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Yang M, Zhang Y, Zhang T, Zhou H, Ren J, Zhou D, Yang T. Altered dynamic functional connectivity of motor cerebellum with sensorimotor network and default mode network in juvenile myoclonic epilepsy. Front Neurol 2024; 15:1373125. [PMID: 38903166 PMCID: PMC11187336 DOI: 10.3389/fneur.2024.1373125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Accepted: 05/21/2024] [Indexed: 06/22/2024] Open
Abstract
Objective To investigate whether changes occur in the dynamic functional connectivity (dFC) of motor cerebellum with cerebral cortex in juvenile myoclonic epilepsy (JME). Methods We adopted resting-state electroencephalography-functional magnetic resonance imaging (EEG-fMRI) and a sliding-window approach to explore the dFC of motor cerebellum with cortex in 36 JME patients compared with 30 and age-matched health controls (HCs). The motor cerebellum was divided into five lobules (I-V, VI, VIIb, VIIIa, and VIIIb). Additionally, correlation analyses were conducted between the variability of dFC and clinical variables in the Juvenile Myoclonic Epilepsy (JME) group, such as disease duration, age at disease onset, and frequency score of myoclonic seizures. Results Compared to HCs, the JME group presented increased dFC between the motor cerebellum with SMN and DMN. Specifically, connectivity between lobule VIIb and left precentral gyrus and right inferior parietal lobule (IPL); between lobule VIIIa and right inferior frontal gyrus (IFG) and left IPL; and between lobule VIIIb and left middle frontal gyrus (MFG), bilateral superior parietal gyrus (SPG), and left precuneus. In addition, within the JME group, the strength of dFC between lobule VIIIb and left precuneus was negatively (r = -0.424, p = 0.025, Bonferroni correction) related with the frequency score of myoclonic seizures. Conclusion In patients with JME, there is a functional dysregulation between the motor cerebellum with DMN and SMN, and the variability of dynamic functional connectivity may be closely associated with the occurrence of motor symptoms in JME.
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Affiliation(s)
- Menghan Yang
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Yingying Zhang
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Tianyu Zhang
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Huanyu Zhou
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Jiechuan Ren
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Dong Zhou
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Tianhua Yang
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
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Fayad C, Saad K, Kahwagi GJ, Hallit S, Griffin D, Abou-Khalil R, El-Hayek E. A systematic review and meta-analysis of factors related to first line drugs refractoriness in patients with juvenile myoclonic epilepsy (JME). PLoS One 2024; 19:e0300930. [PMID: 38593118 PMCID: PMC11003615 DOI: 10.1371/journal.pone.0300930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Accepted: 03/05/2024] [Indexed: 04/11/2024] Open
Abstract
INTRODUCTION Juvenile Myoclonic Epilepsy (JME) is a prevalent form of epileptic disorder, specifically categorized within the realm of Genetic Generalized Epilepsy (GGE). Its hallmark features encompass unprovoked bilateral myoclonus and tonic-clonic seizures that manifest during adolescence. While most JME patients respond favorably to anti-seizure medication (ASM), a subset experiences refractory JME, a condition where seizures persist despite rigorous ASM treatment, often termed "Drug-Resistant Epilepsy" (DRE). This systematic review and meta-analysis aims to determine the prevalence of refractory JME, and further to identify socio-demographic, electrophysiological and clinical risk factors associated with its occurrence. Pinpointing these factors is crucial as it offers the potential to predict ASM responsiveness, enabling early interventions and tailored care strategies for patients. MATERIAL AND METHODS The systematic review and meta-analysis followed the Cochrane Handbook and adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The study evaluated outcomes post ASM treatment in JME cohorts by searching papers published up to September 2023 in PubMed/MEDLINE, Scopus, and Google Scholar databases. Predefined inclusion criteria were met by 25 eligible studies, forming the basis for analysis. RESULTS A total of 22 potential risk factors for refractory JME were documented. Notably, robust risk factors for treatment resistance included Psychiatric Disorder (Odds Ratio (OR), 3.42 [2.54, 4.61] (95% Confidence Inverval (Cl)), Febrile Seizures (OR, 1.83 [1.14, 2.96] (95% Cl)), Alcohol Consumption (OR, 16.86 [1.94, 146.88] (95%Cl)), Aura (OR, 2.15 [1.04, 4.47] (95%Cl)), childhood absence epilepsy (CAE) evolving into JME (OR, 4.54 [1.61, 12.78] (95%CI)), occurrence of three seizure types (OR, 2.96 [1.96, 4.46] (95%CI)), and Focal EEG abnormalities (OR, 1.85 [1.13, 3.01] (95%Cl)). In addition, there were some non-significant risk factors for DRE because of noticeable heterogeneity. CONCLUSION In aggregate, over 36% of JME patients demonstrated drug resistance, with seven significant risk factors closely linked to this refractoriness. The interplay between these factors and whether they denote treatment non-response or heightened disease burden remains an open question and more studies would be required to fully examine their influence.
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Affiliation(s)
- Claire Fayad
- Department of Biology, Faculty of Arts and Sciences, Holy Spirit University of Kaslik-Jounieh, Lebanon
| | - Kely Saad
- Department of Biology, Faculty of Arts and Sciences, Holy Spirit University of Kaslik-Jounieh, Lebanon
| | - Georges-Junior Kahwagi
- Department of Biology, Faculty of Arts and Sciences, Holy Spirit University of Kaslik-Jounieh, Lebanon
| | - Souheil Hallit
- School of Medicine and Medical Sciences, Holy Spirit University of Kaslik, Jounieh, Lebanon
- Applied Science Research Center, Applied Science Private University, Amman, Jordan
| | - Darren Griffin
- School of Biosciences, University of Kent, Canterbury, United Kingdom
| | - Rony Abou-Khalil
- Department of Biology, Faculty of Arts and Sciences, Holy Spirit University of Kaslik-Jounieh, Lebanon
| | - Elissar El-Hayek
- Department of Biology, Faculty of Arts and Sciences, Holy Spirit University of Kaslik-Jounieh, Lebanon
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Desai J, Sadrieh K, Singh E. Clearance for Driving in Genetic Generalized Epilepsy. J Child Neurol 2024; 39:135-137. [PMID: 38500008 DOI: 10.1177/08830738241240178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/20/2024]
Abstract
A key aspect of management of genetic generalized epilepsy involves assessing seizure control and deciding suitability for driving motor vehicles. We surveyed child neurologists and pediatric epileptologists on key questions that practitioners should ask prior to providing clearance for driving. The results showed a wide variability of practice among responders. We propose a likely appropriate process necessary to determine seizure control.
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Affiliation(s)
- Jay Desai
- Division of Neurology, Children's Hospital Los Angeles, Los Angeles, CA, USA
- Keck School of Medicine at the University of Southern California, Los Angeles, CA, USA
| | - Kiarash Sadrieh
- Division of Neurology, Children's Hospital Los Angeles, Los Angeles, CA, USA
- Keck School of Medicine at the University of Southern California, Los Angeles, CA, USA
| | - Eesha Singh
- University of Southern California, Los Angeles, CA, USA
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4
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Ding Y, Cen Z, Zheng Y, Qiu X, Ye Y, Chen X, Hu L, Wang B, Wang Z, Yin H, Shen C, Ming W, Ge Y, Xie F, Yang D, Ouyang Z, Wang H, Wu S, Ding M, Wang S, Luo W. Seizures and electrophysiological features in familial cortical myoclonic tremor with epilepsy 1. Ann Clin Transl Neurol 2024; 11:414-423. [PMID: 38059543 PMCID: PMC10863925 DOI: 10.1002/acn3.51961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 11/09/2023] [Accepted: 11/11/2023] [Indexed: 12/08/2023] Open
Abstract
OBJECTIVES To investigate and characterize epileptic seizures and electrophysiological features of familial cortical myoclonic tremor with epilepsy (FCMTE) type 1 patients in a large Chinese cohort. METHODS We systematically evaluated 125 FCMTEtype 1 patients carrying the pentanucleotide (TTTCA) repeat expansion in the SAMD12 gene in China. RESULTS Among the 28 probands, epileptic seizures (96.4%, 27/28) were the most common reason for an initial clinic visit. Ninety-seven (77.6%, 97/125) patients had experienced seizures. The seizures onset age was 36.5 ± 9.0 years, which was 6.9 years later than cortical tremors. The seizures were largely rare (<1/year, 58.8%) and occasional (1-6/year, 37.1%). Prolonged prodromes were reported in 57.7% (56/97). Thirty-one patients (24.8%, 31/125) reported photosensitivity history, and 79.5% (31/39) had a photoparoxysmal response. Interictal epileptiform discharges (IEDs) were recorded in 69.1% (56/81) of patients. Thirty-three patients showed generalized IEDs and 72.7% (24/33) were occipitally dominant, while 23 patients presented with focal IEDs with 65.2% (15/23) taking place over the occipital lobe. Overnight EEG of FCMTE patients displayed paradoxical sleep-wake fluctuation, with a higher average IED index of 0.82 ± 0.88/min during wakefulness and a lower IED index of 0.04 ± 0.06/min during non-rapid eye movement sleep stages I-II. INTERPRETATION FCMTE type 1 has a benign course of epilepsy and distinct clinical and electrophysiological features. In addition to a positive family history and cortical myoclonus tremor, the seizure prodromes, specific seizure triggers, photosensitivity, distribution of IEDs, and unique fluctuations during sleep-wake cycle are cues for proper genetic testing and an early diagnosis of FCMTE.
