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Arredondo KH, Jülich K, Roach ES. Tuberous sclerosis complex: Diagnostic features, surveillance, and therapeutic strategies. Semin Pediatr Neurol 2024; 51:101155. [PMID: 39389658 DOI: 10.1016/j.spen.2024.101155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2024] [Revised: 09/05/2024] [Accepted: 09/10/2024] [Indexed: 10/12/2024]
Abstract
Tuberous sclerosis complex (TSC) is a rare neurocutaneous disorder of mTOR pathway dysregulation resulting from pathogenic variants in the TSC1 or TSC2 genes. Expression of this disorder may involve abnormal tissue growth and dysfunction within the brain, kidneys, heart, lungs, eyes, skin, bones, and teeth. Neurological manifestations can include subependymal giant cell astrocytomas (SEGAs), high rates of infantile spasms, drug-resistant epilepsy, developmental delay, cognitive impairment, autism spectrum disorder, and other neurobehavioral manifestations. Here we review the potential clinical manifestations of TSC by system, recommended diagnostic and surveillance testing, genetic testing, currently available therapeutic options, and considerations for education and social support resources given the unique challenges of this multi-system disorder.
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Affiliation(s)
- Kristen H Arredondo
- Department of Neurology, The University of Texas at Austin Dell Medical School, Austin, TX.
| | - Kristina Jülich
- Department of Neurology, The University of Texas at Austin Dell Medical School, Austin, TX.
| | - E Steve Roach
- Department of Neurology, The University of Texas at Austin Dell Medical School, Austin, TX.
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Heuvelmans AM, Proietti Onori M, Frega M, de Hoogen JD, Nel E, Elgersma Y, van Woerden GM. Modeling mTORopathy-related epilepsy in cultured murine hippocampal neurons using the multi-electrode array. Exp Neurol 2024; 379:114874. [PMID: 38914275 DOI: 10.1016/j.expneurol.2024.114874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2024] [Revised: 06/13/2024] [Accepted: 06/19/2024] [Indexed: 06/26/2024]
Abstract
The mechanistic target of rapamycin complex 1 (mTORC1) signaling pathway is a ubiquitous cellular pathway. mTORopathies, a group of disorders characterized by hyperactivity of the mTORC1 pathway, illustrate the prominent role of the mTOR pathway in disease pathology, often profoundly affecting the central nervous system. One of the most debilitating symptoms of mTORopathies is drug-resistant epilepsy, emphasizing the urgent need for a deeper understanding of disease mechanisms to develop novel anti-epileptic drugs. In this study, we explored the multiwell Multi-electrode array (MEA) system as a tool to identify robust network activity parameters in an approach to model mTORopathy-related epilepsy in vitro. To this extent, we cultured mouse primary hippocampal neurons on the multiwell MEA to identify robust network activity phenotypes in mTORC1-hyperactive neuronal networks. mTOR-hyperactivity was induced either through deletion of Tsc1 or overexpression of a constitutively active RHEB variant identified in patients, RHEBp.P37L. mTORC1 dependency of the phenotypes was assessed using rapamycin, and vigabatrin was applied to treat epilepsy-like phenotypes. We show that hyperactivity of the mTORC1 pathway leads to aberrant network activity. In both the Tsc1-KO and RHEB-p.P37L models, we identified changes in network synchronicity, rhythmicity, and burst characteristics. The presence of these phenotypes is prevented upon early treatment with the mTORC1-inhibitor rapamycin. Application of rapamycin in mature neuronal cultures could only partially rescue the network activity phenotypes. Additionally, treatment with the anti-epileptic drug vigabatrin reduced network activity and restored burst characteristics. Taken together, we showed that mTORC1-hyperactive neuronal cultures on the multiwell MEA system present reliable network activity phenotypes that can be used as an assay to explore the potency of new drug treatments targeting epilepsy in mTORopathy patients and may give more insights into the pathophysiological mechanisms underlying epilepsy in these patients.
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Affiliation(s)
- Anouk M Heuvelmans
- Department of Clinical Genetics, Erasmus Medical Center, Rotterdam 3015 CN, the Netherlands; The ENCORE Expertise Center for Neurodevelopmental Disorders, Rotterdam 3015 CN, the Netherlands.
| | - Martina Proietti Onori
- The ENCORE Expertise Center for Neurodevelopmental Disorders, Rotterdam 3015 CN, the Netherlands; Department of Neuroscience, Erasmus Medical Center, Rotterdam 3015 CN, the Netherlands
| | - Monica Frega
- Department of Clinical Neurophysiology, University of Twente, 7522 NB Enschede, the Netherlands
| | - Jeffrey D de Hoogen
- Department of Neuroscience, Erasmus Medical Center, Rotterdam 3015 CN, the Netherlands
| | - Eveline Nel
- Department of Clinical Genetics, Erasmus Medical Center, Rotterdam 3015 CN, the Netherlands
| | - Ype Elgersma
- Department of Clinical Genetics, Erasmus Medical Center, Rotterdam 3015 CN, the Netherlands; The ENCORE Expertise Center for Neurodevelopmental Disorders, Rotterdam 3015 CN, the Netherlands
| | - Geeske M van Woerden
- Department of Clinical Genetics, Erasmus Medical Center, Rotterdam 3015 CN, the Netherlands; The ENCORE Expertise Center for Neurodevelopmental Disorders, Rotterdam 3015 CN, the Netherlands; Department of Neuroscience, Erasmus Medical Center, Rotterdam 3015 CN, the Netherlands.
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Lazea C, Țaranu I, Bolboacă SD. Exploring Cardiovascular Involvement in Tuberous Sclerosis: Insights for Pediatric Clinicians. CHILDREN (BASEL, SWITZERLAND) 2024; 11:674. [PMID: 38929253 PMCID: PMC11201926 DOI: 10.3390/children11060674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/30/2024] [Revised: 05/22/2024] [Accepted: 05/23/2024] [Indexed: 06/28/2024]
Abstract
Tuberous sclerosis is a rare genetic disorder involving mainly the nervous and cardiovascular systems. The early recognition of the cardiovascular manifestations by the pediatrician allows an appropriate management and therefore enhances the quality of life of the affected children. Cardiac rhabdomyomas and the associated arrhythmias are the first cardiac features and they might represent a diagnosis challenge given their wide spectrum of clinical manifestations. We aimed to provide the paediatric practitioners with current knowledge regarding the cardiovascular complications in children with tuberous sclerosis. We overviewed the antenatal and postnatal evolution of cardiovascular manifestations, the systematic screening and long-term follow-up strategy of cardiac rhabdomyomas and arrhythmias in children with tuberous sclerosis.
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Affiliation(s)
- Cecilia Lazea
- Pediatric Clinic 1, Emergency Pediatric Hospital, Calea Moților, No. 68, 400370 Cluj-Napoca, Romania;
- Department Mother and Child, Iuliu Hațieganu University of Medicine and Pharmacy, Calea Moților, No. 68, 400370 Cluj-Napoca, Romania
| | - Ioana Țaranu
- Department of Medical Informatics and Biostatistics, Iuliu Hațieganu University of Medicine and Pharmacy, Louis Pasteur Str., No. 6, 400349 Cluj-Napoca, Romania;
| | - Sorana D. Bolboacă
- Department of Medical Informatics and Biostatistics, Iuliu Hațieganu University of Medicine and Pharmacy, Louis Pasteur Str., No. 6, 400349 Cluj-Napoca, Romania;
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Devinsky O, Jones NA, Cunningham MO, Jayasekera BAP, Devore S, Whalley BJ. Cannabinoid treatments in epilepsy and seizure disorders. Physiol Rev 2024; 104:591-649. [PMID: 37882730 DOI: 10.1152/physrev.00049.2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Revised: 10/17/2023] [Accepted: 10/22/2023] [Indexed: 10/27/2023] Open
Abstract
Cannabis has been used to treat convulsions and other disorders since ancient times. In the last few decades, preclinical animal studies and clinical investigations have established the role of cannabidiol (CBD) in treating epilepsy and seizures and support potential therapeutic benefits for cannabinoids in other neurological and psychiatric disorders. Here, we comprehensively review the role of cannabinoids in epilepsy. We briefly review the diverse physiological processes mediating the central nervous system response to cannabinoids, including Δ9-tetrahydrocannabinol (Δ9-THC), cannabidiol, and terpenes. Next, we characterize the anti- and proconvulsive effects of cannabinoids from animal studies of acute seizures and chronic epileptogenesis. We then review the clinical literature on using cannabinoids to treat epilepsy, including anecdotal evidence and case studies as well as the more recent randomized controlled clinical trials that led to US Food and Drug Administration approval of CBD for some types of epilepsy. Overall, we seek to evaluate our current understanding of cannabinoids in epilepsy and focus future research on unanswered questions.
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Affiliation(s)
- Orrin Devinsky
- Department of Neurology, NYU Grossman School of Medicine, New York, New York, United States
- Department of Neurosurgery, NYU Grossman School of Medicine, New York, New York, United States
- Department of Psychiatry, NYU Grossman School of Medicine, New York, New York, United States
| | | | - Mark O Cunningham
- Discipline of Physiology, School of Medicine, Trinity College Dublin, Dublin, Ireland
| | - B Ashan P Jayasekera
- Biosciences Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
- Department of Neurosurgery, Royal Victoria Hospital, Newcastle upon Tyne, United Kingdom
| | - Sasha Devore
- Department of Neurology, NYU Grossman School of Medicine, New York, New York, United States
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Licchetta L, Bruschi G, Stipa C, Belotti LMB, Ferri L, Mostacci B, Vignatelli L, Minardi R, Di Vito L, Muccioli L, Boni A, Tinuper P, Bisulli F. Tuberous sclerosis complex in adulthood: focus on epilepsy prognosis. Epilepsy Behav 2024; 153:109688. [PMID: 38428171 DOI: 10.1016/j.yebeh.2024.109688] [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: 11/04/2023] [Revised: 01/18/2024] [Accepted: 02/05/2024] [Indexed: 03/03/2024]
Abstract
OBJECTIVE Typically diagnosed in early childhood or adolescence, TSC is a chronic, multisystemic disorder with age-dependent manifestations posing a challenge for transition and for specific surveillance throughout the lifetime. Data on the clinical features and severity of TSC in adults and on the prognosis of epilepsy are scarce. We analyzed the clinical and genetic features of a cohort of adult patients with TSC, to identify the prognostic predictors of seizure remission after a long follow-up. METHOD We conducted a retrospective analysis of patients diagnosed with TSC according to the updated international diagnostic criteria. Pearson's chi-square or Fisher's exact test and Mann Whitney U test were used to compare variables among the Remission (R) and Non-Remission (NR) group. Univariate and multivariate logistic regression analyses were performed. RESULTS We selected 43 patients with TSC and neurological involvement in terms of epilepsy and/or brain lesions, attending the Epilepsy Center of our Institute: of them, 16 (37.2%) were transitioning from the pediatric care and 6 (13.9%) were referred by other specialists. Multiorgan involvement includes cutaneous (86.0%), nephrological (70.7%), hepatic (40.0%), ocular (34.3%), pneumological (28.6%) and cardiac (26.3%) manifestations. Thirty-nine patients (90.7 %) had epilepsy. The mean age at seizure onset was 4 ± 7.3 years: most patients (29, 76.3 %) presented with focal seizures or spasms by age 3 years; only 2 (5.3 %) had seizure onset in adulthood. Twenty-seven patients (69.2 %) experienced multiple seizure types overtime, 23 (59.0 %) had intellectual disability (ID). At last assessment, 14 (35.9 %) were seizure free (R group) and 25 (64.1 %) had drug-resistant seizures (NR group). At logistic regression univariate analysis, ID (OR 7.9, 95 % CI 1.8--34.7), multiple seizure types lifelong (OR 13.2, 95 % CI 2.6- 67.2), spasms/tonic seizures at presentation (OR 6.5, 95 % CI 1.2--35.2), a higher seizure frequency at onset (OR 5.4, 95 % CI 1.2--24.3), abnormal neurological examination (OR 9.8, 95 % CI 1.1--90.6) and pathogenic variants in TSC2 (OR 5.4, 95 % CI 1.2--24.5) were significantly associated with non-remission. In the multivariate analysis, both ID and multiple seizure types lifelong were confirmed as independent predictors of poor seizure outcome. CONCLUSIONS In our cohort of adult patients with TSC, epilepsy remains one of the main neurological challenges with only 5.3% of cases manifesting in adulthood. Approximately 64% of these patients failed to achieve seizure remission. ID and multiple seizure types were the main predictors of poor outcome. Nephrological manifestations require continuous specific follow-up in adults.
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Affiliation(s)
- Laura Licchetta
- IRCCS Istituto delle Scienze Neurologiche di Bologna, European Reference Network for Rare and Complex Epilepsies (EpiCARE), Bologna, Italy
| | - Giulia Bruschi
- IRCCS Istituto delle Scienze Neurologiche di Bologna, European Reference Network for Rare and Complex Epilepsies (EpiCARE), Bologna, Italy; Unit of Neurology and Unit of Clinical Neurophysiology, Department of Neuroscience, University of Padua, Padua, Italy
| | - Carlotta Stipa
- IRCCS Istituto delle Scienze Neurologiche di Bologna, European Reference Network for Rare and Complex Epilepsies (EpiCARE), Bologna, Italy
| | - Laura Maria Beatrice Belotti
- IRCCS Istituto delle Scienze Neurologiche di Bologna, European Reference Network for Rare and Complex Epilepsies (EpiCARE), Bologna, Italy
| | - Lorenzo Ferri
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna Italy.
| | - Barbara Mostacci
- IRCCS Istituto delle Scienze Neurologiche di Bologna, European Reference Network for Rare and Complex Epilepsies (EpiCARE), Bologna, Italy
| | - Luca Vignatelli
- IRCCS Istituto delle Scienze Neurologiche di Bologna, European Reference Network for Rare and Complex Epilepsies (EpiCARE), Bologna, Italy
| | - Raffaella Minardi
- IRCCS Istituto delle Scienze Neurologiche di Bologna, European Reference Network for Rare and Complex Epilepsies (EpiCARE), Bologna, Italy
| | - Lidia Di Vito
- IRCCS Istituto delle Scienze Neurologiche di Bologna, European Reference Network for Rare and Complex Epilepsies (EpiCARE), Bologna, Italy
| | - Lorenzo Muccioli
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna Italy
| | - Antonella Boni
- IRCCS Istituto delle Scienze Neurologiche di Bologna, UOC Neuropsichiatria Dell'età Pediatrica, via Altura 3, Bologna 40138, Italy
| | - Paolo Tinuper
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna Italy
| | - Francesca Bisulli
- IRCCS Istituto delle Scienze Neurologiche di Bologna, European Reference Network for Rare and Complex Epilepsies (EpiCARE), Bologna, Italy; Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna Italy
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Brbić M, Yasunaga M, Agarwal P, Leskovec J. Predicting drug outcome of population via clinical knowledge graph. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.03.06.24303800. [PMID: 38496488 PMCID: PMC10942490 DOI: 10.1101/2024.03.06.24303800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
Optimal treatments depend on numerous factors such as drug chemical properties, disease biology, and patient characteristics to which the treatment is applied. To realize the promise of AI in healthcare, there is a need for designing systems that can capture patient heterogeneity and relevant biomedical knowledge. Here we present PlaNet, a geometric deep learning framework that reasons over population variability, disease biology, and drug chemistry by representing knowledge in the form of a massive clinical knowledge graph that can be enhanced by language models. Our framework is applicable to any sub-population, any drug as well drug combinations, any disease, and to a wide range of pharmacological tasks. We apply the PlaNet framework to reason about outcomes of clinical trials: PlaNet predicts drug efficacy and adverse events, even for experimental drugs and their combinations that have never been seen by the model. Furthermore, PlaNet can estimate the effect of changing population on the trial outcome with direct implications on patient stratification in clinical trials. PlaNet takes fundamental steps towards AI-guided clinical trials design, offering valuable guidance for realizing the vision of precision medicine using AI.
