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An Italian consensus on the management of Lennox-Gastaut syndrome. Seizure 2022; 101:134-140. [DOI: 10.1016/j.seizure.2022.07.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Revised: 07/05/2022] [Accepted: 07/07/2022] [Indexed: 11/19/2022] Open
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The role of inflammatory mediators in epilepsy: Focus on developmental and epileptic encephalopathies and therapeutic implications. Epilepsy Res 2021; 172:106588. [PMID: 33721708 DOI: 10.1016/j.eplepsyres.2021.106588] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 01/28/2021] [Accepted: 02/16/2021] [Indexed: 02/06/2023]
Abstract
In recent years, there has been an increasing interest in the potential involvement of neuroinflammation in the pathogenesis of epilepsy. Specifically, the role of innate immunity (that includes cytokines and chemokines) has been extensively investigated either in animal models of epilepsy and in clinical settings. Developmental and epileptic encephalopathies (DEE) are a heterogeneous group of epileptic disorders, in which uncontrolled epileptic activity results in cognitive, motor and behavioral impairment. By definition, epilepsy in DEE is poorly controlled by common antiepileptic drugs but may respond to alternative treatments, including steroids and immunomodulatory drugs. In this review, we will focus on how cytokines and chemokines play a role in the pathogenesis of DEE and why expanding our knowledge about the role of neuroinflammation in DEE may be crucial to develop new and effective targeted therapeutic strategies to prevent seizure recurrence and developmental regression.
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Borrelli S, El Tahry R. Therapeutic approach to Lennox-Gastaut syndrome: a systematic review. Acta Neurol Belg 2019; 119:315-324. [PMID: 31286465 DOI: 10.1007/s13760-019-01185-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Accepted: 07/02/2019] [Indexed: 01/18/2023]
Abstract
Lennox-Gastaut syndrome (LGS) is a rare, age-related syndrome, characterized by multiple seizure types, mental regression, and specific EEG abnormalities. It is one of the most challenging epilepsy: treatment is rarely effective and the final prognosis remains poor, despite the availability of several antiepileptic drugs, validated through well-designed, randomized, controlled trials. However, it is reasonable to consider non-medical treatments, such as surgery, after failure of two-to-three drugs. This review has as goal to describe systematically the different therapeutic options for LGS, including, not only recognized antiepileptic drugs, but also new oral drugs, immune therapy, diet, surgery, and neurostimulation techniques.
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Affiliation(s)
- Serena Borrelli
- Department of Neurology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Av. Hippocrate 10, 1200, Brussels, Belgium.
| | - Riem El Tahry
- Department of Neurology, Center for Refractory Epilepsy, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Av. Hippocrate 10, 1200, Brussels, Belgium
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Bakker DP, Catsman-Berrevoets CE, Neuteboom RF. Effectiveness of a hybrid corticosteroid treatment regimen on refractory childhood seizures and a review of other corticosteroid treatments. Eur J Paediatr Neurol 2015; 19:553-60. [PMID: 25976064 DOI: 10.1016/j.ejpn.2015.04.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2014] [Revised: 02/20/2015] [Accepted: 04/11/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Many different corticosteroid treatment schedules have been used in order to treat refractory epileptic seizures with encouraging effects on seizure reduction in many epileptic syndromes. OBJECTIVE The objective is to report our experience with a hybrid treatment regimen for refractory seizures in children with epilepsies other than West and Landau-Kleffner syndrome. We hypothesized that a pulse of corticosteroids effectively reduces seizures while low-dosage maintenance treatment reduces side effects. The results are compared with results from a review of reported corticosteroid and ACTH treatments. METHODS In this retrospective observational study, 26 children diagnosed with epilepsy with refractory seizures other than West syndrome and Landau-Kleffner syndrome were eligible for a treatment regimen consisting of three days intravenous methylprednisolone (20 mg per kilogram per day) followed by twelve weeks oral prednisolone (0.5 mg per kilogram on alternate days), concluded with a taper phase. Data on effectiveness and side effects were obtained. End-points were the percentages of patients who became seizure free or responded well. RESULTS Twenty-one patients received the study treatment. Nine (43%) responded well and 6 (29%) became seizure free. All but one patient had a relapse of seizures. Four patients had reversible adverse effects. Data extracted from the literature were consistent with a good response in 48% of 192 children treated with different corticosteroids and in 69% of 103 patients treated with ACTH. CONCLUSION This new hybrid therapy of a pulse of intravenous methylprednisolone and alternate day oral prednisolone is effective with a favourable side effect profile. Results on efficacy and safety justify a randomized controlled trial.
