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Scheffer IE, Zuberi S, Mefford HC, Guerrini R, McTague A. Developmental and epileptic encephalopathies. Nat Rev Dis Primers 2024; 10:61. [PMID: 39237642 DOI: 10.1038/s41572-024-00546-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/29/2024] [Indexed: 09/07/2024]
Abstract
Developmental and epileptic encephalopathies, the most severe group of epilepsies, are characterized by seizures and frequent epileptiform activity associated with developmental slowing or regression. Onset typically occurs in infancy or childhood and includes many well-defined epilepsy syndromes. Patients have wide-ranging comorbidities including intellectual disability, psychiatric features, such as autism spectrum disorder and behavioural problems, movement and musculoskeletal disorders, gastrointestinal and sleep problems, together with an increased mortality rate. Problems change with age and patients require substantial support throughout life, placing a high psychosocial burden on parents, carers and the community. In many patients, the aetiology can be identified, and a genetic cause is found in >50% of patients using next-generation sequencing technologies. More than 900 genes have been identified as monogenic causes of developmental and epileptic encephalopathies and many cell components and processes have been implicated in their pathophysiology, including ion channels and transporters, synaptic proteins, cell signalling and metabolism and epigenetic regulation. Polygenic risk score analyses have shown that common variants also contribute to phenotypic variability. Holistic management, which encompasses antiseizure therapies and care for multimorbidities, is determined both by epilepsy syndrome and aetiology. Identification of the underlying aetiology enables the development of precision medicines to improve the long-term outcome of patients with these devastating diseases.
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Affiliation(s)
- Ingrid E Scheffer
- Epilepsy Research Centre, The University of Melbourne, Austin Health, Heidelberg, Victoria, Australia.
- Florey and Murdoch Children's Research Institutes, Melbourne, Victoria, Australia.
- Department of Paediatrics, The University of Melbourne, Royal Children's Hospital, Parkville, Victoria, Australia.
| | - Sameer Zuberi
- Paediatric Neurosciences Research Group, School of Health & Wellbeing, University of Glasgow, Glasgow, UK
- Paediatric Neurosciences, Royal Hospital for Children, Glasgow, UK
| | - Heather C Mefford
- Center for Paediatric Neurological Disease Research, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Renzo Guerrini
- Neuroscience Department, Children's Hospital Meyer IRCCS, Florence, Italy
- University of Florence, Florence, Italy
| | - Amy McTague
- Developmental Neurosciences, UCL Great Ormond Street Institute of Child Health, London, UK
- Department of Neurology, Great Ormond Street Hospital, London, UK
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2022 Overview of Metabolic Epilepsies. Genes (Basel) 2022; 13:genes13030508. [PMID: 35328062 PMCID: PMC8952328 DOI: 10.3390/genes13030508] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Revised: 03/09/2022] [Accepted: 03/10/2022] [Indexed: 12/04/2022] Open
Abstract
Understanding the genetic architecture of metabolic epilepsies is of paramount importance, both to current clinical practice and for the identification of further research directions. The main goals of our study were to identify the scope of metabolic epilepsies and to investigate their clinical presentation, diagnostic approaches and treatments. The International Classification of Inherited Metabolic Disorders and IEMbase were used as a basis for the identification and classification of metabolic epilepsies. Six hundred metabolic epilepsies have been identified, accounting for as much as 37% of all currently described inherited metabolic diseases (IMD). Epilepsy is a particularly common symptom in disorders of energy metabolism, congenital disorders of glycosylation, neurotransmitter disorders, disorders of the synaptic vesicle cycle and some other IMDs. Seizures in metabolic epilepsies may present variably, and most of these disorders are complex and multisystem. Abnormalities in routine laboratory tests and/or metabolic testing may be identified in 70% of all metabolic epilepsies, but in many cases they are non-specific. In total, 111 metabolic epilepsies (18% of all) have specific treatments that may significantly change health outcomes if diagnosed in time. Although metabolic epilepsies comprise an important and significant group of disorders, their real scope and frequency may have been underestimated.