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Affiliation(s)
- Maria Brbić
- School of Computer and Communication Sciences, Swiss Federal Institute of Technology (EPFL), Lausanne, Switzerland
| | - Michihiro Yasunaga
- Department of Computer Science, Stanford University, Stanford, CA 94305, USA
| | - Prabhat Agarwal
- Department of Computer Science, Stanford University, Stanford, CA 94305, USA
| | - Jure Leskovec
- Department of Computer Science, Stanford University, Stanford, CA 94305, USA
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Tong J, Ji T, Liu T, Liu J, Chen Y, Li Z, Lu N, Li Q. Efficacy and safety of six new antiseizure medications for adjunctive treatment of focal epilepsy and epileptic syndrome: A systematic review and network meta-analysis. Epilepsy Behav 2024; 152:109653. [PMID: 38277848 DOI: 10.1016/j.yebeh.2024.109653] [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: 12/13/2023] [Revised: 01/08/2024] [Accepted: 01/15/2024] [Indexed: 01/28/2024]
Abstract
OBJECTIVE This study aimed to evaluate the efficacy and safety of six new antiseizure medications (ASMs) for adjunctive treatment in adult patients with focal epilepsy and adolescents with Dravet syndrome (DS), Lennox-Gastaut syndrome (LGS), or tuberous sclerosis complex (TSC). METHODS A comprehensive literature search was performed using PubMed, Medline, Embase, and Cochrane library databases from inception to October 13, 2023. We included published studies for a systematic review and a network meta-analysis (NMA). The efficacy and safety were reported in terms of a 50% response rate and dropout rate along with serious adverse events (SAEs). The outcomes were ranked with the surface under the cumulative ranking curve (SUCRA). RESULTS Twenty eligible trials with 5516 patients and 21 interventions, including placebo, contributed to the analysis. Included ASMs were brivaracetam (BRV), cenobamate (CBM), cannabidiol (CBD), fenfluramine (FFM), everolimus (ELM), and soticlestat (SLT). The six new ASMs were compared in four different epilepsy subtypes. In focal epilepsy treatment, BRV seemed to be safe [vs placebo, risk ratio (RR) = 0.69, 95 % confidence interval (CI): 0.25-1.91] and effective (vs placebo, RR = 2.18, 95 % CI: 1.25-3.81). In treating focal epilepsy, CBM 300 mg was more effective at a 50 % response rate (SUCRA 91.8 %) compared with BRV and CBD. However, with the increase in dosage, more SAEs (SUCRA 85.6 %) appeared compared with other ASMs. CBD had good efficacy on LGS (SUCRA 88.4) and DS (SUCRA 66.2), but the effect on adult focal epilepsy was not better than that of placebo [vs placebo, RR = 0.83 (0.36-1.93)]. The NMA indicated that the likelihood of the most appropriate intervention (SUCRA 91.2 %) with minimum side effects(SUCRA 12.5 %)for the DS was FFM. Compared with CBD, high exposure to ELM demonstrated a more effective treatment of TSC (SUCRA 89.7 %). More high-quality SLT studies are needed to further evaluate the efficacy and safety. The comparison-adjusted funnel plots of annualized relapse rate and side effects in the included studies revealed no significant funnel plot asymmetry. CONCLUSIONS This NMA indicated that the most effective treatment strategy for focal epilepsy, DS, Lennox-Gastaut syndrome, and TSC, respectively, included CBM 300 mg, FFM, CBD, and ELM. However, the aforementioned findings need further confirmation.
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Affiliation(s)
- Jingyi Tong
- Department of Neurology, The First Affiliated Hospital of Hainan Medical University, Haikou 570102, China; Key Laboratory of Brain Science Research and Transformation in Tropical Environment of Hainan Province, Hainan Medical University, Haikou 570102, China
| | - Tingting Ji
- Department of Neurology, The First Affiliated Hospital of Hainan Medical University, Haikou 570102, China; Key Laboratory of Brain Science Research and Transformation in Tropical Environment of Hainan Province, Hainan Medical University, Haikou 570102, China
| | - Ting Liu
- Department of Neurology, The First Affiliated Hospital of Hainan Medical University, Haikou 570102, China; Key Laboratory of Brain Science Research and Transformation in Tropical Environment of Hainan Province, Hainan Medical University, Haikou 570102, China
| | - Jiaqi Liu
- Department of Neurology, The First Affiliated Hospital of Hainan Medical University, Haikou 570102, China; Key Laboratory of Brain Science Research and Transformation in Tropical Environment of Hainan Province, Hainan Medical University, Haikou 570102, China
| | - Yibin Chen
- Department of Neurology, The First Affiliated Hospital of Hainan Medical University, Haikou 570102, China; Key Laboratory of Brain Science Research and Transformation in Tropical Environment of Hainan Province, Hainan Medical University, Haikou 570102, China
| | - Zongjun Li
- Department of Neurology, The First Affiliated Hospital of Hainan Medical University, Haikou 570102, China; Key Laboratory of Brain Science Research and Transformation in Tropical Environment of Hainan Province, Hainan Medical University, Haikou 570102, China
| | - Na Lu
- Hainan Medical University, Haikou 570102, China.
| | - Qifu Li
- Department of Neurology, The First Affiliated Hospital of Hainan Medical University, Haikou 570102, China; Key Laboratory of Brain Science Research and Transformation in Tropical Environment of Hainan Province, Hainan Medical University, Haikou 570102, China.
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Challal S, Skiba A, Langlois M, Esguerra CV, Wolfender JL, Crawford AD, Skalicka-Woźniak K. Natural product-derived therapies for treating drug-resistant epilepsies: From ethnopharmacology to evidence-based medicine. JOURNAL OF ETHNOPHARMACOLOGY 2023; 317:116740. [PMID: 37315641 DOI: 10.1016/j.jep.2023.116740] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 05/17/2023] [Accepted: 06/04/2023] [Indexed: 06/16/2023]
Abstract
ETHNOPHARMACOLOGICAL RELEVANCE Epilepsy is one of the most prevalent neurological human diseases, affecting 1% of the population in all age groups. Despite the availability of over 25 anti-seizure medications (ASMs), which are approved in most industrialized countries, approximately 30% of epilepsy patients still experience seizures that are resistant to these drugs. Since ASMs target only limited number of neurochemical mechanisms, drug-resistant epilepsy (DRE) is not only an unmet medical need, but also a formidable challenge in drug discovery. AIM In this review, we examine recently approved epilepsy drugs based on natural product (NP) such as cannabidiol (CBD) and rapamycin, as well as NP-based epilepsy drug candidates still in clinical development, such as huperzine A. We also critically evaluate the therapeutic potential of botanical drugs as polytherapy or adjunct therapy specifically for DRE. METHODS Articles related to ethnopharmacological anti-epileptic medicines and NPs in treating all forms of epilepsy were collected from PubMed and Scopus using keywords related to epilepsy, DRE, herbal medicines, and NPs. The database clinicaltrials.gov was used to find ongoing, terminated and planned clinical trials using herbal medicines or NPs in epilepsy treatment. RESULTS A comprehensive review on anti-epileptic herbal drugs and natural products from the ethnomedical literature is provided. We discuss the ethnomedical context of recently approved drugs and drug candidates derived from NPs, including CBD, rapamycin, and huperzine A. Recently published studies on natural products with preclinical efficacy in animal models of DRE are summarized. Moreover, we highlight that natural products capable of pharmacologically activating the vagus nerve (VN), such as CBD, may be therapeutically useful to treat DRE. CONCLUSIONS The review highlights that herbal drugs utilized in traditional medicine offer a valuable source of potential anti-epileptic drug candidates with novel mechanisms of action, and with clinical promise for the treatment of drug-resistant epilepsy (DRE). Moreover, recently developed NP-based anti-seizure medications (ASMs) indicate the translational potential of metabolites of plant, microbial, fungal and animal origin.
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Affiliation(s)
- Soura Challal
- Institute of Pharmaceutical Sciences of Western Switzerland, University of Geneva, Switzerland; School of Pharmaceutical Sciences, University of Geneva, Switzerland
| | - Adrianna Skiba
- Department of Natural Product Chemistry, Medical University of Lublin, Poland
| | - Mélanie Langlois
- Luxembourg Centre for Systems Biomedicine (LCSB), Belval, Luxembourg
| | - Camila V Esguerra
- Centre for Molecular Medicine Norway (NCMM), University of Oslo, Norway
| | - Jean-Luc Wolfender
- Institute of Pharmaceutical Sciences of Western Switzerland, University of Geneva, Switzerland; School of Pharmaceutical Sciences, University of Geneva, Switzerland
| | - Alexander D Crawford
- Department of Preclinical Sciences and Pathology, Norwegian University of Life Sciences (NMBU), Ås, Norway; Institute for Orphan Drug Discovery, Bremerhavener Innovations- und Gründerzentum (BRIG), Bremerhaven, Germany
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Cockerell I, Christensen J, Hoei-Hansen CE, Holst L, Grenaa Frederiksen M, Issa-Epe AI, Nedregaard B, Solhoff R, Heimdal K, Johannessen Landmark C, Lund C, Nærland T. Effectiveness and safety of everolimus treatment in patients with tuberous sclerosis complex in real-world clinical practice. Orphanet J Rare Dis 2023; 18:377. [PMID: 38042867 PMCID: PMC10693167 DOI: 10.1186/s13023-023-02982-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Accepted: 11/18/2023] [Indexed: 12/04/2023] Open
Abstract
BACKGROUND The randomised double-blinded placebo-controlled EXIST-1-3 studies have showed everolimus effective with adverse effects reported as acceptable in treatment of symptoms in patients with tuberous sclerosis complex (TSC), although evidence of outcomes in clinical practice remains limited. This study aimed to investigate, in clinical practice, the effectiveness and safety of everolimus for epilepsy, renal angiomyolipoma (rAML), and subependymal giant cell astrocytoma (SEGA) in patients with TSC. RESULTS The study included 64 patients with TSC (median age: 19, range 0.9-54 years) receiving everolimus treatment (Norway: n = 35; Denmark: n = 29). Among 45 patients with epilepsy, 14 (31%) were responders experiencing ≥ 50% reduction in seizure frequency in the last 3 months of treatment compared with the last 3 months before treatment. Nineteen (42%) patients changed their anti-seizure medications (ASMs). Responders were more common among patients < 18 years (46%) than among patients ≥ 18 years (14%, p = 0.03). In 29 patients with rAML, everolimus reduced (≥ 30% decrease) and stabilized (< 20% increase, ≤ 30% decrease) longest diameter of rAML in 38% and 59%, respectively, after a mean treatment duration of 37 months. SEGA volume was reduced in three patients by 71%, 43%, and 48% after 39, 34, and 82 months. Adverse effects were reported in 61 of 64 patients (95%) after a median treatment duration of 31 months (range 0-106), with oral ulceration/stomatitis (63%) and upper respiratory tract infections (38%) being the most common. The most common laboratory abnormalities were increased cholesterol (41%), anaemia (30%), and leucopoenia (25%). Grade 3-4 adverse effects were reported in 36% of cases, and life-threatening conditions were reported in two patients. Nine patients discontinued everolimus treatment. CONCLUSIONS Seizure reduction in this study sample was consistent with results from EXIST, but might be lower than expected, given that changes in concomitant ASMs are part of clinical practice. Seizure reduction was associated with younger age. As with EXIST, everolimus reduced or stabilised rAML size in most patients. SEGA volume was reduced in all three patients. Close follow-up is needed for this group, especially for children and patients who may not be able to report adverse effects.
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Affiliation(s)
- Ine Cockerell
- Department of Rare Disorders and Disabilities, National Centre for Rare Epilepsy-Related Disorders, Oslo University Hospital, Pb 4950, 0424, Nydalen, Oslo, Norway.
| | - Jakob Christensen
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Neurology, Aarhus University Hospital, Affiliated Member of the European Reference Network EpiCARE, Aarhus, Denmark
| | - Christina E Hoei-Hansen
- Department of Clinical Medicine, Copenhagen University, Copenhagen, Denmark
- Department of Paediatrics, University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Lotte Holst
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | | | - Aart Imran Issa-Epe
- Section of Abdominal Radiology, Department of Radiology, Oslo University Hospital, Oslo, Norway
| | - Bård Nedregaard
- Section of Neuroradiology, Department of Radiology, Oslo University Hospital, Oslo, Norway
| | - Ragnar Solhoff
- Department of Neurology, Sørlandet Hospital, Arendal, Norway
| | - Ketil Heimdal
- Department of Medical Genetics, Oslo University Hospital, Oslo, Norway
| | - Cecilie Johannessen Landmark
- Department of Pharmacy, Faculty of Health Sciences, Oslo Metropolitan University, Oslo, Norway
- The National Center for Epilepsy (SSE), Member of the ERN EpiCare, Oslo University Hospital, Oslo, Norway
- Section for Clinical Pharmacology, SSE, Department of Pharmacology, Oslo University Hospital, Oslo, Norway
| | - Caroline Lund
- Department of Rare Disorders and Disabilities, National Centre for Rare Epilepsy-Related Disorders, Oslo University Hospital, Pb 4950, 0424, Nydalen, Oslo, Norway
| | - Terje Nærland
- K.G. Jebsen Center for Neurodevelopmental Disorders, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- NevSom, Department of Rare Disorders and Disabilities, Oslo University Hospital, Oslo, Norway
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10
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Mammadova D, Vecko J, Hofmann M, Schüssler SC, Deiters L, Canda A, Wieland AK, Gollwitzer S, Hamer H, Trollmann R. A single-center observational study on long-term neurodevelopmental outcomes in children with tuberous sclerosis complex. Orphanet J Rare Dis 2023; 18:349. [PMID: 37946245 PMCID: PMC10637019 DOI: 10.1186/s13023-023-02959-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 10/25/2023] [Indexed: 11/12/2023] Open
Abstract
BACKGROUND Tuberous sclerosis complex (TSC) is a rare multisystem disorder caused by mutations in the TSC1 or TSC2 gene. More than 90% of patients with TSC develop neurological and/or neuropsychiatric manifestations. The aim of the present study was to determine the developmental and cognitive long-term outcomes of pediatric TSC patients. METHODS This cross-sectional, monocenter study included pediatric TSC patients who received multidisciplinary long-term care with a last visit between 2005 and 2019. Neurological manifestations and cognitive development (BSID, K-ABC) were analyzed in relation to age and type of mutation. RESULTS Thirty-five patients aged 13.5 ± 7.8 years were included in the study. Diagnosis was confirmed genetically in 65.7% of patients (TSC1, 26.1%; TSC2, 65.2%; NMI, 8.7%). Mean age at diagnosis was 1.3 ± 3.5 years; 74.3% of the patients had been diagnosed within the first year of life due to seizures (62.9%) or/and cardiac rhabdomyomas (28.6%). The most common TSC manifestations included structural brain lesions (cortical tubers, 91.4%; subependymal nodules, 82.9%), epilepsy (85.7%), and cardiac rhabdomyomas (62.9%). Mean age at seizure onset was 1.5 ± 2.3 years, with onset in 80.0% of patients within the first two years of life. Infantile spasms, which were the first seizure type in 23.3% of the patients, developed earlier (0.6 ± 0.4 years) than focal seizures (1.8 ± 2.5 years). Refractory epilepsy was present in 21 (70.0%) patients, mild or severe intellectual impairment in 66.6%, and autism spectrum disorders in 11.4%. Severe cognitive impairment (33.3%) was significantly associated with epilepsy type and age at seizure onset (p < 0.05). CONCLUSIONS The results emphasized the phenotypic variability of pediatric-onset TSC and the high rate of neurological and neuropsychiatric morbidity. Early-onset refractory epilepsy was associated with impaired cognitive development. Children of all ages with TSC require multidisciplinary long-term care and individual early-intervention programs.
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Affiliation(s)
- D Mammadova
- Department of Pediatric and Adolescent Medicine, Pediatric Neurology, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Loschgestr. 15, 91054, Erlangen, Germany
| | - J Vecko
- Department of Pediatric and Adolescent Medicine, Pediatric Neurology, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Loschgestr. 15, 91054, Erlangen, Germany
| | - M Hofmann
- Department of Pediatric and Adolescent Medicine, Pediatric Neurology, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Loschgestr. 15, 91054, Erlangen, Germany
| | - S C Schüssler
- Department of Pediatric and Adolescent Medicine, Pediatric Neurology, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Loschgestr. 15, 91054, Erlangen, Germany
| | - L Deiters
- Department of Pediatric and Adolescent Medicine, Pediatric Neurology, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Loschgestr. 15, 91054, Erlangen, Germany
| | - A Canda
- Department of Pediatric and Adolescent Medicine, Pediatric Neurology, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Loschgestr. 15, 91054, Erlangen, Germany
| | - A K Wieland
- Department of Pediatric and Adolescent Medicine, Pediatric Neurology, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Loschgestr. 15, 91054, Erlangen, Germany
- Center of Rare Diseases Erlangen (ZSEER), Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - S Gollwitzer
- Department of Neurology, Epilepsy Center, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
- Center of Rare Diseases Erlangen (ZSEER), Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - H Hamer
- Department of Neurology, Epilepsy Center, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
- Center of Rare Diseases Erlangen (ZSEER), Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Regina Trollmann
- Department of Pediatric and Adolescent Medicine, Pediatric Neurology, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Loschgestr. 15, 91054, Erlangen, Germany.
- Center of Rare Diseases Erlangen (ZSEER), Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany.
