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Caraballo RH, Gallo A, Reyes G, Flores G, Martín E, Intriago L, Ballesta D. Epileptic spasms in clusters without hypsarrhythmia in infancy and childhood: A single age-dependent type of epilepsy or well-defined epileptic syndrome? Epilepsy Res 2024; 202:107354. [PMID: 38518433 DOI: 10.1016/j.eplepsyres.2024.107354] [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: 01/18/2024] [Revised: 02/26/2024] [Accepted: 03/18/2024] [Indexed: 03/24/2024]
Abstract
OBJECTIVE In this study, we present the electroclinical features and outcomes of 92 patients with epileptic spasms (ES) in clusters without modified or classical hypsarrhythmia that started in either in infancy or in childhood; we compared both groups in terms of electroclinical features, etiology, treatment, evolution, and outcome. METHODS Between June 2000 and July 2022, 92 patients met the electroclinical diagnostic criteria of ES in clusters without hypsarrhythmia. Patients with ES associated with other epileptic encephalopathies including West Syndrome, as well as those with the specific etiology of ES and developmental and epileptic encephalopathy associated with CDKL5 were excluded. RESULTS The patients were divided into two groups based on the age at ES onset: those with ES onset before (Group 1) and those with ES onset after 2 years of age (Group 2). The features of ES and the type of associated seizures before and after ES onset, as well as the interictal and ictal EEG and electromyography findings were similar in both groups. The etiologies were mainly structural (40.2%), genetic (11.9%), and unknown (44.6%) in majority of the patients in both groups. Thirty-one patients were seizure-free, while in the remaining patients the seizures continued. Nine patients (9.8%) with unilateral structural lesions underwent surgery with good results. The neurological abnormalities and developmental findings prior to ES onset depended on the underlying etiology. CONCLUSION Our series of patients may represent a well-defined epileptic syndrome or type of epilepsy with onset in infancy or childhood characterized by ES in clusters without hypsarrhythmia associated with focal and generalized seizures and EEG paroxysms without neurological deterioration.
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Affiliation(s)
- Roberto H Caraballo
- Department of Neurology, Hospital de Pediatría Prof. Dr. Juan P Garrahan, Buenos Aires, Argentina.
| | - Adolfo Gallo
- Department of Neurology, Hospital de Pediatría Prof. Dr. Juan P Garrahan, Buenos Aires, Argentina
| | - Gabriela Reyes
- Department of Neurology, Hospital de Pediatría Prof. Dr. Juan P Garrahan, Buenos Aires, Argentina
| | - Giovana Flores
- Department of Neurology, Hospital de Niños Mario Ortiz Suarez, Santa Cruz, Bolivia
| | - Eugenia Martín
- Genomics Laboratory, Hospital de Pediatría Prof. Dr. Juan P Garrahan, Buenos Aires, Argentina
| | - Lenin Intriago
- Department of Neurology, Hospital de Pediatría Prof. Dr. Juan P Garrahan, Buenos Aires, Argentina
| | - Diego Ballesta
- Department of Neurology, Hospital de Pediatría Prof. Dr. Juan P Garrahan, Buenos Aires, Argentina
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Boothman I, Clayton LM, McCormack M, Driscoll AM, Stevelink R, Moloney P, Krause R, Kunz WS, Diehl S, O’Brien TJ, Sills GJ, de Haan GJ, Zara F, Koeleman BP, Depondt C, Marson AG, Stefansson H, Stefansson K, Craig J, Johnson MR, Striano P, Lerche H, Furney SJ, Delanty N, Sisodiya SM, Cavalleri GL. Testing for pharmacogenomic predictors of ppRNFL thinning in individuals exposed to vigabatrin. Front Neurosci 2023; 17:1156362. [PMID: 37790589 PMCID: PMC10542409 DOI: 10.3389/fnins.2023.1156362] [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: 04/25/2023] [Accepted: 08/25/2023] [Indexed: 10/05/2023] Open
Abstract
Background The anti-seizure medication vigabatrin (VGB) is effective for controlling seizures, especially infantile spasms. However, use is limited by VGB-associated visual field loss (VAVFL). The mechanisms by which VGB causes VAVFL remains unknown. Average peripapillary retinal nerve fibre layer (ppRNFL) thickness correlates with the degree of visual field loss (measured by mean radial degrees). Duration of VGB exposure, maximum daily VGB dose, and male sex are associated with ppRNFL thinning. Here we test the hypothesis that common genetic variation is a predictor of ppRNFL thinning in VGB exposed individuals. Identifying pharmacogenomic predictors of ppRNFL thinning in VGB exposed individuals could potentially enable safe prescribing of VGB and broader use of a highly effective drug. Methods Optical coherence topography (OCT) and GWAS data were processed from VGB-exposed individuals (n = 71) recruited through the EpiPGX Consortium. We conducted quantitative GWAS analyses for the following OCT measurements: (1) average ppRNFL, (2) inferior quadrant, (3) nasal quadrant, (4) superior quadrant, (5) temporal quadrant, (6) inferior nasal sector, (7) nasal inferior sector, (8) superior nasal sector, and (9) nasal superior sector. Using the summary statistics from the GWAS analyses we conducted gene-based testing using VEGAS2. We conducted nine different PRS analyses using the OCT measurements. To determine if VGB-exposed individuals were predisposed to having a thinner RNFL, we calculated their polygenic burden for retinal thickness. PRS alleles for retinal thickness were calculated using published summary statistics from a large-scale GWAS of inner retinal morphology using the OCT images of UK Biobank participants. Results The GWAS analyses did not identify a significant association after correction for multiple testing. Similarly, the gene-based and PRS analyses did not reveal a significant association that survived multiple testing. Conclusion We set out to identify common genetic predictors for VGB induced ppRNFL thinning. Results suggest that large-effect common genetic predictors are unlikely to exist for ppRNFL thinning (as a marker of VAVFL). Sample size was a limitation of this study. However, further recruitment is a challenge as VGB is rarely used today because of this adverse reaction. Rare variants may be predictors of this adverse drug reaction and were not studied here.
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Affiliation(s)
- Isabelle Boothman
- School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
- The SFI Futureneuro Research Centre, Royal College of Surgeons in Ireland, Dublin, Ireland
- The SFI Centre for Research Training in Genomics Data Science, Galway, Ireland
| | - Lisa M. Clayton
- Department of Clinical and Experimental Epilepsy, UCL Queen Square Institute of Neurology, London, United Kingdom
- Chalfont Centre for Epilepsy, Bucks, United Kingdom
| | - Mark McCormack
- School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
| | | | - Remi Stevelink
- Department of Genetics, University Medical Center Utrecht, Utrecht, Netherlands
| | - Patrick Moloney
- School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Roland Krause
- Luxembourg Centre for Systems Biomedicine, University of Luxembourg, Esch-sur-Alzette, Luxembourg
| | - Wolfram S. Kunz
- Division of Neurochemistry, Department of Epileptology, University Bonn Medical Center, Bonn, Germany
| | - Sarah Diehl
- Luxembourg Centre for Systems Biomedicine, University of Luxembourg, Esch-sur-Alzette, Luxembourg
| | - Terence J. O’Brien
- Departments of Neuroscience and Neurology, Central Clinical School, The Alfred Hospital, Monash University, Melbourne, VIC, Australia
| | - Graeme J. Sills
- School of Life Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Gerrit-Jan de Haan
- Stichting Epilepsie Instellingen Nederland (SEIN), Heemstede, Netherlands
| | - Federico Zara
- "IRCCS”G. Gaslini" Institute, Genova, Italy
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa, Genova, Italy
| | - Bobby P. Koeleman
- Department of Genetics, University Medical Center Utrecht, Utrecht, Netherlands
| | - Chantal Depondt
- Department of Neurology, Hôpital Erasme, Hôpital Universitaire de Bruxelles, Université Libre de Bruxelles, Brussels, Belgium
| | - Anthony G. Marson
- Department of Pharmacology and Therapeutics, University of Liverpool, Liverpool, United Kingdom
| | | | | | - John Craig
- Department of Neurology, Royal Victoria Hospital, Belfast Health and Social Care Trust, Belfast, United Kingdom
| | - Michael R. Johnson
- Division of Brain Sciences, Imperial College Faculty of Medicine, London, United Kingdom
| | - Pasquale Striano
- "IRCCS”G. Gaslini" Institute, Genova, Italy
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa, Genova, Italy
| | - Holger Lerche
- Department of Neurology and Epileptology, Hertie Institute for Clinical Brain Research, University of Tübingen, Tübingen, Germany
| | - Simon J. Furney
- Genomic Oncology Research Group, Deptartment of Physiology and Medical Physics, Royal College of Surgeons in Ireland (RCSI), Dublin, Ireland
| | - Norman Delanty
- School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Sanjay M. Sisodiya
- Department of Clinical and Experimental Epilepsy, UCL Queen Square Institute of Neurology, London, United Kingdom
- Chalfont Centre for Epilepsy, Bucks, United Kingdom
| | - Gianpiero L. Cavalleri
- School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
- The SFI Futureneuro Research Centre, Royal College of Surgeons in Ireland, Dublin, Ireland
- The SFI Centre for Research Training in Genomics Data Science, Galway, Ireland
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Maász A, Bodó T, Till Á, Molnár G, Masszi G, Labossa G, Herbert Z, Bene J, Hadzsiev K. Three-Year Follow-Up after Intrauterine mTOR Inhibitor Administration for Fetus with TSC-Associated Rhabdomyoma. Int J Mol Sci 2023; 24:12886. [PMID: 37629066 PMCID: PMC10454323 DOI: 10.3390/ijms241612886] [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: 06/30/2023] [Revised: 08/14/2023] [Accepted: 08/15/2023] [Indexed: 08/27/2023] Open
Abstract
Tuberous sclerosis complex (TSC) is a multisystem disorder characterized by seizures, neuropsychiatric disorders, and tumors of the heart, brain, skin, lungs, and kidneys. We present a three-year follow-up of a patient with TSC-associated rhabdomyoma detected in utero. Genetic examination of the fetus and the parents revealed a de novo variant in the TSC2 gene (c.3037delG, p.Asp1013IlefsTer3). Oral everolimus was initiated in the pregnant mother to regress the fetal tumor, which was successful. To the best of our knowledge, there is very little information regarding the use of everolimus therapy during pregnancy. West-syndrome was diagnosed when the proband was four months old. The symptoms were well-manageable, however temporarily. Therapy-resistant focal seizures were frequent. The patient had good vitals and was under regular cardiological control, showed a balanced circulation, and did not require any medication. Subependymal giant cell astrocytoma (SEGA) identified by regular neuroimaging examinations remained unchanged, which may be a consequence of early intrauterine treatment. Early detection of the pathogenic TSC2 variant, followed by in utero administration of everolimus and early vigabatrin therapy, allowed the detection of a milder developmental delay of the proband. Our study emphasizes how early genetic testing and management of epilepsy are pivotal for proper neurodevelopmental impacts and therapeutic strategies.
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Affiliation(s)
- Anita Maász
- Department of Medical Genetics, Medical School and Clinical Centre, University of Pécs, H-7624 Pécs, Hungary
| | - Tímea Bodó
- Bethesda Children’s Hospital, H-1146 Budapest, Hungary
| | - Ágnes Till
- Department of Medical Genetics, Medical School and Clinical Centre, University of Pécs, H-7624 Pécs, Hungary
| | - Gábor Molnár
- Department of Obstetrics and Gynaecology, Medical School and Clinical Centre, University of Pécs, H-7624 Pécs, Hungary
| | - György Masszi
- Department of Paediatrics, Medical School and Clinical Centre, University of Pécs, H-7624 Pécs, Hungary
| | - Gusztáv Labossa
- Department of Obstetrics and Gynaecology, Medical School and Clinical Centre, University of Pécs, H-7624 Pécs, Hungary
| | - Zsuzsanna Herbert
- Department of Medical Imaging, Medical School and Clinical Centre, University of Pécs, H-7624 Pécs, Hungary
| | - Judit Bene
- Department of Medical Genetics, Medical School and Clinical Centre, University of Pécs, H-7624 Pécs, Hungary
| | - Kinga Hadzsiev
- Department of Medical Genetics, Medical School and Clinical Centre, University of Pécs, H-7624 Pécs, Hungary
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Prezioso G, Chiarelli F, Matricardi S. Efficacy and safety of vigabatrin in patients with tuberous sclerosis complex and infantile epileptic spasm syndrome: a systematic review. Expert Rev Neurother 2023; 23:661-671. [PMID: 37243682 DOI: 10.1080/14737175.2023.2216385] [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: 02/14/2023] [Accepted: 05/17/2023] [Indexed: 05/29/2023]
Abstract
INTRODUCTION Tuberous sclerosis complex (TSC) is a common genetic cause of epilepsy. Infantile epileptic spasm syndrome (IESS) is often the presenting neurologic feature, progressively evolving into refractory epilepsy. Vigabatrin (VGB) is often used in clinical practice as a first-line therapy in TSC with IESS. This systematic review aims to collect and analyze the efficacy data about VGB in TSC cases with IESS, in order to evaluate the strength of evidence in the literature. METHODS A systematic search of trials, observational studies, and case series involving patients with TSC and IESS treated with VGB was performed using MEDLINE, CENTRAL, and the US NIH Clinical Trials Registry. Single case studies, animal and non-English language studies were excluded. Seventeen studies were selected, of which 3 were RCTs and 14 were observational studies. RESULTS An overall response rate of 67% (231/343 responders) resulted from the analysis, with a spasm-free rate restricted to RCTs of 88% (29/33 subjects). CONCLUSIONS Although all the studies analyzed reported beneficial effects of VGB in TSC patients with IESS, with higher response rates in comparison to non-TSC subjects with IESS, a low level of evidence and high heterogeneity do not guarantee sufficient strength for therapeutic recommendations.
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Affiliation(s)
- Giovanni Prezioso
- Pediatric Neurologist, Department of Pediatrics, G. D'Annunzio University, Chieti, Italy
| | - Francesco Chiarelli
- Department of Pediatrics, Department of Pediatrics, G. D'Annunzio University, Chieti, Italy
| | - Sara Matricardi
- Pediatric Neurologist, Department of Pediatrics, G. D'Annunzio University, Chieti, Italy
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Li J, Gao Y, Cao J, Cai F, Zhai X. Efficacy analysis of oral dexamethasone in the treatment of infantile spasms and infantile spasms related Lennox-Gastaut syndrome. BMC Pediatr 2023; 23:255. [PMID: 37217894 DOI: 10.1186/s12887-023-04062-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Accepted: 05/05/2023] [Indexed: 05/24/2023] Open
Abstract
OBJECTIVE Treatment with adrenocorticotropic hormone (ACTH) or a corticosteroid is the first choice for infantile spasms (IS), and vigabatrin is the first choice for children with tuberous sclerosis. Although corticosteroids may be also effective against IS and IS-related Lennox-Gastaut syndrome (LGS), the use of dexamethasone (DEX), a kind of corticosteroid, for these diseases has been rarely reported. This retrospective study aimed to evaluate the efficacy and tolerability of DEX for the treatment of IS and IS-related LGS. METHODS Patients diagnosed as having IS (including patients whose condition evolved to LGS after the failure of early treatment) in our hospital between May 2009 and June 2019 were treated with dexamethasone after failure of prednisone treatment. The oral dose of DEX was 0.15-0.3 mg/kg/d. Thereafter, the clinical efficacy, electroencephalogram (EEG) findings, and adverse effects were observed every 4-12 weeks depending on the individual patient's response. Then, the efficacy and safety of DEX in the treatment of IS and IS-related LGS were retrospectively evaluated. RESULTS Among 51 patients (35 cases of IS; 16 cases of IS-related LGS), 35 cases (68.63%) were identified as responders to DEX treatment, comprising 20 cases (39.22%) and 15 cases (29.41%) with complete control and obvious control, respectively. To discuss the syndromes individually, complete control and obvious control were achieved in 14/35 and 9/35 IS cases and in 6/16 and 6/16 IS-related LGS cases, respectively. During DEX withdrawal, 11 of the 20 patients with complete control relapsed (9/14 IS; 2/6 LGS). The duration of dexamethasone treatment (including weaning) in most of the 35 responders was less than 1 year. However, 5 patients were treated with prolonged, low-dose maintenance therapy, which continued for more than 1.5 years. These 5 patients showed complete control, and 3 patients had no recurrence. Except for one child who died of recurrent asthma and epileptic status 3 months after stopping DEX, there were no serious or life-threatening adverse effects during DEX treatment. CONCLUSION Oral DEX is effective and tolerable for IS and IS-related LGS. all LGS patients were evolved from IS in this study. The conclusion may not apply to patients with other etiology and courses of LGS. Even when prednisone or ACTH is failed, DEX may still be considered as a treatment option. For children who respond to DEX but do not show complete control after 6 months of treatment, prolonged treatment with low-dose DEX administered in the morning might be considered.
