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Lynch M, Smith K, Riney K. Clinical seizure semiology is subtle and identification of seizures by parents is unreliable in infants with tuberous sclerosis complex. Epilepsia 2023; 64:386-395. [PMID: 36318046 PMCID: PMC10107460 DOI: 10.1111/epi.17454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 10/28/2022] [Accepted: 10/31/2022] [Indexed: 12/07/2022]
Abstract
OBJECTIVE The objectives of this study were to assess the accuracy of parental seizure detection in infants with antenatally diagnosed tuberous sclerosis complex (TSC), and to document the total seizure burden (clinical and subclinical) in those patients who met criteria for prolonged electroencephalography (EEG) recording. METHODS Consecutive infants at a single institution with antenatally diagnosed TSC who met criteria for prolonged video-EEG (vEEG) were recruited to this study. The vEEG data were reviewed and when a seizure was identified on EEG, the video and audio recording was assessed for evidence of clinical seizure and, if present, whether there was evidence of parent seizure identification. RESULTS Nine infants were enrolled, for whom 674 focal seizures were identified in eight of nine patients across 24 prolonged vEEG recordings, with vEEG total duration of 634 h 49 min (average seizure frequency of 1 focal seizure/h). Only 220 of 674 (32.6%) were clinical seizures, 395 of 674 (58.6%) were subclinical seizures, and 59 of 674 seizures could not be classified. Only 63 of 220 clinical seizures (28.6%) were identified by parents, with 157 of 220 (71.4%) not identified. Thirty clusters of epileptic spasms were detected in one patient. At least one clinical epileptic spasm occurred in 2 of 30 clusters (6.7%), 24 of 30 clusters of epileptic spasms (80%) were electrographic only, and classification was uncertain for 4 of 30 clusters (13.3%). No clinical epileptic spasms were detected by parents. Clinical seizure frequency was significantly underestimated by parents for all patients. SIGNIFICANCE This study demonstrates that in infants with TSC who met criteria for prolonged vEEG, (1) parents significantly under recognize total clinical seizure count, (2) parents fail to identify epileptic spasms, and (3) seizure frequency is high. This highlights that epilepsy treatment decisions should not be based solely on parental clinical seizure identification. Prolonged vEEG monitoring may have an important role in the routine epilepsy care of infants with TSC, as demonstrating undetected high clinical seizure frequency may allow improved epilepsy management decisions.
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Affiliation(s)
- Matthew Lynch
- Neurosciences Unit, Queensland Children's Hospital, South Brisbane, Queensland, Australia
| | - Kirsty Smith
- Neurosciences Unit, Queensland Children's Hospital, South Brisbane, Queensland, Australia
| | - Kate Riney
- Neurosciences Unit, Queensland Children's Hospital, South Brisbane, Queensland, Australia
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
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Whitney R, Zak M, Haile D, Nabavi Nouri M. The state of pediatric tuberous sclerosis complex epilepsy care: Results from a national survey. Epilepsia Open 2022; 7:718-728. [PMID: 36161285 PMCID: PMC9712483 DOI: 10.1002/epi4.12652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Accepted: 09/21/2022] [Indexed: 01/01/2023] Open
Abstract
OBJECTIVE Epilepsy associated with tuberous sclerosis complex (TSC) can be challenging to treat and is associated with significant disease burden. Our objective was to better understand the state of epilepsy care of TSC amongst pediatric neurologists in Canada, identify gaps in care and determine whether access to a dedicated TSC clinic has an impact on epilepsy management. METHODS A survey was developed after a literature review and discussion amongst two pediatric epileptologists and one nurse practitioner with expertise in TSC about the state of epilepsy care of TSC patients in Canada. Canadian pediatric neurologists were asked to participate in sharing their experiences via an anonymous web-based survey through the Canadian League Against Epilepsy (CLAE) and the Canadian Neurological Sciences Federation (CNSF). RESULTS Fifty-seven responses were received. Access to a dedicated TSC clinic was reported by 25% (n = 14). Sixty percent (n = 34) reported performing serial EEG monitoring in infants with TSC and 57% (n = 33) started prophylactic antiseizure therapy when EEG abnormalities were detected, regardless of whether there was access to a TSC clinic (P = .06 and P = .29, respectively). While 52% (n = 29) did not feel comfortable prescribing mTORi for epilepsy, 65% (n = 36) indicated they would consider it with additional training. Epilepsy surgery was offered in 93% (n = 13) of centers with a dedicated TSC clinic but only 45% of centers without a TSC clinic (n = 19) (P = .002). SIGNIFICANCE Our findings demonstrate the variability in neurological care of pediatric patients with TSC as it pertains to epilepsy management. There is a need for the establishment of epilepsy practice guidelines and a national network to support clinical practice, research, and education.
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Affiliation(s)
- Robyn Whitney
- Division of Neurology, Department of PaediatricsMcMaster UniversityHamiltonOntarioCanada
| | - Maria Zak
- Division of Neurology, Department of PaediatricsThe Hospital for Sick ChildrenTorontoOntarioCanada
| | - Denait Haile
- Department of Paediatrics, Schulich School of Dentistry and MedicineWestern UniversityLondonOntarioCanada
| | - Maryam Nabavi Nouri
- Department of Paediatrics, Schulich School of Dentistry and MedicineWestern UniversityLondonOntarioCanada
- Children's Health Research InstituteLawson Health Research InstituteLondonOntarioCanada
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3
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Neal A, Bouet R, Lagarde S, Ostrowsky‐Coste K, Maillard L, Kahane P, Touraine R, Catenoix H, Montavont A, Isnard J, Arzimanoglou A, Hermier M, Guenot M, Bartolomei F, Rheims S, Jung J. Epileptic spasms are associated with increased stereo-electroencephalography derived functional connectivity in tuberous sclerosis complex. Epilepsia 2022; 63:2359-2370. [PMID: 35775943 PMCID: PMC9796462 DOI: 10.1111/epi.17353] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 06/28/2022] [Accepted: 06/28/2022] [Indexed: 01/01/2023]
Abstract
OBJECTIVE Epileptic spasms (ES) are common in tuberous sclerosis complex (TSC). However, the underlying network alterations and relationship with epileptogenic tubers are poorly understood. We examined interictal functional connectivity (FC) using stereo-electroencephalography (SEEG) in patients with TSC to investigate the relationship between tubers, epileptogenicity, and ES. METHODS We analyzed 18 patients with TSC who underwent SEEG (mean age = 11.5 years). The dominant tuber (DT) was defined as the most epileptogenic tuber using the epileptogenicity index. Epileptogenic zone (EZ) organization was quantitatively separated into focal (isolated DT) and complex (all other patterns). Using a 20-min interictal recording, FC was estimated with nonlinear regression, h2 . We calculated (1) intrazone FC within all sampled tubers and normal-appearing cortical zones, respectively; and (2) interzone FC involving connections between DT, other tubers, and normal cortex. The relationship between FC and (1) presence of ES as a current seizure type at the time of SEEG, (2) EZ organization, and (3) epileptogenicity was analyzed using a mixed generalized linear model. Spike rate and distance between zones were considered in the model as covariates. RESULTS Six patients had ES as a current seizure type at time of SEEG. ES patients had a greater number of tubers with a fluid-attenuated inversion recovery hypointense center (p < .001), and none had TSC1 mutations. The presence of ES was independently associated with increased FC within both intrazone (p = .033) and interzone (p = .011) networks. Post hoc analyses identified that increased FC was associated with ES across tuber and nontuber networks. EZ organization and epileptogenicity biomarkers were not associated with FC. SIGNIFICANCE Increased cortical synchrony among both tuber and nontuber networks is characteristic of patients with ES and independent of both EZ organization and tuber epileptogenicity. This further supports the prospect of FC biomarkers aiding treatment paradigms in TSC.
