Corticosteroids for the treatment of Landau-kleffner syndrome and continuous spike-wave discharge during sleep

Efficacy and safety of corticosteroids and ACTH in epileptic syndromes beyond Infantile Epileptic Spasms Syndrome (IESS): A systematic review and meta-analysis

We conducted a systematic review investigating the efficacy and tolerability of adrenocorticotropic hormone (ACTH) and corticosteroids in children with epilepsies other than infantile epileptic spasm syndrome (IESS) that are resistant to anti-seizure medication (ASM). We included retrospective and prospective studies reporting on more than five patients and with clear case definitions and descriptions of treatment and outcome measures. We searched multiple databases and registries, and we assessed the risk of bias in the selected studies using a questionnaire based on published templates. Results were summarized with meta-analyses that pooled logit-transformed proportions or rates. Subgroup analyses and univariable and multivariable meta-regressions were performed to examine the influence of covariates. We included 38 studies (2 controlled and 5 uncontrolled prospective; 31 retrospective) involving 1152 patients. Meta-analysis of aggregate data for the primary outcomes of seizure response and reduction of electroencephalography (EEG) spikes at the end of treatment yielded pooled proportions (PPs) of 0.60 (95% confidence interval [CI] 0.52-0.67) and 0.56 (95% CI 0.43-0.68). The relapse rate was high (PP 0.33, 95% CI 0.27-0.40). Group analyses and meta-regression showed a small benefit of ACTH and no difference between all other corticosteroids, a slightly better effect in electric status epilepticus in slow sleep (ESES) and a weaker effect in patients with cognitive impairment and "symptomatic" etiology. Obesity and Cushing's syndrome were the most common adverse effects, occurring more frequently in trials addressing continuous ACTH (PP 0.73, 95% CI 0.48-0.89) or corticosteroids (PP 0.72, 95% CI 0.54-0.85) than intermittent intravenous or oral corticosteroid administration (PP 0.05, 95% CI 0.02-0.10). The validity of these results is limited by the high risk of bias in most included studies and large heterogeneity among study results. This report was registered under International Prospective Register of Systematic Reviews (PROSPERO) number CRD42022313846. We received no financial support.

Efficacy and Safety of Pulse Intravenous Methylprednisolone in Pediatric Epileptic Encephalopathies: Timing and Networks Consideration

Background: Epileptic encephalopathies (EE) are characterized by severe drug-resistant seizures, early onset, and unfavorable developmental outcomes. This article discusses the use of intravenous methylprednisolone (IVMP) pulse therapy in pediatric patients with EE to evaluate its efficacy and tolerability. Methods: This is a retrospective study from 2020 to 2023. Inclusion criteria were ≤18 years at the time of IVMP pulse therapy and at least 6 months of follow-up. Efficacy and outcome, defined as seizure reduction > 50% (responder rate), were evaluated at 6 and 9 months of therapy, and 6 months after therapy suspension; quality of life (QoL) was also assessed. Variables predicting positive post-IVMP outcomes were identified using statistical analysis. Results: The study included 21 patients, with a responder rate of 85.7% at 6 and 9 months of therapy, and 80.9% at 6 months after therapy suspension. Variables significantly predicting favorable outcome were etiology (p = 0.0475) and epilepsy type (p = 0.0475), with the best outcome achieved in patients with genetic epilepsy and those with encephalopathy related to electrical status epilepticus during slow-wave sleep (ESES). All patients evidenced improvements in QoL at the last follow-up, with no relevant adverse events reported. Conclusions: Our study confirmed the efficacy and high tolerability of IVMP pulse therapy in pediatric patients with EE. Genetic epilepsy and ESES were positive predictors of a favorable clinical outcome. QOL, EEG tracing, and postural-motor development showed an improving trend as well. IVMP pulse therapy should be considered earlier in patients with EE.

Corticosteroids in childhood epilepsies: A systematic review

Corticosteroids have been used for the treatment of patients with epilepsy for more than 6 decades, based on the hypothesis of inflammation in the genesis and/or promotion of epilepsy. We, therefore, aimed to provide a systematic overview of the use of corticosteroid regimes in childhood epilepsies in line with the PRISMA guidelines. We performed a structured literature search via PubMed and identified 160 papers with only three randomized controlled trials excluding the substantial trials on epileptic spasms. Corticosteroid regimes, duration of treatment (days to several months), and dosage protocols were highly variable in these studies. Evidence supports the use of steroids in epileptic spasms; however, there is only limited evidence for a positive effect for other epilepsy syndromes, e.g., epileptic encephalopathy with spike-and-wave activity in sleep [(D)EE-SWAS] or drug-resistant epilepsies (DREs). In (D)EE-SWAS (nine studies, 126 patients), 64% of patients showed an improvement either in the EEG or in their language/cognition following various steroid treatment regimes. In DRE (15 studies, 436 patients), a positive effect with a seizure reduction in 50% of pediatric and adult patients and seizure freedom in 15% was identified; however, no recommendation can be drawn due to the heterozygous cohort. This review highlights the immense need for controlled studies using steroids, especially in DRE, to offer patients new treatment options.

Epilepsy and Cognitive Impairment in Childhood and Adolescence: A Mini-Review

Managing epilepsy in people with an intellectual disability remains a therapeutic challenge and must take into account additional issues such as diagnostic difficulties and frequent drug resistance. Advances in genomic technologies improved our understanding of epilepsy and raised the possibility to develop patients-tailored treatments acting on the key molecular mechanisms involved in the development of the disease. In addition to conventional antiseizure medications (ASMs), ketogenic diet, hormone therapy and epilepsy surgery play an important role, especially in cases of drugresistance. This review aims to provide a comprehensive overview of the mainfactors influencing cognition in children and adolescents with epilepsy and the main therapeutic options available for the epilepsies associated with intellectual disability.

The Effectiveness and Safety of Hormonal Combinations of Antiepileptic Drugs in the Treatment of Epileptic Electrical Continuity in Children during Sleep: A Meta-Analysis

Objective

A systematic evaluation of the efficacy of hormones in combination with antiepileptic drugs (AEDs) compared to AEDs alone in the treatment of children with encephalopathy related to status epilepticus during slow sleep (ESES). This study provides an evidence-based approach to the treatment of children with ESES.

Materials and Methods

To find all relevant studies published before March 2022, we searched PubMed, Embase, Web of Science, Clinical Trials, Cochrane Library, CNKI, and Wanfang databases. We explore the difference between AEDs combined with hormones and AEDs alone for ESES treatment. All outcome data, including Wechsler Intelligence Scale for Children, the effective rate, EEG discharges, and adverse effects rate (AER), were compared using Review Manager 5.3.

Results

There were 805 patients in this study's seven investigations, including 403 in the experimental group and 402 in the control group. Meta-analysis showed that after treatment, compared with the AEDs alone group, the hormone combined with AEDs. The difference in clinical improvement rate [RR = 1.25, 95% CI (1.15, 1.36), p < 0.00001], electroencephalographic (EEG) discharge improvement rate [RR = 1.31, 95% CI (1.22, 1.41), p < 0.00001], and cognitive intelligence score [SMD = 1.02, 95% CI (0.76, 1.28), p < 0.00001] was statistically significant. The differences were statistically significant in terms of 0.00001; the incidence of adverse reactions was higher in the hormone combined with AEDs group than in the AEDs group alone, and the differences were statistically significant [RR = 4.13, 95% CI (1.06, 16.13), p < 0.01], and all adverse reactions improved or disappeared after discontinuation of the drug.

