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The role of inflammatory mediators in epilepsy: Focus on developmental and epileptic encephalopathies and therapeutic implications. Epilepsy Res 2021; 172:106588. [PMID: 33721708 DOI: 10.1016/j.eplepsyres.2021.106588] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 01/28/2021] [Accepted: 02/16/2021] [Indexed: 02/06/2023]
Abstract
In recent years, there has been an increasing interest in the potential involvement of neuroinflammation in the pathogenesis of epilepsy. Specifically, the role of innate immunity (that includes cytokines and chemokines) has been extensively investigated either in animal models of epilepsy and in clinical settings. Developmental and epileptic encephalopathies (DEE) are a heterogeneous group of epileptic disorders, in which uncontrolled epileptic activity results in cognitive, motor and behavioral impairment. By definition, epilepsy in DEE is poorly controlled by common antiepileptic drugs but may respond to alternative treatments, including steroids and immunomodulatory drugs. In this review, we will focus on how cytokines and chemokines play a role in the pathogenesis of DEE and why expanding our knowledge about the role of neuroinflammation in DEE may be crucial to develop new and effective targeted therapeutic strategies to prevent seizure recurrence and developmental regression.
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Abstract
Childhood epileptic encephalopathies are age-dependent disorders of the brain whose hallmarks include loss of neurologic function over time, abnormal electroencephalographic findings, and seizures. Ictal and interictal electrographic activity are conjointly thought to be at the root of the often devastating neuropsychological deterioration, which is specific to the maturing brain. The goals of treatment are not only to control seizures, but also to prevent or reverse neurologic loss of function. In general, time is of the essence in diagnosis, and experienced specialists should promptly design a treatment plan. Hormonal and immune therapies are at the forefront of treatment in many cases, with traditional antiepileptic drugs and surgery (when an identifiable lesion is present) playing a limited role. However, gold standard evidence for treatment of epileptic encephalopathies remains limited. Ongoing clinical and basic research may lead to better understanding of these catastrophic conditions and to better and more effective therapies.
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Affiliation(s)
- Hiroki Nariai
- Saul R. Korey Department of Neurology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Susan Duberstein
- Saul R. Korey Department of Neurology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA,Department of Pediatrics, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, NY, USA
| | - Shlomo Shinnar
- Saul R. Korey Department of Neurology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA,Department of Pediatrics, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, NY, USA,Department of Epidemiology and Population Health, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, NY, USA
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Abstract
This article focuses on the inflammatory processes in patients with generalized epilepsies. We specifically review the data regarding West, Lennox-Gastaut, and Landau-Kleffner syndromes as they have generalized clinical or electroencephalogram features. There is substantial evidence for a pathogenic implication of immune mechanisms in these epilepsies. Animal models and abnormalities in both cellular and humoral immunity support this hypothesis. They also appear to be particularly responsive to immunomodulatory therapies, which has raised the speculation that an unbalanced immune system may play an important role in the pathophysiology of these epileptic syndromes. In this article, we discuss clinical and experimental data that support the potential implication of immune mediated inflammation and immune response in the mechanism of these entities.
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Continuous Spikes and Waves during Sleep: Electroclinical Presentation and Suggestions for Management. EPILEPSY RESEARCH AND TREATMENT 2013; 2013:583531. [PMID: 23991336 PMCID: PMC3748771 DOI: 10.1155/2013/583531] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/25/2013] [Accepted: 07/07/2013] [Indexed: 01/21/2023]
Abstract
Continuous spikes and waves during sleep (CSWS) is an epileptic encephalopathy characterized in most patients by (1) difficult to control seizures, (2) interictal epileptiform activity that becomes prominent during sleep leading to an electroencephalogram (EEG) pattern of electrical status epilepticus in sleep (ESES), and (3) neurocognitive regression. In this paper, we will summarize current epidemiological, clinical, and EEG knowledge on CSWS and will provide suggestions for treatment. CSWS typically presents with seizures around 2-4 years of age. Neurocognitive regression occurs around 5-6 years of age, and it is accompanied by subacute worsening of EEG abnormalities and seizures. At approximately 6-9 years of age, there is a gradual resolution of seizures and EEG abnormalities, but the neurocognitive deficits persist in most patients. The cause of CSWS is unknown, but early developmental lesions play a major role in approximately half of the patients, and genetic associations have recently been described. High-dose benzodiazepines and corticosteroids have been successfully used to treat clinical and electroencephalographic features. Corticosteroids are often reserved for refractory disease because of adverse events. Valproate, ethosuximide, levetiracetam, sulthiame, and lamotrigine have been also used with some success. Epilepsy surgery may be considered in a few selected patients.
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Sánchez Fernández I, Loddenkemper T, Peters JM, Kothare SV. Electrical status epilepticus in sleep: clinical presentation and pathophysiology. Pediatr Neurol 2012; 47:390-410. [PMID: 23127259 DOI: 10.1016/j.pediatrneurol.2012.06.016] [Citation(s) in RCA: 88] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2012] [Accepted: 06/20/2012] [Indexed: 10/27/2022]
Abstract
Electrical status epilepticus in sleep involves an electroencephalographic pattern where interictal epileptiform activity is potentiated in the transition from wakefulness to sleep. Near-continuous spikes and waves that occupy a significant proportion of nonrapid eye movement sleep appear as a result of sleep-potentiated epileptiform activity. This electroencephalographic pattern appears in different electroclinical syndromes that present three common characteristics with different degrees of severity: seizures, sleep-potentiated epileptiform activity, and neuropsychologic regression. Continuous spikes and waves during sleep comprise the severest epileptic encephalopathy in the electroclinical spectrum. Landau-Kleffner syndrome presents with intermediate severity. Some "benign" pediatric focal epileptic syndromes represent the mildest end of this continuum. Based on published data, we provide a framework for clinical and electrical events. The underlying mechanisms leading to sleep potentiation of epileptiform activity in electrical status epilepticus in sleep are incompletely understood. A genetic basis or acquired early developmental insult may disrupt the normal maturation of neuronal networks. These factors may dynamically alter normal processes of brain development, leading to an age-related pattern of electroclinical expression of electrical status epilepticus in sleep.