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Affiliation(s)
- Andrew Neal
- Eduwell team, Inserm U1028, CNRS UMR5292, UCBL1, UJMLyon Neuroscience Research CenterLyonFrance,Department of Functional Neurology and EpileptologyLyon Civil Hospices, member of the ERN EpiCARE, and Lyon 1 UniversityLyonFrance,Department of Neuroscience, Faculty of Medicine, Nursing, and Health SciencesCentral Clinical School, Monash UniversityMelbourneVictoriaAustralia
| | - Romain Bouet
- Eduwell team, Inserm U1028, CNRS UMR5292, UCBL1, UJMLyon Neuroscience Research CenterLyonFrance
| | - Stanislas Lagarde
- Epileptology Department, Timone HospitalPublic Assistance Hospitals of Marseille, member of the ERN EpiCAREMarseilleFrance,Institute of Systems Neurosciences, National Institute of Health and Medical ResearchAix‐Marseille UniversityMarseilleFrance
| | - Karine Ostrowsky‐Coste
- Eduwell team, Inserm U1028, CNRS UMR5292, UCBL1, UJMLyon Neuroscience Research CenterLyonFrance,Department of Pediatric Clinical Epileptology, Sleep Disorders, and Functional NeurologyLyon Civil Hospices, member of the ERN EpiCARELyonFrance
| | - Louis Maillard
- Neurology DepartmentUniversity Hospital of Nancy, member of the ERN EpiCARENancyFrance
| | - Philippe Kahane
- Grenoble‐Alpes University Hospital Center, collaborating partner of the ERN EpiCAREGrenoble‐Alpes University, Grenoble Institute of Neuroscience, National Institute of Health and Medical ResearchGrenobleFrance
| | - Renaud Touraine
- Department of GeneticsSaint Etienne University Hospital Center–North HospitalSaint‐Priest‐en‐JarezFrance
| | - Helene Catenoix
- Eduwell team, Inserm U1028, CNRS UMR5292, UCBL1, UJMLyon Neuroscience Research CenterLyonFrance,Department of Functional Neurology and EpileptologyLyon Civil Hospices, member of the ERN EpiCARE, and Lyon 1 UniversityLyonFrance
| | - Alexandra Montavont
- Eduwell team, Inserm U1028, CNRS UMR5292, UCBL1, UJMLyon Neuroscience Research CenterLyonFrance,Department of Functional Neurology and EpileptologyLyon Civil Hospices, member of the ERN EpiCARE, and Lyon 1 UniversityLyonFrance
| | - Jean Isnard
- Eduwell team, Inserm U1028, CNRS UMR5292, UCBL1, UJMLyon Neuroscience Research CenterLyonFrance,Department of Functional Neurology and EpileptologyLyon Civil Hospices, member of the ERN EpiCARE, and Lyon 1 UniversityLyonFrance
| | - Alexis Arzimanoglou
- Eduwell team, Inserm U1028, CNRS UMR5292, UCBL1, UJMLyon Neuroscience Research CenterLyonFrance,Department of Pediatric Clinical Epileptology, Sleep Disorders, and Functional NeurologyLyon Civil Hospices, member of the ERN EpiCARELyonFrance
| | - Marc Hermier
- Department of NeuroradiologyLyon Civil HospicesLyonFrance
| | - Marc Guenot
- Eduwell team, Inserm U1028, CNRS UMR5292, UCBL1, UJMLyon Neuroscience Research CenterLyonFrance,Department of Functional NeurosurgeryLyon Civil Hospices, member of the ERN EpiCARE, and Lyon 1 UniversityLyonFrance
| | - Fabrice Bartolomei
- Epileptology Department, Timone HospitalPublic Assistance Hospitals of Marseille, member of the ERN EpiCAREMarseilleFrance,Institute of Systems Neurosciences, National Institute of Health and Medical ResearchAix‐Marseille UniversityMarseilleFrance
| | - Sylvain Rheims
- Eduwell team, Inserm U1028, CNRS UMR5292, UCBL1, UJMLyon Neuroscience Research CenterLyonFrance,Department of Functional Neurology and EpileptologyLyon Civil Hospices, member of the ERN EpiCARE, and Lyon 1 UniversityLyonFrance,Epilepsy InstituteLyonFrance
| | - Julien Jung
- Eduwell team, Inserm U1028, CNRS UMR5292, UCBL1, UJMLyon Neuroscience Research CenterLyonFrance,Department of Functional Neurology and EpileptologyLyon Civil Hospices, member of the ERN EpiCARE, and Lyon 1 UniversityLyonFrance
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Nabavi Nouri M, Zak M, Jain P, Whitney R. Epilepsy Management in Tuberous Sclerosis Complex: Existing and Evolving Therapies and Future Considerations. Pediatr Neurol 2022; 126:11-19. [PMID: 34740132 DOI: 10.1016/j.pediatrneurol.2021.09.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Revised: 09/22/2021] [Accepted: 09/25/2021] [Indexed: 10/20/2022]
Abstract
Tuberous sclerosis complex (TSC) is a rare autosomal dominant condition that affects multiple body systems. Disruption of the mammalian target of rapamycin (mTOR) pathway results in abnormal cell growth, proliferation, protein synthesis, and cell differentiation and migration in TSC. In the central nervous system, mTOR disruption is also believed to influence neuronal excitability and promote epileptogenesis. Epilepsy is the most common neurological manifestation of TSC and affects 80% to 90% of individuals with high rates of treatment resistance (up to 75%). The onset of epilepsy in the majority of individuals with TSC occurs before the age of two years, which is a critical time in neurodevelopment. Both medically refractory epilepsy and early-onset epilepsy are associated with intellectual disability in TSC, while seizure control and remission are associated with lower rates of cognitive impairment. Our current knowledge of the treatment of epilepsy in TSC has expanded immensely over the last decade. Several new therapies such as preemptive vigabatrin therapy in infants, cannabidiol, and mTOR inhibitors have emerged in recent years for the treatment of epilepsy in TSC. This review will provide clinicians with a comprehensive overview of the pharmacological and nonpharmacological therapies available for the treatment of epilepsy related to TSC.
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Affiliation(s)
- Maryam Nabavi Nouri
- Division of Neurology, Department of Pediatrics, Western University, London, Ontario, Canada
| | - Maria Zak
- Division of Neurology, Department of Paediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Puneet Jain
- Division of Neurology, Department of Paediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Robyn Whitney
- Division of Neurology, Department of Paediatrics, McMaster University, Hamilton, Ontario, Canada.
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French JA, Bebin M, Dichter MA, Engel J, Hartman AL, Jóźwiak S, Klein P, McNamara J, Twyman R, Vespa P. Antiepileptogenesis and disease modification: Clinical and regulatory issues. Epilepsia Open 2021; 6:483-492. [PMID: 34270884 PMCID: PMC8408600 DOI: 10.1002/epi4.12526] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Revised: 07/05/2021] [Accepted: 07/13/2021] [Indexed: 12/13/2022] Open
Abstract
This is a summary report of clinical and regulatory issues discussed at the 2018 NINDS workshop, entitled “Accelerating Therapies for Antiepileptogenesis and Disease Modification.” The intent of the workshop was to optimize and accelerate development of therapies for antiepileptogenesis (AEG) and disease modification in the epilepsies. The working group discussed nomenclature for antiepileptogenic therapies, subdividing them into “antiepileptogenic therapies” and “disease modifying therapies,” both of which are urgently needed. We use the example of traumatic brain injury to explain issues and complexities in designing a trial for disease‐preventing antiepileptogenic therapies, including identifying timing of intervention, selecting the appropriate dose, and the need for biomarkers. We discuss the recent trials of vigabatrin to prevent onset and modify epilepsy outcome in children with tuberous sclerosis (Epistop and PreVeNT). We describe a potential approach to a disease modification trial in adults, using patients with temporal lobe epilepsy. Finally, we discuss regulatory hurdles for antiepileptogenesis and disease‐modifying trials.
