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Andzelm MM, Stredny CM. Mechanisms and Emerging Therapies for Treatment of Seizures in Pediatric Autoimmune Encephalitis and Autoinflammatory/Autoimmune-Associated Epilepsy. Rheum Dis Clin North Am 2023; 49:875-893. [PMID: 37821201 DOI: 10.1016/j.rdc.2023.06.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/13/2023]
Abstract
There has been increasing understanding of the role of inflammation in seizures and epilepsy, as well as targeted immunomodulatory treatments. In children, immune-mediated seizures often present acutely in the setting of autoimmune encephalitis and are very responsive to immunotherapy with low rates of subsequent epilepsy. Conversely, seizures in autoimmune-associated epilepsies, such as Rasmussen syndrome, can remain refractory to multimodal therapy, including immunomodulation. In this review, the authors discuss the presentations of immune-mediated seizures in children, underlying mechanisms, and emerging therapies.
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Affiliation(s)
- Milena M Andzelm
- Program in Neuroimmunology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Coral M Stredny
- Program in Neuroimmunology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA; Division of Epilepsy and Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA.
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2
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Jaafar F, Obeid M, Beydoun A. Role of Early Intravenous Immunoglobulins in Halting Clinical and Radiographic Disease Progression in Rasmussen Encephalitis. Pediatr Neurol 2023; 145:30-35. [PMID: 37269621 DOI: 10.1016/j.pediatrneurol.2023.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 03/29/2023] [Accepted: 05/08/2023] [Indexed: 06/05/2023]
Abstract
BACKGROUND Rasmussen encephalitis (RE) is a rare progressive presumed autoimmune disorder characterized by pharmacoresistant epilepsy and progressive motor and cognitive deterioration. Despite immunomodulation, more than half of the patients with RE ultimately require functional hemispherotomy. In this study, we evaluated the potential beneficial effects of early initiation of immunomodulation in slowing disease progression and preventing the need for surgical interventions. METHODS A retrospective chart review over a 10-year period was conducted at the American University of Beirut Medical Center to identify patients with RE. Data were collected on seizure characteristics, neurological deficits, electroencephalography, brain magnetic resonance imaging results (including volumetric analyses for an objective assessment of radiographic progression), and treatment modalities. RESULTS Seven patients met the inclusion criteria for RE. All patients received intravenous immunoglobulins (IVIGs) as soon as the diagnosis was entertained. Five patients with only monthly to weekly seizures at the time of IVIG initiation had favorable outcomes without resorting to surgery, along with a relative preservation of the gray matter volumes in the affected cerebral hemispheres. Motor strength was preserved in those patients, and three were seizure free at their last follow-up visit. The two patients who required hemispherotomy were already severely hemiparetic and experiencing daily seizures at the time of IVIG initiation. CONCLUSIONS Our data suggest that the early initiation of IVIG as soon as a diagnosis of RE is suspected, and particularly before the appearance of motor deficits and intractable seizures, can maximize the beneficial effects of immunomodulation in terms of controlling seizures and reducing the rate of cerebral atrophy.
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Affiliation(s)
- Fatima Jaafar
- Division of Child Neurology, Department of Pediatric and Adolescent Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Makram Obeid
- Division of Child Neurology, Department of Neurology, Indiana University School of Medicine, Riley Hospital for Children, Indianapolis, Indiana.
| | - Ahmad Beydoun
- Department of Neurology, American University of Beirut Medical Center, Beirut, Lebanon.
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3
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Rasmussen's encephalitis: Early diagnostic criteria in children. Rev Neurol (Paris) 2022; 178:666-674. [PMID: 35568516 DOI: 10.1016/j.neurol.2022.03.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Revised: 02/23/2022] [Accepted: 03/10/2022] [Indexed: 11/21/2022]
Abstract
Rasmussen's encephalitis (RE) is a rare chronic inflammatory brain disorder resulting in progressive neurodegeneration in one cerebral hemisphere. The inflammatory process is accompanied by progressive loss of function of the affected hemisphere, associated with drug-resistant partial epilepsy. The diagnosis is based on a range of clinical, electroencephalographic, radiological and biochemical arguments, without any specific formal marker, which makes the diagnosis of the disease complex, especially in its initial phase. Seizures are refractory to anti-seizures medication (ASM) and to classical immunomodulatory treatments. These treatments are also ineffective to stop the degenerative process. Only surgical treatment with hemispherotomy (surgical disconnection of a cerebral hemisphere) allows definitive cessation of seizures but this leads to definitive motor and cognitive deficits. The etiology of RE is not known, but there is strong evidence for an immunopathogenic mechanism involving T-cell mediated immunity. The emergence of biotherapies targeting against various cytokines offers potential therapeutic perspectives. This disease is currently a real challenge in terms of: (i) early diagnosis, before the constitution of marked hemispheric atrophy and the appearance of neurological and cognitive consequences; (ii) recognition of incomplete form; (iii) therapeutic management due to advances in the field of targeted treatment of inflammation; (iv) surgery and recovery possibilities.