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11
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Pearsson K, Eklund EA, Rask O, Rosén I, Sjunnesson H, Compagno-Strandberg M. The evolution of epilepsy surgery in tuberous sclerosis in Sweden: A national registry study. Seizure 2023; 112:54-61. [PMID: 37757549 DOI: 10.1016/j.seizure.2023.09.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Revised: 08/04/2023] [Accepted: 09/16/2023] [Indexed: 09/29/2023] Open
Abstract
PURPOSE This study aimed to characterize the Swedish cohort of surgically treated patients with TSC and explore differences in preoperative investigation and outcome over time. METHODS Data on patient and seizure characteristics were retrieved from the Swedish National Epilepsy Surgery Register. Two-year follow-up results were compared between the years 1997-2010 and 2011-2018. Preoperative investigations were re-evaluated. RESULTS Eighteen tuberectomies and seven callosotomies were identified. Seizure freedom after tuberectomy was achieved in 11 % (1/9) 1997-2010 and 56 % (5/9) 2011-2018. The number of tuberectomies increased each decade. Patients operated on in 1997-2010 had higher seizure frequency (median 175 seizures/month vs. 102) and incidence of infantile spasms (4/9 vs. 1/9, none after 2011). There was a trend towards surgery at a younger age (median 86 months 1997-2010 vs. 48 months 2011-2018). None with >200 seizure/month, SEGA, or history of infantile spasms achieved seizure freedom. Two patients underwent anterior callosotomy (1992 and 1994) and became free of drop attacks. Five callosotomies were performed between 2011 and 2013, one patient became free of drop attacks. Two complications with new neurological deficits were reported. The median age at surgery was higher in the callosotomy group (14 years) than in the tuberectomy group (5 years). CONCLUSION Seizure freedom after tuberectomy in patients with TSC has increased over time in our cohort. Signs of a heavier disease burden were more frequently observed 1997-2010 and associated with worse outcomes. Callosotomy operations were prevalent at the beginning of the 2010s.
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Affiliation(s)
- Kevin Pearsson
- Division of Clinical Sciences Helsingborg-Pediatrics, Department of Clinical Sciences Lund, Helsingborg General Hospital, Lund University, Helsingborg, Sweden.
| | - Erik A Eklund
- Pediatrics, Department of Clinical Sciences, Lund, Sweden
| | - Olof Rask
- Department of Clinical Sciences Lund, Division of Child and Adolescent Psychiatry, Lund University, Lund, Sweden
| | - Ingmar Rosén
- Department of Clinical Sciences, Clinical Neurophysiology, Lund University, Lund, Sweden
| | - Håkan Sjunnesson
- Center for Medical Imaging and Physiology, Skåne University Hospital, Lund, Sweden
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12
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Specchio N, Nabbout R, Aronica E, Auvin S, Benvenuto A, de Palma L, Feucht M, Jansen F, Kotulska K, Sarnat H, Lagae L, Jozwiak S, Curatolo P. Updated clinical recommendations for the management of tuberous sclerosis complex associated epilepsy. Eur J Paediatr Neurol 2023; 47:25-34. [PMID: 37669572 DOI: 10.1016/j.ejpn.2023.08.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 08/27/2023] [Accepted: 08/28/2023] [Indexed: 09/07/2023]
Abstract
Children with tuberous sclerosis complex (TSC), may experience a variety of seizure types in the first year of life, most often focal seizure sand epileptic spasms. Drug resistance is seen early in many patients, and the management of TSC associated epilepsy remain a major challenge for clinicians. In 2018 clinical recommendations for the management of TSC associated epilepsy were published by a panel of European experts. In the last five years considerable progress has been made in understanding the neurobiology of epileptogenesis and three interventional randomized controlled trials have changed the therapeutic approach for the management of TSC associated epilepsy. Pre-symptomatic treatment with vigabatrin may delay seizure onset, may reduce seizure severity and reduce the risk of epileptic encephalopathy. The efficacy of mTOR inhibition with adjunctive everolimus was documented in patients with TSC associated refractory seizures and cannabidiol could be another therapeutic option. Epilepsy surgery has significantly improved seizure outcome in selected patients and should be considered early in all patients with drug resistant epilepsy. There is a need to identify patients who may have a higher risk of developing epilepsy and autism spectrum disorder (ASD). In the recent years significant progress has been made owing to the early identification of risk factors for the development of drug-resistant epilepsy. Better understanding of the mechanism underlying epileptogenesis may improve the management for TSC-related epilepsy. Developmental neurobiology and neuropathology give opportunities for the implementation of concepts related to clinical findings, and an early genetic diagnosis and use of EEG and MRI biomarkers may improve the development of pre-symptomatic and disease-modifying strategies.
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Affiliation(s)
- Nicola Specchio
- Clinical and Experimental Neurology, Bambino Gesu' Children's Hospital IRCCS, Full Member of European Reference Network on Rare and Complex Epilepsies EpiCARE, Rome, Italy.
| | - Rima Nabbout
- Department of Pediatric Neurology, Necker Enfants Malades Hospital, Université Paris Cité, Member of the European Reference Network on Rare and Complex Epilepsies EpiCARE, INSERM U1163, Institut Imagine, Paris, France
| | - Eleonora Aronica
- Amsterdam UMC, University of Amsterdam, Amsterdam Neuroscience, Department of (Neuro)Pathology, Amsterdam, Netherlands; Stichting Epilepsie Instellingen Nederland (SEIN), Heemstede, the Netherlands
| | - Stephane Auvin
- APHP, Service de Neurologie Pédiatrique, Centre Epilepsies Rares, Member of the European Reference Network on Rare and Complex Epilepsies EpiCARE, Hôpital Robert Debré, Paris, France; Université Paris-Cité, INSERM NeuroDiderot, Paris, France; Institut Universitaire de France (IUF), Paris, France
| | | | - Luca de Palma
- Clinical and Experimental Neurology, Bambino Gesu' Children's Hospital IRCCS, Full Member of European Reference Network on Rare and Complex Epilepsies EpiCARE, Rome, Italy
| | - Martha Feucht
- Epilepsy Center, Department of Pediatrics, Medical University Vienna, Austria
| | - Floor Jansen
- Department of Pediatric Neurology, Brain Center UMC Utrecht, the Netherlands
| | - Katarzyna Kotulska
- Department of Neurology and Epileptology, The Children's Memorial Health Institute, Warsaw, Poland
| | - Harvey Sarnat
- Department of Paediatrics (Neurology), Pathology and Laboratory Medicine (Neuropathology) and Clinical Neurosciences, University of Calgary Cumming School of Medicine and Alberta Children's Hospital Research Institute (Owerko Centre), Calgary, AB, Canada
| | - Lieven Lagae
- Department of Paediatric Neurology, University of Leuven, Leuven, Belgium
| | - Sergiusz Jozwiak
- Research Department, The Children's Memorial Health Institute, ERN EPICARE, Warsaw, Poland
| | - Paolo Curatolo
- Child Neurology and Psychiatry Unit, Systems Medicine Department, Tor Vergata University, Rome, Italy
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13
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Dhamne SC, Modi ME, Gray A, Bonazzi S, Craig L, Bainbridge E, Lalani L, Super CE, Schaeffer S, Capre K, Lubicka D, Liang G, Burdette D, McTighe SM, Gurnani S, Vermudez SAD, Curtis D, Wilson CJ, Hameed MQ, D'Amore A, Rotenberg A, Sahin M. Seizure reduction in TSC2-mutant mouse model by an mTOR catalytic inhibitor. Ann Clin Transl Neurol 2023; 10:1790-1801. [PMID: 37545094 PMCID: PMC10578885 DOI: 10.1002/acn3.51868] [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: 01/23/2023] [Revised: 07/14/2023] [Accepted: 07/23/2023] [Indexed: 08/08/2023] Open
Abstract
OBJECTIVE Tuberous sclerosis complex (TSC) is a neurodevelopmental disorder caused by autosomal-dominant pathogenic variants in either the TSC1 or TSC2 gene, and it is characterized by hamartomas in multiple organs, such as skin, kidney, lung, and brain. These changes can result in epilepsy, learning disabilities, and behavioral complications, among others. The mechanistic link between TSC and the mechanistic target of the rapamycin (mTOR) pathway is well established, thus mTOR inhibitors can potentially be used to treat the clinical manifestations of the disorder, including epilepsy. METHODS In this study, we tested the efficacy of a novel mTOR catalytic inhibitor (here named Tool Compound 1 or TC1) previously reported to be more brain-penetrant compared with other mTOR inhibitors. Using a well-characterized hypomorphic Tsc2 mouse model, which displays a translationally relevant seizure phenotype, we tested the efficacy of TC1. RESULTS Our results show that chronic treatment with this novel mTOR catalytic inhibitor (TC1), which affects both the mTORC1 and mTORC2 signaling complexes, reduces seizure burden, and extends the survival of Tsc2 hypomorphic mice, restoring species typical weight gain over development. INTERPRETATION Novel mTOR catalytic inhibitor TC1 exhibits a promising therapeutic option in the treatment of TSC.
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Affiliation(s)
- Sameer C. Dhamne
- F.M. Kirby Neurobiology Center, Rosamund Stone Zander Translational Neuroscience Center, Department of Neurology, Boston Children's Hospital, Harvard Medical SchoolBostonMassachusettsUSA
| | - Meera E. Modi
- F.M. Kirby Neurobiology Center, Rosamund Stone Zander Translational Neuroscience Center, Department of Neurology, Boston Children's Hospital, Harvard Medical SchoolBostonMassachusettsUSA
| | - Audrey Gray
- Novartis Institutes for Biomedical ResearchCambridgeMassachusettsUSA
| | - Simone Bonazzi
- Novartis Institutes for Biomedical ResearchCambridgeMassachusettsUSA
| | - Lucas Craig
- Novartis Institutes for Biomedical ResearchCambridgeMassachusettsUSA
| | - Elizabeth Bainbridge
- F.M. Kirby Neurobiology Center, Rosamund Stone Zander Translational Neuroscience Center, Department of Neurology, Boston Children's Hospital, Harvard Medical SchoolBostonMassachusettsUSA
| | - Lahin Lalani
- F.M. Kirby Neurobiology Center, Rosamund Stone Zander Translational Neuroscience Center, Department of Neurology, Boston Children's Hospital, Harvard Medical SchoolBostonMassachusettsUSA
| | - Chloe E. Super
- F.M. Kirby Neurobiology Center, Rosamund Stone Zander Translational Neuroscience Center, Department of Neurology, Boston Children's Hospital, Harvard Medical SchoolBostonMassachusettsUSA
| | - Samantha Schaeffer
- F.M. Kirby Neurobiology Center, Rosamund Stone Zander Translational Neuroscience Center, Department of Neurology, Boston Children's Hospital, Harvard Medical SchoolBostonMassachusettsUSA
| | - Ketthsy Capre
- Novartis Institutes for Biomedical ResearchCambridgeMassachusettsUSA
| | - Danuta Lubicka
- Novartis Institutes for Biomedical ResearchCambridgeMassachusettsUSA
| | - Guiqing Liang
- Novartis Institutes for Biomedical ResearchCambridgeMassachusettsUSA
| | - Doug Burdette
- Novartis Institutes for Biomedical ResearchCambridgeMassachusettsUSA
| | | | - Sarika Gurnani
- F.M. Kirby Neurobiology Center, Rosamund Stone Zander Translational Neuroscience Center, Department of Neurology, Boston Children's Hospital, Harvard Medical SchoolBostonMassachusettsUSA
| | - Sheryl Anne D. Vermudez
- F.M. Kirby Neurobiology Center, Rosamund Stone Zander Translational Neuroscience Center, Department of Neurology, Boston Children's Hospital, Harvard Medical SchoolBostonMassachusettsUSA
| | - Daniel Curtis
- Novartis Institutes for Biomedical ResearchCambridgeMassachusettsUSA
| | | | - Mustafa Q. Hameed
- F.M. Kirby Neurobiology Center, Rosamund Stone Zander Translational Neuroscience Center, Department of Neurology, Boston Children's Hospital, Harvard Medical SchoolBostonMassachusettsUSA
| | - Angelica D'Amore
- F.M. Kirby Neurobiology Center, Rosamund Stone Zander Translational Neuroscience Center, Department of Neurology, Boston Children's Hospital, Harvard Medical SchoolBostonMassachusettsUSA
| | - Alexander Rotenberg
- F.M. Kirby Neurobiology Center, Rosamund Stone Zander Translational Neuroscience Center, Department of Neurology, Boston Children's Hospital, Harvard Medical SchoolBostonMassachusettsUSA
| | - Mustafa Sahin
- F.M. Kirby Neurobiology Center, Rosamund Stone Zander Translational Neuroscience Center, Department of Neurology, Boston Children's Hospital, Harvard Medical SchoolBostonMassachusettsUSA
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14
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Previtali R, Prontera G, Alfei E, Nespoli L, Masnada S, Veggiotti P, Mannarino S. Paradigm shift in the treatment of tuberous sclerosis: Effectiveness of everolimus. Pharmacol Res 2023; 195:106884. [PMID: 37549757 DOI: 10.1016/j.phrs.2023.106884] [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: 02/25/2023] [Revised: 08/03/2023] [Accepted: 08/03/2023] [Indexed: 08/09/2023]
Abstract
Tuberous sclerosis complex (TSC) is an autosomal dominant disease characterised by abnormal cell proliferation and differentiation that affects multiple organs and can lead to the growth of hamartomas. Tuberous sclerosis complex is caused by the disinhibition of the protein mTOR (mammalian target of rapamycin). In the past, various therapeutic approaches, even if only symptomatic, have been attempted to improve the clinical effects of this disease. While all of these therapeutic strategies are useful and are still used and indicated, they are symptomatic therapies based on the individual symptoms of the disease and therefore not fully effective in modifying long-term outcomes. A new therapeutic approach is the introduction of allosteric inhibitors of mTORC1, which allow restoration of metabolic homeostasis in mutant cells, potentially eliminating most of the clinical manifestations associated with Tuberous sclerosis complex. Everolimus, a mammalian target of the rapamycin inhibitor, is able to reduce hamartomas, correcting the specific molecular defect that causes Tuberous sclerosis complex. In this review, we report the findings from the literature on the use of everolimus as an effective and safe drug in the treatment of TSC manifestations affecting various organs, from the central nervous system to the heart.
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Affiliation(s)
- Roberto Previtali
- Pediatric Neurology Unit, Buzzi Children's Hospital, Milan, Italy; Department of Biomedical and Clinical Sciences, University of Milan, Milan, Italy
| | - Giorgia Prontera
- Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Enrico Alfei
- Pediatric Neurology Unit, Buzzi Children's Hospital, Milan, Italy
| | - Luisa Nespoli
- Pediatric Cardiology Unit, Department of Pediatric, Buzzi Children's Hospital, Milan, Italy
| | - Silvia Masnada
- Pediatric Neurology Unit, Buzzi Children's Hospital, Milan, Italy
| | - Pierangelo Veggiotti
- Pediatric Neurology Unit, Buzzi Children's Hospital, Milan, Italy; Department of Biomedical and Clinical Sciences, University of Milan, Milan, Italy
| | - Savina Mannarino
- Pediatric Cardiology Unit, Department of Pediatric, Buzzi Children's Hospital, Milan, Italy.