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Affiliation(s)
- Jieling Li
- Department of Medical general Ward, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, National Clinical Research Center for Child Health and Disorders, China International Science and Technology Cooperation base of Child development and Critical Disorders, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Yujing Gao
- Department of Medical general Ward, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, National Clinical Research Center for Child Health and Disorders, China International Science and Technology Cooperation base of Child development and Critical Disorders, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Jie Cao
- Department of Medical general Ward, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, National Clinical Research Center for Child Health and Disorders, China International Science and Technology Cooperation base of Child development and Critical Disorders, Children's Hospital of Chongqing Medical University, Chongqing, China.
| | - Fangcheng Cai
- Department of Medical general Ward, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, National Clinical Research Center for Child Health and Disorders, China International Science and Technology Cooperation base of Child development and Critical Disorders, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Xiuquan Zhai
- Chongqing Kindcare Children's Hospital, Chongqing, China
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Jain P, Sahu JK, Horn PS, Chau V, Go C, Mahood Q, Arya R. Treatment of children with infantile spasms: A network meta-analysis. Dev Med Child Neurol 2022; 64:1330-1343. [PMID: 35765990 DOI: 10.1111/dmcn.15330] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 05/28/2022] [Accepted: 05/30/2022] [Indexed: 12/12/2022]
Abstract
AIM We performed a systematic review and network meta-analysis (NMA) to obtain comparative effectiveness estimates and rankings of non-surgical interventions used to treat infantile spasms. METHOD All randomized controlled trials (RCTs) including children 2 months to 3 years of age with infantile spasms (with hypsarrhythmia or hypsarrhythmia variants on electroencephalography) receiving appropriate first-line medical treatment were included. Electroclinical and clinical remissions within 1 month of starting treatment were analyzed. RESULTS Twenty-two RCTs comparing first-line treatments for infantile spasms were reviewed; of these, 17 were included in the NMA. Both frequentist and Bayesian network rankings for electroclinical remission showed that high dose adrenocorticotropic hormone (ACTH), methylprednisolone, low dose ACTH and magnesium sulfate (MgSO4 ) combination, low dose ACTH, and high dose prednisolone were most likely to be the 'best' interventions, although these were not significantly different from each other. For clinical remission, low dose ACTH/MgSO4 combination, high dose ACTH (with/without vitamin B6 ), high dose prednisolone, and low dose ACTH were 'best'. INTERPRETATION Treatments including ACTH and high dose prednisolone are more effective in achieving electroclinical and clinical remissions for infantile spasms. WHAT THIS PAPER ADDS Adrenocorticotropic hormone and high dose prednisolone are more effective than other medications for infantile spasms. Symptomatic etiology decreases the likelihood of remission even after adjusting for treatment lag.
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Affiliation(s)
- Puneet Jain
- Epilepsy Program, Division of Neurology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Jitendra K Sahu
- Pediatric Neurology Unit, Department of Pediatrics, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | - Paul S Horn
- Comprehensive Epilepsy Center, Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Vann Chau
- Neonatal Neurology Program, Division of Neurology, Department of Pediatrics, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Cristina Go
- Epilepsy Program, Division of Neurology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Quenby Mahood
- Hospital Library and Archives, Learning Institute, Toronto, ON, Canada
| | - Ravindra Arya
- Comprehensive Epilepsy Center, Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
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Moosa AN, Velayudam KV, Erdemir G. Electroclinical Features in Epilepsy Surgery Candidates With Epileptic Spasms. J Clin Neurophysiol 2022; 39:552-560. [PMID: 35323129 DOI: 10.1097/wnp.0000000000000907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
SUMMARY Electroclinical features in surgical candidates with epileptic spasms differ significantly from the other focal epilepsy phenotypes. EEG findings tend to be more diffuse and less localizing in children with epileptic spasms. These are illustrated with five case studies to highlight three different categories of findings on interictal and ictal EEG: lateralizing , nonlateralizing , and false lateralizing . Hemihypsarrhythmia on interictal EEG is the most striking lateralizing abnormality that occurs in a minority of surgical candidates. Persistent focal epileptiform discharges in one region or asymmetric physiologic rhythms decreased over the abnormal hemisphere may provide localization clues. Ictal EEG patterns are diffuse and nonlocalizing in over half of the patients. Ictal patterns are best expressed in the posterior head regions even in patients with epileptogenic zone in anterior regions. Semiologically, epileptic spasms tend to be symmetrical in majority of surgical candidates. Asymmetric spasms and coexisting focal seizures (concurrent or remote), when present, may provide localization findings. False lateralizing interictal or ictal EEG abnormalities, paradoxically higher over the healthier hemisphere, occur in the setting of large encephaloclastic/volume loss lesions. In these patients, the diffuse discharges are less expressed over the abnormal hemisphere with less cerebral tissue. Recognition of such false lateralizing findings is important to avoid excluding appropriate surgical candidates based on the EEG findings alone. Epileptogenic lesions are visible on brain MRI in majority of surgical candidates with epileptic spasms. Electroclinical findings are often concordant with the lesion, but discordant findings are not uncommon in children with epileptic spasms.
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Affiliation(s)
- Ahsan N Moosa
- Department of Neurology, The Charles Shor Epilepsy Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, U.S.A
| | - Kohila Vani Velayudam
- Pediatric Epilepsy and CHild Neurology (PEACH Neurology), Duluth, Georgia, U.S.A. ; and
| | - Gozde Erdemir
- Division of Pediatric Neurology, University of Maryland, Baltimore, Maryland, U.S.A
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Ramantani G, Bölsterli BK, Alber M, Klepper J, Korinthenberg R, Kurlemann G, Tibussek D, Wolff M, Schmitt B. Treatment of Infantile Spasm Syndrome: Update from the Interdisciplinary Guideline Committee Coordinated by the German-Speaking Society of Neuropediatrics. Neuropediatrics 2022; 53:389-401. [PMID: 35882373 PMCID: PMC9643068 DOI: 10.1055/a-1909-2977] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
OBJECTIVES The manuscript serves as an update on the current management practices for infantile spasm syndrome (ISS). It includes a detailed summary of the level of current evidence of different treatment options for ISS and gives recommendations for the treatment and care of patients with ISS. METHODS A literature search was performed using the Cochrane and Medline Databases (2014 to July 2020). All studies were objectively rated using the Scottish Intercollegiate Guidelines Network. For recommendations, the evidence from these studies was combined with the evidence from studies used in the 2014 guideline. RECOMMENDATIONS If ISS is suspected, electroencephalography (EEG) should be performed within a few days and, if confirmed, treatment should be initiated immediately. Response to first-line treatment should be evaluated clinically and electroencephalographically after 14 days. The preferred first-line treatment for ISS consists of either hormone-based monotherapy (AdrenoCorticoTropic Hormone [ACTH] or prednisolone) or a combination of hormone and vigabatrin. Children with tuberous sclerosis complex and those with contraindications against hormone treatment should be treated with vigabatrin. If first-line drugs are ineffective, second-line treatment options such as ketogenic dietary therapies, sulthiame, topiramate, valproate, zonisamide, or benzodiazepines should be considered. Children refractory to drug therapy should be evaluated early for epilepsy surgery, especially if focal brain lesions are present. Parents should be informed about the disease, the efficacy and adverse effects of the medication, and support options for the family. Regular follow-up controls are recommended.
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Affiliation(s)
- Georgia Ramantani
- Division of Clinical Neurophysiology and Epilepsy, University Children's Hospital, Zurich, Switzerland,Address for correspondence Georgia Ramantani, MD, PhD Department of Neuropediatrics, Steinwiesstrasse 758032 ZurichSwitzerland
| | - Bigna K. Bölsterli
- Division of Clinical Neurophysiology and Epilepsy, University Children's Hospital, Zurich, Switzerland
| | - Michael Alber
- Department of Pediatric Neurology and Developmental Medicine, University Children's Hospital, Tubingen, Germany
| | - Joerg Klepper
- Department of Pediatrics, Klinikum Aschaffenburg-Alzenau, Aschaffenburg, Germany
| | - Rudolf Korinthenberg
- Department of Neuropediatrics and Muscular Diseases, Centre of Pediatrics and Adolescent Medicine, University Medical Centre, Freiburg, Germany
| | - Gerhard Kurlemann
- St. Bonifatius Hospital Lingen, Children's Hospital, Lingen, Germany
| | - Daniel Tibussek
- Center for Pediatric and Teenage Health Care, Child Neurology, Sankt Augustin, Germany
| | - Markus Wolff
- Department of Pediatric Neurology, Vivantes Hospital Neukölln, Berlin, Germany
| | - Bernhard Schmitt
- Division of Clinical Neurophysiology and Epilepsy, University Children's Hospital, Zurich, Switzerland
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Gowda VK, Hiremath R, Gornale V, Shivappa SK, Benakappa N, Benakappa A. A Randomized Controlled Trial on the Study of Effectiveness and Safety of Hormonal (ACTH) Treatment Alone versus Hormonal (ACTH) with Levetiracetam for Epileptic Spasms. J Neurosci Rural Pract 2022; 13:403-410. [PMID: 35946019 PMCID: PMC9357466 DOI: 10.1055/s-0042-1744469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
Abstract
Background West's syndrome (WS) is a triad of epileptic spasms (ESs), psychomotor delay, and hypsarrhythmia. The treatment of ESs is still controversial. Hence, we designed a randomized controlled trial (RCT) to compare the outcomes in children with WS treated with adrenocorticotropic hormone (ACTH) alone versus ACTH and levetiracetam (LEV).
Objectives To compare the treatment outcomes and side effects in children treated with ACTH alone versus ACTH and LEV.
Methods This prospective randomized controlled trial was conducted from December 2017 to May 2019 in tertiary care center, Bangaluru. Children from 2 months to 5 years of age, diagnosed with WS were included. Fifty children in each group were analyzed for efficacy and side effects.
Results There was no difference in the baseline characteristics in both groups. There was no difference in spasms response at the end of 2 weeks between the groups (88 vs. 82%) with p-value of 0.813. The relapse rates were less in ACTH and LEV group (20%) compared with ACTH alone (22%) but statistically not significant (p > 0.1). There was no difference observed in subsequent epilepsy rates (18%) in ACTH versus 19% in ACTH with LEV group (p > 0.1) and side effects. There was improvement in milestones 48% in ACTH with LEV group versus 37% in ACTH alone however statistically not significant (p > 0.1).
Conclusion There was no difference in children treated with ACTH alone versus ACTH and LEV in terms of control of spasms and subsequent epilepsy rates. The relapse rate is less, and developmental outcome is better in ACTH with LEV group but statistically not significant.
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Affiliation(s)
- Vykuntaraju K. Gowda
- Department of Pediatric Neurology, Indira Gandhi Institute of Child Health, Bengaluru, Karnataka, India
| | - Ranjeetha Hiremath
- Department of Pediatrics, Indira Gandhi Institute of Child Health, Bengaluru, Karnataka, India
| | - Vinod Gornale
- Department of Pediatrics, Indira Gandhi Institute of Child Health, Bengaluru, Karnataka, India
| | - Sanjay K. Shivappa
- Department of Pediatrics, Indira Gandhi Institute of Child Health, Bengaluru, Karnataka, India
| | - Naveen Benakappa
- Department of Pediatrics, Indira Gandhi Institute of Child Health, Bengaluru, Karnataka, India
| | - Asha Benakappa
- Department of Pediatrics, Indira Gandhi Institute of Child Health, Bengaluru, Karnataka, India
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Knupp KG, Coryell J, Singh RK, Gaillard WD, Shellhaas RA, Koh S, Mitchell WG, Harini C, Millichap JJ, May A, Dlugos D, Nickels K, Mytinger JR, Keator C, Yozawitz E, Singhal N, Lockrow J, Thomas JF, Juarez-Colunga E. Comparison of Cosyntropin, Vigabatrin, and Combination Therapy in New-Onset Infantile Spasms in a Prospective Randomized Trial. J Child Neurol 2022; 37:186-193. [PMID: 35044272 DOI: 10.1177/08830738211073400] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objective: In a randomized trial, we aimed to evaluate the efficacy of cosyntropin injectable suspension, 1 mg/mL, compared to vigabatrin for infantile spasms syndrome. An additional arm was included to assess the efficacy of combination therapy (cosyntropin and vigabatrin) compared with cosyntropin monotherapy. Methods: Children (2 months to 2 years) with new-onset infantile spasms syndrome and hypsarhythmia were randomized into 3 arms: cosyntropin, vigabatrin, and cosyntropin and vigabatrin combined. Daily seizures and adverse events were recorded, and EEG was repeated at day 14 to assess for resolution of hypsarhythmia. The primary outcome measure was the composite of resolution of hypsarhythmia and absence of clinical spasms at day 14. Fisher exact test was used to compare outcomes. Results: 37 children were enrolled and 34 were included in the final efficacy analysis (1 withdrew prior to treatment and 2 did not return seizure diaries). Resolution of both hypsarhythmia and clinical spasms was achieved in in 9 of 12 participants (75%) treated with cosyntropin, 1/9 (11%) vigabatrin, and 5/13 (38%) cosyntropin and vigabatrin combined. The primary comparison of cosyntropin versus vigabatrin was significant (64% [95% confidence interval 21, 82], P < .01). Adverse events were reported in all 3 treatment arms: 31 (86%) had an adverse event, 7 (19%) had a serious adverse event, and 15 (42%) had an adverse event of special interest with no difference between treatment arms. Significance: This randomized trial was underpowered because of incomplete enrollment, yet it demonstrated that cosyntropin was more effective for short-term outcomes than vigabatrin as initial treatment for infantile spasms.