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Affiliation(s)
- Yao Ding
- Department of NeurologySecond Affiliated Hospital, School of Medicine, Zhejiang UniversityHangzhouZhejiangChina
- Epilepsy CenterSecond Affiliated Hospital, School of Medicine, Zhejiang UniversityHangzhouZhejiangChina
| | - Zhidong Cen
- Department of NeurologySecond Affiliated Hospital, School of Medicine, Zhejiang UniversityHangzhouZhejiangChina
| | - Yang Zheng
- Department of NeurologyZhejiang Chinese Medical University First Affiliated HospitalHangzhouZhejiangChina
| | - Xia Qiu
- Department of NeurologySecond Affiliated Hospital, School of Medicine, Zhejiang UniversityHangzhouZhejiangChina
| | - Yumao Ye
- Department of NeurologySecond Affiliated Hospital, School of Medicine, Zhejiang UniversityHangzhouZhejiangChina
- Department of NeurologyQingyuan County People's HospitalLishuiZhejiangChina
| | - Xinhui Chen
- Department of NeurologySecond Affiliated Hospital, School of Medicine, Zhejiang UniversityHangzhouZhejiangChina
| | - Lingli Hu
- Department of NeurologySecond Affiliated Hospital, School of Medicine, Zhejiang UniversityHangzhouZhejiangChina
- Epilepsy CenterSecond Affiliated Hospital, School of Medicine, Zhejiang UniversityHangzhouZhejiangChina
| | - Bo Wang
- Department of NeurologySecond Affiliated Hospital, School of Medicine, Zhejiang UniversityHangzhouZhejiangChina
| | - Zhongjin Wang
- Epilepsy CenterSecond Affiliated Hospital, School of Medicine, Zhejiang UniversityHangzhouZhejiangChina
| | - Houmin Yin
- Department of NeurologySecond Affiliated Hospital, School of Medicine, Zhejiang UniversityHangzhouZhejiangChina
| | - Chunhong Shen
- Department of NeurologySecond Affiliated Hospital, School of Medicine, Zhejiang UniversityHangzhouZhejiangChina
| | - Wenjie Ming
- Epilepsy CenterSecond Affiliated Hospital, School of Medicine, Zhejiang UniversityHangzhouZhejiangChina
| | - Yi Ge
- Department of NeurologySecond Affiliated Hospital, School of Medicine, Zhejiang UniversityHangzhouZhejiangChina
| | - Fei Xie
- Department of NeurologySir Run Run Shaw Hospital, School of Medicine, Zhejiang UniversityHangzhouZhejiangChina
| | - Dehao Yang
- Department of NeurologySecond Affiliated Hospital, School of Medicine, Zhejiang UniversityHangzhouZhejiangChina
| | - Zhiyuan Ouyang
- Department of NeurologySecond Affiliated Hospital, School of Medicine, Zhejiang UniversityHangzhouZhejiangChina
| | - Haotian Wang
- Department of NeurologySecond Affiliated Hospital, School of Medicine, Zhejiang UniversityHangzhouZhejiangChina
| | - Sheng Wu
- Department of NeurologySecond Affiliated Hospital, School of Medicine, Zhejiang UniversityHangzhouZhejiangChina
| | - Meiping Ding
- Department of NeurologySecond Affiliated Hospital, School of Medicine, Zhejiang UniversityHangzhouZhejiangChina
- Epilepsy CenterSecond Affiliated Hospital, School of Medicine, Zhejiang UniversityHangzhouZhejiangChina
| | - Shuang Wang
- Department of NeurologySecond Affiliated Hospital, School of Medicine, Zhejiang UniversityHangzhouZhejiangChina
- Epilepsy CenterSecond Affiliated Hospital, School of Medicine, Zhejiang UniversityHangzhouZhejiangChina
| | - Wei Luo
- Department of NeurologySecond Affiliated Hospital, School of Medicine, Zhejiang UniversityHangzhouZhejiangChina
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Kothapalli J, Prasad Uppu V, Munikumar M, Kshirsagar SV, Afshan Jabeen S, Sivanarayana G. Structural insights of novel mutational frames in Bromodomain Containing-2 gene (BRD2) in juvenile myoclonic epilepsy: bed, bench, and laptop profiles. Epilepsy Behav 2023; 144:109282. [PMID: 37276801 DOI: 10.1016/j.yebeh.2023.109282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Revised: 04/24/2023] [Accepted: 05/21/2023] [Indexed: 06/07/2023]
Abstract
PURPOSE Juvenile myoclonic epilepsy (JME) is an adolescent onset type of idiopathic generalized epilepsies. Bromodomain containing protein-2 gene (BRD2), a transcriptional regulatory protein, has a susceptible role in the expression of JME. Considering the polymorphic variations observed in exon 3 of the BRD2 gene, we evaluated the molecular interactions with anti-seizure medication in individuals diagnosed with JME. METHODS The genomic DNA was extracted from 5 mL of peripheral venous blood of JME participants (n = 55) and healthy control subjects (n = 55). Detailed anti-seizure medication and outcomes were noted during the study period. Identified novel mutations at nucleotide and protein sequences, compared by multiple sequence alignment. Wild-type (WT) and mutated-type (MT) structures were investigated for molecular docking and interactions with anti-seizure drugs. RESULTS A common variant at c.1707G>A was found among 23 participants, while a single variant at c.1663ins C was found in one participant. The deletion positions were observed at c.1890delA, c.1892A>T, c.1895A>T, c.1896G>T, c.1897T>C, c.1898T>C, c.1899C>T, c.1900G>T, c.1901C>T and c.1902A>T exhibiting stop codon after p.111Pro>stop; these variants resulted in a truncated protein. In silico analysis was conducted to validate changes; docking analysis showed that novel variant has a significant role in the interactions with anti-seizure drugs. SIGNIFICANCE Besides clinical and genetic outcomes, ∼5.45% unique genetical variations were observed in the participants. Significant mimicked at the binding site position (92-111) of human BRD2 ranges ∼8.2%, ∼16.4%, and ∼10.6%. Further, research is needed to identify the importance of polymorphism alterations at the binding site and their molecular interactions with anti-seizure drugs, which might be confirmed in a diverse population with JME.
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Affiliation(s)
- Jyothinath Kothapalli
- Department of Anatomy, Tomo Riba Institute of Health and Medical Sciences, Naharlagun, Arunachal Pradesh, India.
| | - Venkateswara Prasad Uppu
- Model Rural Health Research Unit, Sirwar, Raichur, ICMR-National Institute of Traditional Medicine, Karnataka, India.
| | - Manne Munikumar
- Clinical Division, ICMR-National Institute of Nutrition, Hyderabad, Telangana, India.
| | | | - Shaik Afshan Jabeen
- Department of Neurology, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India.