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15
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Sasongko TH, Kademane K, Chai Soon Hou S, Jocelyn TXY, Zabidi-Hussin Z. Rapamycin and rapalogs for tuberous sclerosis complex. Cochrane Database Syst Rev 2023; 7:CD011272. [PMID: 37432030 PMCID: PMC10334695 DOI: 10.1002/14651858.cd011272.pub3] [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: 07/12/2023]
Abstract
BACKGROUND Potential benefits of rapamycin or rapalogs for treating people with tuberous sclerosis complex (TSC) have been shown. Currently everolimus (a rapalog) is only approved for TSC-associated renal angiomyolipoma and subependymal giant cell astrocytoma (SEGA), but not other manifestations of TSC. A systematic review needs to establish evidence for rapamycin or rapalogs for various manifestations in TSC. This is an updated review. OBJECTIVES To determine the effectiveness of rapamycin or rapalogs in people with TSC for decreasing tumour size and other manifestations and to assess the safety of rapamycin or rapalogs in relation to their adverse effects. SEARCH METHODS We identified relevant studies from the Cochrane-Central-Register-of-Controlled-Trials (CENTRAL), Ovid MEDLINE and ongoing trials registries with no language restrictions. We searched conference proceedings and abstract books of conferences. Date of the last searches: 15 July 2022. SELECTION CRITERIA Randomised controlled trials (RCTs) or quasi-RCTs of rapamycin or rapalogs in people with TSC. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data and assessed the risk of bias of each study; a third review author verified the extracted data and risk of bias decisions. We assessed the certainty of the evidence using GRADE. MAIN RESULTS The current update added seven RCTs, bringing the total number to 10 RCTs (with 1008 participants aged 3 months to 65 years; 484 males). All TSC diagnoses were by consensus criteria as a minimum. In parallel studies, 645 participants received active interventions and 340 placebo. Evidence is low-to-high certainty and study quality is mixed; mostly a low risk of bias across domains, but one study had a high risk of performance bias (lack of blinding) and three studies had a high risk of attrition bias. Manufacturers of the investigational products supported eight studies. Systemic administration Six studies (703 participants) administered everolimus (rapalog) orally. More participants in the intervention arm reduced renal angiomyolipoma size by 50% (risk ratio (RR) 24.69, 95% confidence interval (CI) 3.51 to 173.41; P = 0.001; 2 studies, 162 participants, high-certainty evidence). In the intervention arm, more participants in the intervention arm reduced SEGA tumour size by 50% (RR 27.85, 95% CI 1.74 to 444.82; P = 0.02; 1 study; 117 participants; moderate-certainty evidence) ,and reported more skin responses (RR 5.78, 95% CI 2.30 to 14.52; P = 0.0002; 2 studies; 224 participants; high-certainty evidence). In one 18-week study (366 participants), the intervention led to 25% fewer seizures (RR 1.63, 95% CI 1.27 to 2.09; P = 0.0001) or 50% fewer seizures (RR 2.28, 95% CI 1.44 to 3.60; P = 0.0004); but there was no difference in numbers being seizure-free (RR 5.30, 95% CI 0.69 to 40.57; P = 0.11) (moderate-certainty evidence). One study (42 participants) showed no difference in neurocognitive, neuropsychiatry, behavioural, sensory and motor development (low-certainty evidence). Total adverse events (AEs) did not differ between groups (RR 1.09, 95% CI 0.97 to 1.22; P = 0.16; 5 studies; 680 participants; high-certainty evidence). However, the intervention group experienced more AEs resulting in withdrawal, interruption of treatment, or reduced dose (RR 2.61, 95% CI 1.58 to 4.33; P = 0.0002; 4 studies; 633 participants; high-certainty evidence and also reported more severe AEs (RR 2.35, 95% CI 0.99 to 5.58; P = 0.05; 2 studies; 413 participants; high-certainty evidence). Topical (skin) administration Four studies (305 participants) administered rapamycin topically. More participants in the intervention arm showed a response to skin lesions (RR 2.72, 95% CI 1.76 to 4.18; P < 0.00001; 2 studies; 187 participants; high-certainty evidence) and more participants in the placebo arm reported a deterioration of skin lesions (RR 0.27, 95% CI 0.15 to 0.49; 1 study; 164 participants; high-certainty evidence). More participants in the intervention arm responded to facial angiofibroma at one to three months (RR 28.74, 95% CI 1.78 to 463.19; P = 0.02) and three to six months (RR 39.39, 95% CI 2.48 to 626.00; P = 0.009; low-certainty evidence). Similar results were noted for cephalic plaques at one to three months (RR 10.93, 95% CI 0.64 to 186.08; P = 0.10) and three to six months (RR 7.38, 95% CI 1.01 to 53.83; P = 0.05; low-certainty evidence). More participants on placebo showed a deterioration of skin lesions (RR 0.27, 95% CI 0.15 to 0.49; P < 0.0001; 1 study; 164 participants; moderate-certainty evidence). The intervention arm reported a higher general improvement score (MD -1.01, 95% CI -1.68 to -0.34; P < 0.0001), but no difference specifically in the adult subgroup (MD -0.75, 95% CI -1.58 to 0.08; P = 0.08; 1 study; 36 participants; moderate-certainty evidence). Participants in the intervention arm reported higher satisfaction than with placebo (MD -0.92, 95% CI -1.79 to -0.05; P = 0.04; 1 study; 36 participants; low-certainty evidence), although again with no difference among adults (MD -0.25, 95% CI -1.52 to 1.02; P = 0.70; 1 study; 18 participants; low-certainty evidence). Groups did not differ in change in quality of life at six months (MD 0.30, 95% CI -1.01 to 1.61; P = 0.65; 1 study; 62 participants; low-certainty evidence). Treatment led to a higher risk of any AE compared to placebo (RR 1.72, 95% CI 1.10, 2.67; P = 0.02; 3 studies; 277 participants; moderate-certainty evidence); but no difference between groups in severe AEs (RR 0.78, 95% CI 0.19 to 3.15; P = 0.73; 1 study; 179 participants; moderate-certainty evidence). AUTHORS' CONCLUSIONS Oral everolimus reduces the size of SEGA and renal angiomyolipoma by 50%, reduces seizure frequency by 25% and 50% and implements beneficial effects on skin lesions with no difference in the total number of AEs compared to placebo; however, more participants in the treatment group required a dose reduction, interruption or withdrawal and marginally more experienced serious AEs compared to placebo. Topical rapamycin increases the response to skin lesions and facial angiofibroma, an improvement score, satisfaction and the risk of any AE, but not severe adverse events. With caution regarding the risk of severe AEs, this review supports oral everolimus for renal angiomyolipoma, SEGA, seizure, and skin lesions, and topical rapamycin for facial angiofibroma.
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Affiliation(s)
- Teguh Haryo Sasongko
- Department of Physiology, School of Medicine, International Medical University, Kuala Lumpur, Malaysia
- Institute for Research, Development, and Innovation, International Medical University, Kuala Lumpur, Malaysia
| | - Kumaraswamy Kademane
- Department of Pharmacology, Arunai Medical College and Hospital, Tiruvannamalai, Tamilnadu, India
| | - Stanley Chai Soon Hou
- Perdana University - Royal College of Surgeons in Ireland (RCSI) School of Medicine, Kuala Lumpur, Malaysia
| | - Tan Xin Yi Jocelyn
- Perdana University - Royal College of Surgeons in Ireland (RCSI) School of Medicine, Kuala Lumpur, Malaysia
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16
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Auvin S, Baulac S. mTOR-therapy and targeted treatment opportunities in mTOR-related epilepsies associated with cortical malformations. Rev Neurol (Paris) 2023; 179:337-344. [PMID: 36906459 DOI: 10.1016/j.neurol.2022.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 12/08/2022] [Accepted: 12/13/2022] [Indexed: 03/11/2023]
Abstract
Dysregulation of the mTOR pathway is now well documented in several neurodevelopmental disorders associated with epilepsy. Mutations of mTOR pathway genes are involved in tuberous sclerosis complex (TSC) as well as in a range of cortical malformations from hemimegalencephaly (HME) to type II focal cortical dysplasia (FCD II), leading to the concept of "mTORopathies" (mTOR pathway-related malformations). This suggests that mTOR inhibitors (notably rapamycin (sirolimus), and everolimus) could be used as antiseizure medication. In this review, we provide an overview of pharmacological treatments targeting the mTOR pathway for epilepsy based on lectures from the ILAE French Chapter meeting in October 2022 in Grenoble. There is strong preclinical evidence for the antiseizure effects of mTOR inhibitors in TSC and cortical malformation mouse models. There are also open studies on the antiseizure effects of mTOR inhibitors, as well as one phase III study showing the antiseizure effect of everolimus in TSC patients. Finally, we discuss to which extent mTOR inhibitors might have properties beyond the antiseizure effect on associated neuropsychiatric comorbidities. We also discuss a new way of treatment on the mTOR pathways.
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Affiliation(s)
- S Auvin
- Service de neurologie pédiatrique, EpiCARE ERN membre, Hôpital Robert Debré, AP-HP, Paris, France; Université Paris-Cité, Inserm NeuroDiderot, Paris, France; Institut Universitaire de France (IUF), Paris, France.
| | - S Baulac
- Sorbonne Université, Institut du Cerveau - Paris Brain Institute - ICM, Inserm, CNRS, Hôpital de la Pitié Salpêtrière, 75013 Paris, France
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17
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Menezes CEG, Santos DLD, Nery ES, Serpa ED, Morais LAS, Dutra LS, Portela Filho MB, Goes JS. Everolimus as a therapeutic option in refractory epilepsy in children with tuberous sclerosis: a systematic review. ARQUIVOS DE NEURO-PSIQUIATRIA 2023; 81:392-398. [PMID: 36863402 PMCID: PMC10169230 DOI: 10.1055/s-0042-1758442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/04/2023]
Abstract
BACKGROUND Tuberous sclerosis (TS) is a multisystem genetic disease in which epilepsy is a frequent manifestation and is often difficult to control. Everolimus is a drug with proven efficacy in the treatment of other conditions related to TS, and some evidence suggests that its use benefits the treatment of refractory epilepsy in these patients. OBJECTIVE To evaluate the efficacy of everolimus in controlling refractory epilepsy in children with TS. METHODS A literature review was conducted in the Pubmed, BVS, and Medline databases, using the descriptors Tuberous sclerosis, Children, Epilepsy, and Everolimus. Original clinical trials and prospective studies published in Portuguese or English in the last decade that evaluated the use of everolimus as an adjuvant therapy in the control of refractory epilepsy in pediatric patients with TS were included. RESULTS Our search screened 246 articles from electronic databases, 6 of which were chosen for review. Despite the methodological variations between the studies, most patients benefited from the use of everolimus to control refractory epilepsy, with response rates ranging from 28.6 to 100%. Adverse effects were present in all studies leading to dropouts of some patients; however, the majority were of low severity. CONCLUSION The selected studies suggest a beneficial effect of everolimus in the treatment of refractory epilepsy in children with TS, despite the adverse effects observed. Further studies involving a larger sample in double-blind controlled clinical trials should be performed to provide more information and statistical credibility.
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Affiliation(s)
| | | | - Erick Santos Nery
- Universidade do Estado da Bahia, Departamento de Ciências da Vida, Salvador BA, Brazil
| | - Evelin Duarte Serpa
- Universidade do Estado da Bahia, Departamento de Ciências da Vida, Salvador BA, Brazil
| | | | - Lucas Santana Dutra
- Escola Bahiana de Medicina e Saúde Pública, Departamento de Medicina, Salvador BA, Brazil
| | | | - Julieta Sobreira Goes
- Universidade do Estado da Bahia, Departamento de Ciências da Vida, Salvador BA, Brazil
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18
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Singh A, Hadjinicolaou A, Peters JM, Salussolia CL. Treatment-Resistant Epilepsy and Tuberous Sclerosis Complex: Treatment, Maintenance, and Future Directions. Neuropsychiatr Dis Treat 2023; 19:733-748. [PMID: 37041855 PMCID: PMC10083014 DOI: 10.2147/ndt.s347327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Accepted: 03/22/2023] [Indexed: 04/13/2023] Open
Abstract
Tuberous sclerosis complex (TSC) is a neurogenetic disorder that affects multiple organ systems, including the heart, kidneys, eyes, skin, and central nervous system. The neurologic manifestations have the highest morbidity and mortality, in particular in children. Clinically, patients with TSC often present with new-onset seizures within the first year of life. TSC-associated epilepsy is often difficult to treat and refractory to multiple antiseizure medications. Refractory TSC-associated epilepsy is associated with increased risk of neurodevelopmental comorbidities, including developmental delay, intellectual disability, autism spectrum disorder, and attention hyperactivity disorder. An increasing body of research suggests that early, effective treatment of TSC-associated epilepsy during critical neurodevelopmental periods can potentially improve cognitive outcomes. Therefore, it is important to treat TSC-associated epilepsy aggressively, whether it be with pharmacological therapy, surgical intervention, and/or neuromodulation. This review discusses current and future pharmacological treatments for TSC-associated epilepsy, as well as the importance of early surgical evaluation for refractory epilepsy in children with TSC and consideration of neuromodulatory interventions in young adults.
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Affiliation(s)
- Avantika Singh
- Division of Epilepsy and Neurophysiology, Department of Neurology, Boston Children’s Hospital and Harvard Medical School, Boston, MA, USA
| | - Aristides Hadjinicolaou
- Division of Epilepsy and Neurophysiology, Department of Neurology, Boston Children’s Hospital and Harvard Medical School, Boston, MA, USA
| | - Jurriaan M Peters
- Division of Epilepsy and Neurophysiology, Department of Neurology, Boston Children’s Hospital and Harvard Medical School, Boston, MA, USA
| | - Catherine L Salussolia
- Division of Epilepsy and Neurophysiology, Department of Neurology, Boston Children’s Hospital and Harvard Medical School, Boston, MA, USA
- F.M. Kirby Neurobiology Center, Department of Neurology, Boston Children’s Hospital and Harvard Medical School, Boston, MA, USA
- Correspondence: Catherine L Salussolia, 3 Blackfan Circle, Center for Life Sciences 14060, Boston, MA, 02115, USA, Tel +617-355-7970, Email
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19
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Elkommos S, Mula M. Current and future pharmacotherapy options for drug-resistant epilepsy. Expert Opin Pharmacother 2022; 23:2023-2034. [PMID: 36154780 DOI: 10.1080/14656566.2022.2128670] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Epilepsy is one of the most common and serious neurological conditions, affecting over 70 million individuals worldwide and despite advances in treatment, the proportion of drug-resistant patients has remained largely unchanged. AREAS COVERED The present paper reviews current and future (under preclinical and clinical development) pharmacotherapy options for the treatment of drug-resistant focal and generalized epilepsies. EXPERT OPINION Current pharmacotherapy options for drug-resistant epilepsy include perampanel, brivaracetam and the newly approved cenobamate for focal epilepsies; cannabidiol (Epidiolex) for Lennox-Gastaut Syndrome (LGS), Dravet and Tuberous Sclerosis Complex (TSC); fenfluramine for Dravet syndrome and ganaxolone for seizures in Cyclin-dependent kinase-like 5 (CDKL5) deficiency disorder. Many compounds are under clinical development and may hold promise for future pharmacotherapies. For adult focal epilepsies, padsevonil and carisbamate are at a more advanced Phase III stage of clinical development followed by compounds at Phase II like selurampanel, XEN1101 and JNJ-40411813. For specific epilepsy syndromes, XEN 496 is under Phase III development for potassium voltage-gated channel subfamily Q member 2 developmental and epileptic encephalopathy (KCNQ2-DEE), carisbamate is under Phase III development for LGS and Ganaxolone under Phase III development for TSC. Finally, in preclinical models several molecular targets including inhibition of glycolysis, neuroinflammation and sodium channel inhibition have been identified in animal models although further data in animal and later human studies are needed.
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Affiliation(s)
- Samia Elkommos
- School of Neuroscience, King's College London, United Kingdom.,Atkinson Morley Regional Neurosciences Centre, St George's University Hospitals, United Kingdom
| | - Marco Mula
- Atkinson Morley Regional Neurosciences Centre, St George's University Hospitals, United Kingdom.,Institute of Medical and Biomedical Education, St George's University London, United Kingdom
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20
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Advances in the genetics and neuropathology of tuberous sclerosis complex: edging closer to targeted therapy. Lancet Neurol 2022; 21:843-856. [DOI: 10.1016/s1474-4422(22)00213-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Revised: 03/09/2022] [Accepted: 05/11/2022] [Indexed: 12/23/2022]
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21
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Gataullina S, Galvani G, Touchet S, Nous C, Lemaire E, Laschet J, Chiron C, Dulac O, Dossi E, Brion JD, Messaoudi S, Alami M, Huberfeld G. GluN2C
selective inhibition is a target to develop new antiepileptic compounds. Epilepsia 2022; 63:2911-2924. [PMID: 36054371 DOI: 10.1111/epi.17396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 08/17/2022] [Accepted: 08/17/2022] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Many early-onset epilepsies present as developmental and epileptic encephalopathy associated with refractory seizures, altered psychomotor development, and disorganized interictal cortical activity. Abnormal upregulation of specific N-methyl-d-aspartate receptor (NMDA-R) subunits is being disentangled as one of the mechanisms of severe early-onset epilepsies. In tuberous sclerosis complex (TSC), upregulation of the GluN2C subunit of the NMDA-R with slow deactivation kinetic results in increased neuronal excitation and synchronization. METHODS Starting from an available GluN2C/D antagonist, NMDA-R-modulating compounds were developed and screened using a patch clamp on neuronal culture to select those with the strongest inhibitory effect on glutamatergic NMDA currents. For these selected compounds, blood pharmacokinetics and passage through the blood-brain barrier were studied. We tested the effect of the most promising compounds on epileptic activity in Tsc1+/- mice brain slices with multielectrode array, and then in vivo at postnatal ages P14-P17, comparable with the usual age at epilepsy onset in human TSC. RESULTS Using a double-electrode voltage clamp on isolated NMDA currents, we identified the most prominent antagonists of the GluN2C subunit with no effect on GluN2A as a means of preventing side effects. The best compound passing through the blood-brain barrier was selected. Applied in vivo in six Tsc1+/- mice at P14-P17, this compound reduced or completely stopped spontaneous seizures in four of them, and decreased the background activity disorganization. Furthermore, ictal-like discharges stopped on a human brain sample from an infant with epilepsy due to TSC. INTERPRETATION Subunit-selective inhibition is a valuable target for developing drugs for severe epilepsies resulting from an upregulation of NMDA-R subunit-mediated transmission.
