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Mastrangelo M, Manti F, Ricciardi G, Cinnante EMC, Cameli N, Beatrice A, Tolve M, Pisani F. The diagnostic and prognostic role of cerebrospinal fluid biomarkers in glucose transporter 1 deficiency: a systematic review. Eur J Pediatr 2024; 183:3665-3678. [PMID: 38954008 DOI: 10.1007/s00431-024-05657-6] [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: 03/05/2024] [Revised: 06/13/2024] [Accepted: 06/17/2024] [Indexed: 07/04/2024]
Abstract
The purpose of this study is to investigate the diagnostic and prognostic role of cerebrospinal fluid (CSF) biomarkers in the diagnostic work-up of glucose transporter 1 (GLUT1) deficiency. Reported here is a systematic review according to PRISMA guidelines collecting clinical and biochemical data about all published patients who underwent CSF analysis. Clinical phenotypes were compared between groups defined by the levels of CSF glucose (≤ 2.2 mmol/L versus > 2.2 mmol/L), CSF/blood glucose ratio (≤ 0.45 versus > 0.45), and CSF lactate (≤ 1 mmol/L versus > 1 mmol/L). Five hundred sixty-two patients fulfilled the inclusion criteria with a mean age at the diagnosis of 8.6 ± 6.7 years. Patients with CSF glucose ≤ 2.2 mmol/L and CSF/blood glucose ratio ≤ 0.45 presented with an earlier onset of symptoms (16.4 ± 22.0 versus 54.4 ± 45.9 months, p < 0.01; 15.7 ± 23.8 versus 40.9 ± 38.0 months, p < 0.01) and received an earlier molecular genetic confirmation (92.1 ± 72.8 versus 157.1 ± 106.2 months, p < 0.01). CSF glucose ≤ 2.2 mmol/L was consistently associated with response to ketogenic diet (p = 0.018) and antiseizure medications (p = 0.025). CSF/blood glucose ratio ≤ 0.45 was significantly associated with absence seizures (p = 0.048), paroxysmal exercise-induced dyskinesia (p = 0.046), and intellectual disability (p = 0.016) while CSF lactate > 1 mmol/L was associated with a response to antiseizure medications (p = 0.026) but not to ketogenic diet.Conclusions:This systematic review supported the diagnostic usefulness of lumbar puncture for the early identification of patients with GLUT1 deficiency responsive to treatments especially if they present with co-occurring epilepsy, movement, and neurodevelopmental disorders. What is Known: • Phenotypes of GLUT1 deficiency syndrome range between early epileptic and developmental encephalopathy to paroxysmal movement disorders and developmental impairment What is New: • CSF blood/glucose ratio may predict better than CSF glucose the diagnosis in children presenting with early onset absences • CSF blood/glucose ratio may predict better than CSF glucose the diagnosis in children presenting with paroxysmal exercise induced dyskinesia and intellectual disability. • CSF glucose may predict better than CSF blood/glucose and lactate the response to ketogenic diet and antiseizure medications.
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Affiliation(s)
- Mario Mastrangelo
- Woman/Child Health and Urological Sciences Department, Sapienza University of Rome, Via dei Sabelli 108, 00185, Rome, Italy.
- Unit of Child Neurology and Psychiatry, Department of Neuroscience/Mental Health, Azienda Ospedaliero Universitaria Policlinico Umberto, Rome, Italy.
| | - Filippo Manti
- Unit of Child Neurology and Psychiatry, Department of Neuroscience/Mental Health, Azienda Ospedaliero Universitaria Policlinico Umberto, Rome, Italy
- Department of Human Neuroscience, Sapienza University of Rome, Rome, Italy
| | | | | | - Noemi Cameli
- Department of Human Neuroscience, Sapienza University of Rome, Rome, Italy
| | | | - Manuela Tolve
- Clinical Pathology Unit, Azienda Ospedaliero-Universitaria Policlinico Umberto I, Rome, Italy
| | - Francesco Pisani
- Unit of Child Neurology and Psychiatry, Department of Neuroscience/Mental Health, Azienda Ospedaliero Universitaria Policlinico Umberto, Rome, Italy
- Department of Human Neuroscience, Sapienza University of Rome, Rome, Italy
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Zovi A, Cifani C, Confalonieri C, Lasala R, Sabbatucci M, Vitiello A, Vittori S. Dietary management and access to treatment for patients with glucose deficiency syndrome type 1: an overview review with focus on the European regulatory framework. Eur J Clin Nutr 2024:10.1038/s41430-024-01490-0. [PMID: 39127841 DOI: 10.1038/s41430-024-01490-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2024] [Revised: 07/30/2024] [Accepted: 07/31/2024] [Indexed: 08/12/2024]
Abstract
BACKGROUND Glut-1 deficiency Syndrome (GLUT-1 DS) is a rare disease caused by a mutation in the SLC2A1 gene that codes for the glucose transporter protein GLUT-1 DS. Currently, there is no indicated drug therapy for this condition and ketogenic diet (KD) is the most effective remedy to treat it. OBJECTIVE The objective of this study was to review the published literature that evaluated the effectiveness of KD in the dietary management of GLUT-1 DS syndrome, describing the state-of-the-art the treatment pathway for patients with GLUT-1 DS syndrome in light of the current European regulatory framework within the National Health Services. METHODS The literature search was carried out on September 10, 2023, and all studies conducted in humans diagnosed with GLUT-1 deficiency syndrome and treated with KD were included. RESULTS A total of 156 scientific papers have been extracted. Applying the exclusion criteria, 38 articles have been considered eligible. In 29 out of 38 studies, the main outcome for determining the efficacy of KD was the measurement of the number of epileptic seizures, demonstrating that patients treated with KD experienced improvements with a clear reduction in the number of epileptic attacks. Currently, in the European Union, only one country provides full reimbursement by the national health system for KD. DISCUSSION Although they are crucial for the treatment of GLUT-1 DS, according with current food regulations, KD are not evaluated on the basis of an unambiguous efficacy result, but only on the basis of safety. As a result, it is desirable to carry out clinical studies in the coming years based on the determination of efficacy in target populations, also in view of the marketing of these products on the European market.
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Affiliation(s)
- Andrea Zovi
- Department of Human Health, Animal Health and Ecosystem (One Health) and International Relations, Ministry of Health, Rome, Italy.
- School of Pharmacy, University of Camerino, Camerino, Italy.
| | - Carlo Cifani
- School of Pharmacy, University of Camerino, Camerino, Italy
| | | | - Ruggero Lasala
- Hospital Pharmacy of Corato, Local Health Authority of Bari, Corato, Italy
| | - Michela Sabbatucci
- Department Infectious Diseases, Italian National Institute of Health, Rome, Italy
| | - Antonio Vitiello
- Department of Prevention, Research and Health Emergencies, Ministry of Health, Rome, Italy
| | - Sauro Vittori
- School of Pharmacy, University of Camerino, Camerino, Italy
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3
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Cameron T, Allan K, Kay Cooper. The use of ketogenic diets in children living with drug-resistant epilepsy, glucose transporter 1 deficiency syndrome and pyruvate dehydrogenase deficiency: A scoping review. J Hum Nutr Diet 2024; 37:827-846. [PMID: 38838079 DOI: 10.1111/jhn.13324] [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: 11/13/2023] [Accepted: 05/10/2024] [Indexed: 06/07/2024]
Abstract
BACKGROUND The ketogenic diet (KD) is a high fat, moderate protein and very low carbohydrate diet. It can be used as a medical treatment for drug-resistant epilepsy (DRE), glucose transporter 1 deficiency syndrome and pyruvate dehydrogenase deficiency. The aim of this scoping review was to map the KD literature, with a focus on epilepsy and associated metabolic conditions, to summarise the current evidence-base and identify any gaps. METHODS This review was conducted using JBI scoping review methodological guidance and the PRISMA extension for scoping reviews reporting guidance. A comprehensive literature search was conducted in September 2021 and updated in February 2024 using MEDLINE, CINAHL, AMED, EmBASE, CAB Abstracts, Scopus and Food Science Source databases. RESULTS The initial search yielded 2721 studies and ultimately, data were extracted from 320 studies that fulfilled inclusion criteria for the review. There were five qualitative studies, and the remainder were quantitative, including 23 randomised controlled trials (RCTs) and seven quasi-experimental studies. The USA published the highest number of KD studies followed by China, South Korea and the UK. Most studies focused on the classical KD and DRE. The studies key findings suggest that the KD is efficacious, safe and tolerable. CONCLUSIONS There are opportunities available to expand the scope of future KD research, particularly to conduct high-quality RCTs and further qualitative research focused on the child's needs and family support to improve the effectiveness of KDs.
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Affiliation(s)
- Tracy Cameron
- Royal Aberdeen Children's Hospital, NHS Grampian, Aberdeen, Scotland, UK
- School of Health Sciences, Robert Gordon University, Aberdeen, Scotland, UK
| | - Karen Allan
- School of Health Sciences, Robert Gordon University, Aberdeen, Scotland, UK
| | - Kay Cooper
- School of Health Sciences, Robert Gordon University, Aberdeen, Scotland, UK
- Scottish Centre for Evidence-based, Multi-professional Practice: A JBI Centre of Excellence, Aberdeen, Scotland, UK
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Corradini M, Zanaboni MP, Varesio C, Celario M, Capelli E, Giudice C, Quaranta CA, Mensi MM, Pasca L, De Giorgis V. GLUT1DS focus on dysarthria. Eur J Paediatr Neurol 2024; 51:62-70. [PMID: 38851145 DOI: 10.1016/j.ejpn.2024.05.010] [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: 06/23/2023] [Revised: 05/09/2024] [Accepted: 05/20/2024] [Indexed: 06/10/2024]
Abstract
RESEARCH PURPOSE GLUT1 deficiency syndrome (GLUT1DS) is a rare genetic disorder caused by a mutation in the SLC2A1 gene that limits the transport of glucose across the blood-brain barrier. Speech disorders and dysarthria are typical findings in patients with GLUT1DS, but have never been deeply phenotyped. The aim of the present study was to characterize speech abilities in a sample of patients with GLUT1DS. RESULTS 30 patients with GLUT1DS were recruited. We reported impairments in different speech and oromotor domains: the speech was characterized by dysarthria, inaccurate articulation of consonants, abnormal nasal resonance, errors in intonation and prosody and low intelligibility. We observed difficulties in motor planning and programming. Moreover, we observed a significant difference between the dysarthric level of impairment with genotype groups. CONCLUSIONS The presence of a speech disorder in patients with GLUT1DS represents a core feature of the syndrome. Our findings suggest that patients with GLUT1DS would benefit from a comprehensive neurocognitive assessment to detect strengths and weaknesses of the speech profile. Understanding the speech and language phenotype in GLUT1DS is critical for planning early intervention to positively influence the global development of patients with GLUT1DS.
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Affiliation(s)
- Miriam Corradini
- Department of Child Neurology and Psychiatry, IRCCS Mondino Foundation, Pavia, Italy
| | | | - Costanza Varesio
- Department of Child Neurology and Psychiatry, IRCCS Mondino Foundation, Pavia, Italy; Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy.
| | - Massimiliano Celario
- Department of Child Neurology and Psychiatry, IRCCS Mondino Foundation, Pavia, Italy; Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
| | - Elena Capelli
- Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
| | - Carla Giudice
- Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy; Headache Science and Neurorehabilitation Center, IRCCS Mondino Foundation, Pavia, Italy
| | - Carlo Alberto Quaranta
- Department of Child Neurology and Psychiatry, IRCCS Mondino Foundation, Pavia, Italy; Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
| | - Martina Maria Mensi
- Department of Child Neurology and Psychiatry, IRCCS Mondino Foundation, Pavia, Italy; Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
| | - Ludovica Pasca
- Department of Child Neurology and Psychiatry, IRCCS Mondino Foundation, Pavia, Italy; Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
| | - Valentina De Giorgis
- Department of Child Neurology and Psychiatry, IRCCS Mondino Foundation, Pavia, Italy; Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
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Varesio C, Zanaboni MP, Pasca L, Provenzi L, Ferraris C, Tagliabue A, Pezzotti E, Carpani A, Veggiotti P, DE Giorgis V. Novel insight into GLUT1 deficiency syndrome: screening for emotional and behavioral problems in youths following ketogenic diet. Minerva Pediatr (Torino) 2024; 76:189-196. [PMID: 33820407 DOI: 10.23736/s2724-5276.21.05923-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Glucose transporter type 1 deficiency syndrome (GLUT1DS) is a rare disorder with a broad spectrum of neurological manifestations. The ketogenic diet (KD) is, to date, the gold standard treatment. Behavioral problems, well recognized in patients with chronic conditions, have not been, so far, deeply investigated in GLUT1DS patients. We performed an exploratory study to assess the risk of emotional and behavioral problems and investigated the potential role of influencing factors related to the pathology itself or KD treatment. METHODS This was a mono-center retrospective study involving youths with GLUT1Ds treated with KD and a group of migraine patients age- and gender-matched. Patients were included if the main caregiver completed the Child Behavior Check List 6-18 (CBCL). Descriptive statistics for demographic and clinical data and questionnaire scores were computed. Correlational analyses were used to assess the potential associations of clinical variables and age and time from KD introduction with CBCL scores in GLUT1DS patients. RESULTS We enrolled nine youths with GLUT1DS and 9 with migraine. In the GLUT1DS group, none of the mean scores of the CBCL items fell within the borderline/clinical range, except for social problems located in the borderline range. Investigation for influencing factors revealed the patient's age related to withdrawn/depressive (r=0.709, P=0.032) and social problems (r=.684, P=0.042). Time from the introduction of KD was related to social problems (r=.827, P=0.006). From the comparison with the scores obtained from migraine patients, significantly higher scores emerged in the latter group in internalizing problems (Z=-2.48, P=0.01), externalizing problems (Z=-3.49, P<0.001), anxious/depressed subscale (Z=-2.37, P=0.014), somatic complaints subscale (Z=-2.624, P=0.008), aggressive behavior subscale (Z=-2.539, P=0.011). CONCLUSIONS Although highly exploratory in its nature, this study provides a novel insight into GLUT1DS. Our data suggested that the risk for internalizing problems in GLUT1DS youths was related to higher age and higher time elapsed from KD introduction. They occurred at a sub-clinical level, making them difficult to detect, if not expressly and systematically investigated.