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Affiliation(s)
- Kelly G Knupp
- Pediatrics and Neurology, 12225University of Colorado, Anschutz Campus, Aurora, CO, USA
| | - Jason Coryell
- Department of Pediatrics and Neurology, 89020Oregon Health and Sciences University, Portland, Oregon, USA
| | - Rani K Singh
- Department of Pediatrics, Division of Pediatric Neurology, Atrium Health/Levine Children's Hospital, Charlotte, NC, USA
| | - William D Gaillard
- Department of Pediatrics and Neurology, George Washington University, Washington, DC, USA
| | - Renée A Shellhaas
- Department of Pediatrics, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Sookyong Koh
- Department of Pediatrics, Children's Hospital, 12284University of Nebraska Medical Center, Omaha, NE, USA
| | - Wendy G Mitchell
- Neurology Division, Keck School of Medicine, 8785University of Southern California and Children's Hospital Los Angeles, Los Angeles, CA, USA
| | | | - John J Millichap
- Department of Pediatrics and Neurology, Lurie Children's Hospital, Chicago, Illinois, USA
| | - Alison May
- Department of Neurology, Morgan Stanley Children's Hospital, 21611Columbia University Irving Medical Center, New York, NY, USA
| | - Dennis Dlugos
- Departments of Neurology and Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | | | - John R Mytinger
- Department of Pediatrics, Division of Pediatric Neurology, Nationwide Children's Hospital, The Ohio State University, Columbus, OH, USA
| | - Cynthia Keator
- Jane and John Justin Neurosciences, Cook Children's Medical Center, Fort Worth, TX, USA
| | - Elissa Yozawitz
- Isabelle Rapin Division of Child Neurology, Saul R. Korey Department of Neurology, Department of Pediatrics, 550033Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY, USA
| | - Nilika Singhal
- Department of Neurology, Division of Epilepsy, UCSF Benioff Children's Hospital, San Francisco, CA, USA
| | - Jason Lockrow
- Division of Pediatric Neurology, Department of Pediatrics, University of Washington, Seattle, WA, USA
| | - Jacob F Thomas
- School of Medicine, Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado, Aurora, Colorado, USA
| | - Elizabeth Juarez-Colunga
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
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11
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Guang S, Mao L, Zhong L, Liu F, Pan Z, Yin F, Peng J. Hormonal Therapy for Infantile Spasms: A Systematic Review and Meta-Analysis. Front Neurol 2022; 13:772333. [PMID: 35222241 PMCID: PMC8867209 DOI: 10.3389/fneur.2022.772333] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Accepted: 01/06/2022] [Indexed: 11/13/2022] Open
Abstract
ObjectiveThe limitations of adrenocorticotrophic hormone (ACTH) treatment for infantile spasms (ISs), such as high costs, limited availability, and adverse effects (AEs), make it necessary to explore whether corticosteroids are optimal alternatives. Many other compelling treatments have gone through trials due to the suboptimal effectiveness of hormonal therapy. A systematic review and meta-analysis were performed to evaluate the effectiveness and safety of hormonal therapy for patients with ISs.MethodsEMBASE, Ovid MEDLINE, Cochrane Central Register of Controlled Trials (CENTRAL), and online registers were searched through April 2021 for randomized controlled trials (RCTs).ResultsA total of 19 RCTs (N = 1,279) were included. There was no significant difference in the effectiveness of oral corticosteroids and ACTH in electro-clinical response (risk ratio [RR] = 0.85, 95% CI 0.41–1.76). Low-dose ACTH had similar effectiveness in electro-clinical response compared to usual-dose group (RR = 0.94, 95% CI 0.60–1.47) but conferred a lower risk of AEs (RR = 1.71, 95% CI 1.08–2.71). ACTH was more beneficial in controlling spasms than vigabatrin (VGB) (RR = 1.31, 95% CI 1.05–1.64) for patients without tuberous sclerosis complex (TSC). All RCTs were connected through network meta-analysis, and we found that ketogenic diet (KD), zonisamide, methylprednisolone, or combined treatment of hormonal therapy with topiramate (TPM) or pyridoxine was not different in electro-clinical response compared to usual-dose ACTH.ConclusionOur analysis showed that oral corticosteroids could be optional alternatives when ACTH is not applicable, and ACTH is more beneficial for patients without TSC. Moreover, low-dose ACTH is recommended due to comparative effectiveness but lower risk of AEs. However, due to the high heterogeneity of included patients and treatment protocols, these results must be interpreted with caution. RCTs with multicentric involvement and larger sample size are needed for solid evaluation of other alternative treatments.
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12
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Weingarten MM, Cokley JA, Moffett B, DiCarlo S, Misra SN. Trends and Costs Associated With the Diagnosis and Treatment of Infantile Spasms: A 10-Year Multicenter Retrospective Review. J Pediatr Pharmacol Ther 2021; 27:29-37. [PMID: 35002556 PMCID: PMC8717615 DOI: 10.5863/1551-6776-27.1.29] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Accepted: 06/05/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Early treatment of infantile spasms (IS) may be imperative for improvement of neurodevelopmental outcomes. Existing studies have led to inconclusive recommendations with variation in treatment. Our objective was to determine the national average cost, initial diagnostic workup, treatments, and hospital length of stay for patients with IS. METHODS This retrospective cohort study was designed to review data of patients < 2 years from 43 non-profit institutions. Data obtained included patient demographics, length of stay, admission cost, and treatments used from 2004 to 2014. Cost data were collected and adjusted to 2014 dollars, the year data were analyzed. RESULTS A total of 6183 patients met study criteria (n = 3382, 55% male). Three-quarters of patients (n = 4684, 76%) had an electroencephalogram, 56.4% had brain imaging (n = 3487), and 17% (n = 1050) underwent a lumbar puncture. Medication for IS was initiated during inpatient hospital stay in two-thirds of all patients (n = 4139, 67%). Most patients were initiated on corticotropin (n = 2066, 33%) or topiramate (n = 1804, 29%). Average length of stay was 5.8 days with an average adjusted cost of $18,348. Over time there was an 86.6% increase in cost from an average $12,534.54 (2004) to $23,391.20 (2014), a significant change (p < 0.01). This correlated with an increase in average length of stay. CONCLUSIONS Variability exists in diagnostic workup and pharmacotherapy initiated for IS, which may lead to differences in the cost of hospital stay. Further studies may help determine contributing factors to increased cost and improve health care utilization for IS patients.
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Affiliation(s)
| | - Jon A. Cokley
- Baylor College of Medicine, Texas Children's Hospital, Houston, TX (JAC, BM, SD)
| | - Brady Moffett
- Baylor College of Medicine, Texas Children's Hospital, Houston, TX (JAC, BM, SD)
| | - Shannon DiCarlo
- Baylor College of Medicine, Texas Children's Hospital, Houston, TX (JAC, BM, SD)
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Nabbout R, Kuchenbuch M, Chiron C, Curatolo P. Pharmacotherapy for Seizures in Tuberous Sclerosis Complex. CNS Drugs 2021; 35:965-983. [PMID: 34417984 DOI: 10.1007/s40263-021-00835-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/05/2021] [Indexed: 01/18/2023]
Abstract
Epilepsy is one of the main symptoms affecting the lives of individuals with tuberous sclerosis complex (TSC), causing a high rate of morbidity. Individuals with TSC can present with various types of seizures, epilepsies, and epilepsy syndromes that can coexist or appear in relation to age. Focal epilepsy is the most frequent epilepsy type with two developmental and epileptic encephalopathies: infantile spasms syndrome and Lennox-Gastaut syndrome. Active screening and early management of epilepsy is recommended in individuals with TSC to limit its consequences and its impact on quality of life, cognitive outcome and the economic burden of the disease. The progress in the knowledge of the mechanisms underlying epilepsy in TSC has paved the way for new concepts in the management of epilepsy related to TSC. In addition, we are moving from traditional "reactive" and therapeutic choices with current antiseizure medications used after the onset of seizures, to a proactive approach, aimed at predicting and preventing epileptogenesis and the onset of epilepsy with vigabatrin, and to personalized treatments with mechanistic therapies, namely mechanistic/mammalian target of rapamycin inhibitors. Indeed, epilepsy linked to TSC is one of the only epilepsies for which a predictive and preventive approach can delay seizure onset and improve seizure response. However, the efficacy of such interventions on long-term cognitive and psychiatric outcomes is still under investigation.
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Affiliation(s)
- Rima Nabbout
- Reference Centre for Rare Epilepsies, Department of Pediatric Neurology, Necker Enfants Malades University Hospital, APHP, Université de Paris, 149 rue de Sèvres, 75015, Paris, France.
- UMR 1163, Institut National de la Santé et de la Recherche Médicale (INSERM), Imagine Institute, Université de Paris, Paris, France.
| | - Mathieu Kuchenbuch
- Reference Centre for Rare Epilepsies, Department of Pediatric Neurology, Necker Enfants Malades University Hospital, APHP, Université de Paris, 149 rue de Sèvres, 75015, Paris, France
- UMR 1163, Institut National de la Santé et de la Recherche Médicale (INSERM), Imagine Institute, Université de Paris, Paris, France
| | - Catherine Chiron
- Reference Centre for Rare Epilepsies, Department of Pediatric Neurology, Necker Enfants Malades University Hospital, APHP, Université de Paris, 149 rue de Sèvres, 75015, Paris, France
- Institut National de la Santé et de la Recherche Médicale (INSERM), UMR 1141, Neurospin, Gif sur Yvette, France
| | - Paolo Curatolo
- Department of System Medicine, Child Neurology and Psychiatry Unit, Tor Vergata University Hospital, Rome, Italy
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14
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Nelson JA, Demarest S, Thomas J, Juarez-Colunga E, Knupp KG. Evolution of Infantile Spasms to Lennox-Gastaut Syndrome: What Is There to Know? J Child Neurol 2021; 36:752-759. [PMID: 33764203 DOI: 10.1177/08830738211000514] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Children with infantile spasms may develop Lennox-Gastaut syndrome. The diagnostic criteria for Lennox-Gastaut syndrome are vague, and many experts use varying combinations of the following criteria for diagnosis: paroxysmal fast activity on electroencephalography (EEG), slow spike and wave on EEG, developmental delay, multiple seizure types, and nocturnal tonic seizures. Our objective was to determine the prevalence of Lennox-Gastaut syndrome in a high-risk cohort of children with a history of infantile spasms and the characteristics of infantile spasms that were associated with the diagnosis of Lennox-Gastaut syndrome. METHODS Children with infantile spasms who were diagnosed and treated at Children's Hospital Colorado between 2012 and 2018 were included. Lennox-Gastaut syndrome was defined as having 3 of 5 of the following characteristics: paroxysmal fast activity, slow spike and wave, current developmental delay, multiple seizure types, or tonic seizures. Descriptive statistics were performed using median and interquartile range. Univariable analysis was performed with Pearson chi-square, Fisher exact, or the Kruskal-Wallis test. RESULTS Ninety-seven children met inclusion criteria, and 36% (35/97) met criteria for Lennox-Gastaut syndrome. Developmental delay and history of seizures prior to the onset of infantile spasms were identified as risk factors for the development of Lennox-Gastaut syndrome (P = .003) as was poor response to first treatment for spasms (P = .004). Children with an unknown etiology of infantile spasms were less likely to develop Lennox-Gastaut syndrome (P = .019). Eighty percent (28/35) of the children who met Lennox-Gastaut syndrome criteria lacked a documented diagnosis. CONCLUSIONS Thirty-six percent of children with infantile spasms met criteria for Lennox-Gastaut syndrome. Risk factors for development of Lennox-Gastaut syndrome were developmental delay and seizures prior to the onset of infantile spasms and poor response to first treatment for infantile spasms. Children with an unknown etiology of infantile spasms were less likely to develop Lennox-Gastaut syndrome. Eighty percent of the children who met our criteria were not given a documented diagnosis of Lennox-Gastaut syndrome, which highlights the fact that many children may not be receiving a diagnosis of Lennox-Gastaut syndrome. We recommend establishing clear guidelines for the diagnosis of Lennox-Gastaut syndrome to ensure that the diagnosis is being made accurately.
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Affiliation(s)
- Julie A Nelson
- Department of Pediatrics and Neurology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Scott Demarest
- Department of Pediatrics and Neurology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Jake Thomas
- Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Elizabeth Juarez-Colunga
- Department of Biostatistics and Informatics, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Kelly G Knupp
- Department of Pediatrics and Neurology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
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Abstract
OBJECTIVES This research aimed to study the short-term seizure outcomes following treatment with 8 mg/kg/day prednisolone in children with infantile spasms (IS) refractory to vigabatrin. We hypothesized that high-dose prednisolone may result in similar rates of electroclinical remission when compared to published ACTH rates. METHODS All consecutive children with hypsarrhythmia or hypsarrhythmia variant on EEG with/without IS, who had been treated with vigabatrin as first-line anti-seizure medication (ASM) followed by high-dose oral prednisolone (8 mg/kg/day; maximum 60 mg/day) in cases who did not respond to vigabatrin, were included. Clinical and electroclinical response (ECR) at 2 weeks following initiation of treatment and adverse effects were assessed. RESULTS Sixty-five children were included. A genetic etiology was seen in 38.5% cases. Complete ECR was seen in 30.8% (20/65) of the patients 2 weeks after vigabatrin. Complete ECR was noted in 77.8% (35/45) of the patients, 2 weeks after prednisolone initiation in children who failed vigabatrin, and this was sustained at 6 weeks in 66.7% (30/45) patients. Prednisolone was generally well tolerated. CONCLUSIONS High-dose (8 mg/kg/day) oral prednisolone resulted in sustained complete ECR (at 6 weeks) in two-thirds of the children with hypsarrhythmia or hypsarrhythmia variant on EEG with/without parentally reported IS. It was generally well tolerated and found to be safe.
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16
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Di Napoli C, Gennaro A, Lupica C, Falsaperla R, Leonardi R, Garozzo MT, Polizzi A, Praticò AD, Zanghì A, Ruggieri M. TSC1 and TSC2: Tuberous Sclerosis Complex and Its Related Epilepsy Phenotype. JOURNAL OF PEDIATRIC NEUROLOGY 2021. [DOI: 10.1055/s-0041-1727142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
AbstractTuberous sclerosis complex (TSC) is an autosomal dominant disorder characterized by a multisystemic involvement. In TSC, reduced function of TSC1 and TSC2 genes products (hamartin and tuberin, respectively) leads to an hyperactivation of the mechanistic target of rapamycin (mTOR) pathway and to a consequent cell growth dysregulation. In TSC patients, neurological and neuropsychiatric manifestations, especially epilepsy and neuropsychiatric comorbidities such as autism or intellectual disability, represent the most disabling features. In particular, epilepsy occurrs up to 80% of patients, is often drug resistant and is frequently associated with neurological impairment. Due to the burden of this morbidity, different treatment strategies have been proposed with the purpose to make patients epilepsy free, such as the use of different antiepileptic drugs like vigabatrin, carbamazepine, valproic acid, and levetiracetam. More recently, a mTOR inhibitor (i.e. everolimus) has showed promising results in terms of seizures reduction.