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Affiliation(s)
- Iván Sánchez Fernández
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Geva-Dayan K, Shorer Z, Menascu S, Linder I, Goldberg-Stern H, Heyman E, Lerman-Sagie T, Ben Zeev B, Kramer U. Immunoglobulin treatment for severe childhood epilepsy. Pediatr Neurol 2012; 46:375-81. [PMID: 22633633 DOI: 10.1016/j.pediatrneurol.2012.03.015] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2011] [Accepted: 03/26/2012] [Indexed: 01/06/2023]
Abstract
We have used intravenous immunoglobulin to treat pediatric patients with various severe epileptic conditions. This retrospective, multicenter study comprised 64 consecutive patients treated with immunoglobulins for either epileptic encephalopathy or refractory epilepsy. The rate of full or partial improvement according to specific syndrome involved three of four patients with idiopathic West syndrome, six of 12 patients with electrical status epilepticus in sleep, eight of 19 patients with an undefined syndrome, one of three patients with Landau-Kleffner syndrome, and one of two patients with Rasmussen encephalitis. Intravenous immunoglobulins were ineffective in 10 patients with symptomatic West syndrome, nine with febrile infection-related status epilepticus, three with myoclonic astatic epilepsy, and two with Lennox-Gastaut syndrome. Nine patients (14%) demonstrated complete resolution, and 10 (15.6%) exhibited partial improvement. Of these 19 responders (29.7%), eight relapsed. Although intravenous immunoglobulin is not suitable for all cases of epilepsy, it may prove efficacious for specific epileptic syndromes, mainly idiopathic West syndrome and electrical status epilepticus during sleep.
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Affiliation(s)
- Karen Geva-Dayan
- Pediatric Neurology Unit, Dana Children's Hospital, Tel Aviv, Israel
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Hussain S, Sankar R. Pharmacologic treatment of intractable epilepsy in children: a syndrome-based approach. Semin Pediatr Neurol 2011; 18:171-8. [PMID: 22062941 DOI: 10.1016/j.spen.2011.06.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
Abstract
The successful pharmacologic treatment of intractable childhood epilepsy is predicated upon an accurate classification of the epilepsy syndrome. The selection of an antiepileptic drug is facilitated by the knowledge of syndrome-specific efficacy, the anticipation of potential side effects, and a careful risk-benefit assessment tailored to each patient. As such, the identification of comorbidities and careful monitoring for treatment-emergent adverse events, especially cognitive and behavioral effects, is of utmost importance. Especially in refractory cases, polypharmacy may increase the likelihood of side effects, but carefully chosen combinations can result in synergistic benefit. For most epilepsy syndromes, newer antiepileptic drugs typically yield equivalent efficacy and superior tolerability. Nevertheless, continued research is needed to further contrast the syndrome-specific efficacy and tolerability of available drugs and to foster the development of new agents with superior efficacy and side effect profiles.
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Affiliation(s)
- Shaun Hussain
- David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
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Continuous spike and waves during sleep and electrical status epilepticus in sleep. J Clin Neurophysiol 2011; 28:154-64. [PMID: 21399511 DOI: 10.1097/wnp.0b013e31821213eb] [Citation(s) in RCA: 67] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Continuous spike and waves during sleep is an age-related epileptic encephalopathy that presents with neurocognitive regression, seizures, and an EEG pattern of electrical status epilepticus during sleep. Patients usually present around 5 years of age with infrequent nocturnal unilateral motor seizures that progress within 1 to 2 years to a severe epileptic encephalopathy with frequent seizures of different types, marked neurocognitive regression, and an almost continuous spike-wave EEG pattern during slow-wave sleep. The pathophysiology of continuous spike and waves during sleep is not completely understood, but the corticothalamic neuronal network involved in physiologic oscillating patterns of sleep is thought to be switched into a pathologic discharging mode. Early developmental injury and/or genetic predisposition may play a role in the potentiation of age-related hyperexcitability in the immature brain. A better understanding of the mechanisms leading to electrical status epilepticus during sleep may provide additional therapeutic targets that can improve the outcome of seizures, EEG pattern, and cognitive development in patients with continuous spike and waves during sleep.
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Landau-Kleffner syndrome: a rare auditory processing disorder series of cases and review of the literature. Int J Pediatr Otorhinolaryngol 2011; 75:33-8. [PMID: 21074868 DOI: 10.1016/j.ijporl.2010.10.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2010] [Revised: 09/28/2010] [Accepted: 10/01/2010] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To describe the clinical presentation and treatment of 3 children with an Auditory Processing Disorder with an identifiable neurological cause: Landau-Kleffner syndrome. This classical syndrome is well recognized in pediatric neurology but the diagnosis is less well known to Pediatric Otolaryngology, Speech Language Pathology and Audiology services. METHODS Retrospective chart review of three patients with Landau-Kleffner syndrome. RESULTS In all cases, pharmacological intervention led to clinical and electroencephalographic improvement, but all patients had long-term difficulty with understanding sounds in a noisy environment. Magnetic Resonance Imaging (MRI) of the brain was normal in all three patients. Their language disturbance improved over time. Speech language intervention was helpful in addressing communication difficulties arising from the auditory processing/receptive and expressive language disorder. CONCLUSION A multidisciplinary assessment is the key for early diagnosis, treatment and follow-up in patients with this syndrome.
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Tuchman R, Alessandri M, Cuccaro M. Autism spectrum disorders and epilepsy: moving towards a comprehensive approach to treatment. Brain Dev 2010; 32:719-30. [PMID: 20558021 DOI: 10.1016/j.braindev.2010.05.007] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2010] [Revised: 05/15/2010] [Accepted: 05/17/2010] [Indexed: 11/29/2022]
Abstract
The biological and phenotypic heterogeneity of children with autism spectrum disorders (ASD) and epilepsy presents a significant challenge to the development of effective treatment protocols. There is no single treatment or treatment protocol for children with ASD or epilepsy. Children with co-occurring ASD and epilepsy should undergo a comprehensive assessment that includes investigation of underlying biological etiologies as well assessment of cognitive, language, affective, social and behavioral function prior to initiating treatment. The comprehensive treatment of children with ASD is based on a combination of therapeutic psychosocial interventions in combination with pharmacological agents. A process-oriented approach to assessment and intervention allows careful analysis of the child's response to treatment such that treatment protocols may be revised secondary to any changes in developmental trajectory of the child with ASD and epilepsy. The possibility of developing pharmacological interventions that target both ASD and epilepsy awaits definitive evidence. The best hope for good developmental outcomes in children with ASD and epilepsy is early recognition and comprehensive treatment of both the ASD and epilepsy.
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Affiliation(s)
- Roberto Tuchman
- Department of Neurology, Miami Children's Hospital, Dan Marino Center, Weston, FL, USA.