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4
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Lagarde S, Boucraut J, Bartolomei F. Medical treatment of Rasmussen's Encephalitis: A systematic review. Rev Neurol (Paris) 2022; 178:675-691. [DOI: 10.1016/j.neurol.2022.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Revised: 01/09/2022] [Accepted: 01/10/2022] [Indexed: 11/29/2022]
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Pellegrin S, Baldeweg T, Pujar S, D'Arco F, Cantalupo G, Varadkar S, Cross JH. Immunomodulation With Azathioprine Therapy in Rasmussen Syndrome: A Multimodal Evaluation. Neurology 2020; 96:e267-e279. [PMID: 33046614 DOI: 10.1212/wnl.0000000000011004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Accepted: 08/25/2020] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To verify safety and efficacy of the corticosteroid-sparing drug azathioprine (AZA) in Rasmussen syndrome (RS), we retrospectively analyzed a cohort of patients with RS recruited in a single pediatric neuroscience center. METHODS We compared outcomes in 30 patients with RS who received AZA with 23 patients who were not treated with this drug. We used a multimodal approach to correlate therapy with clinical features (seizures, epilepsia partialis continua [EPC], hemiparesis) and neuroimaging markers of progressive brain atrophy. RESULTS AZA was well tolerated; only 1 patient discontinued treatment due to pancytopenia. In 27 of 30 patients receiving AZA, all of whom were corticosteroid responders, corticosteroid therapy could be weaned or reduced without worsening of seizures in 89%. Patients receiving AZA had a lower prevalence of EPC (42% vs 67% in controls) and hemiparesis (64% vs 92%, respectively). Cox regression showed for the AZA group compared to controls a delayed time to (1) EPC (≈2 years, exp[B] = 0.295, 95% confidence interval [CI] 0.108-0.807; p = 0.017), (2) hemiparesis (≈1 year, exp[B] = 0.315, 95% CI 0.137-0.724; p = 0.007), and (3) surgery (≈2 years, exp[B] = 2.068, 95% CI 1.012-4.227; p = 0.046). However, there were no group differences in cognitive decline over time (IQ change per year) or in hemispheric gray matter atrophy on serial MRI scans. CONCLUSION AZA treatment appears to slow clinical progression of RS in steroid responders; this will give the greatest advantage in patients in the early stages of the disease in whom surgical decision-making may require further time. CLASSIFICATION OF EVIDENCE This study provides Class III evidence that for pediatric patients with RS AZA is well tolerated and slows hemiparesis and appearance of EPC.
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Affiliation(s)
- Serena Pellegrin
- From the Developmental Neurosciences Programme (S.P., T.B., J.H.C.), Great Ormond Street Institute of Child Health, London, UK; Child Neuropsychiatry Unit (S.P., G.C.), University of Verona, Italy; and Great Ormond Street Hospital for Children NHS Foundation Trust (S.P., F.D., S.V., J.H.C.), London, UK
| | - Torsten Baldeweg
- From the Developmental Neurosciences Programme (S.P., T.B., J.H.C.), Great Ormond Street Institute of Child Health, London, UK; Child Neuropsychiatry Unit (S.P., G.C.), University of Verona, Italy; and Great Ormond Street Hospital for Children NHS Foundation Trust (S.P., F.D., S.V., J.H.C.), London, UK
| | - Suresh Pujar
- From the Developmental Neurosciences Programme (S.P., T.B., J.H.C.), Great Ormond Street Institute of Child Health, London, UK; Child Neuropsychiatry Unit (S.P., G.C.), University of Verona, Italy; and Great Ormond Street Hospital for Children NHS Foundation Trust (S.P., F.D., S.V., J.H.C.), London, UK
| | - Felice D'Arco
- From the Developmental Neurosciences Programme (S.P., T.B., J.H.C.), Great Ormond Street Institute of Child Health, London, UK; Child Neuropsychiatry Unit (S.P., G.C.), University of Verona, Italy; and Great Ormond Street Hospital for Children NHS Foundation Trust (S.P., F.D., S.V., J.H.C.), London, UK
| | - Gaetano Cantalupo
- From the Developmental Neurosciences Programme (S.P., T.B., J.H.C.), Great Ormond Street Institute of Child Health, London, UK; Child Neuropsychiatry Unit (S.P., G.C.), University of Verona, Italy; and Great Ormond Street Hospital for Children NHS Foundation Trust (S.P., F.D., S.V., J.H.C.), London, UK
| | - Sophia Varadkar
- From the Developmental Neurosciences Programme (S.P., T.B., J.H.C.), Great Ormond Street Institute of Child Health, London, UK; Child Neuropsychiatry Unit (S.P., G.C.), University of Verona, Italy; and Great Ormond Street Hospital for Children NHS Foundation Trust (S.P., F.D., S.V., J.H.C.), London, UK
| | - J Helen Cross
- From the Developmental Neurosciences Programme (S.P., T.B., J.H.C.), Great Ormond Street Institute of Child Health, London, UK; Child Neuropsychiatry Unit (S.P., G.C.), University of Verona, Italy; and Great Ormond Street Hospital for Children NHS Foundation Trust (S.P., F.D., S.V., J.H.C.), London, UK.