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Affiliation(s)
- Dewi P Bakker
- Erasmus University Hospital-Sophia Children's Hospital, The Netherlands
| | | | - Rinze F Neuteboom
- Erasmus University Hospital-Sophia Children's Hospital, The Netherlands.
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Abstract
Several experimental and clinical studies demonstrated an immunologic basis for different forms of epilepsy. A wide range of immune abnormalities have been reported suggesting the existence of various subtypes of epileptic syndromes with different immunopathogenetic mechanisms. This evidence gives rise to the development of immunologic and immunomodulatory treatments such as usage of steroids, plasmapheresis, and intravenous immunoglobulins, which will be discussed briefly in this article.
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Affiliation(s)
- Çiğdem Özkara
- Department of Neurology, Cerrahpasa Medical Faculty, Istanbul University, Istanbul, Turkey.
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Ferrie CD, Patel A. Treatment of Lennox-Gastaut Syndrome (LGS). Eur J Paediatr Neurol 2009; 13:493-504. [PMID: 19211283 DOI: 10.1016/j.ejpn.2008.12.005] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2007] [Revised: 03/03/2008] [Accepted: 12/27/2008] [Indexed: 11/29/2022]
Abstract
Lennox-Gastaut Syndrome (LGS) is a severe form of epilepsy that usually starts in early to mid childhood and is characterized by multiple seizure types, abnormal electroencephalogram with slow spike-and-wave discharges and cognitive problems. Numerous approaches are currently used to treat LGS, including use of conventional antiepileptic drugs (most commonly sodium valproate, lamotrigine and topiramate), other drug interventions (corticosteroids and intravenous immunoglobulin) and nonpharmacologic treatments (ketogenic diet, corpus callosotomy and vagus nerve stimulation). Rufinamide is the most recent antiepileptic drug to have shown efficacy in the treatment of LGS. Despite the variety of therapeutic options, there have been only five double-blind, placebo-controlled clinical trials of antiepileptic drugs in LGS and none of these were head-to-head comparison trials. The evidence supporting the use of available treatments for LGS is, therefore, not robust. Here, we review the evidence supporting the use of specific therapies in LGS and provide recommendations on how to set appropriate treatment goals, select treatments and minimize polypharmacy. A suggested treatment algorithm is presented and discussed. Sodium valproate is recommended for first-line therapy; if seizures persist, alternative interventions should be trialed on an individually tailored basis.
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Affiliation(s)
- Colin D Ferrie
- Department of Paediatric Neurology, Clarendon Wing, Leeds General Infirmary, Leeds LS2 9NS, UK
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Grosso S, Farnetani M, Mostardini R, Cordelli D, Berardi R, Balestri P. A comparative study of hydrocortisone versus deflazacort in drug-resistant epilepsy of childhood. Epilepsy Res 2008; 81:80-5. [PMID: 18524542 DOI: 10.1016/j.eplepsyres.2008.04.016] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2008] [Revised: 04/16/2008] [Accepted: 04/22/2008] [Indexed: 11/26/2022]
Abstract
Steroids are commonly used for the treatment of intractable epilepsy. Deflazacort has shown similar effects to prednisone, but with a less worrying adverse-effect profile. In this study, we first compared the efficacy, safety, and seizure relapse rate of deflazacort versus hydrocortisone in children affected by drug-resistant epilepsies. This was an open, non-blinded, randomized clinical study of 35 children affected by drug-resistant epilepsies. The study lasted 12 months. Group 1 (16 patients) received hydrocortisone for 6 months; group 2 (19 patients) was treated with deflazacort for the entire study period. Drug efficacy and tolerability were evaluated after 6 months of therapy. Seizure relapse rates were evaluated 12 months after the start of the study. After 6 months of therapy, hydrocortisone was effective in 44% of patients (responders, with a decrease in seizure frequency of >50%). Deflazacort was effective in 47% of patients (P=0.9). Adverse events occurred in 37% of patients using hydrocortisone and in none of those using deflazacort (P=0.002). At the end of the study, seizure relapse rate resulted significantly higher in group 1 than in group 2 (P=0.04). Hydrocortisone may be useful in the treatment of severely drug-resistant childhood epilepsies. However, its effects may be transient. Deflazacort should be considered in the therapeutic armamentarium for epileptic encephalopathies. The drug is as effective as hydrocortisone and may be used in therapy for a long period, with a less worrying adverse-effect profile.