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Affiliation(s)
- S. Gataullina
- Service d’explorations fonctionnelles multidisciplinaires Centre de médecine du sommeil, Antoine Béclère Hospital, APHP, Université Paris Saclay Clamart France
| | - G. Galvani
- AdPueriVitam (APV), Antony France
- Université de Lorraine CNRS, L2CM Nancy France
| | - S. Touchet
- AdPueriVitam (APV), Antony France
- Université de Lorraine CNRS, L2CM Nancy France
| | - C. Nous
- Institut de la Vision, UFR Sciences et Technologies Paris France
| | | | | | - C. Chiron
- Inserm U1141, Paris & APHP, Neuropediatrics, Necker Hospital Paris France
| | - O. Dulac
- AdPueriVitam (APV), Antony France
| | - E. Dossi
- Center for Interdisciplinary Research in Biology, Collège de France, CNRS UMR 7241, INSERM U1050 Université PSL Paris France
| | - J. D. Brion
- Université Paris‐Saclay CNRS UMR 8076, BioCIS Châtenay‐Malabry France
| | - S. Messaoudi
- Université Paris‐Saclay CNRS UMR 8076, BioCIS Châtenay‐Malabry France
| | - M. Alami
- Université Paris‐Saclay CNRS UMR 8076, BioCIS Châtenay‐Malabry France
| | - G. Huberfeld
- Center for Interdisciplinary Research in Biology, Collège de France, CNRS UMR 7241, INSERM U1050 Université PSL Paris France
- Neurology Department, Hôpital Fondation Adolphe de Rothschild Paris France
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22
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Genetic pathogenesis of the epileptogenic lesions in Tuberous Sclerosis Complex: Therapeutic targeting of the mTOR pathway. Epilepsy Behav 2022; 131:107713. [PMID: 33431351 DOI: 10.1016/j.yebeh.2020.107713] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 12/14/2020] [Accepted: 12/14/2020] [Indexed: 12/13/2022]
Abstract
Tuberous sclerosis complex (TSC) is a genetic multisystem disease due to the mutation in one of the two genes TSC1 and TSC2, affecting several organs and systems and carrying a significant risk of early onset and refractory seizures. The pathogenesis of this complex disorder is now well known, with most of TSC-related manifestations being a consequence of the overactivation of the mammalian Target of Rapamycin (mTOR) complex. The discovery of this underlying mechanism paved the way for the use of a class of drugs called mTOR inhibitors including rapamycin and everolimus and specifically targeting this pathway. Rapamycin has been widely used in different animal models of TSC-related epilepsy and proved to be able not only to suppress seizures but also to prevent the development of epilepsy, thus demonstrating an antiepileptogenic potential. In some models, it also showed some benefit on neuropsychiatric manifestations associated with TSC. Everolimus has recently been approved by the US Food and Drug Administration and the European Medical Agency for the treatment of refractory seizures associated with TSC starting from the age of 2 years. It demonstrated a clear benefit when compared to placebo on reducing the frequency of different seizure types and exerting a higher effect in younger children. In conclusion, mTOR cascade can be a potentially major cause of TSC-associated epilepsy and neurodevelopmental disability, and additional research should investigate if early suppression of abnormal mTOR signal with mTOR inhibitors before seizure onset can be a more efficient approach and an effective antiepileptogenic and disease-modifying strategy in infants with TSC.
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23
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Grossen A, Gavula T, Chrusciel D, Evans A, McNall-Knapp R, Taylor A, Fossey B, Brakefield M, Carter C, Schwartz N, Gross N, Jea A, Desai V. Multidisciplinary neurocutaneous syndrome clinics: a systematic review and institutional experience. Neurosurg Focus 2022; 52:E2. [DOI: 10.3171/2022.2.focus21776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2022] [Accepted: 02/23/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE
Neurocutaneous syndromes have variable multisystem involvement. The multiorgan involvement, potential pathologies, and various treatment options necessitate collaboration and open discussion to ensure optimal treatment in any given patient. These disorders provide quintessential examples of chronic medical conditions that require a lifelong, multidisciplinary approach. The objectives of this study were to 1) perform a systematic review, thoroughly assessing different multidisciplinary clinic layouts utilized in centers worldwide; and 2) characterize an institutional experience with the management of these conditions, focusing on the patient demographics, clinical presentation, complications, and therapeutic strategies seen in a patient population.
METHODS
A systematic review of studies involving multidisciplinary clinics and their reported structure was performed according to PRISMA guidelines using the PubMed database. Then a retrospective chart review of patients enrolled in the Oklahoma Children’s Hospital Neurocutaneous Syndromes Clinic was conducted.
RESULTS
A search of the PubMed database yielded 251 unique results. Of these, 15 papers were included in the analysis, which identified 16 clinics that treated more than 2000 patients worldwide. The majority of these clinics treated patients with neurofibromatosis (13/16). The remaining clinics treated patients with von Hippel–Lindau syndrome (n = 1), tuberous sclerosis complex (n = 1), and multiple neurocutaneous syndromes (n = 1). The most commonly represented subspecialties in these clinics were genetics (15/16) and neurology (13/16). Five clinics (31%) solely saw pediatric patients, 10 clinics saw a combination of children and adults, and the final clinic had separate pediatric and adult clinics. The retrospective chart review of the Neurocutaneous Syndromes Clinic demonstrated that 164 patients were enrolled and seen in the clinic from April 2013 to December 2021. Diagnoses were made based on clinical findings or results of genetic testing; 115 (70%) had neurofibromatosis type 1, 9 (5.5%) had neurofibromatosis type 2, 35 (21%) had tuberous sclerosis complex, 2 (1%) had von Hippel–Lindau syndrome, 2 (1%) had Gorlin syndrome, and the remaining patient (0.6%) had Aarskog-Scott syndrome. Patient demographics, clinical presentation, complications, and therapeutic strategies are also discussed.
CONCLUSIONS
To the best of the authors’ knowledge, this is the first detailed description of a comprehensive pediatric neurocutaneous clinic in the US that serves patients with multiple syndromes. There is currently heterogeneity between described multidisciplinary clinic structures and practices. More detailed accounts of clinic compositions and practices along with patient data and outcomes are needed in order to establish the most comprehensive and efficient multidisciplinary approach for neurocutaneous syndromes.
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Affiliation(s)
- Audrey Grossen
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
- Department of Pediatric Neurosurgery, Oklahoma Children’s Hospital, Oklahoma City, Oklahoma
| | - Theresa Gavula
- Department of Pediatrics, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Deepti Chrusciel
- Department of Pediatric Neurology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma; and
| | - Alexander Evans
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
- Department of Pediatric Neurosurgery, Oklahoma Children’s Hospital, Oklahoma City, Oklahoma
| | - Rene McNall-Knapp
- Department of Pediatrics, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Ashley Taylor
- Department of Pediatrics, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Benay Fossey
- Department of Pediatrics, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Margaret Brakefield
- Department of Pediatrics, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Carrick Carter
- Department of Pediatrics, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Nadine Schwartz
- Department of Pediatric Neurology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma; and
| | - Naina Gross
- Department of Pediatric Neurosurgery, Saint Francis Hospital, Tulsa, Oklahoma
| | - Andrew Jea
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
- Department of Pediatric Neurosurgery, Oklahoma Children’s Hospital, Oklahoma City, Oklahoma
| | - Virendra Desai
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
- Department of Pediatric Neurosurgery, Oklahoma Children’s Hospital, Oklahoma City, Oklahoma
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24
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Sadowski K, Sijko K, Domańska-Pakieła D, Borkowska J, Chmielewski D, Ulatowska A, Józwiak S, Kotulska K. Antiepileptic Effect and Safety Profile of Rapamycin in Pediatric Patients With Tuberous Sclerosis Complex. Front Neurol 2022; 13:704978. [PMID: 35572924 PMCID: PMC9100395 DOI: 10.3389/fneur.2022.704978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 02/04/2022] [Indexed: 11/25/2022] Open
Abstract
Background Epilepsy develops in 70–90% of children with Tuberous Sclerosis Complex (TSC) and is often resistant to medication. Treatment with mTOR pathway inhibitors is an important therapeutic option in drug-resistant epilepsy associated with TSC. Our study evaluated the antiepileptic effect of rapamycin in the pediatric population of patients diagnosed with TSC. Methods This single center, open-label study evaluated safety and anti-epileptic efficacy of 12 months of rapamycin treatment in 32 patients aged from 11 months to 14 years with drug-resistant TSC- associated epilepsy. Results After the first 6 months of treatment, the improvement in seizure frequency, defined as at least a 50% reduction in the number of seizures per week compared to baseline, was seen in 18 individuals (56.25%). We observed no change in 12 individuals (37.5%) and worsening, defined as increase in the number of seizures—in 2 patients (6.25%). The overall improvement defined as at least a 50% reduction in seizure frequency was found in 65.6% of all patients after 12 months with 28% of patients obtaining complete remission. Another five patients experienced at least an 80% reduction in the frequency of seizures. Concomitant treatment with vigabatrin, and to a much lesser extent topiramate and levetiracetam, was an additional favorable prognostic factor for the success of the therapy. A linear relationship between the cumulative dose of rapamycin and its therapeutic effect was observed. The safety profile of the drug was satisfactory. In none of the observed cases did the adverse events reach the level that required withdrawal of the rapamycin treatment. The reason for dropouts was insufficient drug efficacy in 3 cases. Conclusions Long-term use of rapamycin, especially in combination with vigabatrin, might be a beneficial therapeutic option in the treatment of drug-resistant epilepsy in children with TSC.
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Affiliation(s)
- Krzysztof Sadowski
- Department of Neurology and Epileptology, Children's Memorial Health Institute, Warsaw, Poland
- *Correspondence: Krzysztof Sadowski
| | - Kamil Sijko
- Department of Neurology and Epileptology, Children's Memorial Health Institute, Warsaw, Poland
- Transition Technologies, Warsaw, Poland
| | - Dorota Domańska-Pakieła
- Department of Neurology and Epileptology, Children's Memorial Health Institute, Warsaw, Poland
| | - Julita Borkowska
- Department of Neurology and Epileptology, Children's Memorial Health Institute, Warsaw, Poland
| | - Dariusz Chmielewski
- Department of Neurology and Epileptology, Children's Memorial Health Institute, Warsaw, Poland
| | - Agata Ulatowska
- Department of Neurology and Epileptology, Children's Memorial Health Institute, Warsaw, Poland
| | - Sergiusz Józwiak
- Department of Neurology and Epileptology, Children's Memorial Health Institute, Warsaw, Poland
- Department of Child Neurology, Medical University of Warsaw, Warsaw, Poland
| | - Katarzyna Kotulska
- Department of Neurology and Epileptology, Children's Memorial Health Institute, Warsaw, Poland
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25
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Vasquez A, Buraniqi E, Wirrell EC. New and emerging pharmacologic treatments for developmental and epileptic encephalopathies. Curr Opin Neurol 2022; 35:145-154. [PMID: 35102126 DOI: 10.1097/wco.0000000000001029] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Summarize evidence on Developmental and Epileptic Encephalopathies (DEEs) treatments focusing on new and emerging pharmacologic therapies (see Video, http://links.lww.com/CONR/A61, Supplementary Digital Content 1, which provides an overview of the review). RECENT FINDINGS Advances in the fields of molecular genetics and neurobiology have led to the recognition of underlying pathophysiologic mechanisms involved in an increasing number of DEEs that could be targeted with precision therapies or repurposed drugs, some of which are currently being evaluated in clinical trials. Prompt, optimal therapy is critical, and promising therapies approved or in clinical trials for tuberous sclerosis complex, Dravet and Lennox-Gastaut Syndromes including mammalian target of rapamycin inhibitors, selective membrane channel and antisense oligonucleotide modulation, and repurposed drugs such as fenfluramine, stiripentol and cannabidiol, among others, may improve seizure burden and neurological outcomes. There is an urgent need for collaborative efforts to evaluate the efficacy and safety of emerging DEEs therapies. SUMMARY Development of new therapies promise to address unmet needs for patients with DEEs, including improvement of neurocognitive function and quality of life.
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Affiliation(s)
- Alejandra Vasquez
- Division of Child and Adolescent Neurology, Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
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26
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Specchio N, Pavia GC, de Palma L, De Benedictis A, Pepi C, Conti M, Marras CE, Vigevano F, Curatolo P. Current role of surgery for tuberous sclerosis complex-associated epilepsy. Pediatr Investig 2022; 6:16-22. [PMID: 35382422 PMCID: PMC8960933 DOI: 10.1002/ped4.12312] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Accepted: 12/30/2021] [Indexed: 11/18/2022] Open
Abstract
Tuberous sclerosis complex (TSC) is a rare multisystem, autosomal dominant neurocutaneous syndrome in which epilepsy is the most common of several neurological and psychiatric manifestations. Around two thirds of patients develop drug-resistant epilepsy for whom surgical resection of epileptogenic foci is indicated when seizures remain inadequately controlled following trial of two antiseizure medications. The challenge with presurgical and surgical approaches with patients with TSC is overcoming the complexity from the number of tubers and the multiplex epileptogenic network forming the epileptogenic zone. Data suggest that seizure freedom is achieved by 55%-60% of patients, but predictive factors for success have remained elusive, which makes for unconfident selection of surgical candidates. This article presents three different cases as illustrations of the potential challenges faced when assessing the suitability of TSC patients for epilepsy surgery.
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Affiliation(s)
- Nicola Specchio
- Rare and Complex Epilepsy Unit, Department of NeurosciencesBambino Gesù Children's Hospital, IRCCSRomeItaly
| | - Giusy Carfi Pavia
- Rare and Complex Epilepsy Unit, Department of NeurosciencesBambino Gesù Children's Hospital, IRCCSRomeItaly
| | - Luca de Palma
- Rare and Complex Epilepsy Unit, Department of NeurosciencesBambino Gesù Children's Hospital, IRCCSRomeItaly
| | | | - Chiara Pepi
- Rare and Complex Epilepsy Unit, Department of NeurosciencesBambino Gesù Children's Hospital, IRCCSRomeItaly
| | - Marta Conti
- Rare and Complex Epilepsy Unit, Department of NeurosciencesBambino Gesù Children's Hospital, IRCCSRomeItaly
| | - Carlo Efisio Marras
- Neurosurgery Unit, Department of NeurosciencesBambino Gesù Children's Hospital, IRCCSRomeItaly
| | - Federico Vigevano
- Department of NeurosciencesBambino Gesù Children's Hospital, IRCCSRomeItaly
| | - Paolo Curatolo
- Child Neurology and Psychiatry Unit, Systems Medicine DepartmentTor Vergata UniversityRomeItaly
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27
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van Vliet EA, Marchi N. Neurovascular unit dysfunction as a mechanism of seizures and epilepsy during aging. Epilepsia 2022; 63:1297-1313. [PMID: 35218208 PMCID: PMC9321014 DOI: 10.1111/epi.17210] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Revised: 02/23/2022] [Accepted: 02/23/2022] [Indexed: 11/30/2022]
Abstract
The term neurovascular unit (NVU) describes the structural and functional liaison between specialized brain endothelium, glial and mural cells, and neurons. Within the NVU, the blood‐brain barrier (BBB) is the microvascular structure regulating neuronal physiology and immune cross‐talk, and its properties adapt to brain aging. Here, we analyze a research framework where NVU dysfunction, caused by acute insults or disease progression in the aging brain, represents a converging mechanism underlying late‐onset seizures or epilepsy and neurological or neurodegenerative sequelae. Furthermore, seizure activity may accelerate brain aging by sustaining regional NVU dysfunction, and a cerebrovascular pathology may link seizures to comorbidities. Next, we focus on NVU diagnostic approaches that could be tailored to seizure conditions in the elderly. We also examine the impending disease‐modifying strategies based on the restoration of the NVU and, more in general, the homeostatic control of anti‐ and pro‐inflammatory players. We conclude with an outlook on current pre‐clinical knowledge gaps and clinical challenges pertinent to seizure onset and conditions in an aging population.
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Affiliation(s)
- Erwin A van Vliet
- Amsterdam UMC, University of Amsterdam, dept. of (Neuro)pathology, Amsterdam, the Netherlands.,University of Amsterdam, Swammerdam Institute for Life Sciences, Center for Neuroscience, Amsterdam, the Netherlands
| | - Nicola Marchi
- Cerebrovascular and Glia Research, Department of Neuroscience, Institute of Functional Genomics, University of Montpellier, CNRS, INSERM, Montpellier, France
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28
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Aeby A, Ceulemans B, Lagae L. Treatment of Focal-Onset Seizures in Children: Should This Be More Etiology-Driven? Front Neurol 2022; 13:842276. [PMID: 35330806 PMCID: PMC8940242 DOI: 10.3389/fneur.2022.842276] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Accepted: 01/24/2022] [Indexed: 01/22/2023] Open
Abstract
To accelerate the process of licensing antiseizure medication (ASM) in children, extrapolation of efficacy data for focal-onset seizures from adults to children ≥2 or ≥4 years of age is now accepted. We summarized the efficacy evidence from randomized, controlled trials that was used to grant approval for the pediatric indication of focal-onset seizures for the different ASMs available in Europe. Data from high-quality randomized, controlled trials in young children are limited, especially on the use of ASMs in monotherapy. Licensure trials are typically focused on seizure type irrespective of etiology or epilepsy syndrome. We elaborate on the importance of etiology- or syndrome-driven research and treatment, illustrating this with examples of childhood epilepsy syndromes characterized by predominantly focal-onset seizures. Some of these syndromes respond well to standard ASMs used for focal-onset seizures, but others would benefit from a more etiology- or syndrome-driven approach. Advances in molecular genetics and neuroimaging have made it possible to reveal the underlying cause of a child's epilepsy and tailor research and treatment. More high-quality randomized, controlled trials based on etiology or syndrome type are needed, including those assessing effects on cognition and behavior. In addition, study designs such as "N-of-1 trials" could elucidate possible new treatment options in rare epilepsies. Broadening incentives currently in place to stimulate the development and marketing of drugs for rare diseases (applicable to some epilepsy syndromes) to more common pediatric epilepsy types and syndromes might be a means to enable high-quality trials, and ultimately allow more evidence-based treatment in children.