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Lindquist BE, Timbie C, Voskobiynyk Y, Paz JT. Thalamocortical circuits in generalized epilepsy: Pathophysiologic mechanisms and therapeutic targets. Neurobiol Dis 2023; 181:106094. [PMID: 36990364 PMCID: PMC10192143 DOI: 10.1016/j.nbd.2023.106094] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 02/02/2023] [Accepted: 03/19/2023] [Indexed: 03/29/2023] Open
Abstract
Generalized epilepsy affects 24 million people globally; at least 25% of cases remain medically refractory. The thalamus, with widespread connections throughout the brain, plays a critical role in generalized epilepsy. The intrinsic properties of thalamic neurons and the synaptic connections between populations of neurons in the nucleus reticularis thalami and thalamocortical relay nuclei help generate different firing patterns that influence brain states. In particular, transitions from tonic firing to highly synchronized burst firing mode in thalamic neurons can cause seizures that rapidly generalize and cause altered awareness and unconsciousness. Here, we review the most recent advances in our understanding of how thalamic activity is regulated and discuss the gaps in our understanding of the mechanisms of generalized epilepsy syndromes. Elucidating the role of the thalamus in generalized epilepsy syndromes may lead to new opportunities to better treat pharmaco-resistant generalized epilepsy by thalamic modulation and dietary therapy.
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Affiliation(s)
- Britta E Lindquist
- UCSF Department of Neurology, Division of Neurocritical Care, United States of America; UCSF Department of Neurology, Division of Pediatric Epilepsy, United States of America; UCSF Department of Neurology, United States of America
| | - Clare Timbie
- Gladstone Institute of Neurological Disease, United States of America; UCSF Department of Neurology, Division of Pediatric Epilepsy, United States of America; UCSF Department of Neurology, United States of America
| | - Yuliya Voskobiynyk
- Gladstone Institute of Neurological Disease, United States of America; UCSF Department of Neurology, United States of America
| | - Jeanne T Paz
- Gladstone Institute of Neurological Disease, United States of America; UCSF Department of Neurology, United States of America; Kavli Institute for Fundamental Neuroscience, UCSF, United States of America.
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Sleep quality and circadian rhythm profile of persons with juvenile myoclonic epilepsy in a tertiary epilepsy center: A case-control study. Seizure 2023; 104:1-5. [PMID: 36435032 DOI: 10.1016/j.seizure.2022.11.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Revised: 10/19/2022] [Accepted: 11/05/2022] [Indexed: 11/09/2022] Open
Abstract
PURPOSE This study evaluated sleep quality, chronotype, and excessive diurnal somnolence in persons with Juvenile Myoclonic Epilepsy (JME) and their possible association with clinical variables. METHODS This cross-sectional controlled study evaluated 49 consecutive patients (65% females, mean age 27.53 years) with an electroclinical diagnosis of JME and 49 healthy controls (55% females, mean age 28.55 years). The Pittsburgh Sleep Quality Inventory (PSQI) was used to assess sleep quality and the Epworth Sleepiness Scale (ESS) to evaluate excessive daytime sleepiness. The patients' chronotype was evaluated by the Morningness-Eveningness Questionnaire (MEQ). Epilepsy-related factors gathered from the medical chart and personal interview were epilepsy duration, age at onset, frequency of myoclonic (Mcl), generalized tonic-clonic (GTC) and absence (ABS) seizures, pharmacoresponse, and current antiseizure medication (ASM). RESULTS Persons with JME did not differ from the control group regarding daytime sleepiness (p=0.840); however, the JME group had worse sleep quality (p=0.01) than the controls. Persons with JME presented a more evening chronotype than controls (p = 0.003). The age at onset, epilepsy duration, frequency of Mcl seizure, frequency of GTC seizure, frequency of ABS seizure, and drug response did not predict ESS and MEQ scales. Pharmacoresponsive patients had lower PSQI scores compared with pharmacoresistant patients (p=0.036). CONCLUSION Persons with JME have worse sleep quality and a more evening chronotype. Notably, pharmacoresistant patients present a worse sleep quality that deserves attention and special care due to the relationship between sleep deprivation and seizure worsening.
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Characterization of cortical activity in juvenile myoclonic epilepsy by gradient magnetic field topography. Clin Neurophysiol 2022; 141:62-74. [PMID: 35853311 DOI: 10.1016/j.clinph.2022.06.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 06/16/2022] [Accepted: 06/27/2022] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Gradient magnetic field topography (GMFT) illustrates the magnetic field gradients of epileptic spike or polyspikes (S/PS) activities on a volume-rendered brain surface. The purpose is to characterize cortical activation in juvenile myoclonic epilepsy (JME). METHODS We compared interictal S/PS activities in 10 patients with JME to five patients with Lennox-Gastaut syndrome (LGS). We defined areas with gradients exceeding 300fT/cm as activated zones (AZs) on GMFT. We defined the hemisphere where an AZ initially appeared as the "preceding hemisphere". We localized the foci where AZs arose and evaluated their spatiotemporal changes. RESULTS In JME, the localization of S/PS in the preceding hemisphere was frontal in 18 activities (28%), parietal in 10 (15%), and frontal/parietal in 33 (51%), and in the contralateral hemisphere it was frontal in 14 (32%), parietal in 6 (14%), and frontal/parietal in 19 (43%). In LGS, AZs arose in every lobe of the brain. The median interhemispheric time difference was 7 ms (range: 0-20) in JME, which was significantly shorter than the 19 ms (1-50) observed among patients with LGS (p < 0.0001). CONCLUSIONS AZs are localized within the bilateral frontal and parietal regions. AZs arose serially from foci with small time differences. SIGNIFICANCE These results are consistent with regional network involvement in JME.
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9
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Hirsch E, French J, Scheffer IE, Bogacz A, Alsaadi T, Sperling MR, Abdulla F, Zuberi SM, Trinka E, Specchio N, Somerville E, Samia P, Riney K, Nabbout R, Jain S, Wilmshurst JM, Auvin S, Wiebe S, Perucca E, Moshé SL, Tinuper P, Wirrell EC. ILAE definition of the Idiopathic Generalized Epilepsy Syndromes: Position statement by the ILAE Task Force on Nosology and Definitions. Epilepsia 2022; 63:1475-1499. [PMID: 35503716 DOI: 10.1111/epi.17236] [Citation(s) in RCA: 144] [Impact Index Per Article: 72.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Revised: 03/18/2022] [Accepted: 03/21/2022] [Indexed: 12/13/2022]
Abstract
In 2017, the International League Against Epilepsy (ILAE) Classification of Epilepsies described the "genetic generalized epilepsies" (GGEs), which contained the "idiopathic generalized epilepsies" (IGEs). The goal of this paper is to delineate the four syndromes comprising the IGEs, namely childhood absence epilepsy, juvenile absence epilepsy, juvenile myoclonic epilepsy, and epilepsy with generalized tonic-clonic seizures alone. We provide updated diagnostic criteria for these IGE syndromes determined by the expert consensus opinion of the ILAE's Task Force on Nosology and Definitions (2017-2021) and international external experts outside our Task Force. We incorporate current knowledge from recent advances in genetic, imaging, and electroencephalographic studies, together with current terminology and classification of seizures and epilepsies. Patients that do not fulfill criteria for one of these syndromes, but that have one, or a combination, of the following generalized seizure types: absence, myoclonic, tonic-clonic and myoclonic-tonic-clonic seizures, with 2.5-5.5 Hz generalized spike-wave should be classified as having GGE. Recognizing these four IGE syndromes as a special grouping among the GGEs is helpful, as they carry prognostic and therapeutic implications.
