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Champsas D, Zhang X, Rosch R, Ioannidou E, Gilmour K, Cooray G, Woodhall G, Pujar S, Kaliakatsos M, Wright SK. NORSE/FIRES: how can we advance our understanding of this devastating condition? Front Neurol 2024; 15:1426051. [PMID: 39175762 PMCID: PMC11338801 DOI: 10.3389/fneur.2024.1426051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2024] [Accepted: 07/29/2024] [Indexed: 08/24/2024] Open
Abstract
Introduction New onset refractory status epilepticus (NORSE) is a rare and devastating condition characterised by the sudden onset of refractory status epilepticus (RSE) without an identifiable acute or active structural, toxic, or metabolic cause in an individual without a pre-existing diagnosis of epilepsy. Febrile infection-related epilepsy syndrome (FIRES) is considered a subcategory of NORSE and presents following a febrile illness prior to seizure onset. NORSE/FIRES is associated with high morbidity and mortality in children and adults. Methods and results In this review we first briefly summarise the reported clinical, paraclinical, treatment and outcome data in the literature. We then report on existing knowledge of the underlying pathophysiology in relation to in vitro and in vivo pre-clinical seizure and epilepsy models of potential relevance to NORSE/FIRES. Discussion We highlight how pre-clinical models can enhance our understanding of FIRES/NORSE and propose future directions for research.
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Affiliation(s)
- Dimitrios Champsas
- Department of Neurology, Great Ormond Street Hospital (GOSH), London, United Kingdom
- Institute of Health and Neurodevelopment, School of Health and Life Sciences, Aston University, Birmingham, United Kingdom
| | - Xushuo Zhang
- Institute of Health and Neurodevelopment, School of Health and Life Sciences, Aston University, Birmingham, United Kingdom
| | - Richard Rosch
- Department of Clinical Neurophysiology, King’s College Hospital London NHS Foundation Trust, London, United Kingdom
- Departments of Neurology and Pediatrics, Columbia University, New York, NY, United States
| | - Evangelia Ioannidou
- Department of Neurology, Great Ormond Street Hospital (GOSH), London, United Kingdom
| | - Kimberly Gilmour
- Department of Immunology, Great Ormond Street Hospital (GOSH), London, United Kingdom
- Biomedical Research Centre (BRC), London, United Kingdom
- Institute of Child Health, University College London, London, United Kingdom
| | - Gerald Cooray
- Department of Neurophysiology, Great Ormond Street Hospital (GOSH), London, United Kingdom
- Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Gavin Woodhall
- Institute of Health and Neurodevelopment, School of Health and Life Sciences, Aston University, Birmingham, United Kingdom
| | - Suresh Pujar
- Department of Neurology, Great Ormond Street Hospital (GOSH), London, United Kingdom
- Institute of Child Health, University College London, London, United Kingdom
| | - Marios Kaliakatsos
- Department of Neurology, Great Ormond Street Hospital (GOSH), London, United Kingdom
- Institute of Child Health, University College London, London, United Kingdom
| | - Sukhvir K. Wright
- Institute of Health and Neurodevelopment, School of Health and Life Sciences, Aston University, Birmingham, United Kingdom
- Birmingham Women’s and Children’s Hospital NHS Trust, Birmingham, United Kingdom
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Lee S, Kim SH, Kim HD, Lee JS, Ko A, Kang HC. Identification of etiologies according to baseline clinical features of pediatric new-onset refractory status epilepticus in single center retrospective study. Seizure 2024; 120:49-55. [PMID: 38908141 DOI: 10.1016/j.seizure.2024.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Revised: 06/09/2024] [Accepted: 06/10/2024] [Indexed: 06/24/2024] Open
Abstract
PURPOSE New-onset refractory status epilepticus (NORSE) is defined as a state of prolonged seizure activity that does not improve despite the appropriate administration of medications, with underlying causes unknown after the initial diagnosis of status epilepticus. Because episodes of NORSE are accompanied by severe complications and a high risk of mortality, the prompt identification of the underlying cause is crucial for effective treatment and outcome prediction. This study assessed the relationship of NORSE etiologies with baseline clinical features in pediatric population. METHODS Seventy-one pediatric patients, under 18 years of age at the initial diagnosis (4.50 ± 4.04, mean ± standard deviation), who experienced at least one episode of NORSE and underwent a comprehensive diagnostic evaluation between January 2005 and June 2020 at our center, were retrospectively selected. We reviewed clinical features at disease onset and long-term follow-up data. Uniform manifold approximation and projection (UMAP) was used to distinguish etiological clusters according to baseline clinical characteristics, and further analysis was performed based on underlying etiologies. RESULTS Two distinct etiological groups-genetic and non-genetic-were identified based on the UMAP of clinical characteristics. Dravet syndrome (12/15, 80%) was more predominant in patients with a genetic diagnosis, whereas cryptogenic NORSE and encephalitis were prevalent in patients without a genetic diagnosis. The analysis of etiological categories revealed that age at the onset of status epilepticus (P=0.021) and progression to super refractory status epilepticus (SRSE) (P=0.038) were independently associated with differences in etiologies. CONCLUSION Several clinical features in patients with NORSE, including the age of onset and the development of SRSE, can help identify underlying causes, which necessitate prompt and adequate treatment.
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Affiliation(s)
- Sangbo Lee
- Division of Pediatric Neurology, Epilepsy Research Institute, Severance Hospital, Department of Pediatrics, Yonsei University College of Medicine, Yonsei-ro 50-1, Seodaemun-gu, Seoul 03722, South Korea.
| | - Se Hee Kim
- Division of Pediatric Neurology, Epilepsy Research Institute, Severance Hospital, Department of Pediatrics, Yonsei University College of Medicine, Yonsei-ro 50-1, Seodaemun-gu, Seoul 03722, South Korea.
| | - Heung Dong Kim
- Division of Pediatric Neurology, Epilepsy Research Institute, Severance Hospital, Department of Pediatrics, Yonsei University College of Medicine, Yonsei-ro 50-1, Seodaemun-gu, Seoul 03722, South Korea.
| | - Joon Soo Lee
- Division of Pediatric Neurology, Epilepsy Research Institute, Severance Hospital, Department of Pediatrics, Yonsei University College of Medicine, Yonsei-ro 50-1, Seodaemun-gu, Seoul 03722, South Korea.
| | - Ara Ko
- Division of Pediatric Neurology, Epilepsy Research Institute, Severance Hospital, Department of Pediatrics, Yonsei University College of Medicine, Yonsei-ro 50-1, Seodaemun-gu, Seoul 03722, South Korea.
| | - Hoon-Chul Kang
- Division of Pediatric Neurology, Epilepsy Research Institute, Severance Hospital, Department of Pediatrics, Yonsei University College of Medicine, Yonsei-ro 50-1, Seodaemun-gu, Seoul 03722, South Korea.
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Giovannini G, Giannoccaro MP, Cioclu MC, Orlandi N, Liguori R, Meletti S. FADD gene pathogenic variants causing recurrent febrile infection-related epilepsy syndrome: Case report and literature review. Epilepsia 2024; 65:e119-e124. [PMID: 38752438 DOI: 10.1111/epi.18008] [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: 12/19/2023] [Revised: 04/26/2024] [Accepted: 04/26/2024] [Indexed: 07/17/2024]
Abstract
FIRES and NORSE are clinical presentations of disease processes that, to date, remain unexplained without an established etiology in many cases. Neuroinflammation is thought to have paramount importance in the genesis of these conditions. We hereby report the clinical, EEG, brain MRI, and genetic findings of a nuclear family with recurrent febrile-related encephalopathy with refractory de novo Status Epilepticus. Whole-exome sequencing (WES) revealed a homozygous p.C105W pathogenic variant of FADD gene (FAS-associated protein with death domain, FADD), known to cause ultrarare forms of autosomal recessive immunodeficiency that could be associated with variable degrees of lymphoproliferation, cerebral atrophy, and cardiac abnormalities. The FADD-related conditions disrupt FAS-mediated apoptosis and can cause a clinical picture with the characteristics of FIRES. This observation is important because, on one hand, it increases the number of reported patients with FADD deficiency, showing that this disorder may present variable expressivity, and on the other hand, it demonstrates a genetic cause of FIRES involving a cell-mediated inflammation regulatory pathway. This finding supports early treatment with immunomodulatory therapy and could represent a new avenue of research in the field of new onset refractory status epilepticus and related conditions.
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Affiliation(s)
- Giada Giovannini
- Neurology Unit, OCB Hospital, Azienda Ospedaliera-Universitaria, Modena, Italy
- Department of Biomedical, Metabolic, and Neural Science, University of Modena and Reggio Emilia, Modena, Italy
- Clinical and Experimental Medicine, University of Modena and Reggio Emilia, Modena, Italy
| | - Maria Pia Giannoccaro
- IRCCS Istituto Delle Scienze Neurologiche di Bologna, Bologna, Italy
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
| | - Maria Cristina Cioclu
- Neurology Unit, OCB Hospital, Azienda Ospedaliera-Universitaria, Modena, Italy
- Department of Biomedical, Metabolic, and Neural Science, University of Modena and Reggio Emilia, Modena, Italy
| | - Niccolò Orlandi
- Neurology Unit, OCB Hospital, Azienda Ospedaliera-Universitaria, Modena, Italy
- Clinical and Experimental Medicine, University of Modena and Reggio Emilia, Modena, Italy
| | - Rocco Liguori
- IRCCS Istituto Delle Scienze Neurologiche di Bologna, Bologna, Italy
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
| | - Stefano Meletti
- Neurology Unit, OCB Hospital, Azienda Ospedaliera-Universitaria, Modena, Italy
- Department of Biomedical, Metabolic, and Neural Science, University of Modena and Reggio Emilia, Modena, Italy
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Costello DJ, Matthews E, Aurangzeb S, Doran E, Stack J, Wesselingh R, Dugan P, Choi H, Depondt C, Devinsky O, Doherty C, Kwan P, Monif M, O'Brien TJ, Sen A, Gaspard N. Clinical outcomes among initial survivors of cryptogenic new-onset refractory status epilepsy (NORSE). Epilepsia 2024; 65:1581-1588. [PMID: 38498313 DOI: 10.1111/epi.17950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2023] [Revised: 02/05/2024] [Accepted: 03/04/2024] [Indexed: 03/20/2024]
Abstract
OBJECTIVE New-onset refractory status epilepticus (NORSE) is a rare but severe clinical syndrome. Despite rigorous evaluation, the underlying cause is unknown in 30%-50% of patients and treatment strategies are largely empirical. The aim of this study was to describe clinical outcomes in a cohort of well-phenotyped, thoroughly investigated patients who survived the initial phase of cryptogenic NORSE managed in specialist centers. METHODS Well-characterized cases of cryptogenic NORSE were identified through the EPIGEN and Critical Care EEG Monitoring Research Consortia (CCEMRC) during the period 2005-2019. Treating epileptologists reported on post-NORSE survival rates and sequelae in patients after discharge from hospital. Among survivors >6 months post-discharge, we report the rates and severity of active epilepsy, global disability, vocational, and global cognitive and mental health outcomes. We attempt to identify determinants of outcome. RESULTS Among 48 patients who survived the acute phase of NORSE to the point of discharge from hospital, 9 had died at last follow-up, of whom 7 died within 6 months of discharge from the tertiary care center. The remaining 39 patients had high rates of active epilepsy as well as vocational, cognitive, and psychiatric comorbidities. The epilepsy was usually multifocal and typically drug resistant. Only a minority of patients had a good functional outcome. Therapeutic interventions were heterogenous during the acute phase of the illness. There was no clear relationship between the nature of treatment and clinical outcomes. SIGNIFICANCE Among survivors of cryptogenic NORSE, longer-term outcomes in most patients were life altering and often catastrophic. Treatment remains empirical and variable. There is a pressing need to understand the etiology of cryptogenic NORSE and to develop tailored treatment strategies.