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Affiliation(s)
- Alec Aeby
- Pediatric Neurology, Queen Fabiola Children's University Hospital, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Berten Ceulemans
- Department of Pediatric Neurology, Antwerp University Hospital, University of Antwerp, Antwerp, Belgium
| | - Lieven Lagae
- Reference Center for Refractory Epilepsy, Pediatric Neurology, Department of Development and Regeneration, University Hospitals Leuven, Leuven, Belgium
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Liu LY, Teng JMC, Spunt SL, Strelo JL, Kwong BY, Zaba LC. Dermatologic toxicities of targeted antineoplastic agents and immune checkpoint inhibitor therapy in pediatric patients: A systematic review. Pediatr Blood Cancer 2021; 68:e29346. [PMID: 34569142 DOI: 10.1002/pbc.29346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 08/26/2021] [Accepted: 08/28/2021] [Indexed: 11/09/2022]
Abstract
Cutaneous adverse events (cAEs) from targeted antineoplastic agents and immune checkpoint inhibitors are common in children with cancer and may lead to dose reduction or cessation of critical oncologic treatment. Timely diagnosis and proper management of cAEs in pediatric oncology patients is essential to optimize ongoing cancer-directed therapy and improve quality of life. This systematic review of published studies summarizes dermatologic toxicities to targeted anticancer treatments and immune checkpoint inhibitors.
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Affiliation(s)
- Lucy Y Liu
- Department of Dermatology, Stanford University School of Medicine, Stanford, California, USA
| | - Joyce M C Teng
- Department of Dermatology, Stanford University School of Medicine, Stanford, California, USA.,Department of Dermatology, Division of Pediatric Dermatology, Stanford University School of Medicine, Stanford, California, USA
| | - Sheri L Spunt
- Department of Pediatrics, Division of Hematology/Oncology, Stanford University School of Medicine, Stanford, California, USA
| | - Jenna L Strelo
- Cutaneous Oncology, Stanford University Medical Center and Cancer Institute, Stanford, California, USA
| | - Bernice Y Kwong
- Department of Dermatology, Stanford University School of Medicine, Stanford, California, USA.,Cutaneous Oncology, Stanford University Medical Center and Cancer Institute, Stanford, California, USA
| | - Lisa C Zaba
- Department of Dermatology, Stanford University School of Medicine, Stanford, California, USA.,Cutaneous Oncology, Stanford University Medical Center and Cancer Institute, Stanford, California, USA
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30
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Iyer RR, Strahle JM, Groves ML. Neurosurgical Considerations of Neurocutaneous Syndromes. Neurosurg Clin N Am 2021; 33:81-89. [PMID: 34801145 DOI: 10.1016/j.nec.2021.09.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The phakomatoses are a group of genetic and acquired disorders characterized by neurologic, cutaneous, and often ocular manifestations, thus commonly referred to as neurocutaneous syndromes. In several of these conditions the underlying genetic pathophysiology has been elucidated, which will continue to play an important role in advancing therapeutic techniques. This article focuses on several examples of such neurocutaneous syndromes, with special attention to the relevant neurosurgical considerations of these patients.
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Affiliation(s)
- Rajiv R Iyer
- Department of Neurosurgery/Division of Pediatric Neurosurgery, University of Utah/Primary Children's Hospital, 100 N. Mario Capecchi Drive Suite 3850, Salt Lake City, UT 84113, USA.
| | - Jennifer M Strahle
- Pediatric Neuro Spine Program, Pediatric Cerebrovascular Surgery, Division of Pediatric Neurosurgery, Department of Neurosurgery, Washington University School of Medicine, 1 Childrens Pl Suite 4S20, St. Louis, MO 63110, USA
| | - Mari L Groves
- Department of Neurosurgery, Johns Hopkins School of Medicine, 600 N. Wolfe Street Phipps 554, Baltimore, MD 21287, USA
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31
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Jozwiak S, Curatolo P. Editorial: Tuberous Sclerosis Complex - Diagnosis and Management. Front Neurol 2021; 12:755868. [PMID: 34675876 PMCID: PMC8523789 DOI: 10.3389/fneur.2021.755868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 08/20/2021] [Indexed: 11/13/2022] Open
Affiliation(s)
- Sergiusz Jozwiak
- Department of Child Neurology, Medical University of Warsaw, Warsaw, Poland
| | - Paolo Curatolo
- Department of System Medicine, University of Rome Tor Vergata, Rome, Italy
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32
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Nabbout R, Belousova E, Benedik MP, Carter T, Cottin V, Curatolo P, Dahlin M, D'Amato L, Beaure d'Augères G, de Vries PJ, Ferreira JC, Feucht M, Fladrowski C, Hertzberg C, Jozwiak S, Lawson JA, Macaya A, Marques R, O'Callaghan F, Qin J, Sauter M, Shah S, Takahashi Y, Touraine R, Youroukos S, Zonnenberg B, Jansen AC, Kingswood JC. Historical Patterns of Diagnosis, Treatments, and Outcome of Epilepsy Associated With Tuberous Sclerosis Complex: Results From TOSCA Registry. Front Neurol 2021; 12:697467. [PMID: 34566842 PMCID: PMC8455825 DOI: 10.3389/fneur.2021.697467] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 08/02/2021] [Indexed: 12/01/2022] Open
Abstract
Background: Epilepsy is the most common neurological manifestation in individuals with tuberous sclerosis complex (TSC). However, real-world evidence on diagnosis and treatment patterns is limited. Here, we present data from TuberOus Sclerosis registry to increase disease Awareness (TOSCA) on changes in patterns of epilepsy diagnosis, treatments, and outcomes over time, and detailed epilepsy characteristics from the epilepsy substudy. Methods: TuberOus Sclerosis registry to increase disease Awareness (TOSCA) was a multicentre, international disease registry, consisting of a main study that collected data on overall diagnostic characteristics and associated clinical features, and six substudies focusing on specific TSC manifestations. The epilepsy substudy investigated detailed epilepsy characteristics and their correlation to genotype and intelligence quotient (IQ). Results: Epilepsy was reported in 85% of participants, more commonly in younger individuals (67.8% in 1970s to 91.8% in last decade), while rate of treatments was similar across ages (>93% for both infantile spasms and focal seizures, except prior to 1960). Vigabatrin (VGB) was the most commonly used antiepileptic drugs (AEDs). Individuals with infantile spasms showed a higher treatment response over time with lower usage of steroids. Individuals with focal seizures reported similar rates of drug resistance (32.5–43.3%). Use of vagus nerve stimulation (VNS), ketogenic diet, and surgery remained low. Discussion: The epilepsy substudy included 162 individuals from nine countries. At epilepsy onset, most individuals with infantile spasms (73.2%) and focal seizures (74.5%) received monotherapies. Vigabatrin was first-line treatment in 45% of individuals with infantile spasms. Changes in initial AEDs were commonly reported due to inadequate efficacy. TSC1 mutations were associated with less severe epilepsy phenotypes and more individuals with normal IQ. In individuals with TSC diagnosis before seizure onset, electroencephalogram (EEG) was performed prior to seizures in only 12.5 and 25% of subsequent infantile spasms and focal seizures, respectively. Conclusions: Our study confirms the high prevalence of epilepsy in TSC individuals and less severe phenotypes with TSC1 mutations. Vigabatrin improved the outcome of infantile spasms and should be used as first-line treatment. There is, however, still a need for improving therapies in focal seizures. Electroencephalogram follow-up prior to seizure-onset should be promoted for all infants with TSC in order to facilitate preventive or early treatment.
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Affiliation(s)
- Rima Nabbout
- Department of Pediatric Neurology, Reference Centre for Rare Epilepsies, Member of EPICARE Network, Necker Enfants Malades Hospital, Université de Paris, Institut Imagine (Inserm U1163), Paris, France
| | - Elena Belousova
- Department of Pediatrics, Research and Clinical Institute of Pediatrics, Pirogov Russian National Research Medical University, Moscow, Russia
| | - Mirjana P Benedik
- Department of Pediatric Neurology, SPS Paediatric Clinic, Ljubljana, Slovenia
| | - Tom Carter
- Tuberous Sclerosis Association, Nottingham, United Kingdom
| | - Vincent Cottin
- Department of Respiratory Medicine, Hôpital Louis Pradel, Claude Bernard University Lyon 1, Lyon, France
| | - Paolo Curatolo
- Department of Neurology, Tor Vergata University Hospital, Rome, Italy
| | - Maria Dahlin
- Neuropediatric Unit, Karolinska University Hospital, Stockholm, Sweden
| | | | | | - Petrus J de Vries
- Division of Child and Adolescent Psychiatry, University of Cape Town, Cape Town, South Africa
| | - José C Ferreira
- Neurologia Pediátrica, Centro Hospitalar Lisboa Ocidental, Lisbon, Portugal
| | - Martha Feucht
- Department of Pediatrics and Adolescent Medicine, Medical University of Vienna (Affiliated Partner of the ERN EpiCARE), Vienna, Austria
| | - Carla Fladrowski
- Tuberous Sclerosis Association ONLUS, Milan, Italy.,European Tuberous Sclerosis Complex Association, Dattein, Germany
| | - Christoph Hertzberg
- Zentrum für Sozialpädiatrie und Neuropädiatrie (DBZ), Vivantes Hospital Neukoelln, Berlin, Germany
| | - Sergiusz Jozwiak
- Department of Child Neurology, Medical University of Warsaw, Warsaw, Poland.,Department of Neurology and Epileptology, The Children's Memorial Health Institute, Warsaw, Poland
| | - John A Lawson
- Department of Neurology, The Tuberous Sclerosis Multidisciplinary Management Clinic, Sydney Children's Hospital, Randwick, NSW, Australia
| | - Alfons Macaya
- Department of Pediatric Neurology, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Ruben Marques
- Novartis Farma S.p.A., Origgio, Italy.,Institute of Biomedicine, University of Leon, León, Spain
| | - Finbar O'Callaghan
- Paediatric Neuroscience, Institute of Child Health, University College London, London, United Kingdom
| | - Jiong Qin
- Department of Pediatrics, Peking University People's Hospital, Beijing, China
| | | | - Seema Shah
- Novartis Healthcare Pvt. Ltd., Hyderabad, India
| | - Yukitoshi Takahashi
- National Epilepsy Center, National Hospital Organization (NHO), Shizuoka Institute of Epilepsy and Neurological Disorders, Shizuoka, Japan
| | - Renaud Touraine
- Department of Genetics, Centre Hospitalier Universitaire (CHU)-Hôpital Nord, Saint Etienne, France
| | - Sotiris Youroukos
- First Department of Paediatrics, Athens University Medical School, St. Sophia Children's Hospital, Athens, Greece
| | - Bernard Zonnenberg
- Department of Internal Medicine, University Medical Center, Utrecht, Netherlands
| | - Anna C Jansen
- Pediatric Neurology Unit, Department of Pediatrics, UZ Brussel Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - J Chris Kingswood
- Cardiology Clinical Academic Group, Molecular and Clinical Sciences Research Centre, St Georges University of London, London, United Kingdom
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Nabbout R, Kuchenbuch M, Chiron C, Curatolo P. Pharmacotherapy for Seizures in Tuberous Sclerosis Complex. CNS Drugs 2021; 35:965-983. [PMID: 34417984 DOI: 10.1007/s40263-021-00835-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/05/2021] [Indexed: 01/18/2023]
Abstract
Epilepsy is one of the main symptoms affecting the lives of individuals with tuberous sclerosis complex (TSC), causing a high rate of morbidity. Individuals with TSC can present with various types of seizures, epilepsies, and epilepsy syndromes that can coexist or appear in relation to age. Focal epilepsy is the most frequent epilepsy type with two developmental and epileptic encephalopathies: infantile spasms syndrome and Lennox-Gastaut syndrome. Active screening and early management of epilepsy is recommended in individuals with TSC to limit its consequences and its impact on quality of life, cognitive outcome and the economic burden of the disease. The progress in the knowledge of the mechanisms underlying epilepsy in TSC has paved the way for new concepts in the management of epilepsy related to TSC. In addition, we are moving from traditional "reactive" and therapeutic choices with current antiseizure medications used after the onset of seizures, to a proactive approach, aimed at predicting and preventing epileptogenesis and the onset of epilepsy with vigabatrin, and to personalized treatments with mechanistic therapies, namely mechanistic/mammalian target of rapamycin inhibitors. Indeed, epilepsy linked to TSC is one of the only epilepsies for which a predictive and preventive approach can delay seizure onset and improve seizure response. However, the efficacy of such interventions on long-term cognitive and psychiatric outcomes is still under investigation.
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Affiliation(s)
- Rima Nabbout
- Reference Centre for Rare Epilepsies, Department of Pediatric Neurology, Necker Enfants Malades University Hospital, APHP, Université de Paris, 149 rue de Sèvres, 75015, Paris, France.
- UMR 1163, Institut National de la Santé et de la Recherche Médicale (INSERM), Imagine Institute, Université de Paris, Paris, France.
| | - Mathieu Kuchenbuch
- Reference Centre for Rare Epilepsies, Department of Pediatric Neurology, Necker Enfants Malades University Hospital, APHP, Université de Paris, 149 rue de Sèvres, 75015, Paris, France
- UMR 1163, Institut National de la Santé et de la Recherche Médicale (INSERM), Imagine Institute, Université de Paris, Paris, France
| | - Catherine Chiron
- Reference Centre for Rare Epilepsies, Department of Pediatric Neurology, Necker Enfants Malades University Hospital, APHP, Université de Paris, 149 rue de Sèvres, 75015, Paris, France
- Institut National de la Santé et de la Recherche Médicale (INSERM), UMR 1141, Neurospin, Gif sur Yvette, France
| | - Paolo Curatolo
- Department of System Medicine, Child Neurology and Psychiatry Unit, Tor Vergata University Hospital, Rome, Italy
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34
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Clark GD, Lotze TE. Novel Treatments and Clinical Research in Child Neurology. Neurol Clin 2021; 39:719-722. [PMID: 34215383 DOI: 10.1016/j.ncl.2021.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
The molecular understanding of the pathogenic mechanisms responsible for neurologic diseases of children has led to a remarkable period of research that addresses the root causes of diseases. The promise of this research has been realized with cures and treatments that correct underlying deficiencies. The breakneck rate at which new research is being proposed promises to usher in a transformation of child neurology from a diagnostic and supportive field into an interventional one. Training child neurology residents in clinical research and therapeutic intervention is increasingly important to assure the ongoing ability to support research discoveries and treatment.
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Affiliation(s)
- Gary D Clark
- Department of Pediatrics, Division of Neurology and Developmental Neuroscience, Baylor College of Medicine, 6701 Fannin Street Suite 1250, Houston, TX 77030, USA
| | - Timothy E Lotze
- Department of Pediatrics, Division of Neurology and Developmental Neuroscience, Baylor College of Medicine, 6701 Fannin Street Suite 1250, Houston, TX 77030, USA.
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35
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Targeted Therapies in Rare Brain Tumours. Int J Mol Sci 2021; 22:ijms22157949. [PMID: 34360713 PMCID: PMC8348084 DOI: 10.3390/ijms22157949] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Revised: 07/19/2021] [Accepted: 07/21/2021] [Indexed: 12/14/2022] Open
Abstract
Rare central nervous system (CNS) tumours represent a unique challenge. Given the difficulty of conducting dedicated clinical trials, there is a lack of therapies for these tumours supported by high quality evidence, and knowledge regarding the impact of standard treatments (i.e., surgery, radiotherapy or chemotherapy) is commonly based on retrospective studies. Recently, new molecular techniques have led to the discovery of actionable molecular alterations. The aim of this article is to review recent progress in the molecular understanding of and therapeutic options for rare brain tumours, both in children and adults. We will discuss options such as targeting the mechanistic target of rapamycin (mTOR) pathway in subependymal giant cells astrocytomas (SEGAs) of tuberous sclerosis and BRAF V600E mutation in rare glial (pleomorphic xanthoastrocytomas) or glioneuronal (gangliogliomas) tumours, which are a model of how specific molecular treatments can also favourably impact neurological symptoms (such as seizures) and quality of life. Moreover, we will discuss initial experiences in targeting new molecular alterations in gliomas, such as isocitrate dehydrogenase (IDH) mutations and neurotrophic tyrosine receptor kinase (NTRK) fusions, and in medulloblastomas such as the sonic hedgehog (SHH) pathway.