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Abstract
The study of antibodies to the glutamate AMPA receptor subtype 3 in the pathogenesis of severe epilepsy associated with Rasmussen's encephalitis helped to crystallize the concept of autoimmune epilepsy. This work has been used as a paradigm to investigate autoimmunity, especially the humoral components, in several severe childhood epilepsies and more recently, in some of the more common acquired adult epilepsies. In addition, it helped prompt many open-label trials of immunotherapy for various epilepsies. We discuss the evidence that antiglutamate AMPA receptor subtype 3 antibodies are pathogenic and review the findings of the studies of immunotherapy for epilepsy. We conclude that immune treatments can have useful disease-modifying effects in some rare epilepsies, such as Rasmussen's encephalitis, at least in the short term and that their potential should be studied in the management of some forms of severe adult epilepsy.
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Affiliation(s)
- Mia Levite
- Dept of Neurobiology, The Weizmann Institute of Science, 76100 Rehovot, Israel.
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Mikati MA, Kurdi R, El-Khoury Z, Rahi A, Raad W. Intravenous immunoglobulin therapy in intractable childhood epilepsy: open-label study and review of the literature. Epilepsy Behav 2010; 17:90-4. [PMID: 20004620 DOI: 10.1016/j.yebeh.2009.10.020] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2009] [Revised: 10/20/2009] [Accepted: 10/21/2009] [Indexed: 12/24/2022]
Abstract
Our aim was to investigate the long term effectiveness of intravenous immunoglobulin (IVIG) against intractable childhood epilepsy in the era of new antiepileptics and to determine the predictors of a favorable response in a prospective open-label add-on study. Of thirty-seven 9.9+/-0.9-year-old patients (11 with partial seizures, 26 with generalized seizures of whom 9 had West syndrome and 17 Lennox-Gastaut syndrome) followed for 15+/-3 months, 43% had a >50% decrease in seizures (including 15% seizure free, 229+/-58 compared with 104+/-3 seizures/month, P=0.035: generalized 246+/-318 to 117+/-200, P=0.025, partial 191+/-437 to 72+/-179, P>0.05; power=0.2). Males were more likely to respond than females (P=0.011, odds ratio=9.3). Review of the literature revealed nine other articles reporting efficacy of IVIG against epileptic seizures. Only one other used statistical methods and, unlike ours, showed only a trend toward seizure frequency reduction without achieving statistical significance, presumably because it was underpowered. These results indicate large-scale controlled studies of IVIG in epilepsy are still needed.
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Affiliation(s)
- Mohamad A Mikati
- Adult and Pediatric Epilepsy Program, Department of Pediatrics and Adolescent Medicine, American University of Beirut Medical Center, Beirut, Lebanon.
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Lagae L. Rational treatment options with AEDs and ketogenic diet in Landau-Kleffner syndrome: still waiting after all these years. Epilepsia 2009; 50 Suppl 7:59-62. [PMID: 19682054 DOI: 10.1111/j.1528-1167.2009.02222.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Antiepileptic drugs (AEDs) remain a first treatment approach in Landau-Kleffner syndrome (LKS) and related syndromes. In the current literature, only class IV evidence is available. Inclusion criteria and outcome parameters are ill-defined. Most commonly, valproate, ethosuximide, and/or benzodiazepines are used. More recent case series show that sulthiame and especially levetiracetam can be considered as effective drugs. Smaller studies also point to the ketogenic diet as a valuable treatment option in LKS.
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Affiliation(s)
- Lieven Lagae
- Department of Pediatric Neurology, University Hospitals KULeuven, Herestraat 49, Leuven, Belgium.
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Scheltens-de Boer M. Guidelines for EEG in encephalopathy related to ESES/CSWS in children. Epilepsia 2009; 50 Suppl 7:13-7. [DOI: 10.1111/j.1528-1167.2009.02211.x] [Citation(s) in RCA: 112] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Arts WFM, Aarsen FK, Scheltens-de Boer M, Catsman-Berrevoets CE. Landau-Kleffner syndrome and CSWS syndrome: Treatment with intravenous immunoglobulins. Epilepsia 2009; 50 Suppl 7:55-8. [DOI: 10.1111/j.1528-1167.2009.02221.x] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Elovaara I, Apostolski S, van Doorn P, Gilhus NE, Hietaharju A, Honkaniemi J, van Schaik IN, Scolding N, Soelberg Sørensen P, Udd B. EFNS guidelines for the use of intravenous immunoglobulin in treatment of neurological diseases. Eur J Neurol 2008; 15:893-908. [DOI: 10.1111/j.1468-1331.2008.02246.x] [Citation(s) in RCA: 219] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Abstract
Electrical status epilepticus in sleep (ESES) describes an electroencephalographic pattern showing significant activation of epileptiform discharges in sleep. The terms continuous spike wave in slow-wave sleep (CSWS) and Landau-Kleffner syndrome (LKS) describe the clinical epileptic syndromes seen with ESES. Although there is an overlap between these 2 syndromes, children with CSWS present with a more global regression have more problematic epilepsy and have EEG foci located predominantly in frontotemporal or frontocentral regions. In contrast, children with LKS present with an acquired auditory agnosia, fewer seizures, and EEG foci in the posterotemporal regions. ESES requires a high degree of clinical suspicion because slow-wave sleep must be recorded to confirm this diagnosis. Treatment of ESES extends beyond just control of the seizures; amelioration of the continuous epileptiform discharge must occur to improve neuropsychological outcome. Although there is little evidence to guide treatment, conventional antiepileptic drugs play only a minimal role. Steroid therapy and high-dose benzodiazepines are most commonly used, but other therapies including intravenous gamma-globulin, the ketogenic diet, and surgical therapy with multiple subpial transaction have shown efficacy in small case series. Although epilepsy resolves with time in most cases, many children are left with significant cognitive or language impairment. Longer duration of ESES appears to be the major predictor of poor outcome; markedly abnormal neuronal activity during a critical period for synaptogenesis may result in aberrant synapse formation, explaining the poorer neuropsychological outcome. Early recognition and effective therapy are necessary to improve long-term prognosis in this condition.
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Carmant L. Can we improve the outcome of epileptic encephalopathies? FUTURE NEUROLOGY 2007. [DOI: 10.2217/14796708.2.2.219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
The Canadian pediatric epilepsy network defines an epileptic encephalopathy (EE) as: “a brain dysfunction manifested by a progressive decline in cognitive and behavioral functions that is associated with frequent seizures and/or interictal epileptiform discharges in a child with medically refractory epilepsy.” Outcomes of these EEs are usually poor owing to the presence of continuous epileptic discharges and/or very frequent seizures, leading to excitotoxic cell death. In addition, early diagnosis is often delayed because of the subtle initial manifestations, and an inadequate choice of treatment not only worsens the seizures acutely but possibly alters long-term prognosis. Steroids, a ketogenic diet and vagal nerve stimulation are possible alternatives to improve the outcome of certain EEs, but I believe developing new therapeutic agents that target the mechanisms implicated in animal models should be favored. Possible targets include γ-aminobutyric acid B receptors, calcium channels or intracellular calcium stores.