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Affiliation(s)
- Costanza Varesio
- Department of Child Neurology and Psychiatry, IRCCS Mondino Foundation, Pavia, Italy -
- Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy -
| | - Martina P Zanaboni
- Department of Child Neurology and Psychiatry, IRCCS Mondino Foundation, Pavia, Italy
| | - Ludovica Pasca
- Department of Child Neurology and Psychiatry, IRCCS Mondino Foundation, Pavia, Italy
- Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
| | - Livio Provenzi
- Department of Child Neurology and Psychiatry, IRCCS Mondino Foundation, Pavia, Italy
| | - Cinzia Ferraris
- Nutrition and Eating Disorder Research Center, Department of Public Health, Experimental and Forensic Medicine University of Pavia, Pavia, Italy
| | - Anna Tagliabue
- Nutrition and Eating Disorder Research Center, Department of Public Health, Experimental and Forensic Medicine University of Pavia, Pavia, Italy
| | - Elena Pezzotti
- Department of Child Neurology and Psychiatry, IRCCS Mondino Foundation, Pavia, Italy
- Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
| | - Adriana Carpani
- Department of Child Neurology and Psychiatry, IRCCS Mondino Foundation, Pavia, Italy
| | - Pierangelo Veggiotti
- Unit of Pediatric Neurology, Vittore Buzzi Hospital, Milan, Italy
- Department of Biomedical and Clinical Sciences, Luigi Sacco Hospital, University of Milan, Milan, Italy
| | - Valentina DE Giorgis
- Department of Child Neurology and Psychiatry, IRCCS Mondino Foundation, Pavia, Italy
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6
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Kim YS, Kim W, Na JH, Lee YM. Nutritional Intervention Through Ketogenic Diet in GLUT1 Deficiency Syndrome. Clin Nutr Res 2023; 12:169-176. [PMID: 37593212 PMCID: PMC10432162 DOI: 10.7762/cnr.2023.12.3.169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 07/12/2023] [Accepted: 07/14/2023] [Indexed: 08/19/2023] Open
Abstract
Glucose transporter type 1 (GLUT1) deficiency syndrome (DS) is a metabolic brain disorder caused by a deficiency resulting from SLC2A1 gene mutation and is characterized by abnormal brain metabolism and associated metabolic encephalopathy. Reduced glucose supply to the brain leads to brain damage, resulting in delayed neurodevelopment in infancy and symptoms such as eye abnormalities, microcephaly, ataxia, and rigidity. Treatment options for GLUT1 DS include ketogenic diet (KD), pharmacotherapy, and rehabilitation therapy. Of these, KD is an essential and the most important treatment method as it promotes brain neurodevelopment by generating ketone bodies to produce energy. This case is a focused study on intensive KD nutritional intervention for an infant diagnosed with GLUT1 DS at Gangnam Severance Hospital from May 2022 to January 2023. During the initial hospitalization, nutritional intervention was performed to address poor intake via the use of concentrated formula and an attempt was made to introduce complementary feeding. After the second hospitalization and diagnosis of GLUT1 DS, positive effects on the infant's growth and development, nutritional status, and seizure control were achieved with minimal side effects by implementing KD nutritional intervention and adjusting the type and dosage of anticonvulsant medications. In conclusion, for patients with GLUT1 DS, it is important to implement a KD with an appropriate ratio of ketogenic to nonketogenic components to supply adequate energy. Furthermore, individualized and intensive nutritional management is necessary to improve growth, development, and nutritional status.
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Affiliation(s)
- Young-Sun Kim
- Department of Nutrition and Food Control, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul 06273, Korea
| | - Woojeong Kim
- Department of Nutrition and Food Control, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul 06273, Korea
| | - Ji-Hoon Na
- Department of Pediatrics, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul 06273, Korea
| | - Young-Mock Lee
- Department of Pediatrics, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul 06273, Korea
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7
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Hassan A. Episodic Ataxias: Primary and Secondary Etiologies, Treatment, and Classification Approaches. Tremor Other Hyperkinet Mov (N Y) 2023; 13:9. [PMID: 37008993 PMCID: PMC10064912 DOI: 10.5334/tohm.747] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Accepted: 03/03/2023] [Indexed: 03/30/2023] Open
Abstract
Background Episodic ataxia (EA), characterized by recurrent attacks of cerebellar dysfunction, is the manifestation of a group of rare autosomal dominant inherited disorders. EA1 and EA2 are most frequently encountered, caused by mutations in KCNA1 and CACNA1A. EA3-8 are reported in rare families. Advances in genetic testing have broadened the KCNA1 and CACNA1A phenotypes, and detected EA as an unusual presentation of several other genetic disorders. Additionally, there are various secondary causes of EA and mimicking disorders. Together, these can pose diagnostic challenges for neurologists. Methods A systematic literature review was performed in October 2022 for 'episodic ataxia' and 'paroxysmal ataxia', restricted to publications in the last 10 years to focus on recent clinical advances. Clinical, genetic, and treatment characteristics were summarized. Results EA1 and EA2 phenotypes have further broadened. In particular, EA2 may be accompanied by other paroxysmal disorders of childhood with chronic neuropsychiatric features. New treatments for EA2 include dalfampridine and fampridine, in addition to 4-aminopyridine and acetazolamide. There are recent proposals for EA9-10. EA may also be caused by gene mutations associated with chronic ataxias (SCA-14, SCA-27, SCA-42, AOA2, CAPOS), epilepsy syndromes (KCNA2, SCN2A, PRRT2), GLUT-1, mitochondrial disorders (PDHA1, PDHX, ACO2), metabolic disorders (Maple syrup urine disease, Hartnup disease, type I citrullinemia, thiamine and biotin metabolism defects), and others. Secondary causes of EA are more commonly encountered than primary EA (vascular, inflammatory, toxic-metabolic). EA can be misdiagnosed as migraine, peripheral vestibular disorders, anxiety, and functional symptoms. Primary and secondary EA are frequently treatable which should prompt a search for the cause. Discussion EA may be overlooked or misdiagnosed for a variety of reasons, including phenotype-genotype variability and clinical overlap between primary and secondary causes. EA is highly treatable, so it is important to consider in the differential diagnosis of paroxysmal disorders. Classical EA1 and EA2 phenotypes prompt single gene test and treatment pathways. For atypical phenotypes, next generation genetic testing can aid diagnosis and guide treatment. Updated classification systems for EA are discussed which may assist diagnosis and management.
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Varesio C, De Giorgis V, Veggiotti P, Nardocci N, Granata T, Ragona F, Pasca L, Mensi MM, Borgatti R, Olivotto S, Previtali R, Riva A, Mancardi MM, Striano P, Cavallin M, Guerrini R, Operto FF, Pizzolato A, Di Maulo R, Martino F, Lodi A, Marini C. GLUT1-DS Italian registry: past, present, and future: a useful tool for rare disorders. Orphanet J Rare Dis 2023; 18:63. [PMID: 36944981 PMCID: PMC10029278 DOI: 10.1186/s13023-023-02628-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Accepted: 02/06/2023] [Indexed: 03/23/2023] Open
Abstract
BACKGROUND GLUT1 deficiency syndrome is a rare, genetically determined neurological disorder for which Ketogenic Dietary Treatment represents the gold standard and lifelong treatment. Patient registries are powerful tools providing insights and real-world data on rare diseases. OBJECTIVE To describe the implementation of a national web-based registry for GLUT1-DS. METHODS This is a retrospective and prospective, multicenter, observational registry developed in collaboration with the Italian GLUT1-DS association and based on an innovative, flexible and configurable cloud computing technology platform, structured according to the most rigorous requirements for the management of patient's sensitive data. The Glut1 Registry collects baseline and follow-up data on the patient's demographics, history, symptoms, genotype, clinical, and instrumental evaluations and therapies. RESULTS Five Centers in Italy joined the registry, and two more Centers are currently joining. In the first two years of running, data from 67 patients (40 females and 27 males) have been collected. Age at symptom onset was within the first year of life in most (40, 60%) patients. The diagnosis was formulated in infancy in almost half of the cases (34, 51%). Symptoms at onset were mainly paroxysmal (mostly epileptic seizure and paroxysmal ocular movement disorder) or mixed paroxysmal and fixed symptoms (mostly psychomotor delay). Most patients (53, 79%) are currently under Ketogenic dietary treatments. CONCLUSIONS We describe the principles behind the design, development, and deployment of the web-based nationwide GLUT1-DS registry. It represents a stepping stone towards a more comprehensive understanding of the disease from onset to adulthood. It also represents a virtuous model from a technical, legal, and organizational point of view, thus representing a possible paradigmatic example for other rare disease registry implementation.
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Affiliation(s)
- Costanza Varesio
- Department of Child Neurology and Psychiatry, IRCCS Mondino Foundation (Member of ERN-Epicare), Pavia, Italy
- Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
| | - Valentina De Giorgis
- Department of Child Neurology and Psychiatry, IRCCS Mondino Foundation (Member of ERN-Epicare), Pavia, Italy.
- Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy.
| | - Pierangelo Veggiotti
- Pediatric Neurology Unit, Vittore Buzzi Hospital, Milan, Italy
- Department of Biomedical and Clinical Sciences, Luigi Sacco Hospital, University of Milan, Milan, Italy
| | - Nardo Nardocci
- Department of Pediatric Neuroscience Fondazione, IRCCS Istituto Neurologico Carlo Besta (Member of ERN-Epicare), Milan, Italy
| | - Tiziana Granata
- Department of Pediatric Neuroscience Fondazione, IRCCS Istituto Neurologico Carlo Besta (Member of ERN-Epicare), Milan, Italy
| | - Francesca Ragona
- Department of Pediatric Neuroscience Fondazione, IRCCS Istituto Neurologico Carlo Besta (Member of ERN-Epicare), Milan, Italy
| | - Ludovica Pasca
- Department of Child Neurology and Psychiatry, IRCCS Mondino Foundation (Member of ERN-Epicare), Pavia, Italy
- Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
| | - Martina Maria Mensi
- Department of Child Neurology and Psychiatry, IRCCS Mondino Foundation (Member of ERN-Epicare), Pavia, Italy
| | - Renato Borgatti
- Department of Child Neurology and Psychiatry, IRCCS Mondino Foundation (Member of ERN-Epicare), Pavia, Italy
- Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
| | - Sara Olivotto
- Pediatric Neurology Unit, Vittore Buzzi Hospital, Milan, Italy
| | - Roberto Previtali
- Department of Biomedical and Clinical Sciences, Luigi Sacco Hospital, University of Milan, Milan, Italy
| | - Antonella Riva
- IRCCS Istituto Giannina Gaslini (Member of ERN-Epicare), Genoa, Italy
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, Università Degli Studi di Genova, Genoa, Italy
| | | | - Pasquale Striano
- IRCCS Istituto Giannina Gaslini (Member of ERN-Epicare), Genoa, Italy
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, Università Degli Studi di Genova, Genoa, Italy
| | - Mara Cavallin
- Neuroscience Department, Meyer Children's University Hospital (Member of ERN-Epicare), Florence, Italy
| | - Renzo Guerrini
- Neuroscience Department, Meyer Children's University Hospital (Member of ERN-Epicare), Florence, Italy
| | - Francesca Felicia Operto
- Child Neuropsychiatry Unit, Department of Medicine, Surgery and Dentistry, University of Salerno, Salerno, Italy
| | | | | | | | - Andrea Lodi
- Associazione Italiana Glut1 aps, Milan, Italy
| | - Carla Marini
- Child Neurology and Psychiatric Unit, Salesi Children's Hospital, Ancona, Italy
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9
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Nabatame S, Tanigawa J, Tominaga K, Kagitani-Shimono K, Yanagihara K, Imai K, Ando T, Tsuyusaki Y, Araya N, Matsufuji M, Natsume J, Yuge K, Bratkovic D, Arai H, Okinaga T, Matsushige T, Azuma Y, Ishihara N, Miyatake S, Kato M, Matsumoto N, Okamoto N, Takahashi S, Hattori S, Ozono K. Association between cerebrospinal fluid parameters and developmental and neurological status in glucose transporter 1 deficiency syndrome. J Neurol Sci 2023; 447:120597. [PMID: 36965413 DOI: 10.1016/j.jns.2023.120597] [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: 08/28/2022] [Revised: 01/30/2023] [Accepted: 02/26/2023] [Indexed: 03/06/2023]
Abstract
OBJECTIVE In glucose transporter 1 deficiency syndrome (Glut1DS), cerebrospinal fluid glucose (CSFG) and CSFG to blood glucose ratio (CBGR) show significant differences among groups classified by phenotype or genotype. The purpose of this study was to investigate the association between these biochemical parameters and Glut1DS severity. METHODS The medical records of 45 patients who visited Osaka University Hospital between March 2004 and December 2021 were retrospectively examined. Neurological status was determined using the developmental quotient (DQ), assessed using the Kyoto Scale of Psychological Development 2001, and the Scale for the Assessment and Rating of Ataxia (SARA). CSF parameters included CSFG, CBGR, and CSF lactate (CSFL). RESULTS CSF was collected from 41 patients, and DQ and SARA were assessed in 24 and 27 patients, respectively. Simple regression analysis showed moderate associations between neurological status and biochemical parameters. CSFG resulted in a higher R2 than CBGR in these analyses. CSF parameters acquired during the first year of life were not comparable to those acquired later. CSFL was measured in 16 patients (DQ and SARA in 11 and 14 patients, respectively). Although simple regression analysis also showed moderate associations between neurological status and CSFG and CSFL, the multiple regression analysis for DQ and SARA resulted in strong associations through the use of a combination of CSFG and CSFL as explanatory variables. CONCLUSION The severity of Glut1DS can be predicted from CSF parameters. Glucose and lactate are independent contributors to the developmental and neurological status in Glut1DS.
