The landscape of infantile epileptic spasms syndrome in South Asia: peculiarities, challenges, and way forward

Short-Term Effectiveness and Tolerability of Vigabatrin Therapy in Infantile Epileptic Spasms Syndrome

The study evaluated the short-term effectiveness and tolerability of vigabatrin therapy in children with infantile epileptic spasms syndrome (IESS). Children with IESS were enrolled within two weeks of initiation of vigabatrin and prospectively followed up to 12 wk for complete cessation of epileptic spasms (ES) and occurrence of adverse events. Of 107 children studied, there was a preponderance of structural etiology (82.2%) and male sex (69.2%). Thirty percent of children achieved a complete cessation of ES for at least four weeks at a median dose of 95 mg/kg/d (Q1, Q3: 50, 125). Among responders, 84.4% achieved cessation of ES within two weeks of initiation of therapy. 12.5% of children had a relapse over a 12-wk follow-up. Thirteen percent of children had adverse events, drowsiness being the most common (9.3%). The present study demonstrated modest short-term clinical effectiveness and tolerability of vigabatrin therapy in children with hormonal-therapy-resistant IESS.

Update on Cannabidiol in Drug-Resistant Epilepsy

Cannabidiol (CBD) has arisen as a promising therapeutic option for children with drug-resistant epilepsy (DRE). CBD has received regulatory nod from different regulatory authorities in the United States, Europe, and India for children with DRE particularly, Dravet syndrome (DS), Lennox Gastaut syndrome (LGS), and Tuberous sclerosis complex (TSC). Recent clinical trials and observational studies highlight the potential of CBD to lower seizure frequency and provide better quality of life in children affected by these disorders. The safety profile is generally favorable with minor common adverse events such as somnolence, diarrhea, and gastrointestinal issues. Furthermore, the expense associated with CBD remains a notable concern, especially in low- and middle-income countries such as India, where access to this promising treatment may be constrained. This draws attention to the cost-effective perspective of CBD. This review aims to explore the pharmacological properties of CBD, its mechanisms of action, and the clinical evidence supporting its use in various pediatric epilepsies, including LGS, DS, and TSC. Additionally, this review sheds light on the current regulatory landscape in India where CBD use is still in its nascent stages, and discusses the challenges and opportunities for integrating CBD into clinical practice.

First-choice hormonal therapies for children with infantile epileptic spasms syndrome in South Asia: A network meta-analysis of randomized controlled trials

Considering the peculiar challenges with infantile epileptic spasms syndrome (IESS) in South Asia and a wide variation in the usage of hormonal therapies, we compared the efficacy and safety of various hormonal therapies for children with IESS in South Asia. We searched PubMed, Embase, Scopus, and Web of Science databases from the inception until April 2024. We included only randomized clinical trials (RCTs) evaluating the efficacy and safety of hormonal therapies for IESS in the South Asian region. Complete cessation of epileptic spasms (ES), electro-clinical response, and time taken to be spasm-free at 2 or 6 weeks of therapy were efficacy outcomes, while the occurrence of adverse events was the safety outcome. Effect estimates were reported as odds ratio (OR) or mean difference (MD) with 95% confidence intervals (CI) and Cochrane risk of bias 2.0 (ROB 2.0) used for quality assessment of each study. The surface under the cumulative ranking curve (SUCRA) was used to rank the different therapies and reported as a p-score ranging from 0 to 1. Of 747 citations, nine RCTs comprising 566 children with IESS were included. After 2-week treatment, dexamethasone (OR: 6.72; 95% CI: 1.47, 30.72), adrenocorticotropic hormone therapy (ACTH) high dose (HD) (OR: 5.30; 95% CI: 1.05, 26.91), and prednisolone HD (OR: 2.41; 95% CI:1.07, 5.46) had shown significantly greater efficacy for cessation of EScompared with ACTH low dose (LD). Similarly, for electroclinical response, dexamethasone (OR: 9.63; 95% CI: 1.99, 46.70) and prednisolone HD (OR: 3.46; 95% CI: 1.38, 8.68) had greater efficacy compared with ACTH LD. Safety outcomes revealed that hypertension was significantly less common with ACTH LD and prednisolone HD as compared with ACTH HD. This study provides quality evidence on preferred first-choice hormonal therapy for managing IESS in South Asia. ACTH HD, dexamethasone, and prednisolone HD are the most effective hormonal therapy options with dose-dependent therapeutic efficacy. PLAIN LANGUAGE SUMMARY: This study provides insights into the selection of first-line hormonal therapies among the various treatments for managing infantile epileptic spasms syndrome (IESS) in South Asia. The study findings suggested that the effectiveness of these therapies is dose-dependent, with high doses of ACTH, dexamethasone, and prednisolone being the most effective for achieving cessation of epileptic spasms.

Optimal lead time for treatment of infantile epileptic spasms syndrome-a secondary data analysis

Background

Infantile epileptic spasms syndrome (IESS) is a common epileptic syndrome in infancy. Current first-line treatments include adrenocorticotropic hormone (ACTH), corticosteroids and vigabatrin, with early control of epileptic spasms potentially benefiting long-term outcomes, such as improved psychomotor development. Early treatment, which means the prompt use of first-line treatments, is crucial for achieving an initial response in IESS. However, to date, no clear definition of the specific timeframe that constitutes early treatment has been identified. The objective of this study is to perform a secondary analysis of our previously published IESS cohort data to determine a suitable lead time.