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Affiliation(s)
| | - Martina Bebin
- UAB School of Medicine and UAB Epilepsy Center, Birmingham, AL, USA
| | | | - Jerome Engel
- David Geffen School of Medicine at, UCLA and the Brain Research Institute, Los Angeles, CA, USA
| | - Adam L Hartman
- Division of Clinical Research, National Institute of Neurological Disorders and Stroke/NIH, Bethesda, MD, USA
| | - Sergiusz Jóźwiak
- Department of Child Neurology, Medical University of Warsaw, Warsaw, Poland
| | - Pavel Klein
- Mid-Atlantic Epilepsy and Sleep Center, Bethesda, MD, USA
| | - James McNamara
- Department of Neurobiology, Duke University School of Medicine, Durham, NC, USA
| | | | - Paul Vespa
- Departments of Neurology and Neurosurgery, David Geffen School of Medicine UCLA, Los Angeles, CA, USA
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Di Napoli C, Gennaro A, Lupica C, Falsaperla R, Leonardi R, Garozzo MT, Polizzi A, Praticò AD, Zanghì A, Ruggieri M. TSC1 and TSC2: Tuberous Sclerosis Complex and Its Related Epilepsy Phenotype. JOURNAL OF PEDIATRIC NEUROLOGY 2021. [DOI: 10.1055/s-0041-1727142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
AbstractTuberous sclerosis complex (TSC) is an autosomal dominant disorder characterized by a multisystemic involvement. In TSC, reduced function of TSC1 and TSC2 genes products (hamartin and tuberin, respectively) leads to an hyperactivation of the mechanistic target of rapamycin (mTOR) pathway and to a consequent cell growth dysregulation. In TSC patients, neurological and neuropsychiatric manifestations, especially epilepsy and neuropsychiatric comorbidities such as autism or intellectual disability, represent the most disabling features. In particular, epilepsy occurrs up to 80% of patients, is often drug resistant and is frequently associated with neurological impairment. Due to the burden of this morbidity, different treatment strategies have been proposed with the purpose to make patients epilepsy free, such as the use of different antiepileptic drugs like vigabatrin, carbamazepine, valproic acid, and levetiracetam. More recently, a mTOR inhibitor (i.e. everolimus) has showed promising results in terms of seizures reduction.
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Affiliation(s)
- Claudia Di Napoli
- Postgraduate Training Program in Genetics, Department of Biomedical and Biotechnological Sciences, Section of Genetics, University of Catania, Catania, Italy
| | - Alessia Gennaro
- Postgraduate Training Program in Genetics, Department of Biomedical and Biotechnological Sciences, Section of Genetics, University of Catania, Catania, Italy
| | - Carmelania Lupica
- Postgraduate Training Program in Genetics, Department of Biomedical and Biotechnological Sciences, Section of Genetics, University of Catania, Catania, Italy
| | - Raffaele Falsaperla
- Unit of Pediatrics and Pediatric Emergency, University Hospital “Policlinico Rodolico-San Marco,” Catania, Italy
- Unit of Neonatal Intenstive Care and Neonatology, University Hospital “Policlinico Rodolico-San Marco,” Catania, Italy
| | - Roberta Leonardi
- Department of Clinical and Experimental Medicine, Section of Pediatrics and Child Neuropsychiatry, Unit of Rare Diseases of the Nervous System in Childhood, University of Catania, Catania, Italy
| | - Maria Teresa Garozzo
- Unit of Pediatrics and Pediatric Emergency, Hospital “Cannizzaro,” Catania, Italy
| | - Agata Polizzi
- Chair of Pediatrics, Department of Educational Sciences, University of Catania, Catania, Italy
| | - Andrea D. Praticò
- Department of Clinical and Experimental Medicine, Section of Pediatrics and Child Neuropsychiatry, Unit of Rare Diseases of the Nervous System in Childhood, University of Catania, Catania, Italy
| | - Antonio Zanghì
- Department of General Surgery and Medical-Surgical Specialty, University of Catania, Catania, Italy
| | - Martino Ruggieri
- Chair of Pediatrics, Department of Educational Sciences, University of Catania, Catania, Italy
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Sharma S, Kaushik JS, Srivastava K, Goswami JN, Sahu JK, Vinayan KP, Mittal R. Association of Child Neurology (AOCN) — Indian Epilepsy Society (IES) Consensus Guidelines for the Diagnosis and Management of West Syndrome. Indian Pediatr 2021. [DOI: 10.1007/s13312-021-2097-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Moavero R, Kotulska K, Lagae L, Benvenuto A, Emberti Gialloreti L, Weschke B, Riney K, Feucht M, Krsek P, Nabbout R, Jansen AC, Wojdan K, Borkowska J, Sadowski K, Hertzberg C, Van Schooneveld MM, Samueli S, Maulisovà A, Aronica E, Kwiatkowski DJ, Jansen FE, Jozwiak S, Curatolo P. Is autism driven by epilepsy in infants with Tuberous Sclerosis Complex? Ann Clin Transl Neurol 2020; 7:1371-1381. [PMID: 32705817 PMCID: PMC7448162 DOI: 10.1002/acn3.51128] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 06/16/2020] [Accepted: 06/17/2020] [Indexed: 01/19/2023] Open
Abstract
Objective To evaluate the relationship between age at seizure onset and neurodevelopmental outcome at age 24 months in infants with TSC, as well as the effect on neurodevelopmental outcome of early versus conventional treatment of epileptic seizures with vigabatrin (80–150 mg/kg/day). Methods Infants with TSC, aged ≤4 months and without previous seizures were enrolled in a prospective study and closely followed with monthly video EEG and serial standardized neurodevelopmental testing (Bayley Scales of Infant Development and Autism Diagnostic Observation Schedule). Results Eighty infants were enrolled. At the age of 24 months testing identified risk of Autism Spectrum Disorder (ASD) in 24/80 children (30.0%), and developmental delay (DD) in 26/80 (32.5%). Children with epilepsy (51/80; 63.8%) had a higher risk of ASD (P = 0.02) and DD (P = 0.001). Overall, no child presented with moderate or severe DD at 24 months (developmental quotient < 55). In 20% of children abnormal developmental trajectories were detected before the onset of seizures. Furthermore, 21% of all children with risk of ASD at 24 months had not developed seizures at that timepoint. There was no significant difference between early and conventional treatment with respect to rate of risk of ASD (P = 0.8) or DD (P = 0.9) at 24 months. Interpretation This study confirms a relationship between epilepsy and risk of ASD/DD. However, in this combined randomized/open label study, early treatment with vigabatrin did not alter the risk of ASD or DD at age 2 years.