Conclusions

The combination of hormones with AEDs for the treatment of epileptic electrical continuity in sleep has advantages over AEDs alone in terms of controlling seizures, improving EEG abnormalities, and improving cognition. The combination of hormones with AEDs has advantages over AEDs alone in controlling seizures, improving EEG abnormalities, and improving cognition and is relatively safe.

Clinical profile of patients with rolandic epilepsy at a clinic in rural Maharashtra

Purpose:

To describe the seizure pattern, treatment strategies and outcome in a series of children with Rolandic seizures or childhood epilepsy with centrotemporal spikes.

Materials and Methods:

Patients were defined as Rolandic epilepsy if on electroencephalographic studies high voltage spike and waves were seen in centrotemporal areas, could be followed by slow waves, often activated on sleep and could shift from one side to other or be secondarily generalized. Typical (TRS) or benign were those with normal intellect. Atypical rolandic seizures (ARS) were those associated with neuroregression of language and cognitive milestones. Patients were treated with antiepileptic drugs if more than one episode occurred or the first episode was generalized status epilepticus.

Results:

Thirty-three patients were included over the period of eight years (2012-2020). There was male preponderance (21 males versus 12 females). Four patients (12.12%) later evolved into Landau Kleffner syndrome (ARS group). The mean age of onset of epilepsy in the TRS group (29 patients) was 7.2 (+/-2.2) with the youngest patient being 4 years and the eldest being 12 years. In the ARS group the mean age of onset was 5 yrs. (+/-1.41). In the TRS group, 23 (79.31%) patients were managed on monotherapy AED. Seventeen patients (58.62%) responded (remission) to carbamazepine monotherapy alone. Six patients (20.68%) could afford oxcarbazepine monotherapy and went in remission with this therapy. In the ARS group all patients required three drugs (valproate, clobazam and levetiracetam). By the end of the study period, 23/33 (75.75%) patients remained seizure free.

Conclusions:

Most patients with rolandic seizures have excellent prognosis being seizure free around puberty. The neurological outcome in most patients was normal.

Role of pulse methylprednisolone in epileptic encephalopathy: A retrospective observational analysis

OBJECTIVES

To study the effect of monthly pulses of intravenous methylprednisolone (IVMP) on seizure and global outcomes in children with epileptic encephalopathy (EE).

METHODS

This retrospective study was undertaken in a tertiary care epilepsy center in India. Consecutive patients with EE who had received IVMP as adjunctive therapy for a minimum of 3 months and had at least one pre-and post-steroid EEG each, were identified and a structured questionnaire was used to collect information including outcomes at 3 months post-steroid course completion and beyond, as available.

RESULTS

Ninety-seven patients (M:F=71:26) fulfilling the inclusion criteria with a mean age at onset of seizures being 20.52 ± 25.69 months were included. Commonest seizure types were myoclonic (66%); Lennaux-Gastaut and West Syndromes accounted for 57 % and 24 % patients respectively. The etiology was unknown in 52 %. All children were on a combination of standard anti-seizure drugs. The duration of IVMP pulse therapy was 7.72 ± 6.25 months. One-fourth (26 %) patients experienced minor adverse events. Greater than 50 % seizure burden reduction was seen in 66 % patients at 3 months with seizure-freedom in 25 %. A total of 45 (46 %) patients became seizure-free in the cohort eventually with continuation of steroids beyond 3 months. Children with idiopathic EEs, normal neuroimaging, myoclonic jerks, and West syndrome showed the best response. The presence of burst-suppression and generalized paroxysmal fast activity (GPFA) predicted inadequate response.

CONCLUSIONS

Adjunct pulse doses of IVMP are safe, well-tolerated, and effective in reducing seizures and improving global outcomes in children with idiopathic EEs, West syndrome, normal neuroimaging, and myoclonic jerks. Seizure freedom might be delayed in a subset of these patients, hence duration of therapy beyond 3 months may be warranted.

The role of inflammatory mediators in epilepsy: Focus on developmental and epileptic encephalopathies and therapeutic implications

In recent years, there has been an increasing interest in the potential involvement of neuroinflammation in the pathogenesis of epilepsy. Specifically, the role of innate immunity (that includes cytokines and chemokines) has been extensively investigated either in animal models of epilepsy and in clinical settings. Developmental and epileptic encephalopathies (DEE) are a heterogeneous group of epileptic disorders, in which uncontrolled epileptic activity results in cognitive, motor and behavioral impairment. By definition, epilepsy in DEE is poorly controlled by common antiepileptic drugs but may respond to alternative treatments, including steroids and immunomodulatory drugs. In this review, we will focus on how cytokines and chemokines play a role in the pathogenesis of DEE and why expanding our knowledge about the role of neuroinflammation in DEE may be crucial to develop new and effective targeted therapeutic strategies to prevent seizure recurrence and developmental regression.

Ictal EEG in patients with autistic spectrum disorder and epilepsy

OBJECTIVE

Autism spectrum disorder (ASD) is a neurodevelopmental disorder frequently associated with epilepsy and epilepsy is a leading cause of death in ASD patients. Despite growing interest in genetic, neurophysiological and clinical overlaps, data on ictal electroencephalographic (EEG) recordings in ASD are lacking since behavioral disorders often make it difficult to obtain EEG recordings. We examined ictal EEG features in a consecutive series of patients with ASD and epilepsy.

METHODS

We retrospectively identified 400 consecutive patients with ASD and epilepsy at our Level 4 Epilepsy center between 2015 and 2019; 45 had at least one EEG-recorded seizure captured. Demographics, age of nonfebrile seizure onset, age of ASD diagnosis, language, magnetic resonance imagining findings, genetic testing and EEG studies were reviewed. Seizures were classified by semiologic and electrographic features. Ictal findings were analyzed.

RESULTS

A total of 497 seizures were captured in 45 patients: 20 patients with focal onset epilepsy had 126 seizures (median: 1, range: 1-30), 17 patients with generalized onset epilepsy had 88 seizures (median: 2, range: 1-15), 7 patients with Lennox-Gastaut syndrome had 270 seizures (median: 12, range: 1-74) and one patient had both right hemisphere focal and generalized onsets (12 focal, 1 generalized).

SIGNIFICANCE

Our study is the first to analyze a large set of ictal data in patients with autism spectrum disorder, a population traditionally difficult to obtain ictal recordings. Our results confirm the diverse spectrum of seizure types and provide clinical-EEG correlates of seizures in ASD patients. Both focal-onset and generalized-onset seizures were recorded, confirming that ASD patients have higher rates of both focal and generalized epilepsy syndromes. Among patients with focal epilepsy, temporal and frontal onsets were frequent, suggesting the possibility of epilepsy surgery or brain stimulation. EEG to classify seizures and epilepsies is critical to determine therapeutic options and effort should be made to obtain EEGs in this heterogenous population.

