Short-term nonhormonal and nonsteroid treatment in West syndrome

Effectiveness and Safety of Nitrazepam in Children with Resistant West Syndrome

OBJECTIVES

To study the effectiveness, tolerability, and safety of oral nitrazepam in children with resistant West syndrome (WS).

METHODS

This prospective observational study was conducted at a tertiary care hospital in North India from January 2019 to October 2020. Children with WS resistant to standard therapy were enrolled within 7 d of initiation of nitrazepam and prospectively followed-up for cessation of spasms and adverse events.

RESULTS

Forty-one children with resistant WS initiated on nitrazepam therapy were evaluated. The median age at onset of spasms was 6 mo (Q1, Q3: 4, 8). There was a preponderance of male gender (71%) and structural causes (78%). More than half of the enrolled children had failed four or more antiseizure medications (ASM) for epileptic spasms. The study participants had a long lead-time-to-treatment (LTTT) for the initial standard therapy (median: 2 mo; Q1, Q3: 1, 5) and nitrazepam (median: 11 mo; Q1, Q3: 8, 16). Nitrazepam was instituted as monotherapy in 7 (17%) children and as an adjunct in the rest. Twenty-one (51%) children achieved persistent cessation of epileptic spasms. However, the electroclinical response was observed in 17 (42%) children. Drowsiness, sialorrhea, and decreased appetite were the most commonly observed adverse events. Most adverse events were mild to moderate in severity and did not require dose reduction or change of medication. There was no significant difference between the responders and nonresponders in terms of LTTT, age at onset, or etiology.

CONCLUSIONS

Nitrazepam is a safe and feasible treatment alternative in children with resistant WS resulting in persistent cessation of spasms and electroclinical response in nearly half of patients.

Pharmacotherapy for Seizures in Tuberous Sclerosis Complex

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.

Orthodontic treatment need for adolescents in the Campania region: the malocclusion impact on self-concept

BACKGROUND

Dental malocclusions can be considered not only as an oral health problem, because they are linked to quality of life perception. Many factors related to malocclusion have strong influences on the perception of facial esthetics (eg, anterior tooth alignment, tooth shape and position, lip thickness, symmetric gingival or tooth contour, lip profile, and overjet). Many reports have shown that the perception of facial esthetics can influence psychological development from early childhood to adulthood. The aim of this study is to investigate the effect of dental malocclusion on self-esteem in a sample of adolescents.

MATERIALS AND METHODS

The study population was composed of 516 orthodontically untreated subjects (256 males) mean ages 13.75±1.977 years recruited from schools in the Campania region of Italy between January 2011 and July 2011. To evaluate the self-esteem grade in our population, all subjects filled out the Multidimensional Self Concept Scale questionnaire and attended an orthodontic clinical evaluation to estimate dental occlusal aspects.

RESULTS

Pearson's analysis shows the relationship in our sample between some occlusal characteristics (crossbite and dental crowding) and aspects of self-concept evaluation (social, competence, academic, physical, and global score) of the Multidimensional Self Concept Scale questionnaire. Moreover, logistic regression analysis shows the potential role of dental crowding (odds ratio 5.359; 95% confidence interval 3.492-8.225) and crossbite (odds ratio 6.153; 95% confidence interval 3.545-10.678) as risk factors for development of global self-concept score abnormalities.

CONCLUSION

Our findings confirm the relationship between psychosocial well-being, self-esteem, and dental malocclusion among adolescents.

