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Macdonald-Laurs E, Warren AEL, Francis P, Mandelstam SA, Lee WS, Coleman M, Stephenson SEM, Barton S, D'Arcy C, Lockhart PJ, Leventer RJ, Harvey AS. The clinical, imaging, pathological and genetic landscape of bottom-of-sulcus dysplasia. Brain 2024; 147:1264-1277. [PMID: 37939785 DOI: 10.1093/brain/awad379] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 09/20/2023] [Accepted: 10/22/2023] [Indexed: 11/10/2023] Open
Abstract
Bottom-of-sulcus dysplasia (BOSD) is increasingly recognized as a cause of drug-resistant, surgically-remediable, focal epilepsy, often in seemingly MRI-negative patients. We describe the clinical manifestations, morphological features, localization patterns and genetics of BOSD, with the aims of improving management and understanding pathogenesis. We studied 85 patients with BOSD diagnosed between 2005-2022. Presenting seizure and EEG characteristics, clinical course, genetic findings and treatment response were obtained from medical records. MRI (3 T) and 18F-FDG-PET scans were reviewed systematically for BOSD morphology and metabolism. Histopathological analysis and tissue genetic testing were performed in 64 operated patients. BOSD locations were transposed to common imaging space to study anatomical location, functional network localization and relationship to normal MTOR gene expression. All patients presented with stereotyped focal seizures with rapidly escalating frequency, prompting hospitalization in 48%. Despite 42% patients having seizure remissions, usually with sodium channel blocking medications, most eventually became drug-resistant and underwent surgery (86% seizure-free). Prior developmental delay was uncommon but intellectual, language and executive dysfunction were present in 24%, 48% and 29% when assessed preoperatively, low intellect being associated with greater epilepsy duration. BOSDs were missed on initial MRI in 68%, being ultimately recognized following repeat MRI, 18F-FDG-PET or image postprocessing. MRI features were grey-white junction blurring (100%), cortical thickening (91%), transmantle band (62%), increased cortical T1 signal (46%) and increased subcortical FLAIR signal (26%). BOSD hypometabolism was present on 18F-FDG-PET in 99%. Additional areas of cortical malformation or grey matter heterotopia were present in eight patients. BOSDs predominated in frontal and pericentral cortex and related functional networks, mostly sparing temporal and occipital cortex, and limbic and visual networks. Genetic testing yielded pathogenic mTOR pathway variants in 63% patients, including somatic MTOR variants in 47% operated patients and germline DEPDC5 or NPRL3 variants in 73% patients with familial focal epilepsy. BOSDs tended to occur in regions where the healthy brain normally shows lower MTOR expression, suggesting these regions may be more vulnerable to upregulation of MTOR activity. Consistent with the existing literature, these results highlight (i) clinical features raising suspicion of BOSD; (ii) the role of somatic and germline mTOR pathway variants in patients with sporadic and familial focal epilepsy associated with BOSD; and (iii) the role of 18F-FDG-PET alongside high-field MRI in detecting subtle BOSD. The anatomical and functional distribution of BOSDs likely explain their seizure, EEG and cognitive manifestations and may relate to relative MTOR expression.