Epilepsy-Work-Up and Management in Children

Pediatric epilepsy is a highly variable condition due to age-related expression of syndromes that require specific diagnosis, evaluations, and treatments. Children with epilepsy differ from their adult counterparts in many important ways, mostly related to the age-related expression of specific epilepsy syndromes. This results in many important considerations related to the epilepsy diagnosis, classification, evaluations to determine an etiology, as well as treatment guidelines. A good understanding of these factors will help to establish an accurate epilepsy diagnosis, which in turn will guide appropriate testing and treatment decisions. In this way, patients will have improved seizure outcomes, and families will be educated appropriately and provided with the most accurate prognostic information available. The purpose of this article is to review the diagnosis, work-up, and management of pediatric epilepsy.

Pharmacological treatment for continuous spike-wave during slow wave sleep syndrome and Landau-Kleffner Syndrome

BACKGROUND

Continuous spike-wave during slow wave sleep syndrome (CSWS) and Landau-Kleffner syndrome (LKS) are two epileptic encephalopathies that present with neurocognitive regression, aphasia, and clinical seizures, typically presenting in children around five years of age. The pathophysiology of these conditions is not completely understood. Some studies suggest a common origin for both. No systematic reviews have assessed the efficacy of pharmacological interventions for these conditions.

OBJECTIVES

To assess the benefit and adverse effects of pharmacological interventions for the treatment of CSWS and LKS.

SEARCH METHODS

On 8 September 2020, we searched the Cochrane Register of Studies (CRS Web) and MEDLINE Ovid (1946 to September 04, 2020). We applied no language restrictions. CRS Web includes randomised or quasi-randomised, controlled trials from CENTRAL, PubMed, Embase, ClinicalTrials.gov, and the World Health Organization International Clinical Trials Registry Platform.

SELECTION CRITERIA

Randomised controlled trials, quasi-randomised controlled trials, and cluster-randomised trials comparing antiepileptic drugs alone, or with steroids or intravenous immunoglobulins, or both versus other antiepileptic drugs, or placebo, or no treatment, administered to children with CSWS and LKS. We planned to compare treatments for the two conditions separately.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed studies identified by the search strategy for inclusion. The primary outcomes considered in this review were neuropsychological-neurolinguistic functions.

MAIN RESULTS

Our search strategy yielded 18 references. Two review authors independently assessed all references. We did not find any completed studies to include. We identified one ongoing trial, which was terminated because of lack of enrolment.

AUTHORS' CONCLUSIONS

There was no evidence from trials to support or refute the use of pharmacological treatment for continuous spike-wave during slow wave sleep syndrome or Landau-Kleffner syndrome. Well-designed randomised controlled trials are needed to inform practice.

Treatment strategies for encephalopathy related to status epilepticus during slow sleep, a narrative review of the literature

Encephalopathy related to Status Epilepticus during slow Sleep (ESES) is an age-dependent syndrome characterized by the appearance of neuropsychological and behavioral disorders associated with extreme activation of epileptic activity during sleep. The major goal of therapy in ESES is to prevent neuropsychological deficits. Effective therapy to reduce seizures and resolve the EEG pattern of status epilepticus during sleep (SES) may be crucial to improve long-term prognosis. However, whether to improve neurodevelopmental deficits by suppressing or eliminating SES remains unknown. The purpose of this article is to review current therapeutic options in ESES, in order to provide better alternatives. Treatment options consist of antiepileptic drugs, steroids, immunoglobulins, the ketogenic diet, and surgery. Maybe therapy targeted mechanisms can be developed with deep insight into the etiology of ESES.

Methylprednisolone pulse therapy in 31 patients with refractory epilepsy: A single-center retrospective analysis

PURPOSE

We investigated the efficacy of methylprednisolone pulse therapy (MP) and responder characteristics in patients with refractory epilepsy.

METHODS

We reviewed medical records of our center to identify patients with refractory epilepsy treated with MP other than continuous spikes and waves during slow sleep (CSWS), Landau-Kleffner syndrome (LKS), or Rasmussen's syndrome (RS) between 2004 and 2015. A course of MP consisted of intravenous methylprednisolone (30 mg/kg/day) on three consecutive days. Patients received multiple courses at intervals of four weeks. We examined seizure outcome, developmental outcome, antibodies to N-methyl-d-aspartate (NMDA)-type glutamate receptors (GluRs), cerebral spinal fluid (CSF)-albumin/serum-albumin ratio, and interictal electroencephalograms (EEGs). Responder to MP was defined as maintaining seizure reduction rate (SRR) ≥50% for three months after the first course of MP.

RESULTS

Thirty-one consecutive patients treated with MP at our center were studied. Seizure types were focal onset impaired awareness seizure (FIAS) only (n = 23), FIAS with epileptic spasms (ES) (n = 7), and ES only (n = 1). Responder rate was 32.2% (10/31 patients), and seizure-free rate was 9.7% (3/31). Responders constituted 43.5% of patients without ES. No patient with ES was responder. Behavior and cognition also improved in 6 of 10 responders. History of seizure aggravation after inactivated vaccine before MP was found significantly higher rate in responder patients, comparing with nonresponder patients (p = 0.01).

CONCLUSION

Methylprednisolone pulse therapy may be considered for possible treatment in patients with focal epilepsy with drug-resistant seizures without ES, and it may improve cognitive function and behavioral comorbidities.

Immunotherapy for GRIN2A and GRIN2D-related epileptic encephalopathy

BACKGROUND

GRIN-related developmental-epileptic encephalopathies are associated with a spectrum of neurodevelopmental disorders, including intellectual disability, epilepsy including continuous spike-and-wave during sleep syndrome (CSWS), or epilepsy-aphasia spectrum phenotypes such as in Landau-Kleffner syndrome. Efficacy of IVIG treatment was recently reported in a patient with LKS related to GRIN2A mutation.

AIM AND METHODS

We describe the efficacy of Immunotherapy in 5 consecutive patients (4 males, age range 6 months-13 years) with molecularly confirmed GRIN-related epileptic encephalopathy (4 with GRIN2A- related epilepsy-aphasia spectrum/epileptic encephalopathy with CSWS, accompanied by verbal, communicative and behavioural regression, and one patient with GRIN2D - related infantile developmental-epileptic encephalopathy). All patients had global developmental delay/ intellectual disability in various degrees, and were resistant to anticonvulsants, but none of the patients had frequent clinical seizures. All patients received monthly infusion of IVIG 2 g/ kg for 6 months; 2 patients were also treated with high-dose corticosteroids.

RESULTS

Normalization or near normalization of the EEG was noted in 3 patients, from whom 2 had mild improvement in verbal abilities and communication skills. Perceptual/spatial abilities, as well as executive functions and attention span, remained significantly impaired.

CONCLUSION

according to this preliminary, open-label study, Immunotherapy may lead to a clinical and electrographic improvement in patients with GRIN-related developmental-epileptic encephalopathies. Further studies to validate the efficacy of immunotherapy and the potential role of autoimmunity in GRIN-related disorders are needed.

