Clinical spectrum and treatment outcome of West Syndrome in children from Northern India

Sequential Treatment with Modified Atkins Diet and Low Glycemic Index Treatment for Drug-Resistant Epilepsy in Children

OBJECTIVES

 The present study was designed to study the efficacy of sequential dietary therapy with a modified Atkins diet (mAD) followed by low glycemic index treatment (LGIT) in treating drug-resistant epilepsy in children.

METHODS

 This interventional study was conducted from February 2021 to February 2022 among children aged 6 months to 5 years who had failed to respond to more than two conventional and correctly chosen antiseizure medications. The primary endpoint was the proportion of good responders, that is, children with more than 50% seizure reduction. Secondary outcome measures were the proportion of children with seizure freedom, > 90% seizure reduction, and the nature of parent-reported adverse events.

RESULTS

 A total of 45 children were recruited for the study, with 6 children being lost to follow-up at 12 weeks. At 12 weeks, 30 of 39 (76.9%) children were good responders with more than 50% seizure reduction. Of these 30 children, 11 (24.4%) had more than 90% seizure reduction, with 9 (20%) achieving complete spasm freedom. Constipation was the most common side effect of the diet among the enrolled subjects.

CONCLUSION

 Clinicians can consider sequential dietary therapy with a mAD in the first month followed by LGIT in the next 2 months for treating children who could not tolerate mAD beyond 1 month.

A Randomized Controlled Trial on the Study of Effectiveness and Safety of Hormonal (ACTH) Treatment Alone versus Hormonal (ACTH) with Levetiracetam for Epileptic Spasms

Background West's syndrome (WS) is a triad of epileptic spasms (ESs), psychomotor delay, and hypsarrhythmia. The treatment of ESs is still controversial. Hence, we designed a randomized controlled trial (RCT) to compare the outcomes in children with WS treated with adrenocorticotropic hormone (ACTH) alone versus ACTH and levetiracetam (LEV).

Objectives To compare the treatment outcomes and side effects in children treated with ACTH alone versus ACTH and LEV.

Methods This prospective randomized controlled trial was conducted from December 2017 to May 2019 in tertiary care center, Bangaluru. Children from 2 months to 5 years of age, diagnosed with WS were included. Fifty children in each group were analyzed for efficacy and side effects.

Results There was no difference in the baseline characteristics in both groups. There was no difference in spasms response at the end of 2 weeks between the groups (88 vs. 82%) with p-value of 0.813. The relapse rates were less in ACTH and LEV group (20%) compared with ACTH alone (22%) but statistically not significant (p > 0.1). There was no difference observed in subsequent epilepsy rates (18%) in ACTH versus 19% in ACTH with LEV group (p > 0.1) and side effects. There was improvement in milestones 48% in ACTH with LEV group versus 37% in ACTH alone however statistically not significant (p > 0.1).

Conclusion There was no difference in children treated with ACTH alone versus ACTH and LEV in terms of control of spasms and subsequent epilepsy rates. The relapse rate is less, and developmental outcome is better in ACTH with LEV group but statistically not significant.

A Review of the Prevalence, Etiology, Diagnosis, and Management of Pediatric Epilepsies in India

Pediatric seizures are one of the most common neurological manifestations seen in pediatrics. Unravelling the etiology, timely and appropriate investigations followed by suitable therapies are essential for improving quality of life. During the pandemic, focused group discussions were conducted among 50 pediatric neurologists across five cities in India to gather insights on treatment practices in pediatric epilepsy and to optimize therapeutic strategies and alternative approaches for rational use of antiepileptic medications. These discussions were mainly aimed at reviewing current literature on prevalence, etiology, diagnosis, and management of epilepsy in children and subsequently rationalizing diagnostic and treatment approaches in routine clinical practice. Epileptic encephalopathies comprise of childhood epilepsy with progressive cerebral dysfunction. Genomics plays a vital role in identifying the underlying genetic associations, empowering precision therapy. Currently, the ketogenic diet has become a well-recognized modality for reducing severity of seizures. To overcome the high incidence of adverse effects due to older antiepileptic drugs, newer drugs are being developed to improve ease of use, diminish drug interactions, decrease adverse effects, and identify drugs with unique mechanisms of action. Common lacunae in practice include information gaps, educating parents, or caregivers about rational drug use and ensuring compliance to antiepileptic medications. This article discussed the consensus clinical viewpoint of expert clinicians, as well as insights on optimized treatment of pediatric epilepsies in both infancy and childhood. It also discusses aspects, like reducing drug burden, emerging therapies in the identification of the genetic basis of epilepsies, and targeted therapy alternatives, for pediatric populations in the Indian scenario.