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Affiliation(s)
- Daniel J Costello
- Epilepsy service, Department of Neurology, Cork University Hospital & College of Medicine and Health, University College Cork, Cork, Ireland
- The SFI Futureneuro Research Centre, Royal College of Surgeons in Ireland, Dublin, Ireland
| | | | - Sidra Aurangzeb
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Elisabeth Doran
- Academic Unit of Neurology, School of Medicine, Trinity College Dublin
| | - Jessica Stack
- Epilepsy service, Department of Neurology, Cork University Hospital & College of Medicine and Health, University College Cork, Cork, Ireland
| | - Robb Wesselingh
- Department of Neuroscience, The Central Clinical School, Alfred Health, Monash University, Melbourne, Australia
| | - Patricia Dugan
- New York University Langone Health Comprehensive Epilepsy Center, New York, New York, USA
| | - Hyunmi Choi
- Department of Neurology, Hôpital Universitaire de Bruxelles, Université Libre de Bruxelles, Brussels, Belgium
| | - Chantal Depondt
- Department of Neurology, Hôpital Universitaire de Bruxelles, Université Libre de Bruxelles, Brussels, Belgium
| | - Orrin Devinsky
- New York University Langone Health Comprehensive Epilepsy Center, New York, New York, USA
| | - Colin Doherty
- The SFI Futureneuro Research Centre, Royal College of Surgeons in Ireland, Dublin, Ireland
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Patrick Kwan
- Department of Neuroscience, The Central Clinical School, Alfred Health, Monash University, Melbourne, Australia
| | - Mastura Monif
- Department of Neuroscience, The Central Clinical School, Alfred Health, Monash University, Melbourne, Australia
| | - Terence J O'Brien
- Department of Neuroscience, The Central Clinical School, Alfred Health, Monash University, Melbourne, Australia
| | - Arjune Sen
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Nicolas Gaspard
- Department of Neurology, Erasme Hospital, Route de Lennik, Brussels, Belgium
- Department of Neurology, Yale University Medical School, New Haven, Connecticut, USA
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Bolle AE, Gaist T, Kuljis AME, Blaabjerg M, Beier CP. NORSE seasonality may vary geographically in adults. Epilepsia Open 2024; 9:1088-1095. [PMID: 38635008 PMCID: PMC11145602 DOI: 10.1002/epi4.12944] [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: 12/13/2023] [Revised: 04/02/2024] [Accepted: 04/03/2024] [Indexed: 04/19/2024] Open
Abstract
The mechanisms causing new onset refractory status epilepticus (NORSE) are often unknown. Recently, a seasonal variation with NORSE peaking during the summer was described in a mixed cohort of adults and children why we here studied the seasonal variation in a Danish status epilepticus (SE) cohort. This retrospective cohort study comprised SE patients aged ≥18 diagnosed and treated 2008-2017 at the Odense University Hospital. Clinical characteristics and seasonality of patients fulfilling the diagnostic criteria for NORSE were compared with patients with refractory SE (RSE) due to other reasons and with the seasonal variation of autoantibodies associated with autoimmune encephalitis in the Danish autoimmune encephalitis register. In this cohort, 26 patients met NORSE criteria. As compared to RSE patients not fulfilling NORSE criteria (n = 152), NORSE patients were more likely to have symptoms of systemic inflammation (C-reactive protein concentrations ≥10 mg/L or fever ≥38°C) at admission; nine fulfilled the criteria for febrile infection related epilepsy syndrome (FIRES). In contrast to the even seasonal distribution of patients with RSE not fulfilling the NORSE criteria, admissions due to NORSE peaked during the winter (46.1%, p = 0.04 as compared to non-NORSE RSE); six out of nine FIRES episodes occurred in the winter season. The seasonal variation was not explained by a seasonal variation of the detection rates of autoantibodies associated with autoimmune encephalitis (incl. NMDAR, LGI1, CASPR2, GABAR, GFAP) in a Danish nationwide register (n = 259). In conclusion, we confirm the seasonality of NORSE in a Danish cohort, however, with a peak during winter suggesting a geographical variation not solely explained by autoimmune encephalitis associated with known autoantibodies. PLAIN LANGUAGE SUMMARY: The study investigated the seasonal patterns of new-onset refractory status epilepticus (NORSE), i.e. severe seizures that occur without an obvious cause and require very intensive treatment. In contrast to the previously observed peak frequency in summer, this Danish study found that NORSE cases peak in winter. Furthermore, the seasonal variation in NORSE cases was not found to be associated with autoimmune encephalitis caused by known autoantibodies. Together with the high rate of patients showing symptoms of systemic inflammation compared to other status epilepticus patients, the data suggest a link between misdirected immune system responses and NORSE. The study can therefore help in the further search for the currently unknown causes of NORSE.
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Affiliation(s)
- Andrea Enerstad Bolle
- Department of NeurologyOdense University HospitalOdenseDenmark
- BRIDGE – Brain Research Inter Disciplinary Guided ExcellenceOdense University HospitalOdenseDenmark
| | - Thomas Gaist
- Department of NeurologyOdense University HospitalOdenseDenmark
| | | | - Morten Blaabjerg
- Department of NeurologyOdense University HospitalOdenseDenmark
- BRIDGE – Brain Research Inter Disciplinary Guided ExcellenceOdense University HospitalOdenseDenmark
- Department of Clinical ResearchUniversity of Southern DenmarkOdenseDenmark
| | - Christoph Patrick Beier
- Department of NeurologyOdense University HospitalOdenseDenmark
- BRIDGE – Brain Research Inter Disciplinary Guided ExcellenceOdense University HospitalOdenseDenmark
- Department of Clinical ResearchUniversity of Southern DenmarkOdenseDenmark
- OPEN, Open Patient Data Explorative NetworkOdense University HospitalOdenseDenmark
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Benghanem S, Pruvost-Robieux E, Neligan A, Walker MC. Status epilepticus: what's new for the intensivist. Curr Opin Crit Care 2024; 30:131-141. [PMID: 38441162 DOI: 10.1097/mcc.0000000000001137] [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: 03/12/2024]
Abstract
PURPOSE OF REVIEW Status epilepticus (SE) is a common neurologic emergency affecting about 36.1/100 000 person-years that frequently requires intensive care unit (ICU) admission. There have been advances in our understanding of epidemiology, pathophysiology, and EEG monitoring of SE, and there have been large-scale treatment trials, discussed in this review. RECENT FINDINGS Recent changes in the definitions of SE have helped guide management protocols and we have much better predictors of outcome. Observational studies have confirmed the efficacy of benzodiazepines and large treatment trials indicate that all routinely used second line treatments (i.e., levetiracetam, valproate and fosphenytoin) are equally effective. Better understanding of the pathophysiology has indicated that nonanti-seizure medications aimed at underlying pathological processes should perhaps be considered in the treatment of SE; already immunosuppressant treatments are being more widely used in particular for new onset refractory status epilepticus (NORSE) and Febrile infection-related epilepsy syndrome (FIRES) that sometimes revealed autoimmune or paraneoplastic encephalitis. Growing evidence for ICU EEG monitoring and major advances in automated analysis of the EEG could help intensivist to assess the control of electrographic seizures. SUMMARY Research into the morbi-mortality of SE has highlighted the potential devastating effects of this condition, emphasizing the need for rapid and aggressive treatment, with particular attention to cardiorespiratory and neurological complications. Although we now have a good evidence-base for the initial status epilepticus management, the best treatments for the later stages are still unclear and clinical trials of potentially disease-modifying therapies are long overdue.
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Affiliation(s)
- Sarah Benghanem
- Medical Intensive Care Unit, Cochin hospital, APHP.Centre
- University of Paris cite - Medical School
- INSERM 1266, psychiatry and neurosciences institute of Paris (IPNP)
| | - Estelle Pruvost-Robieux
- University of Paris cite - Medical School
- INSERM 1266, psychiatry and neurosciences institute of Paris (IPNP)
- Neurophysiology and epileptology department, Sainte Anne hospital, Paris, France
| | - Aidan Neligan
- Homerton University Hospital NHS Foundation Trust, Homerton Row
- UCL Queen Square Institute of Neurology, Queen Square, London
- Centre for Preventive Neurology, Wolfson Institute of Population Health, QMUL, UK
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Alaskar AM, Aljohani MA, Dionisio S, Asiry MA, Alqadi K. Time to FIRE NORSE: A single acronym for a heterogeneous presentation. Further information from a case series and discussion of the literature. J Neuroimmunol 2024; 388:578298. [PMID: 38330780 DOI: 10.1016/j.jneuroim.2024.578298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2023] [Revised: 01/12/2024] [Accepted: 01/25/2024] [Indexed: 02/10/2024]
Abstract
PURPOSE New-Onset Refractory Status Epilepticus (NORSE) is a rare and severe form of refractory status epilepticus without an apparent underlying cause at presentation or prior history of epilepsy. We aimed to describe the clinical features, etiology, treatment, and outcomes of NORSE in adults in a quaternary-level hospital in Saudi Arabia. METHODOLOGY In this retrospective cohort study, inclusion criteria involved patients over 14 years old who met the 2018 consensus definition for NORSE. Patients were identified using a combination of medical record admission labels 'status epilepticus' and 'encephalitis', and continuous EEG reports documenting status epilepticus. Demographic, clinical, and radiological data were collected and then analyzed for factors correlated with specific etiologies, better functional outcomes, and future diagnosis of epilepsy. RESULTS We found 24 patients presenting with NORSE between 2010 and 2021. Fever/infectious symptoms were the most common prodrome. Elevated inflammatory serum and cerebrospinal fluid markers in most patients. Brain MRI revealed T2/FLAIR hyperintensity patterns, predominantly affecting limbic and perisylvian structures. The etiology of NORSE varied, with immune-related causes being the most common. Long-term outcomes were poor, with a high mortality rate and most survivors developing drug-resistant epilepsy. CONCLUSION This study provides valuable insights into NORSE's clinical characteristics, highlighting the heterogeneity of this condition. The poor outcome is likely related to the progressive nature of the underlying disease, where refractory seizures are a clinical symptom. Thus, we propose to focus future research on the etiology rather than the NORSE acronym.
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Affiliation(s)
| | - Majed A Aljohani
- King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia
| | - Sasha Dionisio
- King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia; Alfaisal University, Riyadh, Saudi Arabia; University of Queensland, Brisbane, Australia
| | - Mohammed A Asiry
- King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia
| | - Khalid Alqadi
- King Salman Ibn Abdulaziz Medical City, Madinah, Saudi Arabia.
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Ruttkowski L, Wallot I, Korell M, Daur E, Seipelt P, Leonhardt A, Weber S, Mand N. Case report: Febrile infection-related epilepsy syndrome in a 14-year-old girl with multiple organ failure and lethal outcome. Front Neurosci 2024; 18:1255841. [PMID: 38505775 PMCID: PMC10948546 DOI: 10.3389/fnins.2024.1255841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Accepted: 02/07/2024] [Indexed: 03/21/2024] Open
Abstract
We report a case of an otherwise healthy 14-year-old girl with febrile infection-related epilepsy syndrome (FIRES), multiple organ failure (MOF), and ultimately a lethal outcome. This is a rare case of FIRES with MOF and consecutive death. Only a few cases have been described in the literature. The adolescent girl was initially admitted to our pediatric emergency department with a first episode of generalized tonic-clonic seizures after a short history of fever a week before admission. Seizures progressed rapidly into refractory status epilepticus without any evidence of the underlying cause, and treatment subsequently had to be escalated to thiopental anesthesia. Since the initial diagnostics showed no promising leads, the rare syndrome of FIRES was suspected, representing a catastrophic epileptic encephalopathy linked to a prior benign febrile infection. Methylprednisolone, intravenous immunoglobulins, and a ketogenic diet were initiated. Respiratory, circulatory, kidney, and liver failure developed during treatment, requiring increasing intensive care. Multiple attempts to deescalate antiepileptic treatment resulted in recurrent status epilepticus. A cranial MRI on the 10th day of treatment revealed diffuse brain edema and no cerebral perfusion. The patient was declared dead on the 11th day of treatment. FIRES should be taken into account in previously healthy children with a new onset of difficult-to-treat seizures after a short febrile infection when no other cause is apparent. First-line treatment, besides seizure control, is the early initiation of immunomodulatory therapy and the start of a ketogenic diet. As treatment is difficult and MOF may develop, patients should be transferred to a specialized children's hospital providing full intensive care.
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Affiliation(s)
- Lars Ruttkowski
- Pediatric Intensive Care, Department of Pediatrics, Philipps-University Marburg, Marburg, Germany
| | - Ines Wallot
- Pediatric Neurology, Department of Pediatrics, Philipps-University Marburg, Marburg, Germany
| | - Marie Korell
- Pediatric Intensive Care, Department of Pediatrics, Philipps-University Marburg, Marburg, Germany
| | - Elke Daur
- Pediatric Intensive Care, Department of Pediatrics, Philipps-University Marburg, Marburg, Germany
| | - Peter Seipelt
- Pediatric Neurology, Department of Pediatrics, Philipps-University Marburg, Marburg, Germany
| | - Andreas Leonhardt
- Pediatric Intensive Care, Department of Pediatrics, Philipps-University Marburg, Marburg, Germany
| | - Stefanie Weber
- Pediatric Nephrology, Department of Pediatrics, Philipps-University Marburg, Marburg, Germany
| | - Nadine Mand
- Pediatric Intensive Care, Department of Pediatrics, Philipps-University Marburg, Marburg, Germany
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9
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Carson R, Stredny CM. Severe, Refractory Seizures: New-Onset Refractory Status Epilepticus and Febrile Infection-Related Epilepsy Syndrome. Med Clin North Am 2024; 108:201-213. [PMID: 37951651 DOI: 10.1016/j.mcna.2023.05.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2023]
Abstract
NORSE (new-onset refractory status epilepticus) and FIRES (febrile infection-related epilepsy syndrome) represent presentations of new-onset status epilepticus without apparent underlying structural, metabolic, or toxic etiology. The cause of NORSE/FIRES remains cryptogenic in up to half of cases, and an abnormal response of the innate immune system has been implicated. Consensus guidelines recommend broad diagnostic investigation and empiric treatment with immunotherapy. NORSE/FIRES is associated with poor outcomes including cognitive impairment and epilepsy, but early recognition and treatment may be important for improving outcomes.
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Affiliation(s)
- Ross Carson
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Coral M Stredny
- Division of Epilepsy and Clinical Neurophysiology, Program in Neuroimmunology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA.