Language and behavioral outcomes of treatment with pulse-dose prednisone for electrical status epilepticus in sleep (ESES)

Few studies have examined treatment response in electrical status epilepticus in sleep (ESES), and fewer still have evaluated the effect of corticosteroid treatment employing a pulse-dose regimen. The aim of this study was to examine the effectiveness of pulse-dose prednisone in treating language and behavioral disturbances that often accompany ESES. The sample included 17 patients age 5 to 10 years at time of baseline electroencephalogram (EEG) and neuropsychological assessments. For all patients, focal, multifocal, or generalized spike and wave activity occupied greater than 50% of the nonrapid eye movement (REM) sleep record. Patients were seen for follow-up EEG recording and neuropsychological testing with an average of 10 months following initiation of pulse-dose prednisone. Improvement in language or behavior was examined in relation to resolution of ESES on EEG, age at seizure onset and treatment, duration of ESES, duration of treatment, lesional versus nonlesional epilepsy, history of language or behavioral regression, seizure control at follow-up, and intelligence quotient (IQ). With the exception of a greater likelihood of patients with low IQ to demonstrate improvement in language or behavior, improvement was seen in most patients, irrespective of ESES or other factors.

Dexamethasone ameliorates the damage of hippocampal filamentous actin cytoskeleton but is not sufficient to cease epileptogenesis in pilocarpine induced epileptic mice

Rogressive deconstruction of filament actin (F-actin) in hippocampal neurons in the epileptic brain have been associated with epileptogenesis. Previous clinical studies suggest that glucocorticoids treatment plays beneficial roles in refractory epilepsy. Glucocorticoids treatment affects dendritic spine morphology by regulating local glucocorticoid receptors and F-actin cytoskeleton dynamics. However, how glucocorticoids regulate epileptogenesis by controlling F-actin cytoskeleton is not clear yet. Here we study the function of glucocorticoids in epileptogenesis by examining F-actin abundance, hippocampal neuron number, and synaptic markers in pilocarpine-induced epileptic mice in the presence or absence of dexamethasone (DEX) treatment. We found that spontaneous seizure duration was significantly reduced; F-actin damage in hippocampal subfields was remarkably attenuated; loss of pyramidal cells was dramatically decreased; more intact synaptic structures indicated by pre- and postsynaptic markers were preserved in multiple hippocampal regions after DEX treatment. However, the number of ZNT3 positive particles in the molecular layer in the hippocampus of pilocarpine epileptic mice was not altered after DEX treatment. Although not sufficient to cease epileptogenesis, our results suggest that dexamethasone treatment ameliorates the damage of epileptic brain by stabilizing F-actin cytoskeleton in the pilocarpine epileptic mice.

Selected rare paediatric communication neurological disorders

The purpose of this review is to discuss rare neurological disorders with respect to communication difficulties typical of children. Firstly, communication disorders with special focus on rare communication neurological disorders are discussed. Secondly, on the basis of literature review, the authors explore clinical studies on the most typical rare children's communication neurological disorders. Thirdly, on the basis of the findings from the clinical studies, they set a few recommendations for their medical therapies and management. The methodology was based on the literature review of research studies exploring the research issue. The findings show that the intervention strategies appear to have positive effects on the improvement of speech and language production among children suffering from Landau-Kleffner syndrome and childhood apraxia of speech. Nevertheless, randomized control trials are needed in order to accelerate and facilitate an early and relevant diagnosis and treatment management. In addition, a multidisciplinary approach seems to be the most appropriate for the accurate diagnosis and comprehensive treatment.

Baicalein improves cognitive deficits and hippocampus impairments in temporal lobe epilepsy rats

Temporal lobe epilepsy (TLE) is a chronic neurological disorder that is a refractory disease. Baicalein possesses various pharmacological activities, including neuroprotection in neurodegenerative disease. However, whether baicalein is protective in the treatment of TLE is not determined. Therefore, the present study investigated the role of baicalein in the treatment of TLE. Baicalein was injected intraperitoneally to TLE rats for two weeks after the onset of spontaneous recurrent seizures (SRS). Rats were observed for the occurrence of SRS, and cognitive and hippocampus injuries were evaluated. Oxidative stress and inflammatory cytokines were measured. Corticosterone and its receptor, actin-associated protein F-actin and cofilin-1 were investigated in the brains of epileptic rats. Baicalein significantly improved cognition and reduced hippocampus damage and mossy fibre sprouting in TLE rats without obvious SRS suppression. Baicalein produced excellent anti-oxidative and anti-inflammatory effects in TLE rats. Baicalein restored the disruption of the glucocorticoid signal pathway and actin-associated protein in TLE rats. These results suggest that the neuroprotective effects of baicalein on cognition and the hippocampus are associated with the suppression of oxidative stress and inflammation and the regulation of the glucocorticoid pathway and actin-associated protein in TLE rats. This evidence supports the use of baicalein as an adjuvant agent for epilepsy treatment.

The Value of Electroencephalogram in Assessing Children With Speech and Language Impairments

Purpose We sought to estimate the prevalence of isolated epileptiform activity (IEA) in children with speech and language impairments and discuss the utility of an electroencephalogram (EEG) in assessing these children. Method We conducted a systematic review and searched for eligible studies in 8 databases. All languages were included, and meta-analyses were performed. Results We found 55 prevalence estimates (8 with control group). The odds of having IEA were 6 times greater for children with speech and language impairments than for typically developing children. The overall pooled prevalence of IEA was 27.3%. A wide variation between the prevalence estimates was, to a certain degree, explained by type of impairment (8.1% in speech impairments, 25.8% in language impairments, and 51.5% in language regression). Sleep EEGs detected a significantly higher prevalence than awake EEGs. Although the presence of epilepsy gave a significantly higher prevalence than if epilepsy was not present, 33.5% of children with language impairment but without epilepsy were found to have IEA in sleep EEGs. Conclusions This systematic review shows that IEA is 6 times more prevalent in children with speech and language impairment than in typically developing children. However, the prevalence rates vary to a great extent. Uncovering IEA will, in addition to information from other clinical assessments, provide a more comprehensive understanding of the child's impairments. We argue that, although EEG is of questionable value when assessing children with speech impairments, sleep EEG could be valuable when assessing children with language impairments and, in particular, children who experience language regression.

Review of Clinical Studies Targeting Inflammatory Pathways for Individuals With Autism

Immune dysfunction and abnormal immune response may be associated with certain mechanisms underlying autism spectrum disorder (ASD). The early evidence for this link was based on the increased incidence of ASD in children with a history of maternal infection during pregnancy. Observational studies show increased prevalence of immune-related disorders-ranging from atopy, food allergy, viral infections, asthma, primary immunodeficiency, to autoimmune disorders-in individuals with ASD and their families. Evidence of neuroglial activation and focal brain inflammation in individuals with ASD implies that the central nervous system immunity may also be atypical in some individuals with ASD. Also, both peripheral and central inflammatory responses are suggested to be associated with ASD-related behavioral symptoms. Atypical immune responses may be evident in specific ASD subgroups, such as those with significant gastrointestinal symptoms. The present review aimed to evaluate current literature of potential interventions that target inflammatory pathways for individuals with ASD and to summarize whether these interventions were associated with improvement in autism symptoms and adaptation. We found that the current literature on the efficacy of anti-inflammatory interventions in ASD is still limited and large-scale randomized controlled trials are needed to provide robust evidence. We concluded that the role of immune-mediated mechanisms in the emergence of ASD or related challenges may be specific to subsets of individuals (e.g. those with concurrent immunological disorders, developmental regression, or high irritability). These subsets of individuals of ASD might be more likely to benefit from interventions that target immune-mediated mechanisms and with whom next-stage immune-mediated clinical trials could be conducted.