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Affiliation(s)
- Shin Nabatame
- Department of Pediatrics, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka 565-0871, Japan.
| | - Junpei Tanigawa
- Department of Pediatrics, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka 565-0871, Japan.
| | - Koji Tominaga
- Department of Pediatrics, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka 565-0871, Japan; Department of Child Development, United Graduate School of Child Development, Osaka University, 2-2 Yamadaoka, Suita, Osaka 565-0871, Japan.
| | - Kuriko Kagitani-Shimono
- Department of Pediatrics, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka 565-0871, Japan; Department of Child Development, United Graduate School of Child Development, Osaka University, 2-2 Yamadaoka, Suita, Osaka 565-0871, Japan.
| | - Keiko Yanagihara
- Department of Pediatric Neurology, Osaka Women's and Children's Hospital, 840 Murodocho, Izumi, Osaka 594-1101, Japan.
| | - Katsumi Imai
- Department of Clinical Research, National Epilepsy Center, NHO Shizuoka Institute of Epilepsy and Neurological Disorders, 886 Urushiyama, Aoi, Shizuoka, Shizuoka 420-8688, Japan.
| | - Toru Ando
- Department of Pediatric Medicine, Municipal Tsuruga Hospital, 1-6-60, Mishimacho, Tsuruga, Fukui 914-8502, Japan.
| | - Yu Tsuyusaki
- Division of Neurology, Kanagawa Children's Medical Center, 2-138-4 Mutsukawa, Minami, Yokohama, Kanagawa 232-8555, Japan.
| | - Nami Araya
- Department of Pediatrics, School of Medicine, Iwate Medical University, 2-1-1 Idaidori, Yahaba, Shiwa, Iwate 028-3695, Japan; Epilepsy Clinic Bethel Satellite Sendai-Station, Comfort Hotel Sendai-Higashiguchi #1F, 205-5 Nakakecho, Miyagino, Sendai, Miyagi 983-0864, Japan.
| | - Mayumi Matsufuji
- Department of Pediatrics, Kagoshima City Hospital, 37-1 Uearatacho, Kagoshima, Kagoshima 890-8760, Japan.
| | - Jun Natsume
- Department of Developmental Disability Medicine, Nagoya University Graduate School of Medicine, 65 Tsurumaicho, Showa, Nagoya, Aichi 466-8550, Japan.
| | - Kotaro Yuge
- Department of Pediatrics and Child Health, Kurume University School of Medicine, 67 Asahimachi, Kurume, Fukuoka 830-0011, Japan.
| | - Drago Bratkovic
- Metabolic Clinic, Women's and Children's Hospital, 72 King William Rd, North Adelaide 5006, SA, Australia.
| | - Hiroshi Arai
- Department of Pediatric Neurology, Bobath Memorial Hospital, 1-6-5 Higashinakahama, Joto, Osaka, Osaka 536-0023, Japan.
| | - Takeshi Okinaga
- Department of Pediatrics, Bell Land General Hospital, 500-3 Higashiyama, Naka, Sakai, Osaka, 599-8247, Japan.
| | - Takeshi Matsushige
- Department of Pediatrics, Yamaguchi University Graduate School of Medicine, 1-1-1 Minamikogushi, Ube, Yamaguchi 755-8505, Japan.
| | - Yoshiteru Azuma
- Department of Pediatrics, Aichi Medical University, 1-1, Yazakokarimata, Nagakute, Aichi 480-1195, Japan; Department of Human Genetics, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa, Yokohama, Kanagawa 236-0004, Japan.
| | - Naoko Ishihara
- Department of Pediatrics, Fujita Health University School of Medicine, 1-98 Dengakugakubo, Kutsukakecho, Toyoake, Aichi 470-1192, Japan.
| | - Satoko Miyatake
- Department of Human Genetics, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa, Yokohama, Kanagawa 236-0004, Japan; Clinical Genetics Department, Yokohama City University Hospital, 3-9 Fukuura, Kanazawa, Yokohama, Kanagawa 236-0004, Japan.
| | - Mitsuhiro Kato
- Department of Pediatrics, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa, Tokyo 142-8555, Japan.
| | - Naomichi Matsumoto
- Department of Human Genetics, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa, Yokohama, Kanagawa 236-0004, Japan.
| | - Nobuhiko Okamoto
- Department of Medical Genetics, Osaka Women's and Children's Hospital, 840 Murodocho, Izumi, Osaka 594-1101, Japan.
| | - Satoru Takahashi
- Department of Pediatrics, Asahikawa Medical University, 2-1-1-1 Midorigaoka-higashi, Asahikawa, Hokkaido 078-8510, Japan.
| | - Satoshi Hattori
- Department of Biomedical Statistics, Graduate School of Medicine and Integrated Frontier Research for Medical Science Division, Institute for Open and Transdisciplinary Research Initiatives (OTRI), Osaka University, 2-2 Yamadaoka, Suita, Osaka 565-0871, Japan.
| | - Keiichi Ozono
- Department of Pediatrics, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka 565-0871, Japan.
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Kathote G, Ma Q, Angulo G, Chen H, Jakkamsetti V, Dobariya A, Good LB, Posner B, Park JY, Pascual JM. Identification of Glucose Transport Modulators In Vitro and Method for Their Deep Learning Neural Network Behavioral Evaluation in Glucose Transporter 1-Deficient Mice. J Pharmacol Exp Ther 2023; 384:393-405. [PMID: 36635085 DOI: 10.1124/jpet.122.001428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Revised: 12/07/2022] [Accepted: 12/27/2022] [Indexed: 01/14/2023] Open
Abstract
Metabolic flux augmentation via glucose transport activation may be desirable in glucose transporter 1 (Glut1) deficiency syndrome (G1D) and dementia, whereas suppression might prove useful in cancer. Using lung adenocarcinoma cells that predominantly express Glut1 relative to other glucose transporters, we screened 9,646 compounds for effects on the accumulation of an extracellularly applied fluorescent glucose analog. Five drugs currently prescribed for unrelated indications or preclinically characterized robustly enhanced intracellular fluorescence. Additionally identified were 37 novel activating and nine inhibitory compounds lacking previous biologic characterization. Because few glucose-related mechanistic or pharmacological studies were available for these compounds, we developed a method to quantify G1D mouse behavior to infer potential therapeutic value. To this end, we designed a five-track apparatus to record and evaluate spontaneous locomotion videos. We applied this to a G1D mouse model that replicates the ataxia and other manifestations cardinal to the human disorder. Because the first two drugs that we examined in this manner (baclofen and acetazolamide) exerted various impacts on several gait aspects, we used deep learning neural networks to more comprehensively assess drug effects. Using this method, 49 locomotor parameters differentiated G1D from control mice. Thus, we used parameter modifiability to quantify efficacy on gait. We tested this by measuring the effects of saline as control and glucose as G1D therapy. The results indicate that this in vivo approach can estimate preclinical suitability from the perspective of G1D locomotion. This justifies the use of this method to evaluate our drugs or other interventions and sort candidates for further investigation. SIGNIFICANCE STATEMENT: There are few or no activators and few clinical inhibitors of glucose transport. Using Glut1-rich cells exposed to a glucose analog, we identified, in highthroughput fashion, a series of novel modulators. Some were drugs used to modify unrelated processes and some represented large but little studied chemical compound families. To facilitate their preclinical efficacy characterization regardless of potential mechanism of action, we developed a gait testing platform for deep learning neural network analysis of drug impact on Glut1-deficient mouse locomotion.
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Affiliation(s)
- Gauri Kathote
- Rare Brain Disorders Program, Department of Neurology (G.K., Q.M., G.A., V.J., A.D., L.B.G., J.M.P.), Department of Biochemistry (H.C., B.P.), Department of Pathology (J.Y.P.), Department of Physiology (J.M.P.), Department of Pediatrics (J.M.P.), and Eugene McDermott Center for Human Growth & Development/Center for Human Genetics (J.Y.P., J.M.P.), University of Texas Southwestern Medical Center, Dallas, Texas
| | - Qian Ma
- Rare Brain Disorders Program, Department of Neurology (G.K., Q.M., G.A., V.J., A.D., L.B.G., J.M.P.), Department of Biochemistry (H.C., B.P.), Department of Pathology (J.Y.P.), Department of Physiology (J.M.P.), Department of Pediatrics (J.M.P.), and Eugene McDermott Center for Human Growth & Development/Center for Human Genetics (J.Y.P., J.M.P.), University of Texas Southwestern Medical Center, Dallas, Texas
| | - Gustavo Angulo
- Rare Brain Disorders Program, Department of Neurology (G.K., Q.M., G.A., V.J., A.D., L.B.G., J.M.P.), Department of Biochemistry (H.C., B.P.), Department of Pathology (J.Y.P.), Department of Physiology (J.M.P.), Department of Pediatrics (J.M.P.), and Eugene McDermott Center for Human Growth & Development/Center for Human Genetics (J.Y.P., J.M.P.), University of Texas Southwestern Medical Center, Dallas, Texas
| | - Hong Chen
- Rare Brain Disorders Program, Department of Neurology (G.K., Q.M., G.A., V.J., A.D., L.B.G., J.M.P.), Department of Biochemistry (H.C., B.P.), Department of Pathology (J.Y.P.), Department of Physiology (J.M.P.), Department of Pediatrics (J.M.P.), and Eugene McDermott Center for Human Growth & Development/Center for Human Genetics (J.Y.P., J.M.P.), University of Texas Southwestern Medical Center, Dallas, Texas
| | - Vikram Jakkamsetti
- Rare Brain Disorders Program, Department of Neurology (G.K., Q.M., G.A., V.J., A.D., L.B.G., J.M.P.), Department of Biochemistry (H.C., B.P.), Department of Pathology (J.Y.P.), Department of Physiology (J.M.P.), Department of Pediatrics (J.M.P.), and Eugene McDermott Center for Human Growth & Development/Center for Human Genetics (J.Y.P., J.M.P.), University of Texas Southwestern Medical Center, Dallas, Texas
| | - Aksharkumar Dobariya
- Rare Brain Disorders Program, Department of Neurology (G.K., Q.M., G.A., V.J., A.D., L.B.G., J.M.P.), Department of Biochemistry (H.C., B.P.), Department of Pathology (J.Y.P.), Department of Physiology (J.M.P.), Department of Pediatrics (J.M.P.), and Eugene McDermott Center for Human Growth & Development/Center for Human Genetics (J.Y.P., J.M.P.), University of Texas Southwestern Medical Center, Dallas, Texas
| | - Levi B Good
- Rare Brain Disorders Program, Department of Neurology (G.K., Q.M., G.A., V.J., A.D., L.B.G., J.M.P.), Department of Biochemistry (H.C., B.P.), Department of Pathology (J.Y.P.), Department of Physiology (J.M.P.), Department of Pediatrics (J.M.P.), and Eugene McDermott Center for Human Growth & Development/Center for Human Genetics (J.Y.P., J.M.P.), University of Texas Southwestern Medical Center, Dallas, Texas
| | - Bruce Posner
- Rare Brain Disorders Program, Department of Neurology (G.K., Q.M., G.A., V.J., A.D., L.B.G., J.M.P.), Department of Biochemistry (H.C., B.P.), Department of Pathology (J.Y.P.), Department of Physiology (J.M.P.), Department of Pediatrics (J.M.P.), and Eugene McDermott Center for Human Growth & Development/Center for Human Genetics (J.Y.P., J.M.P.), University of Texas Southwestern Medical Center, Dallas, Texas
| | - Jason Y Park
- Rare Brain Disorders Program, Department of Neurology (G.K., Q.M., G.A., V.J., A.D., L.B.G., J.M.P.), Department of Biochemistry (H.C., B.P.), Department of Pathology (J.Y.P.), Department of Physiology (J.M.P.), Department of Pediatrics (J.M.P.), and Eugene McDermott Center for Human Growth & Development/Center for Human Genetics (J.Y.P., J.M.P.), University of Texas Southwestern Medical Center, Dallas, Texas.
| | - Juan M Pascual
- Rare Brain Disorders Program, Department of Neurology (G.K., Q.M., G.A., V.J., A.D., L.B.G., J.M.P.), Department of Biochemistry (H.C., B.P.), Department of Pathology (J.Y.P.), Department of Physiology (J.M.P.), Department of Pediatrics (J.M.P.), and Eugene McDermott Center for Human Growth & Development/Center for Human Genetics (J.Y.P., J.M.P.), University of Texas Southwestern Medical Center, Dallas, Texas.
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11
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Stenshorne I, Syvertsen M, Ramm-Pettersen A, Henning S, Weatherup E, Bjørnstad A, Brüggemann N, Spetalen T, Selmer KK, Koht J. Monogenic developmental and epileptic encephalopathies of infancy and childhood, a population cohort from Norway. Front Pediatr 2022; 10:965282. [PMID: 35979408 PMCID: PMC9376386 DOI: 10.3389/fped.2022.965282] [Citation(s) in RCA: 2] [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: 06/09/2022] [Accepted: 07/07/2022] [Indexed: 12/01/2022] Open
Abstract
INTRODUCTION Developmental and epileptic encephalopathies (DEE) is a group of epilepsies where the epileptic activity, seizures and the underlying neurobiology contributes to cognitive and behavioral impairments. Uncovering the causes of DEE is important in order to develop guidelines for treatment and follow-up. The aim of the present study was to describe the clinical picture and to identify genetic causes in a patient cohort with DEE without known etiology, from a Norwegian regional hospital. METHODS Systematic searches of medical records were performed at Drammen Hospital, Vestre Viken Health Trust, to identify patients with epilepsy in the period 1999-2018. Medical records were reviewed to identify patients with DEE of unknown cause. In 2018, patients were also recruited consecutively from treating physicians. All patients underwent thorough clinical evaluation and updated genetic diagnostic analyses. RESULTS Fifty-five of 2,225 patients with epilepsy had DEE of unknown etiology. Disease-causing genetic variants were found in 15/33 (45%) included patients. Three had potentially treatable metabolic disorders (SLC2A1, COQ4 and SLC6A8). Developmental comorbidity was higher in the group with a genetic diagnosis, compared to those who remained undiagnosed. Five novel variants in known genes were found, and the patient phenotypes are described. CONCLUSION The results from this study illustrate the importance of performing updated genetic investigations and/or analyses in patients with DEE of unknown etiology. A genetic cause was identified in 45% of the patients, and three of these patients had potentially treatable conditions where available targeted therapy may improve patient outcome.