Clinical profile, treatment modalities, and outcomes in patients with infantile spasms: A retrospective study from the United Arab of Emirates (UAE)

BACKGROUND

Infantile spasms (IS) are an epileptic encephalopathy where the prognosis is generally poor, with most patients exhibiting psychomotor retardation or intractable epilepsy. However, it is claimed that early and aggressive treatment is related to better response rate and outcome, especially in patients with idiopathic IS.

OBJECTIVE

To investigate different treatment modalities and outcomes in patients with IS attending a pediatric neurology clinic at a specialized neurology center in Abu Dhabi, United Arab Emirates.

METHODS

Retrospective chart review was done for detailed history, demographic data, etiology, neuro-diagnostic workup, treatment modalities, and the outcomes for all patients diagnosed with IS from September 2014 to September 2019.

RESULTS

Three treatment modalities were identified as 1st line- Prednisolone United Kingdom Infantile Spasms Study (UKISS) (N = 15, 46.8%), Anti-Seizure Medications (ASMs) (N = 12, 37.5%), and Vigabatrin (N = 5, 15.6%). The complete response rate to Vigabatrin as a 1st line treatment showed the highest statistical significance (X² = 7.34, p = 0.007). Patients with idiopathic IS showed a comparable response to treatment to those with symptomatic IS. Additional response to 2nd line treatment with Prednisolone UKISS protocol (25%) and Vigabatrin (15%) was noted in patients who showed partial or no response to the 1st line treatment. None of our patients received Adrenocorticotropic Hormone as treatment. All patients with desirable final outcomes were with idiopathic IS and none were symptomatic.

CONCLUSION

More than a third of our patients showed poor treatment response whenever they were not offered treatment according to the current available protocols. This indicates an urgent need for having a unified treatment protocol that takes into consideration the availability of medications, professional expertise as well as diagnostic workup outside major tertiary care centers in our region.

Depression, Anxiety, and Parenting Stress among Mothers of Children with West Syndrome

The present cross-sectional study was designed to determine the prevalence of depression, anxiety, and parenting stress in mothers of children aged 6 mo to 5 y with West syndrome compared to mothers of healthy children. The enrolled mothers were subjected to interview-based administration of the Hamilton Anxiety Scale (HAS), Beck Depression Inventory (BDI-II), and Parenting Stress Scale (PSS). Maternal anxiety [HAM score: 9 (5, 14) vs. 1 (0, 2.2); p < 0.01], depression [BDI score: 11 (7, 19) vs. 1 (0, 3); p < 0.01], and parental stress [PSS score: 40 (32, 45) vs. 22 (20, 24); p < 0.01] were significantly higher among mothers of children with West syndrome when compared to controls. Logistic regression revealed maternal education to be a significant predictor of depression among mothers of children with West syndrome. Anxiety, depression, and parental stress were higher among mothers of children with West syndrome and they should be additionally screened.

Intravenous Methylprednisolone Versus Oral Prednisolone for West Syndrome: A Randomized Open-Label Trial

OBJECTIVE

To compare intravenous methylprednisolone (IVMP) with oral prednisolone (OP) for the treatment of West syndrome.

METHODS

In this randomized, open-label trial, children aged 2 to 30 mo presenting with epileptic spasms with hypsarrhythmia or its variants on EEG were randomized to receive either IVMP (30 mg/kg/d for 3 d followed by oral prednisolone taper) or OP (4 mg/kg/d for two weeks followed by taper). The primary outcome measure was spasms cessation on day 14. Secondary outcomes included time to response, electroclinical remission at 2 and 6 wk, and frequency of adverse effects. ( ClinicalTrials.gov Identifier: NCT03876444).

RESULTS

Sixty children were enrolled; 31 in the IVMP and 29 in the OP arm. Proportion of children achieving spasms cessation at day 14 was similar in both groups (54.8% versus 68.9%, p = 0.26). Time to achieve remission was lower in the IVMP group (mean 5.4 ± 0.9 versus 9.5 ± 2.6 d, p < 0.0001). Electroclinical remission at 2 wk was similar in both groups (51.6% versus 44.8%, p = 0.59) but lower at 6 wk in the IVMP group (45.2% versus 75.9%, p < 0.015). Adverse effects like sleep disturbance, irritability and hypertension were more common in IVMP group whereas weight gain was more common in the OP group.

CONCLUSIONS

There was no significant difference in spasms cessation between the groups on day 14 although remission was higher at 6 wk in OP group. Our study suggests that OP was better than IVMP in efficacy and sustained remission with fewer adverse effects.

Evaluation of the Modified Atkins Diet for the Treatment of Epileptic Spasms Refractory to Hormonal Therapy: A Randomized Controlled Trial

OBJECTIVES

We aimed to evaluate the efficacy of the modified Atkins diet in children with epileptic spasms who had failed hormonal therapy.