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Bellamkonda N, Phillips HW, Chen JS, Tucker AM, Maniquis C, Mathern GW, Fallah A. Epilepsy surgery for Rasmussen encephalitis: the UCLA experience. J Neurosurg Pediatr 2020; 26:389-397. [PMID: 32679562 DOI: 10.3171/2020.4.peds2098] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2020] [Accepted: 04/21/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Rasmussen encephalitis (RE) is a rare inflammatory neurological disorder typically involving one hemisphere and resulting in drug-resistant epilepsy and progressive neurological decline. Here, the authors present seizure outcomes in children who underwent epilepsy surgery for RE at a single institution. METHODS The records of consecutive patients who had undergone epilepsy surgery for RE at the UCLA Mattel Children's Hospital between 1982 and 2018 were retrospectively reviewed. Basic demographic information, seizure history, procedural notes, and postoperative seizure and functional outcome data were analyzed. RESULTS The cohort included 44 patients, 41 of whom had sufficient data for analysis. Seizure freedom was achieved in 68%, 48%, and 22% of the patients at 1, 5, and 10 years, respectively. The median time to the first seizure for those who experienced seizure recurrence after surgery was 39 weeks (IQR 11-355 weeks). Anatomical hemispherectomy, as compared to functional hemispherectomy, was independently associated with a longer time to postoperative seizure recurrence (HR 0.078, p = 0.03). There was no statistically significant difference in postoperative seizure recurrence between patients with complete hemispherectomy and those who had less-than-hemispheric surgery. Following surgery, 68% of the patients could ambulate and 84% could speak regardless of operative intervention. CONCLUSIONS A large proportion of RE patients will have seizure relapse after surgery, though patients with anatomical hemispherectomies may have a longer time to postoperative seizure recurrence. Overall, the long-term data in this study suggest that hemispheric surgery can be seen as palliative treatment for seizures rather than a cure for RE.
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Affiliation(s)
| | | | - Jia-Shu Chen
- Departments of1Neurosurgery.,4Department of Neuroscience, Brown University, Providence, Rhode Island; and
| | - Alexander M Tucker
- 5Department of Neurosurgery, Children's Hospital of Philadelphia, Pennsylvania
| | | | - Gary W Mathern
- Departments of1Neurosurgery.,3Psychiatry and Biobehavioral Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Aria Fallah
- Departments of1Neurosurgery.,2Pediatrics, and
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Mameniškienė R, Wolf P. Epilepsia partialis continua: A review. Seizure 2017; 44:74-80. [DOI: 10.1016/j.seizure.2016.10.010] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2016] [Revised: 10/12/2016] [Accepted: 10/13/2016] [Indexed: 11/24/2022] Open
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Cao K, Liu M, Wang C, Liu Q, Yang K, Tao L, Guo X. Five-Year Long-Term Prognosis of Epileptic Children After Hemispheric Surgery: A Systematic Review and Meta-analysis. Medicine (Baltimore) 2016; 95:e3743. [PMID: 27281073 PMCID: PMC4907651 DOI: 10.1097/md.0000000000003743] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2015] [Revised: 04/13/2016] [Accepted: 04/21/2016] [Indexed: 11/26/2022] Open
Abstract
To estimate children's long-term seizure outcomes after hemispheric surgery and the associated predictors.A systematic review of 4 databases and a meta-analysis were performed from January 1, 1995 to August 31, 2015. The databases included PubMed, Embase, Science Direct, and Web of Science; patients were classified into the Engel Class I group and the Engel Class II to IV group, according to their seizure outcomes. Nine potential predictors were then stratified across the groups and estimated using the Wilcoxon rank-sum test for continuous variables and the Chi-squared test for categorical variables.The search yielded 15 retrospective studies, with a total sample size of 380. Five years after surgery, 268 (0.71, 95% confidence interval [CI]: 0.64-0.78) children were seizure free; the seizure onset age in the Engel Class I group was significantly higher than that of the Engel Class II to IV group (standardized mean difference [SMD] = 0.26, 95% CI: 0.03-0.49, P = 0.028); specifically, when predicting the positive long-term outcomes, the odds ratio for late onset age (≥3.6 months, median value of the Engel Class II-IV group) versus early onset age was 2.65 (95% CI: 1.454-4.836, z = 3.18, P = 0.001). The abnormal magnetic resonance imaging (MRI) findings were more predictive for positive seizure outcomes than the normal findings (odds ratio [OR] = 4.60, 95% CI: 1.27-16.62, P = 0.02).Following hemispheric surgery, the long-term prognosis of children with epilepsy was good. Late seizure onset (age ≥ 3.6 months) and abnormal MRI findings were positive predictors for long-term seizure control in children.