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Brigo F, Zelano J, Abraira L, Bentes C, Ekdahl CT, Lattanzi S, Ingvar Lossius M, Redfors P, Rouhl RPW, Russo E, Sander JW, Vogrig A, Wickström R. Proceedings of the "International Congress on Structural Epilepsy & Symptomatic Seizures" (STESS, Gothenburg, Sweden, 29-31 March 2023). Epilepsy Behav 2024; 150:109538. [PMID: 38039602 DOI: 10.1016/j.yebeh.2023.109538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Revised: 11/09/2023] [Accepted: 11/09/2023] [Indexed: 12/03/2023]
Affiliation(s)
- Francesco Brigo
- Innovation, Research and Teaching Service (SABES-ASDAA), Teaching Hospital of the Paracelsus Medical Private University (PMU), Bolzano, Italy.
| | - Johan Zelano
- Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden; Institute of Neuroscience and Physiology, Department of Clinical Neuroscience, Sahlgrenska Academy, Gothenburg University, Sweden; Wallenberg Center of Molecular and Translational Medicine, Gothenburg University, Sweden
| | - Laura Abraira
- Neurology Department, Epilepsy Unit, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain; Epilepsy Unit, Neurology Department, Vall d'Hebron University Hospital, Barcelona, Spain; Epilepsy Research Group, Vall d'Hebron Institut de Recerca (VHIR), Barcelona, Spain
| | - Carla Bentes
- Neurophysiological Monitoring Unit - EEG/Sleep Laboratory, Refractory Epilepsy Reference Centre (member of EpiCARE), Centro Hospitalar Universitário Lisboa Norte, Lisbon, Portugal; Centro de Estudos Egas Moniz, Faculty of Medicine, Lisbon University, Lisbon, Portugal
| | - Christine T Ekdahl
- Division of Clinical Neurophysiology and Department of Clinical Sciences, Lund University, Sweden; Lund Epilepsy Center, Department of Clinical Sciences, Lund University, Sweden
| | - Simona Lattanzi
- Neurological Clinic, Department of Experimental and Clinical Medicine, Marche Polytechnic University, Ancona, Italy
| | - Morten Ingvar Lossius
- National Centre for Epilepsy, Division of Clinical Neuroscience, Oslo University Hospital, Member of the ERN EpiCARE, Oslo, Norway; Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Petra Redfors
- Department of Neurology, Member of the ERN EpiCARE, Sahlgrenska University Hospital, Gothenburg, Sweden; Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Rob P W Rouhl
- Department of Neurology, Maastricht University Medical Centre+, Maastricht, The Netherlands; Academic Centre for Epileptology Kempenhaeghe/MUMC+ Heeze and Maastricht, The Netherlands; School for Mental Health and Neuroscience, Maastricht University, Maastricht, The Netherlands
| | - Emilio Russo
- Science of Health Department, University Magna Grecia of Catanzaro, Italy
| | - Josemir W Sander
- Department of Clinical & Experimental Epilepsy, UCL Queen Square Institute of Neurology, Queen Square, London, UK; Centre for Epilepsy, Chalfont St Peter, Bucks., SL9 0RJ, United Kingdom; Stichting Epilepsie Instellingen Nederland (SEIN), Heemstede 2103 SW, The Netherlands; Neurology Department, West of China Hospital, Sichuan University, Chengdu 610041, China
| | - Alberto Vogrig
- Department of Medicine (DAME), University of Udine, Udine, Italy; Clinical Neurology, Department of Head-Neck and Neuroscience, Azienda Sanitaria Universitaria Friuli Centrale (ASU FC), Udine, Italy
| | - Ronny Wickström
- Neuropediatric Unit, Karolinska University Hospital and Karolinska Institutet, Stockholm, Sweden
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Rossetti AO, Claassen J, Gaspard N. Status epilepticus in the ICU. Intensive Care Med 2024; 50:1-16. [PMID: 38117319 DOI: 10.1007/s00134-023-07263-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 10/26/2023] [Indexed: 12/21/2023]
Abstract
Status epilepticus (SE) is a common medical emergency associated with significant morbidity and mortality. Management that follows published guidelines is best suited to improve outcomes, with the most severe cases frequently being managed in the intensive care unit (ICU). Diagnosis of convulsive SE can be made without electroencephalography (EEG), but EEG is required to reliably diagnose nonconvulsive SE. Rapidly narrowing down underlying causes for SE is crucial, as this may guide additional management steps. Causes may range from underlying epilepsy to acute brain injuries such as trauma, cardiac arrest, stroke, and infections. Initial management consists of rapid administration of benzodiazepines and one of the following non-sedating intravenous antiseizure medications (ASM): (fos-)phenytoin, levetiracetam, or valproate; other ASM are increasingly used, such as lacosamide or brivaracetam. SE that continues despite these medications is called refractory, and most commonly treated with continuous infusions of midazolam or propofol. Alternatives include further non-sedating ASM and non-pharmacologic approaches. SE that reemerges after weaning or continues despite management with propofol or midazolam is labeled super-refractory SE. At this step, management may include non-sedating or sedating compounds including ketamine and barbiturates. Continuous video EEG is necessary for the management of refractory and super-refractory SE, as these are almost always nonconvulsive. If possible, management of the underlying cause of seizures is crucial particularly for patients with autoimmune encephalitis. Short-term mortality ranges from 10 to 15% after SE and is primarily related to increasing age, underlying etiology, and medical comorbidities. Refractoriness of treatment is clearly related to outcome with mortality rising from 10% in responsive cases, to 25% in refractory, and nearly 40% in super-refractory SE.
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Affiliation(s)
- Andrea O Rossetti
- Department of Neurology, Lausanne University Hospital (CHUV) and University of Lausanne, Lausanne, Switzerland
| | - Jan Claassen
- Department of Neurology, Columbia University Irving Medical Center, New York Presbyterian Hospital, New York, NY, USA
| | - Nicolas Gaspard
- Service de Neurologie, Hôpital Universitaire de Bruxelles, Hôpital Erasme, Université Libre de Bruxelles, Route de Lennik 808, 1070, Brussels, Belgium.
- Department of Neurology, Yale University School of Medicine, New Haven, CT, USA.
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12
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Nakada R, Terasawa Y, Sato T, Takatsu H, Kaito N, Iguchi Y. [A case of cryptogenic new-onset refractory status epilepticus (NORSE) in which cerebrospinal fluid IL-6 was elevated with increased seizure frequency early in the disease: a case report]. Rinsho Shinkeigaku 2023; 63:843-846. [PMID: 37989289 DOI: 10.5692/clinicalneurol.cn-001879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2023]
Abstract
A 25-year-old male presented with clonic seizures three days following a fever. The patient developed status epilepticus and required mechanical ventilation and intravenous anesthesia. The patient's epileptic seizures persisted despite administering intravenous anesthesia and multiple anti-epileptic drugs. The clinical presentation in this case, without pre-existing relevant neurological disorder and an active structural, toxic, or metabolic cause in the acute phase, was compatible with new-onset refractory status epilepticus (NORSE). After immunotherapy, including intravenous methylprednisolone, plasma exchange, and intravenous immunoglobulin therapy, the epileptic discharge on electroencephalogram (EEG) decreased gradually, and mechanical ventilation was discontinued. Neversless the final outcome was poor. The patient's condition was finally diagnosed as cryptogenic NORSE. The IL-6 levels in the cerebrospinal fluid showed a significant increase between day 6 and 11 after onset, during which time there was a rapid escalation in seizure frequency on EEG. Considering this, IL-6 may be involved in the process of seizure exacerbation.
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Affiliation(s)
- Ryoji Nakada
- Department of Neurology, The Jikei University School of Medicine
| | - Yuka Terasawa
- Department of Neurology, The Jikei University School of Medicine
| | - Takeo Sato
- Department of Neurology, The Jikei University School of Medicine
| | - Hiroki Takatsu
- Department of Neurology, The Jikei University School of Medicine
| | - Nobuyoshi Kaito
- Department of Neurosurgery, The Jikei University School of Medicine
| | - Yasuyuki Iguchi
- Department of Neurology, The Jikei University School of Medicine
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Mahama CN, Louisa M, Octaviana F, Suryandari DA, Budikayanti A, Wibowo H. Investigation of Correlation between Resistance to Diazepam and Expression of Inflammatory Markers in The Peripheral Blood of Patients with Status Epilepticus. Acta Med Acad 2023; 52:169-181. [PMID: 38407083 PMCID: PMC10945326 DOI: 10.5644/ama2006-124.423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 12/01/2023] [Indexed: 02/27/2024] Open
Abstract
OBJECTIVE This study investigated several inflammatory markers' gene and protein expression in status epilepticus (SE) and their correlation with diazepam resistance. MATERIALS AND METHODS Peripheral blood samples were collected from 18 adult patients with SE in Cipto Mangunkusumo Central Hospital, consisting of 12 diazepam-responsive and six diazepam-resistant samples, within 72 hours of the onset of the seizure. We collected baseline demographic and clinical data from each subject. Peripheral blood mononuclear cells (PBMCs) were isolated, cultured, stimulated with lipopolysaccharide (LPS) 1 mg/ml, and harvested for RNA isolation. The RNA was used to determine the expression of Human Mobility Group Box 1 (HMGB1), Interleukin- 6 (IL-6), IL-10, Toll-like Receptor 4 (TLR4), and Glial fibrillary acidic protein (GFAP). In addition, we performed serum protein assay of HMGB1, IL-6, IL-10, TLR4, and GFAP to compare with gene expression. RESULTS We found a significant difference between the responsive and resistant groups for serum HMGB1 and IL-6 concentration. The mRNA expression of HMGB1 and IL-6 was significantly higher in LPS-stimulated samples in the responsive but not in the resistant groups. The ratio of IL-6 to IL-10 showed a significant difference between LPS and control in the responsive group. Diazepam response was significantly correlated with seizure duration and serum protein concentration of HMGB1. CONCLUSION HMGB1 was highly expressed in the resistant group and strongly correlated with diazepam response, and there was a significant increase in HMGB1 mRNA expression in response to LPS stimulation. These findings suggest that targeting HMGB1 may be a promising therapeutic strategy and that HMGB1 levels could be a valuable biomarker for predicting diazepam resistance in SE.
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Affiliation(s)
- Corry Novita Mahama
- Doctoral Program in Biomedical Sciences, Faculty of Medicine Universitas Indonesia, Jakarta, Indonesia.
| | - Melva Louisa
- Department of Pharmacology and Therapeutics, Faculty of Medicine Universitas Indonesia, Jakarta, Indonesia
| | - Fitri Octaviana
- Department of Neurology, Cipto Mangunkusumo Central Hospital, Faculty of Medicine Universitas Indonesia, Jakarta, Indonesia
| | - Dwi Anita Suryandari
- Department of Medical Biology, Faculty of Medicine Universitas Indonesia, Jakarta, Indonesia
| | - Astri Budikayanti
- Department of Neurology, Cipto Mangunkusumo Central Hospital, Faculty of Medicine Universitas Indonesia, Jakarta, Indonesia
| | - Heri Wibowo
- Department of Parasitology, Faculty of Medicine Universitas Indonesia, Jakarta, Indonesia
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14
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Eisele A, Schwager M, Bögli SY, Reichen I, Dargvainiene J, Wandinger KP, Imbach L, Haeberlin M, Keller E, Jelcic I, Galovic M, Brandi G. The role of neuronal antibodies in cryptogenic new onset refractory status epilepticus. Epilepsia 2023; 64:e229-e236. [PMID: 37607299 DOI: 10.1111/epi.17755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 08/18/2023] [Accepted: 08/18/2023] [Indexed: 08/24/2023]
Abstract
Most cases with new onset refractory status epilepticus (NORSE) remain cryptogenic despite extensive diagnostic workup. The aim of this study was to analyze the etiology and clinical features of NORSE and investigate known or potentially novel autoantibodies in cryptogenic NORSE (cNORSE). We retrospectively assessed the medical records of adults with status epilepticus at a Swiss tertiary referral center between 2010 and 2021. Demographic, diagnostic, therapeutic, and outcome parameters were characterized. We performed post hoc screening for known or potentially novel autoantibodies including immunohistochemistry (IHC) on rat brain with cerebrospinal fluid (CSF) and serum samples of cNORSE. Twenty patients with NORSE were identified. Etiologies included infections (n = 4), Creutzfeldt-Jakob disease (n = 1), CASPR2 autoimmune encephalitis (n = 1), and carotid artery stenosis with recurrent perfusion deficit (n = 1). Thirteen cases (65%) were cryptogenic despite detailed evaluation. A posteriori IHC for neuronal autoantibodies yielded negative results in all available serum (n = 11) and CSF (n = 9) samples of cNORSE. Our results suggest that neuronal antibodies are unlikely to play a major role in the pathogenesis of cNORSE. Future studies should rather focus on other-especially T-cell- and cytokine-mediated-mechanisms of autoinflammation in this devastating disease, which is far too poorly understood so far.
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Affiliation(s)
- Amanda Eisele
- Department of Neurology and Clinical Neuroscience Center, University Hospital and University of Zurich, Zurich, Switzerland
| | - Matthias Schwager
- Institute for Intensive Care Medicine, University Hospital Zurich, Zurich, Switzerland
| | - Stefan Yu Bögli
- Department of Neurology and Clinical Neuroscience Center, University Hospital and University of Zurich, Zurich, Switzerland
| | - Ina Reichen
- Department of Neurology and Clinical Neuroscience Center, University Hospital and University of Zurich, Zurich, Switzerland
| | - Justina Dargvainiene
- Institute of Clinical Chemistry, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Klaus-Peter Wandinger
- Institute of Clinical Chemistry, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Lukas Imbach
- Swiss Epilepsy Center, Klinik Lengg, Zurich, Switzerland
| | - Marcellina Haeberlin
- Department of Neurology and Clinical Neuroscience Center, University Hospital and University of Zurich, Zurich, Switzerland
| | - Emanuela Keller
- Institute for Intensive Care Medicine, University Hospital Zurich, Zurich, Switzerland
- Department of Neurosurgery and Clinical Neuroscience Center, University Hospital and University of Zurich, Zurich, Switzerland
| | - Ilijas Jelcic
- Department of Neurology and Clinical Neuroscience Center, University Hospital and University of Zurich, Zurich, Switzerland
| | - Marian Galovic
- Department of Neurology and Clinical Neuroscience Center, University Hospital and University of Zurich, Zurich, Switzerland
| | - Giovanna Brandi
- Institute for Intensive Care Medicine, University Hospital Zurich, Zurich, Switzerland
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15
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Andzelm MM, Stredny CM. Mechanisms and Emerging Therapies for Treatment of Seizures in Pediatric Autoimmune Encephalitis and Autoinflammatory/Autoimmune-Associated Epilepsy. Rheum Dis Clin North Am 2023; 49:875-893. [PMID: 37821201 DOI: 10.1016/j.rdc.2023.06.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/13/2023]
Abstract
There has been increasing understanding of the role of inflammation in seizures and epilepsy, as well as targeted immunomodulatory treatments. In children, immune-mediated seizures often present acutely in the setting of autoimmune encephalitis and are very responsive to immunotherapy with low rates of subsequent epilepsy. Conversely, seizures in autoimmune-associated epilepsies, such as Rasmussen syndrome, can remain refractory to multimodal therapy, including immunomodulation. In this review, the authors discuss the presentations of immune-mediated seizures in children, underlying mechanisms, and emerging therapies.
