early recognition and intervention remain research priorities.
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Affiliation(s)
- Nicola Specchio
- Rare and Complex Epilepsy Unit, Department of Neuroscience, Bambino Gesù Children's Hospital, IRCCS , Rome, 00165, Italy.,Member of European Reference Network EpiCARE
| | - Nicola Pietrafusa
- Rare and Complex Epilepsy Unit, Department of Neuroscience, Bambino Gesù Children's Hospital, IRCCS , Rome, 00165, Italy
| | - Alessandro Ferretti
- Rare and Complex Epilepsy Unit, Department of Neuroscience, Bambino Gesù Children's Hospital, IRCCS , Rome, 00165, Italy
| | - Luca De Palma
- Rare and Complex Epilepsy Unit, Department of Neuroscience, Bambino Gesù Children's Hospital, IRCCS , Rome, 00165, Italy
| | - Marta Elena Santarone
- Department of Neuroscience, Bambino Gesù Children's Hospital, IRCCS , 00165, Rome, Italy
| | - Chiara Pepi
- Rare and Complex Epilepsy Unit, Department of Neuroscience, Bambino Gesù Children's Hospital, IRCCS , Rome, 00165, Italy.,Child Neurology and Psychiatry Unit, Systems Medicine Department, Tor Vergata University , 00133, Rome, Italy
| | - Marina Trivisano
- Rare and Complex Epilepsy Unit, Department of Neuroscience, Bambino Gesù Children's Hospital, IRCCS , Rome, 00165, Italy
| | - Federico Vigevano
- Member of European Reference Network EpiCARE.,Department of Neuroscience, Bambino Gesù Children's Hospital, IRCCS , 00165, Rome, Italy
| | - Paolo Curatolo
- Child Neurology and Psychiatry Unit, Systems Medicine Department, Tor Vergata University , 00133, Rome, Italy
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19
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van der Poest Clement E, Jansen FE, Braun KPJ, Peters JM. Update on Drug Management of Refractory Epilepsy in Tuberous Sclerosis Complex. Paediatr Drugs 2020; 22:73-84. [PMID: 31912454 DOI: 10.1007/s40272-019-00376-0] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Tuberous sclerosis complex (TSC) is a genetic neurocutaneous disorder with epilepsy as a common and early presenting symptom. The neurological phenotype, however, is variable and unpredictable. Early and refractory seizures, infantile spasms in particular, are associated with a poor neurological outcome. Preliminary data suggests early and aggressive seizure control may mitigate the detrimental neurodevelopmental effects of epilepsy. For infantile spasms, vigabatrin is the first line of treatment, and steroids and classic antiepileptic drugs (AEDs) are suitable for second line. Based on retrospective data, vigabatrin should be considered for other indications, especially in infants with focal seizures, as this may prevent infantile spasms, but also in children and adults with epileptic spasms and tonic seizures. Otherwise, for most seizure types, treatment is similar to that for patients without TSC, including the use of novel AEDs, although limited data are available. Three major developments are changing the field of epilepsy management in TSC. First, final recommendations on preventive treatment with vigabatrin will result from two multicenter trials in the US (PREVeNT, clinicaltrials.gov #NCT02849457) and Europe (EPISTOP, clinicaltrials.gov #NCT02098759). Second, treatment with everolimus, an inhibitor of the mechanistic target of rapamycin (mTOR), reduced seizures when compared to placebo. Further, mTOR inhibitors may have an overall disease-modifying effect. Third, the role of cannabidiol in the treatment of refractory seizures in TSC is yet to be established. With treatment recommendations in TSC, we keep an eye on the prize for the broader field of pediatric epilepsy: the lessons learned from TSC are likely applicable to other epileptic encephalopathies.
