Update on diagnosis and management of childhood epilepsies

Seizures and Epilepsy in Childhood

PURPOSE OF REVIEW

This article highlights basic concepts of seizures and epilepsy in pediatric patients, as well as basic treatment principles for this age group.

RECENT FINDINGS

Epilepsy is the most common neurologic disorder in childhood. Accurate diagnosis is key; in older children, epileptic seizures need to be differentiated from various paroxysmal nonepileptic events, whereas in neonates, the majority of seizures are subclinical (electroencephalographic). Antiseizure medications remain the first-line treatment, but ketogenic diet and epilepsy surgery have also shown positive outcomes and can decrease drug burden. Genetic causes account for approximately 30% of cases, and the recognition of electroclinical syndromes is being replaced by the concept of genetic spectrums. Precision medicine therapies are promising, but wide application in daily practice still has a long way to go. Early access to specialist centers and optimal treatments positively affects prognosis and future neurodevelopment.

SUMMARY

Although novel findings from all fields of research are being incorporated into everyday clinical practice, a better quality of life for children with seizures and epilepsy and their families is the ultimate priority.

Predictive factors of epilepsy outcome in a sample of Egyptian pre-elderly and elderly population

Background

Elderly people with epilepsy are large, but neglected group. Data on the predictive factors for recurrent seizures in the elderly population are inconclusive or are not known for the majority of patients. This is especially true for the Egyptian population as no specific study was concluded to address this issue before.

Objectives

The aim of this study was to detect the predictive factors of epilepsy outcome in a sample of Egyptian aged population.

Materials and methods

A total of 100 patients aged 50 years or older with epilepsy diagnosed according to International League Against Epilepsy (ILAE) latest definition were included in the study and followed up for 6 months as regards seizure control. All participants were prospectively evaluated for epidemiological, clinical, radiological, electrodiagnostic, and laboratory data.

Results

The outcome was statistically significant affected in relation to absence of medical comorbidities (P = 0.037), seizure etiology (P = 0.007), history of status epilepticus (P <  0.001), MRI brain findings (P = 0.005), EEG changes (P <  0.001), Ca (P = 0.01), and Mg level (P = 0.046).

Conclusion

We conclude that aged Egyptian epileptic population with no medical comorbidities, normal MRI brain, or normal EEG can be predicted to have good outcome of their epilepsy while patients with post stroke epilepsy, abnormal MRI brain, and abnormal EEG, with low serum Ca or Mg level can be predicted to have poor outcome.

Anti-seizure activity of African medicinal plants: The identification of bioactive alkaloids from the stem bark of Rauvolfia caffra using an in vivo zebrafish model

ETHNOPHARMACOLOGICAL RELEVANCE

Epilepsy is one of the major chronic diseases that does not have a cure to date. Adverse drug reactions have been reported from the use of available anti-epileptic drugs (AEDs) which are also effective in only two-thirds of the patients. Accordingly, the identification of scaffolds with promising anti-seizure activity remains an important first step towards the development of new anti-epileptic therapies, with improved efficacy and reduced adverse effects. Herbal medicines are widely used in developing countries, including in the treatment of epilepsy but with little scientific evidence to validate this use. In the search for new epilepsy treatment options, the zebrafish has emerged as a chemoconvulsant-based model for epilepsy, mainly because of the many advantages that zebrafish larvae offer making them highly suitable for high-throughput drug screening.

AIM OF THE STUDY

In this study, 20 medicinal plants traditionally used in South Africa to treat epilepsy were screened for anti-epileptic activity using a zebrafish larvae model.

MATERIALS AND METHODS

Toxicity triaging was conducted on 120 crude extracts, 44 fractions and three isolated compounds to determine the maximum tolerated concentration (MTC) of each extract, fraction or compound. MTC values were used to guide the concentration range selection in bioactivity studies. The effectiveness of crude extracts, fractions and isolated compounds from Rauvolfia caffra Sond. in suppression of pentylenetetrazole (PTZ) induced seizure-like behaviour in a 6-dpf zebrafish larvae model was measured using the PTZ assay.