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Affiliation(s)
- Milena M Andzelm
- Program in Neuroimmunology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Coral M Stredny
- Program in Neuroimmunology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA; Division of Epilepsy and Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA.
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16
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Thomschewski A, Giovannini G, Gaspard N, Steinbrenner M, Wickström R, Jacobs J. Editorial: Advances in diagnosing and treating new-onset refractory status epilepticus (NORSE). Front Neurol 2023; 14:1270702. [PMID: 37712084 PMCID: PMC10499399 DOI: 10.3389/fneur.2023.1270702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 08/03/2023] [Indexed: 09/16/2023] Open
Affiliation(s)
- Aljoscha Thomschewski
- Department of Neurology, Christian-Doppler University Hospital, Paracelsus Medical University, Salzburg, Austria
| | - Giada Giovannini
- Unitá di Neurologia, Azienda Ospedaliera Universitaria di Modena, Modena, Italy
| | - Nicolas Gaspard
- Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Mirja Steinbrenner
- Clinic for Neurology With Experimental Neurology, Charité University Medicine Berlin, Berlin, Germany
| | - Ronny Wickström
- Department of Women's and Children's Health, Karolinska Institutet, Solna, Sweden
| | - Julia Jacobs
- Alberta Children's Hospital, University of Calgary, Calgary, AB, Canada
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17
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deCampo D, Xian J, Karlin A, Sullivan KR, Ruggiero SM, Galer P, Ramos M, Abend NS, Gonzalez A, Helbig I. Investigating the genetic contribution in febrile infection-related epilepsy syndrome and refractory status epilepticus. Front Neurol 2023; 14:1161161. [PMID: 37077567 PMCID: PMC10106651 DOI: 10.3389/fneur.2023.1161161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Accepted: 03/10/2023] [Indexed: 04/05/2023] Open
Abstract
IntroductionFebrile infection-related epilepsy syndrome (FIRES) is a severe childhood epilepsy with refractory status epilepticus after a typically mild febrile infection. The etiology of FIRES is largely unknown, and outcomes in most individuals with FIRES are poor.MethodsHere, we reviewed the current state-of-the art genetic testing strategies in individuals with FIRES. We performed a systematic computational analysis to identify individuals with FIRES and characterize the clinical landscape using the Electronic Medical Records (EMR). Among 25 individuals with a confirmed FIRES diagnosis over the last decade, we performed a comprehensive review of genetic testing and other diagnostic testing.ResultsManagement included use of steroids and intravenous immunoglobulin (IVIG) in most individuals, with an increased use of immunomodulatory agents, including IVIG, plasma exchange (PLEX) and immunosuppressants such as cytokine inhibitors, and the ketogenic diet after 2014. Genetic testing was performed on a clinical basis in almost all individuals and was non-diagnostic in all patients. We compared FIRES with both status epilepticus (SE) and refractory status epilepticus (RSE) as a broader comparison cohort and identified genetic causes in 36% of patients with RSE. The difference in genetic signatures between FIRES and RSE suggest distinct underlying etiologies. In summary, despite the absence of any identifiable etiologies in FIRES, we performed an unbiased analysis of the clinical landscape, identifying a heterogeneous range of treatment strategies and characterized real-world clinical practice.DiscussionFIRES remains one of the most enigmatic conditions in child neurology without any known etiologies to date despite significant efforts in the field, suggesting a clear need for further studies and novel diagnostic and treatment approaches.
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Affiliation(s)
- Danielle deCampo
- Division of Neurology, Children’s Hospital of Philadelphia, Philadelphia, PA, United States
- The Epilepsy NeuroGenetics Initiative (ENGIN), Children's Hospital of Philadelphia, Philadelphia, PA, United States
- Department of Biomedical and Health Informatics (DBHi), Children’s Hospital of Philadelphia, Philadelphia, PA, United States
| | - Julie Xian
- Division of Neurology, Children’s Hospital of Philadelphia, Philadelphia, PA, United States
- The Epilepsy NeuroGenetics Initiative (ENGIN), Children's Hospital of Philadelphia, Philadelphia, PA, United States
- Department of Biomedical and Health Informatics (DBHi), Children’s Hospital of Philadelphia, Philadelphia, PA, United States
| | - Alexis Karlin
- Division of Neurology, Children’s Hospital of Philadelphia, Philadelphia, PA, United States
- The Epilepsy NeuroGenetics Initiative (ENGIN), Children's Hospital of Philadelphia, Philadelphia, PA, United States
- Department of Biomedical and Health Informatics (DBHi), Children’s Hospital of Philadelphia, Philadelphia, PA, United States
| | - Katie R. Sullivan
- Division of Neurology, Children’s Hospital of Philadelphia, Philadelphia, PA, United States
- The Epilepsy NeuroGenetics Initiative (ENGIN), Children's Hospital of Philadelphia, Philadelphia, PA, United States
- Department of Biomedical and Health Informatics (DBHi), Children’s Hospital of Philadelphia, Philadelphia, PA, United States
| | - Sarah M. Ruggiero
- Division of Neurology, Children’s Hospital of Philadelphia, Philadelphia, PA, United States
- The Epilepsy NeuroGenetics Initiative (ENGIN), Children's Hospital of Philadelphia, Philadelphia, PA, United States
- Department of Biomedical and Health Informatics (DBHi), Children’s Hospital of Philadelphia, Philadelphia, PA, United States
| | - Peter Galer
- Division of Neurology, Children’s Hospital of Philadelphia, Philadelphia, PA, United States
- The Epilepsy NeuroGenetics Initiative (ENGIN), Children's Hospital of Philadelphia, Philadelphia, PA, United States
- Department of Biomedical and Health Informatics (DBHi), Children’s Hospital of Philadelphia, Philadelphia, PA, United States
| | - Mark Ramos
- Department of Biomedical and Health Informatics (DBHi), Children’s Hospital of Philadelphia, Philadelphia, PA, United States
| | - Nicholas S. Abend
- Division of Neurology, Children’s Hospital of Philadelphia, Philadelphia, PA, United States
- The Epilepsy NeuroGenetics Initiative (ENGIN), Children's Hospital of Philadelphia, Philadelphia, PA, United States
- Department of Biomedical and Health Informatics (DBHi), Children’s Hospital of Philadelphia, Philadelphia, PA, United States
| | - Alex Gonzalez
- Department of Biomedical and Health Informatics (DBHi), Children’s Hospital of Philadelphia, Philadelphia, PA, United States
| | - Ingo Helbig
- Division of Neurology, Children’s Hospital of Philadelphia, Philadelphia, PA, United States
- The Epilepsy NeuroGenetics Initiative (ENGIN), Children's Hospital of Philadelphia, Philadelphia, PA, United States
- Department of Biomedical and Health Informatics (DBHi), Children’s Hospital of Philadelphia, Philadelphia, PA, United States
- Department of Neurology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States
- *Correspondence: Ingo Helbig,
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Indelicato E, Pfeilstetter J, Zech M, Unterberger I, Wanschitz J, Berweck S, Boesch S. New-Onset Refractory Status Epilepticus Due to a Novel MT-TF Variant. NEUROLOGY GENETICS 2023; 9:e200063. [PMID: 37090940 PMCID: PMC10117698 DOI: 10.1212/nxg.0000000000200063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 01/25/2023] [Indexed: 03/17/2023]
Abstract
ObjectiveThe gene MT-TF encodes the mitochondrial tRNA of phenylalanine (tRNAphe). Its variations have been described as extremely rare etiologies of a variety of mitochondrial phenotypes.MethodsBy means of whole-exome sequencing (WES), we detected a novel likely causative MT-TF variant (m.610T>C) in a family presenting with a combined movement disorder and epilepsy phenotype. The variant was present at 97% heteroplasmy in the peripheral blood and in a homoplasmic state in skin fibroblast-derived DNA.ResultsThe inaugural manifestation in the index patient was new-onset refractory myoclonic status epilepticus (NORSE) at the age of 29 years. Her son presented later with developmental regression and myoclonic epilepsy. On the beginning of valproate because of ongoing myoclonic seizures, the index patient developed a generalized brain edema requiring bilateral craniotomy. In the course of the disease, epileptic manifestations abated, and both patients developed a severe movement disorder phenotype with prominent spastic-dystonic features. Both patients did not display any further sign of mitochondrial disease.DiscussionOur report expands the clinicogenetic background of tRNAphedisease spectrum and highlights pitfalls in the diagnostics and management of mitochondrial epilepsy. The present findings advocate the introduction of rapid genetic testing in the diagnostic flow chart of NORSE in adults.
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Affiliation(s)
- Elisabetta Indelicato
- Center for Rare Movement Disorders Innsbruck (E.I., S. Boesch); Department of Neurology (E.I., I.U., J.W., S. Boesch), Medical University of Innsbruck, Austria; Hospital for Neuropediatrics and Neurological Rehabilitation (J.P., S. Berweck), Centre of Epilepsy for Children and Adolescents, Schoen Klinik Vogtareuth, Germany; Institute of Neurogenomics (M.Z.), Helmholtz Zentrum München; Institute of Human Genetics (M.Z.), School of Medicine, Technical University of Munich; and Department of Pediatric Neurology and Developmental Medicine Dr. von Hauner Children´s Hospital (S. Berweck), Ludwig Maximilian University of Munich, Germany
| | - Johannes Pfeilstetter
- Center for Rare Movement Disorders Innsbruck (E.I., S. Boesch); Department of Neurology (E.I., I.U., J.W., S. Boesch), Medical University of Innsbruck, Austria; Hospital for Neuropediatrics and Neurological Rehabilitation (J.P., S. Berweck), Centre of Epilepsy for Children and Adolescents, Schoen Klinik Vogtareuth, Germany; Institute of Neurogenomics (M.Z.), Helmholtz Zentrum München; Institute of Human Genetics (M.Z.), School of Medicine, Technical University of Munich; and Department of Pediatric Neurology and Developmental Medicine Dr. von Hauner Children´s Hospital (S. Berweck), Ludwig Maximilian University of Munich, Germany
| | - Michael Zech
- Center for Rare Movement Disorders Innsbruck (E.I., S. Boesch); Department of Neurology (E.I., I.U., J.W., S. Boesch), Medical University of Innsbruck, Austria; Hospital for Neuropediatrics and Neurological Rehabilitation (J.P., S. Berweck), Centre of Epilepsy for Children and Adolescents, Schoen Klinik Vogtareuth, Germany; Institute of Neurogenomics (M.Z.), Helmholtz Zentrum München; Institute of Human Genetics (M.Z.), School of Medicine, Technical University of Munich; and Department of Pediatric Neurology and Developmental Medicine Dr. von Hauner Children´s Hospital (S. Berweck), Ludwig Maximilian University of Munich, Germany
| | - Iris Unterberger
- Center for Rare Movement Disorders Innsbruck (E.I., S. Boesch); Department of Neurology (E.I., I.U., J.W., S. Boesch), Medical University of Innsbruck, Austria; Hospital for Neuropediatrics and Neurological Rehabilitation (J.P., S. Berweck), Centre of Epilepsy for Children and Adolescents, Schoen Klinik Vogtareuth, Germany; Institute of Neurogenomics (M.Z.), Helmholtz Zentrum München; Institute of Human Genetics (M.Z.), School of Medicine, Technical University of Munich; and Department of Pediatric Neurology and Developmental Medicine Dr. von Hauner Children´s Hospital (S. Berweck), Ludwig Maximilian University of Munich, Germany
| | - Julia Wanschitz
- Center for Rare Movement Disorders Innsbruck (E.I., S. Boesch); Department of Neurology (E.I., I.U., J.W., S. Boesch), Medical University of Innsbruck, Austria; Hospital for Neuropediatrics and Neurological Rehabilitation (J.P., S. Berweck), Centre of Epilepsy for Children and Adolescents, Schoen Klinik Vogtareuth, Germany; Institute of Neurogenomics (M.Z.), Helmholtz Zentrum München; Institute of Human Genetics (M.Z.), School of Medicine, Technical University of Munich; and Department of Pediatric Neurology and Developmental Medicine Dr. von Hauner Children´s Hospital (S. Berweck), Ludwig Maximilian University of Munich, Germany
| | - Steffen Berweck
- Center for Rare Movement Disorders Innsbruck (E.I., S. Boesch); Department of Neurology (E.I., I.U., J.W., S. Boesch), Medical University of Innsbruck, Austria; Hospital for Neuropediatrics and Neurological Rehabilitation (J.P., S. Berweck), Centre of Epilepsy for Children and Adolescents, Schoen Klinik Vogtareuth, Germany; Institute of Neurogenomics (M.Z.), Helmholtz Zentrum München; Institute of Human Genetics (M.Z.), School of Medicine, Technical University of Munich; and Department of Pediatric Neurology and Developmental Medicine Dr. von Hauner Children´s Hospital (S. Berweck), Ludwig Maximilian University of Munich, Germany
| | - Sylvia Boesch
- Center for Rare Movement Disorders Innsbruck (E.I., S. Boesch); Department of Neurology (E.I., I.U., J.W., S. Boesch), Medical University of Innsbruck, Austria; Hospital for Neuropediatrics and Neurological Rehabilitation (J.P., S. Berweck), Centre of Epilepsy for Children and Adolescents, Schoen Klinik Vogtareuth, Germany; Institute of Neurogenomics (M.Z.), Helmholtz Zentrum München; Institute of Human Genetics (M.Z.), School of Medicine, Technical University of Munich; and Department of Pediatric Neurology and Developmental Medicine Dr. von Hauner Children´s Hospital (S. Berweck), Ludwig Maximilian University of Munich, Germany
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19
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Tyvaert L. How autoimmunity changed our diagnostic practice in epileptology? Rev Neurol (Paris) 2023; 179:316-329. [PMID: 36804011 DOI: 10.1016/j.neurol.2022.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Revised: 11/06/2022] [Accepted: 11/08/2022] [Indexed: 02/17/2023]
Abstract
Since few years, a new etiology of epilepsy emerges with the labelling of new autoantibodies against the central nervous system. In 2017, the International League Against Epilepsy (ILAE) concluded that autoimmunity is one of six etiologies contributing to epilepsy and that autoimmune epilepsy is directly caused by immune disorders in which seizures constitute a core symptom. Epileptic disorders of immune origin are now distinguished in two different entities: acute symptomatic seizures secondary to autoimmune (ASS) and autoimmune-associated epilepsy (AAE) with different expected clinical outcome under immunotherapy. If acute encephalitis is usually related to ASS with a classic good control of the disease under immunotherapy, clinical phenotype characterized by isolated seizures (new onset seizures and chronic focal epilepsy patients) may be due to either ASS or to AAE. Decision of Abs testing and early immunotherapy initiation needs the development of clinical scores able to select patients with high risk of positive Abs testings. If this selection is now included in the usual medical care of encephalitic patients, specifically with NORSE, the actual bigger challenge is in patients with non or only mild encephalitic symptoms followed for new onset seizures or chronic focal epilepsy patients of unknown origin. The emergence of this new entity provides new therapeutic strategies with specific etiologic and probably anti epileptogenic medication rather than the usual and nonspecific ASM. In the world of the epileptology, this new autoimmune entity appears as a big challenge with an exciting chance to improve or even definitely cure patients of their epilepsy. However, the detection of these patients has to be done in the early phase of the disease to offer the best outcome.