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Affiliation(s)
- Kai Cao
- From the Department of Epidemiology and Health Statistics, School of Public Health, Capital Medical University (KC, CW, QL, KY, LT, XG); Beijing Municipal Key Laboratory of Clinical Epidemiology (KC, CW, QL, KY, LT, XG); Beijing Key Laboratory of Environment Toxicology (ML); School of Public Health, Capital Medical University (ML); and Beijing Institute of Ophthalmology, Beijing Tongren Eye Center, Beijing Tongren Hospital, Capital Medical University, Beijing Ophthalmology & Visual Science Key Laboratory (KC), Beijing, China
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9
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Lagarde S, Villeneuve N, Trébuchon A, Kaphan E, Lepine A, McGonigal A, Roubertie A, Barthez MAJ, Trommsdorff V, Lefranc J, Wehbi S, des Portes V, Laguitton V, Quartier P, Scavarda D, Giusiano B, Milh M, Bulteau C, Bartolomei F. Anti-tumor necrosis factor alpha therapy (adalimumab) in Rasmussen's encephalitis: An open pilot study. Epilepsia 2016; 57:956-66. [DOI: 10.1111/epi.13387] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/16/2016] [Indexed: 12/11/2022]
Affiliation(s)
- Stanislas Lagarde
- Clinical Neurophysiology and Epileptology Department; Timone Hospital; APHM; Marseille France
| | - Nathalie Villeneuve
- Henri Gastaut Hospital; Marseille France
- Pediatric Neurology Department; Timone Hospital; APHM; Marseille France
| | - Agnès Trébuchon
- Clinical Neurophysiology and Epileptology Department; Timone Hospital; APHM; Marseille France
| | - Elsa Kaphan
- Neurology Department; Timone Hospital; APHM; Marseille France
| | - Anne Lepine
- Henri Gastaut Hospital; Marseille France
- Pediatric Neurology Department; Timone Hospital; APHM; Marseille France
| | - Aileen McGonigal
- Clinical Neurophysiology and Epileptology Department; Timone Hospital; APHM; Marseille France
| | - Agathe Roubertie
- Pediatric Neurology Department; “Gui de Chauliac” Hospital; Montpellier France
| | | | | | - Jérémie Lefranc
- Pediatric Neurology Department; Brest Hospital; Brest France
| | - Samer Wehbi
- Pediatrics Department; André Mignot Hospital; Le Chesnay France
| | | | | | - Pierre Quartier
- Pediatric Immunology-Hematology and Rheumatology Unit and IMAGINE Institute; “Necker-Enfants Malades” Hospital; APHP; Paris France
| | - Didier Scavarda
- Pediatric Neurosurgery Department; Timone Hospital; APHM; Marseille France
| | - Bernard Giusiano
- Division of Public Health; Timone Hospital; APHM; Marseille France
- Brain Dynamic Institute; INSERM UMR 1106 and Aix-Marseille University; Marseille France
| | - Mathieu Milh
- Pediatric Neurology Department; Timone Hospital; APHM; Marseille France
| | - Christine Bulteau
- Pediatric Neurosurgery Department; Ophthalmologic Foundation “A. de Rothschild”; Paris France
| | - Fabrice Bartolomei
- Pediatric Neurosurgery Department; Timone Hospital; APHM; Marseille France
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Bakker DP, Catsman-Berrevoets CE, Neuteboom RF. Effectiveness of a hybrid corticosteroid treatment regimen on refractory childhood seizures and a review of other corticosteroid treatments. Eur J Paediatr Neurol 2015; 19:553-60. [PMID: 25976064 DOI: 10.1016/j.ejpn.2015.04.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2014] [Revised: 02/20/2015] [Accepted: 04/11/2015] [Indexed: 10/23/2022]
Abstract
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.
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Affiliation(s)
- Dewi P Bakker
- Erasmus University Hospital-Sophia Children's Hospital, The Netherlands
| | | | - Rinze F Neuteboom
- Erasmus University Hospital-Sophia Children's Hospital, The Netherlands.