METHODS

Children aged 9 months to 3 years having daily epileptic spasms despite a trial of ACTH or oral prednisolone and 1 additional anticonvulsant medication were enrolled. Children were randomly assigned to receive the modified Atkins diet either immediately or after a delay of 4 weeks. The ongoing anticonvulsant medications were continued unchanged. The primary outcome variable was the proportion of children who achieved spasm freedom as per parental reports at 4 weeks. Secondary outcomes included time to spasm cessation, proportion of children with electroclinical remission, the proportion of children with >50% reduction of spasms at 4 weeks, and adverse effects of the diet. (ClinicalTrials.gov Identifier: NCT03807141).

RESULTS

A total of 91 children were enrolled in the study; 46 in the diet group and 45 in the control group. At the end of 4 weeks, 11 children in the diet group were spasm free compared with none in the control group (P ≤ .001). The median time to achieve spasm cessation was 10 days (interquartile range 9-20). Nine of these had resolution of hypsarrhythmia on electroencephalography (EEG). Thirty (65.2%) in the diet group had >50% reduction in spasms, compared with none in the control group (P < .001). The most common side effect was constipation, noted in 34.8% of the children.

CONCLUSIONS

The modified Atkins diet was found to be effective and well tolerated in children with epileptic spasms refractory to hormonal therapy.

Long-term epilepsy control, motor function, cognition, sleep and quality of life in children with West syndrome

PURPOSE

To assess epilepsy, motor function, cognitive, sleep, and quality of life outcomes and their predictors in a follow-up cohort with West syndrome (WS) at ≥5 years of age.

METHODS

Cross-sectional evaluation in a follow-up cohort of WS (aged 5-14 years), between July 2018 and December 2019, was performed at a tertiary-care referral center in Northern India. 164 children were assessed in-person for epilepsy severity, functional status (gross motor and hand function), social quotient, behavioral comorbidities, sleep problems, and quality of life (QoL) using Early Childhood Epilepsy Severity Scale, Gross Motor Function Classification System, Manual Ability Classification System, Vineland Social Maturity Scale, Diagnostic and Statistical Manual of Mental disorders-5 criteria, Children's Sleep Habits Questionnaire, and PedsQL-Epilepsy module respectively. Furthermore, 238 children with the inability to visit the hospital were assessed through telephonic interview along with retrospective case record review for epilepsy control, gross and fine motor measures.

RESULTS

402 children with WS (75 % boys) with regular follow-up were studied and the majority (80 %) had underlying structural etiology. The median age (interquartile range) of the cohort was 92 (78-107) months. Of these, 60 % had evolved to Lennox-Gastaut syndrome (LGS). The following long-term outcomes were observed: ongoing epilepsy (261/402), unfavorable motor status (130/402), moderate to profound intellectual disability (111/164), autistic spectrum disorder (42/164), attention-deficit hyperactivity disorder (18/164), poor sleep (135/164), and impaired QoL (115/164). Non-structural etiology (odds ratio [OR] = 3.8, 95 % confidence interval [CI]: 2.1-5.5, p=<0·0001) and older age (>5 months) at the onset of epileptic spasms (OR = 2·9, 95 % CI: 1.5-5.0, p=<0·0001) were associated with enduring seizure freedom for more than two years.

CONCLUSION

The present study revealed a preponderance of structural etiology and a high rate of transition to LGS. Early age at onset of spasms (before five months) and structural etiology were the predictors of unfavorable long-term epilepsy outcome. QoL was impaired in more than two-thirds of patients and it correlated significantly with cognitive, sleep, motor, and behavioral outcomes. However, the results of our study should be interpreted in the context of significant attrition of the original cohort.

Clinical profile of children with West syndrome: A retrospective chart review

Background:

This study was intended to document the clinical profile and treatment outcome of West syndrome in children attending a tertiary care centre in Northern India.

Methods:

Data were collected by a retrospective chart review of children diagnosed with West syndrome between January 2017 to January 2018. Information was recorded pertaining to the age at onset and presentation, etiology, and associated co-morbidities; results of electroencephalography (EEG) and neuroimaging; treatment given; and final outcome. The following drugs were used for treatment: ACTH (n = 7), prednisolone (n = 17), vigabatrin (n = 25), sodium valproate (n = 28), clonazepam (n = 30), and levetiracetam (n = 13) and modified Atkins diet (n = 7). The response was categorized as spasm cessation, partial improvement (>50% improvement), or no improvement.

Results:

Records of 30 children (21 boys) were analyzed. The median (IQR) age at onset was 4 (3, 6.5) months. The median (IQR) lag time to treatment was 5 (2,14) months. Eight (26%) were premature, 2 (7%) were small for gestational age, birth asphyxia in 56%, neonatal encephalopathy in 62%. EEG findings were hypsarrhythmia in 13 (43.3%) children and modified hypsarrhythmia in 9 (30%) children. MRI finding was periventricular leukomalacia (54.1%), cystic encephalomalacia (13.8%), normal MRI (20.7%) and one had arrested hydrocephalus. There was no improvement with valproate (93%), clonazepam (89%), levetiracetam (78%). Cessation of spasm was achieved with vigabatrin (28%), prednisolone (38.2%), ACTH (42.8%). Hypsarrhythmia resolved with improvement in of background and other epileptiform abnormalities in 17 children.