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Affiliation(s)
- Romina Moavero
- Child Neurology and Psychiatry Unit, Systems Medicine Department, Tor Vergata University, Via Montpellier 1, Rome, 00133, Italy.,Child Neurology Unit, Neuroscience and Neurorehabilitation Department, "Bambino Gesù" Children's Hospital, IRCCS, P.zza S. Onofrio 4, Rome, 00165, Italy
| | - Katarzyna Kotulska
- Department of Neurology and Epileptology, The Children's Memorial Health Institute, Al. Dzieci Polskich 20, Warsaw, 04-730, Poland
| | - Lieven Lagae
- Department of Development and Regeneration-Section Pediatric Neurology, University Hospitals KU Leuven, Leuven, Belgium
| | - Arianna Benvenuto
- Child Neurology and Psychiatry Unit, Systems Medicine Department, Tor Vergata University, Via Montpellier 1, Rome, 00133, Italy
| | - Leonardo Emberti Gialloreti
- Department of Biomedicine and Prevention, Tor Vergata University of Rome, Via Montpellier 1, Rome, 00133, Italy
| | - Bernhard Weschke
- Department of Child Neurology, Charité University Medicine Berlin, Augustenburger Platz 1, Berlin, 13353, Germany
| | - Kate Riney
- Neuroscience Unit, Queensland Children's Hospital, 501 Stanley Street, South Brisbane, QLD, 4101, Australia.,School of Clinical Medicine, University of Queensland, St Lucia, QLD, 4072, Australia
| | - Martha Feucht
- Department of Pediatrics, Medical University Vienna, Vienna, Austria
| | - Pavel Krsek
- Department of Paediatric Neurology, Charles University, Second Faculty of Medicine and Motol University Hospital, Prague, Czech Republic
| | - Rima Nabbout
- Department of Pediatric Neurology, Reference Centre for Rare Epilepsies, Necker- Enfants Malades Hospital, University Paris Descartes, Imagine Institute, Paris, France
| | - Anna C Jansen
- Pediatric Neurology Unit-UZ Brussel, Brussels, Belgium
| | - Konrad Wojdan
- Warsaw University of Technology, Institute of Heat Engineering, Warsaw, Poland.,Transition Technologies, ul. Pawia 5, Warsaw, 01-030, Poland
| | - Julita Borkowska
- Department of Neurology and Epileptology, The Children's Memorial Health Institute, Al. Dzieci Polskich 20, Warsaw, 04-730, Poland
| | - Krzysztof Sadowski
- Department of Neurology and Epileptology, The Children's Memorial Health Institute, Al. Dzieci Polskich 20, Warsaw, 04-730, Poland
| | - Christoph Hertzberg
- Diagnose und Behandlungszentrum für Kinder und Jugendliche, Vivantes Klinikum Neuköln, Berlin, Germany
| | - Monique M Van Schooneveld
- Department of Child Neurology, Brain Center University Medical Center Utrecht, Utrecht, The Netherlands
| | - Sharon Samueli
- Department of Pediatrics, Medical University Vienna, Vienna, Austria
| | - Alice Maulisovà
- Department of Paediatric Neurology, Charles University, Second Faculty of Medicine and Motol University Hospital, Prague, Czech Republic
| | - Eleonora Aronica
- Department of (Neuro)Pathology, Amsterdam UMC, University of Amsterdam, Amsterdam Neuroscience, Meibergdreef 9, Amsterdam, The Netherlands.,Stichting Epilepsie Instellingen Nederland (SEIN), Heemstede, The Netherlands
| | | | - Floor E Jansen
- Department of Child Neurology, Brain Center University Medical Center Utrecht, Utrecht, The Netherlands
| | - Sergiusz Jozwiak
- Department of Neurology and Epileptology, The Children's Memorial Health Institute, Al. Dzieci Polskich 20, Warsaw, 04-730, Poland.,Department of Child Neurology, Medical University of Warsaw, Warsaw, Poland
| | - Paolo Curatolo
- Child Neurology and Psychiatry Unit, Systems Medicine Department, Tor Vergata University, Via Montpellier 1, Rome, 00133, Italy
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Alsowat D, Zak M, McCoy B, Kabir N, Al-Mehmadi S, Chan V, Whitney R. A Review of Investigations for Patients With Tuberous Sclerosis Complex Who Were Referred to the Tuberous Sclerosis Clinic at The Hospital for Sick Children: Identifying Gaps in Surveillance. Pediatr Neurol 2020; 102:44-48. [PMID: 31362847 DOI: 10.1016/j.pediatrneurol.2019.06.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Revised: 06/26/2019] [Accepted: 06/29/2019] [Indexed: 01/09/2023]
Abstract
OBJECTIVE As a newly established tuberous sclerosis clinic (TSC) clinic at The Hospital for Sick Children, we reviewed our referrals to determine if children with TSC received appropriate surveillance as advised by the 2012 International Tuberous Sclerosis Complex Consensus Recommendations. METHODS We completed a retrospective review of all patients seen in the TSC clinic from January 2016 to December 2017 to determine if children referred to the clinic had appropriate surveillance as suggested by the Tuberous Sclerosis Complex Consensus Recommendations. RESULTS Ninety patients were seen in the TSC clinic. The median age at first visit was 9.9 years, and 47 were males. Seventy-six percent had undergone genetic testing before the initial clinic visit; however, genetic counseling was completed in only 66%. Brain magnetic resonance imaging was completed in 94%, abdominal imaging was completed in 91%, and an echocardiography and electrocardiography in 88% and 83%, respectively. In addition, dermatology and ophthalmology evaluations were completed in 78% and 91%, respectively. Assessment of TSC-associated neuropsychiatric disorders (TAND) was only completed in 4% of the patients. CONCLUSIONS Systems surveillance was completed in the majority before the first TSC clinic visit. However, TSC-associated neuropsychiatric disorder screening was completed in few cases. This suggests that referring physicians may not be familiar with the neuropsychiatric manifestations of TSC and that there may be underdiagnosed or undertreated illness. Future emphasis should be placed on educating all practitioners to assess and treat tuberous sclerosis complex-associated neuropsychiatric disorder in tuberous sclerosis complex.
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Affiliation(s)
- Daad Alsowat
- Division of Neurology, Department of Pediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Maria Zak
- Division of Neurology, Department of Pediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Bláthnaid McCoy
- Division of Neurology, Department of Pediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Nadia Kabir
- Division of Neurology, Department of Pediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Sameer Al-Mehmadi
- Department of Pediatrics, King Abdullah Bin Abdulaziz University Hospital, Riyadh, Saudi Arabia
| | - Valerie Chan
- Division of Neurology, Department of Pediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Robyn Whitney
- Division of Neurology, Department of Pediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada.
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Kim D, Kim HJ, You SJ, Yum MS, Ko TS. Diagnosis of Tuberous Sclerosis Complex and Epilepsy Outcomes in Children with Fetal Cardiac Rhabdomyoma: A Long Term Follow-up Study. ANNALS OF CHILD NEUROLOGY 2019. [DOI: 10.26815/acn.2019.00185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
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11
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Modifying genetic epilepsies - Results from studies on tuberous sclerosis complex. Neuropharmacology 2019; 166:107908. [PMID: 31962286 DOI: 10.1016/j.neuropharm.2019.107908] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2019] [Revised: 12/03/2019] [Accepted: 12/05/2019] [Indexed: 12/12/2022]
Abstract
Tuberous sclerosis complex (TSC) is an autosomal dominant neurocutaneous disorder affecting approximately 1 in 6,000 in general population and represents one of the most common genetic causes of epilepsy. Epilepsy affects 90% of the patients and appears in the first 2 years of life in the majority of them. Early onset of epilepsy in the first year of life is associated with high risk of cognitive decline and neuropsychiatric problems including autism. Recently TSC has been recognized as a model of genetic epilepsies. TSC is a genetic condition with known dysregulated mTOR pathway and is increasingly viewed as a model for human epileptogenesis. Moreover, TSC is characterized by a hyperactivation of mTOR (mammalian target of rapamycin) pathway, and mTOR activation was showed to be implicated in epileptogenesis in many animal models and human epilepsies. Recently published studies documented positive effect of preventive or disease modifying treatment of epilepsy in infants with high risk of epilepsy with significantly lower incidence of epilepsy and better cognitive outcome. Further studies on preventive treatment of epilepsy in other genetic epilepsies of early childhood are considered. This article is part of the special issue entitled 'New Epilepsy Therapies for the 21st Century - From Antiseizure Drugs to Prevention, Modification and Cure of Epilepsy'.