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Affiliation(s)
- Emma Macdonald-Laurs
- Department of Neurology, The Royal Children's Hospital, Parkville, Victoria 3052Australia
- Department of Neuroscience, Murdoch Children's Research Institute, Parkville 3052, Australia
- Department of Paediatrics, The University of Melbourne, Parkville 3052, Australia
| | - Aaron E L Warren
- Department of Neuroscience, Murdoch Children's Research Institute, Parkville 3052, Australia
- Department of Medicine (Austin Health), The University of Melbourne, Heidelberg 3084, Australia
| | - Peter Francis
- Department of Medical Imaging, The Royal Children's Hospital, Parkville 3052, Australia
| | - Simone A Mandelstam
- Department of Neuroscience, Murdoch Children's Research Institute, Parkville 3052, Australia
- Department of Paediatrics, The University of Melbourne, Parkville 3052, Australia
- Department of Medical Imaging, The Royal Children's Hospital, Parkville 3052, Australia
| | - Wei Shern Lee
- Department of Paediatrics, The University of Melbourne, Parkville 3052, Australia
- Department of Genomic Medicine, Bruce Lefroy Centre, Murdoch Children's Research Institute, Parkville 3052, Australia
| | - Matthew Coleman
- Department of Paediatrics, The University of Melbourne, Parkville 3052, Australia
- Department of Genomic Medicine, Bruce Lefroy Centre, Murdoch Children's Research Institute, Parkville 3052, Australia
| | - Sarah E M Stephenson
- Department of Paediatrics, The University of Melbourne, Parkville 3052, Australia
- Department of Genomic Medicine, Bruce Lefroy Centre, Murdoch Children's Research Institute, Parkville 3052, Australia
| | - Sarah Barton
- Department of Neurology, The Royal Children's Hospital, Parkville, Victoria 3052Australia
- Department of Neuroscience, Murdoch Children's Research Institute, Parkville 3052, Australia
- Department of Paediatrics, The University of Melbourne, Parkville 3052, Australia
| | - Colleen D'Arcy
- Department of Pathology, The Royal Children's Hospital, Parkville 3052, Australia
| | - Paul J Lockhart
- Department of Paediatrics, The University of Melbourne, Parkville 3052, Australia
- Department of Genomic Medicine, Bruce Lefroy Centre, Murdoch Children's Research Institute, Parkville 3052, Australia
| | - Richard J Leventer
- Department of Neurology, The Royal Children's Hospital, Parkville, Victoria 3052Australia
- Department of Neuroscience, Murdoch Children's Research Institute, Parkville 3052, Australia
- Department of Paediatrics, The University of Melbourne, Parkville 3052, Australia
| | - A Simon Harvey
- Department of Neurology, The Royal Children's Hospital, Parkville, Victoria 3052Australia
- Department of Neuroscience, Murdoch Children's Research Institute, Parkville 3052, Australia
- Department of Paediatrics, The University of Melbourne, Parkville 3052, Australia
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Maeda A, Neshige S, Katsumata R, Nonaka M, Ishibashi H, Maruyama H. Exacerbation of Repetitive Falls Due to Atonic Seizures Following Perampanel Administration. Cureus 2023; 15:e40818. [PMID: 37485229 PMCID: PMC10362973 DOI: 10.7759/cureus.40818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/22/2023] [Indexed: 07/25/2023] Open
Abstract
A 47-year-old man presented with tonic-clonic seizures characterized by convulsions. He repeatedly exhibited seizures despite treatment with four anti-seizure medications. During the titration process of perampanel (PER), the seizures paradoxically increased in intensity and frequency, resulting in trauma. Video electroencephalogram monitoring revealed interictal rapid rhythms and generalized spikes and documented atonic seizures. Thus, the patient was diagnosed with Lennox-Gastaut syndrome. Upon discontinuation of PER, the patient's atonic seizures with falls improved, probably suggesting a paradoxical effect of PER. A non-competitive antagonist selective for AMPA (α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid) receptors may have caused the weakness and delayed recovery from prolonged atonia that caused injuries.
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Affiliation(s)
- Akiko Maeda
- Department of Clinical Neuroscience and Therapeutics, Hiroshima University Graduate School of Biomedical and Health Sciences, Hiroshima, JPN
| | - Shuichiro Neshige
- Department of Clinical Neuroscience and Therapeutics, Hiroshima University, Hiroshima, JPN
| | - Riho Katsumata
- Department of Clinical Neuroscience and Therapeutics, Hiroshima University Graduate School of Biomedical and Health Sciences, Hiroshima, JPN
| | - Megumi Nonaka
- Department of Clinical Neuroscience and Therapeutics, Hiroshima University, Hiroshima, JPN
| | - Haruka Ishibashi
- Department of Clinical Neuroscience and Therapeutics, Hiroshima University Graduate School of Biomedical and Health Sciences, Hiroshima, JPN