Conclusion:

The present research highlights favourable response of West syndrome to oral steroids, vigabatrin and ACTH with limited role of conventional antiepileptic drugs like sodium valporate, levetiracetam and clonazepam. Primary care physician plays a vital role in early recognition and treatment of epileptic spasm.

West Syndrome Is an Exceptional Presentation of Pyridoxine- and Pyridoxal Phosphate-Dependent Epilepsy: Data From a French Cohort and Review of the Literature

Objective: To characterize the electro-clinical presentation of patients with pyridoxine-dependent epilepsy (PDE) and pyridoxal phosphate (PLP)-dependent epilepsy in order to determine whether some of them could be diagnosed as de novo West syndrome, i. e., West syndrome that starts after the age of 2 months without other types of seizures (focal seizures for instance) before the onset of epileptic spasms. Methods: We analyzed data from an unpublished cohort of 28 genetically confirmed cases of PDE with antiquitine (ATQ) deficiency and performed a review of the literature looking for description of West syndrome in patients with either PDE with ATQ deficiency or PLP-dependent epilepsy with Pyridox(am)ine phosphate oxidase (PNPO) deficiency. Results: Of the 28 cases from the ATQ deficiency French cohort, 5 had spasms. In four cases, spasms were associated with other types of seizures (myoclonus, focal seizures). In the last case, seizures started on the day of birth. None of these cases corresponded to de novo West syndrome. The review of the literature found only one case of PNPO deficiency presenting as de novo West syndrome and no case of ATQ deficiency. Significance: The presentation of PDE- and PLP-dependent epilepsy as de novo West syndrome is so exceptional that it probably does not justify a systematic trial of pyridoxine or PLP. We propose considering a therapeutic trial with these vitamins in West syndrome if spasms are associated with other seizure types or start before the age of 2 months.

Infantile spasms: Etiology, lead time and treatment response in a resource limited setting

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Neonatal hypoglycemic brain injury was the commonest cause of Infantile Spasms (IS).

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Comprehensive genetic evaluation was performed in presumed genetic IS patients.

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Molecular diagnosis was achieved in 44% of presumed genetic patients.

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Longer lead time to treatment was significantly associated with resistant spasms.

This study explores the etiology and lead time to treatment for infantile spasm (IS) patients and their effect on treatment responsiveness, in a limited resource setting. Patients with IS onset age ≤12 months’, seen over 3 years were recruited retrospectively. Clinical information, neuroimaging and genetic results retrieved. Patients categorized into three primary etiological groups: Structural (including Structural Genetic), Genetic, and Unknown. The effect of etiology and lead time from IS onset to initiating appropriate treatment on spasm resolution, evaluated. Total 113 patients were eligible. Mean IS onset age was 6.86(±4.25) months (M: F 3.3:1). Patients were grouped into: Structural 85, Genetic 11 and Unknown 17. Etiology was ascertained in 94/113 (83.1%) with neonatal hypoglycemic brain injury (NHBI) being the most common (40/113, 36%). A genetic etiology identified in 17 (including 6 Structural Genetic, of which five had Tuberous Sclerosis). Structural group was less likely to be treatment resistant (p = 0.013, OR 0.30 [0.12–0.76]). Median treatment lead time – 60 days. Longer lead time to treatment was significantly associated with resistant spasms (χ² for trend = 10.0, p = 0.0015). NHBI was the commonest underlying cause of IS. There was significant time lag to initiating appropriate treatment, affecting treatment responsiveness.

Management practices for West syndrome in South Asia: A survey study and meta-analysis

OBJECTIVES

Considering the dearth of literature on West syndrome (WS) from South Asian countries, this study aimed to evaluate the management practices in South Asia by an online survey and meta-analysis.

METHODS

An online questionnaire was sent to 223 pediatric neurologists/pediatricians in India, Pakistan, Myanmar, Sri Lanka, Bhutan, Nepal, and Bangladesh. Their responses were evaluated and supplemented by a meta-analysis.