RESULTS

Following a preliminary toxicity triage and bioactivity screen of crude extracts from 20 African plants used traditionally for the treatment and management of epilepsy, the methanolic extract of Rauvolfia caffra Sond. was identified as the most promising at suppressing PTZ induced seizure-like behaviour in a zebrafish larvae model. Subsequent bioactivity-guided fractionation and spectroscopic structural elucidation resulted in the isolation and identification of two tryptoline derivatives; a previously unreported alkaloid to which we assigned the trivial name rauverine H (1) and the known alkaloid pleiocarpamine (2). Pleiocarpamine was found to reduce PTZ-induced seizures in a dose-dependent manner.

CONCLUSIONS

Accordingly, pleiocarpamine represents a promising scaffold for the development of new anti-seizure therapeutic compounds. Furthermore, the results of this study provide preliminary evidence to support the traditional use of Rauvolfia caffra Sond. in the treatment and management of epilepsy. These findings warrant further studies on the anti-epileptic potential of Rauvolfia caffra Sond. using other models.

Pregabalin adjunctive therapy for focal onset seizures in children 1 month to <4 years of age: A double-blind, placebo-controlled, video-electroencephalographic trial

OBJECTIVE

To evaluate the efficacy and safety of pregabalin as adjunctive treatment for children (aged 1 month-<4 years) with focal onset seizures (FOS) using video-electroencephalography (V-EEG).

METHODS

This randomized, placebo-controlled, international study included V-EEG seizure monitoring (48-72 hours) at baseline and over the last 3 days of 14-day (5-day dose escalation; 9-day fixed dose) double-blind pregabalin treatment (7 or 14 mg/kg/d in three divided doses). This was followed by a double-blind 1-week taper. The primary efficacy endpoint was log-transformed seizure rate (log_e [24-hour seizure rate + 1]) for all FOS recorded during the double-blind V-EEG monitoring, evaluated in subjects who took ≥1 dose of study medication, experienced ≥1 baseline seizure(s), and had a treatment phase V-EEG. Safety and tolerability were assessed by adverse events (AEs), clinical laboratory data, physical/neurological examinations, vital signs, and electrocardiograms.

RESULTS

Overall, 175 patients were randomized (mean age = 28.2 months; 59% male, 69% white, 30% Asian) in a 2:1:2 ratio to pregabalin 7 or 14 mg/kg/d (n = 71 or n = 34, respectively), or placebo (n = 70). Pregabalin 14 mg/kg/d (n = 28) resulted in a statistically significant 35% reduction of log_e (24-hour seizure rate + 1) versus placebo (n = 53; P = .022), an effect that was not observed with pregabalin 7 mg/kg/d (n = 59; P = .461). The most frequently reported treatment-emergent AEs for pregabalin 7 mg/kg/d, 14 mg/kg/d, and placebo, respectively, were somnolence (11.3%, 17.6%, and 5.7%) and upper respiratory tract infection (7.0%, 11.8%, and 11.4%). All AEs were mild to moderate in severity.

SIGNIFICANCE

Pregabalin 14 mg/kg/d (but not 7 mg/kg/d) significantly reduced seizure rate in children with FOS, when assessed using V-EEG, compared with placebo. Both pregabalin dosages were generally safe and well tolerated in children 1 month to <4 years of age with FOS. Safety and tolerability were consistent with the known profile of pregabalin in older children with epilepsy.

Infantile Spasms: Clinical profile and treatment outcomes

Background and Objective

Infantile spasm (IS) is one of the severe epileptic encephalopathies which affect children in early two years of life. Our objective was to determine the clinical profile, etiology and outcome of treatment in children with infantile spasms attending tertiary care hospital at Karachi, Pakistan.

Methods

This is retrospective study of 36 patients out of 94 registered as IS, aged three months to two years, managed and followed up at Aga Khan University Hospital, Karachi, from 2010 to 2015. Data of all children with IS was collected from case record. Details including clinical observations, lab investigations, anti-epileptic medications and treatment outcome was collected and analyzed. Patients who received treatment for six weeks to document response were included. The treatment response was categorized as complete response, partial response (>50% improvement) and no response. Data was analyzed on SPSS using descriptive statistics.