Early identification of epileptic encephalopathy with continuous spikes-and-waves during sleep: A case-control study

Epileptic encephalopathy with continuous spikes-and-waves during sleep (EE-CSWS) is a rare childhood epilepsy syndrome characterized by a regression in cognitive, behavioral and psychiatric functioning, seizures and a specific electroencephalographic pattern. An early recognition and an appropriate treatment might play a key role in the outcome of this epileptic encephalopathy. We conducted a case-control study to evaluate if there is any clinical or electroencephalographic sign suggestive of EE-CSWS after the first seizure. We retrospectively identified 10 EE-CSWS patients with available EEG recordings at time of the first seizure. We matched them with 10 controls from our first seizure clinics. All EEG recording were analyzed for the study. We did not find any clinical or EEG features that would suggest later development of EE-CSWS. As reported by others, the occurrence of multiple seizures types and a seizure worsening during the follow-up is more frequent in the cases than in the controls. These clinical criteria might be used as a red flag in clinical practice to identify the very few patients with EE-CSWS among the frequent patients with BECTS.

Cognitive and Social Outcomes of Epileptic Encephalopathies

The term "epileptic encephalopathy" denotes a disorder in which seizures or frequent interictal discharges exacerbate neurocognitive dysfunction beyond what would be expected on the basis of underlying etiology. However, many underlying causes of epileptic encephalopathy also result in neurocognitive deficits, and it can be challenging to discern to what extent these deficits can be improved with better seizure control. Additionally, as seizures in these conditions are typically refractory, children are often exposed to high doses of multiple antiepileptic drugs which further exacerbate these comorbidities. This review will summarize the neurocognitive and social outcomes in children with various epileptic encephalopathies. Prompt, accurate diagnosis of epilepsy syndrome and etiology allows selection of optimal therapy to maximize seizure control, limiting the impact of ongoing seizures and frequent epileptiform abnormalities on the developing brain. Furthermore, mandatory screening for comorbidities allows early recognition and focused therapy for these commonly associated conditions to maximize neurocognitive outcome.

Autoimmune epilepsy

Seizures are a common manifestation of autoimmune limbic encephalitis and multifocal paraneoplastic disorders. Accumulating evidence supports an autoimmune basis for seizures in the absence of syndromic manifestations of encephalitis. The autoimmune epilepsies are immunologically mediated disorders in which recurrent seizures are a primary and persistent clinical feature. When other etiologies have been excluded, an autoimmune etiology is suggested in a patient with epilepsy upon detection of neural autoantibodies and/or the presence of inflammatory changes on cerebrospinal fluid (CSF) or magnetic resonance imaging. In such patients, immunotherapy may be highly effective, depending on the particular autoimmune epilepsy syndrome present. In this chapter, several autoimmune epilepsy syndromes are discussed. First, epilepsies secondary to other primary autoimmune disorders will be discussed, and then those associated with antibodies that are likely to be pathogenic, such as voltage-gated potassium channel-complex and N-methyl-d-aspartate receptor, gamma-aminobutyric acid A and B receptor antibodies. For each syndrome, the typical clinical, imaging, electroencephaloram, CSF, and serologic features, and pathophysiology and treatment are described. Finally, suggested guidelines for the recognition, evaluation, and treatment of autoimmune epilepsy syndromes are provided.

Inflammatory mediators in human epilepsy: A systematic review and meta-analysis

BACKGROUND

Accumulating evidence suggests a role for inflammation in the pathophysiology of epilepsy.

METHODS

We performed a systematic review and meta-analysis of studies that investigated inflammatory mediators in human epilepsy. Studies reporting on inflammatory mediators in serum, cerebrospinal fluid or brain tissue of epilepsy patients were included. Studies comparing patients to controls were included in a meta-analysis.

RESULTS

66 articles reporting on 1934 patients were included. IL-1ra, IL-1β, IL-6, IL-10, IFN-γ and TNF-α were the most extensively investigated proteins. Elevated levels for IL-1ra, IL-1β, IL-6 and CXCL8/IL-8 were reported in several different epilepsy etiologies and media, while other proteins were specifically increased for one etiology. IL-1α, IL-7 and IL-13, as well as the chemokines CCL2-5, -19 and -22, were increased exclusively in brain tissue. In an aggregate meta-analysis, we found significantly different protein levels for serum IL-6, IL-17 and CSF IL-1β and IL-10.

CONCLUSION

Inflammatory pathways are involved in epilepsy. Future studies may further clarify their role, and prove potential of targeted anti-inflammatory treatment.

A prospective study of dexamethasone therapy in refractory epileptic encephalopathy with continuous spike-and-wave during sleep

PURPOSE

Epileptic encephalopathy with continuous spike-and-wave during sleep (CSWS) is an intractable form of epilepsy that has no consensus protocol for corticosteroid therapy. This prospective study aimed to evaluate the efficacy and tolerability of dexamethasone for the treatment of CSWS.

METHODS

Patients (age: 4 years to 12 years and 5 months) with CSWS that failed to respond to several antiepileptic drugs and prednisolone at our pediatric neurology outpatient clinic between 2007 and 2015 were treated with dexamethasone and prospectively analyzed. An initial 4-week dexamethasone (0.15 mg/kg/day p.o.) scheme was employed, and response was assessed. If effective, dexamethasone was maintained for 2-3 months and then slowly weaned over several months, depending on individual patient response at each follow-up. Systemic evaluations (clinical evaluations, electroencephalography recordings, and analysis of side effects) were performed regularly thereafter.

RESULTS

Among 15 patients, 7 were defined as initial responders after 4-week dexamethasone treatment based on comprehensive clinical and electroencephalogram evaluations. The duration of dexamethasone treatment (including weaning) in these 7 patients was 6 to 10 months, and the follow-up duration was 6 months to 7 years. Three patients had no relapse after dexamethasone withdrawal at last follow-up. Among the other 4 patients, relapse was observed during dexamethasone withdrawal (n=1) or at 2-6 months after discontinuation of dexamethasone therapy (n=3). There were no serious or life-threatening side effects, and all observed side effects were reversible after discontinuation of dexamethasone.

CONCLUSIONS

Continuous oral dexamethasone treatment is an effective and tolerable therapy and should be an option for the treatment of CSWS.

Effectiveness of a hybrid corticosteroid treatment regimen on refractory childhood seizures and a review of other corticosteroid treatments

BACKGROUND

Many different corticosteroid treatment schedules have been used in order to treat refractory epileptic seizures with encouraging effects on seizure reduction in many epileptic syndromes.

OBJECTIVE

The objective is to report our experience with a hybrid treatment regimen for refractory seizures in children with epilepsies other than West and Landau-Kleffner syndrome. We hypothesized that a pulse of corticosteroids effectively reduces seizures while low-dosage maintenance treatment reduces side effects. The results are compared with results from a review of reported corticosteroid and ACTH treatments.