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Affiliation(s)
- Claudia Di Napoli
- Postgraduate Training Program in Genetics, Department of Biomedical and Biotechnological Sciences, Section of Genetics, University of Catania, Catania, Italy
| | - Alessia Gennaro
- Postgraduate Training Program in Genetics, Department of Biomedical and Biotechnological Sciences, Section of Genetics, University of Catania, Catania, Italy
| | - Carmelania Lupica
- Postgraduate Training Program in Genetics, Department of Biomedical and Biotechnological Sciences, Section of Genetics, University of Catania, Catania, Italy
| | - Raffaele Falsaperla
- Unit of Pediatrics and Pediatric Emergency, University Hospital “Policlinico Rodolico-San Marco,” Catania, Italy
- Unit of Neonatal Intenstive Care and Neonatology, University Hospital “Policlinico Rodolico-San Marco,” Catania, Italy
| | - Roberta Leonardi
- Department of Clinical and Experimental Medicine, Section of Pediatrics and Child Neuropsychiatry, Unit of Rare Diseases of the Nervous System in Childhood, University of Catania, Catania, Italy
| | - Maria Teresa Garozzo
- Unit of Pediatrics and Pediatric Emergency, Hospital “Cannizzaro,” Catania, Italy
| | - Agata Polizzi
- Chair of Pediatrics, Department of Educational Sciences, University of Catania, Catania, Italy
| | - Andrea D. Praticò
- Department of Clinical and Experimental Medicine, Section of Pediatrics and Child Neuropsychiatry, Unit of Rare Diseases of the Nervous System in Childhood, University of Catania, Catania, Italy
| | - Antonio Zanghì
- Department of General Surgery and Medical-Surgical Specialty, University of Catania, Catania, Italy
| | - Martino Ruggieri
- Chair of Pediatrics, Department of Educational Sciences, University of Catania, Catania, Italy
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Fortini S, Valenzuela GR, Fasulo L, Caraballo R. West syndrome: A study of 26 patients receiving short-term therapy. Epilepsy Behav 2021; 114:107235. [PMID: 32694038 DOI: 10.1016/j.yebeh.2020.107235] [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: 03/24/2020] [Revised: 04/12/2020] [Accepted: 06/05/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVE We describe the electroclinical characteristics of a series of 26 patients with idiopathic West syndrome (WS), who had an excellent response to treatment with vigabatrin (VGB) and corticosteroids alone or in combination. METHODS Evaluating the records of 178 patients with WS studied at Garrahan Hospital, Niño Jesús Hospital, and Clínica San Lucas between January 2005 and June 2017, we selected 26 patients that met the inclusion criteria of idiopathic WS. The inclusion criteria for idiopathic WS were (1) no personal history of disease, (2) normal neurological examination and neurodevelopment, (3) symmetric spasms in clusters not preceded by any other type of seizure, (d) symmetric hypsarrhythmia, (e) normal electroencephalogram (EEG) background, e.g., normal sleep EEG pattern, (f) normal magnetic resonance imaging (MRI) recording, (g) normal neurometabolic and genetic studies, and (h) at least 2 years of follow-up. RESULTS Fifteen boys and 11 girls met the inclusion criteria of idiopathic WS. The current age of the children ranges between 2 years 10 months and 12 years 10 months. Age at first epileptic spasms (ES) ranged from 4 to 11 months, with a mean age of 7 and a median of 7.5 months, respectively; ES were in clusters, bilateral and symmetrical in all cases. Spasms were flexor in nine (34.7%), mixed flexor-extensor in 15 (57.7%), and extensor in three (7.6%). In all patients the EEG showed typical pattern of hypsarrhythmia. CONCLUSION These patients with idiopathic WS who have an excellent response to initial treatment should be treated for a short period of time with adrenocorticotropic hormone (ACTH) and VGB alone or in combination.
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Affiliation(s)
- Sebastián Fortini
- Department of Neurology, Hospital de Pediatría Niño Jesús, Tucumán, Argentina
| | | | - Lorena Fasulo
- Department of Neurology, Clínica San Lucas, Neuquén, Argentina
| | - Roberto Caraballo
- Department of Neurology, Hospital de Pediatría "Prof. Dr. Juan P Garrahan", Buenos Aires, Argentina.
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Riikonen R, Lähdetie J, Kokki H. ACTH Treatment of Infantile Spasms: Low-Moderate- Versus High-Dose, Natural Versus Synthetic ACTH-A Retrospective Cohort Study. Pediatr Neurol 2020; 111:46-50. [PMID: 32951660 DOI: 10.1016/j.pediatrneurol.2020.06.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Revised: 06/06/2020] [Accepted: 06/10/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND High dosages of natural adrenocorticotropic hormone are used in many centers in the United States for the treatment of infantile spasms. However, lower dosages of synthetic adrenocorticotropic hormone (tetracosactide) might be equally efficient as high dosages. We analyzed the treatment options for infantile spasms, especially regarding the adrenocorticotropic hormone dosage and the formulation (natural versus synthetic) and evaluated which options were more effective in a retrospective cohort from 1960 to 1976. METHODS We compared the short-term response rates of patients treated with high dosages of natural adrenocorticotropic hormone (120 IU/day) (N = 31) (Group1) with those of patients treated with low-moderate dosages of natural adrenocorticotropic hormone (40 IU/day) (N = 52) (Group2). We also compared the short-term response rates of patients treated with natural adrenocorticotropic hormone (N = 83) with those of patients treated with synthetic adrenocorticotropic hormone, (N = 23) (Group3). The responses were evaluated clinically and by electroencephalography at two to three weeks after the onset of therapy. RESULTS A response was seen in 24 of 31 children treated with high dosages and in 43 of 52 children treated with low-moderate dosages of natural adrenocorticotropic hormone (P = 0.56). All children with an unknown etiology responded to both high and low-moderate dosages of natural adrenocorticotropic hormone. The proportion of children with a good early response to synthetic adrenocorticotropic hormone (16 of 23) did not differ from the proportion of children with a good early response treated with natural adrenocorticotropic hormone (67 of 83) (P = 0.25). CONCLUSIONS High dosages of adrenocorticotropic hormone are not more effective than low-moderate dosages in the short term for treating infantile spasms. Synthetic adrenocorticotropic hormone is equally effective as natural adrenocorticotropic hormone.
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Affiliation(s)
- Raili Riikonen
- Professor in Child Neurology, Children's Hospital, University of Eastern Finland and Kuopio University Hospital, Kuopio, Finland.
| | - Jaana Lähdetie
- Child Neurologist, University of Turku, University Hospital of Turku, Turku, Finland
| | - Hannu Kokki
- Associated Professor in Anesthesiology and Intensive Care Medicine, School of Medicine, University of Eastern, Kuopio, Finland
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Velíšek L, Velíšková J. Modeling epileptic spasms during infancy: Are we heading for the treatment yet? Pharmacol Ther 2020; 212:107578. [PMID: 32417271 PMCID: PMC7299814 DOI: 10.1016/j.pharmthera.2020.107578] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Accepted: 05/07/2020] [Indexed: 12/22/2022]
Abstract
Infantile spasms (IS or epileptic spasms during infancy) were first described by Dr. William James West (aka West syndrome) in his own son in 1841. While rare by definition (occurring in 1 per 3200-3400 live births), IS represent a major social and treatment burden. The etiology of IS varies - there are many (>200) different known pathologies resulting in IS and still in about one third of cases there is no obvious reason. With the advancement of genetic analysis, role of certain genes (such as ARX or CDKL5 and others) in IS appears to be important. Current treatment strategies with incomplete efficacy and serious potential adverse effects include adrenocorticotropin (ACTH), corticosteroids (prednisone, prednisolone) and vigabatrin, more recently also a combination of hormones and vigabatrin. Second line treatments include pyridoxine (vitamin B6) and ketogenic diet. Additional treatment approaches use rapamycin, cannabidiol, valproic acid and other anti-seizure medications. Efficacy of these second line medications is variable but usually inferior to hormonal treatments and vigabatrin. Thus, new and effective models of this devastating condition are required for the search of additional treatment options as well as for better understanding the mechanisms of IS. Currently, eight models of IS are reviewed along with the ideas and mechanisms behind these models, drugs tested using the models and their efficacy and usefulness. Etiological variety of IS is somewhat reflected in the variety of the models. However, it seems that for finding precise personalized approaches, this variety is necessary as there is no "one-size-fits-all" approach possible for both IS in particular and epilepsy in general.
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Affiliation(s)
- Libor Velíšek
- Departments of Cell Biology & Anatomy, New York Medical College, Valhalla, NY, USA; Departments of Pediatrics, New York Medical College, Valhalla, NY, USA; Departments of Neurology, New York Medical College, Valhalla, NY, USA.
| | - Jana Velíšková
- Departments of Cell Biology & Anatomy, New York Medical College, Valhalla, NY, USA; Departments of Neurology, New York Medical College, Valhalla, NY, USA; Departments of Obstetrics & Gynecology, New York Medical College, Valhalla, NY, USA
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20
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Mao L, Kessi M, Peng P, He F, Zhang C, Yang L, Wu L, Yin F, Peng J. The patterns of response of 11 regimens for infantile spasms. Sci Rep 2020; 10:11509. [PMID: 32661290 PMCID: PMC7359312 DOI: 10.1038/s41598-020-68403-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2020] [Accepted: 06/21/2020] [Indexed: 12/04/2022] Open
Abstract
Infantile spasms (ISs) is a devastating form of an early infantile epileptic encephalopathy. The patterns of response of multiple regimens, and the difference in response rates for the cases who receive first-line therapies on time versus those who receive them after non-first-line therapies are unknown. We performed a study involving 314 ISs cases aiming to investigate the patterns of response of 11 regimens, and the difference in response rates for the cases received first-line therapies as first two regimens versus those who received other drugs prior to first-line options. As a result, the efficacy of each regimen was: the foremost two regimens; 36.99%, third; 10.27%, fourth; 6.16%, fifth; 5.48%, and from the sixth regimen onwards, each additional regimen added ≤ 2% probability of seizure freedom. There was a statistically significant difference in seizure freedom rates between cases received first-line therapies as first or second regimen versus those who received them later. Our study revealed for the first time that in ISs cases, seizure freedom is likely to be observed within the first five regimens, and an early administration of first-line therapies is superior to non-first-line options. These results will aid in management of ISs cases.
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Affiliation(s)
- Leilei Mao
- Department of Pediatrics, Xiangya Hospital, Central South University, Changsha, China
| | - Miriam Kessi
- Department of Pediatrics, Xiangya Hospital, Central South University, Changsha, China
| | - Pan Peng
- Department of Pediatrics, Xiangya Hospital, Central South University, Changsha, China
| | - Fang He
- Department of Pediatrics, Xiangya Hospital, Central South University, Changsha, China
| | - Ciliu Zhang
- Department of Pediatrics, Xiangya Hospital, Central South University, Changsha, China
| | - Lifen Yang
- Department of Pediatrics, Xiangya Hospital, Central South University, Changsha, China
| | - Liwen Wu
- Department of Pediatrics, Xiangya Hospital, Central South University, Changsha, China
| | - Fei Yin
- Department of Pediatrics, Xiangya Hospital, Central South University, Changsha, China.,Hunan Intellectual and Developmental Disabilities Research Center, Changsha, China
| | - Jing Peng
- Department of Pediatrics, Xiangya Hospital, Central South University, Changsha, China. .,Hunan Intellectual and Developmental Disabilities Research Center, Changsha, China.
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21
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Abstract
Children with infantile spasms are likely to have a poor outcome. Outcome measures for infantile spasms include primary response to treatment, relapse of spasms, neurological development, death, and progression to another type of epilepsy (Consensus Statements of the WEST Delphi Group 2004). This review is based mainly on prospective studies and emphasizes data about the current first-line drugs, adrenocorticotropic hormone, vigabatrin, and prednisolone, taking into account the proportion of patients with known and unknown etiology, which has a very strong effect on seizure outcome. In most studies, hormonal treatment (adrenocorticotropic hormone or prednisolone) is the optimal monotherapy, except for patients with tuberous sclerosis complex, in whom vigabatrin appears superior. Combination therapy (hormones plus vigabatrin) may well be more effective than either agent alone. The underlying etiology is the most important prognostic factor. In studies with a long follow-up (up to 50 years), a favorable cognitive outcome has been observed in approximately one quarter of patients and complete seizure freedom in one-third. Autism is relatively frequent, and premature mortality is high throughout life. Modifiable prognostic factors include early recognition of the spasms with prompt treatment, short duration of hypsarrhythmia, prompt treatment of relapses of spasms and multifocal epileptic discharges, and early treatment of adverse effects. It is hoped that eventually advanced genetics and molecular data will allow an understanding of the pathogenetic mechanisms of many specific etiologies to allow disease-specific treatment such as is emerging for tuberous sclerosis.
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Affiliation(s)
- Raili Riikonen
- Children's Hospital, University of Eastern Finland and Kuopio University Hospital, Kuopio, Finland.
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22
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Cannabidiol in treatment of refractory epileptic spasms: An open-label study. Epilepsy Behav 2020; 106:106988. [PMID: 32169600 DOI: 10.1016/j.yebeh.2020.106988] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2019] [Revised: 02/16/2020] [Accepted: 02/17/2020] [Indexed: 10/24/2022]
Abstract
OBJECTIVE This study aimed to evaluate clinical efficacy and safety of purified pharmaceutical cannabidiol (CBD) as an adjunctive therapy in refractory childhood-onset epileptic spasms (ES). METHODS Nine patients with ES were enrolled in an Institutional Review Board (IRB)- and Food and Drug Administration (FDA)-approved expanded access investigational new drug trial. Patients received plant-derived highly purified CBD in oral solution in addition to their baseline medications at an initial dosage of 5 mg/kg/day, which was increased by 5 mg/kg/day every week to an initial target dosage of 25 mg/kg/day. Seizure frequency, adverse event, and parents' subjective reports of cognitive and behavioral changes were recorded after 2 weeks and 1, 2, 3, 6, 9, and 12 months of CBD treatment. Responder rates (percent of patients with >50% reduction in ES frequency from baseline) were calculated. Electrographic changes were studied in relation to CBD initiation and clinical response. RESULTS Overall, the responder rates in 9 patients were 67%, 78%, 67%, 56%, 78%, 78%, and 78% after 2 weeks and 1, 2, 3, 6, 9, and 12 months of CBD treatment, respectively. Three out of nine patients (33%) were ES free after two months of treatment. Parents reported subjective improvements in cognitive and behavioral domains. Side effects, primarily drowsiness, were seen in 89% of patients (n = 8). Eight of the nine (89%) patients had electroencephalographic (EEG) studies prior to and after initiation of CBD. Three out of five patients (60%) had resolution in their hypsarrhythmia pattern. SIGNIFICANCE Purified pharmaceutical CBD may be an effective and safe adjunctive therapy in refractory ES and may also be associated with improvements in electrographic findings.
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23
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Specchio N, Pietrafusa N, Ferretti A, De Palma L, Santarone ME, Pepi C, Trivisano M, Vigevano F, Curatolo P. Treatment of infantile spasms: why do we know so little? Expert Rev Neurother 2020; 20:551-566. [PMID: 32316776 DOI: 10.1080/14737175.2020.1759423] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
INTRODUCTION Infantile spasm (IS) is an epileptic syndrome with typical onset within the first 2 years of life. This condition might be caused by several etiologies. IS is associated with pathological neuronal networks; however, definite hypotheses on neurobiological processes are awaited. AREAS COVERED Changes in NMDA and GABAB receptors and increase of Ca2+ conductance are some of the possible pathophysiological mechanisms. Animal models can help, but most have only some features of IS. Outcome is strongly affected by etiology and the timing of treatment, which relies still on ACTH, oral steroids, and vigabatrin. No significant differences in terms of efficacy have been documented, though a combination of ACTH and vigabatrin seems to be associated with better long-term outcomes. Despite the increasing knowledge about the etiology and pathophysiology of IS, in the last years, no new treatment approaches have been recognized to be able to modify the neurobiological process underlying IS. Precision medicine has far to come in IS. EXPERT OPINION Recently, no new therapeutic options for IS have emerged, probably due to the lack of reliable animal models and to the extreme variability in etiologies. Consequently, the outlook for patients and families is poor and early recognition and intervention remain research priorities.