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Affiliation(s)
- L Tyvaert
- Department of neurology, hospital central, CHRU Nancy, Nancy, France; UMR 7039 CRAN, Université de Lorraine, Nancy, France.
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Sculier C, Gaspard N. New-onset refractory status epilepticus and febrile infection-related epilepsy syndrome. Curr Opin Neurol 2023; 36:110-116. [PMID: 36762646 DOI: 10.1097/wco.0000000000001137] [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: 02/11/2023]
Abstract
PURPOSE OF REVIEW The concept and understanding of new-onset refractory status epilepticus (NORSE), and its subtype with prior fever known as febrile infection-related epilepsy syndrome (FIRES) have evolved in the recent past. This review aims to summarize the recent developments in the pathophysiology, diagnosis and management of these challenging conditions. RECENT FINDINGS NORSE and FIRES can have many different causes. Although the list of possible causes is still growing, they mostly fall in the categories of autoimmune encephalitis and genetic disorders. However, despite extensive investigations, most cases of NORSE and FIRES remain cryptogenic. Recent studies have pointed towards the key role of autoinflammation as a unifying pathophysiological mechanism in these cases. These findings also support the use of immunomodulatory treatment in this setting. Consensus recommendations on the management of NORSE and FIRES have recently been published. SUMMARY NORSE and FIRES remain challenging conditions to diagnose and treat. Recent findings from clinical and basic research and new recommendations, reviewed in this article, contribute to an emerging framework for management and future research.
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Affiliation(s)
- Claudine Sculier
- Service de Neurologie Pédiatrique, Hôpital Universitaire de Bruxelles - Hôpital Erasme
| | - Nicolas Gaspard
- Service de Neurologie, Hôpital Universitaire de Bruxelles - Hôpital Erasme, Bruxelles, Belgique
- Neurology Department, Yale University School of Medicine, New Haven, Connecticut, USA
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21
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Lattanzi S, Trinka E, Brigo F, Meletti S. Clinical scores and clusters for prediction of outcomes in status epilepticus. Epilepsy Behav 2023; 140:109110. [PMID: 36758360 DOI: 10.1016/j.yebeh.2023.109110] [Citation(s) in RCA: 5] [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: 10/15/2022] [Revised: 01/22/2023] [Accepted: 01/24/2023] [Indexed: 02/09/2023]
Abstract
Status epilepticus (SE) is a life-threatening condition and may have long-term negative sequelae. Short- and long-term outcomes encompass mortality, deterioration of functional status compared to baseline, refractoriness to treatment, recurrence of SE, and development of epilepsy, cognitive impairment, and behavioral disturbances. So far, the greatest amount of evidence is available for the prediction of short-term mortality. Conversely, the knowledge regarding long-term consequences among SE survivors is still scarce and several issues have not yet been resolved. The heterogeneity of SE renders the prognostication of outcomes challenging. Although aetiology is the main determinant of the outcome, different prognostic predictors have been identified. In this regard, data on group effects need to be integrated into prognostic scores to allow individual risk stratification. Importantly, many of the present scores are not designed to enable repetition to follow patient evolution. A new paradigm for the assessment of SE outcomes should consider variables that become available and/or can be retested during the course of SE. Neuroimaging findings, serum biomarkers, treatment characteristics, complications during SE, peri-ictal and postictal characteristics after SE cessation look as promising determinants of outcome and are suitable for inclusion in future models to enhance the quality and increase the reliability of prediction. This paper was presented at the 8th London-Innsbruck Colloquium on Status Epilepticus and Acute Seizures held in September 2022.
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Affiliation(s)
- Simona Lattanzi
- Neurological Clinic, Department of Experimental and Clinical Medicine, Marche Polytechnic University, Ancona, Italy.
| | - Eugen Trinka
- Department of Neurology, Christian Doppler Klinik, Paracelsus Medical University, Salzburg, Austria; Center for Cognitive Neuroscience, Salzburg, Austria; Public Health, Health Services Research and HTA, University for Health Sciences, Medical Informatics and Technology, Hall i.T, Austria
| | - Francesco Brigo
- Department of Neuroscience, Biomedicine and Movement Science, University of Verona, Italy; Division of Neurology, "Franz Tappeiner" Hospital, Merano (BZ), Italy
| | - Stefano Meletti
- Neurology Unit, OCB Hospital, AOU Modena, Modena, Italy; Department of Biomedical, Metabolic and Neural Science, Center for Neuroscience and Neurotechnology, University of Modena and Reggio Emilia, Modena, Italy
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22
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Vezzani A, Di Sapia R, Kebede V, Balosso S, Ravizza T. Neuroimmunology of status epilepticus. Epilepsy Behav 2023; 140:109095. [PMID: 36753859 DOI: 10.1016/j.yebeh.2023.109095] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 01/14/2023] [Indexed: 02/09/2023]
Abstract
Status epilepticus (SE) is a very heterogeneous clinical condition often refractory to available treatment options. Evidence in animal models shows that neuroinflammation arises in the brain during SE due to the activation of innate immune mechanisms in brain parenchyma cells. Intervention studies in animal models support the involvement of neuroinflammation in SE onset, duration, and severity, refractoriness to treatments, and long-term neurological consequences. Clinical evidence shows that neuroinflammation occurs in patients with SE of diverse etiologies likely representing a common phenomenon, thus broadening the involvement of the immune system beyond the infective and autoimmune etiologies. There is urgent need for novel therapies for refractory SE that rely upon a better understanding of the basic mechanisms underlying this clinical condition. Preclinical and clinical evidence encourage consideration of specific anti-inflammatory treatments for controlling SE and its consequences in patients.
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Affiliation(s)
- Annamaria Vezzani
- Department of Acute Brain Injury, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Italy.
| | - Rossella Di Sapia
- Department of Acute Brain Injury, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Italy
| | - Valentina Kebede
- Department of Acute Brain Injury, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Italy
| | - Silvia Balosso
- Department of Acute Brain Injury, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Italy
| | - Teresa Ravizza
- Department of Acute Brain Injury, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Italy
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23
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Gaspard N, Shorvon S. Is NORSE a meaningful clinical entity? Epilepsy Behav 2023; 141:109097. [PMID: 36807989 DOI: 10.1016/j.yebeh.2023.109097] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Revised: 01/13/2023] [Accepted: 01/14/2023] [Indexed: 02/21/2023]
Abstract
This article summarises the arguments for and against the proposition, debated at the 8th London-Innsbruck Colloquium on Status Epilepticus and Acute Seizures, that: 'NORSE is a meaningful clinical entity'. Here the two sides of the argument are briefly presented. This article is published as part of the special issue of Epilepsy & Behavior which are the proceedings of the 8th London-Innsbruck Colloquium on Status Epilepticus and Acute Seizures.
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Affiliation(s)
- Nicolas Gaspard
- Service de Neurologie, Hôpital Universitaire de Bruxelles - Hôpital Erasme, Bruxelles, Belgium; Department of Neurology, Yale University, New Haven, CT, USA
| | - Simon Shorvon
- UCL Queen Square Institute of Neurology, London, Great Britain, United Kingdom.
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24
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Benaiteau M, Valton L, Gardy L, Denuelle M, Debs R, Wucher V, Rulquin F, Barbeau EJ, Bonneville F, Pariente J, Curot J. Specific profiles of new-onset vs. non-inaugural status epilepticus: From diagnosis to 1-year outcome. Front Neurol 2023; 14:1101370. [PMID: 36860570 PMCID: PMC9969963 DOI: 10.3389/fneur.2023.1101370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Accepted: 01/06/2023] [Indexed: 02/05/2023] Open
Abstract
While new-onset status epilepticus (NOSE) is a harbinger of chronic epilepsy, prospective medical data are sparse in terms of specifying whether the evolution of status epilepticus (SE) and seizure expression in NOSE resembles what occurs in patients who have already been diagnosed with epilepsy [non-inaugural SE (NISE)] in all aspects apart from its inaugural nature. The aim of this study was to compare the clinical, MRI, and EEG features that could distinguish NOSE from NISE. We conducted a prospective monocentric study in which all patients ≥18 years admitted for SE over a 6-month period were included. A total of 109 patients (63 NISE and 46 NOSE cases) were included. Despite similar modified Rankin scores before SE, several aspects of the clinical history distinguished NOSE from NISE patients. NOSE patients were older and frequently had neurological comorbidity and preexisting cognitive decline, but they had a similar prevalence of alcohol consumption to NISE patients. NOSE and NISE evolve in the same proportions as refractory SE (62.5% NOSE, 61% NISE) and share common features such as the same incidence (33% NOSE, 42% NISE, and p = 0.53) and volumes of peri-ictal abnormalities on MRI. However, in NOSE patients, we observed greater non-convulsive semiology (21.7% NOSE, 6% NISE, and p = 0.02), more periodic lateral discharges on EEG (p = 0.004), later diagnosis, and higher severity according to the STESS and EMSE scales (p < 0.0001). Mortality occurred in 32.6% of NOSE patients and 21% of NISE patients at 1 year (p = 0.19), but with different causes of death occurring at different time points: more early deaths directly linked to SE at 1 month occurred in the NOSE group, while there were more remote deaths linked to causal brain lesions in the NISE group at final follow-up. In survivors, 43.6% of the NOSE cases developed into epilepsy. Despite acute causal brain lesions, the novelty related to its inaugural nature is still too often associated with a delay in diagnosing SE and a poorer outcome, which justifies the need to more clearly specify the various types of SE to constantly raise awareness among clinicians. These results highlight the relevance of including novelty-related criteria, clinical history, and temporality of occurrence in the nosology of SE.