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Grosmaitre C, Jambaqué I, Dorfmuller G, Rodrigo S, Ville D, Delalande O, Bulteau C. Exceptional verbal intelligence after hemispherotomy in a child with Rasmussen encephalitis. Neurocase 2015; 21:144-7. [PMID: 24471481 DOI: 10.1080/13554794.2013.878724] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
We report a longitudinal case study of a left-handed girl who underwent left hemispherotomy at 7 years for Rasmussen encephalitis (RE). Presurgical evaluation showed mild hemiparesis, no visual defect, and light neuropsychological impairment with short-term memory weakness. Language fMRI showed a right hemispheric dominance. Postoperatively, the patient exhibited right hemiplegia and hemianopsia but preserved intellectual capacities. She became seizure-free, and antiepileptic medication was discontinued. Long-term follow-up showed very high verbal intelligence at 11 years of age (VCI of 155) and improvement in working memory as well as language and reading abilities. Furthermore, a significant visuoverbal discrepancy became increasingly pronounced. Thus, early surgical treatment of epilepsy avoided the global cognitive deterioration usually associated with RE. Finally, such a high level of verbal functioning combined with low spatial reasoning with a single hemisphere provides additional information on the neurocognitive profile of children with RE after hemispherotomy.
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Press C, Wallace A, Chapman KE. The Janus-faced nature of Rasmussen's encephalitis. Semin Pediatr Neurol 2014; 21:129-36. [PMID: 25149947 DOI: 10.1016/j.spen.2014.04.018] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Rasmussen encephalitis (RE) is an inflammatory unilateral progressive medically refractory epilepsy associated with hemiparesis, cognitive dysfunction, and hemispheric atrophy. Here, we present 2 cases from our institution that demonstrate the dual nature of RE in 2 similarly aged children. Overall, 2 types of RE have been described: type 1 has a short prodromal phase and more explosive onset and type 2 has a longer prodromal of partial seizures followed by hemiparesis and atrophy. Younger patients are more likely to fit into the type 1 presentation and have been described as more likely to have dual pathology. Perhaps the patients with a more acute onset are more likely to have a dual pathology as is found in our 2 cases. We review the typical findings in RE and discuss current treatment options, highlighting new experimental treatments.
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Affiliation(s)
- Craig Press
- Department of Neurology, Children's Hospital Colorado, University of Colorado, Anschutz Medical Campus, Aurora, CO
| | - Adam Wallace
- Department of Neurology, Children's Hospital Colorado, University of Colorado, Anschutz Medical Campus, Aurora, CO
| | - Kevin E Chapman
- Department of Neurology, Children's Hospital Colorado, University of Colorado, Anschutz Medical Campus, Aurora, CO.
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Granata T, Matricardi S, Ragona F, Freri E, Casazza M, Villani F, Deleo F, Tringali G, Gobbi G, Tassi L, Lo Russo G, Marras CE, Specchio N, Vigevano F, Fusco L. Hemispherotomy in Rasmussen encephalitis: long-term outcome in an Italian series of 16 patients. Epilepsy Res 2014; 108:1106-19. [PMID: 24815913 DOI: 10.1016/j.eplepsyres.2014.03.018] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2013] [Revised: 03/13/2014] [Accepted: 03/24/2014] [Indexed: 10/25/2022]
Abstract
Surgical disconnection of the affected hemisphere is considered the treatment of choice for Rasmussen encephalitis (RE), however few data on long-term outcomes after disconnective surgery are available. We report on long-term seizure, cognitive and motor outcomes after disconnective surgery in 16 (8 M, 8 F) RE patients. Pre- and post-operative evaluations included long-term video-EEG monitoring, MRI, assessment of motor function, and cognitive evaluation. Hemispherotomy, by various techniques was used to obtain functional disconnection of the affected hemisphere. The patients, of median current age 23.5 years, range 12-33, were operated on between 1993 and 2009. Median age at disease onset was 5.8 years (range 3-11.4). Median time from seizure onset to surgery was 3.8 years, range 8 months to 21 years. Post-surgical follow-up was a median of 9.5 years, range 3-20. At surgery all patients were receiving two or more antiepileptic drugs (AEDs). All but three patients were seizure-free at latest follow-up. AEDs had been stopped in ten patients; in the remaining six AEDs were markedly reduced. Postural control improved in all patients. Gain in cognitive functioning was significantly (p=0.002) related to disease duration. The long-term outcomes, in terms of seizure control, motor improvement, and cognitive improvement provide important support for disconnective surgery as first choice treatment for RE.