METHODS

In this retrospective observational study, 26 children diagnosed with epilepsy with refractory seizures other than West syndrome and Landau-Kleffner syndrome were eligible for a treatment regimen consisting of three days intravenous methylprednisolone (20 mg per kilogram per day) followed by twelve weeks oral prednisolone (0.5 mg per kilogram on alternate days), concluded with a taper phase. Data on effectiveness and side effects were obtained. End-points were the percentages of patients who became seizure free or responded well.

RESULTS

Twenty-one patients received the study treatment. Nine (43%) responded well and 6 (29%) became seizure free. All but one patient had a relapse of seizures. Four patients had reversible adverse effects. Data extracted from the literature were consistent with a good response in 48% of 192 children treated with different corticosteroids and in 69% of 103 patients treated with ACTH.

CONCLUSION

This new hybrid therapy of a pulse of intravenous methylprednisolone and alternate day oral prednisolone is effective with a favourable side effect profile. Results on efficacy and safety justify a randomized controlled trial.

Corticosteroids including ACTH for childhood epilepsy other than epileptic spasms

BACKGROUND

This is an updated version of the original Cochrane review published in Issue 1, 2007.Epilepsy is a disorder with recurrent epileptic seizures. Corticosteroids have been used in the treatment of children with epilepsy and have significant adverse effects. Their efficacy and tolerability have not been clearly established.

OBJECTIVES

To determine the efficacy, in terms of seizure control, improvements in cognition and in quality of life and tolerability of steroids compared to placebo or other antiepileptic drugs in children with epilepsy, excluding epileptic spasms.

SEARCH METHODS

We searched the following databases: The Cochrane Epilepsy Group Specialized Register (1 August 2014); CENTRAL, (The Cochrane Library Issue 7, July 2014); MEDLINE (1946 to 1 August 2014); EMBASE (1966 to December 2004); Database of Abstracts of Reviews of Effectiveness (DARE; Issue 3 of the database published in The Cochrane Library Issue 7, July 2014); ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform ICTRP (1 August 2014).We checked the reference lists of retrieved studies for additional reports of relevant studies.

SELECTION CRITERIA

All randomised controlled trials of administration of corticosteroids to children (less than 16 years) with epilepsy.

DATA COLLECTION AND ANALYSIS

For this update two review authors independently selected trials for inclusion and extracted data. Outcomes included cessation of seizures, reduction in seizure frequency, improvement in cognition, quality of life and adverse effects of steroids.

MAIN RESULTS

A single RCT was included that recruited five children in a double blind cross-over trial. One child was withdrawn prematurely from the study and another had infantile spasms and hence was excluded from further analysis. Adrenocorticotrophin hormone (ACTH 4-9) was administered. Of the three children analysed, one showed a reduction in seizures of 25% to 50% at both the low and higher doses of corticosteroids compared to placebo; one child showed a reduction in seizures at the higher dose only and one child showed no reduction in seizures at either dose. No adverse effects were reported.

AUTHORS' CONCLUSIONS

Since the last version of this review no new evidence has been found for the efficacy of corticosteroids in treating childhood epilepsies. Clinicians using steroids in childhood epilepsies, other than for epileptic spasms, should take this into account before using these agents.

Current controversies in the relationships between autism and epilepsy

The controversies that have arisen in endeavoring to establish the nature of the relationships between autism and epilepsy might be summarized in a few simple questions, most of which do not yet have clear, complete answers. Does epilepsy cause autism? Does autism cause epilepsy? Are there underlying brain mechanisms that predispose to both conditions? What is the role of genetics in this regard? What is the importance of prenatal, perinatal, and postnatal environmental factors? Do any of the proposed relationships between autism and epilepsy provide insight into useful management or treatment? Is the prognosis of either autism or epilepsy different when the other condition is also present? What is the role of additional comorbidities, such as intellectual impairment or attention deficit hyperactivity disorder, in the relationship between the two conditions and in influencing treatment choices? From the evidence currently available, it would appear that epilepsy can rarely be the cause of autistic features but is not the cause of autism in most cases. There is currently no credible mechanism for suggesting that autism might cause epilepsy. There is strong evidence for an underlying predisposition for both conditions, particularly arising from genetic investigations. However, many issues remain unresolved. Considering the amount of research that has been published in this area, it is surprising that so few definitive answers have been established. The papers in this issue's special section provide additional insights into the relationships between autism and epilepsy; while they do not provide answers to all the questions, they represent considerable progress in this area and, at the very least, give some strong indication of what research might, in the future, provide such answers.

Incidence and behavioral correlates of epileptiform abnormalities in autism spectrum disorders

Autism spectrum disorders (ASD) are associated with an increased incidence of epilepsy and of epileptiform discharges on electroencephalograms. It is unknown whether epileptiform discharges correlate with symptoms of ASD. We completed a retrospective chart review of 101 patients with ASD who had overnight electroencephalograms. We looked for a relationship between epileptiform abnormalities and diagnosis, history of regression, communication skills, and other features associated with ASD. There was a higher incidence of epileptiform activity in children with stereotypies and aggressive behavior. The incidence of epileptiform abnormalities was significantly lower in Asperger's compared with more severe forms of autism. Results suggest that increasing severity of autistic symptoms may be associated with higher likelihood of epileptiform abnormalities. Whether treatment alters outcome is unknown.

Corticosteroid therapy in regressive autism: a retrospective study of effects on the Frequency Modulated Auditory Evoked Response (FMAER), language, and behavior

Background

Up to a third of children with Autism Spectrum Disorder (ASD) manifest regressive autism (R-ASD).They show normal early development followed by loss of language and social skills. Absent evidence-based therapies, anecdotal evidence suggests improvement following use of corticosteroids. This study examined the effects of corticosteroids for R-ASD children upon the 4 Hz frequency modulated evoked response (FMAER) arising from language cortex of the superior temporal gyrus (STG) and upon EEG background activity, language, and behavior. An untreated clinical convenience sample of ASD children served as control sample.

Methods

Twenty steroid-treated R-ASD (STAR) and 24 not-treated ASD patients (NSA), aged 3 - 5 years, were retrospectively identified from a large database. All study participants had two sequential FMAER and EEG studies;Landau-Kleffner syndrome diagnosis was excluded. All subjects’ records contained clinical receptive and expressive language ratings based upon a priori developed metrics. The STAR group additionally was scored behaviorally regarding symptom severity as based on the Diagnostic and Statistical Manual IV (DSM-IV) ASD criteria list. EEGs were visually scored for abnormalities. FMAER responses were assessed quantitatively by spectral analysis. Treated and untreated group means and standard deviations for the FMAER, EEG, language, and behavior, were compared by paired t-test and Fisher’s exact tests.

Results

The STAR group showed a significant increase in the 4 Hz FMAER spectral response and a significant reduction in response distortion compared to the NSA group. Star group subjects’ language ratings were significantly improved and more STAR than NSA group subjects showed significant language improvement. Most STAR group children showed significant behavioral improvement after treatment. STAR group language and behavior improvement was retained one year after treatment. Groups did not differ in terms of minor EEG abnormalities. Steroid treatment produced no lasting morbidity.

Conclusions

Steroid treatment was associated with a significantly increased FMAER response magnitude, reduction of FMAER response distortion, and improvement in language and behavior scores. This was not observed in the non-treated group. These pilot findings warrant a prospective randomized validation trial of steroid treatment for R-ASD utilizing FMAER, EEG, and standardized ASD, language and behavior measures, and a longer follow-up period.