RESULTS

Of 125 responses received (response rate: 56%), around 60% of responders observed male preponderance and an approximate lead-time-to-treatment (LTTT) of 4-12 weeks. The commonest etiology observed was a static structural insult (88.6% of responders). Most commonly used first-line drug (country-wise) was as follows: India-adrenocorticotropin hormone (ACTH, 50%); Pakistan-oral steroids (45.5%); Myanmar, Sri Lanka, and Nepal-oral steroids (94.4%); Bangladesh-ACTH (2/2); Bhutan-vigabatrin (3/5). ACTH and vigabatrin are not available in Myanmar and Nepal. The most commonly used regime for ACTH was maximal-dose-at-initiation-regime in India, Sri Lanka, and Bangladesh and gradually escalating-regime in Pakistan. Maximum dose of prednisolone was variable-most common response from India: 3-4 mg/kg/d; Pakistan, Bhutan, and Bangladesh: 2 mg/kg/d; Sri Lanka, Nepal, and Myanmar: 5-8 mg/kg/d or 60 mg/d. The total duration of hormonal therapy (including tapering) ranged from 4 to 12 weeks (67/91). Most responders considered cessation of spasms for four weeks as complete response (54/111) and advised electroencephalography (EEG; 104/123) to check for hypsarrhythmia resolution. Difficult access to pediatric EEG in Bhutan and Nepal is concerning. More than 95% of responders felt a need for more awareness. The meta-analysis supported the preponderance of male gender (68%; confidence interval [CI]: 64%-73%), structural etiology(80%; CI 73%-86%), longer LTTT (2.4 months; CI 2.1-2.6 months), and low response rate to hormonal therapy(18% and 28% for ACTH and oral steroids respectively) in WS in South Asia.

SIGNIFICANCE

This study highlights the practices and challenges in the management of WS in South Asia. These include a preponderance of male gender and structural etiology, a longer LTTT, difficult access to pediatric EEG, nonavailability of ACTH and vigabatrin in some countries, and low effectiveness of hormonal therapy in this region.

Electroclinical spectrum of childhood epilepsy secondary to neonatal hypoglycemic brain injury in a low resource setting: A 10-year experience

PURPOSE

Neonatal hypoglycemic brain injury (NHBI) is being increasingly recognized as an important cause of drug resistant childhood epilepsy in low resource settings. We report the electro-clinical spectrum of children with epilepsy secondary to NHBI.

METHODS

This was a retrospective study of children enrolled in the Epilepsy Clinic from January 2009 to August 2019. Data of children who had developed epilepsy after documented symptomatic neonatal hypoglycemia was collected. Details of clinical profile, seizure types, neurodevelopmental co-morbidities, EEG, neuroimaging findings and seizure outcomes were noted.

RESULTS

One hundred and seventy children were enrolled. The mean age at seizure onset was 10.3 months (SD 0.5 months). The seizures types were epileptic spasms (76.5%), focal with visual auras (11.2%), bilateral tonic clonic (7.1%), myoclonic (3.5%) and atonic seizures (1.8%). The EEG findings included classical hypsarrhythmia (49.4%), hypsarrhythmia variant (27.1%), focal occipital or temporo-occipital spike wave discharges (10.6%), multifocal discharges (4.7%), diffuse slow spike and wave with bursts of fast rhythms (2.4%), continuous spike waves during sleep (1.2%) and normal EEG (4.7%). MRI showed gliosis with or without encephalomalacia in the occipital lobe with or without parietal lobe in 96.5% of the patients. Co-morbidities included global developmental delay (91.2%), cerebral palsy (48.7%), vision impairment (48.2%), microcephaly (38.2%), hearing impairment (19.4%), and behavioural problems (16.5%). Drug resistant childhood epilepsy was seen in 116 (68.2%) patients.

CONCLUSIONS

Our study highlights the varied electroclinical and radiological spectrum and the adverse epilepsy and neurodevelopmental outcomes associated with NHBI.

Neuro-Developmental and Epilepsy Outcomes of Children with West Syndrome: A Cross-Sectional Study from North India

Objectives:

To assess the neurodevelopmental outcome of West syndrome (WS) in Indian children, who differ in their clinical profile from the western population.

Materials and Methods:

This cross-sectional study enrolled children aged 2--5 years with prior diagnosis of WS between November 2013 and March 2015. They were assessed for epilepsy outcome and developmental outcome using developmental profile 3 (DP3) and vineland adaptive behavioral scale II (VABS II).

Results:

Sixty-one children were enrolled. Perinatal asphyxia (40.9%), neonatal hypoglycemia (14.8%), and neonatal meningitis (9.8%) were predominant causes among the children with known etiology. Favorable epilepsy outcome (seizure freedom for >6 months) was observed in 29/61 patients (47.5%). Moderate to severe developmental delay was observed in 55/61 children (91.8%). Favorable developmental outcome (GDS by DP3 >70) was observed in just 5/61 (8%) patients.

Conclusions:

This study highlights the high prevalence of developmental delay in this population of children with WS, with adverse perinatal events being the most common etiology.

Topiramate as an Adjunct in the Management of West Syndrome

OBJECTIVE

To evaluate the safety, tolerability, and effectiveness of oral topiramate therapy in children with West syndrome.

METHODS

The present study was designed as a prospective, observational study and was performed from July 2016 through June 2018 at a tertiary care pediatrics centre in North India. The study was approved by Institute Ethics Committee.