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36
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Schubert-Bast S, Strzelczyk A. Review of the treatment options for epilepsy in tuberous sclerosis complex: towards precision medicine. Ther Adv Neurol Disord 2021; 14:17562864211031100. [PMID: 34349839 PMCID: PMC8290505 DOI: 10.1177/17562864211031100] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Accepted: 06/21/2021] [Indexed: 12/24/2022] Open
Abstract
Tuberous sclerosis complex (TSC) is a rare genetic disorder caused by mutations in the TSC1 or TSC2 genes, which encode proteins that antagonise the mammalian isoform of the target of rapamycin complex 1 (mTORC1) - a key mediator of cell growth and metabolism. TSC is characterised by the development of benign tumours in multiple organs, together with neurological manifestations including epilepsy and TSC-associated neuropsychiatric disorders (TAND). Epilepsy occurs frequently and is associated with significant morbidity and mortality; however, the management is challenging due to the intractable nature of the seizures. Preventative epilepsy treatment is a key aim, especially as patients with epilepsy may be at a higher risk of developing severe cognitive and behavioural impairment. Vigabatrin given preventatively reduces the risk and severity of epilepsy although the benefits for TAND are inconclusive. These promising results could pave the way for evaluating other treatments in a preventative capacity, especially those that may address the underlying pathophysiology of TSC, including everolimus, cannabidiol and the ketogenic diet (KD). Everolimus is an mTOR inhibitor approved for the adjunctive treatment of refractory TSC-associated seizures that has demonstrated significant reductions in seizure frequency compared with placebo, improvements that were sustained after 2 years of treatment. Highly purified cannabidiol, recently approved in the US as Epidiolex® for TSC-associated seizures in patients ⩾1 years of age, and the KD, may also participate in the regulation of the mTOR pathway. This review focusses on the pivotal clinical evidence surrounding these potential targeted therapies that may form the foundation of precision medicine for TSC-associated epilepsy, as well as other current treatments including anti-seizure drugs, vagus nerve stimulation and surgery. New future therapies are also discussed, together with the potential for preventative treatment with targeted therapies. Due to advances in understanding the molecular genetics and pathophysiology, TSC represents a prototypic clinical syndrome for studying epileptogenesis and the impact of precision medicine.
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Affiliation(s)
- Susanne Schubert-Bast
- Epilepsy Center Frankfurt Rhine-Main, Center of Neurology and Neurosurgery, Goethe-University Frankfurt, Frankfurt am Main, Germany
| | - Adam Strzelczyk
- Epilepsy Center Frankfurt Rhine-Main, Goethe-University Frankfurt, Schleusenweg 2-16, Frankfurt am Main, 60528, Germany
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37
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D'Gama AM, Poduri A. Precision Therapy for Epilepsy Related to Brain Malformations. Neurotherapeutics 2021; 18:1548-1563. [PMID: 34608615 PMCID: PMC8608994 DOI: 10.1007/s13311-021-01122-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/04/2021] [Indexed: 02/04/2023] Open
Abstract
Malformations of cortical development (MCDs) represent a range of neurodevelopmental disorders that are collectively common causes of developmental delay and epilepsy, especially refractory childhood epilepsy. Initial treatment with antiseizure medications is empiric, and consideration of surgery is the standard of care for eligible patients with medically refractory epilepsy. In the past decade, advances in next generation sequencing technologies have accelerated progress in understanding the genetic etiologies of MCDs, and precision therapies for focal MCDs are emerging. Notably, mutations that lead to abnormal activation of the mammalian target of rapamycin (mTOR) pathway, which provides critical control of cell growth and proliferation, have emerged as a common cause of malformations. These include tuberous sclerosis complex (TSC), hemimegalencephaly (HME), and some types of focal cortical dysplasia (FCD). TSC currently represents the best example for the pathway from gene discovery to relatively safe and efficacious targeted therapy for epilepsy related to MCDs. Based on extensive pre-clinical and clinical data, the mTOR inhibitor everolimus is currently approved for the treatment of focal refractory seizures in patients with TSC. Although clinical studies are just emerging for FCD and HME, we believe the next decade will bring significant advancements in precision therapies for epilepsy related to these and other MCDs.
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Affiliation(s)
- Alissa M D'Gama
- Divisions of Newborn Medicine and Genetics and Genomics, Department of Pediatrics, Boston Children's Hospital, Boston, MA, USA
- Epilepsy Genetics Program, Department of Neurology, Boston Children's Hospital, Boston, MA, USA
- Departments of Neurology and Pediatrics, Harvard Medical School, Boston, MA, USA
- Broad Institute of Harvard and MIT, Cambridge, MA, USA
| | - Annapurna Poduri
- Epilepsy Genetics Program, Department of Neurology, Boston Children's Hospital, Boston, MA, USA.
- Departments of Neurology and Pediatrics, Harvard Medical School, Boston, MA, USA.
- Broad Institute of Harvard and MIT, Cambridge, MA, USA.
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38
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Galanopoulou AS, Löscher W, Lubbers L, O’Brien TJ, Staley K, Vezzani A, D’Ambrosio R, White HS, Sontheimer H, Wolf JA, Twyman R, Whittemore V, Wilcox KS, Klein B. Antiepileptogenesis and disease modification: Progress, challenges, and the path forward-Report of the Preclinical Working Group of the 2018 NINDS-sponsored antiepileptogenesis and disease modification workshop. Epilepsia Open 2021; 6:276-296. [PMID: 34033232 PMCID: PMC8166793 DOI: 10.1002/epi4.12490] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 04/04/2021] [Accepted: 04/12/2021] [Indexed: 12/12/2022] Open
Abstract
Epilepsy is one of the most common chronic brain diseases and is often associated with cognitive, behavioral, or other medical conditions. The need for therapies that would prevent, ameliorate, or cure epilepsy and the attendant comorbidities is a priority for both epilepsy research and public health. In 2018, the National Institute of Neurological Disease and Stroke (NINDS) convened a workshop titled "Accelerating the Development of Therapies for Antiepileptogenesis and Disease Modification" that brought together preclinical and clinical investigators and industry and regulatory bodies' representatives to discuss and propose a roadmap to accelerate the development of antiepileptogenic (AEG) and disease-modifying (DM) new therapies. This report provides a summary of the discussions and proposals of the Preclinical Science working group. Highlights of the progress of collaborative preclinical research projects on AEG/DM of ongoing research initiatives aiming to improve infrastructure and translation to clinical trials are presented. Opportunities and challenges of preclinical epilepsy research, vis-à-vis clinical research, were extensively discussed, as they pertain to modeling of specific epilepsy types across etiologies and ages, the utilization of preclinical models in AG/DM studies, and the strategies and study designs, as well as on matters pertaining to transparency, data sharing, and reporting research findings. A set of suggestions on research initiatives, infrastructure, workshops, advocacy, and opportunities for expanding the borders of epilepsy research were discussed and proposed as useful initiatives that could help create a roadmap to accelerate and optimize preclinical translational AEG/DM epilepsy research.
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Affiliation(s)
- Aristea S. Galanopoulou
- Saul R. Korey Department of NeurologyDominick P. Purpura Department of NeuroscienceIsabelle Rapin Division of Child NeurologyAlbert Einstein College of MedicineBronxNYUSA
| | - Wolfgang Löscher
- Department of Pharmacology, Toxicology, and PharmacyUniversity of Veterinary Medicine HannoverHannoverGermany
| | | | - Terence J. O’Brien
- Department of NeuroscienceCentral Clinical SchoolAlfred HealthMonash UniversityMelbourneVic.Australia
| | - Kevin Staley
- Department of NeurologyMassachusetts General HospitalBostonMAUSA
| | - Annamaria Vezzani
- Department of NeuroscienceIRCCS‐Mario Negri Institute for Pharmacological ResearchMilanoItaly
| | | | - H. Steve White
- Department of PharmacySchool of PharmacyUniversity of WashingtonSeattleWAUSA
| | | | - John A. Wolf
- Center for Brain Injury and RepairDepartment of NeurosurgeryUniversity of PennsylvaniaPhiladelphiaPAUSA
- Corporal Michael J. Crescenz Veterans Affairs Medical CenterPhiladelphiaPAUSA
| | | | - Vicky Whittemore
- National Institute of Neurological Disorders and StrokeNational Institutes of HealthBethesdaMDUSA
| | - Karen S. Wilcox
- Department of Pharmacology & ToxicologyUniversity of UtahSalt Lake CityUTUSA
| | - Brian Klein
- National Institute of Neurological Disorders and StrokeNational Institutes of HealthBethesdaMDUSA
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Abstract
INTRODUCTION Focal cortical dysplasias (FCDs) represent the most common etiology in pediatric drug-resistant focal epilepsies undergoing surgical treatment. The localization, extent and histopathological features of FCDs are considerably variable. Somatic mosaic mutations of genes that encode proteins in the PI3K-AKTmTOR pathway, which also includes the tuberous sclerosis associated genes TSC1 and TSC2, have been implicated in FCD type II in a substantial subset of patients. Surgery is the principal therapeutic option for FCD-related epilepsy. Advanced neurophysiological and neuroimaging techniques have improved surgical outcome and reduced the risk of postsurgical deficits. Pharmacological MTOR inhibitors are being tested in clinical trials and might represent an example of personalized treatment of epilepsy based on the known mechanisms of disease, used alone or in combination with surgery. AREAS COVERED This review will critically analyze the advances in the diagnosis and treatment of FCDs, with a special focus on the novel therapeutic options prompted by a better understanding of their pathophysiology. EXPERT OPINION Focal cortical dysplasia is a main cause of drug-resistant epilepsy, especially in children. Novel, personalized approaches are needed to more effectively treat FCD-related epilepsy and its cognitive consequences.
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Affiliation(s)
- Renzo Guerrini
- Neuroscience Department, Children's Hospital Meyer-University of Florence, Florence, Italy
| | - Carmen Barba
- Neuroscience Department, Children's Hospital Meyer-University of Florence, Florence, Italy
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40
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Specchio N, Curatolo P. Developmental and epileptic encephalopathies: what we do and do not know. Brain 2021; 144:32-43. [PMID: 33279965 DOI: 10.1093/brain/awaa371] [Citation(s) in RCA: 68] [Impact Index Per Article: 22.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 07/16/2020] [Accepted: 08/17/2020] [Indexed: 02/06/2023] Open
Abstract
Developmental encephalopathies, including intellectual disability and autistic spectrum disorder, are frequently associated with infant epilepsy. Epileptic encephalopathy is used to describe an assumed causal relationship between epilepsy and developmental delay. Developmental encephalopathies pathogenesis more independent from epilepsy is supported by the identification of several gene variants associated with both developmental encephalopathies and epilepsy, the possibility for gene-associated developmental encephalopathies without epilepsy, and the continued development of developmental encephalopathies even when seizures are controlled. Hence, 'developmental and epileptic encephalopathy' may be a more appropriate term than epileptic encephalopathy. This update considers the best studied 'developmental and epileptic encephalopathy' gene variants for illustrative support for 'developmental and epileptic encephalopathy' over epileptic encephalopathy. Moreover, the interaction between epilepsy and developmental encephalopathies is considered with respect to influence on treatment decisions. Continued research in genetic testing will increase access to clinical tests, earlier diagnosis, better application of current treatments, and potentially provide new molecular-investigated treatments.
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Affiliation(s)
- Nicola Specchio
- Department of Neuroscience, Bambino Gesu Children's Hospital, IRCCS, Full Member of European Reference Network on Rare and Complex Epilepsies EpiCARE, Piazza S, 00165 Rome, Italy
| | - Paolo Curatolo
- Systems Medicine Department, Child Neurology and Psychiatry Unit, Tor Vergata University Hospital of Rome, 00133 Rome, Italy
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Mastrangelo M, Commone C, Greco C, Leuzzi V. TSC1 as a Novel Gene for Sleep-Related Hypermotor Epilepsy: A Child with a Mild Phenotype of Tuberous Sclerosis. Neuropediatrics 2021; 52:146-149. [PMID: 33578443 DOI: 10.1055/s-0041-1722881] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Sleep-related hypermotor epilepsy (SHE) is a rare syndrome that presents with hyperkinetic asymmetric tonic/dystonic seizures with vegetative signs, vocalization, and emotional facial expression, mainly during light non-rapid eye movement sleep stages. The role of various genes (CHRNA4, CHRNB2, CHRNA2, KCNT1, DEPDC5, NPRL2, NPRL3, and PRIMA1) has previously been reported, though genetic etiology is assessed in less than 10% of cases. We report the case of a 5-year-old female carrying the TSC1 variant c.843del p.(Ser282Glnfs*36) who presented with a mild phenotype of tuberous sclerosis, including carbamazepine-responsive SHE, normal neurocognitive functioning, hypomelanotic macules, no abnormalities outside the central nervous system, and tubers at neuroimaging. The presented case extends the list of SHE-related genes to include TSC1, thus suggesting a central pathogenic role of mammalian target of rapamycin (mTOR) cascade dysfunction in SHE and introducing a possible use of mTOR inhibitors in this epileptic syndrome.
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Affiliation(s)
- Mario Mastrangelo
- Child Neurology and Infantile Psychiatry Unit, Department of Human Neuroscience, Sapienza University of Rome, Italy
| | - Chiara Commone
- Child Neurology and Infantile Psychiatry Unit, Department of Human Neuroscience, Sapienza University of Rome, Italy
| | - Carlo Greco
- Child Neurology and Infantile Psychiatry Unit, Department of Human Neuroscience, Sapienza University of Rome, Italy
| | - Vincenzo Leuzzi
- Child Neurology and Infantile Psychiatry Unit, Department of Human Neuroscience, Sapienza University of Rome, Italy
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42
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Kingswood JC, Belousova E, Benedik MP, Budde K, Carter T, Cottin V, Curatolo P, Dahlin M, D'Amato L, d'Augères GB, de Vries PJ, Ferreira JC, Feucht M, Fladrowski C, Hertzberg C, Jozwiak S, Lawson JA, Macaya A, Marques R, Nabbout R, O'Callaghan F, Qin J, Sander V, Sauter M, Shah S, Takahashi Y, Touraine R, Youroukos S, Zonnenberg B, Jansen AC. TuberOus SClerosis registry to increAse disease awareness (TOSCA) Post-Authorisation Safety Study of Everolimus in Patients With Tuberous Sclerosis Complex. Front Neurol 2021; 12:630378. [PMID: 33833726 PMCID: PMC8021912 DOI: 10.3389/fneur.2021.630378] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 02/03/2021] [Indexed: 11/20/2022] Open
Abstract
This non-interventional post-authorisation safety study (PASS) assessed the long-term safety of everolimus in patients with tuberous sclerosis complex (TSC) who participated in the TuberOus SClerosis registry to increase disease Awareness (TOSCA) clinical study and received everolimus for the licensed indications in the European Union. The rate of adverse events (AEs), AEs that led to dose adjustments or treatment discontinuation, AEs of potential clinical interest, treatment-related AEs (TRAEs), serious AEs (SAEs), and deaths were documented. One hundred seventy-nine patients were included in the first 5 years of observation; 118 of 179 patients had an AE of any grade, with the most common AEs being stomatitis (7.8%) and headache (7.3%). AEs caused dose adjustments in 56 patients (31.3%) and treatment discontinuation in nine patients (5%). AEs appeared to be more frequent and severe in children. On Tanner staging, all patients displayed signs of age-appropriate sexual maturation. Twenty-two of 106 female (20.8%) patients had menstrual cycle disorders. The most frequent TRAEs were stomatitis (6.7%) and aphthous mouth ulcer (5.6%). SAEs were reported in 54 patients (30.2%); the most frequent SAE was pneumonia (>3% patients; grade 2, 1.1%, and grade 3, 2.8%). Three deaths were reported, all in patients who had discontinued everolimus for more than 28 days, and none were thought to be related to everolimus according to the treating physicians. The PASS sub-study reflects the safety and tolerability of everolimus in the management of TSC in real-world routine clinical practice.