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Affiliation(s)
- Edouard Hirsch
- Francis Rohmer Neurology Epilepsy Units, National Institute of Health and Medical Research 1258, Federation of Translational Medicine of Strasbourg, Strasbourg University, Strasbourg, France
| | - Jacqueline French
- New York University Grossman School of Medicine and NYU Langone Health, New York, New York, USA
| | - Ingrid E Scheffer
- Austin Health and Royal Children's Hospital, Florey Institute, Murdoch Children's Research Institute, University of Melbourne, Melbourne, Victoria, Australia
| | - Alicia Bogacz
- Institute of Neurology, Clinical Hospital, Faculty of Medicine, University of the Republic, Montevideo, Uruguay
| | - Taoufik Alsaadi
- Department of Neurology, American Center for Psychiatry and Neurology, Abu Dhabi, United Arab Emirates
| | - Michael R Sperling
- Department of Neurology, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Fatema Abdulla
- Salmaniya Medical Complex-Government Hospital, Manama, Bahrain
| | - Sameer M Zuberi
- Paediatric Neurosciences Research Group, Royal Hospital for Children and Institute of Health & Wellbeing, University of Glasgow, member of EpiCARE, Glasgow, UK
| | - Eugen Trinka
- Department of Neurology and Neuroscience Institute, Christian Doppler University Hospital, Paracelsus Medical University, Center for Cognitive Neuroscience, member of EpiCARE, Salzburg, Austria.,Department of Public Health, Health Services Research, and Health Technology Assessment, University for Health Sciences, Medical Informatics, and Technology, Hall in Tirol, Austria
| | - Nicola Specchio
- Rare and Complex Epilepsy Unit, Department of Neuroscience, Bambino Gesù Children's Hospital, Scientific Institute for Research and Health Care, member of EpiCARE, Rome, Italy
| | - Ernest Somerville
- Prince of Wales Hospital, University of New South Wales, Sydney, New South Wales, Australia
| | - Pauline Samia
- Department of Pediatrics and Child Health, Aga Khan University, East Africa, Nairobi, Kenya
| | - Kate Riney
- Neurosciences Unit, Queensland Children's Hospital, South Brisbane, Queensland, Australia.,Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Rima Nabbout
- Reference Center for Rare Epilepsies, Department of Pediatric Neurology, Necker-Enfants Malades Hospital, Public Hospital Network of Paris, member of EpiCARE, Imagine Institute, National Institute of Health and Medical Research, Mixed Unit of Research 1163, University of Paris, Paris, France
| | | | - Jo M Wilmshurst
- Department of Paediatric Neurology, Red Cross War Memorial Children's Hospital, Neuroscience Institute, University of Cape Town, Cape Town, South Africa
| | - Stephane Auvin
- Pediatric Neurology, Public Hospital Network of Paris, Robert Debré Hospital, NeuroDiderot, National Institute of Health and Medical Research, Department Medico-Universitaire, Innovation Robert-Debré, University of Paris, Paris, France.,University Institute of France, Paris, France
| | - Samuel Wiebe
- Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
| | - Emilio Perucca
- Department of Neuroscience, Monash University, Melbourne, Victoria, Australia.,Department of Medicine, Austin Health, University of Melbourne, Heidelberg, Victoria, Australia
| | - Solomon L Moshé
- Isabelle Rapin Division of Child Neurology, Saul R. Korey Department of Neurology, and Departments of Neuroscience and Pediatrics, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, New York, USA
| | - Paolo Tinuper
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy.,Institute of Neurological Sciences, Scientific Institute for Research and Health Care, member of EpiCARE, Bologna, Italy
| | - Elaine C Wirrell
- Divisions of Child and Adolescent Neurology and Epilepsy, Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
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Can Disruption of Basal Ganglia-Thalamocortical Circuit in Wilson Disease Be Associated with Juvenile Myoclonic Epilepsy Phenotype? Brain Sci 2022; 12:brainsci12050553. [PMID: 35624941 PMCID: PMC9138607 DOI: 10.3390/brainsci12050553] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 04/20/2022] [Accepted: 04/22/2022] [Indexed: 02/05/2023] Open
Abstract
In this paper, we describe the multimodal MRI findings in a patient with Wilson disease and a seizure disorder, characterized by an electroclinical picture resembling juvenile myoclonic epilepsy. The brain structural MRI showed a deposition of ferromagnetic materials in the basal ganglia, with marked hypointensities in T2-weighted images of globus pallidus internus bilaterally. A resting-state fMRI study revealed increased functional connectivity in the patient, compared to control subjects, in the following networks: (1) between the primary motor cortex and several cortical regions, including the secondary somatosensory cortex and (2) between the globus pallidus and the thalamo-frontal network. These findings suggest that globus pallidus alterations, due to metal accumulation, can lead to a reduction in the normal globus pallidus inhibitory tone on the thalamo-(motor)-cortical pathway. This, in turn, can result in hyperconnectivity in the motor cortex circuitry, leading to myoclonus and tonic-clonic seizures. We suppose that, in this patient, Wilson disease generated a ‘lesion model’ of myoclonic epilepsy.
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Analysis of Clinical Characteristics, Background, and Paroxysmal Activity in EEG of Patients with Juvenile Myoclonic Epilepsy. Brain Sci 2021; 12:brainsci12010029. [PMID: 35053773 PMCID: PMC8773902 DOI: 10.3390/brainsci12010029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2021] [Revised: 12/24/2021] [Accepted: 12/25/2021] [Indexed: 11/17/2022] Open
Abstract
Juvenile myoclonic epilepsy (JME) appears in adolescence with myoclonic, absence, and generalized tonic clonic (GTC) seizures with paroxysmal activity of polyspike and slow wave (PSW), or spike and wave (SW) complexes in EEG. Our aim was to analyze the clinical characteristics, background EEG activity, and paroxysmal events in 41 patients with JME. Background EEG activity was analyzed with visual, quantitative (QEEG), and neurometric parameters. Our JME patients started with absence seizures at 11.4 ± 1.5 years old, myoclonic seizures at 13.6 ± 2.5 years, and GTC seizures at 15.1 ± 0.8 years. The seizures presented in awakening at 7:39 h with sleep deprivation, alcoholic beverage intake, and stress as the most frequent precipitant factors. Paroxysmal activity was of PSW and fast SW complexes with 40.5 ± 62.6 events/hour and a duration of 1.7 s. Right asymmetric paroxysmal activity was present in 68.3% of patients. Background EEG activity was abnormal in 31.7% of patients with visual analysis. With QEEG beta AP (absolute power) increase and AP delta decrease were the most frequent abnormalities found. Spectral analysis showed that 48.7% of patients had normal results, and 26.83% and 24.4% had higher and lower frequencies than 10.156 Hz, respectively. We concluded that, with visual analysis, background EEG activity was abnormal in a few patients and the abnormalities increased when QEEG was used.
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A systematic review of resting-state and task-based fmri in juvenile myoclonic epilepsy. Brain Imaging Behav 2021; 16:1465-1494. [PMID: 34786666 DOI: 10.1007/s11682-021-00595-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/20/2021] [Indexed: 10/19/2022]
Abstract
Functional neuroimaging modalities have enhanced our understanding of juvenile myoclonic epilepsy (JME) underlying neural mechanisms. Due to its non-invasive, sensitive and analytical nature, functional magnetic resonance imaging (fMRI) provides valuable insights into relevant functional brain networks and their segregation and integration properties. We systematically reviewed the contribution of resting-state and task-based fMRI to the current understanding of the pathophysiology and the patterns of seizure propagation in JME Altogether, despite some discrepancies, functional findings suggest that corticothalamo-striato-cerebellar network along with default-mode network and salience network are the most affected networks in patients with JME. However, further studies are required to investigate the association between JME's main deficiencies, e.g., motor and cognitive deficiencies and fMRI findings. Moreover, simultaneous electroencephalography-fMRI (EEG-fMRI) studies indicate that alterations of these networks play a role in seizure modulation but fall short of identifying a causal relationship between altered functional properties and seizure propagation. This review highlights the complex pathophysiology of JME, which necessitates the design of more personalized diagnostic and therapeutic strategies in this group.