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Affiliation(s)
- Nicola Specchio
- Rare and Complex Epilepsy Unit, Department of Neuroscience, Bambino Gesù Children's Hospital, IRCCS , Rome, 00165, Italy.,Member of European Reference Network EpiCARE
| | - Nicola Pietrafusa
- Rare and Complex Epilepsy Unit, Department of Neuroscience, Bambino Gesù Children's Hospital, IRCCS , Rome, 00165, Italy
| | - Alessandro Ferretti
- Rare and Complex Epilepsy Unit, Department of Neuroscience, Bambino Gesù Children's Hospital, IRCCS , Rome, 00165, Italy
| | - Luca De Palma
- Rare and Complex Epilepsy Unit, Department of Neuroscience, Bambino Gesù Children's Hospital, IRCCS , Rome, 00165, Italy
| | - Marta Elena Santarone
- Department of Neuroscience, Bambino Gesù Children's Hospital, IRCCS , 00165, Rome, Italy
| | - Chiara Pepi
- Rare and Complex Epilepsy Unit, Department of Neuroscience, Bambino Gesù Children's Hospital, IRCCS , Rome, 00165, Italy.,Child Neurology and Psychiatry Unit, Systems Medicine Department, Tor Vergata University , 00133, Rome, Italy
| | - Marina Trivisano
- Rare and Complex Epilepsy Unit, Department of Neuroscience, Bambino Gesù Children's Hospital, IRCCS , Rome, 00165, Italy
| | - Federico Vigevano
- Member of European Reference Network EpiCARE.,Department of Neuroscience, Bambino Gesù Children's Hospital, IRCCS , 00165, Rome, Italy
| | - Paolo Curatolo
- Child Neurology and Psychiatry Unit, Systems Medicine Department, Tor Vergata University , 00133, Rome, Italy
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24
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McGarry L, Messer R, Cree-Green M, Ray K, Knupp K. Incidence of Hypertension Among Children Treated With Adrenocorticotropic Hormone (ACTH) or Prednisolone for Infantile Spasms. J Child Neurol 2020; 35:215-220. [PMID: 31769329 DOI: 10.1177/0883073819886244] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Children with infantile spasms are often treated with hormonal therapies including adrenocorticotropic hormone (ACTH) and prednisolone. These have numerous systemic side effects including hypertension and, rarely, fatal cardiomyopathy; however, the incidence of these side effects has not been well described. This study aims to quantify the incidence and short-term sequelae of hypertension in this population. A retrospective chart review was performed at a single institution. Children 2 months to 2 years old with newly diagnosed infantile spasms treated from 2013 to 2017 were included. Variables collected included age, sex, etiology and treatment of infantile spasms, documented or missed diagnosis of hypertension, treatment of hypertension, echocardiogram results, referrals for hypertension, and persistence of hypertension 2 to 4 months after treatment. Analyses included descriptive statistics with percentiles, means, and medians. Differences between groups were assessed using Fisher exact tests. Hypertension occurred in 34/77 children (44%) during treatment with ACTH and 4/11 children (36%) during treatment with prednisolone. No child developed hypertension during treatment with nonhormonal therapies. The incidence of hypertension between ACTH and prednisolone groups was not significantly different (P = .75). The incidence of hypertension was significantly higher in the ACTH and prednisolone groups compared to the nonhormonal group (P < .001 for each). Sixteen children received echocardiograms, with no cases of cardiomyopathy. Two children had persistent hypertension at 2 months after discontinuation of hormonal therapy. Hypertension is a very common side effect of hormonal therapy for infantile spasms; however, few developed long-term hypertension and none developed cardiomyopathy. Further study is needed to determine the role of antihypertensive treatment for hormone-related hypertension.
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Affiliation(s)
- Laurel McGarry
- Department of Pediatrics, Division of Neurology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Ricka Messer
- Department of Pediatrics, Division of Neurology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Melanie Cree-Green
- Department of Pediatrics, Division of Endocrinology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Krista Ray
- Department of Pediatrics, Division of Nephrology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Kelly Knupp
- Department of Pediatrics, Division of Neurology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
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25
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Felbamate in the treatment of refractory epileptic spasms. Epilepsy Res 2020; 161:106284. [PMID: 32058261 DOI: 10.1016/j.eplepsyres.2020.106284] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Revised: 01/29/2020] [Accepted: 02/01/2020] [Indexed: 11/24/2022]
Abstract
Several small case series provide conflicting impressions of the efficacy of felbamate for treatment of epileptic spasms. Using a large single-center cohort of children with epileptic spasms, we retrospectively evaluated the efficacy and safety of felbamate. We identified all patients with video-EEG confirmed epileptic spasms who were treated with felbamate at our center. We quantified felbamate exposure by calculating peak and weighted-average weight-based dose. Clinical response was defined as resolution of epileptic spasms for at least 28 days, beginning not more than 3 months after felbamate initiation. Electroclinical response was defined as clinical response accompanied by overnight video-EEG demonstrating freedom from epileptic spasms and hypsarrhythmia. Among a cohort of 476 infants, we identified 62 children who were treated with felbamate, of whom 58 had previously failed treatment with hormonal therapy or vigabatrin. Median peak and weighted-average felbamate dosages were 47 and 40 mg/kg/day, respectively. Five (8%) children were classified as clinical responders and two (3%) children were classified as electroclinical responders. Among 17 patients with latency from epileptic spasms onset to felbamate initiation of less than 12 months, we observed 4 (24%) clinical responders. This study suggests that felbamate may be efficacious for treatment of epileptic spasms and that further rigorous study is warranted.
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26
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van der Poest Clement E, Jansen FE, Braun KPJ, Peters JM. Update on Drug Management of Refractory Epilepsy in Tuberous Sclerosis Complex. Paediatr Drugs 2020; 22:73-84. [PMID: 31912454 DOI: 10.1007/s40272-019-00376-0] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Tuberous sclerosis complex (TSC) is a genetic neurocutaneous disorder with epilepsy as a common and early presenting symptom. The neurological phenotype, however, is variable and unpredictable. Early and refractory seizures, infantile spasms in particular, are associated with a poor neurological outcome. Preliminary data suggests early and aggressive seizure control may mitigate the detrimental neurodevelopmental effects of epilepsy. For infantile spasms, vigabatrin is the first line of treatment, and steroids and classic antiepileptic drugs (AEDs) are suitable for second line. Based on retrospective data, vigabatrin should be considered for other indications, especially in infants with focal seizures, as this may prevent infantile spasms, but also in children and adults with epileptic spasms and tonic seizures. Otherwise, for most seizure types, treatment is similar to that for patients without TSC, including the use of novel AEDs, although limited data are available. Three major developments are changing the field of epilepsy management in TSC. First, final recommendations on preventive treatment with vigabatrin will result from two multicenter trials in the US (PREVeNT, clinicaltrials.gov #NCT02849457) and Europe (EPISTOP, clinicaltrials.gov #NCT02098759). Second, treatment with everolimus, an inhibitor of the mechanistic target of rapamycin (mTOR), reduced seizures when compared to placebo. Further, mTOR inhibitors may have an overall disease-modifying effect. Third, the role of cannabidiol in the treatment of refractory seizures in TSC is yet to be established. With treatment recommendations in TSC, we keep an eye on the prize for the broader field of pediatric epilepsy: the lessons learned from TSC are likely applicable to other epileptic encephalopathies.
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Affiliation(s)
| | - Floor E Jansen
- Department of Child Neurology, University Medical Center Utrecht Brain Center, Utrecht, The Netherlands
| | - Kees P J Braun
- Department of Child Neurology, University Medical Center Utrecht Brain Center, Utrecht, The Netherlands
| | - Jurriaan M Peters
- Division of Epilepsy and Clinical Neurophysiology, Boston Children's Hospital and Harvard Medical School, 300 Longwood Ave, FE9, Boston, 02115, USA.
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27
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Lee M, Kim MJ, Kim EJ, Woo DC, Yum MS, Ko TS. How can methylprednisolone work on epileptic spasms with malformation of cortical development? Eur J Neurosci 2019; 50:4018-4027. [PMID: 31397941 DOI: 10.1111/ejn.14539] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Revised: 07/04/2019] [Accepted: 07/25/2019] [Indexed: 12/15/2022]
Abstract
Although steroids are suggested as the treatment of choice for infantile spasms, the mechanism of action is still unclear. Using a rat model of malformation of cortical development with refractory infantile spasms, we evaluated the efficacy of methylprednisolone on spasms susceptibility and behaviors. Additionally, we investigated the in vivo electrophysiological and neurochemical changes of the brain after methylprednisolone treatment. Infant rats with prenatal exposure of methylazoxymethanol at gestational day 15 were used. After a single dose of methylprednisolone or three different doses of methylprednisolone for 3 days, spasms were triggered by intraperitoneal injection of N-methyl-d-aspartic acid. In rats with 3 days of methylprednisolone pretreatment and their controls, behavioral testing was performed at postnatal day 15. In vivo magnetic resonance imaging was conducted at postnatal day 15 after 3 days of methylprednisolone treatment. The rats with single methylprednisolone pretreatment showed significantly delayed onset of spasms and multiple doses of methylprednisolone significantly suppressed the development of spasms in a dose-dependent manner. After multiple methylprednisolone pretreatment and a cluster of N-methyl-d-aspartic acid-induced spasms, the rats showed significantly increased freezing behaviors to conditioned stimuli. Glutamate-weighted chemical exchange saturation transfer revealed significant elevation of glutamate concentration in the cortices of the rats with multiple methylprednisolone pretreatments. Methylprednisolone pretreatment could attenuate N-methyl-d-aspartic acid-induced spasms with in vivo neurochemical and electrophysiological changes, which indicates this steroid's action on the brain and in epilepsy.
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Affiliation(s)
- Minyoung Lee
- Department of Pediatrics, Asan Medical Center Children's Hospital, Ulsan University College of Medicine, Seoul, Korea
| | - Min-Jee Kim
- Department of Pediatrics, Eulji University Hospital, Eulji University College of Medicine, Daejeon, Korea
| | - Eun-Jin Kim
- Department of Pediatrics, Asan Medical Center Children's Hospital, Ulsan University College of Medicine, Seoul, Korea
| | - Dong-Cheol Woo
- Department of Pediatrics, Asan Medical Center Children's Hospital, Ulsan University College of Medicine, Seoul, Korea
| | - Mi-Sun Yum
- Department of Pediatrics, Asan Medical Center Children's Hospital, Ulsan University College of Medicine, Seoul, Korea
| | - Tae-Sung Ko
- Department of Pediatrics, Asan Medical Center Children's Hospital, Ulsan University College of Medicine, Seoul, Korea
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28
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Abstract
Focal-onset seizures are among the most common forms of seizures in children and adolescents and can be caused by a wide diversity of acquired or genetic etiologies. Despite the increasing array of antiseizure drugs available, treatment of focal-onset seizures in this population remains problematic, with as many as one-third of children having seizures refractory to medications. This review discusses contemporary concepts in focal seizure classification and pathophysiology and describes the antiseizure medications most commonly chosen for this age group. As antiseizure drug efficacy is comparable in children and adults, here we focus on pharmacokinetic aspects, drug-drug interactions, and side effect profiles. Finally, we provide some suggestions for choosing the optimal medication for the appropriate patient.
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Affiliation(s)
- Clare E Stevens
- Division of Pediatric Neurology, Department of Neurology, Johns Hopkins Hospital, The Johns Hopkins University School of Medicine, Rubenstein Bldg 2157, 200N. Wolfe Street, Baltimore, MD, 21287, USA
| | - Carl E Stafstrom
- Division of Pediatric Neurology, Department of Neurology, Johns Hopkins Hospital, The Johns Hopkins University School of Medicine, Rubenstein Bldg 2157, 200N. Wolfe Street, Baltimore, MD, 21287, USA.
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29
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Hahn J, Lee H, Kang HC, Lee JS, Kim HD, Kim SH, Chang MJ. Clobazam as an adjunctive treatment for infantile spasms. Epilepsy Behav 2019; 95:161-165. [PMID: 31059922 DOI: 10.1016/j.yebeh.2019.03.040] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Revised: 03/20/2019] [Accepted: 03/20/2019] [Indexed: 10/26/2022]
Abstract
Infantile spasms constitute a catastrophic epileptic condition. Seizures in approximately half of children with infantile spasms fail to improve with initial treatment attempts; at present, data regarding alternative treatments are limited. We assessed the efficacy of clobazam as an adjunctive therapy in patients whose seizures failed to respond to initial regimens of standard treatment for infantile spasms. All patients from Severance Children's Hospital who received clobazam as adjunctive therapy for infantile spasms were selected for the study. The efficacy of clobazam was evaluated by assessing the daily spasm frequency. Patients were categorized as complete responders if the spasms disappeared within 2 weeks of introducing clobazam, and the patients became spasm-free during weeks 3 and 4. Tolerability was gauged by analyzing adverse events and discontinuation rates. In all, 171 patients qualified for the analysis. Clobazam was introduced after the administration of 2.6 (median; interquartile range [IQR], 1.0-4.0) failed antiepileptic drugs (AEDs), at the age of 8.2 months (IQR, 6.0-10.0 months). After clobazam therapy was initiated, 38 (22.2%) patients became spasm-free for ≥2 weeks. Thirteen out of the 38 complete responders remained spasm-free until the last follow-up and did not require the administration of other AEDs. In 10 patients, the electroencephalogram (EEG) tracings were also within normal limits. These patients were successfully weaned off of all AEDs. Patients with conditions of unknown etiology, who had fewer prior exposures to AEDs, and had not received prior adrenocorticotropic hormone (ACTH)/steroids were more likely to have complete spasm control than the others. Adverse effects were minor, and only 6 of 101 (6%) patients who experienced adverse events had their treatments discontinued during the 3-month follow-up period. The most common adverse events observed were hypersalivation, sedation, and sleep disturbance. Thus, clobazam might be an effective and safe alternative therapeutic option in patients whose seizures failed to respond to initial regimens of standard treatment for infantile spasms. Further prospective studies on clobazam for infantile spasms, focusing on specific good response groups, dosing protocols, and long-term outcome are needed.
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Affiliation(s)
- Jongsung Hahn
- Department of Pharmacy and Yonsei Institute of Pharmaceutical Sciences, College of Pharmacy, Yonsei University, Incheon, Republic of Korea
| | - Hyunji Lee
- Division of Pediatric Neurology, Department of Pediatrics, Epilepsy Research Institute, Severance Children's Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Hoon-Chul Kang
- Division of Pediatric Neurology, Department of Pediatrics, Epilepsy Research Institute, Severance Children's Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Joon Soo Lee
- Division of Pediatric Neurology, Department of Pediatrics, Epilepsy Research Institute, Severance Children's Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Heung Dong Kim
- Division of Pediatric Neurology, Department of Pediatrics, Epilepsy Research Institute, Severance Children's Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Se Hee Kim
- Division of Pediatric Neurology, Department of Pediatrics, Epilepsy Research Institute, Severance Children's Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea.
| | - Min Jung Chang
- Department of Pharmacy and Yonsei Institute of Pharmaceutical Sciences, College of Pharmacy, Yonsei University, Incheon, Republic of Korea.
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30
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Abstract
The treatment of infantile spasms is challenging, especially in the context of the following: (1) a severe phenotype with high morbidity and mortality; (2) the urgency of diagnosis and successful early response to therapy; and (3) the paucity of effective, safe, and well-tolerated therapies. Even after initially successful treatment, relapse risk is substantial and the most effective therapies pose considerable risk with long-term administration. In evaluating any treatment for infantile spasms, the key short-term outcome measure is freedom from both epileptic spasms and hypsarrhythmia. In contrast, the most important long-term outcomes are enduring seizure-freedom and measures of intellectual performance in later childhood and adulthood. First-line treatment options-namely hormonal therapy and vigabatrin-display moderate to high efficacy but also exhibit substantial side-effect burdens. Data on efficacy and safety of each class of therapy, as well as the combination of these therapies, are reviewed in detail. Specific hormonal therapies (adrenocorticotropic hormone and various corticosteroids) are contrasted. Those etiologies that prompt specific therapies are reviewed briefly, as are an array of second-line therapies supported by less-compelling data. The ketogenic diet is discussed in greater detail, with a focus on the limitations of numerous available studies that generally suggest that it is efficacious. Special discussion is allocated to cannabidiol-the investigational therapy that has received the most attention, and which is already in use in the form of various artisanal cannabis extracts. Finally, a treatment algorithm reflecting the concepts and controversies discussed in this review is presented.