P-glycoprotein alters blood-brain barrier penetration of antiepileptic drugs in rats with medically intractable epilepsy

P-glycoprotein is one of the earliest known multidrug transporters and plays an important role in resistance to chemotherapeutic drugs. In this study, we detected levels of P-glycoprotein and its mRNA expression in a rat brain model of medically intractable epilepsy established by amygdala kindling and drug selection. We investigated whether inhibition of P-glycoprotein affects the concentration of antiepileptic drugs in cortical extracellular fluid. We found that levels of P-glycoprotein and its mRNA expression were upregulated in epileptic cerebral tissue compared with cerebral tissue from normal rats. The concentrations of two antiepileptic drugs, carbamazepine and phenytoin, were very low in the cortical extracellular fluid of rats with medically intractable epilepsy, and were restored after blockade of P-glycoprotein by verapamil. These results show that increased P-glycoprotein levels alter the ability of carbamazepine and phenytoin to penetrate the blood-brain barrier and reduce the concentrations of these agents in extracellular cortical fluid. High P-glycoprotein levels may be involved in resistance to antiepileptic drugs in medically intractable epilepsy.

West syndrome: early remission is not assurance of normal final outcome

BACKGROUND

West syndrome (WS), an age-specific epilepsy of infancy and early childhood, considered of poor prognosis, may have remission. With the objective of describing the clinical features, treatment and outcome of the children with WS followed in a Latin American country, we devised a retrospective study.

METHODS

Infants with recurrent spasms, and typical or atypical hypsarrhythmia on electroencephalography (EEG) were included, and their medical report reviewed with particular interest on therapy (anti-epileptic drug, steroids) and outcome. Short-term (remission of spasms up to 6 months after the beginning) and long-term outcome (development and seizure status over the age of 2 years) were focused.

RESULTS

Of the 37 selected infants, most (29/37, 78.3%) were classified as symptomatic, and neonatal history of hypoxia (10/29) was the most frequent etiology. The majority had a typical hypsarrhythmia EEG pattern. Most used a combination of anti-epileptic drugs and steroids. A favourable short-term outcome occurred in 20 infants, but only three had normal development and were seizure free after the age of 2 years.

CONCLUSION

Early seizure remission is not assurance of normal final outcome in WS.

Multicenter long-term follow-up of children with idiopathic West syndrome: ACTH versus vigabatrin

BACKGROUND AND PURPOSE

Long-term follow-up of children with idiopathic West syndrome (WS) treated with adrenocorticotropic hormone (ACTH) or vigabatrin.

METHODS

Records of 28 normal magnetic resonance imaging (MRI) WS cases were reviewed for seizure development and cognitive outcome in relation to treatment type and lag.

RESULTS

Average age at disease onset was 5.5 months, and average lag time to treatment was 25 days. Fourteen patients were treated with ACTH (eight early and six late), and 14 with vigabatrin (without delay). Response rates were 88% for ACTH and 80% for vigabatrin. Short-term outcomes for seizure cessation and electroencephalography normalization were identical between the groups. In the long-term, early ACTH treatment was better than the rest combined. Average follow-up time was 9 years. A normal cognitive outcome was achieved in 100% of the early-ACTH group, 67% of the late-ACTH group and 54% of the vigabatrin group (P = 0.03). Seizures subsequently developed in 54% of the vigabatrin group, in 33% of the late ACTH group, and 0% of the early ACTH group (P < 0.05).

CONCLUSIONS

Idiopathic WS with normal MRI is associated with a good cognitive outcome. Early ACTH treatment, administered within 1 month, yields a better cognitive and seizure outcome than vigabatrin or late ACTH.

Current role of vigabatrin in infantile spasms

Vigabatrin (VGB), a selective irreversible inhibitor of gamma-aminobutyric acid transaminase, has proved to be effective against cryptogenic and symptomatic infantile spasms (IS). Unfortunately, reports of serious visual field defects have led to a drastic reduction in the use of the drug. This review is based on a systematic search in the literature for evidence regarding efficacy and safety of VGB in IS. Based on a specific mechanism of action, there is a solid evidence of clinical efficacy of VGB in children with Tuberous Sclerosis. Similarly, VGB could represent a potential effective therapy also for spasms due to focal cortical dysplasia. In infants with spasms due to other causes, the risk of ophthalmologic toxicity should be carefully weighted against the benefit of controlling spasms.