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12
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Jozwiak S, Słowińska M, Borkowska J, Sadowski K, Łojszczyk B, Domańska-Pakieła D, Chmielewski D, Kaczorowska-Frontczak M, Głowacka J, Sijko K, Kotulska K. Preventive Antiepileptic Treatment in Tuberous Sclerosis Complex: A Long-Term, Prospective Trial. Pediatr Neurol 2019; 101:18-25. [PMID: 31481332 DOI: 10.1016/j.pediatrneurol.2019.07.008] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Revised: 07/15/2019] [Accepted: 07/16/2019] [Indexed: 01/02/2023]
Abstract
BACKGROUD Drug-resistant epilepsy is the main risk factor for future intellectual disability in patients with tuberous sclerosis complex. Clinical epileptic seizures are often preceded by electroencephalographic changes, which provide an opportunity for preventive treatment. We evaluated the neuropsychologic and epilepsy outcomes at school age in children with tuberous sclerosis complex who received preventive antiepileptic treatment in infancy. METHODS We performed a prospective, nonrandomized clinical trial with 14 infants diagnosed with tuberous sclerosis complex in whom serial electroencephalographic recordings were performed and preventive treatment with vigabatrin initiated when active epileptic discharges were detected. An age-matched control group consisted of 31 infants with tuberous sclerosis complex in whom treatment with vigabatrin was given only after onset of clinical seizures. Results of clinical assessment of epilepsy and cognitive outcomes were analyzed. RESULTS All patients in the preventive group (n = 14) and 25 of 31 patients in the standard treatment group were followed through minimum age five years, median 8.8 and 8.0 years in the preventive and standard groups, respectively. The median intelligence quotient was 94 for the preventive group when compared with 46 for the standard group (P < 0.03). Seven of 14 patients (50%) in the preventive group never had a clinical seizure when compared with one of 25 patients (5%) in the standard treatment group (P = 0.001). CONCLUSIONS This study provides evidence that preventive antiepileptic treatment in infants with tuberous sclerosis complex improves long-term epilepsy control and cognitive outcome at school age.
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Affiliation(s)
- Sergiusz Jozwiak
- Department of Child Neurology, Warsaw Medical University, Warsaw, Poland; Department of Neurology and Epileptology, The Children's Memorial Health Institute, Warsaw, Poland.
| | - Monika Słowińska
- Department of Child Neurology, Warsaw Medical University, Warsaw, Poland
| | - Julita Borkowska
- Department of Neurology and Epileptology, The Children's Memorial Health Institute, Warsaw, Poland
| | - Krzysztof Sadowski
- Department of Neurology and Epileptology, The Children's Memorial Health Institute, Warsaw, Poland
| | - Barbara Łojszczyk
- Department of Neurology and Epileptology, The Children's Memorial Health Institute, Warsaw, Poland
| | - Dorota Domańska-Pakieła
- Department of Neurology and Epileptology, The Children's Memorial Health Institute, Warsaw, Poland
| | - Dariusz Chmielewski
- Department of Neurology and Epileptology, The Children's Memorial Health Institute, Warsaw, Poland
| | | | - Jagoda Głowacka
- Department of Neurology and Epileptology, The Children's Memorial Health Institute, Warsaw, Poland; Transition Technologies, Warsaw, Poland
| | - Kamil Sijko
- Department of Neurology and Epileptology, The Children's Memorial Health Institute, Warsaw, Poland; Transition Technologies, Warsaw, Poland
| | - Katarzyna Kotulska
- Department of Neurology and Epileptology, The Children's Memorial Health Institute, Warsaw, Poland
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13
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Annear NMP, Appleton RE, Bassi Z, Bhatt R, Bolton PF, Crawford P, Crowe A, Tossi M, Elmslie F, Finlay E, Gale DP, Henderson A, Jones EA, Johnson SR, Joss S, Kerecuk L, Lipkin G, Morrison PJ, O'Callaghan FJ, Cadwgan J, Ong ACM, Sampson JR, Shepherd C, Kingswood JC. Tuberous Sclerosis Complex (TSC): Expert Recommendations for Provision of Coordinated Care. Front Neurol 2019; 10:1116. [PMID: 31781016 PMCID: PMC6851053 DOI: 10.3389/fneur.2019.01116] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2019] [Accepted: 10/07/2019] [Indexed: 01/31/2023] Open
Affiliation(s)
- Nicholas M P Annear
- St George's University Hospitals NHS Foundation Trust, London, United Kingdom.,Genetics and Genomics Clinical Academic Group, Molecular and Clinical Sciences Research Institute, St George's, University of London, London, United Kingdom
| | | | - Zahabiyah Bassi
- Alder Hey Children's NHS Foundation Trust, Liverpool, United Kingdom
| | - Rupesh Bhatt
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Patrick F Bolton
- King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Pamela Crawford
- York Teaching Hospitals NHS Foundation Trust, York, United Kingdom
| | - Alex Crowe
- Wirral University Teaching Hospitals NHS Foundation Trust, Merseyside, United Kingdom
| | - Maureen Tossi
- Genetics and Genomics Clinical Academic Group, Molecular and Clinical Sciences Research Institute, St George's, University of London, London, United Kingdom.,Tuberous Sclerosis Association, London, United Kingdom
| | - Frances Elmslie
- St George's University Hospitals NHS Foundation Trust, London, United Kingdom.,Genetics and Genomics Clinical Academic Group, Molecular and Clinical Sciences Research Institute, St George's, University of London, London, United Kingdom
| | - Eric Finlay
- Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Daniel P Gale
- Department of Renal Medicine, University College London, London, United Kingdom
| | - Alex Henderson
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Elizabeth A Jones
- Centre for Genomic Medicine, St. Mary's Hospital, Central Manchester University Hospitals NHS Foundation Trust, Manchester, United Kingdom.,Centre for Genomic Medicine, Manchester Academic Health Science Centre, University of Manchester, Manchester, United Kingdom
| | - Simon R Johnson
- Division of Respiratory Medicine, Faculty of Medicine & Health Sciences, University of Nottingham, Nottingham, United Kingdom.,National Centre for Lymphangioleiomyomatosis, Nottingham, United Kingdom
| | - Shelagh Joss
- NHS Greater Glasgow and Clyde, Glasgow, United Kingdom
| | - Larissa Kerecuk
- Birmingham Children's Hospital NHS Foundation Trust, Birmingham, United Kingdom
| | - Graham Lipkin
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Patrick J Morrison
- Tuberous Sclerosis Clinic, Belfast Health and Social Care Trust, Belfast, United Kingdom
| | - Finbar J O'Callaghan
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
| | - Jill Cadwgan
- Evelina London Children's Hospital, St. Thomas' Hospital, London, United Kingdom.,School of Life Course Sciences, King's College London, London, United Kingdom.,Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Albert C M Ong
- Kidney Genetics Group, Academic Nephrology Unit, University of Sheffield Medical School, Sheffield, United Kingdom.,Sheffield Kidney Institute, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom
| | - Julian R Sampson
- Institute of Medical Genetics, Cardiff University School of Medicine, Cardiff, United Kingdom
| | | | - J Chris Kingswood
- St George's University Hospitals NHS Foundation Trust, London, United Kingdom.,Genetics and Genomics Clinical Academic Group, Molecular and Clinical Sciences Research Institute, St George's, University of London, London, United Kingdom.,Brighton and Sussex University Hospitals NHS Trust, Brighton, United Kingdom
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14
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Oppenheimer J, Leviton A, Chiujdea M, Antonetty A, Ojo OW, Garcia S, Weas S, Fleegler EW, Chan E, Loddenkemper T. Caring electronically for young outpatients who have epilepsy. Epilepsy Behav 2018; 87:226-232. [PMID: 30197227 DOI: 10.1016/j.yebeh.2018.06.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Revised: 06/08/2018] [Accepted: 06/11/2018] [Indexed: 01/17/2023]
Abstract
PURPOSE The purpose of this study was to review electronic tools that might improve the delivery of epilepsy care, reduce medical care costs, and empower families to improve self-management capability. METHOD We reviewed the epilepsy-specific literature about self-management, electronic patient-reported or provider-reported outcomes, on-going remote surveillance, and alerting/warning systems. CONCLUSIONS The improved care delivery system that we envision includes self-management, electronic patient (or provider)-reported outcomes, on-going remote surveillance, and alerting/warning systems. This system and variants have the potential to reduce seizure burden through improved management, keep children out of the emergency department and hospital, and even reduce the number of outpatient visits.