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Affiliation(s)
- Shaun A. Hussain
- Division of Pediatric NeurologyDavid Geffen School of MedicineUCLA Mattel Children's HospitalLos AngelesCaliforniaU.S.A.
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31
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Katsarou AM, Li Q, Liu W, Moshé SL, Galanopoulou AS. Acquired parvalbumin-selective interneuronopathy in the multiple-hit model of infantile spasms: A putative basis for the partial responsiveness to vigabatrin analogs? Epilepsia Open 2018; 3:155-164. [PMID: 30564774 PMCID: PMC6293059 DOI: 10.1002/epi4.12280] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/10/2018] [Indexed: 12/13/2022] Open
Abstract
West syndrome, an age-specific epileptic encephalopathy, manifests with infantile spasms (IS) and impaired neurodevelopmental outcomes and epilepsy. The multiple-hit rat model of IS is a chronic model of IS due to structural etiology, in which spasms respond partially to vigabatrin analogs. Using this model, we investigated whether IS due to structural etiology may have deficits in parvalbumin (PRV) and somatostatin (SST) immunoreactive (-ir) interneurons, and calretinin-ir (CR-ir) neurons of the primary somatosensory cortex of postnatal day (PN) 20-24 rats, using specific immunohistochemical assays. PN3 Sprague-Dawley male rats underwent the multiple-hit induction protocol, were monitored until PN20-24, and were transcardially perfused to collect brains for histology. Age-matched sham and naive control male rats were also used. Coronal brain cryosections were stained with anti-PRV, anti-CR, and anti-SST antibodies, and regions of interest (ROIs) from the primary somatosensory cortices were selected to determine PRV-, CR-, and SST-ir cell counts and cortical ROI volumes, with blinding to experimental group. Statistical analyses were done using a linear mixed model accounting for repeated measures. We found PRV-ir interneuronal selective reduction, sparing of the CR-ir and SST-ir neurons, and bilateral cortical atrophy. Our findings provide evidence for acquired PRV-selective interneuronopathy, possibly underlying the pathogenesis of IS, neurodevelopmental deficits, and epilepsy, and potentially contributing to the partial response to vigabatrin analogs in this model.
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Affiliation(s)
- Anna-Maria Katsarou
- Laboratory of Developmental Epilepsy Saul R. Korey Department of Neurology Albert Einstein College of Medicine Bronx New York U.S.A
| | - Qianyun Li
- Laboratory of Developmental Epilepsy Saul R. Korey Department of Neurology Albert Einstein College of Medicine Bronx New York U.S.A
| | - Wei Liu
- Laboratory of Developmental Epilepsy Saul R. Korey Department of Neurology Albert Einstein College of Medicine Bronx New York U.S.A
| | - Solomon L Moshé
- Laboratory of Developmental Epilepsy Saul R. Korey Department of Neurology Albert Einstein College of Medicine Bronx New York U.S.A.,Laboratory of Developmental Epilepsy Isabelle Rapin Division of Child Neurology Dominick P. Purpura Department of Neuroscience Albert Einstein College of Medicine Einstein/Montefiore Epilepsy Center Montefiore Medical Center Bronx New York U.S.A.,Department of Pediatrics Albert Einstein College of Medicine Einstein/Montefiore Epilepsy Center Montefiore Medical Center Bronx New York U.S.A
| | - Aristea S Galanopoulou
- Laboratory of Developmental Epilepsy Saul R. Korey Department of Neurology Albert Einstein College of Medicine Bronx New York U.S.A.,Laboratory of Developmental Epilepsy Isabelle Rapin Division of Child Neurology Dominick P. Purpura Department of Neuroscience Albert Einstein College of Medicine Einstein/Montefiore Epilepsy Center Montefiore Medical Center Bronx New York U.S.A
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Gonzalez-Giraldo E, Stafstrom CE, Stanfield AC, Kossoff EH. Treating Infantile Spasms with High-Dose Oral Corticosteroids: A Retrospective Review of 87 Children. Pediatr Neurol 2018; 87:30-35. [PMID: 30501887 DOI: 10.1016/j.pediatrneurol.2018.06.011] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Revised: 06/14/2018] [Accepted: 06/15/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Hormonal therapy is the treatment of choice in most patients with infantile spasms, but the optimal way to provide this therapy is unclear. Intramuscular adrenocorticotropic hormone (ACTH) has historically used first-line; however, there are significant logistical and financial issues. Our institution has used high-dose prednisolone as the first-line hormonal treatment of infantile spasms since 2006 and published our early experience with 15 infants in 2009. This study updates our institutional experience over more than 10 years of continuous use. METHODS Charts of infants who presented to the Johns Hopkins Hospital with infantile spasms and were treated with high-dose oral prednisolone (40-60 mg/day) from January, 2006 through December, 2016 were reviewed. Electroclinical response was defined as clinical spasm-freedom and resolution of hypsarrhythmia within two weeks of initiation of therapy. Presence of infantile spasms at three months and adverse effects throughout treatment were evaluated. RESULTS Over the 10-year period, 87 infants with new-onset infantile spasms were treated. Electroclinical response occurred in 64% infants within two weeks; 62% were spasm-free at three months. Fifty-two percent had side effects, primarily irritability, weight gain, and gastroesophageal reflux. Five percent had major adverse events, including gastrointestinal bleeding (n = 2), herpes simplex virus reactivation (n = 1), and necrotizing enterocolitis (n = 1). CONCLUSIONS Our results continue to demonstrate that high-dose oral prednisolone is very effective for the treatment of new-onset infantile spasms, with few major adverse effects. Oral prednisolone represents a less expensive, readily available alternative to adrenocorticotropic hormone injections.
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Affiliation(s)
- Ernesto Gonzalez-Giraldo
- Departments of Neurology and Pediatrics, The Johns Hopkins Hospital, Baltimore, Baltimore, Maryland
| | - Carl E Stafstrom
- Departments of Neurology and Pediatrics, The Johns Hopkins Hospital, Baltimore, Baltimore, Maryland
| | - Anthony C Stanfield
- Department of Neurology, The Johns Hopkins Hospital, Baltimore, MD, Baltimore, Maryland
| | - Eric H Kossoff
- Departments of Neurology and Pediatrics, The Johns Hopkins Hospital, Baltimore, Baltimore, Maryland.
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Abel TJ, Losito E, Ibrahim GM, Asano E, Rutka JT. Multimodal localization and surgery for epileptic spasms of focal origin: a review. Neurosurg Focus 2018; 45:E4. [DOI: 10.3171/2018.6.focus18217] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Epileptic spasms (ES) are a common manifestation of intractable epilepsy in early life and can lead to devastating neurodevelopmental consequences. Epilepsy surgery for ES is challenging because of inherent difficulties in localizing the epileptogenic zone in affected infants and children. However, recent clinical series of resective neurosurgery for ES suggest that not only is surgery a viable option for appropriately selected patients, but postoperative seizure outcomes can be similar to those achieved in other types of focal epilepsy. Increased awareness of ES as a potentially focal epilepsy, along with advances in neuroimaging and invasive monitoring technologies, have led to the ability to surgically treat many patients with ES who were previously not considered surgical candidates. In this study, the authors review the current state of epilepsy surgery for ES. Specifically, they address how advances in neuroimaging and invasive monitoring have facilitated patient selection, presurgical evaluation, and ultimately, resection planning.
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Affiliation(s)
- Taylor J. Abel
- 1Division of Neurosurgery, The Hospital for Sick Children, Toronto, Ontario, Canada
- 2Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Emma Losito
- 3Department of Clinical Neurophysiology, APHP, Necker–Enfants Malades Hospital, Paris, France; and
| | - George M. Ibrahim
- 1Division of Neurosurgery, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Eishi Asano
- 4Departments of Pediatrics and Neurology, Children’s Hospital of Michigan, Wayne State University, Detroit, Michigan
| | - James T. Rutka
- 1Division of Neurosurgery, The Hospital for Sick Children, Toronto, Ontario, Canada
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Calderón Romero M, Arce Portillo E, López Lobato M, Muñoz Cabello B, Blanco Martínez B, Madruga Garrido M, Alonso Luego O. Síndrome de West criptogénico: perfil clínico, respuesta al tratamiento y factores pronósticos. An Pediatr (Barc) 2018; 89:176-182. [DOI: 10.1016/j.anpedi.2017.10.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Revised: 10/22/2017] [Accepted: 10/25/2017] [Indexed: 10/18/2022] Open
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Calderón Romero M, Arce Portillo E, López Lobato M, Muñoz Cabello B, Blanco Martínez B, Madruga Garrido M, Alonso Luego O. Cryptogenic West syndrome: Clinical profile, response to treatment and prognostic factors. ANALES DE PEDIATRÍA (ENGLISH EDITION) 2018. [DOI: 10.1016/j.anpede.2017.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
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Abstract
West syndrome (WS), also known as infantile spasms, occurs in infancy with a peak between 4 and 7 months. Spasms, neurodevelopmental regression and hypsarrhythmia on electroencephalogram (EEG) basically define WS. The International League Against Epilepsy commission classifies the aetiologies of WS into genetic, structural, metabolic and unknown. Early diagnosis and a shorter lag time to treatment are essential for the overall outcome of WS patients. These goals are feasible with the addition of brain magnetic resonance imaging (MRI) and genetic and metabolic testing. The present work analysed the medical literature on WS and reports the principal therapeutic protocols of its management. Adrenocorticotropic hormone (ACTH), vigabatrin (VGB) and corticosteroids are the first-line treatments for WS. There is no unique therapeutic protocol for ACTH, but most of the evidence suggests that low doses are as effective as high doses for short-term treatment, which is generally 2 weeks followed by dose tapering. VGB is generally administered at doses from 50 to 150 mg/kg/day, but its related retinal toxicity, which occurs in 21-34% of infants, is most frequently observed when treatment periods last longer than 6 months. Among corticosteroids, a treatment of 14 days of oral prednisolone (40-60 mg/day) has been considered effective and well tolerated. Considering that an early diagnosis and a shorter lag time to treatment are essential for successful outcomes in these patients, further studies on efficacy of the different therapeutic approaches with evaluation of final outcome after cessation of therapy are needed.
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Hartung DM, Johnston K, Cohen DM, Nguyen T, Deodhar A, Bourdette DN. Industry Payments to Physician Specialists Who Prescribe Repository Corticotropin. JAMA Netw Open 2018; 1:e180482. [PMID: 30646086 PMCID: PMC6324413 DOI: 10.1001/jamanetworkopen.2018.0482] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Accepted: 03/30/2018] [Indexed: 12/22/2022] Open
Abstract
Importance Despite great expense and little evidence supporting use over corticosteroids, prescriptions for repository corticotropin (H. P. Acthar Gel; Mallinckrodt Pharmaceuticals) have increased markedly. Aggressive sales tactics and payments from the manufacturer may influence prescribing behavior for this expensive medication. Objective To characterize industry payments to physician specialists who prescribe corticotropin in the Medicare program. Design, Setting, and Participants This study was a cross-sectional analysis of Centers for Medicare & Medicaid Services 2015 Part D prescribing data linked to 2015 Open Payments data. Nephrologists, neurologists, and rheumatologists with more than 10 corticotropin prescriptions (frequent prescribers) in 2015 were included. Exposures Frequency, category, and magnitude of corticotropin-related payments from Mallinckrodt recorded in the Open Payments database. Main Outcomes and Measures Frequency, category, and magnitude of corticotropin-related payments from Mallinckrodt, as well as corticotropin prescriptions and expenditures for Medicare beneficiaries. Results Of the 235 included physicians, 65 were nephrologists; 59, neurologists; and 111, rheumatologists. A majority of frequent corticotropin prescribers (207 [88%]) received corticotropin-related payments from Mallinckrodt. The median (range) total payment for 2015 was $189 ($11-$138 321), with the highest payments ranging from $56 549 to $138 321 across the specialties. More than 20% of frequent prescribers received more than $10 000 and the top quartile of recipients received a median (range) of $33 190 ($9934-$138 321) in total payments per prescriber. Payments for compensation for services other than consulting contributed the most to the total amount. Mallinckrodt payments were positively associated with greater Medicare spending on corticotropin (β = 1.079; 95% CI, 1.044-1.115; P < .001), with every $10 000 in payments associated with a 7.9% increase (approximately $53 000) in Medicare spending on corticotropin. There was no association between corticotropin-related payments and spending on prescriptions for synthetic corticosteroids. Conclusions and Relevance In this study, most nephrologists, neurologists, and rheumatologists who frequently prescribe corticotropin received corticotropin-related payments from Mallinckrodt. These findings suggest that financial conflicts of interest may be driving use of corticotropin in the Medicare program.
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Affiliation(s)
- Daniel M. Hartung
- College of Pharmacy, Oregon State University, Corvallis
- Oregon Health & Science University, Portland
| | - Kirbee Johnston
- College of Pharmacy, Oregon State University, Corvallis
- Oregon Health & Science University, Portland
| | - David M. Cohen
- Division of Nephrology & Hypertension, Department of Medicine, Oregon Health & Science University, Portland
| | - Thuan Nguyen
- School of Public Health, Oregon Health & Science University, Portland
| | - Atul Deodhar
- Division of Arthritis & Rheumatic Diseases, Department of Medicine, Oregon Health & Science University, Portland
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Mazdeh M, Omrani MD, Sayad A, Komaki A, Arsang-Jang S, Taheri M, Ghafouri-Fard S. Expression analysis of cytokine coding genes in epileptic patients. Cytokine 2018; 110:284-287. [PMID: 29396051 DOI: 10.1016/j.cyto.2018.01.017] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2017] [Revised: 01/16/2018] [Accepted: 01/18/2018] [Indexed: 01/02/2023]
Abstract
Epilepsy is a chronic disorder in which immune dysregulation is shown to be involved. Imbalances in the cytokine levels both in serum and brain tissue have been demonstrated in epileptic patients. In the present study, we assessed mRNA expression of TNF-α, TGF-β, IFN-γ, CXCL8, IL-1β, IL-2, 1L-4, IL-6, IL-17 and CXCL8 in blood samples of 40 epileptic patients compared with age- and sex-matched healthy controls by means of quantitative real time PCR. The relative levels of CXCL8 transcripts were significantly higher in total epileptic patients compared with healthy subjects (P = .023). Relative mRNA expression of IFN-γ was significantly higher in female patients compared with female healthy subject (P = .048). In addition, significant correlations have been found between the mRNA levels of mentioned cytokines. Such imbalance between expression of pro-inflammatory and anti-inflammatory cytokines might be implicated in the pathogenesis of epilepsy.