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Affiliation(s)
- Lionel Carmant
- University of Montreal, Department of Pediatrics, Division of Neurology, Director of the Epilepsy Clinic & Epilepsy Research Group, Sainte-Justine Hospital, 3175 Sainte-Catherine Road, Montreal, QC H3T 1C5, Canada
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Hirsch E, Valenti MP, Rudolf G, Seegmuller C, de Saint Martin A, Maquet P, Wioland N, Metz-Lutz MN, Marescaux C, Arzimanoglou A. Landau–Kleffner syndrome is not an eponymic badge of ignorance. Epilepsy Res 2006; 70 Suppl 1:S239-47. [PMID: 16806832 DOI: 10.1016/j.eplepsyres.2006.02.010] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2006] [Revised: 02/05/2006] [Accepted: 02/05/2006] [Indexed: 11/30/2022]
Abstract
In a 1992 editorial article, Landau expressed the hope of collective agreement in the medical community about Landau-Kleffner syndrome (LKS) in terms of diagnosis criteria, etiology, pathophysiology and rational therapy. Since then, neurophysiological and neuroimaging studies have led to the view that LKS is an acquired aphasia, secondary to an epileptic disturbance affecting a cortical area involved in verbal processing. This fits with the hypothesis of a "functional ablation" caused by epileptic activity. Under these criteria, epileptic aphasia becomes a subgroup of the continuous spike-waves syndrome in which epileptic discharges originate from the temporal cortex. Genetic predisposition for KLS could be related to hyperexcitability and synchronization of interneurons within the perisylvian cortices, which generate the spike-waves. Activation of these waves during NREM sleep, following thalamo-cortical uncoupling, might then alter the blood brain barrier and provoke an autoimmune reaction. Interneuron hyperactivity might in turn have an antiepileptic protective effect, associated with the inhibition of a specific function, and spike-waves activity over the long term might eventuate in focal atrophy. This morphological defect might explain the poor verbal outcome in some cases of LKS. From this study we recommend a multicenter control study of good design and methodology be carried out to compare the efficacies of early versus delayed (3 months) corticosteroid treatment in patients with typical LKS that is being treated by clobazam (or diazepam) monotherapy.
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Abstract
Landau-Kleffner syndrome (LKS) is an acquired epileptic aphasia disorder in which children, usually 3-8 years of age who have developed age-appropriate speech, experience language regression with verbal auditory agnosia, abnormal epileptiform activity, behavioral disturbances, and sometimes overt seizures. There are no controlled clinical trials investigating the therapeutic options for LKS. Only open-label data are available. Early diagnosis and initiation of prompt medical treatment appear to be important to achieving better long-term prognosis.Several antiepileptic drugs have been reported to be beneficial in treating this syndrome. These include valproic acid (valproate sodium), diazepam, ethosuximide, clobazam, and clonazepam. Reports on the efficacy of lamotrigine, sultiame, felbamate, nicardipine, vigabatrin, levetiracetam, vagal nerve stimulation, and a ketogenic diet are few and more experience is needed. Carbamazepine and possibly phenobarbital and phenytoin have been reported to occasionally exacerbate the syndrome. As initial therapy, valproic acid or diazepam is often empirically chosen. Subsequently, other antiepileptic drugs, corticosteroids, or intravenous immunoglobulin (IVIG) therapy are often used. Corticosteroid therapy should probably not be delayed more than 1-2 months after the initial diagnosis. Various corticosteroid regimens including oral prednisone and, recently, high doses of intravenous pulse corticosteroids, as well as corticotropin (adrenocorticotropic hormone) have been reported to be effective in LKS. Oral corticosteroids are used more often and usually need to be maintained for a long period of time to prevent relapses. The use of IVIG has been associated with an initial dramatic response in only a few patients. In our experience, a long-term worthwhile improvement has been noted in only 2 of 11 patients. These two patients had an immediate response to IVIG initially and after relapses before eventually achieving a long-term sustained remission. Surgical treatment by multiple subpial transection, which is reserved for patients who have not responded to multiple medical therapies, has been followed in selected cases by a marked improvement in language skills and behavior. However, a widely accepted consensus about suitable candidates for this surgery and about its efficacy is still lacking. Speech therapy, including sign language, and a number of classroom and behavioral interventions are helpful in managing LKS, and should be used in all patients.
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Affiliation(s)
- Mohamad A Mikati
- Department of Pediatrics, and Adult and Pediatric Epilepsy Program, Faculty of Medicine, American University of Beirut, Beirut, Lebanon.
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Sinclair DB, Snyder TJ. Corticosteroids for the treatment of Landau-kleffner syndrome and continuous spike-wave discharge during sleep. Pediatr Neurol 2005; 32:300-6. [PMID: 15866429 DOI: 10.1016/j.pediatrneurol.2004.12.006] [Citation(s) in RCA: 78] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2004] [Revised: 10/19/2004] [Accepted: 12/28/2004] [Indexed: 11/22/2022]
Abstract
Landau-Kleffner syndrome and its variants such as continuous Spike-Wave Discharge during Sleep (CSWS) are progressive epileptic encephalopathies of childhood. The treatment of this unusual group of patients is controversial. We describe our experience in treating patients with Landau-Kleffner syndrome and CSWS with corticosteroids. The patients received Prednisone 1 mg/kg/day for 6 months, 1 year, then yearly. Follow-up was for 1-10 years (mean 4 years). Ten patients, 3 females, 7 males were studied. Age of onset ranged from 2 to 11 years (mean 7.5 years). Eight patients manifested Landau-Kleffner syndrome, and two had CSWS. Most patients had seizures (8/10); however, two patients did not have clinical seizures. MRI was normal in all patients. SPECT scan was abnormal in four patients, normal in three, and not available in three. All but one patient manifested significant improvement in language, cognition, and behaviour, which continued after the corticosteroid trial. Side effects were few (4/10) and transient and consisted of weight gain (2), behavioral change (1), and hypertension (1). Corticosteroids are a safe and effective treatment for patients with Landau-Kleffner syndrome and CSWS. Most patients had improvement in language, cognition, and behaviour after treatment. Side effects are few and reversible, and benefits appear long lasting. Corticosteroids should be considered as a treatment option in children with Landau-Kleffner syndrome and CSWS.