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Affiliation(s)
- Julia Oppenheimer
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | - Alan Leviton
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA.
| | - Madeline Chiujdea
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | - Annalee Antonetty
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | - Oluwafemi William Ojo
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | - Stephanie Garcia
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | - Sarah Weas
- Division of Developmental Medicine, Department of Medicine, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | - Eric W Fleegler
- Division of Emergency Medicine, Department of Medicine, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | - Eugenia Chan
- Division of Developmental Medicine, Department of Medicine, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | - Tobias Loddenkemper
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
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15
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Canevini MP, Kotulska-Jozwiak K, Curatolo P, La Briola F, Peron A, Słowińska M, Strzelecka J, Vignoli A, Jóźwiak S. Current concepts on epilepsy management in tuberous sclerosis complex. AMERICAN JOURNAL OF MEDICAL GENETICS PART C-SEMINARS IN MEDICAL GENETICS 2018; 178:299-308. [PMID: 30255982 DOI: 10.1002/ajmg.c.31652] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/08/2018] [Revised: 08/21/2018] [Accepted: 08/23/2018] [Indexed: 12/12/2022]
Abstract
Tuberous sclerosis complex (TSC) is an autosomal dominant neurocutaneous disease affecting approximately 1 in 6,000 people, and represents one of the most common genetic causes of epilepsy. Epilepsy affects 90% of the patients and appears in the first 2 years of life in the majority of them. Early onset of epilepsy in the first 12 months of life is associated with high risk of cognitive decline and neuropsychiatric problems including autism. Prenatal or early infantile diagnosis of TSC, before the onset of epilepsy, provides a unique opportunity to monitor EEG before the onset of clinical seizures, thus enabling early intervention in the process of epileptogenesis. In this review, we discuss the current status of knowledge on epileptogenesis in TSC, and present recommendations of American and European experts in the field of epilepsy.
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Affiliation(s)
- Maria Paola Canevini
- Child Neuropsychiatry Unit - Epilepsy Center, San Paolo Hospital, Department of Health Sciences, Università degli Studi di Milano, Milan, Italy
| | | | - Paolo Curatolo
- Department of Pediatric Neuropsychiatry, Tor Vergata University, Rome, Italy
| | - Francesca La Briola
- Child Neuropsychiatry Unit - Epilepsy Center, San Paolo Hospital, Department of Health Sciences, Università degli Studi di Milano, Milan, Italy
| | - Angela Peron
- Child Neuropsychiatry Unit - Epilepsy Center, San Paolo Hospital, Department of Health Sciences, Università degli Studi di Milano, Milan, Italy.,Division of Medical Genetics, Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Monika Słowińska
- Department of Neurology and Epileptology, The Children's Memorial Health Institute, Warsaw, Poland.,Department of Pediatric Neurology, Warsaw Medical University, Warsaw, Poland
| | - Jolanta Strzelecka
- Department of Pediatric Neurology, Warsaw Medical University, Warsaw, Poland
| | - Aglaia Vignoli
- Child Neuropsychiatry Unit - Epilepsy Center, San Paolo Hospital, Department of Health Sciences, Università degli Studi di Milano, Milan, Italy
| | - Sergiusz Jóźwiak
- Department of Neurology and Epileptology, The Children's Memorial Health Institute, Warsaw, Poland.,Department of Pediatric Neurology, Warsaw Medical University, Warsaw, Poland
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16
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Management of epilepsy associated with tuberous sclerosis complex: Updated clinical recommendations. Eur J Paediatr Neurol 2018; 22:738-748. [PMID: 29880258 DOI: 10.1016/j.ejpn.2018.05.006] [Citation(s) in RCA: 130] [Impact Index Per Article: 21.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2017] [Revised: 04/12/2018] [Accepted: 05/20/2018] [Indexed: 11/23/2022]
Abstract
Patients with tuberous sclerosis complex (TSC) are at very high risk for developing epilepsy, and the majority experience seizure onset during the first year of life. Early targeted interventions increase the probability of seizure-freedom and may protect neurodevelopment. In 2012, clinical recommendations for the management of epilepsy in patients with TSC were published by a panel of European experts. Since that time novel studies, reports, and expert opinions in preclinical and clinical TSC-related sciences prompted the need for updated recommendations, including epileptogenesis in TSC, the potential role of predictive biomarkers, the possible benefits of presymptomatic diagnosis and preventive treatment, and new treatment options including mTOR inhibitors. A reconvened panel reviewed the current literature to answer specific questions and five panelists discussed the findings, followed by a general discussion during which all issues were debated to achieve consensus regarding recommendations. A draft manuscript based on these discussions and recommendations was then circulated several times among the panelists, who added their own comments. All the panelists/authors agreed with the final manuscript, which was then submitted for publication. The panel concluded that the need for early diagnosis of TSC-associated seizures is now established, electroencephalographic monitoring has good predictive value for epilepsy before seizure onset in TSC, and, until conclusive data from the EPISTOP trial are available, administration of vigabatrin may be considered in children with subclinical epileptiform EEG discharges. The panel also supported the role of adjunctive everolimus for TSC-associated drug-refractory seizures and emphasized the necessity of early surgical evaluation.