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Affiliation(s)
- Mehrdokht Mazdeh
- Neurophysiology Research Center, Hamadan University of Medical Sciences, Hamadan, Iran
| | - Mir Davood Omrani
- Department of Medical Genetics, Shahid Beheshti University of Medical Sciences, Tehran, Iran; Urogenital Stem Cell Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Arezou Sayad
- Neurophysiology Research Center, Hamadan University of Medical Sciences, Hamadan, Iran
| | - Alierza Komaki
- Neurophysiology Research Center, Hamadan University of Medical Sciences, Hamadan, Iran
| | - Shahram Arsang-Jang
- Department of Biostatistics and Epidemiology, Qom University of Medical Sciences, Qom, Iran
| | - Mohammad Taheri
- Department of Medical Genetics, Shahid Beheshti University of Medical Sciences, Tehran, Iran; Urogenital Stem Cell Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
| | - Soudeh Ghafouri-Fard
- Department of Medical Genetics, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
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Abstract
Childhood epileptic encephalopathies are age-dependent disorders of the brain whose hallmarks include loss of neurologic function over time, abnormal electroencephalographic findings, and seizures. Ictal and interictal electrographic activity are conjointly thought to be at the root of the often devastating neuropsychological deterioration, which is specific to the maturing brain. The goals of treatment are not only to control seizures, but also to prevent or reverse neurologic loss of function. In general, time is of the essence in diagnosis, and experienced specialists should promptly design a treatment plan. Hormonal and immune therapies are at the forefront of treatment in many cases, with traditional antiepileptic drugs and surgery (when an identifiable lesion is present) playing a limited role. However, gold standard evidence for treatment of epileptic encephalopathies remains limited. Ongoing clinical and basic research may lead to better understanding of these catastrophic conditions and to better and more effective therapies.
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Affiliation(s)
- Hiroki Nariai
- Saul R. Korey Department of Neurology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Susan Duberstein
- Saul R. Korey Department of Neurology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA,Department of Pediatrics, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, NY, USA
| | - Shlomo Shinnar
- Saul R. Korey Department of Neurology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA,Department of Pediatrics, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, NY, USA,Department of Epidemiology and Population Health, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, NY, USA
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Rosati A, Ilvento L, Lucenteforte E, Pugi A, Crescioli G, McGreevy KS, Virgili G, Mugelli A, De Masi S, Guerrini R. Comparative efficacy of antiepileptic drugs in children and adolescents: A network meta-analysis. Epilepsia 2017; 59:297-314. [PMID: 29270989 DOI: 10.1111/epi.13981] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/21/2017] [Indexed: 12/22/2022]
Abstract
OBJECTIVE To estimate the comparative efficacy among antiepileptic drugs in the pediatric population (0-18 years). METHODS Using the Embase and MEDLINE databases, we updated to February 2017 the search strategy of the National Institute for Health and Care Excellence guidelines for epilepsy. We only included randomized clinical trials conducted in children and mixed-age populations. According to the PRISMA network meta-analysis guideline, the study-level quality assessment was made with the Cochrane risk-of-bias tool. Three investigators independently selected articles. The efficacy outcome was considered to be seizure freedom or ≥50% seizure reduction. RESULTS We selected 46 randomized clinical trials. A total of 5652 individuals were randomized to 22 antiepileptic drugs and placebo. The point estimates of carbamazepine and lamotrigine efficacy showed their superiority with respect to all comparator antiepileptic drugs for the treatment of newly diagnosed focal epilepsy. In refractory focal epilepsy, levetiracetam (odds ratio [OR] = 3.3, 95% credible interval [CrI] = 1.3-7.6) and perampanel (OR = 2.5, 95% CrI = 1.1-5.8) were more effective compared to placebo. Ethosuximide and valproic acid were both superior to lamotrigine against absence seizures. The OR point estimate showed the superiority of adrenocorticotropic hormone over all comparators in infantile spasms. A wide heterogeneity in the length of follow-up was observed among the studies. SIGNIFICANCE This network meta-analysis suggests that the quality of studies should be improved through the use of comparative designs, relevant outcomes, appropriate follow-up length, and more reliable inclusion criteria.
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Affiliation(s)
- Anna Rosati
- Neuroscience Center of Excellence, Meyer Children's Hospital, University of Florence, Florence, Italy
| | - Lucrezia Ilvento
- Neuroscience Center of Excellence, Meyer Children's Hospital, University of Florence, Florence, Italy
| | - Ersilia Lucenteforte
- Department of Neurosciences, Psychology, Drug Research, and Child Health, University of Florence, Florence, Italy
| | - Alessandra Pugi
- Clinical Trial Office, Meyer Children's Hospital, Florence, Italy
| | - Giada Crescioli
- Department of Neurosciences, Psychology, Drug Research, and Child Health, University of Florence, Florence, Italy
| | - Kathleen S McGreevy
- Research, Innovation, and International Relations Office, Meyer Children's Hospital, Florence, Italy
| | - Gianni Virgili
- Department of Surgery and Translational Medicine, University of Florence, Florence, Italy
| | - Alessandro Mugelli
- Department of Neurosciences, Psychology, Drug Research, and Child Health, University of Florence, Florence, Italy
| | | | - Renzo Guerrini
- Neuroscience Center of Excellence, Meyer Children's Hospital, University of Florence, Florence, Italy
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Yin J, Lu Q, Yin F, Wang Y, He F, Wu L, Yang L, Deng X, Chen C, Peng J. Effectiveness and Safety of Different Once-Daily Doses of Adrenocorticotropic Hormone for Infantile Spasms. Paediatr Drugs 2017; 19:357-365. [PMID: 28421469 DOI: 10.1007/s40272-017-0225-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Adrenocorticotropic hormone (ACTH) has been commonly used as a first-line treatment for infantile spasms (IS), but its optimal dose and duration are still unclear. This study is the largest retrospective cohort to document the therapeutic efficacy and tolerability for three gradient doses of ACTH in IU/kg/day units in Chinese patients. OBJECTIVE The aim of our study was to elucidate the effectiveness and safety of three different low doses and duration of ACTH treatment for IS in China. METHODS We conducted a retrospective, chart review of IS cases that were treated with biologic short-acting ACTH and followed up for at least 6 months at a single center in China between June 2010 and June 2016. In total, 200 children met the inclusion criteria. Cases were divided into three groups according to dosage (1, 1.1-1.9, and 2-4 IU/kg/day). Furthermore, we divided the 2-4 IU/kg/day group into 2-3 and 3.1-4 IU/kg/day subgroups. All groups were evaluated for response rates, relapse rates, and adverse effects. RESULTS Electroclinical remission by day 14 occurred in 41.4% of infants given 2-4 IU/kg/day and 36.4% of infants given 1.1-1.9 IU/kg/day, compared with only 14.7% of patients given 1 IU/kg/day (p = 0.004 and 0.03, respectively). Prolonging ACTH treatment for up to 28 days improved response by 24% in all 200 infants. Overall, 73.9% of infants receiving 2-4 IU/kg/day responded, significantly higher than the 52.7% responding to 1.1-1.9 IU/kg/day and the 23.5% responding to 1 IU/kg/day (p < 0.01). There was no significant difference in the number of relapses or adverse effects in the three groups. Moreover, in the 2-4 IU/kg/day group, 74.7% of children receiving 2-3 IU/kg/day of ACTH responded, compared with 70% who responded to 3.1-4 IU/kg/day (p = 0.78). CONCLUSIONS ACTH at a dosage of 2-3 IU/kg/day is superior to 1.1-1.9 and 1 IU/kg/day dosages, is as good as a 3.1-4 IU/kg/day dosage in terms of response rate, and causes no more adverse effects or relapses than other dosages. In addition, prolonging the duration of ACTH treatment can improve response.
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Affiliation(s)
- Jinghua Yin
- Department of Dermatology, The Second Xiangya Hospital, Central South University, Changsha, China
- Hunan Key Laboratory of Medical Epigenomics, Changsha, China
| | - Qianjin Lu
- Department of Dermatology, The Second Xiangya Hospital, Central South University, Changsha, China
- Hunan Key Laboratory of Medical Epigenomics, Changsha, China
| | - Fei Yin
- Department of Pediatrics, Xiangya Hospital, Central South University, Xiangya Road 87, Changsha, Hunan, China
- Hunan Intellectual and Developmental Disabilities Research Center, Changsha, China
| | - Ying Wang
- Department of Pediatrics, Xiangya Hospital, Central South University, Xiangya Road 87, Changsha, Hunan, China
- Hunan Intellectual and Developmental Disabilities Research Center, Changsha, China
| | - Fang He
- Department of Pediatrics, Xiangya Hospital, Central South University, Xiangya Road 87, Changsha, Hunan, China
- Hunan Intellectual and Developmental Disabilities Research Center, Changsha, China
| | - Liwen Wu
- Department of Pediatrics, Xiangya Hospital, Central South University, Xiangya Road 87, Changsha, Hunan, China
- Hunan Intellectual and Developmental Disabilities Research Center, Changsha, China
| | - Lifen Yang
- Department of Pediatrics, Xiangya Hospital, Central South University, Xiangya Road 87, Changsha, Hunan, China
- Hunan Intellectual and Developmental Disabilities Research Center, Changsha, China
| | - Xiaolu Deng
- Department of Pediatrics, Xiangya Hospital, Central South University, Xiangya Road 87, Changsha, Hunan, China
- Hunan Intellectual and Developmental Disabilities Research Center, Changsha, China
| | - Chen Chen
- Department of Pediatrics, Xiangya Hospital, Central South University, Xiangya Road 87, Changsha, Hunan, China
- Hunan Intellectual and Developmental Disabilities Research Center, Changsha, China
| | - Jing Peng
- Department of Pediatrics, Xiangya Hospital, Central South University, Xiangya Road 87, Changsha, Hunan, China.
- Hunan Intellectual and Developmental Disabilities Research Center, Changsha, China.
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Jackson MC, Jafarpour S, Klehm J, Thome-Souza S, Coughlin F, Kapur K, Loddenkemper T. Effect of vigabatrin on seizure control and safety profile in different subgroups of children with epilepsy. Epilepsia 2017; 58:1575-1585. [PMID: 28691157 DOI: 10.1111/epi.13836] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/12/2017] [Indexed: 12/01/2022]
Abstract
OBJECTIVE To evaluate the efficacy and safety of vigabatrin in pediatric epilepsy. METHODS We retrospectively reviewed patients with epilepsy treated with vigabatrin over a 2-year period at a pediatric tertiary center. We assessed the relationship between seizure frequency, etiology, vigabatrin dose, adverse events, medication discontinuation reasons, and electroencephalography (EEG) characteristics. RESULTS One hundred three patients followed at Boston Children's Hospital were treated with vigabatrin and had complete medical records. Within the follow-up interval, 69 (67%) of 103 patients had discontinued vigabatrin therapy. Two patients (1.9%) died during therapy for unknown reasons. Median age at vigabatrin initiation was 8 months (interquartile range [IQR] 5-15). Median starting dose was 48.1 mg/kg per day (IQR 29.8-52.3) with a median target of 100 mg/kg (IQR 81.9-107.9). Median treatment duration was 12.1 months (n = 89, IQR 5.0-22.9) overall, and 13.3 months (IQR 5.2-23.2) for patients who discontinued vigabatrin. The most common reasons for discontinuation were controlled seizures in 31 (43.7%) of 71 and unsatisfactory therapeutic effect in 23 (32.4%) of 71. Median percent seizure reduction from baseline to first follow-up was 83.3% (IQR 27.4-99.8) and 96.7% (IQR 43.3-100) to last follow-up. Twenty-four (38.7%) of 62 patients with a follow-up posttreatment remained seizure-free. Four patients who had initially achieved seizure freedom relapsed. Patients with structural/metabolic etiology had greater median percent seizure reduction at first follow-up than patients with genetic etiology (98.7% vs. 61.4%, respectively, p = 0.001). Hypsarrhythmia resolved after therapy in 18 of 20 (90%, 95% confidence interval [CI] 70-97) patients with pretreatment hypsarrhythmia, and 2 patients presented with hypsarrhythmia posttreatment. Risk of having hypsarrhythmia was reduced by 32% (95% CI 14.9-49.1) posttreatment. SIGNIFICANCE Vigabatrin is efficacious in all seizure types and resolved hypsarrhythmia in most patients. In this series with a median treatment duration of 12.1 months, vigabatrin had a good safety profile with a low rate of discontinuation due to nonophthalmologic and ophthalmologic adverse effects.
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Affiliation(s)
- Michele C. Jackson
- Division of Epilepsy and Clinical Neurophysiology; Department of Neurology; Boston Children's Hospital; Harvard Medical School; Boston Massachusetts U.S.A
| | - Saba Jafarpour
- Division of Epilepsy and Clinical Neurophysiology; Department of Neurology; Boston Children's Hospital; Harvard Medical School; Boston Massachusetts U.S.A
| | - Jacquelyn Klehm
- Division of Epilepsy and Clinical Neurophysiology; Department of Neurology; Boston Children's Hospital; Harvard Medical School; Boston Massachusetts U.S.A
| | - Sigride Thome-Souza
- Division of Epilepsy and Clinical Neurophysiology; Department of Neurology; Boston Children's Hospital; Harvard Medical School; Boston Massachusetts U.S.A
- Psychiatry Department; Clinics Hospital-School of Medicine-University of Sao Paulo; Sao Paulo Brazil
| | - Francesca Coughlin
- Division of Epilepsy and Clinical Neurophysiology; Department of Neurology; Boston Children's Hospital; Harvard Medical School; Boston Massachusetts U.S.A
| | - Kush Kapur
- Division of Epilepsy and Clinical Neurophysiology; Department of Neurology; Boston Children's Hospital; Harvard Medical School; Boston Massachusetts U.S.A
| | - Tobias Loddenkemper
- Division of Epilepsy and Clinical Neurophysiology; Department of Neurology; Boston Children's Hospital; Harvard Medical School; Boston Massachusetts U.S.A
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Gipson TT, Johnston MV. New insights into the pathogenesis and prevention of tuberous sclerosis-associated neuropsychiatric disorders (TAND). F1000Res 2017; 6. [PMID: 28663780 PMCID: PMC5473405 DOI: 10.12688/f1000research.11110.1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/07/2017] [Indexed: 01/13/2023] Open
Abstract
Tuberous sclerosis complex (TSC) is a multi-system disorder resulting from mutations in either the TSC1 or TSC2 genes leading to hyperactivation of mechanistic target of rapamycin (mTOR) signaling. TSC is commonly associated with autism (61%), intellectual disability (45%), and behavioral, psychiatric, intellectual, academic, neuropsychological, and psychosocial difficulties that are collectively referred to as TSC-associated neuropsychiatric disorders (TAND). More than 90% of children with TSC have epilepsy, including infantile spasms, and early onset of seizures, especially infantile spasms, is associated with greater impairment in intellectual development compared with individuals with TSC without seizures. Development of the mTOR inhibitors everolimus and sirolimus has led to considerable progress in the treatment of renal angiomyolipomata, pulmonary lymphangioleiomyomatosis, and subependymal giant cell astrocytomas in the brain. However, similar therapeutic progress is needed in the treatment of TAND.
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Affiliation(s)
- Tanjala T Gipson
- Boling Center for Developmental Disabilities, LeBonheur Children's Hospital, University of Tennessee Health Sciences Center, Memphis, TN, USA
| | - Michael V Johnston
- Kennedy Krieger Institute, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Abstract
OBJECTIVES West syndrome (also known as infantile spasm because of its main seizure type) is a rare form of epilepsy that begins during early infancy. Recent guidelines and reviews on West syndrome recommend the use of adrenocorticotropic hormone steroids, or vigabatrin, as the first-line treatment. However, West syndrome remains to be one of the most challenging epilepsies to treat. Here, we systematically reviewed the current literature obtained during the previous decade. This article provides an overview of the current treatment of infantile spasms. METHODS PubMed and EMBASE were searched to retrieve studies on human published during 2005-2015 and to identify patients with clinical diagnosis of infantile spasms. Drug or diet treatments were used as interventions and comparators. RESULTS We included 55 studies, of which 1 study was a meta-analysis, 9 were randomized controlled trials, 21 were prospective studies, and 24 were retrospective studies. Topiramate, levetiracetam, zonisamide, and sodium valproate with benzodiazepine (clonazepam or nitrazepam) were found to be potential drugs for treating West syndrome besides adrenocorticotropic hormone, steroids, and vigabatrin. Ketogenic diet and modified Atkins diet were also found to be effective. CONCLUSIONS To date, data regarding the efficacy of treatments of West syndrome still remain limited. Some treatments, including topiramate and ketogenic diet, seem promising besides adrenocorticotropic hormone, steroids, and vigabatrin. Well-designed trials are warranted to validate the findings.