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Contier ATR, Alonso NB, Araújo NS, Taura M, Cavalheiro EA. Challenges in the treatment of a chronic disease: A study of narratives of people with juvenile myoclonic epilepsy. Seizure 2021; 90:74-79. [DOI: 10.1016/j.seizure.2021.04.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 03/28/2021] [Accepted: 04/05/2021] [Indexed: 10/21/2022] Open
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Gama AP, Taura M, Alonso NB, Sousa AM, Noffs MHDS, Yacubian EM, Guilhoto LM. Impulsiveness, personality traits and executive functioning in patients with juvenile myoclonic epilepsy. Seizure 2020; 82:125-132. [PMID: 33068959 DOI: 10.1016/j.seizure.2020.09.029] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Revised: 09/28/2020] [Accepted: 09/29/2020] [Indexed: 10/23/2022] Open
Abstract
PURPOSE To evaluate impulsiveness in adult patients with JME and its relationship with personality traits and executive functioning. METHODS Patients completed psychiatric evaluation (DSM IV), Barratt Impulsiveness Scale (BIS-11), Neo Revised Personality Inventory (NEO PI-R) and executive functioning evaluation comprising Controlled Oral Word Association (COWA), Digit Span, Trail Making Tests (TMT), Stroop Test (ST) and Wisconsin Card Sorting Test (WSCT). Healthy controls (63 % female, mean age 35.7 yrs. (±8.37)) were examined to allow calculation of z-scores. RESULTS 50 patients (70 % female; mean age 32.5 yrs. (±9.2)) presented higher scores of Total (z=-0.37; p = 0.005) and Motor Impulsiveness (z=-0.79; p < 0.001) on BIS-11. Motor Impulsiveness was associated with higher rates of mild psychiatric disorders (depression and anxiety) (p = 0.035) and worse myoclonic seizure control (p = 0.007). NEO PI-R showed differences on Neuroticism (z=-0.60; p < 0.001), Openness (z = 0.38; p = 0.043), Agreeableness (z=-0.38; p = 0.033) and Conscientiousness (z=-0.53; p = 0.003). There were positive correlations between BIS-11 and Neuroticism with Total, Motor and Non-Planning Impulsiveness, on the other hand, Conscientiousness was negatively correlated with these as well as with Attentive Impulsiveness. Patients performance was worse than that of controls on COWA (z=-0.43; p = 0.009) and WCST's Total Number of Completed Categories (z=-2.08; p = 0.005), Trials Taken to Complete First Category (z=-1.56; p = 0.013), Percentage of Total Errors (z=-1.56; p < 0.001), Perseverative Errors (z=-0.73; p = 0.002), Non-Perseverative Errors (z=-1.05; p = 0.003) and Conceptual Level Responses (z=-1.52; p < 0.001). Non-Planning Impulsiveness correlated with Performance (ST and TMT). CONCLUSION Patients with JME present with impulsive behavior, personality features and executive dysfunction which are linked and may lead to lack of commitment in treatment and affect other aspects of life.
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Affiliation(s)
- André Peres Gama
- Unidade de Pesquisa e Tratamento das Epilepsias (UNIPETE), Universidade Federal de São Paulo - Unifesp, São Paulo, SP, Brazil
| | - Mariângela Taura
- Unidade de Pesquisa e Tratamento das Epilepsias (UNIPETE), Universidade Federal de São Paulo - Unifesp, São Paulo, SP, Brazil
| | - Neide Barreira Alonso
- Unidade de Pesquisa e Tratamento das Epilepsias (UNIPETE), Universidade Federal de São Paulo - Unifesp, São Paulo, SP, Brazil
| | - Artur Menezes Sousa
- Unidade de Pesquisa e Tratamento das Epilepsias (UNIPETE), Universidade Federal de São Paulo - Unifesp, São Paulo, SP, Brazil
| | - Maria Helena da Silva Noffs
- Unidade de Pesquisa e Tratamento das Epilepsias (UNIPETE), Universidade Federal de São Paulo - Unifesp, São Paulo, SP, Brazil
| | - Elza Márcia Yacubian
- Unidade de Pesquisa e Tratamento das Epilepsias (UNIPETE), Universidade Federal de São Paulo - Unifesp, São Paulo, SP, Brazil
| | - Laura Maria Guilhoto
- Unidade de Pesquisa e Tratamento das Epilepsias (UNIPETE), Universidade Federal de São Paulo - Unifesp, São Paulo, SP, Brazil.
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Stefani S, Kousiappa I, Nicolaou N, Papathanasiou ES, Oulas A, Fanis P, Neocleous V, Phylactou LA, Spyrou GM, Papacostas SS. Neurophysiological and Genetic Findings in Patients With Juvenile Myoclonic Epilepsy. Front Integr Neurosci 2020; 14:45. [PMID: 32973469 PMCID: PMC7468511 DOI: 10.3389/fnint.2020.00045] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Accepted: 07/21/2020] [Indexed: 12/15/2022] Open
Abstract
Objective Transcranial magnetic stimulation (TMS), a non-invasive procedure, stimulates the cortex evaluating the central motor pathways. The response is called motor evoked potential (MEP). Polyphasia results when the response crosses the baseline more than twice (zero crossing). Recent research shows MEP polyphasia in patients with generalized genetic epilepsy (GGE) and their first-degree relatives compared with controls. Juvenile Myoclonic Epilepsy (JME), a GGE type, is not well studied regarding polyphasia. In our study, we assessed polyphasia appearance probability with TMS in JME patients, their healthy first-degree relatives and controls. Two genetic approaches were applied to uncover genetic association with polyphasia. Methods 20 JME patients, 23 first-degree relatives and 30 controls underwent TMS, obtaining 10–15 MEPs per participant. We evaluated MEP mean number of phases, proportion of MEP trials displaying polyphasia for each subject and variability between groups. Participants underwent whole exome sequencing (WES) via trio-based analysis and two-case scenario. Extensive bioinformatics analysis was applied. Results We identified increased polyphasia in patients (85%) and relatives (70%) compared to controls (47%) and significantly higher mean number of zero crossings (i.e., occurrence of phases) (patients 1.49, relatives 1.46, controls 1.22; p < 0.05). Trio-based analysis revealed a candidate polymorphism, p.Glu270del,in SYT14 (Synaptotagmin 14), in JME patients and their relatives presenting polyphasia. Sanger sequencing analysis in remaining participants showed no significant association. In two-case scenario, a machine learning approach was applied in variants identified from odds ratio analysis and risk prediction scores were obtained for polyphasia. The results revealed 61 variants of which none was associated with polyphasia. Risk prediction scores indeed showed lower probability for non-polyphasic subjects on having polyphasia and higher probability for polyphasic subjects on having polyphasia. Conclusion Polyphasia was present in JME patients and relatives in contrast to controls. Although no known clinical symptoms are linked to polyphasia this neurophysiological phenomenon is likely due to common cerebral electrophysiological abnormality. We did not discover direct association between genetic variants obtained and polyphasia. It is likely these genetic traits alone cannot provoke polyphasia, however, this predisposition combined with disturbed brain-electrical activity and tendency to generate seizures may increase the risk of developing polyphasia, mainly in patients and relatives.