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Affiliation(s)
- Ida Stenshorne
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway.,Department of Children and Adolescents, Drammen Hospital, Vestre Viken Health Trust, Drammen, Norway
| | - Marte Syvertsen
- Department of Neurology, Drammen Hospital, Vestre Viken Health Trust, Drammen, Norway
| | - Anette Ramm-Pettersen
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway.,Department of Clinical Neurosciences for Children, Oslo University Hospital, Oslo, Norway
| | - Susanne Henning
- Department of Children and Adolescents, Drammen Hospital, Vestre Viken Health Trust, Drammen, Norway
| | - Elisabeth Weatherup
- Department of Children and Adolescents, Drammen Hospital, Vestre Viken Health Trust, Drammen, Norway
| | - Alf Bjørnstad
- Department of Children and Adolescents, Stavanger University Hospital, Stavanger Health Trust, Stavanger, Norway
| | - Natalia Brüggemann
- Department of Children and Adolescents, Drammen Hospital, Vestre Viken Health Trust, Drammen, Norway
| | - Torstein Spetalen
- Department of Neurology, Drammen Hospital, Vestre Viken Health Trust, Drammen, Norway
| | - Kaja K Selmer
- National Center for Epilepsy, Oslo University Hospital, Oslo, Norway.,Division of Clinical Neuroscience, Department of Research and Innovation, Oslo University Hospital, Oslo, Norway
| | - Jeanette Koht
- Department of Neurology, Oslo University Hospital, Oslo, Norway
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12
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Classic Ketogenic Diet and Modified Atkins Diet in SLC2A1 Positive and Negative Patients with Suspected GLUT1 Deficiency Syndrome: A Single Center Analysis of 18 Cases. Nutrients 2021; 13:nu13030840. [PMID: 33806661 PMCID: PMC8000344 DOI: 10.3390/nu13030840] [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: 01/15/2021] [Revised: 02/10/2021] [Accepted: 02/26/2021] [Indexed: 01/08/2023] Open
Abstract
Background: Glucose transporter type 1 deficiency syndrome (GLUT1DS) is caused by mutations in the SLC2A1 gene and produces seizures, neurodevelopmental impairment, and movement disorders. Ketogenic dietary therapies (KDT) are the gold standard treatment. Similar symptoms may appear in SLC2A1 negative patients. The purpose is to evaluate the effectiveness of KDT in children with GLUT1DS suspected SLC2A1 (+) and (-), side effects (SE), and the impact on patients nutritional status. Methods: An observational descriptive study was conducted to describe 18 children (January 2009–August 2020). SLC2A1 analysis, seizures, movement disorder, anti-epileptic drugs (AEDS), anthropometry, SE, and laboratory assessment were monitored baseline and at 3, 6, 12, and 24 months after the onset of KDT. Results: 6/18 were SLC2A1(+) and 13/18 had seizures. In these groups, the age for debut of symptoms was higher. The mean time from debut to KDT onset was higher in SLC2A1(+). The modified Atkins diet (MAD) was used in 12 (5 SLC2A1(+)). Movement disorder improved (4/5), and a reduction in seizures >50% compared to baseline was achieved in more than half of the epileptic children throughout the follow-up. No differences in effectiveness were found according to the type of KDT. Early SE occurred in 33%. Long-term SE occurred in 10, 5, 7, and 5 children throughout the follow-up. The most frequent SE were constipation, hypercalciuria, and hyperlipidaemia. No differences in growth were found according to the SLC2A1 mutation or type of KDT. Conclusions: CKD and MAD were effective for SLC2A1 positive and negative patients in our cohort. SE were frequent, but mild. Permanent monitoring should be made to identify SE and nutritional deficits.
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13
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Gavrilovici C, Rho JM. Metabolic epilepsies amenable to ketogenic therapies: Indications, contraindications, and underlying mechanisms. J Inherit Metab Dis 2021; 44:42-53. [PMID: 32654164 DOI: 10.1002/jimd.12283] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 07/04/2020] [Accepted: 07/07/2020] [Indexed: 12/20/2022]
Abstract
Metabolic epilepsies arise in the context of rare inborn errors of metabolism (IEM), notably glucose transporter type 1 deficiency syndrome, succinic semialdehyde dehydrogenase deficiency, pyruvate dehydrogenase complex deficiency, nonketotic hyperglycinemia, and mitochondrial cytopathies. A common feature of these disorders is impaired bioenergetics, which through incompletely defined mechanisms result in a wide spectrum of neurological symptoms, such as epileptic seizures, developmental delay, and movement disorders. The ketogenic diet (KD) has been successfully utilized to treat such conditions to varying degrees. While the mechanisms underlying the clinical efficacy of the KD in IEM remain unclear, it is likely that the proposed heterogeneous targets influenced by the KD work in concert to rectify or ameliorate the downstream negative consequences of genetic mutations affecting key metabolic enzymes and substrates-such as oxidative stress and cell death. These beneficial effects can be broadly grouped into restoration of impaired bioenergetics and synaptic dysfunction, improved redox homeostasis, anti-inflammatory, and epigenetic activity. Hence, it is conceivable that the KD might prove useful in other metabolic disorders that present with epileptic seizures. At the same time, however, there are notable contraindications to KD use, such as fatty acid oxidation disorders. Clearly, more research is needed to better characterize those metabolic epilepsies that would be amenable to ketogenic therapies, both experimentally and clinically. In the end, the expanded knowledge base will be critical to designing metabolism-based treatments that can afford greater clinical efficacy and tolerability compared to current KD approaches, and improved long-term outcomes for patients.
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Affiliation(s)
- Cezar Gavrilovici
- Departments of Neurosciences and Pediatrics, University of California San Diego, Rady Children's Hospital, San Diego, California, USA
| | - Jong M Rho
- Departments of Neurosciences and Pediatrics, University of California San Diego, Rady Children's Hospital, San Diego, California, USA
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14
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Effects of ketogenic diet on cognitive function in pentylenetetrazol-kindled rats. Epilepsy Res 2020; 170:106534. [PMID: 33385944 DOI: 10.1016/j.eplepsyres.2020.106534] [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] [Received: 10/22/2020] [Revised: 12/03/2020] [Accepted: 12/07/2020] [Indexed: 10/22/2022]
Abstract
Although the ketogenic diet (KD) is known to control seizures and improve cognition function in patients with drug-refractory epilepsy, the underlying mechanism remains unknown. In the present study, using pentylenetetrazol (PTZ)-induced and kindled rats, we found that KD significantly improved the impaired spatial reference memory of PTZ-kindled rats in the Morris water maze. To explore the mechanism underlying the action of KD in PTZ-kindled rats, quantitative real-time PCR (qRT-PCR) and immunohistochemical analysis were used to detect the expression of GluR1 and NR2B. The results showed that both the mRNA and protein expression of GluR1 and NR2B were significantly downregulated in the hippocampus of PTZ-kindled rats, while KD could observably improve both the mRNA and protein expression of GluR1 and NR2B in the hippocampus of PTZ-kindled rats. Additionally, KD improved the over-activated MAPK in PTZ-kindled rats, but not CAMKII, as detected by enzyme-linked immuno sorbent assay (ELISA), suggesting that the MAPK signaling pathway might be involved in the memory improvement of KD in PTZ-kindled rats. In conclusion, these results demonstrate that KD can indeed improve impaired spatial reference memory in PTZ-kindled rats, and KD can improve the expression of NR2B and GluR1.
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15
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McDonald TJW, Cervenka MC. Ketogenic Diet Therapies for Seizures and Status Epilepticus. Semin Neurol 2020; 40:719-729. [PMID: 33155184 DOI: 10.1055/s-0040-1719077] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Ketogenic diet therapies are high-fat, low-carbohydrate diets designed to mimic a fasting state. Although initially developed nearly one century ago for seizure management, most clinical trials for the management of drug-resistant epilepsy in children as well as adults have been conducted over the last 3 decades. Moreover, ketogenic diets offer promising new adjunctive strategies in the critical care setting for the resolution of acute status epilepticus when traditional antiseizure drugs and anesthetic agents fail. Here, we review the history of ketogenic diet development, the clinical evidence supporting its use for the treatment of drug-resistant epilepsy in children and adults, and the early evidence supporting ketogenic diet feasibility, safety, and potential efficacy in the management of status epilepticus.
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16
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Abstract
Paroxysmal dyskinesia (PxD) is a heterogeneous group of syndromes characterized by recurrent attacks of abnormal movements, triggered by detectable factors, without loss of consciousness. According to the precipitating factors, they are classified as paroxysmal kinesigenic dyskinesia (PKD), paroxysmal non-kinesigenic dyskinesia (PNKD), and paroxysmal exercise-induced dystonia (PED). PxD treatment is based on the combination of nonpharmacologic and pharmacologic approaches. Pharmacologic and nonpharmacologic treatments effective for PNKD and PED also are available. In PxD refractory to conventional treatment, surgery might be an alternative therapeutic option. The course of PRRT2-PKD and MR-1-PNKD is benign, and treatment might not be needed with advancing age.
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17
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Klepper J, Akman C, Armeno M, Auvin S, Cervenka M, Cross HJ, De Giorgis V, Della Marina A, Engelstad K, Heussinger N, Kossoff EH, Leen WG, Leiendecker B, Monani UR, Oguni H, Neal E, Pascual JM, Pearson TS, Pons R, Scheffer IE, Veggiotti P, Willemsen M, Zuberi SM, De Vivo DC. Glut1 Deficiency Syndrome (Glut1DS): State of the art in 2020 and recommendations of the international Glut1DS study group. Epilepsia Open 2020; 5:354-365. [PMID: 32913944 PMCID: PMC7469861 DOI: 10.1002/epi4.12414] [Citation(s) in RCA: 125] [Impact Index Per Article: 31.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Revised: 06/13/2020] [Accepted: 06/16/2020] [Indexed: 12/14/2022] Open
Abstract
Glut1 deficiency syndrome (Glut1DS) is a brain energy failure syndrome caused by impaired glucose transport across brain tissue barriers. Glucose diffusion across tissue barriers is facilitated by a family of proteins including glucose transporter type 1 (Glut1). Patients are treated effectively with ketogenic diet therapies (KDT) that provide a supplemental fuel, namely ketone bodies, for brain energy metabolism. The increasing complexity of Glut1DS, since its original description in 1991, now demands an international consensus statement regarding diagnosis and treatment. International experts (n = 23) developed a consensus statement utilizing their collective professional experience, responses to a standardized questionnaire, and serial discussions of wide-ranging issues related to Glut1DS. Key clinical features signaling the onset of Glut1DS are eye-head movement abnormalities, seizures, neurodevelopmental impairment, deceleration of head growth, and movement disorders. Diagnosis is confirmed by the presence of these clinical signs, hypoglycorrhachia documented by lumbar puncture, and genetic analysis showing pathogenic SLC2A1 variants. KDT represent standard choices with Glut1DS-specific recommendations regarding duration, composition, and management. Ongoing research has identified future interventions to restore Glut1 protein content and function. Clinical manifestations are influenced by patient age, genetic complexity, and novel therapeutic interventions. All clinical phenotypes will benefit from a better understanding of Glut1DS natural history throughout the life cycle and from improved guidelines facilitating early diagnosis and prompt treatment. Often, the presenting seizures are treated initially with antiseizure drugs before the cause of the epilepsy is ascertained and appropriate KDT are initiated. Initial drug treatment fails to treat the underlying metabolic disturbance during early brain development, contributing to the long-term disease burden. Impaired development of the brain microvasculature is one such complication of delayed Glut1DS treatment in the postnatal period. This international consensus statement should facilitate prompt diagnosis and guide best standard of care for Glut1DS throughout the life cycle.
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Affiliation(s)
- Joerg Klepper
- Children's Hospital Aschaffenburg‐AlzenauAschaffenburgGermany
| | - Cigdem Akman
- Department of Neurology and PediatricsVagelos College of Physicians and Surgeons at Columbia UniversityNew YorkNYUSA
| | - Marisa Armeno
- Department of NutritionHospital Pediatria JP GarrahanBuenos AiresArgentina
| | - Stéphane Auvin
- Department of Pediatric NeurologyCHU Hôpital Robert DebreAPHPParisFrance
| | - Mackenzie Cervenka
- Department of NeurologyComprehensive Epilepsy CenterJohns Hopkins University School of MedicineBaltimoreMDUSA
| | - Helen J. Cross
- UCL NIHR BRC Great Ormond Street Institute of Child HealthLondonUK
| | | | - Adela Della Marina
- Department of Neuropediatrics, Developmental Neurology and Social Pediatrics, Centre for Neuromuscular Disorders in Children, University Hospital EssenUniversity of Duisburg‐EssenEssenGermany
| | - Kristin Engelstad
- Department of Neurology and PediatricsVagelos College of Physicians and Surgeons at Columbia UniversityNew YorkNYUSA
| | - Nicole Heussinger
- Department of Pediatric NeurologyParacelsus Medical Private UniversityNurembergGermany
| | - Eric H. Kossoff
- Departments of Neurology and PediatricsJohns Hopkins UniversityBaltimoreMDUSA
| | - Wilhelmina G. Leen
- Department of NeurologyCanisius Wilhemina HospitalNijmegenThe Netherlands
| | - Baerbel Leiendecker
- Department of Neuropediatrics, Developmental Neurology and Social Pediatrics, Centre for Neuromuscular Disorders in Children, University Hospital EssenUniversity of Duisburg‐EssenEssenGermany
| | - Umrao R. Monani
- Center for Motor Neuron Biology & DiseaseDepartments of Neurology and Pathology & Cell BiologyColumbia University Irving Medical CenterNew YorkNYUSA
| | - Hirokazu Oguni
- Department of PediatricsTokyo Women's Medical UniversityTokyoJapan
| | | | - Juan M. Pascual
- Departments of Neurology and Neurotherapeutics, Physiology and PediatricsEugene McDermott Center for Human Growth and DevelopmentThe University of Texas Southwestern Medical CenterDallasTXUSA
| | - Toni S. Pearson
- Mount Sinai Center for Headache & Pain MedicineNew YorkNYUSA
| | - Roser Pons
- First Department of PediatricsAgia Sofia HospitalUniversity of AthensAthensGreece
| | - Ingrid E. Scheffer
- Florey and Murdoch InstitutesAustin Health and Royal Children's HospitalThe University of MelbourneMelbourneVictoriaAustralia
| | - Pierangelo Veggiotti
- Pediatric Neurology V. Buzzi HospitalChild Neuropsychiatry University of MilanMilanItaly
| | - Michél Willemsen
- Department of Pediatric NeurologyRadboud University Medical CentreAmalia Children's HospitalNijmegenNetherlands
| | - Sameer M. Zuberi
- Royal Hospital for Children & College of Medical Veterinary & Life SciencesUniversity of GlasgowGlasgowUK
| | - Darryl C. De Vivo
- Department of Neurology and PediatricsVagelos College of Physicians and Surgeons at Columbia UniversityNew YorkNYUSA
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18
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Baizabal-Carvallo JF, Cardoso F. Chorea in children: etiology, diagnostic approach and management. J Neural Transm (Vienna) 2020; 127:1323-1342. [DOI: 10.1007/s00702-020-02238-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 08/01/2020] [Indexed: 01/07/2023]
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19
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Armeno M, Caraballo R. The evolving indications of KD therapy. Epilepsy Res 2020; 163:106340. [PMID: 32330835 DOI: 10.1016/j.eplepsyres.2020.106340] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Revised: 03/14/2020] [Accepted: 04/08/2020] [Indexed: 02/06/2023]
Abstract
Despite the rapid increase of clinical and basic-science knowledge on ketogenic diet therapies over the past years, it has not always been easy to determine the adequate indications of this treatment. Over the nearly 100 years of use, from being a last resource in the therapeutic algorithm, the diet has become one of the four main treatments for patients with difficult-to-control epilepsy together with antiepileptic drugs, surgery, and vagus nerve stimulation. The use of the diet has also changed. The current paper will briefly discuss the history of the diet together with a review of the literature regarding its most important indications and how they have evolved. The concept of the importance of defining the type of seizure, type of syndrome, and etiology in the selection of patients and timing of diet initiation has been gaining importance. This paper explores how the indications of the diet changed together with the shifting focus of epilepsy teams towards its use in different types of epilepsy and epilepsy syndromes and according to etiologies and as an alternative option in refractory and superrefractory status epilepticus.