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Affiliation(s)
- D Barry Sinclair
- Comprehensive Epilepsy Program, University Of Alberta, Edmonton, Alberta, Canada
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Scholtes FBJ, Hendriks MPH, Renier WO. Cognitive deterioration and electrical status epilepticus during slow sleep. Epilepsy Behav 2005; 6:167-73. [PMID: 15710299 DOI: 10.1016/j.yebeh.2004.11.001] [Citation(s) in RCA: 68] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2003] [Revised: 10/18/2004] [Accepted: 11/05/2004] [Indexed: 11/30/2022]
Abstract
The results of long-term follow-up of 10 children with global or specific cognitive deterioration and, on the electroencephalogram, electrical status epilepticus during sleep (ESES) are described. They were referred because of cognitive deterioration and underwent repeated neurological and neuropsychological examinations and all-night electroencephalography. A previous cognitive level was known or could be estimated in all. Seven children had a continuous spikes and waves during sleep (CSWS) syndrome, with global cognitive deterioration in four and more specific cognitive decline in three, and another three children had Landau-Kleffner syndrome (LKS). Of the last three, two children never had seizures, while the other had localization-related epilepsy. No children experienced aggravation of clinical seizures. However, therapy was disappointing. Cognitive dysfunction did not respond to valproate and/or benzodiazepines in 9 of the 10 children. A frontal epileptic focus was found in 5 of 7 children with CSWS, and a left temporal focus in 2 of 3 children with LKS. The ESES persisted in CSWS for 5-9 years and in LKS for 1-5 years, and disappeared at puberty. Good cognitive recovery after disappearance of ESES occurred in only one child, and partial recovery in four. An unfavorable prognosis of cognitive deterioration seems to be related to long-duration ESES and/or early onset epileptic activity. The authors are of the opinion that cognitive deterioration in children, with or without manifest epileptic seizures, should mandate electroencephalographic investigation during sleep.
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Billiau AD, Wouters CH, Lagae LG. Epilepsy and the immune system: is there a link? Eur J Paediatr Neurol 2005; 9:29-42. [PMID: 15701565 DOI: 10.1016/j.ejpn.2004.10.005] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2004] [Revised: 10/27/2004] [Accepted: 10/28/2004] [Indexed: 11/28/2022]
Abstract
The concept that the immune system plays a role in the epileptogenic process of some epileptic syndromes was first proposed more than 20 years ago. Since then, numerous studies have reported on the existence of a variety of immunological alterations in epileptic patients, on the observation of favourable responses of refractory epilepsy syndromes to immunomodulatory treatment, and on the association of certain well-known immune-mediated disease states with epilepsy. This review comprehensively recapitulates the currently available evidence supporting or arguing against the possible involvement of the immune system in the pathogenesis of certain types of epilepsy. It is concluded that an abundance of facts is in support of this concept and that further studies should be directed at substantiating the pathogenic significance of (auto)immune responses in certain types of epilepsy. Current progress in the functional and molecular immunological research techniques will indisputably contribute to the elucidation of this link.
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Affiliation(s)
- An D Billiau
- Pediatric Rheumatology Department, University Hospital Gasthuisberg, Herestraat 49, B-3000 Leuven, Belgium.
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24
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Okuyaz C, Aydin K, Gücüyener K, Serdaroğlu A. Treatment of electrical status epilepticus during slow-wave sleep with high-dose corticosteroid. Pediatr Neurol 2005; 32:64-7. [PMID: 15607609 DOI: 10.1016/j.pediatrneurol.2004.06.020] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2004] [Accepted: 06/15/2004] [Indexed: 11/26/2022]
Abstract
A 4-year-old female patient with epilepsy with continuous spike-and-waves during slow-wave sleep not classified as Landau-Klefner syndrome, refractory to antiepileptic drugs including valproate, benzodiazepines, and lamotrigine, was treated successfully with high-dose intravenous methylprednisolone therapy. Valproate, clobazam, and lamotrigine were continued at the same dose during and after high-dose intravenous corticosteroid therapy. During corticosteroid therapy, awake and sleep electroencephalogram was recorded every day. On day 7, a dramatic clinical and electroencephalographic response was observed. After high-dose intravenous methylprednisolone, prednisolone was administered orally (2 mg/kg daily) for 2 months, then gradually withdrawn. After the withdrawal of corticosteroid therapy, the patient maintained the clinical improvement in behavior, and no continuous spike-and-wave electrical status epilepticus during slow-wave sleep occurred on routine monthly sleep electroencephalogram performed for the last 6 months. In the present case, an add-on high-dose intravenous corticosteroid seems to be effective in the treatment of patients with electrical status epilepticus during slow-wave sleep syndrome, especially when antiepileptic drugs fail.
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Affiliation(s)
- Cetin Okuyaz
- Department of Pediatric Neurology, Mersin University Medical Faculty, Ankara, Turkey
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25
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Trevathan E. Seizures and epilepsy among children with language regression and autistic spectrum disorders. J Child Neurol 2004; 19 Suppl 1:S49-57. [PMID: 15526970 DOI: 10.1177/088307380401900106] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Clinical and subclinical seizures occur frequently among children with autistic spectrum disorders. Electrographic status epilepticus in sleep, or continuous spike-wave in slow-wave sleep, is a typical feature of acquired epileptic aphasia and Landau-Kleffner syndrome. Seizures and epilepsy are more common among children with autistic spectrum disorder who experience language regression, especially those who experience language regression after the age of 2 years. Although the seizures associated with Landau-Kleffner syndrome and with acquired epileptic aphasia can be easily treated, improvement in language function often does not follow successful treatment of seizures. There are no published randomized clinical trials of treatments for Landau-Kleffner syndrome or for autistic language regression. Broad-spectrum antiepileptic drugs not associated with cognitive slowing are probably the treatment of choice for epilepsy among children with autistic spectrum disorder. Large multisite trials are needed to determine treatment efficacy among children with Landau-Kleffner syndrome and acquired epileptic aphasia and to establish whether there is a cause-effect relationship between electrographic status epilepticus in sleep or continuous spike-wave in slow-wave sleep and autistic language regression.
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Affiliation(s)
- Edwin Trevathan
- Pediatric Epilepsy Center, Departments of Neurology and Pediatrics, Washington University School of Medicine, Campus Box 8111, 660 South Euclid Avenue, St. Louis, MO 63110-1093, USA.