Please see related article http://www.biomedcentral.com/1741-7015/12/79

ILAE official report: a practical clinical definition of epilepsy

Epilepsy was defined conceptually in 2005 as a disorder of the brain characterized by an enduring predisposition to generate epileptic seizures. This definition is usually practically applied as having two unprovoked seizures >24 h apart. The International League Against Epilepsy (ILAE) accepted recommendations of a task force altering the practical definition for special circumstances that do not meet the two unprovoked seizures criteria. The task force proposed that epilepsy be considered to be a disease of the brain defined by any of the following conditions: (1) At least two unprovoked (or reflex) seizures occurring >24 h apart; (2) one unprovoked (or reflex) seizure and a probability of further seizures similar to the general recurrence risk (at least 60%) after two unprovoked seizures, occurring over the next 10 years; (3) diagnosis of an epilepsy syndrome. Epilepsy is considered to be resolved for individuals who either had an age-dependent epilepsy syndrome but are now past the applicable age or who have remained seizure-free for the last 10 years and off antiseizure medicines for at least the last 5 years. "Resolved" is not necessarily identical to the conventional view of "remission or "cure." Different practical definitions may be formed and used for various specific purposes. This revised definition of epilepsy brings the term in concordance with common use. A PowerPoint slide summarizing this article is available for download in the Supporting Information section here.

Utility of an immunotherapy trial in evaluating patients with presumed autoimmune epilepsy

OBJECTIVE

To evaluate a trial of immunotherapy as an aid to diagnosis in suspected autoimmune epilepsy.

METHOD

We reviewed the charts of 110 patients seen at our autoimmune neurology clinic with seizures as a chief complaint. Twenty-nine patients met the following inclusion criteria: (1) autoimmune epilepsy suspected based on the presence of ≥ 1 neural autoantibody (n = 23), personal or family history or physical stigmata of autoimmunity, and frequent or medically intractable seizures; and (2) initiated a 6- to 12-week trial of IV methylprednisolone (IVMP), IV immune globulin (IVIg), or both. Patients were defined as responders if there was a 50% or greater reduction in seizure frequency.

RESULTS

Eighteen patients (62%) responded, of whom 10 (34%) became seizure-free; 52% improved with the first agent. Of those receiving a second agent after not responding to the first, 43% improved. A favorable response correlated with shorter interval between symptom onset and treatment initiation (median 9.5 vs 22 months; p = 0.048). Responders included 14/16 (87.5%) patients with antibodies to plasma membrane antigens, 2/6 (33%) patients seropositive for glutamic acid decarboxylase 65 antibodies, and 2/6 (33%) patients without detectable antibodies. Of 13 responders followed for more than 6 months after initiating long-term oral immunosuppression, response was sustained in 11 (85%).

CONCLUSIONS

These retrospective findings justify consideration of a trial of immunotherapy in patients with suspected autoimmune epilepsy.

CLASSIFICATION OF EVIDENCE

This study provides Class IV evidence that in patients with suspected autoimmune epilepsy, IVMP, IVIg, or both improve seizure control.

Continuous Spike-Wave during Slow Wave Sleep and Related Conditions

Continuous spike and wave during slow wave sleep (CSWS) is an epileptic encephalopathy that presents with neurocognitive regression and clinical seizures, and that demonstrates an electroencephalogram (EEG) pattern of electrical status epilepticus during sleep, as defined by the Commission on Classification and Terminology of the International League Against Epilepsy 1989. CSWS is an age-related condition, typically presenting in children around 5 years of age, with clinical seizures which progress within 2 years to a severe epileptic encephalopathy. The pathophysiology of CSWS is not completely understood, but the corticothalamic neuronal network involved in sleep patterns is thought to be involved. Genetic predisposition and injury in early development are thought to play etiological roles. Treatment strategies have involved traditional anticonvulsants, hormonal therapies, and other newer techniques. Outcomes are fair, and the thought is that earlier diagnosis and intervention preserve neurocognitive development, as in the case of other epileptic encephalopathies. Further understanding of the mechanisms of CSWS may lead to improved therapeutic options and thus outcomes of children with CSWS.

Long-term response to high-dose diazepam treatment in continuous spikes and waves during sleep

BACKGROUND

This study evaluated whether the reduction in epileptiform activity after treatment with high-dose diazepam in continuous spikes and waves during sleep persists over time.

PATIENTS

Patients aged 1 to 21 years with continuous spikes and waves during sleep who received high-dose nocturnal diazepam and who had electroencephalogram follow-up were included. Twenty-nine patients met the inclusion criteria and underwent a total of 48 high-dose diazepam treatment cycles.

RESULTS

An overnight reduction of the spike wave percentage of at least 25% (i.e., 75-50%) occurred in 29 cycles (20 patients), and persisted within 6 months in 16 of 29 cycles (12 patients), but returned to baseline in three of 29 cycles (three patients). An overnight reduction of at least 50% (i.e., 75-25%) occurred in 15 cycles (13 patients), and persisted within 6 months in eight of 15 cycles (eight patients), but returned to baseline in three cycles (three patients). Twenty of 29 cycles that responded in the short term had persistent response on follow-up. Thirteen cycles of treatment were associated with mild side effects that did not recur with repeated treatment cycles.

CONCLUSIONS

Treatment with high-dose diazepam reduced epileptiform activity in continuous spikes and waves during sleep in the short term, and improvement persisted for several months in most cycles. Short-term response predicted persistence of this effect on subsequent follow-up.

Continuous Spikes and Waves during Sleep: Electroclinical Presentation and Suggestions for Management

Continuous spikes and waves during sleep (CSWS) is an epileptic encephalopathy characterized in most patients by (1) difficult to control seizures, (2) interictal epileptiform activity that becomes prominent during sleep leading to an electroencephalogram (EEG) pattern of electrical status epilepticus in sleep (ESES), and (3) neurocognitive regression. In this paper, we will summarize current epidemiological, clinical, and EEG knowledge on CSWS and will provide suggestions for treatment. CSWS typically presents with seizures around 2-4 years of age. Neurocognitive regression occurs around 5-6 years of age, and it is accompanied by subacute worsening of EEG abnormalities and seizures. At approximately 6-9 years of age, there is a gradual resolution of seizures and EEG abnormalities, but the neurocognitive deficits persist in most patients. The cause of CSWS is unknown, but early developmental lesions play a major role in approximately half of the patients, and genetic associations have recently been described. High-dose benzodiazepines and corticosteroids have been successfully used to treat clinical and electroencephalographic features. Corticosteroids are often reserved for refractory disease because of adverse events. Valproate, ethosuximide, levetiracetam, sulthiame, and lamotrigine have been also used with some success. Epilepsy surgery may be considered in a few selected patients.

Automated quantification of spikes

Methods for rapid and objective quantification of interictal spikes in raw, unprocessed electroencephalogram (EEG) samples are scarce. We evaluated the accuracy of a tailored automated spike quantification algorithm. The automated quantification was compared with the quantification by two board-certified clinical neurophysiologists (gold-standard) in five steps: 1) accuracy in a single EEG channel (5 EEG samples), 2) accuracy in multiple EEG channels and across different stages of the sleep-wake cycles (75 EEG samples), 3) capacity to detect lateralization of spikes (6 EEG samples), 4) accuracy after application of a machine-learning mechanism (11 EEG samples), and 5) accuracy during wakefulness only (8 EEG samples). Our method was accurate during all stages of the sleep-wake cycle and improved after the application of the machine-learning mechanism. Spikes were correctly lateralized in all cases. Our automated method was accurate in quantifying and detecting the lateralization of interictal spikes in raw unprocessed EEG samples.