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Affiliation(s)
- Marisa Armeno
- Department of Nutrition, Hospital de Pediatria Juan P Garrahan, Combate de los Pozos 1881, C1245 CABA, Buenos Aires, Argentina.
| | - Roberto Caraballo
- Department of Neurology, Hospital de Pediatria Juan P Garrahan, Combate de los Pozos 1881, C1245 CABA, Buenos Aires, Argentina
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20
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Schwantje M, Verhagen LM, van Hasselt PM, Fuchs SA. Glucose transporter type 1 deficiency syndrome and the ketogenic diet. J Inherit Metab Dis 2020; 43:216-222. [PMID: 31605543 PMCID: PMC7078900 DOI: 10.1002/jimd.12175] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2019] [Revised: 08/28/2019] [Accepted: 09/20/2019] [Indexed: 01/11/2023]
Abstract
Glucose transporter type 1 deficiency syndrome (GLUT1DS) is characterised by deficient glucose transport over the blood-brain barrier and reduced glucose availability in the brain. This causes epilepsy, movement disorders, and cognitive impairment. Treatment with ketogenic diet provides ketones as alternative energy source. However, not all GLUT1DS patients are on dietary treatment (worldwide registry: 77/181 [43%] of patients). The current 25-year experience allows evaluation of effects and tolerability of dietary treatment for GLUT1DS. To this end, literature was searched up to January 2019 for individual case reports and series reporting (side) effects of dietary treatment for GLUT1DS. Upon aggregation of data for analysis, we identified 270 GLUT1DS patients with dietary treatment with a mean follow-up of 53 months. Epilepsy improved for 83% of 230 patients and remained unchanged for 17%, movement disorders improved for 82% of 127 patients and remained unchanged for 17%, and cognition improved for 59% of 58 patients and remained stable for 40%. Effects on epilepsy were seen within days/weeks and were most pronounced in patients with early treatment initiation. Effects on movement disorders were noticed within months and were strongest in patients with higher cerebrospinal fluid-to-blood glucose ratio. Although side effects were minimal, 18% of 270 patients reported poor compliance. In individual patients, symptoms deteriorated upon low ketosis, poor compliance, or treatment discontinuation. Based on the good tolerability and strong favourable effect of dietary treatment on GLUT1DS symptoms, we advocate dietary treatment in all GLUT1DS patients and prompt diagnosis or screening to allow early treatment.
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Affiliation(s)
- Marit Schwantje
- Department of Metabolic Diseases, Wilhelmina Children's HospitalUniversity Medical Center UtrechtUtrechtThe Netherlands
| | - Lilly M. Verhagen
- Department of Infectious diseases and Immunology, Wilhelmina Children's HospitalUniversity Medical Center UtrechtUtrechtThe Netherlands
| | - Peter M. van Hasselt
- Department of Metabolic Diseases, Wilhelmina Children's HospitalUniversity Medical Center UtrechtUtrechtThe Netherlands
| | - Sabine A. Fuchs
- Department of Metabolic Diseases, Wilhelmina Children's HospitalUniversity Medical Center UtrechtUtrechtThe Netherlands
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21
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Vaudano AE, Olivotto S, Ruggieri A, Gessaroli G, Talami F, Parmeggiani A, De Giorgis V, Veggiotti P, Meletti S. The effect of chronic neuroglycopenia on resting state networks in GLUT1 syndrome across the lifespan. Hum Brain Mapp 2020; 41:453-466. [PMID: 31710770 PMCID: PMC7313681 DOI: 10.1002/hbm.24815] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2019] [Revised: 09/18/2019] [Accepted: 09/20/2019] [Indexed: 12/20/2022] Open
Abstract
Glucose transporter type I deficiency syndrome (GLUT1DS) is an encephalopathic disorder due to a chronic insufficient transport of glucose into the brain. PET studies in GLUT1DS documented a widespread cortico‐thalamic hypometabolism and a signal increase in the basal ganglia, regardless of age and clinical phenotype. Herein, we captured the pattern of functional connectivity of distinct striatal, cortical, and cerebellar regions in GLUT1DS (10 children, eight adults) and in healthy controls (HC, 19 children, 17 adults) during rest. Additionally, we explored for regional connectivity differences in GLUT1 children versus adults and according to the clinical presentation. Compared to HC, GLUT1DS exhibited increase connectivity within the basal ganglia circuitries and between the striatal regions with the frontal cortex and cerebellum. The excessive connectivity was predominant in patients with movement disorders and in children compared to adults, suggesting a correlation with the clinical phenotype and age at fMRI study. Our findings highlight the primary role of the striatum in the GLUT1DS pathophysiology and confirm the dependency of symptoms to the patients' chronological age. Despite the reduced chronic glucose uptake, GLUT1DS exhibit increased connectivity changes in regions highly sensible to glycopenia. Our results may portrait the effect of neuroprotective brain strategy to overcome the chronic poor energy supply during vulnerable ages.
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Affiliation(s)
- Anna Elisabetta Vaudano
- Neurology Unit, OCSAE Hospital, AOU Modena, Modena, Italy.,Department of Biomedical, Metabolic, and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Sara Olivotto
- Pediatric Neurology Unit, V. Buzzi Hospital, University of Milan, Milan, Italy
| | - Andrea Ruggieri
- Department of Biomedical, Metabolic, and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | | | - Francesca Talami
- Department of Biomedical, Metabolic, and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Antonia Parmeggiani
- Child Neurology and Psychiatry Unit, Policlinico S. Orsola-Malpighi, Bologna, Italy.,Department of Medical and Surgical Sciences, University of Bologna, Italy
| | | | | | - Stefano Meletti
- Neurology Unit, OCSAE Hospital, AOU Modena, Modena, Italy.,Department of Biomedical, Metabolic, and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
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22
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Abstract
Traditionally treatment of epileptic seizures has been symptomatic, namely medication has been targeted at raising the threshold to the occurrence of epileptic seizures. This has had little impact on the rate of drug resistance over time, or impact on comorbidities such as learning and behaviour particularly in the early onset epilepsies. The advent of advanced neuroimaging and genomics has revealed the cause of the epilepsy in a much higher percentage, and advanced our knowledge as to the underlying pathophysiology. This has given us the opportunity to turn to the possibility of interventional treatment, targeting the underlying cause, and consequently the possibility of changing the natural history of disease. Here we review the options open to us, and the evidence to date.
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Affiliation(s)
- J Helen Cross
- UCL NIHR BRC Great Ormond Street Institute of Child Health, London, WC1N 1EH, UK.
| | - Lieven Lagae
- Paediatric Neurology, University Hospitals Leuven, Herestraat 49, Leuven, BE B-3000, Belgium
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23
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Abstract
Chorea is a movement disorder characterized by ongoing random-appearing sequences of discrete involuntary movements or movement fragments. Chorea results from dysfunction of the complex neuronal networks that interconnect the basal ganglia, thalamus, and related frontal lobe cortical areas. The complexity of basal ganglia circuitry and vulnerability of those circuits to injury explains why chorea results from a wide variety of conditions. Because etiology-specific treatments or effective symptomatic treatments are available for causes of chorea, defining the underlying disease is important. The treatment of chorea can be considered in three main categories: (1) terminating or modifying exposure to the causative agent, (2) symptomatic treatment of chorea, and (3) treatment targeting the underlying etiology. Symptomatic treatment decision of chorea should be based on the functional impact on the child caused by chorea itself. There have been no reported randomized, placebo-controlled trials of symptomatic treatment for chorea in childhood. Thus the recommendations are based on clinical experience, case reports, expert opinions, and small comparative studies. Better knowledge of mechanisms underlying childhood chorea will provide more etiology-based treatments in the future.
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24
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K.P. D, Kishore A. Treatable cerebellar ataxias. Clin Park Relat Disord 2020; 3:100053. [PMID: 34316636 PMCID: PMC8298807 DOI: 10.1016/j.prdoa.2020.100053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Revised: 03/28/2020] [Accepted: 03/31/2020] [Indexed: 12/03/2022] Open
Abstract
Cerebellar ataxic syndrome is a heterogenous class of disorders which can result from a miscellany of causes- genetic or acquired. There are a few metabolic, immune mediated, inflammatory and hereditary causes of ataxia which can be diagnosed from the gamut of possibilities, offering great relief to the ailing patient, their family and the treating physician. A pragmatic algorithm for diagnosing treatable causes of ataxia includes a thorough clinical history, meticulous examination for associated signs and an investigative mind to clinch the diagnosis. With novel diagnostic techniques and targeted therapies, early diagnosis and treatment can lead to favourable outcomes. In this review, diseases presenting predominantly as cerebellar ataxia and are treatable by targeted therapies are discussed.
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25
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Appleton RE, Gupta R. Cerebral palsy: not always what it seems. Arch Dis Child 2019; 104:809-814. [PMID: 30413492 DOI: 10.1136/archdischild-2018-315633] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Revised: 10/10/2018] [Accepted: 10/10/2018] [Indexed: 12/17/2022]
Abstract
Cerebral palsy (CP) is not a disease, but a neurological syndrome, a combination of signs and symptoms, some of which may occur in neurodegenerative or metabolic disorders, particularly those with an onset in the first 2 years of life. There are many different causes of the syndrome. All children with CP should undergo brain MRI, even with an identified antenatal or perinatal insult. Children with CP should be referred to a paediatric neurologist or a clinical geneticist, or both, if appropriate and particularly in the absence of a known perinatal cerebral insult, with brain MRI that is reported to be normal, a progression in, or new, signs or where there is a reported 'family history of CP'. Finally, a few of the CP syndromes may be readily treatable and potentially prevent irreversible neurological and cognitive impairment.
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Affiliation(s)
- Richard E Appleton
- The Roald Dahl EEG Unit, Neurophysiology Department, Alder Hey Children's Health Park, Liverpool, UK
| | - Rajat Gupta
- Department of Neurology, Birmingham Children's Hospital, Birmingham, UK
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26
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Quality of Life in Chronic Ketogenic Diet Treatment: The GLUT1DS Population Perspective. Nutrients 2019; 11:nu11071650. [PMID: 31330987 PMCID: PMC6682968 DOI: 10.3390/nu11071650] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Revised: 07/10/2019] [Accepted: 07/17/2019] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Glucose transporter type 1 deficiency syndrome (GLUT1DS) is a rare, genetically determined neurological disorder, for which Ketogenic Diet (KD) represents the gold standard life-long treatment. The aim of this study is to investigate health related quality of life in a well characterized cohort of patients affected by GLUT1DS treated with KD, evaluating factors that can influence patients' and parents' quality of life perception. METHODS This is a double center exploratory research study. A postal survey with auto-administrable questionnaires was conducted among 17 subjects (aged 3-22 years) with diagnosis of GLUT1DS, receiving a stable KD treatment for more than 1 year. The Pediatric Quality of Life Inventory (PedsQL) 4.0 Generic Core Scales was adopted. Clinical variables analyzed in relation to quality of life were frequency of epileptic seizures and movement disorder since KD introduction, presence of intellectual disability (ID), and KD ratio. RESULTS Quality of life global scores were impaired both in parents' and children's perspectives, with a significant concordance. Taking into consideration subscales, the average was 64.17 (range 10-100) for physical functioning, 74.23 (range 30-100) for emotional functioning, 62.64 (range 10-100) for social functioning, and 56 (range 15-92) for school functioning. CONCLUSIONS In patients with GLUT1DS the quality of life perception is comparable to that of other patients with chronic disease. In our sample, the presence of movement disorder seems to be a crucial element in quality of life perception.
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27
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The ketogenic diet in children 3 years of age or younger: a 10-year single-center experience. Sci Rep 2019; 9:8736. [PMID: 31217425 PMCID: PMC6584655 DOI: 10.1038/s41598-019-45147-6] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Accepted: 06/03/2019] [Indexed: 01/31/2023] Open
Abstract
The ketogenic diet (KD) is an effective treatment option for intractable epilepsy. Here, we reviewed the last 10 years of our experience with the KD and characterized its use in patients under 3 years of age. Medical records of all patients under the age of 3 years who were treated with the ketogenic diet from April 2004 to June 2014 were retrospectively reviewed. One hundred and nine patients with drug-resistant epilepsy were included. The mean age at the initiation of the KD was 1.4 ± 0.8 years old. The youngest patient was 3 weeks old. After 3 months, 39% (42/109) of patients responded to the KD and experienced more than 50% seizure reduction. Of those 42 patients, 20 (18%) achieved complete seizure control. Patients with a genetic etiology showed a better response to the KD in seizure reduction than the other patients (p = 0.03). Age at initiation of the KD was not related to eventual seizure outcome (p = 0.6). The KD continues to be an effective, safe, and well tolerated treatment option for infants with intractable epilepsy.