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Affiliation(s)
- J Chris Kingswood
- Genomics Clinical Academic Group, Molecular and Clinical Sciences Research Centre, St George's Hospital, University of London, London, United Kingdom
| | - Elena Belousova
- Research and Clinical Institute of Paediatrics, Pirogov Russian National Research Medical University, Moscow, Russia
| | | | - Klemens Budde
- Internal Medicine and Nephrology, Hypertensiology DHL, University Medicine Berlin, Berline, Germany
| | - Tom Carter
- Tuberous Sclerosis Association, Nottingham, United Kingdom
| | - Vincent Cottin
- Hôpital Louis Pradel, Claude Bernard University Lyon, Lyon, France
| | | | - Maria Dahlin
- Karolinska University Hospital, Stockholm, Sweden
| | | | | | - Petrus J de Vries
- Division of Child and Adolescent Psychiatry, University of Cape Town, Cape Town, South Africa
| | | | - Martha Feucht
- Universitätsklinik für Kinder-und Jugendheilkunde, Vienna, Austria
| | - Carla Fladrowski
- Associazione Sclerosi Tuberosa ONLUS, Milan, Italy.,European Tuberous Sclerosis Complex Association, In den Birken, Dattein, Neuharlingersiel, Germany
| | | | - Sergiusz Jozwiak
- Department of Child Neurology, Medical University of Warsaw, Warsaw, Poland.,Department of Neurology and Epileptology, The Children's Memorial Health Institute, Warsaw, Poland
| | - John A Lawson
- The Tuberous Sclerosis Multidisciplinary Management Clinic, Sydney Children's Hospital, Randwick, NSW, Australia
| | - Alfons Macaya
- Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Ruben Marques
- Novartis Farma S.p.A., Origgio, Italy.,Institute of Biomedicine (IBIOMED), University of León, León, Spain
| | - Rima Nabbout
- Department of Paediatric Neurology, Necker Enfants Malades Hospital, Paris Descartes University, Paris, France
| | - Finbar O'Callaghan
- Institute of Child Health, University College London, London, United Kingdom
| | - Jiong Qin
- Department of Paediatrics, Peking University People's Hospital, Beijing, China
| | | | | | - Seema Shah
- Novartis Healthcare Pvt. Ltd, Hyderabad, India
| | - Yukitoshi Takahashi
- National Epilepsy Center, Shizuoka Institute of Epilepsy and Neurological Disorders, NHO, Shizuoka, Japan
| | - Renaud Touraine
- Department of Genetics, CHU-Hôpital Nord, Saint Etienne, France
| | | | | | - Anna C Jansen
- Pediatric Neurology Unit, Department of Paediatrics, UZ Brussel VUB, Brussels, Belgium
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43
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Johannessen Landmark C, Potschka H, Auvin S, Wilmshurst JM, Johannessen SI, Kasteleijn-Nolst Trenité D, Wirrell EC. The role of new medical treatments for the management of developmental and epileptic encephalopathies: Novel concepts and results. Epilepsia 2021; 62:857-873. [PMID: 33638459 DOI: 10.1111/epi.16849] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 01/28/2021] [Accepted: 01/30/2021] [Indexed: 12/20/2022]
Abstract
Developmental and epileptic encephalopathies (DEEs) are among the most challenging of all epilepsies to manage, given the exceedingly frequent and often severe seizure types, pharmacoresistance to conventional antiseizure medications, and numerous comorbidities. During the past decade, efforts have focused on development of new treatment options for DEEs, with several recently approved in the United States or Europe, including cannabidiol as an orphan drug in Dravet and Lennox-Gastaut syndromes and everolimus as a possible antiepileptogenic and precision drug for tuberous sclerosis complex, with its impact on the mammalian target of rapamycin pathway. Furthermore, fenfluramine, an old drug, was repurposed as a novel therapy in the treatment of Dravet syndrome. The evolution of new insights into pathophysiological processes of various DEEs provides possibilities to investigate novel and repurposed drugs and to place them into the context of their role in future management of these patients. The purpose of this review is to provide an overview of these new medical treatment options for the DEEs and to discuss the clinical implications of these results for improved treatment.
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Affiliation(s)
- Cecilie Johannessen Landmark
- Program for Pharmacy, Department of Life Sciences and Health, Faculty of Health Sciences, Oslo Metropolitan University, Oslo, Norway.,National Center for Epilepsy, Oslo University Hospital, Oslo, Norway.,Section for Clinical Pharmacology, Department of Pharmacology, Oslo University Hospital, Oslo, Norway
| | - Heidrun Potschka
- Institute of Pharmacology, Toxicology, and Pharmacy, Ludwig Maximilian University of Munich, Munich, Germany
| | - Stéphane Auvin
- Pediatric Neurology Department, Robert Debré Hospital, Public Hospital Network of Paris, Paris, France.,Mixed Unit of Research NeuroDiderot U1141, University of Paris, Paris, France
| | - Jo M Wilmshurst
- Paediatric Neurology Department, Red Cross War Memorial Children's Hospital, Neuroscience Institute, University of Cape Town, Cape Town, South Africa
| | - Svein I Johannessen
- National Center for Epilepsy, Oslo University Hospital, Oslo, Norway.,Section for Clinical Pharmacology, Department of Pharmacology, Oslo University Hospital, Oslo, Norway
| | | | - Elaine C Wirrell
- Divisions of Child and Adolescent Neurology and Epilepsy, Mayo Clinic, Rochester, Minnesota, USA
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44
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Li YF, Thom M, Jacques TS. Novel therapeutic targets in epilepsy: oxidative stress and iron metabolism. Neuropathol Appl Neurobiol 2021; 46:519-521. [PMID: 32155661 DOI: 10.1111/nan.12615] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Affiliation(s)
- Y-F Li
- Pathology Department, Tri-Service General Hospital & National Defence Medical Centre, Taipei, Taiwan, ROC
| | - M Thom
- Department of Neuropathology, UCL Institute of Neurology, London, UK
| | - T S Jacques
- Developmental Biology and Cancer Research & Teaching Department, UCL Great Ormond Street Institute of Child Health, London, UK.,Departments of Histopathology, Great Ormond Street Hospital NHS Foundation Trust, London, UK
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45
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Stockinger J, Strzelczyk A, Nemecek A, Cicanic M, Bösebeck F, Brandt C, Hamer H, Intravooth T, Steinhoff BJ. Everolimus in adult tuberous sclerosis complex patients with epilepsy: Too late for success? A retrospective study. Epilepsia 2021; 62:785-794. [PMID: 33534134 DOI: 10.1111/epi.16829] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Revised: 01/08/2021] [Accepted: 01/12/2021] [Indexed: 01/17/2023]
Abstract
OBJECTIVE There is evidence that everolimus (EVE) significantly reduces seizure frequency in epilepsy patients with tuberous sclerosis complex (TSC). Given that TSC-related proliferative processes are more dynamic during brain development, seizure outcomes of patients treated with EVE may be age-related and may be less convincing in adult patients. The aim of this study was to assess the effectiveness and the safety profile of EVE in adults in clinical practice. METHODS We performed a multicenter retrospective chart review of TSC subjects with active epilepsy who started EVE in adulthood (≥18 years of age) at seven German epilepsy centers. The primary endpoint was the retention rate after 6 months. RESULTS A total of 45 subjects with a mean age of 31.6 ± 11.1 years at EVE start fulfilled the inclusion criteria. Retention rate after 6 months was 98% (43/44 evaluable subjects). Response rate (seizure reduction ≥ 50%) was 33% (14/43 evaluable subjects; four completely seizure-free). We did not find a significant relationship between epilepsy outcome parameters and patient age at EVE start. Adverse events were reported in 19 subjects and were judged to be serious in six patients. Three patients died during the observation period. SIGNIFICANCE Evidence suggests that EVE is an effective add-on treatment for epilepsy in adult TSC patients, surprisingly without any age limit to individual benefit. A strong age-dependent effect within the period of adulthood seems unlikely. Even if there was no proof of a causal relationship between deaths and EVE intake, patients with EVE should be carefully monitored, especially for infections and stomatitis.
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Affiliation(s)
| | - Adam Strzelczyk
- Epilepsy Center Frankfurt Rhine-Main, Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Andrea Nemecek
- Berlin-Brandenburg Epilepsy Center, Charité, Berlin, Germany
| | | | - Frank Bösebeck
- Agaplesion Diakonieklinikum Rotenburg Epilepsy Center, Rotenburg, Germany
| | | | - Hajo Hamer
- Erlangen Epilepsy Center, Erlangen University Hospital, Erlangen, Germany
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46
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Everolimus als krankheitsspezifische Therapieoption bei mit tuberöser Sklerose assoziierter, therapierefraktärer Epilepsie – ein systematischer Überblick. ZEITSCHRIFT FUR EPILEPTOLOGIE 2021. [DOI: 10.1007/s10309-020-00393-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
ZusammenfassungTuberöse Sklerose („tuberous sclerosis complex“ [TSC]) ist eine seltene genetische Erkrankung, die neben kutanen und viszeralen Organmanifestationen typischerweise bereits in einem sehr frühen Erkrankungsstadium mit einer schweren, meist therapierefraktären Epilepsie einhergeht. Aufgrund seiner direkten Wirkung am durch TSC dysregulierten mTOR-Signalweg sowie der synergistischen Effekte auf andere Organmanifestationen kommt das Rapamycin-Derivat Everolimus (EVE) zunehmend zur Anwendung. Ziel dieses systematischen Reviews ist, die Wirksamkeit, Sicherheit und Verträglichkeit von EVE bei Patienten mit TSC-assoziierter, therapierefraktärer Epilepsie aufzuarbeiten.
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47
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Accogli A, Geraldo AF, Piccolo G, Riva A, Scala M, Balagura G, Salpietro V, Madia F, Maghnie M, Zara F, Striano P, Tortora D, Severino M, Capra V. Diagnostic Approach to Macrocephaly in Children. Front Pediatr 2021; 9:794069. [PMID: 35096710 PMCID: PMC8795981 DOI: 10.3389/fped.2021.794069] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Accepted: 12/02/2021] [Indexed: 01/19/2023] Open
Abstract
Macrocephaly affects up to 5% of the pediatric population and is defined as an abnormally large head with an occipitofrontal circumference (OFC) >2 standard deviations (SD) above the mean for a given age and sex. Taking into account that about 2-3% of the healthy population has an OFC between 2 and 3 SD, macrocephaly is considered as "clinically relevant" when OFC is above 3 SD. This implies the urgent need for a diagnostic workflow to use in the clinical setting to dissect the several causes of increased OFC, from the benign form of familial macrocephaly and the Benign enlargement of subarachnoid spaces (BESS) to many pathological conditions, including genetic disorders. Moreover, macrocephaly should be differentiated by megalencephaly (MEG), which refers exclusively to brain overgrowth, exceeding twice the SD (3SD-"clinically relevant" megalencephaly). While macrocephaly can be isolated and benign or may be the first indication of an underlying congenital, genetic, or acquired disorder, megalencephaly is most likely due to a genetic cause. Apart from the head size evaluation, a detailed family and personal history, neuroimaging, and a careful clinical evaluation are crucial to reach the correct diagnosis. In this review, we seek to underline the clinical aspects of macrocephaly and megalencephaly, emphasizing the main differential diagnosis with a major focus on common genetic disorders. We thus provide a clinico-radiological algorithm to guide pediatricians in the assessment of children with macrocephaly.
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Affiliation(s)
- Andrea Accogli
- Division of Medical Genetics, Department of Medicine, McGill University Health Centre, Montreal, QC, Canada
| | - Ana Filipa Geraldo
- Diagnostic Neuroradiology Unit, Imaging Department, Centro Hospitalar Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal
| | - Gianluca Piccolo
- Pediatric Neurology and Neuromuscular Diseases Unit, IRCCS Giannina Gaslini Institute, Genoa, Italy
| | - Antonella Riva
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), University of Genoa, Genoa, Italy
| | - Marcello Scala
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), University of Genoa, Genoa, Italy
| | - Ganna Balagura
- Pediatric Neurology and Neuromuscular Diseases Unit, IRCCS Giannina Gaslini Institute, Genoa, Italy
| | - Vincenzo Salpietro
- Pediatric Neurology and Neuromuscular Diseases Unit, IRCCS Giannina Gaslini Institute, Genoa, Italy.,Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), University of Genoa, Genoa, Italy
| | - Francesca Madia
- Pediatric Clinic and Endocrinology, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Mohamad Maghnie
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), University of Genoa, Genoa, Italy.,Pediatric Clinic and Endocrinology, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Federico Zara
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), University of Genoa, Genoa, Italy.,Medical Genetics Unit, IRCCS Giannina Gaslini Institute, Genoa, Italy
| | - Pasquale Striano
- Pediatric Neurology and Neuromuscular Diseases Unit, IRCCS Giannina Gaslini Institute, Genoa, Italy.,Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), University of Genoa, Genoa, Italy
| | - Domenico Tortora
- Neuroradiology Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | | | - Valeria Capra
- Medical Genetics Unit, IRCCS Giannina Gaslini Institute, Genoa, Italy
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Sidira C, Vargiami E, Dragoumi P, Zafeiriou DI. Hemimegalencephaly and tuberous sclerosis complex: A rare yet challenging association. Eur J Paediatr Neurol 2021; 30:58-65. [PMID: 33387903 DOI: 10.1016/j.ejpn.2020.12.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 10/20/2020] [Accepted: 12/17/2020] [Indexed: 12/18/2022]
Abstract
Hemimegalencephaly is a rare malformation of cortical development characterised by enlargement of one cerebral hemisphere. The association between hemimegalencephaly and tuberous sclerosis complex, an autosomal dominant genetic disorder, is uncommon and has so far been reported only in a few cases. Intractable epilepsy and severe developmental delay are typical clinical manifestations. Aberrant activation of the mTOR signalling pathway is considered to be the hallmark of the pathogenesis of these two disorders. Thus, mTOR inhibitors such as everolimus represent a promising therapeutic approach to mTOR-associated manifestations. We present a thorough literature review of the association between hemimegaloencephaly and tuberous sclerosis complex.
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Affiliation(s)
- Christina Sidira
- 1st Paediatric Department, Developmental Centre "A. Fokas", Aristotle University of Thessaloniki, "Hippokration" General Hospital, Thessaloniki, Greece
| | - Efthymia Vargiami
- 1st Paediatric Department, Developmental Centre "A. Fokas", Aristotle University of Thessaloniki, "Hippokration" General Hospital, Thessaloniki, Greece
| | - Pinelopi Dragoumi
- 1st Paediatric Department, Developmental Centre "A. Fokas", Aristotle University of Thessaloniki, "Hippokration" General Hospital, Thessaloniki, Greece
| | - Dimitrios I Zafeiriou
- 1st Paediatric Department, Developmental Centre "A. Fokas", Aristotle University of Thessaloniki, "Hippokration" General Hospital, Thessaloniki, Greece.
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49
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Uliel-Sibony S, Chernuha V, Meirson H, Fattal-Valevski A. Medical treatment of tuberous sclerosis-related epilepsy. Childs Nerv Syst 2020; 36:2511-2517. [PMID: 32829444 DOI: 10.1007/s00381-020-04772-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Accepted: 06/23/2020] [Indexed: 01/13/2023]
Abstract
Epilepsy is one of the most frequent CNS manifestations of tuberous sclerosis, and for most patients, it is the major debilitating factor. In up to 70% of the cases, the epilepsy is refractory and usually associated with significant behavioral as well as developmental consequences. Therefore, controlling seizures is one of the biggest medical and surgical challenges. Understanding the cellular mechanism involved in the disease empowered targeted research aimed toward early intervention in the epileptogenicity process. In this review, we present an update on the pharmacological treatments in tuberous sclerosis-related epilepsy.
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Affiliation(s)
- Shimrit Uliel-Sibony
- Pediatric Neurology Institute, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center and Sackler Faculty of Medicine, Tel Aviv, Israel. .,Pediatric Neurology institute, Dana-Dwek Children's Hospital, Tel-Aviv Sourasky Medical Center, 6 Weizmann Street, 64239, Tel Aviv, Israel.
| | - Veronika Chernuha
- Pediatric Neurology Institute, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center and Sackler Faculty of Medicine, Tel Aviv, Israel
| | - Hadas Meirson
- Pediatric Neurology Institute, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center and Sackler Faculty of Medicine, Tel Aviv, Israel
| | - Aviva Fattal-Valevski
- Pediatric Neurology Institute, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center and Sackler Faculty of Medicine, Tel Aviv, Israel
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50
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Zimmer TS, Broekaart DWM, Gruber VE, van Vliet EA, Mühlebner A, Aronica E. Tuberous Sclerosis Complex as Disease Model for Investigating mTOR-Related Gliopathy During Epileptogenesis. Front Neurol 2020; 11:1028. [PMID: 33041976 PMCID: PMC7527496 DOI: 10.3389/fneur.2020.01028] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2020] [Accepted: 08/06/2020] [Indexed: 12/13/2022] Open
Abstract
Tuberous sclerosis complex (TSC) represents the prototypic monogenic disorder of the mammalian target of rapamycin (mTOR) pathway dysregulation. It provides the rational mechanistic basis of a direct link between gene mutation and brain pathology (structural and functional abnormalities) associated with a complex clinical phenotype including epilepsy, autism, and intellectual disability. So far, research conducted in TSC has been largely neuron-oriented. However, the neuropathological hallmarks of TSC and other malformations of cortical development also include major morphological and functional changes in glial cells involving astrocytes, oligodendrocytes, NG2 glia, and microglia. These cells and their interglial crosstalk may offer new insights into the common neurobiological mechanisms underlying epilepsy and the complex cognitive and behavioral comorbidities that are characteristic of the spectrum of mTOR-associated neurodevelopmental disorders. This review will focus on the role of glial dysfunction, the interaction between glia related to mTOR hyperactivity, and its contribution to epileptogenesis in TSC. Moreover, we will discuss how understanding glial abnormalities in TSC might give valuable insight into the pathophysiological mechanisms that could help to develop novel therapeutic approaches for TSC or other pathologies characterized by glial dysfunction and acquired mTOR hyperactivation.
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Affiliation(s)
- Till S Zimmer
- Department of (Neuro)Pathology, Amsterdam Neuroscience, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, Netherlands
| | - Diede W M Broekaart
- Department of (Neuro)Pathology, Amsterdam Neuroscience, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, Netherlands
| | | | - Erwin A van Vliet
- Department of (Neuro)Pathology, Amsterdam Neuroscience, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, Netherlands.,Swammerdam Institute for Life Sciences, Center for Neuroscience, University of Amsterdam, Amsterdam, Netherlands
| | - Angelika Mühlebner
- Department of (Neuro)Pathology, Amsterdam Neuroscience, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, Netherlands
| | - Eleonora Aronica
- Department of (Neuro)Pathology, Amsterdam Neuroscience, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, Netherlands.,Stichting Epilepsie Instellingen Nederland (SEIN), Heemstede, Netherlands
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