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Tumienė B, del Toro Riera M, Grikiniene J, Samaitiene-Aleknienė R, Praninskienė R, Monavari AA, Sykut-Cegielska J. Multidisciplinary Care of Patients with Inherited Metabolic Diseases and Epilepsy: Current Perspectives. J Multidiscip Healthc 2022; 15:553-566. [PMID: 35387391 PMCID: PMC8977775 DOI: 10.2147/jmdh.s251863] [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: 12/02/2021] [Accepted: 03/17/2022] [Indexed: 11/25/2022] Open
Abstract
More than 650 inherited metabolic diseases may present with epilepsy or seizures. These diseases are often multisystem, life-long and induce complex needs of patients and families. Multidisciplinary care involves all stages of disease management: diagnostics, specific or symptomatic, acute and chronic treatments, and integrated care that takes into account not only medical, but also manifold psychosocial, educational, vocational and other needs of patients and their caregivers. Care coordination is indispensable to ensure smooth transitions of care across life and disease stages, including management of emergencies, transition from pediatric to adult services and palliative care. Care pathways are highly diverse and have to find the right balance between highly specialized and locally provided services. While multidisciplinary teams consist of many professionals, a named supervising physician in a highly specialized healthcare setting and a care coordinator are highly important. As the greatest burden of care always falls onto the shoulders of patients and/or families, patient empowerment should be a part of every care pathway and include provision of required information, involvement into common decision-making, patient’s and family’s education, support for self-management, liaison with peer support groups and emotional/ psychological support. Due to the rarity and complexity of these diseases, sufficient expertise may not be available in a national healthcare system and cross-border services (virtual or physical) in the recently developed European Reference Networks should be ensured through the proper organization of referral systems in each EU and EEA country. Finally, digital technologies are particularly important in the provision of services for patients with rare diseases and can significantly increase the availability of highly specialized services and expertise.
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Affiliation(s)
- Birutė Tumienė
- Institute of Biomedical Sciences, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
- Vilnius University Hospital Santaros klinikos, Vilnius, Lithuania
- Correspondence: Birutė Tumienė, Institute of Biomedical Sciences, Faculty of Medicine, Vilnius University, Santariskiu str. 2, Vilnius, LT-06681, Lithuania, Tel +370 614 45026, Email
| | - Mireia del Toro Riera
- Pediatric Neurology Department, Unit of Hereditary Metabolic Disorders, Hospital Universitari Vall d’Hebron, Barcelona, Spain
| | - Jurgita Grikiniene
- Clinic of Children’s Diseases, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Rūta Samaitiene-Aleknienė
- Clinic of Children’s Diseases, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Rūta Praninskienė
- Clinic of Children’s Diseases, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Ahmad Ardeshir Monavari
- National Centre for Inherited Metabolic Disorders, Children’s Health Ireland at Temple Street Dublin, Dublin, Ireland
- University College Dublin, Dublin, Ireland
| | - Jolanta Sykut-Cegielska
- Department of Inborn Errors of Metabolism and Paediatrics, the Institute of Mother and Child, Warsaw, Poland
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Guerrini R, Balestrini S, Wirrell EC, Walker MC. Monogenic Epilepsies: Disease Mechanisms, Clinical Phenotypes, and Targeted Therapies. Neurology 2021; 97:817-831. [PMID: 34493617 PMCID: PMC10336826 DOI: 10.1212/wnl.0000000000012744] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 08/18/2021] [Indexed: 02/05/2023] Open
Abstract