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Affiliation(s)
| | - Floor E Jansen
- Department of Child Neurology, University Medical Center Utrecht Brain Center, Utrecht, The Netherlands
| | - Kees P J Braun
- Department of Child Neurology, University Medical Center Utrecht Brain Center, Utrecht, The Netherlands
| | - Jurriaan M Peters
- Division of Epilepsy and Clinical Neurophysiology, Boston Children's Hospital and Harvard Medical School, 300 Longwood Ave, FE9, Boston, 02115, USA.
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Etiologic classification of infantile spasms using positron emission/magnetic resonance imaging and the efficacy of adrenocorticotropic hormone therapy. Eur J Nucl Med Mol Imaging 2020; 47:1585-1595. [PMID: 31901104 DOI: 10.1007/s00259-019-04665-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Accepted: 12/20/2019] [Indexed: 10/25/2022]
Abstract
PURPOSE The aim of this study was to investigate if the etiologic classification of infantile spasm (IS) using positron emission tomography/magnetic resonance imaging (PET/MR) is feasible. Based on the classified etiologic groups, we further evaluated the efficacy of adrenocorticotropic hormone (ACTH) therapy in different IS groups. MATERIALS AND METHODS One hundred fifty-five children diagnosed with IS were included in this study. A qualitative assessment of the PET/MR images was performed. The abnormal lesions localized with both MR and PET images were considered to be epileptic foci, and the patients with these lesions were classified into the structural-metabolic group. For the remaining patients, quantitative analyses were further performed on whole-brain T1-weighted (T1WI) and PET images, based on the asymmetry index of bilateral volumes and metabolic quantifications. Patients with asymmetry indices above a certain threshold (15%) were classified into the structural-metabolic group. The patients without positive finding from either qualitative or quantitative analyses were assigned to the unknown etiology group. The efficacy of ACTH therapy was evaluated in the different IS groups. RESULTS Among the 155 children with IS, 18 genetic cases were first diagnosed by the genetic testing. In the remaining 137 cases, 49 cases were identified with structural-metabolic etiology using qualitative PET/MR assessments. Fifty-two cases were newly diagnosed with quantitative analysis. The remaining 36 cases were classified into the unknown etiology group. The efficacy of ACTH therapy was statistically different for the different etiology groups (p < 0.001). The respective efficacy rates for the genetic, qualitative structural-metabolic, quantitative structural-metabolic, and unknown etiology groups were 27.8% (5/18), 30.61% (15/49), 34.62% (18/52), and 72.22% (26/36), respectively. CONCLUSIONS The combination of PET and MR provides additional diagnostic information for IS. Quantitative analysis can further improve patient etiologic classifications and the predication of therapy efficacies.
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Modifying genetic epilepsies - Results from studies on tuberous sclerosis complex. Neuropharmacology 2019; 166:107908. [PMID: 31962286 DOI: 10.1016/j.neuropharm.2019.107908] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2019] [Revised: 12/03/2019] [Accepted: 12/05/2019] [Indexed: 12/12/2022]
Abstract
Tuberous sclerosis complex (TSC) is an autosomal dominant neurocutaneous disorder affecting approximately 1 in 6,000 in general population and represents one of the most common genetic causes of epilepsy. Epilepsy affects 90% of the patients and appears in the first 2 years of life in the majority of them. Early onset of epilepsy in the first year of life is associated with high risk of cognitive decline and neuropsychiatric problems including autism. Recently TSC has been recognized as a model of genetic epilepsies. TSC is a genetic condition with known dysregulated mTOR pathway and is increasingly viewed as a model for human epileptogenesis. Moreover, TSC is characterized by a hyperactivation of mTOR (mammalian target of rapamycin) pathway, and mTOR activation was showed to be implicated in epileptogenesis in many animal models and human epilepsies. Recently published studies documented positive effect of preventive or disease modifying treatment of epilepsy in infants with high risk of epilepsy with significantly lower incidence of epilepsy and better cognitive outcome. Further studies on preventive treatment of epilepsy in other genetic epilepsies of early childhood are considered. This article is part of the special issue entitled 'New Epilepsy Therapies for the 21st Century - From Antiseizure Drugs to Prevention, Modification and Cure of Epilepsy'.