| | - Hirofumi Maruyama
- Department of Clinical Neuroscience and Therapeutics, Hiroshima University Graduate School of Biomedical and Health Sciences, Hiroshima, JPN
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Takebayashi Y, Neshige S, Shishido T, Hayashi Y, Segawa A, Nakamori M, Nezu T, Aoki S, Yamazaki Y, Ueno H, Ohshita T, Iida K, Maruyama H. Paradoxical effects of levetiracetam in people with epilepsy with rhythmic epileptiform discharges. Epilepsy Behav 2023; 143:109225. [PMID: 37130461 DOI: 10.1016/j.yebeh.2023.109225] [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: 01/23/2023] [Revised: 04/10/2023] [Accepted: 04/12/2023] [Indexed: 05/04/2023]
Abstract
OBJECTIVE To elucidate the incidence and risk factors for paradoxical effects (i.e., increased seizure frequency, increased seizure severity, or onset of new seizure types) of levetiracetam (LEV) in people with epilepsy (PWE) and identify the usefulness of electroencephalography (EEG) in predicting these effects. METHODS We examined data for consecutive PWE treated with LEV. All PWE underwent EEG and magnetic resonance imaging (MRI) before LEV administration. We also evaluated the incidence of paradoxical LEV effects and conducted multivariate logistic regression analyses to identify the associated factors. RESULTS In total, 210 (66.2%) of 317 PWEs treated in our department had a history of LEV use. The incidence of paradoxical LEV effects was 5.2% (n = 11) and was significantly associated with a high LEV dose (p = 0.029), high seizure frequency (p = 0.005), temporal lobe epilepsy (p = 0.004), focal awareness seizure (p = 0.004), focal impaired awareness seizure (p = 0.007), spike (p = 0.015), rhythmic epileptiform discharges (REDs; p = 0.003), and MRI-identified focal cortical dysplasia (FCD; p < 0.0001). Multivariate analyses revealed that REDs (odds ratio [OR] = 5.35, p = 0.048, 95% confidence interval [CI]: 1.01-28.21) were independently associated with paradoxical LEV effects. CONCLUSIONS Paradoxical LEV effects occurred in PWE, particularly in those with drug-resistant focal epilepsy. Furthermore, the occurrence of REDs in EEG was an independent factor associated with the paradoxical effects of LEV in PWE.
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Affiliation(s)
- Yoshiko Takebayashi
- Department of Clinical Neuroscience and Therapeutics, Hiroshima University, Graduate School of Biomedical and Health Sciences, 1-2-3 Kasumi, Minamiku, Hiroshima 734-8551, Japan
| | - Shuichiro Neshige
- Department of Clinical Neuroscience and Therapeutics, Hiroshima University, Graduate School of Biomedical and Health Sciences, 1-2-3 Kasumi, Minamiku, Hiroshima 734-8551, Japan; Epilepsy Center, Hiroshima University Hospital, 1-2-3 Kasumi, Minamiku, Hiroshima 734-8551, Japan.
| | - Takeo Shishido
- Department of Clinical Neuroscience and Therapeutics, Hiroshima University, Graduate School of Biomedical and Health Sciences, 1-2-3 Kasumi, Minamiku, Hiroshima 734-8551, Japan
| | - Yuki Hayashi
- Department of Clinical Neuroscience and Therapeutics, Hiroshima University, Graduate School of Biomedical and Health Sciences, 1-2-3 Kasumi, Minamiku, Hiroshima 734-8551, Japan
| | - Akiko Segawa
- Department of Clinical Neuroscience and Therapeutics, Hiroshima University, Graduate School of Biomedical and Health Sciences, 1-2-3 Kasumi, Minamiku, Hiroshima 734-8551, Japan
| | - Masahiro Nakamori
- Department of Clinical Neuroscience and Therapeutics, Hiroshima University, Graduate School of Biomedical and Health Sciences, 1-2-3 Kasumi, Minamiku, Hiroshima 734-8551, Japan
| | - Tomohisa Nezu
- Department of Clinical Neuroscience and Therapeutics, Hiroshima University, Graduate School of Biomedical and Health Sciences, 1-2-3 Kasumi, Minamiku, Hiroshima 734-8551, Japan
| | - Shiro Aoki
- Department of Clinical Neuroscience and Therapeutics, Hiroshima University, Graduate School of Biomedical and Health Sciences, 1-2-3 Kasumi, Minamiku, Hiroshima 734-8551, Japan
| | - Yu Yamazaki
- Department of Clinical Neuroscience and Therapeutics, Hiroshima University, Graduate School of Biomedical and Health Sciences, 1-2-3 Kasumi, Minamiku, Hiroshima 734-8551, Japan
| | - Hiroki Ueno
- Department of Clinical Neuroscience and Therapeutics, Hiroshima University, Graduate School of Biomedical and Health Sciences, 1-2-3 Kasumi, Minamiku, Hiroshima 734-8551, Japan
| | - Tomohiko Ohshita
- Department of Clinical Neuroscience and Therapeutics, Hiroshima University, Graduate School of Biomedical and Health Sciences, 1-2-3 Kasumi, Minamiku, Hiroshima 734-8551, Japan
| | - Koji Iida
- Epilepsy Center, Hiroshima University Hospital, 1-2-3 Kasumi, Minamiku, Hiroshima 734-8551, Japan; Department of Neurosurgery, Hiroshima University, Graduate School of Biomedical and Health Sciences, 1-2-3 Kasumi, Minamiku, Hiroshima 734-8551, Japan