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26
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McVicar KA, Shinnar S. Landau-Kleffner syndrome, electrical status epilepticus in slow wave sleep, and language regression in children. ACTA ACUST UNITED AC 2004; 10:144-9. [PMID: 15362173 DOI: 10.1002/mrdd.20028] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The Landau-Kleffner syndrome (LKS) and electrical status epilepticus in slow wave sleep (ESES) are rare childhood-onset epileptic encephalopathies in which loss of language skills occurs in the context of an epileptiform EEG activated in sleep. Although in LKS the loss of function is limited to language, in ESES there is a wider spectrum of cognitive impairment. The two syndromes are distinct but have some overlap. The relationship between the epileptiform EEG abnormalities and the loss of cognitive function remains controversial, even in LKS which is the most widely accepted as an acquired epileptic aphasia. Language regression also occurs in younger children, frequently in the context of a more global autistic regression. Many of these children have epileptiform EEGs. The term autistic regression with epileptiform EEG has been proposed for these children. Whether these children are part of an extended LKS spectrum is very controversial, because there are differences in age of onset, clinical phenotype, and EEG findings. An understanding of the available data on clinical characteristics, EEG findings, pathology, prognosis, and treatment of these syndromes is essential for further progress in this area.
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Affiliation(s)
- Kathryn A McVicar
- Departments of Neurology, Pediatrics, the Comprehensive Epilepsy Management Center, Montefiore Medical Center, The Albert Einstein College of Medicine, Bronx, New York 10467, USA
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27
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Abstract
A 5-year-old girl with Landau-Kleffner syndrome is discussed. The child began having seizures at age 4 associated with language deterioration despite anticonvulsant therapy. With levetiracetam monotherapy to a dose of 60 mg/kg/day and discontinuation of carbamazepine and valproic acid, her language has improved and seizures are controlled. Levetiracetam should be considered as therapy for Landau-Kleffner syndrome.
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Affiliation(s)
- Eric H Kossoff
- Department of Neurology, The Johns Hopkins Hospital, Jefferson 128, 600 North Wolfe Street, Baltimore, MD 21287-1000, USA.
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28
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Bingel U, Pinter JD, Sotero de Menezes M, Rho JM. Intravenous immunoglobulin as adjunctive therapy for juvenile spasms. J Child Neurol 2003; 18:379-82. [PMID: 12886970 DOI: 10.1177/08830738030180061001] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Intravenous immunoglobulin has been reported to be an effective treatment for infantile spasms. Juvenile spasms are electrically and clinically similar to infantile spasms but occur in a later age group. We retrospectively reviewed the charts of five children (aged 4.5-11.5 years) at our institution. Their primary seizure type was juvenile spasms and they were treated with a single inpatient course of intravenous immunoglobulin (400 mg/kg/day intravenously for 5 consecutive days) on an adjunctive basis. Seizure frequency was determined from parental reports. By 3 months after treatment, improvement (a 50-92% reduction in seizure frequency) was noted in four patients; sustained benefit was seen in three patients for up to 12 months. One patient showed no response at 3 and 6 months and had an increase in seizure frequency at 1 year. We conclude that single-course intravenous immunoglobulin can be effective as adjunctive therapy for juvenile spasms and that benefit can persist for many months. However, larger controlled, prospective clinical trials are needed to validate this unconventional treatment modality for specific seizure types such as juvenile spasms.
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Affiliation(s)
- Ulrike Bingel
- University of Washington, Children's Hospital and Regional Medical Center, Seattle, USA
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29
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Kolski H, Otsubo H. The Landau-Kleffner syndrome. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2002; 497:195-208. [PMID: 11993733 DOI: 10.1007/978-1-4615-1335-3_18] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/24/2023]
Abstract
Landau-Kleffner Syndrome is a rare childhood disorder which involves seizures and acquired aphasia. Anticonvulsants, or the passage of time, may control the seizures, but speech recovery is variable, and the aphasia may persist.
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Affiliation(s)
- Hanna Kolski
- The Hospital for Sick Children, Toronto, Ontario, Canada
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30
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Abstract
Landau-Kleffner syndrome is marked by an acquired aphasia in children who have had normal language and motor development. A 3.5-year-old girl was referred to our clinic with stuttering. She was diagnosed as having benign myoclonic epilepsy of infancy at 3.5 months of age and treated with valproic acid. Her electroencephalogram (EEG) returned to normal at the end of the first year. The therapy was stopped after a 2-year seizure-free period. She started to stutter prominently 3 months after the discontinuation of antiepilepsy drugs. She had no verbal agnosia. Her EEG revealed multiple spike and wave discharges. She was diagnosed as having Landau-Kleffner syndrome. Her previous epilepsy history had contributed to her having obtained an EEG in the early period. We suggest that if a child with normal language function starts to stutter, Landau-Kleffner syndrome must be considered in the differential diagnosis.
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Affiliation(s)
- Sarenur Tütüncüoğlu
- Department of Pediatrics, Division of Child Neurology, Ege University Faculty of Medicine, Izmir, Turkey
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31
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Abstract
There is an increased but variable risk of epilepsy in autism. Three main factors--age, cognitive level, and type of language disorder--account for variability in the reported prevalence of epilepsy. The prevalence is highest in studies that have included adolescents and young adults, individuals with moderate to severe mental retardation and those with motor deficits, and individuals with severe receptive language deficits. The association of autism with clinical or subclinical epilepsy might denote common genetic factors in some cases. Whether subclinical epilepsy has adverse effects on cognition, language, and behaviour is debated, as is the relation of autistic regression with an epileptiform electroencephalogram to Landau-Kleffner syndrome. There is no evidence-based treatment recommendation for individuals with autism, regression, and subclinical epilepsy. Double-blind studies with sufficient power to resolve this issue are urgently needed.
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Affiliation(s)
- Roberto Tuchman
- Miami Children's Hospital, Dan Marino Center, Department of Neurology, Weston, FL 33331, USA.
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Wiles CM, Brown P, Chapel H, Guerrini R, Hughes RAC, Martin TD, McCrone P, Newsom-Davis J, Palace J, Rees JH, Rose MR, Scolding N, Webster ADB. Intravenous immunoglobulin in neurological disease: a specialist review. J Neurol Neurosurg Psychiatry 2002; 72:440-8. [PMID: 11909900 PMCID: PMC1737833 DOI: 10.1136/jnnp.72.4.440] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Treatment of neurological disorders with intravenous immunoglobulin (IVIg) is an increasing feature of our practice for an expanding range of indications. For some there is evidence of benefit from randomised controlled trials, whereas for others evidence is anecdotal. The relative rarity of some of the disorders means that good randomised control trials will be difficult to deliver. Meanwhile, the treatment is costly and pressure to "do something" in often distressing disorders considerable. This review follows a 1 day meeting of the authors in November 2000 and examines current evidence for the use of IVIg in neurological conditions and comments on mechanisms of action, delivery, safety and tolerability, and health economic issues. Evidence of efficacy has been classified into levels for healthcare interventions (tables 1 and 2).