A monogenic etiology can be identified in up to 40% of people with severe epilepsy. To address earlier and more appropriate treatment strategies, clinicians are required to know the implications that specific genetic causes might have on pathophysiology, natural history, comorbidities, and treatment choices. In this narrative review, we summarize concepts on the genetic epilepsies based on the underlying pathophysiologic mechanisms and present the current knowledge on treatment options based on evidence provided by controlled trials or studies with lower classification of evidence. Overall, evidence robust enough to guide antiseizure medication (ASM) choices in genetic epilepsies remains limited to the more frequent conditions for which controlled trials and observational studies have been possible. Most monogenic disorders are very rare and ASM choices for them are still based on inferences drawn from observational studies and early, often anecdotal, experiences with precision therapies. Precision medicine remains applicable to only a narrow number of patients with monogenic epilepsies and may target only part of the actual functional defects. Phenotypic heterogeneity is remarkable, and some genetic mutations activate epileptogenesis through their developmental effects, which may not be reversed postnatally. Other genes seem to have pure functional consequences on excitability, acting through either loss- or gain-of-function effects, and these may have opposite treatment implications. In addition, the functional consequences of missense mutations may be difficult to predict, making precision treatment approaches considerably more complex than estimated by deterministic interpretations. Knowledge of genetic etiologies can influence the approach to surgical treatment of focal epilepsies. Identification of germline mutations in specific genes contraindicates surgery while mutations in other genes do not. Identification, quantification, and functional characterization of specific somatic mutations before surgery using CSF liquid biopsy or after surgery in brain specimens will likely be integrated in planning surgical strategies and reintervention after a first unsuccessful surgery as initial evidence suggests that mutational load may correlate with the epileptogenic zone. Promising future directions include gene manipulation by DNA or mRNA targeting; although most are still far from clinical use, some are in early phase clinical development.
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Affiliation(s)
- Renzo Guerrini
- From the Neuroscience Department (R.G., S.B.), Meyer Children's Hospital-University of Florence, Italy; Department of Clinical and Experimental Epilepsy (S.B., M.C.W.), UCL Queen Square Institute of Neurology, London; Chalfont Centre for Epilepsy (S.B.), Buckinghamshire, UK; and Divisions of Child and Adolescent Neurology and Epilepsy (E.C.W.), Department of Neurology, Mayo Clinic, Rochester, MN.
| | - Simona Balestrini
- From the Neuroscience Department (R.G., S.B.), Meyer Children's Hospital-University of Florence, Italy; Department of Clinical and Experimental Epilepsy (S.B., M.C.W.), UCL Queen Square Institute of Neurology, London; Chalfont Centre for Epilepsy (S.B.), Buckinghamshire, UK; and Divisions of Child and Adolescent Neurology and Epilepsy (E.C.W.), Department of Neurology, Mayo Clinic, Rochester, MN
| | - Elaine C Wirrell
- From the Neuroscience Department (R.G., S.B.), Meyer Children's Hospital-University of Florence, Italy; Department of Clinical and Experimental Epilepsy (S.B., M.C.W.), UCL Queen Square Institute of Neurology, London; Chalfont Centre for Epilepsy (S.B.), Buckinghamshire, UK; and Divisions of Child and Adolescent Neurology and Epilepsy (E.C.W.), Department of Neurology, Mayo Clinic, Rochester, MN
| | - Matthew C Walker
- From the Neuroscience Department (R.G., S.B.), Meyer Children's Hospital-University of Florence, Italy; Department of Clinical and Experimental Epilepsy (S.B., M.C.W.), UCL Queen Square Institute of Neurology, London; Chalfont Centre for Epilepsy (S.B.), Buckinghamshire, UK; and Divisions of Child and Adolescent Neurology and Epilepsy (E.C.W.), Department of Neurology, Mayo Clinic, Rochester, MN
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A hemlock salad: a case report of super-refractory status epilepticus after accidental hemlock ingestion. Neurol Sci 2021; 42:4335-4339. [PMID: 34189661 DOI: 10.1007/s10072-021-05421-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Accepted: 06/17/2021] [Indexed: 10/21/2022]
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Clinical characterization of status epilepticus in childhood: a retrospective study in 124 patients. Seizure 2020; 78:127-133. [DOI: 10.1016/j.seizure.2020.03.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2020] [Revised: 03/10/2020] [Accepted: 03/29/2020] [Indexed: 10/24/2022] Open
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