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28
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Bekker YAC, Lambrechts DA, Verhoeven JS, van Boxtel J, Troost C, Kamsteeg EJ, Willemsen MA, Braakman HMH. Failure of ketogenic diet therapy in GLUT1 deficiency syndrome. Eur J Paediatr Neurol 2019; 23:404-409. [PMID: 30885501 DOI: 10.1016/j.ejpn.2019.02.012] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Revised: 02/20/2019] [Accepted: 02/24/2019] [Indexed: 11/16/2022]
Abstract
PURPOSE Epilepsy in GLUT1 deficiency syndrome is generally drug-resistant; ketogenic diet (KD) therapy is the mainstay of therapy, as production of ketones provides the brain with an alternative energy source, bypassing the defect in GLUT1. Failure of KD therapy and risk factors for failure have been sparsely published. METHODS We performed a retrospective study of GLUT1DS patients with refractory epilepsy failing on KD therapy, to identify their clinical characteristics. RESULTS Failure of the ketogenic diet was due to KD inefficacy (poor effect despite adequate ketosis), as well as intolerance and an inability to attain ketosis. Our cohort of seven patients in whom KD therapy failed stood out for their advanced age at seizure onset, i.e. almost 4 years vs 8 months in large series, female sex, as well as their advanced age at diagnosis and initiation of KD therapy. EEG recordings during KD therapy can aid in the assessment of effectiveness of the KD therapy. CONCLUSIONS GLUT1DS is generally described as a treatable disorder and existing case series do not provide details of treatment failure. In select patients with GLUT1DS, KD therapy fails, rendering GLUT1DS an essentially untreatable disorder. Failure of the ketogenic diet was due to KD inefficacy (poor effect despite adequate ketosis), as well as intolerance and an inability to attain ketosis. Failure to reduce seizure frequency with deterioration of the EEG findings should lead to consideration of cessation of KD therapy.
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Affiliation(s)
- Yvonne A C Bekker
- Department of Pediatric Neurology, Amalia Children's Hospital, Radboud University Medical Center & Donders Institute for Brain, Cognition and Behaviour, Nijmegen, the Netherlands
| | - Danielle A Lambrechts
- Department of Neurology, Academic Center for Epileptology, Kempenhaeghe and Maastricht University Medical Centre, Heeze, the Netherlands
| | - Judith S Verhoeven
- Department of Neurology, Academic Center for Epileptology, Kempenhaeghe and Maastricht University Medical Centre, Heeze, the Netherlands
| | - Jessy van Boxtel
- Department of Dietetics, Academic Center for Epileptology, Kempenhaeghe and Maastricht University Medical Centre, Heeze, the Netherlands
| | - Caroline Troost
- Department of Dietetics, Academic Center for Epileptology, Kempenhaeghe and Maastricht University Medical Centre, Heeze, the Netherlands
| | - Erik-Jan Kamsteeg
- Department of Human Genetics, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Michèl A Willemsen
- Department of Pediatric Neurology, Amalia Children's Hospital, Radboud University Medical Center & Donders Institute for Brain, Cognition and Behaviour, Nijmegen, the Netherlands
| | - Hilde M H Braakman
- Department of Neurology, Academic Center for Epileptology, Kempenhaeghe and Maastricht University Medical Centre, Heeze, the Netherlands.
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29
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De Giorgis V, Masnada S, Varesio C, Chiappedi MA, Zanaboni M, Pasca L, Filippini M, Macasaet JA, Valente M, Ferraris C, Tagliabue A, Veggiotti P. Overall cognitive profiles in patients with GLUT1 Deficiency Syndrome. Brain Behav 2019; 9:e01224. [PMID: 30714351 PMCID: PMC6422708 DOI: 10.1002/brb3.1224] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Revised: 11/13/2018] [Accepted: 12/05/2018] [Indexed: 01/09/2023] Open
Abstract
INTRODUCTION Glucose Transporter Type I Deficiency Syndrome (GLUT1DS) classical symptoms are seizures, involuntary movements, and cognitive impairment but so far the literature has not devoted much attention to the last. METHODS In our retrospective study involving 25 patients with established GLUT1DS diagnosis, we describe the cognitive impairment of these patients in detail and their response to the ketogenic diet in terms of cognitive improvement. RESULTS We outlined a specific cognitive profile where performance skills were more affected than verbal ones, with prominent deficiencies in visuospatial and visuomotor abilities. We demonstrated the efficacy of ketogenic diet (KD) on cognitive outcome, with particular improvement tin total and verbal IQ; we found that timing of KD introduction was inversely related to IQ outcome: the later the starting of KD, the lower the IQ, more notable nonverbal scale (verbal IQ correlation coefficient -0.634, p-value = 0.015). We found a significant direct correlation between cognition and CSF/blood glucose ratio values: the higher the ratio, the better the cognitive improvement in response to diet (from T0-baseline evaluation to T1 on average 18 months after introduction of KD-: TIQ correlation coefficient 0.592, p-value = 0.26; VIQ correlation coefficient 0.555, p-value = 0.039). Finally, we demonstrated that a longer duration of treatment is necessary to find an improvement in patients with "severely low ratio." CONCLUSION Our results were consistent with the hypothesis that timing of the diet introduction is a predictive factor of cognitive outcome in these patients, confirming that earlier initiation of the diet may prevent the onset of all GLUT1DS symptoms: epilepsy, movement disorders, and cognitive impairment.
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Affiliation(s)
- Valentina De Giorgis
- Department of Child Neurology and Psychiatry, IRCCS Mondino Foundation, Pavia, Italy
| | - Silvia Masnada
- Department of Child Neurology and Psychiatry, IRCCS Mondino Foundation, Pavia, Italy.,Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
| | - Costanza Varesio
- Department of Child Neurology and Psychiatry, IRCCS Mondino Foundation, Pavia, Italy.,Brain and Behavior Department, University of Pavia, Pavia, Italy
| | - Matteo A Chiappedi
- Department of Child Neurology and Psychiatry, IRCCS Mondino Foundation, Pavia, Italy
| | - Martina Zanaboni
- Department of Child Neurology and Psychiatry, IRCCS Mondino Foundation, Pavia, Italy
| | - Ludovica Pasca
- Department of Child Neurology and Psychiatry, IRCCS Mondino Foundation, Pavia, Italy.,Brain and Behavior Department, University of Pavia, Pavia, Italy
| | - Melissa Filippini
- Child Neurology Unit, IRCCS Istituto delle Scienze Neurologiche, Bologna, Italy
| | - Joyce A Macasaet
- Department of Neurosciences, Makati Medical Center, Manila, Philippines
| | - Marialuisa Valente
- Genomic and post-Genomic Center, IRCCS ''C. Mondino'' National Neurological Institute, Pavia, Italy
| | - Cinzia Ferraris
- Human Nutrition and Eating Disorder Research Center, Department of Public Health, Experimental and Forensic Medicine University of Pavia, Pavia, Italy
| | - Anna Tagliabue
- Human Nutrition and Eating Disorder Research Center, Department of Public Health, Experimental and Forensic Medicine University of Pavia, Pavia, Italy
| | - Pierangelo Veggiotti
- Pediatric Neurology Unit, "V. Buzzi" Hospital, Milan, Italy.,Biomedical and Clinical Sciences Department, L Sacco, University of Milan, Milan, Italy
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30
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Abstract
Epilepsy was among the first disease areas to begin to apply principles of precision medicine to its treatment. This review looks at the role of investigation in ensuring the safety and effectiveness of antiepileptic drug treatment. Using sound principles, we can see that the use of genetic testing will advance treatment of epilepsy in reducing harm and adverse effects and enhancing efficacy.
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Affiliation(s)
- John Paul Leach
- University of Glasgow, Wolfson Medical School Building, Glasgow, Lanarkshire, G12 8QQ, UK
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31
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Abstract
Paroxysmal dyskinesias (PD) are hyperkinetic movement disorders where patients usually retain consciousness. Paroxysmal dyskinesias can be kinesigenic (PKD), nonkinesigenic (PNKD), and exercise induced (PED). These are usually differentiated from each other based on their phenotypic and genotypic characteristics. Genetic causes of PD are continuing to be discovered. Genes found to be involved in the pathogenesis of PD include MR-1, PRRT2, SLC2A1, and KCNMA1. The differential diagnosis is broad as PDs can mimic psychogenic events, seizure, or other movement disorders. This review also includes secondary causes of PDs, which can range from infections, metabolic, structural malformations to malignancies. Treatment is usually based on the correct identification of type of PD. PKD responds well to antiepileptic medications, whereas PNKD and PED respond to avoidance of triggers and exercise, respectively. In this article, we review the classification, clinical features, genetics, differential diagnosis, and management of PD.
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Affiliation(s)
- Sara McGuire
- Department of Pediatrics, Section of Neurology, St. Christopher's Hospital for Children, Drexel University College of Medicine, Philadelphia, PA
| | - Swati Chanchani
- Department of Pediatrics, Section of Neurology, St. Christopher's Hospital for Children, Drexel University College of Medicine, Philadelphia, PA
| | - Divya S Khurana
- Department of Pediatrics, Section of Neurology, St. Christopher's Hospital for Children, Drexel University College of Medicine, Philadelphia, PA.
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32
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Williams TJ, Cervenka MC. The role for ketogenic diets in epilepsy and status epilepticus in adults. Clin Neurophysiol Pract 2017; 2:154-160. [PMID: 30214989 PMCID: PMC6123874 DOI: 10.1016/j.cnp.2017.06.001] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Revised: 05/19/2017] [Accepted: 06/02/2017] [Indexed: 01/01/2023] Open
Abstract
Ketogenic diets offer adjunctive therapy for chronic epilepsy and refractory status epilepticus. Studies support feasibility and efficacy of the classic ketogenic diet and its variants in adults. Potential complications and side effects of diet therapy are often preventable and manageable. Strategies are needed to improve diet adherence.
Ketogenic diet (KD) therapies are high fat, low carbohydrate diets designed to mimic a fasting state. Although studies demonstrate KD’s success in reducing seizures stretching back nearly a century, the last 25 years have seen a resurgence in diet therapy for the management of drug-resistant epilepsy in children as well as adults. With ≥50% seizure reduction efficacy rates in adults of 22–55% for the classic KD and 12–67% for the modified Atkins diet, diet therapy may be in many instances comparable to a trial of an additional anti-epileptic medication and potentially with fewer side effects and other health benefits. Moreover, ketogenic diets offer promising new adjunctive strategies for the treatment of acute status epilepticus in the intensive care setting. Here, we review the efficacy and utility of ketogenic diets for the management of chronic epilepsy and refractory status epilepticus in adults and offer practical guidelines for diet implementation and maintenance.
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Affiliation(s)
- Tanya J Williams
- Department of Neurology, Johns Hopkins University School of Medicine, 600 North Wolfe Street, Meyer 2-147, Baltimore, MD, USA
| | - Mackenzie C Cervenka
- Department of Neurology, Johns Hopkins University School of Medicine, 600 North Wolfe Street, Meyer 2-147, Baltimore, MD, USA
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33
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Pucciarelli V, Bertoli S, Codari M, De Amicis R, De Giorgis V, Battezzati A, Veggiotti P, Sforza C. The face of Glut1-DS patients. Clin Anat 2017; 30:644-652. [DOI: 10.1002/ca.22890] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Accepted: 04/21/2017] [Indexed: 12/12/2022]
Affiliation(s)
- Valentina Pucciarelli
- LAFAS, Laboratorio di Anatomia Funzionale dell'Apparato Stomatognatico, Dipartimento di Scienze Biomediche per la Salute, Università degli Studi di Milano; Italy
| | - Simona Bertoli
- Dipartimento di Scienze per gli Alimenti; la Nutrizione e l'Ambiente, Università degli Studi di Milano; Milano Italy
| | - Marina Codari
- Unit of Radiology, IRCCS Policlinico San Donato; San Donato Milanese Milan Italy
| | - Ramona De Amicis
- Dipartimento di Scienze per gli Alimenti; la Nutrizione e l'Ambiente, Università degli Studi di Milano; Milano Italy
| | - Valentina De Giorgis
- Department of Child Neurology and Psychiatry; C. Mondino National Neurological Institute; Pavia Italy
| | - Alberto Battezzati
- Dipartimento di Scienze per gli Alimenti; la Nutrizione e l'Ambiente, Università degli Studi di Milano; Milano Italy
| | - Pierangelo Veggiotti
- Department of Child Neurology and Psychiatry; C. Mondino National Neurological Institute; Pavia Italy
- Brain and Behaviour Department; University of Pavia; Italy
| | - Chiarella Sforza
- LAFAS, Laboratorio di Anatomia Funzionale dell'Apparato Stomatognatico, Dipartimento di Scienze Biomediche per la Salute, Università degli Studi di Milano; Italy
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34
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Ramm-Pettersen A, Nakken KO, Haavardsholm KC, Selmer KK. GLUT1-deficiency syndrome: Report of a four-generation Norwegian family with a mild phenotype. Epilepsy Behav 2017; 70:1-4. [PMID: 28407523 DOI: 10.1016/j.yebeh.2017.02.016] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2016] [Revised: 02/07/2017] [Accepted: 02/09/2017] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Glucose transporter type 1 deficiency syndrome (GLUT1-DS) is a rare metabolic encephalopathy with a wide variation of clinical phenotypes. Familial variants are often milder than de novo cases, and may therefore remain undiagnosed. The aim of this study was to characterize the clinical course of GLUT1-DS in a four-generation Norwegian family where the oldest generations had never received any treatment. METHOD Through interviews and clinical investigations, we characterized a family of 26 members, where 11 members had symptoms strongly suggesting GLUT1-DS. All members were offered genetic testing of the SLC2A1 gene. Affected members were offered treatment with ketogenic diet, and the effect of the treatment was registered. RESULTS We sequenced the SLC2A1 gene in 13 members, and found that 10, all with symptoms, had the c.823G>A (p.Ala275Thr) variant. All affected members had experienced early-onset epilepsy, paroxysmal exercise-induced dyskinesias, and most had mild learning disability. Moreover, some had symptoms and signs of a distal neuropathy in addition to reduced sense of orientation and excessive daytime sleep. Their load of symptoms had decreased over the years, although that they never had received any treatment. Nevertheless, those who started dietary treatment all experienced an improved quality of life. CONCLUSION We report a four-generation family with GLUT1-DS where the disease has a mild course, even when untreated. In addition to classical GLUT1-DS features, we also describe symptoms which have never been reported in GLUT1-DS previously. As such, this family extends the phenotypic spectrum of GLUT1-DS and underlines the importance of diagnosing also relatively mildly affected patients, even in adult life, as they also seem to benefit from dietary treatment.