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17
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Savini MN, Mingarelli A, Vignoli A, La Briola F, Chiesa V, Peron A, Mai R, Tassi L, Mastrangelo M, Zambrelli E, Turner K, Canevini MP. Ictal signs in tuberous sclerosis complex: Clinical and video-EEG features in a large series of recorded seizures. Epilepsy Behav 2018; 85:14-20. [PMID: 29906696 DOI: 10.1016/j.yebeh.2018.05.027] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Revised: 04/26/2018] [Accepted: 05/14/2018] [Indexed: 11/26/2022]
Abstract
Epilepsy is the most common neurological symptom in tuberous sclerosis complex (TSC), occurring in 72-85% of affected individuals. Despite the large number of patients reported, their electroclinical phenotype has been rarely described. We analyzed seizure semiology through ictal video-electroencephalography (V-EEG) recordings in a large series of patients. In this multicenter study, we reviewed V-EEGs of 51 patients: ictal recordings were analyzed in correlation with their clinical variables. The median age of epilepsy onset was six months (one day-16 years), with onset in the first year of life in 71% patients (36/51), in 10 of them during the neonatal period. Sixty-five percent of patients (33/51) experienced epileptic spasms in their life, with late-onset (>two years) in five; 42% of the epileptic spasms persisted after age two years, despite the onset in the first year of life. We identified four different electroclinical subsets: focal epilepsy (35%, 18/51), Lennox-Gastaut Syndrome evolution (27%, 14/51), focal seizures with persisting spasms (33%, 17/51), and spasms only (4%, 2/51). We reviewed 45 focal seizures, 13 clusters of epileptic spasms, and seven generalized seizures. In 12 patients, we recorded different seizure types. In 71% of the focal seizures (32/45), the ictal pattern was focal without diffusion. In 38% of the patients (5/13) epileptic spasms were related to typical diffuse slow wave pattern associated with superimposed fast activity, with focal predominance. Focal seizures and focal spasms resulted as the most frequent seizure types in TSC. Seizure onset was variable but showing a predominant involvement of the frontocentral regions (40%). Discrete clinical signs characterized the seizures, and behavioral arrest was the predominant first clinical objective sign. Epileptic spasms were a typical presentation at all ages, frequently asymmetrical and associated with lateralizing features, especially in older patients.
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Affiliation(s)
- Miriam Nella Savini
- Epilepsy Center-Child Neuropsychiatric Unit, ASST Santi Paolo e Carlo, Milan, Italy; Department of Health Sciences, University of Milan, Italy
| | - Alessia Mingarelli
- Epilepsy Center-Child Neuropsychiatric Unit, ASST Santi Paolo e Carlo, Milan, Italy
| | - Aglaia Vignoli
- Epilepsy Center-Child Neuropsychiatric Unit, ASST Santi Paolo e Carlo, Milan, Italy; Department of Health Sciences, University of Milan, Italy.
| | - Francesca La Briola
- Epilepsy Center-Child Neuropsychiatric Unit, ASST Santi Paolo e Carlo, Milan, Italy
| | - Valentina Chiesa
- Epilepsy Center-Child Neuropsychiatric Unit, ASST Santi Paolo e Carlo, Milan, Italy
| | - Angela Peron
- Epilepsy Center-Child Neuropsychiatric Unit, ASST Santi Paolo e Carlo, Milan, Italy; Department of Health Sciences, University of Milan, Italy
| | - Roberto Mai
- "C. Munari" Epilepsy Surgery Center, GOM Niguarda, Milan, Italy
| | - Laura Tassi
- "C. Munari" Epilepsy Surgery Center, GOM Niguarda, Milan, Italy
| | | | - Elena Zambrelli
- Epilepsy Center-Child Neuropsychiatric Unit, ASST Santi Paolo e Carlo, Milan, Italy
| | - Katherine Turner
- Epilepsy Center-Child Neuropsychiatric Unit, ASST Santi Paolo e Carlo, Milan, Italy
| | - Maria Paola Canevini
- Epilepsy Center-Child Neuropsychiatric Unit, ASST Santi Paolo e Carlo, Milan, Italy; Department of Health Sciences, University of Milan, Italy
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18
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Benova B, Petrak B, Kyncl M, Jezdik P, Maulisova A, Jahodova A, Komarek V, Krsek P. Early predictors of clinical and mental outcome in tuberous sclerosis complex: A prospective study. Eur J Paediatr Neurol 2018; 22:632-641. [PMID: 29636221 DOI: 10.1016/j.ejpn.2018.03.001] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Revised: 02/15/2018] [Accepted: 03/07/2018] [Indexed: 02/06/2023]
Abstract
AIM We aimed to identify early predictors of intractable epilepsy, intellectual disability (ID) and autism spectrum disorders (ASD) in the cohort of TSC patients initially diagnosed with cardiac rhabdomyomas (CR). METHOD Over the period of twelve years we prospectively obtained clinical, neuropsychological, electrophysiological and neuroimaging data in a group of 22 TSC patients (9 females, 13 males) with the pre/perinatal diagnosis of CR, included to the study at the time of diagnosis. Afterwards, we statistically determined variables associated with ID, ASD and intractable epilepsy. RESULTS Development of ID was predicted by severe epilepsy (a higher number of anti-epileptic drugs used), a higher number of dysplastic lesions on MRI, and abnormal background activity on EEG (p < 0.05). Predictors of ASD included early developmental delay, abnormal background activity on EEG at the end of follow-up and a higher number of areas with dysplastic features on MRI (p < 0.05). Intractable epilepsy was associated with a higher number of areas with dysplastic features on MRI, ID and with TSC2 genotype. CONCLUSION Adverse mental and clinical outcome was associated with intractable epilepsy and the severe anatomical brain involvement; therefore, our centre developed a tailored protocol for early identification of TSC patients at a higher risk of developing intractable epilepsy with its deleterious effect on cognitive outcome.
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Affiliation(s)
- Barbora Benova
- Department of Paediatric Neurology, 2nd Faculty of Medicine, Charles University and Motol University Hospital, V Úvalu 84, Praha 5, 150 06, Czech Republic; 2nd Faculty of Medicine, Charles University, V Úvalu 84, Praha 5, 150 06, Czech Republic
| | - Borivoj Petrak
- Department of Paediatric Neurology, 2nd Faculty of Medicine, Charles University and Motol University Hospital, V Úvalu 84, Praha 5, 150 06, Czech Republic
| | - Martin Kyncl
- 2nd Faculty of Medicine, Charles University, V Úvalu 84, Praha 5, 150 06, Czech Republic; Department of Radiology, 2nd Faculty of Medicine, Charles University and Motol University Hospital, V Úvalu 84, Praha 5, 150 06, Czech Republic
| | - Petr Jezdik
- Department of Paediatric Neurology, 2nd Faculty of Medicine, Charles University and Motol University Hospital, V Úvalu 84, Praha 5, 150 06, Czech Republic; Department of Measurement, Czech Technical University in Prague, Faculty of Electrical Engineering, Technická 2, Praha 6, 166 27, Czech Republic
| | - Alice Maulisova
- Department of Clinical Psychology, Motol University Hospital, V Úvalu 84, Praha 5, 150 06, Czech Republic; Charles University, Faculty of Arts, Department of Psychology, Prague, Nám. Jana Palacha 1/2, Praha 1-Staré Město, 116 38, Czech Republic
| | - Alena Jahodova
- Department of Paediatric Neurology, 2nd Faculty of Medicine, Charles University and Motol University Hospital, V Úvalu 84, Praha 5, 150 06, Czech Republic; 2nd Faculty of Medicine, Charles University, V Úvalu 84, Praha 5, 150 06, Czech Republic
| | - Vladimir Komarek
- Department of Paediatric Neurology, 2nd Faculty of Medicine, Charles University and Motol University Hospital, V Úvalu 84, Praha 5, 150 06, Czech Republic; 2nd Faculty of Medicine, Charles University, V Úvalu 84, Praha 5, 150 06, Czech Republic
| | - Pavel Krsek
- Department of Paediatric Neurology, 2nd Faculty of Medicine, Charles University and Motol University Hospital, V Úvalu 84, Praha 5, 150 06, Czech Republic; 2nd Faculty of Medicine, Charles University, V Úvalu 84, Praha 5, 150 06, Czech Republic.