Electrical status epilepticus in sleep: clinical presentation and pathophysiology

Electrical status epilepticus in sleep involves an electroencephalographic pattern where interictal epileptiform activity is potentiated in the transition from wakefulness to sleep. Near-continuous spikes and waves that occupy a significant proportion of nonrapid eye movement sleep appear as a result of sleep-potentiated epileptiform activity. This electroencephalographic pattern appears in different electroclinical syndromes that present three common characteristics with different degrees of severity: seizures, sleep-potentiated epileptiform activity, and neuropsychologic regression. Continuous spikes and waves during sleep comprise the severest epileptic encephalopathy in the electroclinical spectrum. Landau-Kleffner syndrome presents with intermediate severity. Some "benign" pediatric focal epileptic syndromes represent the mildest end of this continuum. Based on published data, we provide a framework for clinical and electrical events. The underlying mechanisms leading to sleep potentiation of epileptiform activity in electrical status epilepticus in sleep are incompletely understood. A genetic basis or acquired early developmental insult may disrupt the normal maturation of neuronal networks. These factors may dynamically alter normal processes of brain development, leading to an age-related pattern of electroclinical expression of electrical status epilepticus in sleep.

Neurocognitive and neurobehavioral disabilities in Epilepsy with Electrical Status Epilepticus in slow sleep (ESES) and related syndromes

AIM

The aims of this study were to assess the cognitive and behavioral problems of patients with Epilepsy with Electrical Status Epilepticus in slow sleep (ESES) and related syndromes and to review their EEG (electroencephalography) findings and treatment options.

RESULTS

Fourteen patients with ESES were evaluated and treated in 2010. Nine children had continuous spike and wave during slow-wave sleep (CSWS)/ESES syndrome, 3 had Atypical BECTS (benign epilepsy with centrotemporal spikes), 1 had Opercular syndrome, and 1 had Landau-Kleffner syndrome. The duration of ESES ranged from 6 to 52 months. Eleven (91%) children had behavioral issues, most prominent being hyperactivity. Seven of the 13 children (53%) showed evidence of borderline to moderate cognitive impairment. A total of 28 EEG findings of ESES were analyzed for SWI (spike-wave index). Antiepileptic drugs received by the patients included valproate, clobazam, levetiracetam, and others. Eleven patients had been treated with oral steroids and it was found to be efficacious in seven (63%).

CONCLUSION

Disabilities caused by ESES affect multiple domains. Patients with an SWI>50% should be followed up frequently with neuropsychological assessments. Steroids appear to be effective, although there is a need to standardize the dose and duration of treatment.

Epileptic Encephalopathies with Status Epilepticus during Sleep: New Techniques for Understanding Pathophysiology and Therapeutic Options

Encephalopathy with status epilepticus during sleep (ESES) is an epileptic encephalopathy, as defined by the International League Against Epilepsy (ILAE) Task Force on Classification and Terminology, that is, a condition in which the epileptic processes themselves are believed to contribute to the disturbance in cerebral function. Clinical manifestations of ESES are heterogeneous: apart from different seizure types, they consist in combinations of cognitive, motor, and behavioural disturbances associated with a peculiar electroencephalographic pattern of paroxysmal activity significantly activated during slow sleep, which culminates in a picture of continuous spikes and waves during sleep (CSWS). The pathophysiological mechanisms underlying this condition are still incompletely understood. Establishing a clear-cut correlation between EEG abnormalities and clinical data, though interesting, is very complex. Computer-assisted EEG analyses especially if combined with functional magnetic resonance imaging (EEG-fMRI) and metabolic neuroimaging have recently emerged as useful approaches to better understand the pathophysiological processes underlying ESES. Treatment of ESES is not just limited to seizures control but it should be focused on controlling neuropsychological outcome through an improvement of the continuous epileptiform activity. General agreement on treatment guidelines is still lacking. Implementation of new techniques might allow a better understanding of the pathophysiology of ESES and could enhance therapeutics options.

The effect of levetiracetam on focal nocturnal epileptiform activity during sleep--a placebo-controlled double-blind cross-over study

Electric Status Epilepticus during Sleep (ESES) occurs in children with and without epilepsy. It may be related to disturbances as autism spectrum disorder, attention-deficit hyperactivity disorder and acquired aphasia (Landau-Kleffner syndrome). Antiepileptic drug (AED) treatment has been reported in small studies without placebo control. This study was designed to assess AED effect in a placebo-controlled double-blind cross-over study. Levetiracetam (LEV) was chosen based on clinical evidence. Eighteen patients fulfilled the inclusion criteria. The mean spike index at baseline was 56, falling to a mean of 37 at the end of the LEV treatment period. Assessed with a 2-way ANOVA, there is a significant treatment effect (p<0.0002). To the best of our knowledge, this is the first placebo-controlled double-blind cross-over study for any AED in patients with ESES. The effect of LEV is comparable with its effect in treatment of epileptic seizures.

Pharmacologic treatment of intractable epilepsy in children: a syndrome-based approach

The successful pharmacologic treatment of intractable childhood epilepsy is predicated upon an accurate classification of the epilepsy syndrome. The selection of an antiepileptic drug is facilitated by the knowledge of syndrome-specific efficacy, the anticipation of potential side effects, and a careful risk-benefit assessment tailored to each patient. As such, the identification of comorbidities and careful monitoring for treatment-emergent adverse events, especially cognitive and behavioral effects, is of utmost importance. Especially in refractory cases, polypharmacy may increase the likelihood of side effects, but carefully chosen combinations can result in synergistic benefit. For most epilepsy syndromes, newer antiepileptic drugs typically yield equivalent efficacy and superior tolerability. Nevertheless, continued research is needed to further contrast the syndrome-specific efficacy and tolerability of available drugs and to foster the development of new agents with superior efficacy and side effect profiles.

Continuous spike and waves during sleep and electrical status epilepticus in sleep

Continuous spike and waves during sleep is an age-related epileptic encephalopathy that presents with neurocognitive regression, seizures, and an EEG pattern of electrical status epilepticus during sleep. Patients usually present around 5 years of age with infrequent nocturnal unilateral motor seizures that progress within 1 to 2 years to a severe epileptic encephalopathy with frequent seizures of different types, marked neurocognitive regression, and an almost continuous spike-wave EEG pattern during slow-wave sleep. The pathophysiology of continuous spike and waves during sleep is not completely understood, but the corticothalamic neuronal network involved in physiologic oscillating patterns of sleep is thought to be switched into a pathologic discharging mode. Early developmental injury and/or genetic predisposition may play a role in the potentiation of age-related hyperexcitability in the immature brain. A better understanding of the mechanisms leading to electrical status epilepticus during sleep may provide additional therapeutic targets that can improve the outcome of seizures, EEG pattern, and cognitive development in patients with continuous spike and waves during sleep.