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Affiliation(s)
| | - Karl O Nakken
- National Center for Epilepsy, Oslo University Hospital, Norway
| | - Kathrine C Haavardsholm
- National Center for Epilepsy, Oslo University Hospital, Norway; National Center for Rare Epilepsy-Related Disorders, Oslo University Hospital, Norway
| | - Kaja Kristine Selmer
- Department of Medical Genetics, University of Oslo and Oslo University Hospital, Norway; National Center for Rare Epilepsy-Related Disorders, Oslo University Hospital, Norway
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Mei D, Parrini E, Marini C, Guerrini R. The Impact of Next-Generation Sequencing on the Diagnosis and Treatment of Epilepsy in Paediatric Patients. Mol Diagn Ther 2017; 21:357-373. [DOI: 10.1007/s40291-017-0257-0] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Abstract
OPINION STATEMENT The mainstay of treatment of epilepsy has been antiepileptic drugs; however, despite the emergence of new agents, a consistent proportion remain drug-resistant. Newer AEDs show promise. However, as it becomes clear that the epilepsies are a group of diseases rather than a single disorder the prospect of targeted treatment in some may become a reality.
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Affiliation(s)
- Katharina Vezyroglou
- Great Ormond Street Hospital for Children NHS Trust, Great Ormond Street, London, WC1N 3JH, UK
| | - J Helen Cross
- Clinical Neurosciences, 30 Guilford St, London, WC1N 1EH, UK. .,Great Ormond Street Hospital for Children NHS Trust, Great Ormond Street, London, WC1N 3JH, UK.
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Branco AF, Ferreira A, Simões RF, Magalhães-Novais S, Zehowski C, Cope E, Silva AM, Pereira D, Sardão VA, Cunha-Oliveira T. Ketogenic diets: from cancer to mitochondrial diseases and beyond. Eur J Clin Invest 2016; 46:285-98. [PMID: 26782788 DOI: 10.1111/eci.12591] [Citation(s) in RCA: 95] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2015] [Accepted: 01/12/2016] [Indexed: 12/13/2022]
Abstract
BACKGROUND The employment of dietary strategies such as ketogenic diets, which force cells to alter their energy source, has shown efficacy in the treatment of several diseases. Ketogenic diets are composed of high fat, moderate protein and low carbohydrates, which favour mitochondrial respiration rather than glycolysis for energy metabolism. DESIGN This review focuses on how oncological, neurological and mitochondrial disorders have been targeted by ketogenic diets, their metabolic effects, and the possible mechanisms of action on mitochondrial energy homeostasis. The beneficial and adverse effects of the ketogenic diets are also highlighted. RESULTS AND CONCLUSIONS Although the full mechanism by which ketogenic diets improve oncological and neurological conditions still remains to be elucidated, their clinical efficacy has attracted many new followers, and ketogenic diets can be a good option as a co-adjuvant therapy, depending on the situation and the extent of the disease.
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Affiliation(s)
- Ana F Branco
- CNC - Center for Neuroscience and Cell Biology, University of Coimbra, Coimbra, Portugal
| | - André Ferreira
- CNC - Center for Neuroscience and Cell Biology, University of Coimbra, Coimbra, Portugal
| | - Rui F Simões
- CNC - Center for Neuroscience and Cell Biology, University of Coimbra, Coimbra, Portugal
| | | | - Cheryl Zehowski
- Department of Biomedical Sciences, University of Minnesota Medical School, Duluth, MN, USA
| | - Elisabeth Cope
- Department of Applied Medical Sciences, University of Southern Maine, Portland, ME, USA
| | - Ana Marta Silva
- CNC - Center for Neuroscience and Cell Biology, University of Coimbra, Coimbra, Portugal
| | - Daniela Pereira
- CNC - Center for Neuroscience and Cell Biology, University of Coimbra, Coimbra, Portugal
| | - Vilma A Sardão
- CNC - Center for Neuroscience and Cell Biology, University of Coimbra, Coimbra, Portugal
| | - Teresa Cunha-Oliveira
- CNC - Center for Neuroscience and Cell Biology, University of Coimbra, Coimbra, Portugal
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38
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Use of dietary therapies amongst patients with GLUT1 deficiency syndrome. Seizure 2016; 35:83-7. [PMID: 26803281 DOI: 10.1016/j.seizure.2016.01.011] [Citation(s) in RCA: 72] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Revised: 01/07/2016] [Accepted: 01/07/2016] [Indexed: 01/01/2023] Open
Abstract
PURPOSE GLUT-1 deficiency syndrome (GLUT1DS) is a neurologic disorder manifesting as epilepsy, abnormal movements, and cognitive delay. The currently accepted treatment of choice is the classic 4:1 ratio ketogenic diet. METHODS A 2-page survey was distributed to all attendees of a family-centered conference for GLUT1DS in July 2015. The surveys were completed by parents, collected anonymously, and information analyzed in a database. RESULTS Surveys were received from 92 families, of which 90 (98%) had been treated with dietary therapies. Diets used were extremely varied: 59 were treated with the classic ketogenic diet (KD), 29 with the Modified Atkins Diet (MAD), 4 with the Medium-chain Triglyceride (MCT) Diet and 2 with the low glycemic index treatment. The mean diet duration was 5.5 years (range: 1 month-20 years). Of those with seizures, 95% of the children had >50% seizure reduction and 80% had >90% seizure reduction. Children who were seizure-free were currently younger on average (8.2 vs. 11.6 years, p=0.01) and slightly younger at GLUT1DS diagnosis (3.8 vs. 5.3 years, p=0.05). There was an equal percentage of children seizure-free receiving the KD/MCT Diets compared to the MAD/Low Glycemic Index Treatment (74% vs. 63%, p=0.30). The majority (64%) were not receiving anticonvulsants. CONCLUSION This represents the largest series of KD experience in children with GLUT1DS. Nearly all patients surveyed were on dietary therapies for long durations with reported excellent seizure control, often without anticonvulsant drugs. Several different ketogenic diets were utilized with similar efficacy. Early diagnosis and treatment were correlated with success.
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39
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The Therapeutic Potential of the Ketogenic Diet in Treating Progressive Multiple Sclerosis. Mult Scler Int 2015; 2015:681289. [PMID: 26839705 PMCID: PMC4709725 DOI: 10.1155/2015/681289] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2015] [Accepted: 12/02/2015] [Indexed: 01/04/2023] Open
Abstract
Until recently, multiple sclerosis has been viewed as an entirely inflammatory disease without acknowledgment of the significant neurodegenerative component responsible for disease progression and disability. This perspective is being challenged by observations of a dissociation between inflammation and neurodegeneration where the neurodegenerative component may play a more significant role in disease progression. In this review, we explore the relationship between mitochondrial dysfunction and neurodegeneration in multiple sclerosis. We review evidence that the ketogenic diet can improve mitochondrial function and discuss the potential of the ketogenic diet in treating progressive multiple sclerosis for which no treatment currently exists.
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Schoeler NE, Cross JH, Drury S, Lench N, McMahon JM, MacKay MT, Scheffer IE, Sander JW, Sisodiya SM. Favourable response to ketogenic dietary therapies: undiagnosed glucose 1 transporter deficiency syndrome is only one factor. Dev Med Child Neurol 2015; 57:969-76. [PMID: 25914049 DOI: 10.1111/dmcn.12781] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/16/2015] [Indexed: 12/23/2022]
Abstract
AIM We aimed to determine whether response to ketogenic dietary therapies (KDT) was due to undiagnosed glucose transporter type 1 deficiency syndrome (GLUT1-DS). METHOD Targeted resequencing of the SLC2A1 gene was completed in individuals without previously known GLUT1-DS who received KDT for their epilepsy. Hospital records were used to obtain demographic and clinical data. Response to KDT at various follow-up points was defined as seizure reduction of at least 50%. Seizure freedom achieved at any follow-up point was also documented. Fisher's exact and gene-burden association tests were conducted using the PLINK/SEQ open-source genetics library. RESULTS Of the 246 participants, one was shown to have a novel variant in SLC2A1 that was predicted to be deleterious. This individual was seizure-free on KDT. Rates of seizure freedom in cases without GLUT1-DS were below 8% at each follow-up point. Two cases without SLC2A1 mutations were seizure-free at every follow-up point recorded. No significant results were obtained from Fisher's exact or gene-burden association tests. INTERPRETATION A favourable response to KDT is not solely explained by mutations in SLC2A1. Other genetic factors should be sought to identify those who are most likely to benefit from dietary treatment for epilepsy, particularly those who may achieve seizure freedom.
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Affiliation(s)
- Natasha E Schoeler
- NIHR University College London Hospitals Biomedical Research Centre, UCL Institute of Neurology, London, UK.,UCL Institute of Child Health, London, UK
| | - Judith Helen Cross
- UCL Institute of Child Health, London, UK.,Young Epilepsy, Lingfield, UK.,Great Ormond Street Hospital for Children, London, UK
| | - Suzanne Drury
- NE Thames Regional Genetics Service, Great Ormond Street Hospital for Children, London, UK
| | - Nicholas Lench
- NE Thames Regional Genetics Service, Great Ormond Street Hospital for Children, London, UK.,Congenica Ltd, Cambridge, UK
| | - Jacinta M McMahon
- Epilepsy Research Centre, The University of Melbourne, Austin Health, Melbourne, Vic., Australia
| | - Mark T MacKay
- Royal Children's Hospital, Melbourne, Vic., Australia.,Murdoch Children's Research Institute, Melbourne, Vic., Australia
| | - Ingrid E Scheffer
- Royal Children's Hospital, Melbourne, Vic., Australia.,Departments of Medicine and Paediatrics, The University of Melbourne, Austin Health, Melbourne, Vic., Australia
| | - Josemir W Sander
- NIHR University College London Hospitals Biomedical Research Centre, UCL Institute of Neurology, London, UK.,Sichting Epilepsie Instellingen Nederland (SEIN), Heemstede, the Netherlands.,Epilepsy Society, Chalfont, St. Peter, UK
| | - Sanjay M Sisodiya
- NIHR University College London Hospitals Biomedical Research Centre, UCL Institute of Neurology, London, UK.,Epilepsy Society, Chalfont, St. Peter, UK
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Abstract
OPINION STATEMENT Paroxysmal dyskinesia represents a group of uncommon movement disorders that are characterized by episodes of abnormal movements arising from a baseline of normal or nearly normal movement. Recent advances in the genetics of these disorders have helped provide some unification of classification schemes and better understanding. However, the approach to treatment continues to be based on the phenotype more than the genotype. The treatment approach is primarily based on the factors that precipitate the episodes of abnormal movements. For paroxysmal kinesigenic dyskinesia (PKD) in which the spells are triggered by sudden movement, treatment with anticonvulsants that target voltage-sensitive sodium channels (e.g., carbamazepine or phenytoin) is highly effective. For paroxysmal nonkinesigenic dyskinesia (PNKD), treatment with benzodiazepines is effective in many patients. PNKD episodes are often precipitated by caffeine, ethanol, or sleep deprivation, and lifestyle modifications are often helpful. Paroxysmal exertion-induced dyskinesia (PED) is less likely to respond to medications, but the ketogenic diet or modified Atkins diet may provide benefit. As more knowledge is gained about the underlying biology of these disorders, additional treatments may emerge.
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Bertoli S, Neri IG, Trentani C, Ferraris C, De Amicis R, Battezzati A, Veggiotti P, De Giorgis V, Tagliabue A. Short-term effects of ketogenic diet on anthropometric parameters, body fat distribution, and inflammatory cytokine production in GLUT1 deficiency syndrome. Nutrition 2015; 31:981-7. [PMID: 26059372 DOI: 10.1016/j.nut.2015.02.017] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2014] [Revised: 01/25/2015] [Accepted: 02/24/2015] [Indexed: 01/08/2023]
Abstract
OBJECTIVE The aim of this study was to evaluate the effects of a 12-wk ketogenic diet (KD) on inflammatory status, adipose tissue activity biomarkers, and abdominal visceral (VAT) and subcutaneous fat (SAT) in children affected by glucose transporter 1 deficiency syndrome GLUT1 DS. METHODS We carried out a short-term longitudinal study on 10 children (mean age: 8.4 y, range 3.3-12 y, 5 girls, 5 boys) to determine fasting serum proinflammatory cytokines (high sensitivity C-reactive protein, tumor necrosis factor-α interleukin-6), adipocyte-derived chemokines (leptin and adiponectin), lipid profile, homeostatic model assessment-insulin resistance (HOMA-IR), quantitative insulin sensitivity index (QUICKI), anthropometric measurements, and VAT and SAT (by ultrasonography). RESULTS Children showed no significant changes in inflammatory and adipose tissue activity biomarkers, blood glucose, lipid profile, anthropometric measurements, VAT, and SAT. Fasting insulin decreased (6 ± 3.2 μU/mL versus 3 ± 2 μU/mL; P = 0.001), and both HOMA-IR and QUICKI indexes were significantly modified (1.2 ± 0.6 versus 0.6 ± 0.4; P = 0.002; 0.38 ± 0.03 versus 0.44 ± 0.05; P = 0.002, respectively). CONCLUSIONS Only HOMA-IR and QUICKI indexes changed after 12 wk on a KD, suggesting that over a short period of time KD does not affect inflammatory cytokines production and abdominal fat distribution despite being a high-fat diet. Long-term studies are needed to provide answers concerning adaptive metabolic changes during KD.