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Affiliation(s)
- Stefani Stefani
- Cyprus School of Molecular Medicine, Nicosia, Cyprus.,Neurology Clinic B, The Cyprus Institute of Neurology and Genetics, Nicosia, Cyprus
| | - Ioanna Kousiappa
- Cyprus School of Molecular Medicine, Nicosia, Cyprus.,Neurology Clinic B, The Cyprus Institute of Neurology and Genetics, Nicosia, Cyprus
| | - Nicoletta Nicolaou
- Medical School, University of Nicosia, Nicosia, Cyprus.,Centre for Neuroscience and Integrative Brain Research (CENIBRE), University of Nicosia, Nicosia, Cyprus
| | - Eleftherios S Papathanasiou
- Cyprus School of Molecular Medicine, Nicosia, Cyprus.,Neurology Clinic B, The Cyprus Institute of Neurology and Genetics, Nicosia, Cyprus
| | - Anastasis Oulas
- Cyprus School of Molecular Medicine, Nicosia, Cyprus.,Bioinformatics Group, The Cyprus Institute of Neurology and Genetics, Nicosia, Cyprus
| | - Pavlos Fanis
- Cyprus School of Molecular Medicine, Nicosia, Cyprus.,Department of Molecular Genetics, Function & Therapy, The Cyprus Institute of Neurology and Genetics, Nicosia, Cyprus
| | - Vassos Neocleous
- Cyprus School of Molecular Medicine, Nicosia, Cyprus.,Department of Molecular Genetics, Function & Therapy, The Cyprus Institute of Neurology and Genetics, Nicosia, Cyprus
| | - Leonidas A Phylactou
- Cyprus School of Molecular Medicine, Nicosia, Cyprus.,Department of Molecular Genetics, Function & Therapy, The Cyprus Institute of Neurology and Genetics, Nicosia, Cyprus
| | - George M Spyrou
- Cyprus School of Molecular Medicine, Nicosia, Cyprus.,Bioinformatics Group, The Cyprus Institute of Neurology and Genetics, Nicosia, Cyprus
| | - Savvas S Papacostas
- Cyprus School of Molecular Medicine, Nicosia, Cyprus.,Neurology Clinic B, The Cyprus Institute of Neurology and Genetics, Nicosia, Cyprus.,Medical School, University of Nicosia, Nicosia, Cyprus.,Centre for Neuroscience and Integrative Brain Research (CENIBRE), University of Nicosia, Nicosia, Cyprus
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Paiva ML, Lima EM, Siqueira IB, Rzezak P, Koike C, Moschetta SP, Vincentiis S, Alessi R, Khafif TC, Mendoza M, Valente KD. Seizure control and anxiety: Which factor plays a major role in social adjustment in patients with Juvenile Myoclonic Epilepsy? Seizure 2020; 80:234-239. [PMID: 32663782 DOI: 10.1016/j.seizure.2020.06.033] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2020] [Revised: 06/28/2020] [Accepted: 06/30/2020] [Indexed: 11/25/2022] Open
Abstract
PURPOSE This study aimed to determine the presence of anxiety disorder and severity of anxiety symptoms in an extensive series of consecutive patients with JME and its association with epilepsy-related factors. In addition, we evaluated the impact of anxiety and clinical variables on social adjustment. METHODS We prospectively evaluated 112 (56.2 % females, mean age 27.2 years) patients with an electroclinical diagnosis of JME and 61 (52.4 % females, mean age 29.3 years) healthy controls. Anxiety symptoms were assessed by the State and Trait Anxiety Inventory (STAI). Social functioning was addressed with Self-Report Social Adjustment Scale (SAS). The patient group was also evaluated with a psychiatric interview. RESULTS Patients with JME presented more severe anxiety symptoms and worse social adjustment compared with controls. The presence of anxiety disorder and the severity of anxiety symptoms was associated with frequent seizures - generalized tonic-clonic seizures (p = 0.008) and drug-resistant epilepsy (p = 0.021). Regarding social adjustment, the severity of anxiety symptoms was associated with lower economic adjustment (p = 0.039), while the presence of anxiety disorder impacted family relationships (p 0.025). The presence of hard-to-control myoclonic seizure was associated with lower scores on work (p = 0.019), leisure activities (p = 0.008), family relationship (p = 0.022) and overall social adjustment (p = 0.038). CONCLUSION Patients with JME have severe anxiety symptoms and worse social adjustment. Anxiety disorder and symptoms were associated with frequent seizures and drug-resistant epilepsy. Epilepsy-related factors and anxiety impaired distinct aspects of social functioning.
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Affiliation(s)
- Maria Luisa Paiva
- Laboratory of Clinical Neurophysiology, Department of Psychiatry, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), Brazil
| | - Ellen Marise Lima
- Laboratory of Clinical Neurophysiology, Department of Psychiatry, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), Brazil
| | - Isabelle Bimbatti Siqueira
- Laboratory of Clinical Neurophysiology, Department of Psychiatry, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), Brazil
| | - Patricia Rzezak
- Laboratory of Clinical Neurophysiology, Department of Psychiatry, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), Brazil
| | - Camila Koike
- Laboratory of Clinical Neurophysiology, Department of Psychiatry, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), Brazil
| | - Sylvie P Moschetta
- Laboratory of Clinical Neurophysiology, Department of Psychiatry, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), Brazil
| | - Silvia Vincentiis
- Laboratory of Clinical Neurophysiology, Department of Psychiatry, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), Brazil
| | - Rudá Alessi
- Laboratory of Clinical Neurophysiology, Department of Psychiatry, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), Brazil
| | - Tatiana Cohab Khafif
- Bipolar Disorder Program, Department of Psychiatry, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), Brazil
| | - Melanie Mendoza
- Laboratory of Clinical Neurophysiology, Department of Psychiatry, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), Brazil
| | - Kette D Valente
- Laboratory of Clinical Neurophysiology, Department of Psychiatry, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), Brazil.
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Krämer G. Zur Geschichte des Janz-Syndroms (juvenile myoklonische Epilepsie). ZEITSCHRIFT FÜR EPILEPTOLOGIE 2020. [DOI: 10.1007/s10309-020-00319-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Abstract
Common genetic generalised epilepsy syndromes encountered by clinicians include childhood and juvenile absence epilepsies, juvenile myoclonic epilepsy and generalised tonic-clonic seizures on awakening. Treatment of these syndromes involves largely the use of broad-spectrum antiseizure drugs. Those effective for the generalised epilepsies include sodium valproate, phenobarbital, ethosuximide, clobazam, clonazepam, lamotrigine, levetiracetam, topiramate, zonisamide and, more recently, perampanel and brivaracetam. Results from the few rigorous studies comparing outcomes with drugs for genetic generalised epilepsies show valproate to be the most effective. The majority of patients with genetic generalised epilepsy syndromes will become seizure free on antiseizure monotherapy; those for whom control proves elusive may benefit from combination regimens. Early counselling regarding management may assist the patient to come to terms with their diagnosis and improve long-term outcomes. Treatment can be lifelong in some individuals, although others may remain seizure free without medication. Choice of antiseizure medication depends on the efficacy for specific seizure types, as well as tolerability. For patients prescribed comedication, drug interactions should be considered. In particular, for young women taking oral hormonal contraceptives, ≥ 200 mg/day of topiramate can decrease the circulating concentration of ethinylestradiol and ≥ 12 mg/day of perampanel can induce levonorgestrel metabolism. The use of valproate in women of childbearing potential is limited by associated teratogenic and neurodevelopmental effects in offspring. Given that valproate is often the antiseizure drug of choice for genetic generalised epilepsies, this creates a dilemma for patients and clinicians. Decision making can be aided by comprehensive assessment and discussion of treatment options. Psychiatric comorbidities are common in adolescents and adults with genetic generalised epilepsies. These worsen the prognosis, both in terms of seizure control and quality of life. Attendant lifestyle issues can impact significantly on the individual and society. Frontal lobe dysfunction, which can present in patients with juvenile myoclonic epilepsy, can adversely affect the long-term outlook, regardless of the nature of seizure control. Ongoing management requires consideration of psychosocial and behavioural factors that can complicate diagnosis and treatment. An assured supportive attitude by the neurologist can be an important contributor to a positive outcome. The mechanisms underlying genetic generalised epilepsies, including genetic abnormalities, are unclear at present. As the pathophysiology is unravelled, this may lead to the development of novel therapies and improved outcomes for patients with these syndromes.
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Affiliation(s)
- Linda J Stephen
- West Glasgow Ambulatory Care Hospital, Dalnair St, Glasgow, G3 8SJ, UK.
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Paiva ML, Rzezak P, Santos B, Lima EM, Moschetta SP, Vincentiis S, Alessi R, Mendoza M, Valente KD. Dissociation between decision making under ambiguity and risk in patients with juvenile myoclonic epilepsy. Epilepsy Behav 2019; 101:106548. [PMID: 31678809 DOI: 10.1016/j.yebeh.2019.106548] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Revised: 09/05/2019] [Accepted: 09/06/2019] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Decision making (DM) is one aspect of impulsivity that can be defined by the ability to decide between two or more options in a given situation. To date, there are at least two types of DM that differ in the level of uncertainty, and how much information about consequences is provided. In this study, we aimed to evaluate the two domains of DM - under risk and ambiguous - with a comprehensive evaluation in a group of patients with juvenile myoclonic epilepsy (JME), and correlate with patients' characteristics, clinical variables, and neuropsychological evaluation for executive functions. METHODS We evaluated 35 patients with JME and 39 healthy controls using the Iowa Gambling Task for DM under ambiguity and the Game Dice Task for DM under risk. We assessed the performance in Iowa Gambling Task and Game Dice Task through net scores, safe and risky choices, besides the type of decisions across time. RESULTS Patients with JME had a higher number of risky choices compared to controls in the Game Dice Task. There was no significant difference between patients and controls in the Iowa Gambling Task. However, patients with higher seizure frequency had worse scores on decks C and D (safe choices) from the Iowa Gambling Task. CONCLUSION Patients with JME have worse performance on DM under risk. The same was not observed for DM under ambiguity. Epilepsy-related factors and the presence of psychiatric disorders, but not executive dysfunction, were associated with a lower tendency for safe choices. These findings showed a dissociation between DM processes in patients with JME and a tendency to make disadvantageous decisions with measurable risks.