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Affiliation(s)
- C M Wiles
- Sobell Department of Neurophysiology, Institute of Neurology, Queen Square, London WCIN 3BG, UK.
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Abstract
We administered 2 gm/kg of intravenous gamma globulin (IVIG) to each of five consecutive patients with Landau-Kleffner syndrome, over 4 days. We compared the 1-month baseline to that following IVIG using a severity score assessing speech, comprehension, behavior, seizures, and electroencephalography. There was a significant drop in this score after IVIG (P = 0.025). Two patients had a dramatic response to IVIG, with complete resolution of symptoms. This finding suggests that IVIG has at least some efficacy for the therapy of Landau-Kleffner syndrome.
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Affiliation(s)
- Mohamad A Mikati
- Epilepsy Program and Department of Pediatrics, American University of Beirut,New York, New York 10022, USA
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34
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Abstract
Landau-Kleffner syndrome (LKS), or acquired epileptiform aphasia, is an epilepsy syndrome involving progressive neuropsychological impairment related to the appearance of paroxysmal electroencephalograph (EEG) activity. LKS appears to share a common pathophysiologic mechanism with continuous spike-wave of sleep (CSWS), acquired epileptic opercular syndrome (AEOS), and even benign childhood epilepsy with centrotemporal spikes (BECTS), with differentiating factors including age of onset, area of primary epileptogenicity, and severity of clinical presentation. This article covers the clinical, diagnostic, therapeutic, and prognostic features of LKS. In a child with autistic spectrum disorder, the presence of a fluctuating clinical course or regression should raise suspicion for the presence of associated epilepsy.
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Affiliation(s)
- Phillip L. Pearl
- Department of Neurology, Children's National Medical Center, and George Washington University School of Medicine, Washington, D.C.;Neurosciences Scientific Operations, Novartis Pharmaceuticals Corporation, East Hanover, New Jersey;Department of Neurology, Children's Hospital, and Harvard Medical School, Boston, Massachusetts
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35
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Abstract
Childhood idiopathic language deterioration is a rare condition in which children lose previously gained language skills. In some children this language deterioration occurs in association with behavioral seizures or EEG epileptiform activity. The effectiveness of antiepileptic drugs in this patient population is not known. Here we retrospectively reviewed records of 57 children with childhood idiopathic language deterioration associated with seizures or epileptiform activity on their EEG who received valproate for the purpose of treating their language impairment. In 22 of the children improvement in language skills was observed. In two children language returned to normal while in the other 20 the improvement was modest. Children who responded to valproate had an earlier age of onset of the aphasia than children who were nonresponders. Seizure type, EEG findings, developmental status, and presence or absence of a frequency-modulated auditory evoked potential were not related to response. This study demonstrates that valproate can be helpful in improving language function in some children with idiopathic language deterioration associated with seizures or epileptiform activity on the EEG.
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36
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Abstract
An eight-year-old male child presenting with history of generalized convulsions, gradual loss of speech and generalized EEG (electroencephalography) abnormalities was diagnosed as Landau Kleffner Syndrome. He initially developed generalized convulsions which later changed to partial seizures during the course of illness. He was started on sodium valproate and continued with the drug (30 mg/kg/day) on which, he showed improvement in speech, behavior, hyperkinesis and frequency of convulsions during the follow-up.
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Affiliation(s)
- S Bharani
- Department of Pediatrics, Medical College, Baroda-390 001, Gujarat, India.
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37
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Ballaban-Gil K, Tuchman R. Epilepsy and epileptiform EEG: association with autism and language disorders. MENTAL RETARDATION AND DEVELOPMENTAL DISABILITIES RESEARCH REVIEWS 2001; 6:300-8. [PMID: 11107195 DOI: 10.1002/1098-2779(2000)6:4<300::aid-mrdd9>3.0.co;2-r] [Citation(s) in RCA: 118] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The relationship between epilepsy, language, behavior, and cognition is not well understood. Developmental and acquired disabilities such as autistic spectrum disorders, Landau-Kleffner Syndrome, electrical status epilepticus in sleep, and developmental dysphasias have been associated with epileptiform abnormalities. These disorders share many common features and raise important questions regarding this intricate relationship. This article reviews these disorders and discusses the proposed interaction between epileptiform abnormalities and cognitive dysfunction. Diagnostic and treatment issues will also be reviewed.
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Affiliation(s)
- K Ballaban-Gil
- Departments of Neurology and Pediatrics and the Montefiore/AECOM Epilepsy Management Unit, Albert Einstein College of Medicine, Bronx, New York, USA
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38
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Abstract
Atypical features in benign epilepsy of childhood with centrotemporal spikes (BECTS) are not uncommon. There are children with BECTS who do not have a benign outcome in terms of neuropsychologic functioning. BECTS have been linked with Landau-Kleffner syndrome (LKS) and continuous spikes and waves during slow sleep (CSWS). At the Medical College of Georgia from January 1988 to June 1999, 78 children, ages 2-16 years, were identified to have electroencephalogram evidence of centrotemporal spikes. Their medical records were reviewed for developmental history, behavioral problems, and school performance. Children with structural lesions/other epileptic syndromes were excluded. Fifty-six demonstrated a history of clinical seizures compatible with BECTS and 22 demonstrated centrotemporal spikes without clinical seizures. Among all children with centrotemporal spikes, 9% (n = 7) were diagnosed with mild intellectual disability (intelligence quotient < 70), 10% (n = 8) with borderline functioning, 31% (n = 24) with behavioral problems, and 17% (n = 13) with specific learning disabilities. Three children with BECTS experienced language delay and regression. Seizure control for BECTS usually is achieved without much difficulty, with excellent long-term prognosis. However, the data presented indicate that a large number of BECTS patients exhibit learning or behavior problems that require intervention. A small number may demonstrate language outcome similar to children with LKS and CSWS.