RESULTS

Data on 39 children with West syndrome were analyzed. Topiramate was used as an adjunct in 38 children who failed to hormonal therapy and/or vigabatrin and as initial monotherapy in one case. The study participants had a long treatment lag to hormonal therapy (median 2 mo, IQR 1-8), a preponderance of male sex (67%) and structural etiology (87%). Nine (23%) children had a cessation of epileptic spasms at a median dose of 3.8 mg/kg/d. However, seven children with initial response had relapses. There were no significant group differences between responders and non-responders. Overall, topiramate was well tolerated. Somnolence and lethargy with decreased oral intake were commonly observed adverse effects.

CONCLUSIONS

The study observed poor effectiveness of topiramate therapy, which is partially due to a long treatment lag and a high proportion of structural etiology.

Safety, tolerability, and effectiveness of oral zonisamide therapy in comparison with intramuscular adrenocorticotropic hormone therapy in infants with West syndrome

West syndrome is a distinct, infantile onset, epileptic encephalopathy, associated with poor neurodevelopmental outcome. The present study was designed as a randomized, open-label, pilot study to evaluate the safety, feasibility, and effectiveness of oral zonisamide therapy in comparison with adrenocorticotropic hormone therapy in infants with West syndrome. Thirty infants with West syndrome were randomized to receive treatment with either synthetic, intramuscular adrenocorticotropic hormone (30-60 IU) or oral zonisamide (4-25 mg/kg/day). The study participants had a long treatment lag and preponderance of male sex (90%). The primary effectiveness outcome measure was the cessation of epileptic spasms at 2 weeks of initiation of therapy and persistent till 6 weeks as per West Delphi consensus statement recommendations. Comparison of efficacies of zonisamide versus adrenocorticotropic hormone was as following: the cessation of epileptic spasms (27% vs. 40%, p = 0.70), resolution of hypsarrhythmia at 14 days (20% vs. 33%, p = 0.68) and resolution of hypsarrhythmia at 6 weeks (36% vs. 71%, p = 0.14). Overall, the study observed a poor efficacy of both adrenocorticotropic hormone and zonisamide therapy, which is probably due to long treatment lag and a high proportion of structural aetiology. However, oral zonisamide appeared to be safe and tolerable in the study.

Infantile Spasms: Clinical profile and treatment outcomes

Background and Objective

Infantile spasm (IS) is one of the severe epileptic encephalopathies which affect children in early two years of life. Our objective was to determine the clinical profile, etiology and outcome of treatment in children with infantile spasms attending tertiary care hospital at Karachi, Pakistan.

Methods

This is retrospective study of 36 patients out of 94 registered as IS, aged three months to two years, managed and followed up at Aga Khan University Hospital, Karachi, from 2010 to 2015. Data of all children with IS was collected from case record. Details including clinical observations, lab investigations, anti-epileptic medications and treatment outcome was collected and analyzed. Patients who received treatment for six weeks to document response were included. The treatment response was categorized as complete response, partial response (>50% improvement) and no response. Data was analyzed on SPSS using descriptive statistics.

Results

Thirty- six patients (38.29%) with IS fulfilled eligibility criteria. The mean ± SD age at presentation was 4.6±2.1 months. Male to female ratio was 2:1. Consanguinity and developmental motor delay was observed in 66.6% and 89% respectively. Symptomatic etiology was predominant (61%) and hypoxic ischemic insult (32%) was the commonest underlying cause. EEG and MRI were diagnostic tools whereas metabolic studies were not helpful. Multiple antiepileptic drugs were used for seizure control and vigabatrin was the most frequently used (88%) drug. Short term treatment response was not different in idiopathic or symptomatic infantile spasms.

Conclusion

Majority of patients had symptomatic infantile spasms and generalized tonic clonic along with myoclonic jerks were predominant seizure types. EEG and MRI were diagnostic in most of cases. Multiple AEDs were required to control seizures and VGB was most common drug (88%) used. Treatment outcome was not different in idiopathic and symptomatic groups.

Vitamin B12 Deficiency in Children With Infantile Spasms: A Case-Control Study

There have been few case reports showing association of vitamin B₁₂ deficiency with infantile spasms. We planned this study to see if there was an association of serum vitamin B₁₂ deficiency in children with development of infantile spasms. Cases included children with infantile spasms of ages 6 months to 3 years. The controls were children in the same age group who had global developmental delay but no history of epileptic spasms. Mean serum vitamin B₁₂, serum homocysteine, and urinary methylmalonic acid levels were measured in both groups and compared. Children with infantile spasms had lower mean serum vitamin B₁₂ levels (354.1 pg/mL; standard deviation 234.1 pg/mL) as compared to children with global developmental delay without spasms (466.7 pg/mL; standard deviation 285.5 pg/mL) ( P value < .05). Mean serum homocysteine level (13.9 vs 7.8 μmol/L, P = .02) and mean urinary methylmalonic acid level (68.1 mmol/mol of creatinine vs 26.1 mmol/mol of creatinine, P = .03) were elevated in children with infantile spasms than in controls. Fourteen children (35.0%) with infantile spasms were vitamin B₁₂ deficient compared with 3 (7.50%) controls ( P = .005). Thus, vitamin B₁₂ deficiency may have an association with infantile spasms. More studies are needed before recommending routine measurement of serum B₁₂ levels in children with infantile spasms.