| | - Hirofumi Maruyama
- Department of Clinical Neuroscience and Therapeutics, Hiroshima University, Graduate School of Biomedical and Health Sciences, 1-2-3 Kasumi, Minamiku, Hiroshima 734-8551, Japan; Epilepsy Center, Hiroshima University Hospital, 1-2-3 Kasumi, Minamiku, Hiroshima 734-8551, Japan
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Celdran de Castro A, Nascimento FA, Beltran-Corbellini Á, Toledano R, Garcia-Morales I, Gil-Nagel A, Aledo-Serrano Á. Levetiracetam, from broad-spectrum use to precision prescription: A narrative review and expert opinion. Seizure 2023; 107:121-131. [PMID: 37023625 DOI: 10.1016/j.seizure.2023.03.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 03/18/2023] [Accepted: 03/22/2023] [Indexed: 04/07/2023] Open
Abstract
Levetiracetam (LEV) is an antiseizure medication (ASM) whose mechanism of action involves the modulation of neurotransmitters release through binding to the synaptic vesicle glycoprotein 2A. It is a broad-spectrum ASM displaying favorable pharmacokinetic and tolerability profiles. Since its introduction in 1999, it has been widely prescribed, becoming the first-line treatment for numerous epilepsy syndromes and clinical scenarios. However, this might have resulted in overuse. Increasing evidence, including the recently published SANAD II trials, suggests that other ASMs are reasonable therapeutic options for generalized and focal epilepsies. Not infrequently, these ASMs show better safety and effectiveness profiles compared to LEV (partially due to the latter's well-known cognitive and behavioral adverse effects, present in up to 20% of patients). Moreover, it has been shown that the underlying etiology of epilepsy is significantly linked to ASMs response in particular scenarios, highlighting the importance of an etiology-based ASM choice. In the case of LEV, it has demonstrated an optimal effectiveness in Alzheimer's disease, Down syndrome, and PCDH19-related epilepsies whereas, in other etiologies such as malformations of cortical development, it may show negligible effects. This narrative review analyzes the current evidence related to the use of LEV for the treatment of seizures. Illustrative clinical scenarios and practical decision-making approaches are also addressed, therefore aiming to define a rational use of this ASM.
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Chen W, Jin B, Aung T, He C, Chen C, Wang S, Ding Y, Ding F, Wang C, Li H, Jiang B, Zheng Z, Dai H, Zhu J, Geng Y, Ding M, Wang S. Response to antiseizure medications in epileptic patients with malformation of cortical development. Ther Adv Neurol Disord 2021; 14:17562864211050027. [PMID: 34671424 PMCID: PMC8521419 DOI: 10.1177/17562864211050027] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Accepted: 09/12/2021] [Indexed: 11/16/2022] Open
Abstract
Background Malformation of cortical development (MCD) is one of the most common causes of pharmacoresistant epilepsy. Improving the knowledge of antiseizure medications (ASMs) treatment response in epileptic patients with MCD is crucial for optimal treatment options, either pharmacological therapy or non-pharmacological intervention. Aim To investigate the patterns of medical treatment outcome and the predictors for seizure freedom (SF) with ASM regimens in epilepsy caused by MCD. Methods The epileptic patients with MCD were consecutively enrolled from March 2013 to June 2019. SF was defined as no seizures for at least 12 months or three times the longest pretreatment inter-seizure interval, whichever was longer. Outcomes were classified into three patterns: pattern A: patients achieved SF at one point and remained so throughout follow-up; pattern B: patients' seizures fluctuated between periods of SF and relapse; pattern C: SF never attained. The terminal SF was defined if the patients remained SF at the last follow-up visit. Results A total of 164 epileptic patients with MCD were included. Pattern A was observed in 22, pattern B in 42, and pattern C in 100 patients. SF was ever achieved in 64 (pattern A and B) patients. Twenty-nine patients had terminal SF after a median follow-up time of 4.3 years. With continuing ASM treatment, seizure relapse risk was very low after a 5-year seizure-free period. The pretreatment seizure frequency was the only independent predictor for pattern A and seizure relapse. Sodium channel blockers monotherapy (33.8%) was more effective than levetiracetam (4.5%) in rendering SF in the initial ASM regimen. Conclusion Medical treatment can be successful in a minority of epileptic patients with MCD, and pretreatment seizure frequency helps to predict the treatment outcome. An unequal efficacy of ASMs in epilepsy caused by MCD suggests etiological evaluation is vital in the management of focal epilepsy.