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20
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Tye C, Thomas LE, Sampson JR, Lewis J, O'Callaghan F, Yates JRW, Bolton PF. Secular changes in severity of intellectual disability in tuberous sclerosis complex: A reflection of improved identification and treatment of epileptic spasms? Epilepsia Open 2018; 3:276-280. [PMID: 29881807 PMCID: PMC5983114 DOI: 10.1002/epi4.12111] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/15/2018] [Indexed: 11/10/2022] Open
Abstract
Tuberous sclerosis complex (TSC) is a multisystem genetic disorder caused by mutations in TSC1 or TSC2. Epilepsy occurs in 80%-90% of affected individuals during their lifetime, and up to one-third of children with TSC will develop epileptic (infantile) spasms, for which vigabatrin has been shown to be particularly effective. Epilepsy severity and epileptic spasms are consistent markers of risk for the development of intellectual impairment in TSC. Although previous studies demonstrate a bimodal distribution of intellectual ability in TSC, recent findings suggest a unimodal distribution, which may reflect a change in IQ distribution over time. We compared 3 large historical UK cohorts of TSC (n = 331) that show varied distributions of intellectual ability, first ruling out differences in study methodology. Later-born individuals had a higher frequency of reported spasms and higher likelihood of vigabatrin administration, but were less likely to have profound intellectual impairment, compared to the earlier-born individuals. Our findings suggest that epileptic spasms went undetected in the older patients and therefore were not treated, leading to a higher occurrence of profound impairment, whereas the later born cohort had better access to treatment. These findings support the importance of early identification and treatment of seizures in TSC.
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Affiliation(s)
- Charlotte Tye
- Department of Child & Adolescent Psychiatry and MRC Social Genetic & Developmental Psychiatry Centre Institute of Psychiatry, Psychology & Neuroscience King's College London London United Kingdom
| | - Laura E Thomas
- Division of Cancer and Genetics Institute of Medical Genetics Cardiff University School of Medicine Cardiff United Kingdom
| | - Julian R Sampson
- Division of Cancer and Genetics Institute of Medical Genetics Cardiff University School of Medicine Cardiff United Kingdom
| | - Julia Lewis
- Mental Health and Learning Disabilities Division Anuerin Bevan University Health Board Newport United Kingdom
| | - Finbar O'Callaghan
- Institute of Child Health University College London London United Kingdom
| | - John R W Yates
- Department of Medical Genetics University of Cambridge Cambridge United Kingdom
| | - Patrick F Bolton
- Department of Child & Adolescent Psychiatry and MRC Social Genetic & Developmental Psychiatry Centre Institute of Psychiatry, Psychology & Neuroscience King's College London London United Kingdom
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21
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Słowińska M, Jóźwiak S, Peron A, Borkowska J, Chmielewski D, Sadowski K, Jurkiewicz E, Vignoli A, La Briola F, Canevini MP, Kotulska-Jóźwiak K. Early diagnosis of tuberous sclerosis complex: a race against time. How to make the diagnosis before seizures? Orphanet J Rare Dis 2018; 13:25. [PMID: 29378663 PMCID: PMC5789613 DOI: 10.1186/s13023-018-0764-z] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2017] [Accepted: 01/10/2018] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Tuberous sclerosis complex (TSC) is a genetic disorder with an incidence of 1:6000 live births and associated with the development of benign tumors in several organs. It is also characterized by high rates of neurological and neuropsychiatric abnormalities, including epilepsy affecting 70-90% of patients and being one of the major risk factors of intellectual disability. The first seizures in TSC patients appear usually between the 4th and the 6th months of life. Recent studies have shown the beneficial role of preventative antiepileptic treatment in TSC patients, with the possibility for improvement of cognitive outcome. Moreover, European recommendations suggest early introduction of Vigabatrin if ictal discharges occur on EEG recordings, with or without clinical manifestation. The aim of this study was to define the most useful approach to make the diagnosis of TSC before seizure onset (before age 4th months), in order to start early EEG monitoring with possible preventative treatment intervention. METHODS We performed a retrospective review of children who were suspected of having TSC due to single or multiple cardiac tumors as the first sign of the disease. We analyzed the medical records in terms of conducted clinical tests and TSC signs, which were observed until the end of the 4th month of age. Subsequently, we described the different clinical scenarios and recommendations for early diagnosis. RESULTS 82/100 children were diagnosed with TSC within the first 4 months of life. Apart from cardiac tumors, the most frequently observed early TSC signs were subependymal nodules (71/100, 71%), cortical dysplasia (66/100, 66%), and hypomelanotic macules (35/100, 35%). The most useful clinical studies for early TSC diagnosis were brain magnetic resonance imaging (MRI), skin examination and echocardiography. Genetic testing was performed in 49/100 of the patients, but the results were obtained within the first 4 months of life in only 3 children. CONCLUSIONS Early diagnosis of TSC, before seizure onset, is feasible and it is becoming pivotal for epilepsy management and improvement of cognitive outcome. Early TSC diagnosis is mostly based on clinical signs. Brain MRI, echocardiography, skin examination and genetic testing should be performed early in every patient suspected of having TSC.
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Affiliation(s)
- Monika Słowińska
- Department of Neurology and Epileptology, The Children’s Memorial Health Institute, Al. Dzieci Polskich 20, 04-730 Warszawa, Poland
- Department of Child Neurology, Medical University of Warsaw, Ul. Żwirki I Wigury 63A, 02-091 Warszawa, Poland
| | - Sergiusz Jóźwiak
- Department of Neurology and Epileptology, The Children’s Memorial Health Institute, Al. Dzieci Polskich 20, 04-730 Warszawa, Poland
- Department of Child Neurology, Medical University of Warsaw, Ul. Żwirki I Wigury 63A, 02-091 Warszawa, Poland
| | - Angela Peron
- Child Neuropsychiatry Unit - Epilepsy Center, San Paolo Hospital, Via Antonio di Rudinì, 8, 20142 Milan, Italy
- Department of Health Sciences, Università degli Studi di Milano, Via Antonio di Rudinì, 8, 20142 Milan, Italy
- Department of Pediatrics, Division of Medical Genetics, University of Utah School of Medicine, Salt Lake City, UT USA
| | - Julita Borkowska
- Department of Neurology and Epileptology, The Children’s Memorial Health Institute, Al. Dzieci Polskich 20, 04-730 Warszawa, Poland
| | - Dariusz Chmielewski
- Department of Neurology and Epileptology, The Children’s Memorial Health Institute, Al. Dzieci Polskich 20, 04-730 Warszawa, Poland
| | - Krzysztof Sadowski
- Department of Neurology and Epileptology, The Children’s Memorial Health Institute, Al. Dzieci Polskich 20, 04-730 Warszawa, Poland
| | - Elżbieta Jurkiewicz
- Department of Radiology, The Children’s Memorial Health Institute, Al. Dzieci Polskich 20, 04-730 Warszawa, Poland
| | - Aglaia Vignoli
- Child Neuropsychiatry Unit - Epilepsy Center, San Paolo Hospital, Via Antonio di Rudinì, 8, 20142 Milan, Italy
- Department of Health Sciences, Università degli Studi di Milano, Via Antonio di Rudinì, 8, 20142 Milan, Italy
| | - Francesca La Briola
- Child Neuropsychiatry Unit - Epilepsy Center, San Paolo Hospital, Via Antonio di Rudinì, 8, 20142 Milan, Italy
| | - Maria Paola Canevini
- Child Neuropsychiatry Unit - Epilepsy Center, San Paolo Hospital, Via Antonio di Rudinì, 8, 20142 Milan, Italy
- Department of Health Sciences, Università degli Studi di Milano, Via Antonio di Rudinì, 8, 20142 Milan, Italy
| | - Katarzyna Kotulska-Jóźwiak
- Department of Neurology and Epileptology, The Children’s Memorial Health Institute, Al. Dzieci Polskich 20, 04-730 Warszawa, Poland
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