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Affiliation(s)
- Simona Bertoli
- International Center for the Assessment of Nutritional Status (ICANS), Department of Food Environmental and Nutritional Sciences (DeFENS), University of Milan, Milan, Italy.
| | - Ilaria Giulini Neri
- International Center for the Assessment of Nutritional Status (ICANS), Department of Food Environmental and Nutritional Sciences (DeFENS), University of Milan, Milan, Italy
| | - Claudia Trentani
- Human Nutrition and Eating Disorder Research Center, Department of Public, Health, Experimental and Forensic Medicine University of Pavia, Pavia, Italy
| | - Cinzia Ferraris
- Human Nutrition and Eating Disorder Research Center, Department of Public, Health, Experimental and Forensic Medicine University of Pavia, Pavia, Italy
| | - Ramona De Amicis
- International Center for the Assessment of Nutritional Status (ICANS), Department of Food Environmental and Nutritional Sciences (DeFENS), University of Milan, Milan, Italy
| | - Alberto Battezzati
- International Center for the Assessment of Nutritional Status (ICANS), Department of Food Environmental and Nutritional Sciences (DeFENS), University of Milan, Milan, Italy
| | - Pierangelo Veggiotti
- Department of Child Neurology and Psychiatry C. Mondino National, Neurological Institute, Via Mondino, Pavia, Italy; Brain and Behaviour Department, University of Pavia, Pavia, Italy
| | | | - Anna Tagliabue
- Human Nutrition and Eating Disorder Research Center, Department of Public, Health, Experimental and Forensic Medicine University of Pavia, Pavia, Italy
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Ramirez-Zamora A, Zeigler W, Desai N, Biller J. Treatable causes of cerebellar ataxia. Mov Disord 2015; 30:614-23. [PMID: 25757427 DOI: 10.1002/mds.26158] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2014] [Revised: 12/09/2014] [Accepted: 12/29/2014] [Indexed: 12/21/2022] Open
Abstract
The cerebellar ataxia syndromes are a heterogeneous group of disorders clinically characterized by the presence of cerebellar dysfunction. Initial assessment of patients with progressive cerebellar ataxia is complex because of an extensive list of potential diagnoses. A detailed history and comprehensive examination are required for an accurate diagnosis and hierarchical diagnostic investigations. Although no cure exists for most of these conditions, a small group of metabolic, hereditary, inflammatory, and immune-mediated etiologies of cerebellar ataxia are amenable to disease-modifying, targeted therapies. Over the past years, disease-specific treatments have emerged. Thus, clinicians must become familiar with these disorders because maximal therapeutic benefit is only possible when done early. In this article, we review disorders in which cerebellar ataxia is a prominent clinical feature requiring targeted treatments along with specific management recommendations.
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Ramm-Pettersen A, Stabell KE, Nakken KO, Selmer KK. Does ketogenic diet improve cognitive function in patients with GLUT1-DS? A 6- to 17-month follow-up study. Epilepsy Behav 2014; 39:111-5. [PMID: 25240122 DOI: 10.1016/j.yebeh.2014.08.015] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2014] [Revised: 08/05/2014] [Accepted: 08/07/2014] [Indexed: 11/17/2022]
Abstract
The aim of this study was to investigate the effects of ketogenic diet (KD) on cognitive function in patients with glucose transporter protein 1 deficiency syndrome (GLUT1-DS). Six patients with GLUT1-DS who were referred to the National Centre for Epilepsy in Norway during the period of November 2011-September 2013 were included. They were diagnosed with GLUT1-DS on the basis of early-onset seizures and developmental delay (with or without movement disorders or microcephaly) in addition to CSF-to-blood glucose ratio below 0.5. They were all treated with either classical KD or modified Atkins diet (MAD). The effect of the diet with >90% reduction in the seizure frequency was, in retrospect, considered as a support for the diagnosis. The patients underwent standardized neuropsychological assessment before the diet was initiated, and they were reassessed after a minimum of six months on the diet. The neuropsychological tests were individually selected for each patient in order to match their cognitive level. The main finding was a considerable improvement in several aspects of neuropsychological functioning after 6-17 months of dietary treatment in all the six patients. The greatest progress was seen in the youngest children. Our findings suggest that early diagnosis and dietary treatment are important in order to prevent developmental delay. However, also adults with GLUT1-DS may profit from dietary treatment by improving alertness, setting the stage for enhanced learning capacity, as well as physical endurance and quality of life.
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Affiliation(s)
| | | | - Karl O Nakken
- Department of Refractory Epilepsy-SSE, Oslo University Hospital, Norway
| | - Kaja Kristine Selmer
- Department of Medical Genetics, Oslo University Hospital and University of Oslo, Norway; National Centre for Rare Epilepsy-related Disorders, Oslo University Hospital, Norway
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Erro R, Sheerin UM, Bhatia KP. Paroxysmal dyskinesias revisited: a review of 500 genetically proven cases and a new classification. Mov Disord 2014; 29:1108-16. [PMID: 24963779 DOI: 10.1002/mds.25933] [Citation(s) in RCA: 137] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2013] [Revised: 04/30/2014] [Accepted: 05/13/2014] [Indexed: 12/31/2022] Open
Abstract
Paroxysmal movement disorders are a heterogeneous group of conditions manifesting as episodic dyskinesia with sudden onset and lasting a variable duration. Based on the difference of precipitating factors, three forms are clearly recognized, namely, paroxysmal kinesigenic (PKD), non-kinesigenic (PNKD), and exercise induced (PED). The elucidation of the genetic cause of various forms of paroxysmal dyskinesia has led to better clinical definitions based on genotype-phenotype correlations in the familial forms. However, it has been increasingly recognized that (1) there is a marked pleiotropy of mutations in such genes with still expanding clinical spectra; and (2) not all patients clinically presenting with either PKD, PNKD, or PED have mutations in these genes. We aimed to review the clinical features of 500 genetically proven cases published to date. Based on our results, it is clear that there is not a complete phenotypic-genotypic correlation, and therefore we suggest an algorithm to lead the genetic analyses. Given the fact that the reliability of current clinical categorization is not entirely valid, we further propose a novel classification for paroxysmal dyskinesias, which takes into account the recent genetic discoveries in this field.
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Affiliation(s)
- Roberto Erro
- Sobell Department of Motor Neuroscience and Movement Disorders, University College London, Institute of Neurology, London, United Kingdom
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Veggiotti P, De Giorgis V. Dietary Treatments and New Therapeutic Perspective in GLUT1 Deficiency Syndrome. Curr Treat Options Neurol 2014; 16:291. [PMID: 24634059 DOI: 10.1007/s11940-014-0291-8] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OPINION STATEMENT GLUT1 deficiency syndrome (GLUT1DS) results from impaired glucose transport into the brain: awareness of its wide phenotypic spectrum is a prerequisite in order to ensure an early diagnosis, treating the patients is the subsequent challenge to allow prompt compensation for the brain's lack of fuel. The ketogenic diet (KD) plays a primary role in the treatment of GLUT1DS because it provides ketone bodies as an alternative source to meet the demands of energy of the brain. Therefore, we recommend early initiation of the KD based on the assumption that early diagnosis and treatment improves the long term neurological outcome: the classic KD (4:1 or 3:1) at the present time is the most proven and effective in GLUT1DS. A KD should be continued at least until adolescence, although there are reports of good tolerability even in adulthood, possibly with a less rigorous ratio; in our experience seizure and movement disorder control can be achieved by a 2:1 ketogenic ratio but the relationship between ketosis and neurodevelopmental outcome remains undetermined. Other types of KDs can, therefore, be considered. The Modified Atkins diet, for example, is also well tolerated and provides effective symptom control; furthermore, this diet has the advantage of being easy to prepare and more palatable, which are important requirements for good compliance. Nevertheless, about 20 % of these patients have compliance trouble or the same diet loses its effectiveness over time; for these reasons, new therapeutic strategies are currently under investigation but further studies on pathophysiological mechanisms and potential effects of novel "diets" or "therapies" are needed for this new pathology.
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Affiliation(s)
- Pierangelo Veggiotti
- Department of Child Neurology and Psychiatry C. Mondino National Neurological Institute, Via Mondino, 2, 27100, Pavia, Italy,
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Occurrence of GLUT1 deficiency syndrome in patients treated with ketogenic diet. Epilepsy Behav 2014; 32:76-8. [PMID: 24508593 DOI: 10.1016/j.yebeh.2014.01.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2013] [Revised: 01/10/2014] [Accepted: 01/12/2014] [Indexed: 11/23/2022]
Abstract
Glucose transporter 1 deficiency syndrome (GLUT1-DS) is a treatable metabolic encephalopathy caused by a mutation in the SLC2A1 gene. This mutation causes a compromised transport of glucose across the blood-brain barrier. The treatment of choice is ketogenic diet, with which most patients become seizure-free. At the National Centre for Epilepsy, we have, since 2005, offered treatment with ketogenic diet (KD) and modified Atkins diet (MAD) to children with difficult-to-treat epilepsy. As we believe many children with GLUT1-DS are unrecognized, the aim of this study was to search for patients with GLUT1-DS among those who had been responders (>50% reduction in seizure frequency) to KD or MAD. Of the 130 children included, 58 (44%) were defined as responders. Among these, 11 were already diagnosed with GLUT1-DS. No mutations in the SLC2A1 gene were detected in the remaining patients. However, the clinical features of these patients differed considerably from the patients diagnosed with GLUT1-DS. While 9 out of 10 patients with GLUT1-DS became seizure-free with dietary treatment, only 3 out of the 33 remaining patients were seizure-free with KD or MAD treatment. We therefore conclude that a seizure reduction of >50% following dietary treatment is not a suitable criterion for identifying patients with GLUT1-DS, as these patients generally achieve complete seizure freedom shortly after diet initiation.
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Leen WG, Taher M, Verbeek MM, Kamsteeg EJ, van de Warrenburg BP, Willemsen MA. GLUT1 deficiency syndrome into adulthood: a follow-up study. J Neurol 2014; 261:589-99. [PMID: 24413642 DOI: 10.1007/s00415-014-7240-z] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2013] [Revised: 12/30/2013] [Accepted: 01/01/2014] [Indexed: 10/25/2022]
Abstract
GLUT1 deficiency syndrome (GLUT1DS) is a treatable neurometabolic disorder in which glucose transport into the brain is disturbed. Besides the classic phenotype of intellectual disability, epilepsy, and movement disorders, other phenotypes are increasingly recognized. These include, for example, idiopathic generalized epilepsy and paroxysmal exercise-induced dyskinesia. Since the disorder has only been recognized for two decades and is mostly diagnosed in children, little is known about the disease course. Our purpose was to investigate the disease course of GLUT1DS patients with the classic, complex phenotype from infancy into adulthood. We performed a systematic literature review as well as a cohort study, including GLUT1DS patients aged 18 years and older. The literature search yielded a total of 91 adult GLUT1DS patients, of which 33 patients (one-third) had a complex phenotype. The cohort study included seven GLUT1DS patients with a complex phenotype who were prospectively followed up in our clinic from childhood into adulthood. Our results show that epilepsy is a prominent feature during childhood in classic GLUT1DS patients. During adolescence, however, epilepsy diminishes or even disappears, but new paroxysmal movement disorders, especially paroxysmal exercise-induced dyskinesia, either appear or worsen if already present in childhood. Intellectual disability was not systematically assessed, but cognitive functions appeared to be stabile throughout life. Like children, adolescents may benefit from a ketogenic diet or variants thereof.
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Affiliation(s)
- W G Leen
- Department of Neurology, Radboud University Medical Centre, Donders Institute for Brain, Cognition and Behaviour, 935 Neurology, PO BOX 9101, 6500 HB, Nijmegen, The Netherlands,
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Kossoff EH, Cervenka MC, Henry BJ, Haney CA, Turner Z. A decade of the modified Atkins diet (2003–2013): Results, insights, and future directions. Epilepsy Behav 2013; 29:437-42. [PMID: 24386671 DOI: 10.1016/j.yebeh.2013.09.032] [Citation(s) in RCA: 96] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The modified Atkins diet has been used since 2003 for the treatment of children and adults with refractory epilepsy.This “alternative” ketogenic diet is started in clinic, without fasting, hospitalization, and restriction of protein,calories, or fluid intake. Now after 10 years of continued use, approximately 400 patients have been reported in over 30 studies of the modified Atkins diet as treatment for intractable seizures, with results demonstrating similar efficacy to the ketogenic diet and improved tolerability. The modified Atkins diet is being increasingly used in the adult population. Clinical trials have provided insight into the mechanisms of action of dietary therapies overall. This review will discuss the past decade of experience with the modified Atkins diet as well as predictions for its role in the treatment of epilepsy a decade from now.
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GLUT1 deficiency syndrome: an update. Rev Neurol (Paris) 2013; 170:91-9. [PMID: 24269118 DOI: 10.1016/j.neurol.2013.09.005] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2013] [Revised: 08/01/2013] [Accepted: 09/02/2013] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Glucose transporter type 1 deficiency syndrome is caused by heterozygous, mostly de novo, mutations in the SLC2A1 gene encoding the glucose transporter GLUT1. Mutations in this gene limit brain glucose availability and lead to cerebral energy deficiency. STATE OF THE ART The phenotype is characterized by the variable association of mental retardation, acquired microcephaly, complex motor disorders, and paroxysmal manifestations including seizures and non-epileptic paroxysmal episodes. Clinical severity varies from mild motor dysfunction to severe neurological disability. In patients with mild phenotypes, paroxysmal manifestations may be the sole manifestations of the disease. In particular, the diagnosis should be considered in patients with paroxysmal exercise-induced dyskinesia or with early-onset generalized epilepsy. Low CSF level of glucose, relative to blood level, is the best biochemical clue to the diagnosis although not constantly found. Molecular analysis of the SLC2A1 gene confirms the diagnosis. Ketogenic diet is the cornerstone of the treatment and implicates a close monitoring by a multidisciplinary team including trained dieticians. Non-specific drugs may be used as add-on symptomatic treatments but their effects are often disappointing. CONCLUSION Glucose transporter type 1 deficiency syndrome is likely under diagnosed due to its complex and pleiotropic phenotype. Proper identification of the affected patients is important for clinical practice since the disease is treatable.
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