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Affiliation(s)
- Marie Benaiteau
- French Reference Center on Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, University Hospital of Lyon HCL, Lyon, France,Neurology Department, Toulouse University Hospital, Toulouse, France,*Correspondence: Marie Benaiteau ✉
| | - Luc Valton
- Neurology Department, Toulouse University Hospital, Toulouse, France,Brain and Cognition Research Center (CerCo), French National Scientific Research Center, UMR5549, Toulouse, France,Luc Valton ✉
| | - Ludovic Gardy
- Brain and Cognition Research Center (CerCo), French National Scientific Research Center, UMR5549, Toulouse, France
| | - Marie Denuelle
- Neurology Department, Toulouse University Hospital, Toulouse, France,Brain and Cognition Research Center (CerCo), French National Scientific Research Center, UMR5549, Toulouse, France
| | - Rachel Debs
- Neurology Department, Toulouse University Hospital, Toulouse, France
| | - Valentin Wucher
- French Reference Center on Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, University Hospital of Lyon HCL, Lyon, France,Synaptopathies and Autoantibodies (SynatAc) Team, NeuroMyoGene-MeLis Institute, INSERM U1314/CNRS UMR 5284, University of Lyon, Lyon, France
| | - Florence Rulquin
- Neurology Department, Toulouse University Hospital, Toulouse, France
| | - Emmanuel J. Barbeau
- Brain and Cognition Research Center (CerCo), French National Scientific Research Center, UMR5549, Toulouse, France,Faculty of Health, University of Toulouse-Paul Sabatier, Toulouse, France
| | - Fabrice Bonneville
- Faculty of Health, University of Toulouse-Paul Sabatier, Toulouse, France,INSERM, U1214, Toulouse Neuro Imaging Center (ToNIC), Toulouse, France,Neuroradiology Department, Toulouse University Hospital, Toulouse, France
| | - Jérémie Pariente
- Neurology Department, Toulouse University Hospital, Toulouse, France,Faculty of Health, University of Toulouse-Paul Sabatier, Toulouse, France,INSERM, U1214, Toulouse Neuro Imaging Center (ToNIC), Toulouse, France
| | - Jonathan Curot
- Neurology Department, Toulouse University Hospital, Toulouse, France,Brain and Cognition Research Center (CerCo), French National Scientific Research Center, UMR5549, Toulouse, France,Faculty of Health, University of Toulouse-Paul Sabatier, Toulouse, France,Jonathan Curot ✉
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25
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Tharmaraja T, Ho JSY, Neligan A, Rajakulendran S. The etiology and mortality of new-onset refractory status epilepticus (NORSE) in adults: A systematic review and meta-analysis. Epilepsia 2023; 64:1113-1124. [PMID: 36727541 DOI: 10.1111/epi.17523] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Revised: 01/30/2023] [Accepted: 01/31/2023] [Indexed: 02/03/2023]
Abstract
New-onset refractory status epilepticus (NORSE) is a devastating neurological presentation. There is a paucity of large studies on NORSE as it is a relatively new clinical syndrome. The aim of this review was to summarize the etiologies and establish a mortality rate for NORSE. Two independent authors systematically searched the following electronic databases from January 1, 2005 April 20, 2021: PubMed, Embase, OVID, Scopus, Web of Science, "Clinicaltrials.gov," and the International Standard Randomised Controlled Trial Number (ISRCTN) registry. We included all primary research studies of NORSE in adults and excluded commentaries, reviews, pre-clinical studies, and pediatric populations. Etiology was extracted from all studies meeting eligibility criteria, whereas data relating to treatments, hospital stay, functional outcomes, and mortality were extracted from studies with sample size ≥5. We conducted a random-effects meta-analysis of mortality rate with meta-regression testing for significant covariates. Of 1482 studies, 109 case reports and case series met our criteria, comprising 395 cases of NORSE. The most common etiology was cryptogenic in 197 cases (49.9%), followed by autoimmune in 143 cases (36.2%). The pooled mortality rate was 22% (95% confidence interval 17%-27%; N studies = 15), with low heterogeneity ( I 2 = 0%). Meta-regression revealed that year of study, treatment with ketogenic diet or immunotherapy, percentage of cryptogenic cases, and length of intensive care unit stay were not significant covariates for mortality. Common treatments included antiseizure medications (median 5), general anesthesia, and immunotherapy such as corticosteroids, intravenous immunoglobulin, and plasma exchange. Mean length of intensive care admission was 33.4 days, with 52% of cases diagnosed with epilepsy on discharge. Neurocognitive impairment was a common sequela of NORSE. NORSE is associated with a high mortality. Half of cases remain cryptogenic, which presents a diagnostic challenge. Future focus should be on elucidating the underlying neurobiology and determining the most effective therapeutic interventions.
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Affiliation(s)
- Thahesh Tharmaraja
- Leonard Wolfson Experimental Neurology Centre, The National Hospital for Neurology and Neurosurgery, London, UK
| | - Jamie Sin Ying Ho
- Royal Free Hospital, Royal Free London NHS Foundation Trust, London, UK
| | - Aidan Neligan
- UCL Queen Square Institute of Neurology, London, UK
- Homerton University Hospital NHS Foundation Trust, London, UK
| | - Sanjeev Rajakulendran
- UCL Queen Square Institute of Neurology, London, UK
- The National Hospital for Neurology and Neurosurgery, London, UK
- The North Middlesex University Hospital, London, UK
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26
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Astner-Rohracher A, Mauritz M, Leitinger M, Rossini F, Kalss G, Neuray C, Retter E, Wortmann SB, Achleitner MT, Mayr JA, Trinka E. A case report: New-onset refractory status epilepticus in a patient with FASTKD2-related mitochondrial disease. Front Neurol 2023; 13:1063733. [PMID: 36712458 PMCID: PMC9875587 DOI: 10.3389/fneur.2022.1063733] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Accepted: 12/14/2022] [Indexed: 01/13/2023] Open
Abstract
Objectives New-onset refractory status epilepticus (NORSE) is associated with high morbidity and mortality. Despite extensive work-up, the underlying etiology remains unknown in 50% of affected individuals. Mitochondrial disorders represent rare causes of NORSE. Biallelic variants in FASTKD2 were reported as a cause of infantile encephalomyopathy with refractory epilepsy. Case description In the study, we report a previously healthy 14-year-old with a new, homozygous FASTKD2 variant presenting with NORSE. Following a seizure-free period of 7 years, he experienced another super-refractory SE and subsequently developed drug-resistant focal epilepsy, mild myopathy, optic atrophy, and discrete psychomotor slowing. Structural MRI at the time of NORSE showed right temporo-parieto-occipital FLAIR hyperintensity and diffusion restriction, with extensive right hemispheric atrophy at the age of 22 years. Whole-exome sequencing revealed a novel homozygous loss of function variant [c.(1072C>T);(1072C>T)] [p.(Arg358Ter);(Arg358Ter)] in FASTKD2 (NM_001136193), resulting in a premature termination codon in the protein-coding region and loss of function of FASTKD2. Oxidative phosphorylation (OXPHOS) in muscle and skin fibroblasts was unremarkable. Conclusion This is the first case of a normally developed adolescent with a new homozygous loss of function variant in FASTKD2, manifesting with NORSE. The phenotypical spectrum of FASTKD2-related mitochondrial disease is heterogeneous, ranging from recurrent status epilepticus and refractory focal epilepsy in an adolescent with normal cognitive development to severe forms of infantile mitochondrial encephalopathy. Although mitochondrial diseases are rare causes of NORSE, clinical features such as young age at onset and multi-system involvement should trigger genetic testing. Early diagnosis is essential for counseling and treatment considerations.
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Affiliation(s)
- Alexandra Astner-Rohracher
- Department of Neurology, Neurocritical Care, and Neurorehabilitation, Christian Doppler University Hospital, Centre for Cognitive Neuroscience, Paracelsus Medical University, Salzburg, Austria,Neuroscience Institute, Christian Doppler University Hospital, Centre for Cognitive Neuroscience Paracelsus Medical University Hospital, Salzburg, Austria
| | - Matthias Mauritz
- Department of Neurology, Neurocritical Care, and Neurorehabilitation, Christian Doppler University Hospital, Centre for Cognitive Neuroscience, Paracelsus Medical University, Salzburg, Austria,Neuroscience Institute, Christian Doppler University Hospital, Centre for Cognitive Neuroscience Paracelsus Medical University Hospital, Salzburg, Austria
| | - Markus Leitinger
- Department of Neurology, Neurocritical Care, and Neurorehabilitation, Christian Doppler University Hospital, Centre for Cognitive Neuroscience, Paracelsus Medical University, Salzburg, Austria,Neuroscience Institute, Christian Doppler University Hospital, Centre for Cognitive Neuroscience Paracelsus Medical University Hospital, Salzburg, Austria
| | - Fabio Rossini
- Department of Neurology, Neurocritical Care, and Neurorehabilitation, Christian Doppler University Hospital, Centre for Cognitive Neuroscience, Paracelsus Medical University, Salzburg, Austria,Neuroscience Institute, Christian Doppler University Hospital, Centre for Cognitive Neuroscience Paracelsus Medical University Hospital, Salzburg, Austria
| | - Gudrun Kalss
- Department of Neurology, Neurocritical Care, and Neurorehabilitation, Christian Doppler University Hospital, Centre for Cognitive Neuroscience, Paracelsus Medical University, Salzburg, Austria,Neuroscience Institute, Christian Doppler University Hospital, Centre for Cognitive Neuroscience Paracelsus Medical University Hospital, Salzburg, Austria
| | - Caroline Neuray
- Department of Neurology, Neurocritical Care, and Neurorehabilitation, Christian Doppler University Hospital, Centre for Cognitive Neuroscience, Paracelsus Medical University, Salzburg, Austria
| | | | - Saskia B. Wortmann
- University Children's Hospital, Paracelsus Medical University, Salzburg, Austria,Department of Pediatrics, Radboud Center for Mitochondrial Medicine, Amalia Children's Hospital, Radboudumc, Nijmegen, Netherlands
| | | | - Johannes A. Mayr
- University Children's Hospital, Paracelsus Medical University, Salzburg, Austria
| | - Eugen Trinka
- Department of Neurology, Neurocritical Care, and Neurorehabilitation, Christian Doppler University Hospital, Centre for Cognitive Neuroscience, Paracelsus Medical University, Salzburg, Austria,Neuroscience Institute, Christian Doppler University Hospital, Centre for Cognitive Neuroscience Paracelsus Medical University Hospital, Salzburg, Austria,Karl Landsteiner Institute for Neurorehabilitation and Space Neurology, Salzburg, Austria,Department of Public Health, Health Services Research and Health Technology Assessment, UMIT–University for Health Sciences, Medical Informatics and Technology, Hall in Tirol, Austria,*Correspondence: Eugen Trinka ✉
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Nabbout R, Matricardi S, De Liso P, Dulac O, Oualha M. Ketogenic diet for super-refractory status epilepticus (SRSE) with NORSE and FIRES: Single tertiary center experience and literature data. Front Neurol 2023; 14:1134827. [PMID: 37122314 PMCID: PMC10133555 DOI: 10.3389/fneur.2023.1134827] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Accepted: 03/27/2023] [Indexed: 05/02/2023] Open
Abstract
Background and purpose Ketogenic diet (KD) is an emerging treatment option for super-refractory status epilepticus (SRSE). We evaluated the effectiveness of KD in patients presenting SRSE including NORSE (and its subcategory FIRES). Methods A retrospective review of the medical records was performed at the Necker Enfants Malades Hospital. All children with SRSE in whom KD was started during the last 10 years were included. A systematic search was carried out for all study designs, including at least one patient of any age with SRSE in whom KD was started. The primary outcome was the responder rate and Kaplan-Meier survival curves were generated for the time-to-KD response. As secondary outcomes, Cox proportional hazard models were created to assess the impact of NORSE-related factors on KD efficacy. Results Sixteen children received KD for treatment of SRSE, and three had NORSE presentation (one infectious etiology, two FIRES). In medical literature, 1,613 records were initially identified, and 75 were selected for review. We selected 276 patients receiving KD during SRSE. The most common etiology of SRSE was acute symptomatic (21.3%), among these patients, 67.7% presented with NORSE of immune and infectious etiologies. Other etiologies were remote symptomatic (6.8%), progressive symptomatic (6.1%), and SE in defined electroclinical syndromes (14.8%), including two patients with genetic etiology and NORSE presentation. The etiology was unknown in 50.7% of the patients presenting with cryptogenic NORSE, of which 102 presented with FIRES. Overall, most patients with NORSE benefit from KD (p < 0.004), but they needed a longer time to achieve RSE resolution after starting KD compared with other non-NORSE SRSE (p = 0.001). The response to KD in the NORSE group with identified etiology compared to the cryptogenic NORSE was significantly higher (p = 0.01), and the time to achieve SE resolution after starting KD was shorter (p = 0.04). Conclusions The search for underlying etiology should help to a better-targeted therapy. KD can have good efficacy in NORSE; however, the time to achieve SE resolution seems to be longer in cryptogenic cases. These findings highlight the therapeutic role of KD in NORSE, even though this favorable response needs to be better confirmed in prospective controlled studies.
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Affiliation(s)
- Rima Nabbout
- Reference Center for Rare Epilepsies, Department of Pediatric Neurology, Necker-Enfants Malades Hospital, Assistance Publique Hôpitaux de Paris, University Paris Cité, Member of ERN EpiCARE, Paris, France
- Imagine Institute, National Institute of Health and Medical Research, Mixed Unit of Research 1163, University Paris Cité, Paris, France
- *Correspondence: Rima Nabbout ;
| | - Sara Matricardi
- Reference Center for Rare Epilepsies, Department of Pediatric Neurology, Necker-Enfants Malades Hospital, Assistance Publique Hôpitaux de Paris, University Paris Cité, Member of ERN EpiCARE, Paris, France
- Department of Pediatrics, University of Chieti, Chieti, Italy
| | - Paola De Liso
- Neurology Unit, Department of Neuroscience, Bambino Gesù Children's Hospital, Member of ERN EpiCARE, Rome, Italy
| | - Olivier Dulac
- Reference Center for Rare Epilepsies, Department of Pediatric Neurology, Necker-Enfants Malades Hospital, Assistance Publique Hôpitaux de Paris, University Paris Cité, Member of ERN EpiCARE, Paris, France
| | - Mehdi Oualha
- Pediatric Intensive Care Unit, Necker-Enfants Malades Hospital, Assistance Publique Hôpitaux de Paris, Université de Paris, Paris, France
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28
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Seizures, Epilepsy, and NORSE Secondary to Autoimmune Encephalitis: A Practical Guide for Clinicians. Biomedicines 2022; 11:biomedicines11010044. [PMID: 36672553 PMCID: PMC9855825 DOI: 10.3390/biomedicines11010044] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 12/08/2022] [Accepted: 12/12/2022] [Indexed: 12/29/2022] Open
Abstract
The most recent International League Against Epilepsy (ILAE) classification has included "immune etiology" along with other well-known causes of epilepsy. This was possible thanks to the progress in detection of pathogenic neural antibodies (Abs) in a subset of patients, and resulted in an increased interest in identifying potentially treatable causes of otherwise refractory seizures. Most autoimmune encephalitides (AE) present with seizures, but only a minority of cases evolve to long-term epilepsy. The risk of epilepsy is higher for patients harboring Abs targeting intracellular antigens (T cell-mediated and mostly paraneoplastic, such as Hu, CV2/CRMP5, Ma2, GAD65 Abs), compared with patients with neuronal surface Abs (antibody-mediated and less frequently paraneoplastic, such as NMDAR, GABAbR, LGI1, CASPR2 Abs). To consider these aspects, conceptual definitions for two entities were provided: acute symptomatic seizures secondary to AE, and autoimmune-associated epilepsy, which reflect the different pathophysiology and prognoses. Through this manuscript, we provide an up-to-date review on the current state of knowledge concerning diagnosis and management of patients with Ab-mediated encephalitis and associated epilepsy. Special emphasis is placed on clinical aspects, such as brain magnetic resonance imaging (MRI) and cerebrospinal fluid (CSF) specificities, electroencephalographic (EEG) findings, cancer screening and suggestions for a rational therapeutic approach.