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Walters DC, Arning E, Bottiglieri T, Jansen EEW, Salomons GS, Brown MN, Schmidt MA, Ainslie GR, Roullet JB, Gibson KM. Metabolomic analyses of vigabatrin (VGB)-treated mice: GABA-transaminase inhibition significantly alters amino acid profiles in murine neural and non-neural tissues. Neurochem Int 2019; 125:151-162. [PMID: 30822440 DOI: 10.1016/j.neuint.2019.02.015] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Revised: 02/19/2019] [Accepted: 02/20/2019] [Indexed: 11/18/2022]
Abstract
The anticonvulsant vigabatrin (VGB; SabrilR) irreversibly inhibits GABA transaminase to increase neural GABA, yet its mechanism of retinal toxicity remains unclear. VGB is suggested to alter several amino acids, including homocarnosine, β-alanine, ornithine, glycine, taurine, and 2-aminoadipic acid (AADA), the latter a homologue of glutamic acid. Here, we evaluate the effect of VGB on amino acid concentrations in mice, employing a continuous VGB infusion (subcutaneously implanted osmotic minipumps), dose-escalation paradigm (35-140 mg/kg/d, 12 days), and amino acid quantitation in eye, visual and prefrontal cortex, total brain, liver and plasma. We hypothesized that continuous VGB dosing would reveal numerous hitherto undescribed amino acid disturbances. Consistent amino acid elevations across tissues included GABA, β-alanine, carnosine, ornithine and AADA, as well as neuroactive aspartic and glutamic acids, serine and glycine. Maximal increase of AADA in eye occurred at 35 mg/kg/d (41 ± 2 nmol/g (n = 21, vehicle) to 60 ± 8.5 (n = 8)), and at 70 mg/kg/d for brain (97 ± 6 (n = 21) to 145 ± 6 (n = 6)), visual cortex (128 ± 6 to 215 ± 19) and prefrontal cortex (124 ± 11 to 200 ± 13; mean ± SEM; p < 0.05), the first demonstration of tissue AADA accumulation with VGB in mammal. VGB effects on basic amino acids, including guanidino-species, suggested the capacity of VGB to alter urea cycle function and nitrogen disposal. The known toxicity of AADA in retinal glial cells highlights new avenues for assessing VGB retinal toxicity and other off-target effects.
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Affiliation(s)
- Dana C Walters
- Department of Pharmacotherapy, College of Pharmacy and Pharmaceutical Sciences, Washington State University, Spokane, WA, USA
| | - Erland Arning
- Baylor Scott & White Research Institute, Institute of Metabolic Disease, Dallas, TX, USA
| | - Teodoro Bottiglieri
- Baylor Scott & White Research Institute, Institute of Metabolic Disease, Dallas, TX, USA
| | - Erwin E W Jansen
- Metabolic Laboratory, Department of Clinical Chemistry, Amsterdam University Medical Center, the Netherlands
| | - Gajja S Salomons
- Metabolic Laboratory, Department of Clinical Chemistry, Amsterdam University Medical Center, the Netherlands
| | - Madalyn N Brown
- Department of Pharmacotherapy, College of Pharmacy and Pharmaceutical Sciences, Washington State University, Spokane, WA, USA
| | - Michelle A Schmidt
- Department of Pharmacotherapy, College of Pharmacy and Pharmaceutical Sciences, Washington State University, Spokane, WA, USA
| | - Garrett R Ainslie
- Department of Pharmacotherapy, College of Pharmacy and Pharmaceutical Sciences, Washington State University, Spokane, WA, USA
| | - Jean-Baptiste Roullet
- Department of Pharmacotherapy, College of Pharmacy and Pharmaceutical Sciences, Washington State University, Spokane, WA, USA
| | - K Michael Gibson
- Department of Pharmacotherapy, College of Pharmacy and Pharmaceutical Sciences, Washington State University, Spokane, WA, USA.