Treatment of infantile spasms

Infantile spasms are associated with a diverse range of conditions, and treatment options are available. However, outcomes remain generally poor, particularly for those with symptomatic etiologies. First-line therapy is considered to be hormonal (adrenocorticotropic hormone; ACTH), which some evidence suggests is more effective when started early. However, side effects may place limits on its use acutely and long-term. There is additional evidence for vigabatrin, specifically for infantile spasms secondary to tuberous sclerosis complex. In refractory cases, candidacy for surgical management should be explored, along with new-generation anticonvulsants (eg, topiramate, zonisamide) and the ketogenic diet. There is urgent need for further treatment trials comparing anticonvulsants with ACTH and a satisfactory animal model for the study of spasms.

A plausible explanation for superiority of adreno-cortico-trophic hormone (ACTH) over oral corticosteroids in management of infantile spasms (West syndrome)

West syndrome (WS), an age dependent epileptic encephalopathy is identified as a triad of infantile spasms (IS), psychomotor retardation and a specific EEG pattern known as hypsarrhythmia. The exact pathophysiology still remains unclear, although a majority of cases reveal history of exposure to stress, mainly hypoxic-ischemia. The management remains empirical with a poor prognosis. Adrenocorticotrophic hormone (ACTH) and oral steroids continue to remain gold standard treatment. Vigabatrin (VGB), a newer anti-epileptic drug has emerged as an effective alternative but recent observation of a serious visual defect (constriction of peripheral field of vision that is likely to exaggerate the disability status of the WS patient) associated with its administration is gradually limiting its therapeutic usage and popularity. A number of studies have shown superiority of ACTH over oral steroids in the management of West syndrome, but the explanation for this long-standing observation is missing; however, this clinical observation has led to a wide acceptance of the implication of corticotropin releasing hormone (CRH) in causing spasms and at the same time also explaining the relief in spasms obtained by the inhibition of CRH secretion by ACTH and oral steroids. This hypothesis-article compares the negative feedback influences of ACTH and oral steroids on CRH secretion and shows that ACTH exerts a dual significantly stronger inhibitory influence on CRH secretion that far exceeds the inhibition exerted by oral steroids. Thus, this difference in feedback mechanism may be the major factor responsible for the superior therapeutic efficacy of ACTH over oral steroids in the management of West syndrome.

[Efficacy and tolerability of vigabatrin in West syndrome]

West syndrome (WS) is a severe epileptic encephalopathy of childhood, characterized by spasms, developmental deterioration and hipsarhythymia.

OBJECTIVE

To evaluate the safety and efficacy of vigabatrin (VGB) in the treatment of WS.

METHOD

We evaluated every patient diagnosed with WS seen at the pediatric epilepsy clinic and exposed to VGB. Patients were interviewed according to a semistructured questionnaire and we analyzed gender, age, etiology (cryptogenic or symptomatic), associated diseases, age of seizure onset, neuroimaging findings, EEG prior and after VGB, use of other antiepileptic drugs, time for seizure control, electroretinogram, visual complaints, adverse events and family history of epilepsy.

RESULTS

Twenty-three patients were evaluated, 16 boys, ages ranging from 1.25 years to 11.5 years (mean=5y3m). Sixteen (69.5%) patients were seizure free, five (22%) had partial seizure control and in two (8.5%) there was no improvement. Only one patient presented gabaergic retinopathy. Six (26%) patients presented adverse events: somnolence, aggressivity or retinopathy. Patients with seizure onset after 6 months of age presented better results after VGB introduction (p<0.05). There was no difference in seizure control according to duration of epilepsy before VGB treatment or etiology of the seizures (p>0.05). After VGB, no patient presented hipsarrhythymia and 50% had a normal EEG.

CONCLUSION

Although VGB may be associated with serious adverse events such as gabaergic retinopathy, our results show that it should be considered in the treatment of WS.