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Affiliation(s)
- A W Yung
- Department of Neurology, Section of Child Neurology, Medical College of Georgia, Augusta, Georgia 30912, USA
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39
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Galanopoulou AS, Bojko A, Lado F, Moshé SL. The spectrum of neuropsychiatric abnormalities associated with electrical status epilepticus in sleep. Brain Dev 2000; 22:279-95. [PMID: 10891635 DOI: 10.1016/s0387-7604(00)00127-3] [Citation(s) in RCA: 130] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Electrical status epilepticus in sleep (ESES) is an electrographic pattern consisting of an almost continuous presence of spike-wave discharges in slow wave sleep. ESES is frequently encountered in pediatric syndromes associated with epilepsy or cognitive and language dysfunction. It can be present in various evolutionary stages of a spectrum of diseases, the prototypes of which are the 'continuous spikes and waves during slow wave sleep' syndrome (CSWS), the Landau-Kleffner syndrome (LKS), as well as in patients initially presenting as benign childhood epilepsy with centrotemporal spikes (BECTS). The purpose of this article is to review the literature data on the semiology, electrographic findings, prognosis, therapeutic options, as well as the current theories on the pathophysiology of these disorders. The frequent overlap of CSWS, LKS, and BECTS urges an increased level of awareness for the occasional transition from benign conditions such as BECTS to more devastating syndromes such as LKS and CSWS. Identification of atypical signs and symptoms, such as high discharge rates, prolonged duration of ESES, neuropsychiatric and cognitive dysfunction, lack of responsiveness to medications, and pre-existing neurologic conditions is of paramount importance in order to initiate the appropriate diagnostic measures. Prolonged and if needed repetitive sleep electroencephalographs (EEGs) are warranted for proper diagnosis.
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Affiliation(s)
- A S Galanopoulou
- Department of Neurology, Albert Einstein College of Medicine, 1410 Pelham Parkway South, NY 10461, Bronx, USA.
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40
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Mikati MA, Saab R. Successful use of intravenous immunoglobulin as initial monotherapy in Landau-Kleffner syndrome. Epilepsia 2000; 41:880-6. [PMID: 10897161 DOI: 10.1111/j.1528-1157.2000.tb00257.x] [Citation(s) in RCA: 69] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
PURPOSE There is a need for new and more effective therapies for Landau-Kleffner syndrome. In this article we present the first case in which a patient with Landau-Kleffner syndrome was given intravenous immunoglobulin (IVIG) as his first and only therapy and responded to it. METHODS This previously healthy, left-handed boy presented at 31 months of age with a 3-month history of auditory agnosia, behavioral abnormalities, and progressive, eventually complete loss of speech. Electroencephalography (EEG) showed frequent and, in sleep, continuous right central and temporal spike slow wave discharges. Metabolic workup, magnetic resonance imaging, and auditory evoked potentials were normal. Cerebrospinal fluid IgG index was high (18%). The patient was treated with IVIG, as his initial and only therapy, receiving 500 mg/kg/day over four consecutive days. RESULTS On the third day of IVIG, the patient started using single words, and on the fourth, two-word sentences. Two weeks later his speech and behavior returned to normal. At the end of 4 days of IVIG therapy, EEG was within normal limits. Two months later, however, he had a severe relapse clinically and by EEG. He promptly responded to another course of IVIG. A subsequent cerebrospinal fluid IgG index showed normalization (6%). Three months later he had essentially normal speech and behavior. CONCLUSIONS Repeated, immediate, and remarkable clinical and EEG responses of this patient suggest that IVIG was helpful as first-line therapy in the treatment of Landau-Kleffner syndrome. It also supports the hypothesis that immunological mechanisms contributed to his symptoms.
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Affiliation(s)
- M A Mikati
- Adult and Pediatric Epilepsy Program and Department of Pediatrics, American University of Beirut, Beirut, Lebanon.
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41
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Abstract
Epilepsy, and its treatment, can affect the development and use of language in a number of different ways. The seizures may be a symptom of a lesion in areas of the brain essential for language function, and the complications of both the seizures and of the drugs can interfere with learning. However, the purpose of this review is to consider the role of epileptic activity as demonstrated by electrical discharges in the electroencephalogram (EEG), whether these are accompanied by overt seizures or not, on cerebral function especially that of language. The Landau-Kleffner, the continuous spike-waves during sleep, and the benign epilepsy of childhood with Rolandic spikes syndromes are considered; as well as the evidence of epileptic discharges affecting language development. If there are doubts that a patient is suffering from epilepsy the diagnosis may be difficult; and anyone involved in the treatment of language disorders should keep this possibility in mind. Particularly during childhood an EEG, awake and asleep, should be an important part of the assessment of both developmental and acquired dysphasia. The control of overt fits may be relatively easy, but drugs are not so effective in controlling the epileptic activity in the EEG. The treatment of such discharges used to be discouraged, but the evidence is now strongly in favour of employing both medical and surgical treatment. The results in restoring language function are sometimes dramatic.
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Affiliation(s)
- N Gordon
- Huntlywood, 3 Styal Road, Wilmslow, SK9 4AE, UK
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42
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Tsuru T, Mori M, Mizuguchi M, Momoi MY. Effects of high-dose intravenous corticosteroid therapy in Landau-Kleffner syndrome. Pediatr Neurol 2000; 22:145-7. [PMID: 10738922 DOI: 10.1016/s0887-8994(99)00127-7] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Two children with Landau-Kleffner syndrome were successfully treated with antiepileptic drugs and a high-dose intravenous corticosteroid. A combination of valproate and a benzodiazepine (clonazepam or diazepam) ameliorated epileptic seizures and electroencephalographic spikes and waves, but speech disturbances persisted. Both patients were treated with an intravenous infusion of high-dose methylprednisolone sodium succinate (20 mg/kg daily) for 3 consecutive days. This infusion was repeated three times with a 4-day interval between treatments, which resulted in a rapid improvement in speech ability. After intravenous therapy, prednisolone was given orally (2 mg/kg daily for 1 month, then gradually withdrawn), which maintained the clinical improvement in speech.
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Affiliation(s)
- T Tsuru
- Department of Pediatrics, Jichi Medical School, Tochigi, Japan
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43
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Bergqvist AG, Chee CM, Lutchka LM, Brooks-Kayal AR. Treatment of acquired epileptic aphasia with the ketogenic diet. J Child Neurol 1999; 14:696-701. [PMID: 10593544 DOI: 10.1177/088307389901401102] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Acquired epileptic aphasia remains a poorly understood entity, which is frequently difficult to treat. Previously described treatment modalities have included antiepileptic drugs, corticosteroids, intravenous immunoglobulin, and multiple subpial transections. We describe three patients with acquired epileptic aphasia refractory to traditional treatments who were successfully treated with the ketogenic diet. All three patients had lasting improvement of their language, behavior, and seizures for 26, 24, and 12 months, respectively. This is the first reported series of patients with acquired epileptic aphasia successfully treated with the ketogenic diet, and suggests a new therapeutic alternative for patients with this often difficult-to-treat disorder.
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Affiliation(s)
- A G Bergqvist
- Pediatric Regional Epilepsy Program, Division of Neurology, The Children's Hospital of Philadelphia, PA 19104, USA.
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