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Walters DC, Jansen EEW, Ainslie GR, Salomons GS, Brown MN, Schmidt MA, Roullet J, Gibson KM. Preclinical tissue distribution and metabolic correlations of vigabatrin, an antiepileptic drug associated with potential use-limiting visual field defects. Pharmacol Res Perspect 2019; 7:e00456. [PMID: 30631446 PMCID: PMC6321982 DOI: 10.1002/prp2.456] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Revised: 12/06/2018] [Accepted: 12/07/2018] [Indexed: 01/30/2023] Open
Abstract
Vigabatrin (VGB; (S)-(+)/(R)-(-) 4-aminohex-5-enoic acid), an antiepileptic irreversibly inactivating GABA transaminase (GABA-T), manifests use-limiting ocular toxicity. Hypothesizing that the active S enantiomer of VGB would preferentially accumulate in eye and visual cortex (VC) as one potential mechanism for ocular toxicity, we infused racemic VGB into mice via subcutaneous minipump at 35, 70, and 140 mg/kg/d (n = 6-8 animals/dose) for 12 days. VGB enantiomers, total GABA and β-alanine (BALA), 4-guanidinobutyrate (4-GBA), and creatine were quantified by mass spectrometry in eye, brain, liver, prefrontal cortex (PFC), and VC. Plasma VGB concentrations increased linearly by dose (3 ± 0.76 (35 mg/kg/d); 15.1 ± 1.4 (70 mg/kg/d); 34.6 ± 3.2 μmol/L (140 mg/kg/d); mean ± SEM) with an S/R ratio of 0.74 ± 0.02 (n = 14). Steady state S/R ratios (35, 70 mg/kg/d doses) were highest in eye (5.5 ± 0.2; P < 0.0001), followed by VC (3.9 ± 0.4), PFC (3.6 ± 0.3), liver (2.9 ± 0.1), and brain (1.5 ± 0.1; n = 13-14 each). Total VGB content of eye exceeded that of brain, PFC and VC at all doses. High-dose VGB diminished endogenous metabolite production, especially in PFC and VC. GABA significantly increased in all tissues (all doses) except brain; BALA increases were confined to liver and VC; and 4-GBA was prominently increased in brain, PFC and VC (and eye at high dose). Linear correlations between enantiomers and GABA were observed in all tissues, but only in PFC/VC for BALA, 4-GBA, and creatine. Preferential accumulation of the VGB S isomer in eye and VC may provide new insight into VGB ocular toxicity.
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Affiliation(s)
- Dana C. Walters
- Department of PharmacotherapyCollege of Pharmacy and Pharmaceutical SciencesWashington State UniversitySpokaneWashington
| | - Erwin E. W. Jansen
- Metabolic LaboratoryDepartment of Clinical ChemistryAmsterdam University Medical CenterAmsterdamThe Netherlands
| | - Garrett R. Ainslie
- Department of PharmacotherapyCollege of Pharmacy and Pharmaceutical SciencesWashington State UniversitySpokaneWashington
| | - Gajja S. Salomons
- Metabolic LaboratoryDepartment of Clinical ChemistryAmsterdam University Medical CenterAmsterdamThe Netherlands
| | - Madalyn N. Brown
- Department of PharmacotherapyCollege of Pharmacy and Pharmaceutical SciencesWashington State UniversitySpokaneWashington
| | - Michelle A. Schmidt
- Department of PharmacotherapyCollege of Pharmacy and Pharmaceutical SciencesWashington State UniversitySpokaneWashington
| | - Jean‐Baptiste Roullet
- Department of PharmacotherapyCollege of Pharmacy and Pharmaceutical SciencesWashington State UniversitySpokaneWashington
| | - K. M. Gibson
- Department of PharmacotherapyCollege of Pharmacy and Pharmaceutical SciencesWashington State UniversitySpokaneWashington
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