Methods

An analysis was conducted using a cohort of 263 children with IESS who had previously received ACTH first-line treatment. This study investigated whether intervening within a certain treatment time window could potentially increase or decrease the likelihood of a short-term response.

Results

Out of the 263 children with IESS, 108 achieved a short-term response. The lead time of the response group was significantly shorter than that of the non-response group [1.50 (interquartile range, 1.00, 3.00) vs. 2.00 (interquartile range, 1.00, 5.00) months; P=0.003]. A restricted cubic spline graph with several adjusted variables, including time of first spasm and aetiological classification, showed a significant linear relationship between lead time and short-term response and a non-linear trend (inverted U-shaped curve), with a significant inflection point at 1.6 months. Using 1.5 months as the cutoff and dichotomising lead time, the adjusted logistic regression results showed that in children with a lead time >1.5 months, the likelihood of a short-term response decreased with increasing lead time [odds ratio (OR) =0.59, 95% confidence interval (CI): 0.33-0.92, P=0.041), whereas children with a lead time ≤1.5 months showed no significant association between lead time and short-term response (OR =1.03, 95% CI: 0.72-1.47, P=0.89).

Conclusions

For children with IESS, initiating first-line treatment within 1.5 months of the onset of spasms is recommended. For those who start first-line treatment after more than 1.5 months from the onset, the likelihood of a short-term response may significantly decrease as the lead time increases.

Factors influencing efficacy and relapse of adrenocorticotropic hormone in infantile epileptic spasms syndrome

BACKGROUND

Infantile epileptic spasms syndrome (IESS) is a severe epileptic condition characterized by persistent uncontrolled seizures, with some children experiencing recurrent seizures despite multiple pharmacological therapies. The prognostic risk factorsassociated with IESS remain unclear. This study aimed to evaluate the factors influencing the efficacy and relapse of adrenocorticotropic hormone (ACTH) treatment for IESS in infants, as well as to assess the correlation between the Burden of Amplitudes and Epileptiform Discharges (BASED) score and clinical outcomes.

METHODS

A retrospective analysis was conducted on a cohort of 88 pediatric patients diagnosed with IESS who received ACTH therapy at our hospital from February 2016 to August 2023. Patients were categorized into response (n = 47) and non-response (n = 41) groups based on their treatment response at day 28. Responders were further classified into relapse and non-relapse groups. A modified Poisson regression model and receiver operating characteristic (ROC) curves were employed to evaluate the positive predictive values.

RESULTS

In this study, a total of 47 patients (53.4 %) responded to ACTH treatment. Patients in the response group demonstrated significantly greater reductions in BASED scores by day 14 of ACTH treatment, yielding an area under the curve (AUC) of 0.859 (95 % CI: 0.782-0.937, P＜0.05), with a sensitivity of 68.1 % and a specificity of 95.1 %. The optimal cut-off point was established at ≥ 2, corresponding to a Youden index of 0.632. Notably, patientswho were on anti-seizure medications (ASMs) before ACTH treatment and those with developmental delay prior to the onset of spasms exhibited lower short-term response rates (P＜0.05), although these factors did not demonstrate predictive value. Among the responders, 20 cases (42.6 %) experienced a relapse, with only those patients showing specific abnormalities on cranial magnetic resonance imaging (MRI) exhibiting a statistically higher proportion of relapse.

CONCLUSION

Patients receiving ASMs before ACTH treatment and those with developmental delays prior to the onset of spasms may have a less favorable therapeutic response. A reduction in BASED scores of 2 or greater by day 14 of ACTH treatment may signify a potentially positive treatment response. Additionally, patients with IESS who present with specific abnormalities on cranial MRI may have an increased likelihood of relapse following ACTH treatment.

Electroclinical Landscape of Infantile Epileptic Spasms Syndrome

OBJECTIVES

To elucidate the electroclinical characteristics of infantile epileptic spasms syndrome (IESS) and to determine any potential association among these with underlying etiologies and response to therapy.

METHODS

Sixty-eight, treatment-naive children with IESS underwent long-term video electroencephalogram (EEG) recording, which was used to characterize the semiology, ictal, and inter-ictal EEG patterns. Children were further followed up to assess electroclinical predictors of etiologies and short-term therapeutic response.

RESULTS

Of 68 children enrolled (69% boys), the median age at enrollment was 10.5 mo (IQR-8). Eighty-eight percent of children had flexor spasms, followed by mixed (7%) and extensor (4.4%). Asymmetrical spasms were noted in 17.6% children, and all of them had underlying structural etiology. Two children had the status of epileptic spasms. In the present cohort, authors recognized five distinct ictal EEG correlates of epileptic spasms; the frontocentral dominant slow wave was the most prevalent (32%), followed by the generalized slow-wave complex with superimposed fast rhythm in 29.4%. The occipital dominant slow wave complex was a peculiar pattern in 16%. The major underlying etiologies were hypoxic-ischemic brain injuries (36.7%) and neonatal hypoglycemic brain injuries (22%). Besides asymmetric spasms, authors could not identify any significant association among electroclinical characteristics, underlying etiologies and response to therapy in this study.

CONCLUSIONS

The electroclinical landscape of IESS is peculiar and diverse in developing countries. The presence of asymmetrical spasms indicated underlying structural etiology.