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29
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Watanabe T, Nakamori M, Ishikawa K, Motoda A, Neshige S, Yamamoto S, Katahira K, Higaki T, Ueno H, Iizuka T, Maruyama H. Reversible Brain Atrophy in Cryptogenic New-onset Refractory Status Epilepticus: A Case Report. Intern Med 2022. [PMID: 36351577 DOI: 10.2169/internalmedicine.0465-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Cryptogenic new-onset refractory status epilepticus (C-NORSE) is a neurologic emergency condition characterized by refractory status epilepticus (RSE) of unknown cause. Brain atrophy in a setting of C-NORSE is usually irreversible. A 33-year-old woman who was highly suspected of C-NORSE once showed mild frontotemporal atrophy on brain magnetic resonance imaging (MRI), but follow-up MRI revealed recovery of the brain atrophy. Her cognitive function also gradually improved, with a reduction in seizure frequency. Early initiation of intensive immunotherapy with anti-seizure medications may have minimized irreversible brain damage associated with RSE, resulting in a relatively good outcome.
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Affiliation(s)
- Tomoaki Watanabe
- Department of Clinical Neuroscience and Therapeutics, Hiroshima University Graduate School of Biomedical and Health Sciences, Japan
| | - Masahiro Nakamori
- Department of Clinical Neuroscience and Therapeutics, Hiroshima University Graduate School of Biomedical and Health Sciences, Japan
| | - Kenichi Ishikawa
- Department of Clinical Neuroscience and Therapeutics, Hiroshima University Graduate School of Biomedical and Health Sciences, Japan
| | - Atsuko Motoda
- Department of Clinical Neuroscience and Therapeutics, Hiroshima University Graduate School of Biomedical and Health Sciences, Japan
| | - Shuichiro Neshige
- Department of Clinical Neuroscience and Therapeutics, Hiroshima University Graduate School of Biomedical and Health Sciences, Japan
| | - Shotaro Yamamoto
- Department of Internal Medicine, Mitsugi General Hospital, Japan
| | - Kento Katahira
- Department of Rehabilitation, Mitsugi General Hospital, Japan
| | - Toru Higaki
- Graduate School of Advanced Science and Engineering, Hiroshima University, Japan
| | - Hiroki Ueno
- Department of Clinical Neuroscience and Therapeutics, Hiroshima University Graduate School of Biomedical and Health Sciences, Japan
| | - Takahiro Iizuka
- Department of Neurology, Kitasato University School of Medicine, Japan
| | - Hirofumi Maruyama
- Department of Clinical Neuroscience and Therapeutics, Hiroshima University Graduate School of Biomedical and Health Sciences, Japan
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30
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Shibahara T, Sakamoto K, Yoshino F, Matsuoka M, Tachibana M, Kamezaki K, Kuroda J, Kuroiwa M, Nakane H. Usefulness of arterial spin labeling in identifying status epilepticus secondary to acquired thrombotic thrombocytopenic purpura. eNeurologicalSci 2022; 29:100435. [DOI: 10.1016/j.ensci.2022.100435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 11/09/2022] [Accepted: 11/10/2022] [Indexed: 11/16/2022] Open
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Wickstrom R, Taraschenko O, Dilena R, Payne ET, Specchio N, Nabbout R, Koh S, Gaspard N, Hirsch LJ. International consensus recommendations for management of New Onset Refractory Status Epilepticus (NORSE) incl. Febrile Infection-Related Epilepsy Syndrome (FIRES): Statements and Supporting Evidence. Epilepsia 2022; 63:2840-2864. [PMID: 35997591 PMCID: PMC9828002 DOI: 10.1111/epi.17397] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Revised: 07/14/2022] [Accepted: 08/18/2022] [Indexed: 01/12/2023]
Abstract
OBJECTIVE To develop consensus-based recommendations for the management of adult and paediatric patients with NORSE/FIRES based on best evidence and experience. METHODS The Delphi methodology was followed. A facilitator group of 9 experts was established, who defined the scope, users and suggestions for recommendations. Following a review of the current literature, recommendation statements concerning diagnosis, treatment and research directions were generated which were then voted on a scale of 1 (strongly disagree) to 9 (strongly agree) by a panel of 48 experts in the field. Consensus that a statement was appropriate was reached if the median score was greater or equal to 7, and inappropriate if the median score was less than or equal to 3. The analysis of evidence was mapped to the results of each statement included in the Delphi survey. RESULTS Overall, 85 recommendation statements achieved consensus. The recommendations are divided into five sections: 1) disease characteristics, 2) diagnostic testing and sampling, 3) acute treatment, 4) treatment in the post-acute phase, and 5) research, registries and future directions in NORSE/FIRES. The detailed results and discussion of all 85 statements are outlined herein. A corresponding summary of findings and practical flowsheets are presented in a companion article. SIGNIFICANCE This detailed analysis offers insight into the supporting evidence and the current gaps in the literature that are associated with expert consensus statements related to NORSE/FIRES. The recommendations generated by this consensus can be used as a guide for the diagnosis, evaluation, and management of patients with NORSE/FIRES, and for planning of future research.
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Affiliation(s)
- Ronny Wickstrom
- Neuropaediatric UnitDepartment of Women's and Children's HealthKarolinska Institutet and Karolinska University HospitalStockholmSweden
| | - Olga Taraschenko
- Department of Neurological SciencesUniversity of Nebraska Medical CenterOmahaNebraskaUSA
| | - Robertino Dilena
- Neuropathophysiology UnitFoundation IRCCS Ca' Granda Ospedale Maggiore PoliclinicoMilanItaly
| | - Eric T. Payne
- Department of Pediatrics, Section of NeurologyAlberta Children's HospitalCalgaryAlbertaCanada
| | - Nicola Specchio
- Rare and Complex Epilepsy Unit, Department of NeurosciencesBambino Gesù Children's Hospital, IRCCS, Full Member of European Reference Network EpiCARERomeItaly
| | - Rima Nabbout
- Department of Pediatric Neurology, APHP, Member of EPICARE ERN, Centre de Reference Epilepsies RaresUniversite de Paris, Institut Imagine, INSERM 1163ParisFrance
| | - Sookyong Koh
- Department of Pediatrics, Children's Hospital and Medical CenterUniversity of NebraskaOmahaNebraskaUSA
| | | | - Lawrence J. Hirsch
- Department of Neurology, Comprehensive Epilepsy CenterYale UniversityNew HavenConnecticutUSA
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Malter MP, Neuneier J. Super-refractory status epilepticus in adults. Neurol Res Pract 2022; 4:35. [PMID: 35989337 PMCID: PMC9394073 DOI: 10.1186/s42466-022-00199-4] [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: 01/17/2022] [Accepted: 06/10/2022] [Indexed: 11/13/2022] Open
Abstract
Introduction Super-refractory status epilepticus (SRSE) represents the culmination of refractory status epilepticus (RSE) and carries a significant risk of poor neurological outcome and high mortality. RSE is not defined primarily by seizure duration, but by failure to respond to appropriate antiseizure treatment. SRSE is present when a RSE persists or recurs after more than 24 h of treatment with anesthetics. No evidence-based treatment algorithms can be provided for SRSE. Therefore, we propose a pragmatic standard operating procedure (SOP) for the management of SRSE that addresses the existing uncertainties in the treatment of SRSE and provides options for resolution and decision-making.
Comments First, we recommend the assessment of persistent seizure activity and the evaluation of differential diagnoses to confirm correct diagnosis. Relevant differential diagnoses include psychogenic non-epileptic seizures, hypoxic, metabolic, or toxic encephalopathies, and tetanus. During SE or in severe encephalopathies, a so-called electroclinical ictal-interictal continuum may occur, which denotes an intermediate stage that cannot be defined with certainty as ictal or interictal by EEG and should not lead to harmful overtreatment. Because both prognosis and specific treatment options depend crucially on the etiology of SRSE, the etiological evaluation should be performed rapidly. When SRSE is confirmed, various pharmacological and non-pharmacological treatment options are available. Conclusion We provide a pragmatical SOP for adult people with SRSE.
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Wickström R, Taraschenko O, Dilena R, Payne ET, Specchio N, Nabbout R, Koh S, Gaspard N, Hirsch LJ. International consensus recommendations for management of New Onset Refractory Status Epilepticus (NORSE) including Febrile Infection-Related Epilepsy Syndrome (FIRES): Summary and Clinical Tools. Epilepsia 2022; 63:2827-2839. [PMID: 35951466 PMCID: PMC9826478 DOI: 10.1111/epi.17391] [Citation(s) in RCA: 38] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 08/10/2022] [Accepted: 08/10/2022] [Indexed: 01/11/2023]
Abstract
OBJECTIVE To develop consensus-based recommendations for the management of adult and pediatric patients with NORSE/FIRES based on best available evidence and expert opinion. METHODS The Delphi methodology was followed. A facilitator group of 9 experts was established, who defined the scope, users and suggestions for recommendations. Following a review of the current literature, recommendation statements concerning diagnosis, treatment and research directions were generated which were then voted on a scale of 1 (strongly disagree) to 9 (strongly agree) by a panel of 48 experts in the field. Consensus that a statement was appropriate was reached if the median score was greater than or equal to 7, and inappropriate if the median score was less than or equal to 3. RESULTS Overall, 85 recommendation statements achieved consensus. The recommendations are divided into five sections: 1) disease characteristics, 2) diagnostic testing and sampling, 3) acute treatment, 4) treatment in the post-acute phase, and 5) research, registries and future directions in NORSE/FIRES. These are summarized in this article along with two practical clinical flowsheets: one for diagnosis and evaluation and one for acute treatment. A corresponding evidence-based analysis of all 85 recommendations alongside responses by the Delphi panel is presented in a companion article. SIGNIFICANCE The recommendations generated by this consensus can be used as a guide for the diagnosis, evaluation, and management of patients with NORSE/FIRES, and for planning of future research.
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Affiliation(s)
- Ronny Wickström
- Neuropaediatric Unit, Department of Women's and Children's HealthKarolinska Institutet and Karolinska University HospitalStockholmSweden
| | - Olga Taraschenko
- Department of Neurological SciencesUniversity of Nebraska Medical CenterOmahaNebraskaUSA
| | - Robertino Dilena
- Neuropathophysiology UnitFoundation IRCCS Ca' Granda Ospedale Maggiore PoliclinicoMilanItaly
| | - Eric T. Payne
- Department of Pediatrics, Section of NeurologyAlberta Children's HospitalCalgaryAlbertaCanada
| | - Nicola Specchio
- Rare and Complex Epilepsy Unit, Department of NeurosciencesBambino Gesù Children's Hospital, IRCCS, Full Member of European Reference Network EpiCARERomeItaly
| | - Rima Nabbout
- Department of Pediatric Neurology, APHP, Member of EPICARE ERN, Centre de Reference Epilepsies RaresUniversite de Paris, Institut Imagine, INSERM 1163ParisFrance
| | - Sookyong Koh
- Department of Pediatrics, Children's Hospital and Medical CenterUniversity of NebraskaOmahaNebraskaUSA
| | - Nicolas Gaspard
- Hôpital Erasme, Université Libre de BruxellesBrusselsBelgium
| | - Lawrence J. Hirsch
- Department of Neurology, Comprehensive Epilepsy CenterYale UniversityNew HavenConnecticutUSA
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Matricardi S, Casciato S, Bozzetti S, Mariotto S, Stabile A, Freri E, Deleo F, Sartori S, Nosadini M, Pappalardo I, Meletti S, Giovannini G, Zucchi E, Di Bonaventura C, Di Gennaro G, Ferrari S, Zuliani L, Zoccarato M, Vogrig A, Lattanzi S, Michelucci R, Gambardella A, Ferlazzo E, Fusco L, Granata T, Villani F. Epileptic phenotypes in autoimmune encephalitis: from acute symptomatic seizures to autoimmune-associated epilepsy. J Neurol Neurosurg Psychiatry 2022; 93:jnnp-2022-329195. [PMID: 35879055 DOI: 10.1136/jnnp-2022-329195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2022] [Accepted: 07/06/2022] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To describe the clinical and paraclinical findings, treatment options and long-term outcomes in autoimmune encephalitis (AE), with a close look to epilepsy. METHODS In this retrospective observational cohort study, we enrolled patients with new-onset seizures in the context of AE. We compared clinical and paraclinical findings in patients with and without evidence of antibodies. RESULTS Overall, 263 patients (138 females; median age 55 years, range 4-86) were followed up for a median time of 30 months (range 12-120). Antineuronal antibodies were detected in 63.50%.Antibody-positive patients had multiple seizure types (p=0.01) and prevalent involvement of temporal regions (p=0.02). A higher prevalence of episodes of SE was found in the antibody-negative group (p<0.001).Immunotherapy was prescribed in 88.60%, and effective in 61.80%. Independent predictors of favourable outcome of the AE were early immunotherapy (p<0.001) and the detection of antineuronal surface antibodies (p=0.01).Autoimmune-associated epilepsy was the long-term sequela in 43.73%, associated with cognitive and psychiatric disturbances in 81.73%. Independent predictors of developing epilepsy were difficult to treat seizures at onset (p=0.04), a high number of antiseizure medications (p<0.001), persisting interictal epileptiform discharges at follow-up (p<0.001) and poor response to immunotherapy during the acute phase (p<0.001). CONCLUSIONS The recognition of seizures secondary to AE represents a rare chance for aetiology-driven seizures management. Early recognition and treatment at the pathogenic level may reduce the risk of long-term irreversible sequelae. However, the severity of seizures at onset is the major risk factor for the development of chronic epilepsy.This study provides class IV evidence for management recommendations.