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Affiliation(s)
- Maria L Paiva
- Laboratory of Clinical Neurophysiology, Department of Psychiatry, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP, Brazil
| | - Patricia Rzezak
- Laboratory of Clinical Neurophysiology, Department of Psychiatry, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP, Brazil
| | - Bernardo Santos
- Laboratory of Clinical Neurophysiology, Department of Psychiatry, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP, Brazil
| | - Ellen M Lima
- Laboratory of Clinical Neurophysiology, Department of Psychiatry, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP, Brazil
| | - Sylvie P Moschetta
- Laboratory of Clinical Neurophysiology, Department of Psychiatry, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP, Brazil
| | - Silvia Vincentiis
- Laboratory of Clinical Neurophysiology, Department of Psychiatry, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP, Brazil
| | - Rudá Alessi
- Laboratory of Clinical Neurophysiology, Department of Psychiatry, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP, Brazil
| | - Melanie Mendoza
- Laboratory of Clinical Neurophysiology, Department of Psychiatry, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP, Brazil
| | - Kette D Valente
- Laboratory of Clinical Neurophysiology, Department of Psychiatry, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP, Brazil.
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Hwang ST, Stevens SJ, Fu AX, Proteasa SV. Intractable Generalized Epilepsy: Therapeutic Approaches. Curr Neurol Neurosci Rep 2019; 19:16. [PMID: 30806817 DOI: 10.1007/s11910-019-0933-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
PURPOSE OF REVIEW To summarize recent developments in therapeutic options, both medical and surgical, for patients with drug-resistant generalized epilepsy syndromes, which continue to be a multifaceted challenge for patients and physicians. RECENT FINDINGS Newer generation pharmaceutical options are now available, such as brivaracetam, rufinamide, lacosamide, perampanel, and cannabidiol. Less restrictive dietary options appear to be nearly as effective as classic ketogenic diet for amelioration of seizures. The latest implantable devices include responsive neurostimulation and deep brain stimulation. Corpus callosotomy is an effective treatment for some seizure types, and newer and less invasive approaches are being explored. Resective surgical options have demonstrated success in carefully selected patients despite generalized electrographic findings on electroencephalogram. The current literature reflects a widening range of clinical experience with newer anticonvulsant medications including cannabinoids, dietary therapies, surgical approaches, and neurostimulation devices for patients with intractable generalized epilepsy.
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Affiliation(s)
- Sean T Hwang
- Zucker School of Medicine at Hofstra Northwell, Hempstead, NY, USA.
| | - Scott J Stevens
- Zucker School of Medicine at Hofstra Northwell, Hempstead, NY, USA
| | - Aradia X Fu
- Zucker School of Medicine at Hofstra Northwell, Hempstead, NY, USA
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Wang Y, Berglund IS, Uppman M, Li TQ. Juvenile myoclonic epilepsy has hyper dynamic functional connectivity in the dorsolateral frontal cortex. Neuroimage Clin 2018; 21:101604. [PMID: 30527355 PMCID: PMC6412974 DOI: 10.1016/j.nicl.2018.11.014] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2018] [Revised: 08/20/2018] [Accepted: 11/18/2018] [Indexed: 01/08/2023]
Abstract
PURPOSE Characterize the static and dynamic functional connectivity for subjects with juvenile myoclonic epilepsy (JME) using a quantitative data-driven analysis approach. METHODS Whole-brain resting-state functional MRI data were acquired on a 3 T whole-body clinical MRI scanner from 18 subjects clinically diagnosed with JME and 25 healthy control subjects. 2-min sliding-window approach was incorporated in the quantitative data-driven data analysis framework to assess both the dynamic and static functional connectivity in the resting brains. Two-sample t-tests were performed voxel-wise to detect the differences in functional connectivity metrics based on connectivity strength and density. RESULTS The static functional connectivity metrics based on quantitative data-driven analysis of the entire 10-min acquisition window of resting-state functional MRI data revealed significantly enhanced functional connectivity in JME patients in bilateral dorsolateral prefrontal cortex, dorsal striatum, precentral and middle temporal gyri. The dynamic functional connectivity metrics derived by incorporating a 2-min sliding window into quantitative data-driven analysis demonstrated significant hyper dynamic functional connectivity in the dorsolateral prefrontal cortex, middle temporal gyrus and dorsal striatum. Connectivity strength metrics (both static and dynamic) can detect more extensive functional connectivity abnormalities in the resting-state functional networks (RFNs) and depict also larger overlap between static and dynamic functional connectivity results. CONCLUSION Incorporating a 2-min sliding window into quantitative data-driven analysis of resting-state functional MRI data can reveal additional information on the temporally fluctuating RFNs of the human brain, which indicate that RFNs involving dorsolateral prefrontal cortex have temporal varying hyper dynamic characteristics in JME patients. Assessing dynamic along with static functional connectivity may provide further insights into the abnormal function connectivity underlying the pathological brain functioning in JME.
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Affiliation(s)
- Yanlu Wang
- Department of Clinical Science, Intervention, and Technology, Karolinska Institute, Stockholm, Sweden; Department of Medical Radiation Physics and Nuclear Medicine, Karolinska University Hospital, Sweden.
| | - Ivanka Savic Berglund
- Department of Women's and Children's Health, Karolinska Institute, Stockholm, Sweden; Department of Neurology, Karolinska University Hospital, Sweden; Department of Neurology, David Geffen School of Medicine, University of California, Los Angeles, USA
| | - Martin Uppman
- Department of Clinical Science, Intervention, and Technology, Karolinska Institute, Stockholm, Sweden
| | - Tie-Qiang Li
- Department of Clinical Science, Intervention, and Technology, Karolinska Institute, Stockholm, Sweden; Department of Medical Radiation Physics and Nuclear Medicine, Karolinska University Hospital, Sweden
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Holmes EAF, Plumpton C, Baker GA, Jacoby A, Ring A, Williamson P, Marson A, Hughes DA. Patient-Focused Drug Development Methods for Benefit-Risk Assessments: A Case Study Using a Discrete Choice Experiment for Antiepileptic Drugs. Clin Pharmacol Ther 2018; 105:672-683. [PMID: 30204252 PMCID: PMC6491963 DOI: 10.1002/cpt.1231] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2018] [Accepted: 08/24/2018] [Indexed: 12/31/2022]
Abstract
Regulatory decisions may be enhanced by incorporating patient preferences for drug benefit and harms. This study demonstrates a method of weighting clinical evidence by patients’ benefit–risk preferences. Preference weights, derived from discrete choice experiments, were applied to clinical trial data to estimate the expected utility of alternative drugs. In a case study, the rank ordering of antiepileptic drugs (AEDs), as indicated from clinical studies, was compared with ordering based on weighting clinical evidence by patients’ preferences. A statistically significant change in rank ordering of AEDs was observed for women of childbearing potential who were prescribed monotherapy for generalized or unclassified epilepsy. Rank ordering inferred from trial data, valproate > topiramate > lamotrigine, was reversed. Modeling the expected utility of drugs might address the need to use more systematic, methodologically sound approaches to collect patient input that can further inform regulatory decision making.
