Efficacy of intravenous immunoglobulin in a cohort of children with drug-resistant epilepsy

Occult Autoimmune Background for Epilepsy-The Preliminary Study on Antibodies Against Neuronal Surface Antigens

Objective: The objective of the study was to determine the incidence of antibodies against neuronal surface antigens (NSA-ab) in patients with different types of epilepsy, in comparison with the subjects diagnosed with immune-mediated disorders. Methods: Forty patients with drug-resistant epilepsy (DRE) of unknown origin, 16 with post-stroke epilepsy, and 23 with systemic autoimmune disorders (SAD) with CNS involvement were included. NSA-ab were sought in serum using indirect immunofluorescence method. Relationships were analyzed between presence of NSA-ab and clinical presentation. Results: NSA-ab was detected in the sera from five patients: anti-DPPX in one patient, anti-AMPAR1/R2 in two, anti-LGI1 in one and, in one case, both anti-CASPR2 and DPPX IgG. Out of these five patients, three represented the SAD subgroup and two the DRE subgroup. None of the patients with post-stroke epilepsy was positive for NSA-ab. Significance: Autoimmune etiology is worth considering in patients with drug-resistant epilepsy of unknown origin. The presence of NSA-ab in patients with systemic autoimmune disorders may be caused by unspecifically enhanced autoimmune reactivity. NSA-ab seem not to be related to epilepsy resulting from ischemic brain injury.

Epilepsy Surgery in Children

Epilepsy in children continues to present a major medical and economic burden on society. Left untreated, seizures can present the risk of sudden death and severe cognitive impairment. It is understood that primary care providers having concerns about abnormal movements or behaviors in children will make a prompt referral to a trusted pediatric neurologist. The authors present a brief introduction to seizure types, classification, and management with particular focus on what surgery for epilepsy can offer. Improved seizure control and its attendant improvements in quality of life can be achieved with timely referral and intervention.

Treating epilepsy with options other than antiepileptic medications

Epilepsy is a common health burden worldwide. Epilepsy is linked to variety of factors, including infectious, vascular, immune, structural, genetic, and metabolic etiologies. Despite the existence of multiple antiepileptic drugs (AEDs), many patients are diagnosed with intractable epilepsy. Many nonpharmacological options are available for epilepsy. Some types of epilepsy respond to cofactors. Other patients may be candidates for a ketogenic diet. Inflammatory mediators, such as intravenous immunoglobulins (IVIgs) and steroids, are other options for epilepsy. Recently, cannabinoids have been approved for epilepsy treatment. Refractory epilepsy can be treated with surgical interventions. Focal resections, hemispherectomies, and corpus callosotomies are some common epilepsy surgery approaches. Neuromodulation techniques are another option. Thermal ablation is a minimally invasive approach for epilepsy treatment. Epilepsy outcomes are improving, and treatment modalities are expanding. Trials of nonpharmacological options for epilepsy patients are recommended. This article summarizes available nonpharmacological options other than AEDs for the treatment of epilepsy.

Pharmacology of new and developing intravenous therapies for the management of seizures and epilepsy

INTRODUCTION

Antiepileptic drugs (AEDs) are administered orally for chronic use. Parenteral formulations might be necessary when the oral route is not feasible (e.g. an impairment of consciousness, trauma, dysphagia, gastrointestinal illness) or for treatment of seizure emergencies. At present, few intravenous (IV) formulations are available on the market.

AREAS COVERED

The purpose of this review is to summarize the pharmacological characteristics and clinical applications of IV medications that have been recently introduced to the armamentarium of epilepsy therapy or are currently being developed. Apart from AEDs, other compounds belonging to different pharmacological classes (e.g. diuretics, anesthetics), which have shown potential effectiveness in seizure control, are taken into consideration, and the pathophysiological premises supporting their use for epilepsy treatment are illustrated. The authors give particular focus to immunomodulatory and immunosuppressive agents, which have become the therapeutic cornerstones for immune-mediated epilepsies, despite regulatory obstacles.

EXPERT OPINION

In several circumstances, especially in the case of seizure-related emergencies, clinical practice seems not match literature-based evidence, and several IV AEDs are still used off-label. Strong evidence derived from randomized clinical trials (RCTs) is needed to support the effectiveness and tolerability of any therapeutic approach, however common and "accepted' it may be, in order to guarantee patient safety and well-being.

Intravenous immunoglobulin G as adjuvant treatment in drug-resistant childhood epilepsy

BACKGROUND

Epilepsy is the most common neurological disease in childhood; depending on the definition of drug-resistant epilepsy, incidence varies from 10% to 23% in the paediatric population. The objective of this study was to account for the decrease in the frequency and/or monthly duration of epileptic seizures in paediatric patients with drug-resistant epilepsy treated with antiepileptic drugs, before and after adding intravenous immunoglobulin G (iIV IgG).

METHODS

This is an analytic, observational, retrospective case-control study. We studied paediatric patients with drug-resistant epilepsy who were treated with IV IgG at the Centro Médico Nacional 20 de Noviembre, in Mexico City, from 2003 to 2013.

RESULTS

One hundred and sixty seven patients (19.5%) had drug-resistant epilepsy and 44 (5.1%) started adjuvant treatment with IV IgG. The mean age of patients at the beginning of treatment was 6.12 years±5.14); aetiology was structural acquired in 28 patients (73.6%), genetic in 5 (13.1%), immune in 1 (2.6%), and unknown in 4 (10.5%). At 2 months from starting IV IgG, seizure duration had reduced to 66.66%; the frequency of seizures was reduced by 64% at 4 months after starting treatment (P<.001).

CONCLUSIONS

According to the results of this study, intravenous immunoglobulin may be an effective therapy for reducing the frequency and duration of seizures in paediatric patients with drug-resistant epilepsy.

Intravenous Immunoglobulin as a Treatment for Intractable Epilepsy Secondary to Focal Cortical Dysplasia: A Meta-analysis

BACKGROUND

The observation of a dramatic response to intravenous immunoglobulin (IVIG) by a child from our center with intractable epilepsy due to focal cortical dysplasia prompted us to perform a meta-analysis on the efficiency of IVIG in this condition. Focal cortical dysplasia is a common cause of intractable epilepsy. Microglial activation and upregulation of neuroinflammatory pathways have been documented in brain specimen from surgically treated patients with intractable epilepsy and focal cortical dysplasia. IVIG has been used for decades to treat patients with intractable epilepsy; however, there is little evidence regarding its efficacy, possibly because of the pathophysiological heterogeneity of patients included in most of the published studies.

METHODS

A search for studies in patients from 0 to 18 years was performed in databases. We found four observational studies-prospective or retrospective-including patients with focal cortical dysplasia with intractable epilepsy treated with IVIG. The primary outcome was a reduction of seizure frequency by more than 50%.

RESULTS

A total of eight patients were included in this meta-analysis. The intravenous immunoglobulin doses ranged from 0.2 to 1 g/kg/day, repeated three to six times over one to 14 months (median: five months). Intravenous immunoglobulin was associated with reduced seizure frequency in six out of eight patients (P < 0.05). Among these six patients, the reduction of seizure frequency lasted for nine months to nine years (median: 3.7 years). There were either no or mild adverse effects of IVIG infusion including postinfusion paresthesia (n = 1) and a transient increase in temperature (n = 1).

CONCLUSIONS

Despite obvious limitations, mainly because of the small number of patients, and the selection biases, this study suggests that, based on the available data, IVIG might be effective in the treatment of intractable epilepsy secondary to focal cortical dysplasia. Further therapeutic trials are mandatory to further clarify the efficacy of IVIG in this condition.