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Affiliation(s)
- Tiziana Granata
- Department of Pediatric Neuroscience, Carlo Besta Neurological Institute, Milan, Italy.
| | - Sara Matricardi
- Department of Pediatric Neuroscience, Carlo Besta Neurological Institute, Milan, Italy; Department of Pediatrics, University of Chieti, Chieti, Italy
| | - Francesca Ragona
- Department of Pediatric Neuroscience, Carlo Besta Neurological Institute, Milan, Italy
| | - Elena Freri
- Department of Pediatric Neuroscience, Carlo Besta Neurological Institute, Milan, Italy
| | - Marina Casazza
- Department of Neurophysiology, Carlo Besta Neurological Institute, Milan, Italy
| | - Flavio Villani
- Clinical Epileptology and Experimental Neurophysiology Unit, Carlo Besta Neurological Institute, Milan, Italy
| | - Francesco Deleo
- Clinical Epileptology and Experimental Neurophysiology Unit, Carlo Besta Neurological Institute, Milan, Italy
| | - Giovanni Tringali
- Department of Neurosurgery, Carlo Besta Neurological Institute, Milan, Italy
| | - Giuseppe Gobbi
- Child Neurology Unit, IRCCS Istituto delle Scienze Neurologiche, Bellaria Hospital, Bologna, Italy
| | - Laura Tassi
- Epilepsy Surgery Centre C. Munari, Milan, Italy
| | | | | | - Nicola Specchio
- Department of Neuroscience, Bambino Gesù Children's Hospital, Rome, Italy
| | - Federico Vigevano
- Department of Neuroscience, Bambino Gesù Children's Hospital, Rome, Italy
| | - Lucia Fusco
- Department of Neuroscience, Bambino Gesù Children's Hospital, Rome, Italy
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14
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Guan Y, Zhou J, Luan G, Liu X. Surgical Treatment of Patients with Rasmussen Encephalitis. Stereotact Funct Neurosurg 2014; 92:86-93. [DOI: 10.1159/000355901] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2013] [Accepted: 09/23/2013] [Indexed: 11/19/2022]
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15
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Rasmussen syndrome: An Argentinean experience in 32 patients. Seizure 2013; 22:360-7. [DOI: 10.1016/j.seizure.2013.02.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2012] [Revised: 01/14/2013] [Accepted: 02/06/2013] [Indexed: 11/20/2022] Open
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Bien CG, Tiemeier H, Sassen R, Kuczaty S, Urbach H, von Lehe M, Becker AJ, Bast T, Herkenrath P, Karenfort M, Kruse B, Kurlemann G, Rona S, Schubert-Bast S, Vieker S, Vlaho S, Wilken B, Elger CE. Rasmussen encephalitis: Incidence and course under randomized therapy with tacrolimus or intravenous immunoglobulins. Epilepsia 2012; 54:543-50. [DOI: 10.1111/epi.12042] [Citation(s) in RCA: 89] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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18
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Heyman E, Lahat E, Gandelman-Marton R. Interictal encephalography can influence patient selection for methylprednisolone therapy in pediatric refractory epilepsy. J Child Neurol 2012; 27:162-7. [PMID: 21881006 DOI: 10.1177/0883073811414905] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
We describe our experience with intravenous methylprednisolone pulse therapy in older children with refractory epilepsy. Patients with refractory epilepsy, who were treated with steroids between 2005 and 2010, were retrospectively selected from the database of the pediatric epilepsy clinic at Assaf Harofeh Medical Center. Eight patients (5 boys) aged 1.1 to 9 years (5.2 ± 2.6) were identified. Intravenous methylprednisolone 30 mg/kg/d was given to all patients for 5 days in addition to a stable dosage of the regular antiepileptic drugs. Transient side effects were reported in 4 of the patients during pulse therapy. Significant clinical improvement was noted in 4 patients, accompanied by a significant reduction of the amplitude of the spike-slow wave discharges on the electroencephalogram (EEG). Children with refractory epilepsy, abnormal EEG background, and high-amplitude spike-slow wave discharges appear to be the best candidates for intravenous methylprednisolone pulse therapy.
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Affiliation(s)
- Eli Heyman
- Department of Pediatric Neurology, Assaf Harofeh Medical Center, Zerifin, Israel
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Papetti L, Nicita F, Granata T, Guerrini R, Ursitti F, Properzi E, Iannetti P, Spalice A. Early add-on immunoglobulin administration in Rasmussen encephalitis: the hypothesis of neuroimmunomodulation. Med Hypotheses 2011; 77:917-20. [PMID: 21885203 DOI: 10.1016/j.mehy.2011.08.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2011] [Revised: 08/04/2011] [Accepted: 08/07/2011] [Indexed: 10/17/2022]
Abstract
Rasmussen encephalitis (RE) is a chronic inflammatory disease leading to unilateral hemispheric atrophy, associated with progressive neurological dysfunction and intractable seizures. The best approach to RE is hemispherectomy. However long-term immunotherapy seems to prevent or slow down hemispheric tissue loss and the associated functional decline. We describe a girl with epilepsia partialis continua (EPC) and progressive neurological dysfunction compatible with RE. The brain MRI showed a lesion that was initially interpreted as focal cortical dysplasia. Combined antiepileptic and immunomodulation were administered for two years with initial beneficial effects. The follow-up MRI, 4 year later showed. atrophic change in right parietal region. The association of antiepileptic and immunomodulation therapies may inhibit pathogenetic mechanisms responsible for neuronal loss in RE, slowing down the progression of the disease.