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Affiliation(s)
- Sara Matricardi
- Child Neurology and Psychiatry Unit, Children's Hospital "G. Salesi", Ospedali Riuniti Ancona, Polytechnic University of Marche, Ancona, Italy
| | | | - Silvia Bozzetti
- Neurology Unit, Department of Neurosciences, Biomedicine, and Movement Sciences, University of Verona, Verona, Italy
- Department of Neurology/Stroke Unit, San Maurizio Hospital, Bolzano, Italy
| | - Sara Mariotto
- Neurology Unit, Department of Neurosciences, Biomedicine, and Movement Sciences, University of Verona, Verona, Italy
| | - Andrea Stabile
- Epilepsy Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Elena Freri
- Department of Paediatric Neuroscience, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Francesco Deleo
- Epilepsy Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Stefano Sartori
- Paediatric Neurology and Neurophysiology Unit, Department of Women's and Children's Health, University Hospital of Padova, Padova, Italy
- Neuroimmunology Group, Paediatric Research Institute "Città della Speranza", Padova, Italy
| | - Margherita Nosadini
- Paediatric Neurology and Neurophysiology Unit, Department of Women's and Children's Health, University Hospital of Padova, Padova, Italy
- Neuroimmunology Group, Paediatric Research Institute "Città della Speranza", Padova, Italy
| | - Irene Pappalardo
- Division of Clinical Neurophysiology and Epilepsy Centre, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Stefano Meletti
- Dept of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
- Neurology Dept, Azienda Ospedaliera-Universitaria di Modena, Modena, Italy
| | - Giada Giovannini
- Dept of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
- Neurology Dept, Azienda Ospedaliera-Universitaria di Modena, Modena, Italy
| | - Elisabetta Zucchi
- Dept of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
- Neurology Dept, Azienda Ospedaliera-Universitaria di Modena, Modena, Italy
| | | | | | - Sergio Ferrari
- Neurology Unit, Department of Neurosciences, Biomedicine, and Movement Sciences, University of Verona, Verona, Italy
| | | | - Marco Zoccarato
- Neurology Unit O.S.A. - Azienda Ospedale Università Padova, Padova, Italy
| | - Alberto Vogrig
- Department of Neurosciences, Santa Maria della Misericordia University Hospital, Udine, Italy
| | - Simona Lattanzi
- Neurological Clinic, Department of Experimental and Clinical Medicine, Polytechnic University of Marche, Ancona, Italy
| | - Roberto Michelucci
- IRCCS - Istituto delle Scienze Neurologiche di Bologna, Unit of Neurology, Bologna, Italy
| | - Antonio Gambardella
- Department of Medical and Surgical Sciences, University Magna Graecia, Catanzaro, Italy
| | - Edoardo Ferlazzo
- Regional Epilepsy Center, BMM Great Metropolitan Hospital, Reggio Calabria, Italy
- Department of Medical and Surgical Sciences, Magna Græcia University of Catanzaro, Catanzaro, Italy
| | - Lucia Fusco
- Department of Neuroscience, Bambino Gesù Children's Hospital, Rome, Italy
| | - Tiziana Granata
- Department of Paediatric Neuroscience, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Flavio Villani
- Division of Clinical Neurophysiology and Epilepsy Centre, IRCCS Ospedale Policlinico San Martino, Genova, Italy
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Löscher W, Howe CL. Molecular Mechanisms in the Genesis of Seizures and Epilepsy Associated With Viral Infection. Front Mol Neurosci 2022; 15:870868. [PMID: 35615063 PMCID: PMC9125338 DOI: 10.3389/fnmol.2022.870868] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Accepted: 04/05/2022] [Indexed: 12/16/2022] Open
Abstract
Seizures are a common presenting symptom during viral infections of the central nervous system (CNS) and can occur during the initial phase of infection ("early" or acute symptomatic seizures), after recovery ("late" or spontaneous seizures, indicating the development of acquired epilepsy), or both. The development of acute and delayed seizures may have shared as well as unique pathogenic mechanisms and prognostic implications. Based on an extensive review of the literature, we present an overview of viruses that are associated with early and late seizures in humans. We then describe potential pathophysiologic mechanisms underlying ictogenesis and epileptogenesis, including routes of neuroinvasion, viral control and clearance, systemic inflammation, alterations of the blood-brain barrier, neuroinflammation, and inflammation-induced molecular reorganization of synapses and neural circuits. We provide clinical and animal model findings to highlight commonalities and differences in these processes across various neurotropic or neuropathogenic viruses, including herpesviruses, SARS-CoV-2, flaviviruses, and picornaviruses. In addition, we extensively review the literature regarding Theiler's murine encephalomyelitis virus (TMEV). This picornavirus, although not pathogenic for humans, is possibly the best-characterized model for understanding the molecular mechanisms that drive seizures, epilepsy, and hippocampal damage during viral infection. An enhanced understanding of these mechanisms derived from the TMEV model may lead to novel therapeutic interventions that interfere with ictogenesis and epileptogenesis, even within non-infectious contexts.
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Affiliation(s)
- Wolfgang Löscher
- Department of Pharmacology, Toxicology and Pharmacy, University of Veterinary Medicine, Hannover, Germany,Center for Systems Neuroscience, Hannover, Germany,*Correspondence: Wolfgang Löscher,
| | - Charles L. Howe
- Division of Experimental Neurology, Department of Neurology, Mayo Clinic, Rochester, MN, United States,Center for Multiple Sclerosis and Autoimmune Neurology, Mayo Clinic, Rochester, MN, United States
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Périn B, Szurhaj W. New onset refractory status epilepticus: State of the art. Rev Neurol (Paris) 2022; 178:74-83. [PMID: 35031143 DOI: 10.1016/j.neurol.2021.12.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 12/14/2021] [Indexed: 12/11/2022]
Abstract
NORSE (new onset refractory status epilepticus) has recently been defined as a clinical presentation, not a specific diagnosis, in a patient without active epilepsy or other preexisting relevant neurological disorder, with new onset of refractory status epilepticus without a clear acute or active structural, toxic or metabolic cause. It includes the concept of FIRES described in children with a similar condition but preceded by a 2-14-day febrile illness. NORSE constitutes the acute phase of an entity preceded by a prodromal phase which may be accompanied by numerous manifestations (febrile episode, behavioural changes, headache, …), and followed by a chronic phase marked by long-term neurological sequelae, cognitive impairment, epilepsy and functional disability. There are many causes of NORSE: autoimmune, infectious, genetic, toxic, … but in half of the cases, despite an exhaustive assessment, the cause remains undetermined. Paraneoplastic and non-paraneoplastic autoimmune encephalitis remains by far the leading cause of NORSE. For these reasons, immunotherapy should be considered rapidly in parallel with the treatment of the status epilepticus, including in cryptogenic NORSE. Good communication with the family is important because the management of the acute phase is long and difficult. Although mortality remains high (11-22%), and sequelae can be severe, the majority of survivors can have a good or fair outcome.
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Affiliation(s)
- B Périn
- Department of clinical neurophysiology, Amiens University Medical Center, France
| | - W Szurhaj
- Department of clinical neurophysiology, Amiens University Medical Center, France; Équipe CHIMERE EA7516, université Picardie Jules-Verne, France.
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Orlandi N, Giovannini G, Mirandola L, Monti G, Marudi A, Mosca F, Lalla A, d'Orsi G, Francavilla M, Meletti S. An ultra-long new onset refractory status epilepticus: Winning the battle but losing the war? Epilepsy Behav Rep 2022; 18:100537. [PMID: 35445189 PMCID: PMC9014360 DOI: 10.1016/j.ebr.2022.100537] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Revised: 03/20/2022] [Accepted: 03/21/2022] [Indexed: 11/29/2022] Open
Abstract
Enduring epileptic seizures can lead to a wide array of neuroradiological and EEG alterations. Even in case of resolution, ultra-long NORSE has severe and disabling consequences. NORSE of unknown etiology is a therapeutic challenge. This case points out the need for disease modifying treatments in NORSE.
New onset refractory status epilepticus (NORSE), is a rare and challenging condition occurring in previously healthy people. The etiology often remains undiscovered and is frequently associated with an unfavorable outcome. We report the electroclinical and neuroradiological evolution of an ultra-long case of NORSE of unknown etiology. A 38-year-old woman with a prodrome of fever, vomiting and diarrhea was admitted to our Intensive Care Unit for refractory convulsive status epilepticus (SE). Her past medical history was unremarkable. Extensive examinations were negative for potential viral, autoimmune and metabolic etiologies. Despite multiple therapeutical attempts with antiseizures medications, anesthetics and immunotherapy, seizures persisted. After nearly 6 months of enduring seizures, SE finally ceased and the patient gradually recovered to a minimum state of awareness. She was then able to communicate through one-word utterances and to understand simple tasks. At a three-years follow-up, she developed multifocal drug-resistant epilepsy, subcortical myoclonus and severe spastic quadraparesis, becoming completely dependent for activities of daily living. To our knowledge, this represents one of the longest cases of NORSE with final status resolution at this time. However, ultra-long SE in this case led to severe and disabling neurological sequelae. Future studies focused on disease modifying treatments for refractory SE are needed.
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Affiliation(s)
- Niccolò Orlandi
- Neurology Unit, OCB Hospital, Azienda Ospedaliera-Universitaria, Modena, Italy
- Department of Biomedical, Metabolic and Neural Science, University of Modena and Reggio Emilia, Modena, Italy
| | - Giada Giovannini
- Neurology Unit, OCB Hospital, Azienda Ospedaliera-Universitaria, Modena, Italy
- PhD Program in Clinical and Experimental Medicine, University of Modena and Reggio Emilia, Modena, Italy
| | - Laura Mirandola
- Department of Biomedical, Metabolic and Neural Science, University of Modena and Reggio Emilia, Modena, Italy
- Neurology Unit, San Giovanni Bosco Hospital, Turin, Italy
| | - Giulia Monti
- Neurology Unit, Ospedale Ramazzini di Carpi, AUSL Modena, Italy
| | - Andrea Marudi
- Intensive Care Unit, OCB Hospital, Azienda Ospedaliera-Universitaria, Modena, Italy
| | - Francesco Mosca
- Intensive Care Unit, OCB Hospital, Azienda Ospedaliera-Universitaria, Modena, Italy
| | - Alessandra Lalla
- Epilepsy Centre – S.C. Neurologia Universitaria, Policlinico Riuniti, Foggia, Italy
| | - Giuseppe d'Orsi
- Neurology Unit, IRCCS Casa Sollievo della Sofferenza, Foggia, Italy
| | | | - Stefano Meletti
- Neurology Unit, OCB Hospital, Azienda Ospedaliera-Universitaria, Modena, Italy
- Department of Biomedical, Metabolic and Neural Science, University of Modena and Reggio Emilia, Modena, Italy
- Corresponding author at: Department of Biomedical, Metabolic, and Neural Sciences, Center for Neurosciences and Neurotechnology, University of Modena and Reggio Emilia, Via Giardini, 1355 – Ospedale Civile S. Agostino Estense, Modena 41126, Italy.
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Arif A, Chavarria Y, Qamar MA, Tebha SS, Butt M, Qamar K, Yosufi A. New-Onset Refractory Status Epilepticus Secondary to COVID-19 Infection in Adults: A Systematic Review. Neuropsychiatr Dis Treat 2022; 18:1951-1961. [PMID: 36065386 PMCID: PMC9440723 DOI: 10.2147/ndt.s381018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2022] [Accepted: 08/20/2022] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND New-onset refractory status epilepticus (NORSE) has been reported in the scientific literature as a phenomenon associated with the COVID-19 infection. Given the resurgence of the newer variants of COVID-19 added with its multi-system manifestations, this project was conducted to study the clinical picture of NORSE secondary to COVID-19 infection. METHODS Three electronic databases were searched using an extensive search strategy from November 2019 to December 2021. Patients reporting NORSE secondary to COVID-19 were included in this review. The status epilepticus severity score (STESS) was calculated by the study authors for individual patients. Statistical analysis was performed using SPSS version 26 with a p-value <0.05 as statistically significant. RESULTS After screening, 12 patients were included in this study with a mean age of 61.6 ± 19.0-year olds. The most common type of status epilepticus reported in our study population was non-convulsive status epilepticus (NCSE) (7 out of 12 patients, 58.3%). The linear regression model revealed that STESS scores were significantly influenced by patients' age (p = 0.004) and intra-hospital occurrence (IHO) of status epilepticus (p = 0.026). Overall, 8 patients (66.7%) were discharged without complications. CONCLUSION Given the observed association of STESS with the aging population and IHO of status epilepticus, special attention is due to the caretakers of this population, while further studies are needed to further build upon this review.
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Affiliation(s)
- Aabiya Arif
- Medical School, Ziauddin University, Karachi, Sindh, Pakistan
| | - Yeny Chavarria
- Department of Neurology, University of California, Irvine, CA, USA
| | | | - Sameer Saleem Tebha
- Department of Neurosurgery and Neurology, Jinnah Medical and Dental College, Karachi, Sindh, Pakistan
| | - Mehwish Butt
- Department of Neurosurgery and Neurology, Jinnah Medical and Dental College, Karachi, Sindh, Pakistan
| | - Khulud Qamar
- Department of Medicine, Dow Medical College, Karachi, Sindh, Pakistan
| | - Abubakr Yosufi
- Medical School, Kabul University of Medical Sciences, Kabul, Afghanistan
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