Knowledge, Attitude and Practice (KAP) Study of Pediatricians on Infantile Spasms

OBJECTIVE

To investigate the knowledge, attitude, and practice of Infantile Spasms among pediatricians.

METHODS

A survey was carried out among pediatricians serving in Punjab, Haryana, Chandigarh, Himachal Pradesh and Delhi. The survey was done by Survey Monkey Software through emails by using a structured questionnaire between July 2016 and December 2017.

RESULTS

A total of 236 pediatricians responded to the survey. Most of the respondents (95.5%) correctly considered Infantile Spasms as a seizure type. The most preferred investigation was Electroencephalogram by 91.8% pediatricians; however, only 57.7% considered it to decide the treatment. Perinatal asphyxia was the most recognized etiology (60.7% pediatricians). For treatment of Infantile Spasms, 66.8% follow Nelson textbook of Pediatrics. Adrenocorticotropic hormone was the most preferred first choice drug by 40% pediatricians. Alternate anti-epileptic drug was considered by 60.9% pediatricians when there is no clinical response. Only 24% pediatricians considered treatment response as a complete cessation of spasms. Majority (90%) of pediatricians felt that there is a necessity for increased awareness and 62% pediatricians felt that available information was insufficient.

CONCLUSIONS

A substantial number of pediatricians lack precise knowledge on evidence-based practice of Infantile Spasms. In developing countries, where pediatricians provide the initial management of Infantile Spasms, there is need to empower them and develop simplified national guidelines/consensus statement for management of Infantile Spasms.

Prognostic Utility of Clinical Epilepsy Severity Score Versus Pretreatment Hypsarrhythmia Scoring in Children With West Syndrome

This cross-sectional study assessed the impact of clinical epilepsy severity and pretreatment hypsarrhythmia severity on epilepsy and cognitive outcomes in treated children with West syndrome. Thirty-three children, aged 1 to 5 years, with infantile spasms were enrolled if pretreatment EEG records were available, after completion of ≥1 year of onset of spasms. Neurodevelopment was assessed by Development Profile 3 and Gross Motor Function Classification System. Epilepsy severity in the past 1 year was determined by the Early Childhood Epilepsy Severity Score (E-Chess). Kramer Global Score of hypsarrhythmia severity was computed. Kramer Global Score (≤8) and E-Chess (≤9) in the past 1 year were associated with favorable epilepsy outcome but not neurodevelopmental or motor outcome.

West syndrome due to vitamin B12 deficiency

Vitamin B12 is one of the essential vitamins affecting various systems of the body. Vitamin B12 deficiency in infants often produces haematological and neurological deficits including macrocyticanaemia, neurodevelopmental delay or regression, irritability, weakness, hypotonia, ataxia, apathy, tremor andseizures. In this article, we report the case of a six-month-old male patient diagnosed with West syndrome associated with vitamin B12 deficiency. Although the patient had no evidence of macrocytic anemia in complete blood count, we measured the level of vitamin B12 because the patient had hypotonicity and found it to be low. No other problem was found in the other investigations directed to the etiology of West syndrome. He was being exclusively breast-fed and vitamin B12 deficiency was related with nutritional inadequacy of his mother. Vitamin B12 deficiency should be considered in the differential diagnosis of patients presenting with different neurological findings. In addition, vitamin B12 deficiency should be considered as a rare cause in West syndrome which has a heterogeneous etiology.

The Clinical Characteristics and Treatment Response in Children with West Syndrome in a Developing Country: A Retrospective Case Record Analysis

This study describes the clinical characteristics, treatment, and outcome of children with West syndrome in a tertiary care hospital in north India. Overall, 310 case records diagnosed from January 2009 to June 2012 were reviewed. The median age of onset of spasms was 5 months (interquartile range = 2.5-7 months). The predominant underlying etiology was perinatal cerebral ischemia (55%). Adrenocorticotropic hormone or oral steroids were received by 92% children, of whom 43% became seizure free. Median lag time for appropriate treatment initiation was significantly less in patients who became seizure free as compared to those with persisting seizures (11 vs 15 months, P = .001) soon after receiving treatment of choice. Later age at onset of spasms was associated with a favorable seizure outcome (P = .03). In a resource-limited setting, unawareness along with treatment costs and repeated visits to the hospital are significant obstacles to optimum management.