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Affiliation(s)
- L Papetti
- Department of Pediatrics, Child Neurology Division, Sapienza University of Rome, Rome, Italy
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20
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Mastrangelo M, Mariani R, Menichella A. Eponym : Rasmussen syndrome. Eur J Pediatr 2010; 169:919-24. [PMID: 20177700 DOI: 10.1007/s00431-010-1148-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2009] [Accepted: 01/19/2010] [Indexed: 11/29/2022]
Abstract
Rasmussen's syndrome (RS) is a rare acquired progressive inflammatory encephalopathy characterized by drug-resistant partial seizures and cognitive deterioration resulting from a gradual impairment and a subsequent atrophy of a single brain hemisphere. It was firstly described by Theodore Rasmussen in 1958. The original etiopathogenic hypothesis of a chronic viral infection no longer holds. Today, the presumed mechanism is a complex autoimmune process comprising an active role of both cytotoxic T lymphocytes and circulating autoantibodies, activating the subunit 3 of the ionotropic glutamate receptor (GluR3Ab). Several medical options, such as antiepileptic drugs and immunomodulatory therapies, deserve consideration to face epileptic manifestations and to slow neurologic regression. Yet, all these therapies turn out to be almost always just temporizing measures. Surgical disconnection of the affected hemisphere ("functional hemispherectomy") is the best therapeutic choice to achieve the arrest of the disease, a good seizure control, the block of neurologic decline, and the improvement of patient's quality of life.
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Affiliation(s)
- Mario Mastrangelo
- Child Neurology Division, Department of Pediatrics, La Sapienza-University of Rome, Viale Regina Elena, 324 00161 Rome, Italy.
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21
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Muto A, Oguni H, Takahashi Y, Shirasaka Y, Sawaishi Y, Yano T, Hoshida T, Osaka H, Nakasu S, Akasaka N, Sugai K, Miyamoto A, Takahashi S, Suzuki M, Ohmori I, Nabatame S, Osawa M. Nationwide survey (incidence, clinical course, prognosis) of Rasmussen's encephalitis. Brain Dev 2010; 32:445-53. [PMID: 19942389 DOI: 10.1016/j.braindev.2009.10.004] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2009] [Accepted: 10/19/2009] [Indexed: 11/16/2022]
Abstract
PURPOSE Rasmussen's encephalitis (RE) is a progressive and catastrophic epileptic disorder caused by chronic localized encephalitis. We performed a nationwide survey of RE to assess the clinical picture, treatment effect, and prognosis of Japanese RE patients. SUBJECTS & METHODS The subjects were 27 patients (male:12; female:15) from 13 medical facilities. All of them satisfied the clinical and neuroimaging criteria for RE, including 14 pathologically proven cases. RESULTS They were divided into the childhood-onset rapidly progressive type (CORP, n=19), and late-onset slowly progressive type (LOSP, n=8). The mean age at epilepsy onset was 4 years and 4 months in CORP, and 16 years in LOSP. The mean period between the onset age of epilepsy and development of frequent seizures was 1 year and 4 months in the former, and 3 years and 4 months in the latter. The immunomodulatory treatment including high-dose steroid (n=14) and high-dose intravenous immunoglobulin therapies (IVIgG, n=12) achieved more than a 50% reduction in the seizure frequency in 5 (36%) and 4 (33%) patients, respectively. Eight and seven patients underwent focal cortical resection and functional hemispherectomy, leading to significant improvement in 5 of the 8 patients and excellent seizure control in all 7 patients, respectively. CONCLUSION Although the high-dose steroid and IVIG therapies may have alleviated the exacerbation of seizures in those with RE, they could not halt the disease progression. Functional hemispherectomy is still the only curative therapy for RE, despite the fact that the early introduction of this procedure remains controversial.