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Affiliation(s)
- Salvatore Grosso
- Department of Pediatrics, Pediatric Neurology Section, University of Siena, Viale M. Bracci, Le Scotte, Siena, Italy.
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Abstract
Corticosteroids (predominantly prednisolone and hydrocortisone) and adrenocorticotropic hormone (ACTH) have been used in the treatment of the epilepsies for over 50 years. Over the past 30 years most reports have focused on epilepsy syndromes and epileptic encephalopathies resistant to treatment with the more conventional anticonvulsant and antiepileptic drugs (AEDs) and specifically West syndrome. There has been relatively little attention on the role of corticosteroids in treating other epilepsies.
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Affiliation(s)
- R Gupta
- The Roald Dahl EEG Unit, Department of Neurology, Royal Liverpool Children's NHS Trust (Alder Hey), Liverpool, UK
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Kohyama J, Sugimoto J, Itoh M, Sakuma H, Shimohira M, Hasegawa T, Iwakawa Y. REM sleep components predict the response to initial treatment of infantile spasms. Epilepsia 1999; 40:992-6. [PMID: 10403225 DOI: 10.1111/j.1528-1157.1999.tb00808.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
PURPOSE The phasic inhibition index (PII) is the rate of the simultaneous occurrence of rapid eye movement bursts (RBs) and phasic chin muscle activity (PCMA) during rapid eye movement sleep (REMS). PII is low insofar as physiologically occurring REM-related phasic inhibition acts on chin muscles. Previously we found that PII was significantly higher in patients with infantile spasms (ISs) who had a recurrence of convulsions than in patients with ISs who exhibited no recurrence. We aimed to predict the response of patients with ISs to conventional anticonvulsants (AEDs) by means of REMS components including PII, expecting to facilitate avoidance of potentially hazardous hormonal therapy. METHODS REMS, recorded before the beginning of any medication, was retrospectively examined in 15 patients with ISs. The patients were classified into two groups according to the response to initial treatment with conventional AEDs. Conventional AEDs were enough to control the spasms in six good responders (GRs), whereas further hormonal therapy was required in nine poor responders (PRs) to control the spasms. RESULTS The amount of REMS was significantly lower in patients with ISs than in controls. GRs had less REMS than did PRs, although no significant difference was observed. Although the frequencies of RB and PCMA showed no significant differences among GRs, PRs, and controls, the average PII value in PRs (12.6+/-3.4; mean+/-SD) was significantly (p < 0.001) higher than that in GRs (6.1+/-1.7). CONCLUSIONS PII is a useful parameter for differentiating GRs from PRs.
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Affiliation(s)
- J Kohyama
- Department of Pediatrics, Faculty of Medicine, Tokyo Medical and Dental University, Yushima, Japan
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O'Regan ME, Brown JK, Goodwin GM, Clarke M. Epileptic aphasia: a consequence of regional hypometabolic encephalopathy? Dev Med Child Neurol 1998; 40:508-16. [PMID: 9746002 DOI: 10.1111/j.1469-8749.1998.tb15408.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
A series of 25 children, 13 females and 12 males, who had an acquired communication disorder together with epilepsy, but did not fulfil the strict criteria of the Landau-Kleffner syndrome, was studied. All children had a clinical neurological evaluation, speech and language assessment, an awake and sleep EEG, cranial MRI, SPET scan, and audiometry. Clinical seizures were most often polymorphic in type (17 of 25). Atypical absences were the commonest individual seizure type occurring in 15 cases. All patients had an unequivocal epileptiform EEG. Normal sleep phenomena were only observed in 10 cases, enhancement of epileptiform activity in sleep was seen in 16. Cranial MRI was abnormal in six and normal in 19 cases. The SPET scans were abnormal in 22 of 25 children. The language deficits were classified neurologically as receptive aphasia, 24 of 25; expressive aphasia, 20 of 25; nominal aphasia, eight of 25; articulatory dyspraxia, 10 of 25; and auditory agnosia, nine of 25. It is hypothesized that the loss of communication skills is due to an encephalopathy secondary to the persistent epileptic discharge and manifests as a hypometabolic area on the SPET scan.
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Affiliation(s)
- M E O'Regan
- Department of Paediatric Neurology, Royal Hospital for Sick Children, Edinburgh, UK
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Millichap JG. Mechanism of Anticonvulsant Action of ACTH. Pediatr Neurol Briefs 1998. [DOI: 10.15844/pedneurbriefs-12-3-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
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