Results

Thirty- six patients (38.29%) with IS fulfilled eligibility criteria. The mean ± SD age at presentation was 4.6±2.1 months. Male to female ratio was 2:1. Consanguinity and developmental motor delay was observed in 66.6% and 89% respectively. Symptomatic etiology was predominant (61%) and hypoxic ischemic insult (32%) was the commonest underlying cause. EEG and MRI were diagnostic tools whereas metabolic studies were not helpful. Multiple antiepileptic drugs were used for seizure control and vigabatrin was the most frequently used (88%) drug. Short term treatment response was not different in idiopathic or symptomatic infantile spasms.

Conclusion

Majority of patients had symptomatic infantile spasms and generalized tonic clonic along with myoclonic jerks were predominant seizure types. EEG and MRI were diagnostic in most of cases. Multiple AEDs were required to control seizures and VGB was most common drug (88%) used. Treatment outcome was not different in idiopathic and symptomatic groups.

Self-confidence for the initial management of health issues in schools: construction and validation of a visual analogue scale

Abstract Objective: To describe the construction and validation of a visual analogue scale of teachers' self-confidence with regard to the initial management of health issues in schools. Method: A methodological study was developed based on theoretical (items' construction and content validation), empirical (semantic analysis and pilot test), and analytical procedures (internal consistency analysis). The project was approved by a research ethics committee. Results: The scale consisted of 12 items regarding the main health issues in schools, presented content validity index of 100% in the second round, was understood by the target audience, and presented high internal consistency among items (Cronbach's alpha of 0.89). Conclusion and implications for practice: An easy-to-use tool that proved to be relevant to meet the dimension of teachers' self-confidence in the initial management of health issues in schools. The scale may contribute to the planning of systematized and effective educational strategies among teachers.

Current role of perampanel in pediatric epilepsy

Perampanel is among the latest AEDs approved, indicated for the treatment of partial-onset seizures with or without secondary generalization, and for primary generalized tonic-clonic seizures, in patients aged 12 years and older. This paper summarizes the clinical recommendations on the current role of perampanel in the treatment of pediatric epilepsies and future directions for research. The optimal dosage should be comprised between 4 and 12 mg/day, with 8 mg/day being the most common dosage used. The rate and severity of adverse events, including psychiatric symptoms, can be decreased by starting at low doses, and titrating slowly. Overall, perampanel presents an acceptable risk/benefit ratio, but special caution should be made to the risk of seizure aggravation and behavioral problems. The favorable cognitive profile, the ease of use of the titration scheme and the once-daily formulation offer advantage over other AEDs and make this drug particularly suitable for adolescent population. Perampanel is a welcome addition to the armamentarium of the existing AEDs, as it represents a new approach in the management of epilepsy, with a novel mechanism of action and a potential to have a considerable impact on the treatment of adolescents with epilepsy.

Smartphone applications for seizure care and management in children and adolescents with epilepsy: Feasibility and acceptability assessment among caregivers in China

OBJECTIVE

to determine the feasibility as well as the attitudes among caregivers of children and adolescents with epilepsy in China towards the use of smart phone applications (apps) for the management of seizures.

METHODS

The caregivers of children and adolescents with epilepsy, ages ranging from 0 to 15 years, were enrolled in the study from the Epilepsy Prevention and Cure Center of West China Hospital within the time period from June 2015 to December 2015. A 10-item questionnaire gauging the attitudes towards using apps for seizure management was administered to the 390 caregivers. Additionally, data on the demographic and clinic characteristics of the children and adolescents with epilepsy for each caregiver were also collected.

RESULTS

The results indicated that approximately 99.2% of caregivers own a mobile phone, of which, 97.9% of these mobile phones were smart phones. Despite only 3.1% (12/390) of caregivers currently having an app regarding the management of a chronic illness, 70.2%(274/390) reported that they would use a free seizure management app. The results of the current study indicated that the likelihood of using such a free app increased if the participant was a male as opposed to a female (P=0.03) and among caregivers with a higher education level, a higher annual household income as well as stable job (P<0.001, P<0.001, P=0.02). No statistically significant difference was found in the likelihood of using such a free app among caregivers living in rural as opposed to urban areas (P=0.3).

CONCLUSIONS

The results of this study imply a favorable attitude towards the use of apps for epilepsy and seizure management among caregivers. The use of such apps in China thus represents a promising strategy among caregivers for seizure management.