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Affiliation(s)
- Wei Chen
- Department of Neurology, Epilepsy Center, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China Department of Neurology, Linhai Second People's Hospital, Taizhou, China
| | - Bo Jin
- Department of Neurology, Zhejiang Provincial People's Hospital, People's Hospital of Hangzhou Medical College, Hangzhou, China
| | - Thandar Aung
- Epilepsy Center, Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Chenmin He
- Department of Neurology, Epilepsy Center, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Cong Chen
- Department of Neurology, Epilepsy Center, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Shan Wang
- Department of Neurology, Epilepsy Center, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Yao Ding
- Department of Neurology, Epilepsy Center, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Fang Ding
- Department of Neurology, Shaoxing People's Hospital, Shaoxing Hospital of Zhejiang University, Shaoxing, China
| | - Chao Wang
- Department of Radiology, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Hong Li
- Department of Radiology, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Biao Jiang
- Department of Radiology, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Zhe Zheng
- Department of Neurosurgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Haibin Dai
- Department of Pharmacy, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Junming Zhu
- Department of Neurosurgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Yu Geng
- Department of Neurology, Zhejiang Provincial People's Hospital, People's Hospital of Hangzhou Medical College, Hangzhou, China
| | - Meiping Ding
- Department of Neurology, Epilepsy Center, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Shuang Wang
- Department of Neurology, Epilepsy Center, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310009, China
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Inoue T, Kobayashi K, Usami K, Shimotake A, Inouchi M, Sakai T, Ikeda A, Takahashi R. [Paradoxical effect of levetiracetam on seizure suppression: three cases showing U curve association between dose and effect]. Rinsho Shinkeigaku 2021; 61:247-252. [PMID: 33762498 DOI: 10.5692/clinicalneurol.cn-001553] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
We experienced 3 adult patients with intractable focal epilepsy treated by levetiracetam (LEV) as polytherapy, who showed paradoxical effect (PE). Starting dose of LEV was small (62.5, 250 mg/day) and we gradually increased by less than 250 mg/day, every more than 2 weeks. Within 6 months after LEV was added, LEV of 750 to 1,000 mg/day brought reduction of seizure frequency. Serum concentration of LEV was 13.3 and 14.0 μg/ml. In order to obtain better seizure control, LEV was increased up to 1,000-2,500 mg/day (19.3-35.0 μg/ml) within one year, and they developed PE. They all showed increased habitual seizures, occurring in cluster. Once dose of LEV deceased down to what produced the maximum seizure suppression, all of the patients regained the better seizure control. It is most likely that at least in some patients like present 3 cases, PE of LEV may express U curve association between dose and effect and that it was only delineated by slow titration.
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Affiliation(s)
- Takeshi Inoue
- Department of Neurology, Kyoto University Graduate School of Medicine
| | - Katsuya Kobayashi
- Department of Neurology, Kyoto University Graduate School of Medicine
| | - Kiyohide Usami
- Department of Epilepsy, Movement Disorders and Physiology, Kyoto University Graduate School of Medicine
| | - Akihiro Shimotake
- Department of Neurology, Kyoto University Graduate School of Medicine
| | - Morito Inouchi
- Department of Epilepsy, Movement Disorders and Physiology, Kyoto University Graduate School of Medicine.,Department of Neurology, Kyoto City Hospital
| | | | - Akio Ikeda
- Department of Epilepsy, Movement Disorders and Physiology, Kyoto University Graduate School of Medicine
| | - Ryosuke Takahashi
- Department of Neurology, Kyoto University Graduate School of Medicine
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Levetiracetam-Induced Seizure Aggravation in Patients With Focal Cortical Dysplasia. Clin Neuropharmacol 2019; 42:146. [PMID: 31192810 DOI: 10.1097/wnf.0000000000000349] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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