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Affiliation(s)
- Ayako Muto
- Department of Pediatrics, Tokyo Women's Medical University, Tokyo, Japan
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22
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Gataullina S, Dulac O. Rassmussen's encephalitis: are there new, better therapeutic medical and surgical guidelines? Epilepsia 2010; 51 Suppl 1:92-3. [PMID: 20331729 DOI: 10.1111/j.1528-1167.2009.02459.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Bien CG, Schramm J. Treatment of Rasmussen encephalitis half a century after its initial description: promising prospects and a dilemma. Epilepsy Res 2009; 86:101-12. [PMID: 19615863 DOI: 10.1016/j.eplepsyres.2009.06.001] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2009] [Revised: 06/03/2009] [Accepted: 06/07/2009] [Indexed: 11/26/2022]
Abstract
Rasmussen encephalitis (RE), initially described half a century ago, is an inflammatory unihemispheric brain disorder. Its two clinical key facets are the progressive tissue and function loss and the epilepsy, often in form of epilepsia partialis continua. For both, treatment options are available. Anti-seizure effect of anti-epilepsy drugs is usually limited to secondarily generalized seizures and complex partial seizures whereas epilepsia partialis continua usually is totally refractory. Hemispherectomy in one of its modern variants offers a very high chance of seizure freedom, however at the price of irreversible loss of functions located in the affected hemisphere. In a proportion of patients, long-term immunotherapy is able to prevent or slow down hemispheric tissue loss and the associated functional decline. It does, however, mostly not improve the epilepsy. Whereas for many patients unequivocal treatment proposals can be readily made, a dilemma may emerge in those with severe epilepsy but still preserved hemispheric function.
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Affiliation(s)
- Christian G Bien
- University of Bonn, Department of Epileptology, Sigmund-Freud-Str. 25, 53105 Bonn, Germany.
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Abstract
Inflammation is known to participate in the mediation of a growing number of acute and chronic neurological disorders. Even so, the involvement of inflammation in the pathogenesis of epilepsy and seizure-induced brain damage has only recently been appreciated. Inflammatory processes, including activation of microglia and astrocytes and production of proinflammatory cytokines and related molecules, have been described in human epilepsy patients as well as in experimental models of epilepsy. For many decades, a functional role for brain inflammation has been implied by the effective use of anti-inflammatory treatments, such as steroids, in treating intractable pediatric epilepsy of diverse causes. Conversely, common pediatric infectious or autoimmune diseases are often accompanied by seizures during the course of illness. In addition, genetic susceptibility to inflammation correlated with an increased risk of epilepsy. Mounting evidence thus supports the hypothesis that inflammation may contribute to epileptogenesis and cause neuronal injury in epilepsy. We provide an overview of the current knowledge that implicates brain inflammation as a common predisposing factor in epilepsy, particularly childhood epilepsy.
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Affiliation(s)
- Jieun Choi
- Department of Pediatrics, Division of Neurology, Northwestern University Children's Memorial Hospital, Chicago, IL, USA
- Department of Pediatrics, Seoul National University Boramae Hospital, Seoul, Korea
| | - Sookyong Koh
- Department of Pediatrics, Division of Neurology, Northwestern University Children's Memorial Hospital, Chicago, IL, USA
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25
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Chiron C, Dulac O, Pons G. Antiepileptic drug development in children: considerations for a revisited strategy. Drugs 2008; 68:17-25. [PMID: 18081370 DOI: 10.2165/00003495-200868010-00002] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
The European Commission and the European Parliament have acknowledged the specific need for a proper evaluation of new drugs in children. The evaluation of the antiepileptic drugs (AEDs) available on the market illustrates the deficit in therapeutic trials for childhood epilepsy syndromes. Currently, the development of AEDs is mainly performed in children with focal epilepsy, whereas infants and the specific age-related epilepsy syndromes, particularly epileptic encephalopathies, are neglected. Infantile epilepsies remain 'therapeutic orphans', although they are the most frequent and deleterious disorders in the area of epilepsy. In order to circumvent the difficulties faced when conducting AED trials in children, we addressed the question of improving feasibility without decreasing quality, while optimally taking into account paediatric ethical requirements. For this review, we first raise the issues of paediatric epilepsies that require special considerations for randomized controlled trials (RCTs) in children. Then, we attempt to determine to what extent adult data could be extrapolated to children. Finally, we review innovative approaches that could be used in the evaluation of AEDs in children. The main specificities of paediatric epilepsies (heterogeneity, severity, cognitive impact, pharmacoresistance, syndrome-specific efficacy profile) are related to brain development and should be taken into consideration when establishing specific guidelines for the evaluation of AEDs in children. Extrapolating efficacy data from adults to children may be possible in focal epilepsy except in infants who need age-specific trials. Epileptic encephalopathies do not exist in adults and require specific trials. Pharmacokinetic data are required below a lower age limit for extrapolation of adult data to be determined in a case-to-case approach. Safety data are required at any paediatric age. RCTs in small but homogeneous populations in each paediatric-specific epileptic syndrome, the use of sequential or responder-enrichment designs, and population pharmacokinetics represent potentially promising approaches to evaluate drugs in children in an efficient way.
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