Randomized, Single-Blind, Parallel Clinical Trial on Efficacy of Oral Prednisolone Versus Intramuscular Corticotropin on Immediate and Continued Spasm Control in West Syndrome

OBJECTIVE

A single-center, single-blind, parallel-group, randomized clinical trial was performed to test the null hypothesis that adrenocorticotropic hormone is not superior to high-dose prednisolone for treatment of newly diagnosed West syndrome.

METHODS

Newly diagnosed infants with West syndrome were randomized to receive 14 days of oral prednisolone (40-60 mg/day) or a synthetically prepared intramuscular long-acting adrenocorticotropic hormone (40-60 IU/every other day [0.5-0.75 mg]) according to the United Kingdom Infantile Spasm Study protocol. They were blindly evaluated for infantile spasm remission by day 14, electroclinical remission (spasm cessation + resolution of hypsarrhythmia on a 30-minute electroencephalograph) by day 14 and continued spasm freedom for 28 days.

RESULTS

Ninety-seven patients were enrolled in the study, with 48 of them receiving prednisolone and 49 receiving ACTH. There was no significant difference in the baseline characteristics or risk factors for the two treatment groups. By day 14, cessation of infantile spasms occurred in 28/48 (58.3%) infants on prednisolone compared with only 18/49 (36.7%) infants given adrenocorticotropic hormone (P = 0.03) and electroclinical remission in 21 on prednisolone compared with nine on adrenocorticotropic hormone (P = 0.007). Sustained spasm control for 28 consecutive days following electroclinical remission occurred in 15 children on prednisolone compared with six on adrenocorticotropic hormone (P = 0.008). The total number of days required for spasm cessation was significantly less in those treated with prednisolone (3.85 days ± 2.4) compared with adrenocorticotropic hormone (8.65 days ± 3.7) (P = 0.001). Among patients who did not achieve remission, there was a non-significant trend toward greater quantitative reduction of spasms with prednisolone than with adrenocorticotropic hormone (P = 0.079).

CONCLUSION

Synthetic adrenocorticotropic hormone of 40-60 IU/every other day did not yield superior rates of electroencephalographic or clinical remission when compared with prednisolone of 40-60 mg/day. Significantly, more patients achieved electroclinical remission when treated with prednisolone than with adrenocorticotropic hormone.

Effect of adrenocorticotropic hormone therapy for epileptic spasms developing after the age of 1 year

PURPOSE

Epileptic spasms sometimes begin after the first year of life, and such seizures are recognized as late-onset spasms (LOS). The prognosis of LOS is poor, and a treatment strategy has not been established. This study aimed to assess the short- and long-term effects of adrenocorticotropic hormone (ACTH) therapy for LOS.

METHODS

We investigated the rate of LOS in 22 patients (14 boys and 8 girls) treated with ACTH therapy. The age at onset of LOS and at the start of ACTH therapy ranged from 12 to 94 months (median, 31.6 ± 22.1 months) and from 12.5 to 116 months (median, 37.5 ± 23.7 months), respectively. We investigated the response rate of LOS treated with ACTH therapy, and compared the clinical features between responders (short-term) and nonresponders.

RESULTS

Nine (41%) of the 22 patients showed cessation of epileptic spasms within 3 months. The epileptic spasms ceased in four of these nine patients for more than 1 year. The age at onset of LOS was significantly associated with short-term seizure cessation (p<0.05). Patients who achieved short-term cessation of seizures received ACTH therapy within 6 months from the onset of LOS.

CONCLUSION

ACTH therapy is a potentially effective treatment when started within 6 months from the onset of LOS. A younger age at onset of LOS is associated with a favorable outcome.

Neurodevelopmental and epilepsy outcome in children aged one to five years with infantile spasms--a North Indian cohort

PURPOSE

The present study was planned as there is paucity of outcome data of children with infantile spasms, from India where profile of patients is different from the western world. Moreover, most previous studies have either not used strict inclusion criteria or standardized psychometric tests for developmental outcome.

METHODS

Ninety-five children, aged one-to-five years under follow up for more than six months in Pediatric Neurology Clinic of a tertiary care hospital with the diagnosis of infantile spasm were enrolled in this cross-sectional study if they had completed one or more years after the onset of spasms. The study period was January-December 2011. Neurodevelopment of each child was assessed using Development Profile 3 and Gross Motor Function Classification System. History regarding epilepsy frequency and control in the last one year was taken.

RESULTS

Perinatal asphyxia was the commonest etiology in 43/95 children (45.2%). Favorable neurodevelopmental outcome was observed in 8/95 patients. Favorable epilepsy outcome in 58/95 (61.1%) patients was associated with treatment lag≤3 months between apparent onset of spasms and institution of therapy {OR 2 (1.1-3.8)} and response to first line antiepileptic drug {5 (2.6-10)}.

CONCLUSIONS

The commonest etiology was potentially preventable perinatal cause. Early appropriate treatment may have a favorable epilepsy outcome.