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Wilmshurst JM, Ibekwe RC, O’Callaghan FJ. Epileptic spasms — 175 years on: Trying to teach an old dog new tricks. Seizure 2017; 44:81-86. [DOI: 10.1016/j.seizure.2016.11.021] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2016] [Accepted: 11/30/2016] [Indexed: 10/20/2022] Open
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Yilmaz S, Tekgul H, Serdaroglu G, Akcay A, Gokben S. Evaluation of ten prognostic factors affecting the outcome of West syndrome. Acta Neurol Belg 2016; 116:519-527. [PMID: 26850102 DOI: 10.1007/s13760-016-0611-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2015] [Accepted: 01/21/2016] [Indexed: 11/26/2022]
Abstract
The aim of this study is to assess the seizure and developmental outcome and to determine the prognostic factors affecting the outcome of West syndrome in an etiologically well-defined large cohort. Demographic features, treatment modalities, etiology, seizure and developmental outcome of 216 cases with West syndrome were recorded retrospectively. Ten prognostic factors possibly affecting the outcome of West syndrome including (1) gender, (2) age at the onset (3) presence of seizures prior to spasms, (4) presence of asymmetric spasm, (5) presence of abnormal neurological signs, (6) treatment lag, (7) etiology, (8) drug chosen as the initial treatment, (9) response to initial treatment regardless of the kind, (10) development of other seizure types after spasms were evaluated in terms of seizure and developmental outcome. Twelve percent of the cases were developmentally normal at the end of 2-year follow-up. Ongoing seizures requiring antiepileptic drug medication at the last follow-up were noted in 90 % of the cases. Hypoxia (29 %), metabolic disorders (11 %), infectious diseases (9 %) and cerebral developmental disorders (8 %) were the most frequent etiological factors. Five of the ten prognostic factors (presence of seizures prior to spasms, presence of abnormal neurological signs, response to initial treatment regardless of the kind, etiology and development of other seizure types after spasms) were found to be statistically significant prognostic factors predicting the outcome. In conclusion, West syndrome is still a catastrophic epileptic encephalopathy. Preventable causes still constitute a substantial portion of the etiological causes of West syndrome. Therefore, the prevention of avoidable causes is at least as important as the treatment.
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Affiliation(s)
- Sanem Yilmaz
- Division of Child Neurology, Department of Pediatrics, Ege University Faculty of Medicine, Bornova, 35100, Izmir, Turkey.
| | - Hasan Tekgul
- Division of Child Neurology, Department of Pediatrics, Ege University Faculty of Medicine, Bornova, 35100, Izmir, Turkey
| | - Gul Serdaroglu
- Division of Child Neurology, Department of Pediatrics, Ege University Faculty of Medicine, Bornova, 35100, Izmir, Turkey
| | - Ayfer Akcay
- Division of Child Neurology, Department of Pediatrics, Ege University Faculty of Medicine, Bornova, 35100, Izmir, Turkey
| | - Sarenur Gokben
- Division of Child Neurology, Department of Pediatrics, Ege University Faculty of Medicine, Bornova, 35100, Izmir, Turkey
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Abstract
Infantile spasms, and specifically within the context of West syndrome , is one of the most common epileptic encephalopathies to occur in early infancy. Early recognition and treatment can improve neurodevelopmental outcome in some cases, although the underlying aetiology is probably the most important prognostic factor in both spasm suppression and developmental outcome. Corticosteroids, either adrenocorticotrophic hormone (ACTH) or prednisolone, and vigabatrin are currently the preferred first-line treatment options. Vigabatrin is the treatment of choice when the underlying cause is tuberous sclerosis complex (TSC). Emerging evidence suggests that a combination of steroid and vigabatrin may be more effective in the suppression of spasms and resolution of hypsarrhythmia, the electro-encephalographic signal of spasms. Several other anti-epileptic drugs (AEDs) (levetiracetam, nitrazepam, sodium valproate, topiramate, zonisamide) are usually used as add-on or adjunctive treatment in refractory cases. Pyridoxine (or pyridoxal phosphate) and the ketogenic diet are established treatment options in refractory cases. There is some evidence that neuro-active steroids, including ganaxolone, may be effective; however, clinical trials undertaken intermittently for over a decade have yet to prove their efficacy, not only for the suppression of infantile spasms but also for the resolution of hypsarrhythmia, which may be as important as seizure control in developmental outcome in these children. Insights into developing novel treatment options have emerged from rodent models of infantile spasms, and research is continuing into the efficacy of rapamycin in improving outcomes in infantile spasms. This review provides a brief overview of the existing scientific literature around treatment options and outlines emerging newer treatment options in infantile spasms.
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Affiliation(s)
- Anand Iyer
- The Roald Dahl Department of Neurophysiology, Alder Hey in the Park Children's NHS Foundation Trust, Eaton Road, Liverpool, L12 2AP, UK.
| | - Richard Appleton
- The Roald Dahl Department of Neurophysiology, Alder Hey in the Park Children's NHS Foundation Trust, Eaton Road, Liverpool, L12 2AP, UK
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Knupp KG, Leister E, Coryell J, Nickels KC, Ryan N, Juarez-Colunga E, Gaillard WD, Mytinger JR, Berg AT, Millichap J, Nordli DR, Joshi S, Shellhaas RA, Loddenkemper T, Dlugos D, Wirrell E, Sullivan J, Hartman AL, Kossoff EH, Grinspan ZM, Hamikawa L. Response to second treatment after initial failed treatment in a multicenter prospective infantile spasms cohort. Epilepsia 2016; 57:1834-1842. [PMID: 27615012 DOI: 10.1111/epi.13557] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/11/2016] [Indexed: 01/17/2023]
Abstract
OBJECTIVE Infantile spasms (IS) represent a severe epileptic encephalopathy presenting in the first 2 years of life. Recommended first-line therapies (hormonal therapy or vigabatrin) often fail. We evaluated response to second treatment for IS in children in whom the initial therapy failed to produce both clinical remission and electrographic resolution of hypsarhythmia and whether time to treatment was related to outcome. METHODS The National Infantile Spasms Consortium established a multicenter, prospective database enrolling infants with new diagnosis of IS. Children were considered nonresponders to first treatment if there was no clinical remission or persistence of hypsarhythmia. Treatment was evaluated as hormonal therapy (adrenocorticotropic hormone [ACTH] or oral corticosteroids), vigabatrin, or "other." Standard treatments (hormonal and vigabatrin) were compared to all other nonstandard treatments. We compared response rates using chi-square tests and multivariable logistic regression models. RESULTS One hundred eighteen infants were included from 19 centers. Overall response rate to a second treatment was 37% (n = 44). Children who received standard medications with differing mechanisms for first and second treatment had higher response rates than other sequences (27/49 [55%] vs. 17/69 [25%], p < 0.001). Children receiving first treatment within 4 weeks of IS onset had a higher response rate to second treatment than those initially treated later (36/82 [44%] vs. 8/34 [24%], p = 0.040). SIGNIFICANCE Greater than one third of children with IS will respond to a second medication. Choosing a standard medication (ACTH, oral corticosteroids, or vigabatrin) that has a different mechanism of action appears to be more effective. Rapid initial treatment increases the likelihood of response to the second treatment.
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Affiliation(s)
- Kelly G Knupp
- Department of Pediatrics and Neurology, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, U.S.A
| | - Erin Leister
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, Colorado, U.S.A
| | - Jason Coryell
- Departments of Pediatrics and Neurology, School of Medicine, Oregon Health & Sciences University, Portland, Oregon, U.S.A
| | - Katherine C Nickels
- Departments of Neurology and Pediatrics, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Nicole Ryan
- Division of Neurology, The Children's Hospital of Philadelphia and Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A
| | - Elizabeth Juarez-Colunga
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, Colorado, U.S.A
| | - William D Gaillard
- Center For Neuroscience, Children's National Health System, Washington, District of Columbia, U.S.A
| | - John R Mytinger
- Division of Pediatric Neurology, Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, Ohio, U.S.A
| | - Anne T Berg
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, U.S.A.,Departments of Pediatrics and Neurology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, U.S.A
| | - John Millichap
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, U.S.A.,Departments of Pediatrics and Neurology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, U.S.A
| | - Douglas R Nordli
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, U.S.A.,Departments of Pediatrics and Neurology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, U.S.A
| | - Sucheta Joshi
- Department of Pediatrics & Communicable Diseases (Division of Pediatric Neurology), University of Michigan, Ann Arbor, Michigan, U.S.A
| | - Renée A Shellhaas
- Department of Pediatrics & Communicable Diseases (Division of Pediatric Neurology), University of Michigan, Ann Arbor, Michigan, U.S.A
| | - Tobias Loddenkemper
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Boston, Massachusetts, U.S.A
| | - Dennis Dlugos
- Division of Neurology, The Children's Hospital of Philadelphia and Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A
| | - Elaine Wirrell
- Departments of Neurology and Pediatrics, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Joseph Sullivan
- Departments of Pediatrics and Neurology, University of California San Francisco, San Francisco, California, U.S.A
| | - Adam L Hartman
- Departments of Neurology and Pediatrics, Johns Hopkins Hospital, Baltimore, Maryland, U.S.A
| | - Eric H Kossoff
- Departments of Neurology and Pediatrics, Johns Hopkins Hospital, Baltimore, Maryland, U.S.A
| | - Zachary M Grinspan
- Departments of Pediatrics and Healthcare Policy & Research, Weill Cornell Medical Center, New York, New York, U.S.A
| | - Lorie Hamikawa
- Department of Neurology, University of Washington, Seattle, Washington, U.S.A
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Herbst SM, Proepper CR, Geis T, Borggraefe I, Hahn A, Debus O, Haeussler M, von Gersdorff G, Kurlemann G, Ensslen M, Beaud N, Budde J, Gilbert M, Heiming R, Morgner R, Philippi H, Ross S, Strobl-Wildemann G, Muelleder K, Vosschulte P, Morris-Rosendahl DJ, Schuierer G, Hehr U. LIS1-associated classic lissencephaly: A retrospective, multicenter survey of the epileptogenic phenotype and response to antiepileptic drugs. Brain Dev 2016; 38:399-406. [PMID: 26494205 DOI: 10.1016/j.braindev.2015.10.001] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2015] [Revised: 09/30/2015] [Accepted: 10/01/2015] [Indexed: 11/24/2022]
Abstract
BACKGROUND Patients with LIS1-associated classic lissencephaly typically present with severe psychomotor retardation and drug-resistant epilepsy within the first year. AIM To analyze the epileptogenic phenotype and response to antiepileptic therapy in LIS1-associated classic lissencephaly. METHOD Retrospective evaluation of 22 patients (8 months-24 years) with genetically and radiologically confirmed LIS1-associated classic lissencephaly in 16 study centers. RESULTS All patients in our cohort developed drug-resistant epilepsy. In 82% onset of seizures was noted within the first six months of life, most frequently with infantile spasms. Later in infancy the epileptogentic phenotype became more variable and included different forms of focal seizures as well generalized as tonic-clonic seizures, with generalized tonic-clonic seizures being the predominant type. Lamotrigine and valproate were rated most successful with good or partial response rates in 88-100% of the patients. Both were evaluated significantly better than levetiracetam (p<0.05) and sulthiame (p<0.01) in the neuropediatric assessment and better than levetiracetam, sulthiame (p<0.05) and topiramate (p<0.01) in the family survey. Phenobarbital and vigabatrin achieved good or partial response in 62-83% of the patients. CONCLUSION Our findings suggest that patients with LIS1-associated lissencephaly might benefit most from lamotrigine, valproate, vigabatrin or phenobarbital.
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Affiliation(s)
- Saskia M Herbst
- Center for and Institute of Human Genetics, University of Regensburg, Regensburg, Germany.
| | - Christiane R Proepper
- Center for and Institute of Human Genetics, University of Regensburg, Regensburg, Germany
| | - Tobias Geis
- Department of Pediatric Neurology, Klinik St. Hedwig, University Children's Hospital Regensburg (KUNO), Regensburg, Germany
| | - Ingo Borggraefe
- Department of Pediatric Neurology, Developmental Medicine and Social Pediatrics, Children's Hospital, University of Munich, Munich, Germany
| | | | - Otfried Debus
- Clemenshospital, Children's Hospital, Münster, Germany
| | - Martin Haeussler
- Frühdiagnosezentrum Würzburg, University Children's Hospital, Würzburg, Germany
| | | | - Gerhard Kurlemann
- University Children's Hospital Muenster, Department of General Pediatrics, Neuropediatrics, Münster, Germany
| | - Matthias Ensslen
- Department of Pediatric Neurology, Developmental Medicine and Social Pediatrics, Children's Hospital, University of Munich, Munich, Germany
| | - Nathalie Beaud
- Department of Neuropediatrics, Westküstenklinikum Heide, Heide, Germany
| | - Joerg Budde
- Department of Pediatrics St. Hedwig, St. Josefskrankenhaus Freiburg, Freiburg, Germany
| | | | | | | | - Heike Philippi
- Center of Developmental Neurology Frankfurt, Frankfurt, Germany
| | - Sophia Ross
- Pediatric Neurology, University Children's Hospital Erlangen, Erlangen, Germany
| | | | | | | | - Deborah J Morris-Rosendahl
- Genomic Medicine, National Heart and Lung Institute, Imperial College London, Royal Brompton Hospital, London, United Kingdom
| | - Gerhard Schuierer
- Center for Neuroradiology, Bezirksklinikum Regensburg, University Medical Center, Regensburg, Germany
| | - Ute Hehr
- Center for and Institute of Human Genetics, University of Regensburg, Regensburg, Germany
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50
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Abstract
INTRODUCTION Stiripentol and vigabatrin are the two anticonvulsant drugs currently approved in severe infantile-onset epilepsies, respectively Dravet syndrome and infantile spasms. AREAS COVERED For both, the indication was discovered by chance thanks to an exploratory study. Both demonstrated indisputable efficacy through randomized-controlled trials. Stiripentol as adjunctive therapy to clobazam and valproate performed better than placebo, and vigabatrin as first-line monotherapy better than the reference steroid therapy in spasms due to tuberous sclerosis. At one-year treatment vigabatrin and steroids were equally efficient in the other etiologies of spasms. However, it took more than 20 years for both drugs to be approved world-wide. EXPERT OPINION Stiripentol suffered from pharmacokinetic potentiation of clobazam, thus raising the question whether it was efficient per se. Finally, animal models and pharmacogenetic data on CYP2C19 confirmed its specific anticonvulsant effect. Stiripentol (in comedication with clobazam and valproate) is therefore to be recommended for Dravet patients. Vigabatrin was found to have a frequent and irreversible retinal toxicity, which required an alternative visual testing to be detected in young children. Today the benefit/risk ratio of vigabatrin as first-line is considered to be positive in infantile spasms, given the severity of this epilepsy and the lack of a safer alternative therapy.
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Affiliation(s)
- Catherine Chiron
- a INSERM U1129, Neuropediatric Department , Necker Enfants-Malades Hospital , Paris , France
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