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Affiliation(s)
- Emily A F Holmes
- Centre for Health Economics and Medicines Evaluation, Bangor University, Bangor, UK
| | - Catrin Plumpton
- Centre for Health Economics and Medicines Evaluation, Bangor University, Bangor, UK
| | - Gus A Baker
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK
| | - Ann Jacoby
- Department of Public Health and Policy, University of Liverpool, Liverpool, UK
| | - Adele Ring
- Institute of Psychology, Health and Society, University of Liverpool, Liverpool, UK
| | - Paula Williamson
- Medical Research Council North West Hub for Trials Methodology Research, Department of Biostatistics, University of Liverpool, Liverpool, UK
| | - Anthony Marson
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK.,Walton Centre National Health Service Foundation Trust, Liverpool, UK
| | - Dyfrig A Hughes
- Centre for Health Economics and Medicines Evaluation, Bangor University, Bangor, UK.,Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK
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23
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Impact of sleep disorders on the risk of seizure recurrence in juvenile myoclonic epilepsy. Epilepsy Behav 2018; 80:21-24. [PMID: 29396358 DOI: 10.1016/j.yebeh.2017.11.023] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2017] [Revised: 11/17/2017] [Accepted: 11/20/2017] [Indexed: 11/20/2022]
Abstract
OBJECTIVE The aim of this study was to investigate the presence of sleep disturbances in patients with juvenile myoclonic epilepsy (JME) using sleep questionnaires. Further, we tried to evaluate whether alterations in sleep quality may influence the clinical expression of JME. METHODS Sixty-two patients with JME treated with levetiracetam were included. Demographic and clinical variables were collected. Moreover, all patients submitted the Pittsburgh Sleep Quality index (PSQI) and the Epworth Sleepiness Scale (ESS) in order to respectively assess sleep quality during the last month and daytime sleepiness. All patients were followed up for a 6-month period and divided in two groups: seizure-free (Group 1) and seizure recurrence (Group 2). The PSQI and ESS scores were synthesized as binary variables <5/≥5 and <10/≥10, respectively. A comprehensive analysis was performed to evaluate the independent effect of the sleep quality and daytime sleepiness on the risk of having seizures during the follow-up. RESULTS Both reduced sleep quality during the last month and daytime sleepiness were associated with an increased risk of suffering from seizures during the follow-up period. In fact, a PSQI score<5 or an ESS score<10 resulted significantly associated with the absence of seizure recurrence (p<0.004 and p<0.001, respectively). Increasing age had a significantly protective effect in the risk of seizure relapse. CONCLUSIONS Our findings show that reduced sleep quality and daytime sleepiness in patients with JME increase the risk of seizure occurrence in spite of an appropriate pharmacological treatment. This negative effect seems to be more relevant in younger patients. Sleep disorders and their specific correction should be taken into consideration for the management of patients with JME.
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24
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Wielaender F, James FMK, Cortez MA, Kluger G, Neßler JN, Tipold A, Lohi H, Fischer A. Absence Seizures as a Feature of Juvenile Myoclonic Epilepsy in Rhodesian Ridgeback Dogs. J Vet Intern Med 2017; 32:428-432. [PMID: 29194766 PMCID: PMC5787207 DOI: 10.1111/jvim.14892] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2017] [Revised: 10/10/2017] [Accepted: 10/31/2017] [Indexed: 01/17/2023] Open
Abstract
Myoclonic epilepsy in Rhodesian Ridgeback (RR) dogs is characterized by myoclonic seizures occurring mainly during relaxation periods, a juvenile age of onset and generalized tonic‐clonic seizures in one‐third of patients. An 8‐month‐old female intact RR was presented for myoclonic seizures and staring episodes that both started at 10 weeks of age. Testing for the DIRAS1 variant indicated a homozygous mutant genotype. Unsedated wireless video‐electroencephalography (EEG) identified frequent, bilaterally synchronous, generalized 4 Hz spike‐and‐wave complexes (SWC) during the staring episodes in addition to the characteristic myoclonic seizures with generalized 4–5 Hz SWC or 4–5 Hz slowing. Photic stimulation did not evoke a photoparoxysmal response. Repeat video‐EEG 2 months after initiation of levetiracetam treatment disclosed a >95% decrease in frequency of myoclonic seizures, and absence seizures were no longer evident. Absence seizures represent another seizure type in juvenile myoclonic epilepsy (JME) in RR dogs, which reinforces its parallels to JME in humans.
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Affiliation(s)
- F Wielaender
- Centre for Clinical Veterinary Medicine, LMU Munich, Munich, Germany
| | - F M K James
- Department of Clinical Studies, Ontario Veterinary College, University of Guelph, Guelph, ON, Canada
| | - M A Cortez
- Department of Pediatrics, University of Toronto, Toronto, ON, Canada.,Neurosciences & Mental Health Program, Peter Gilgan Centre for Research and Learning, SickKids Research Institute, Toronto, ON, Canada
| | - G Kluger
- Department of Neuropediatrics, Epilepsy Center, Schoen Klinik, Vogtareuth, Germany.,Paracelsus Medical University, Salzburg, Austria
| | - J N Neßler
- Department of Small Animal Medicine and Surgery, University of Veterinary Medicine, Hannover, Germany
| | - A Tipold
- Department of Small Animal Medicine and Surgery, University of Veterinary Medicine, Hannover, Germany
| | - H Lohi
- Department of Veterinary Biosciences and Research Programs Unit, Molecular Neurology, University of Helsinki and Folkhalsan Research Centre, Helsinki, Finland
| | - A Fischer
- Centre for Clinical Veterinary Medicine, LMU Munich, Munich, Germany
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25
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Lamotrigine versus valproic acid monotherapy for generalised epilepsy: A meta-analysis of comparative studies. Seizure 2017; 51:95-101. [DOI: 10.1016/j.seizure.2017.08.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2017] [Revised: 07/19/2017] [Accepted: 08/03/2017] [Indexed: 01/08/2023] Open
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26
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dos Santos BP, Marinho CRM, Marques TEBS, Angelo LKG, Malta MVDS, Duzzioni M, de Castro OW, Leite JP, Barbosa FT, Gitaí DLG. Genetic susceptibility in Juvenile Myoclonic Epilepsy: Systematic review of genetic association studies. PLoS One 2017; 12:e0179629. [PMID: 28636645 PMCID: PMC5479548 DOI: 10.1371/journal.pone.0179629] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2016] [Accepted: 06/01/2017] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Several genetic association investigations have been performed over the last three decades to identify variants underlying Juvenile Myoclonic Epilepsy (JME). Here, we evaluate the accumulating findings and provide an updated perspective of these studies. METHODOLOGY A systematic literature search was conducted using the PubMed, Embase, Scopus, Lilacs, epiGAD, Google Scholar and Sigle up to February 12, 2016. The quality of the included studies was assessed by a score and classified as low and high quality. Beyond outcome measures, information was extracted on the setting for each study, characteristics of population samples and polymorphisms. RESULTS Fifty studies met eligibility criteria and were used for data extraction. With a single exception, all studies used a candidate gene approach, providing data on 229 polymorphisms in or near 55 different genes. Of variants investigating in independent data sets, only rs2029461 SNP in GRM4, rs3743123 in CX36 and rs3918149 in BRD2 showed a significant association with JME in at least two different background populations. The lack of consistent associations might be due to variations in experimental design and/or limitations of the approach. CONCLUSIONS Thus, despite intense research evidence established, specific genetic variants in JME susceptibility remain inconclusive. We discussed several issues that may compromise the quality of the results, including methodological bias, endophenotype and potential involvement of epigenetic factors. PROSPERO REGISTRATION NUMBER CRD42016036063.
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Affiliation(s)
- Bruna Priscila dos Santos
- Department of Cellular and Molecular Biology, Institute of Biological Sciences and Health, Federal University of Alagoas, Maceio, Alagoas, Brazil
| | - Chiara Rachel Maciel Marinho
- Department of Cellular and Molecular Biology, Institute of Biological Sciences and Health, Federal University of Alagoas, Maceio, Alagoas, Brazil
| | | | - Layanne Kelly Gomes Angelo
- Department of Cellular and Molecular Biology, Institute of Biological Sciences and Health, Federal University of Alagoas, Maceio, Alagoas, Brazil
| | - Maísa Vieira da Silva Malta
- Department of Cellular and Molecular Biology, Institute of Biological Sciences and Health, Federal University of Alagoas, Maceio, Alagoas, Brazil
| | - Marcelo Duzzioni
- Department of Pharmacology, Institute of Biological Sciences and Health, Federal University of Alagoas, Maceio, Alagoas, Brazil
| | - Olagide Wagner de Castro
- Department of Physiology, Institute of Biological Sciences and Health, Federal University of Alagoas, Maceio, Alagoas, Brazil
| | - João Pereira Leite
- Division of Neurology, Department of Neurosciences and Behavioral Sciences, Ribeirão Preto School of Medicine, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | | | - Daniel Leite Góes Gitaí
- Department of Cellular and Molecular Biology, Institute of Biological Sciences and Health, Federal University of Alagoas, Maceio, Alagoas, Brazil
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27
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Seizure — European Journal of Epilepsy at age 25: Where are we now and where we are going? Seizure 2017; 44:1-3. [DOI: 10.1016/j.seizure.2017.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2017] [Accepted: 01/04/2017] [Indexed: 11/20/2022] Open
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