Effect of ACTH Therapy for Epileptic Spasms without Hypsarrhythmia

Three Patients of the Early Onset Epileptic Spasms without Hypsarrhythmia

Epileptic spasms without hypsarrhythmia occur when patients do not display hypsarrhythmia on electroencephalogram (EEG) at the onset and throughout the clinical course. We report three patients of epileptic spasms in patients with early onset, all of whom experienced other types of seizures.We detail three patients (two boys and one girl) of epileptic spasms without hypsarrhythmia, occurring between 1 and 3 months of age, with no abnormalities detected on neurometabolic analysis and brain magnetic resonance imaging. Long-term video-EEG monitoring revealed epileptic spasms with focal onset seizures in two patients, and epileptic spasms followed by generalized tonic-clonic seizures in one patient. Hypsarrhythmia was never observed in repeated EEG examinations. Two patients achieved seizure freedom and improved development through treatment with topiramate alone or in combination with valproate, without requiring hormonal therapies or vigabatrin. The remaining patient achieved seizure freedom following administration of antiseizure medications, including topiramate, after a trial of adrenocorticotropic hormone therapy.We report the cases of three patients with early onset epileptic spasms without hypsarrhythmia. All patients achieved seizure freedom after topiramate treatment. Topiramate may be considered as a relatively effective antiseizure medication for early onset epileptic spasms without hypsarrhythmia.

Epileptic spasms in clusters without hypsarrhythmia in infancy and childhood: A single age-dependent type of epilepsy or well-defined epileptic syndrome?

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.

Comparing late-onset epileptic spasm outcomes after corpus callosotomy and subsequent disconnection surgery between post-encephalitis/encephalopathy and non-encephalitis/encephalopathy

OBJECTIVE

We aimed to analyze the efficiency of corpus callosotomy (CC) and subsequent disconnection surgeries in patients with late-onset epileptic spasms (LOES) by comparing post-encephalitis/encephalopathy (PE) and non-encephalitis/encephalopathy (NE). We hypothesized these surgeries can control potential focal onset epileptic spasms (ES) in the NE group but not in the PE group.

METHODS

We retrospectively included 23 patients (12 with PE and 11 with NE) who initially underwent CC and subsequent disconnection surgeries (five NE). We compared the clinical courses, seizure types, MRI, video-EEG, epilepsy surgery, and seizure outcomes between the two groups.

RESULTS

The median age of LOES onset in the PE group was 2.8 (range 1.0-10.1 years) and 2.9 years (range 1.1-12.6) in the NE group. Bilateral MRI abnormalities were observed in both groups (PE, n = 12; NE, n = 3; P < 0.05). The PE group presented ES alone (n = 2), ES + focal seizures (FS) (n = 3), ES + generalized seizures (GS) (n = 3), and ES + FS + GS (n = 4) in addition to stimulus-induced startle seizures (SS) (n = 8) (mean 3.1 seizure types/patient). The NE group presented ES alone (n = 1), ES + FS (n = 2), and ES + FS + GS (n = 8) (mean 2.7 seizure types/patient). In the PE group, CC stopped ES (n = 1) and SS (n = 1) and achieved <50% SS (n = 3). In the NE group, CC achieved immediate ES-free status (n = 2) and < 50% ES (n = 1), and additional disconnection surgeries subsided all seizure types (n = 3) based on lateralized interictal/ictal EEG findings. LOES was significantly remitted by surgery in the NE group (6/11 [55%]) compared with the PE group (1/12 [8%]) (P < 0.05).

SIGNIFICANCE

LOES is a drug-resistant, focal/generalized/unknown onset ES. Lateralization of ES in NE could be achieved after CC and eliminated by further disconnection surgeries because of potential focal onset ES. LOES in PE had little benefit from CC for generalized onset ES. However, CC might reduce SS in patients in the PE group with multiple seizure types.

Electroencephalographic changes in purified pharmaceutical cannabidiol therapy

OBJECTIVE

Evaluate electroencephalographic changes in patients receiving purified pharmaceutical cannabidiol (CBD).

METHODS

A total of 104 EEG studies from 52 patients with pediatric-onset refractory epilepsy, who were enrolled in the FDA-approved expanded access investigational new drug program, were retrospectively analyzed for electroencephalographic changes in the background, interictal epileptiform discharges (IEDs), ictal findings, and sleep architecture after CBD treatment.

RESULTS

Patients were between 18 months and 52 years of age. After CBD treatment, 88.4% (46/52) of patients had EEG changes. Eighty-nine percent of these patients had changes in their background, 74% in IEDs, 46% in ictal findings, and 17% in sleep architecture. Seven out of 52 patients had modified hypsarrhythmia on their pre-treatment EEG. The pattern resolved in 2/7 patients (29%), diminished in prevalence in 4/7 (57%) subjects, and remained unchanged in 1/7 (14%) cases. Electrographic improvement was seen in 70% (32/46) of the patients, and worsening in 7% (3/46) of the cases. At the post-CBD EEG, 83% had a reduction in the frequency of the most predominant seizure type, and 25% reported subjective cognitive improvement. Of these patients, 88% (p = 0.09) and 92% (p = 0.45) had corresponding EEG changes, respectively.

CONCLUSION

Our results revealed electrographic changes in association with the CBD treatment. Despite these changes, a substantial association between specific electrographic findings and clinical outcomes was not established.

Status of epileptic spasms: A study of 21 children

OBJECTIVE

We studied cases with long-lasting epileptic spasms (ES) considered as a spasm status analyzing type of epilepsy, epileptic syndrome, etiology, treatment, and outcome in 21 patients.

METHODS

We evaluated the charts of 21 patients seen between June 2006 and July 2017 who met the electroclinical diagnostic criteria of a spasm status. The spasm status was defined as continuous ES lasting 30 min or longer.

RESULTS

The type of ES was mixed in nine patients, flexion in seven, and extension in five. Epileptic spasms were asymmetric in three patients and unilateral in two. They occurred on awakening in all patients, while during sleep they decreased in all and disappeared in three cases. The duration of the spasm status ranged from 40 min to 15 days according to the seizure diaries of patients and video-EEG recordings. Two well-defined subgroups of patients were recognized; the first included patients with West syndrome (WS) and the second other types of severe non-West epilepsy syndromes. The spasm status responded well to oral vigabatrin (VGB) in four patients, oral topiramate (TPM) in three, oral corticosteroids in one, and cannabidiol in another patient. A good response was observed with benzodiazepines in six patients, with phenytoin (PH) in two, and with phenobarbital (PB) in one. Adrenocorticotropic hormone (ACTH) was effective in one patient and the ketogenic diet in two. Prognosis depends on the etiology.

CONCLUSION

In this study we identified patients with WS and other types of severe non-West epilepsy syndromes who had a particular type of long-lasting ES that, in spite of its long duration does not strictly meet the criteria of the International League against Epilepsy (ILAE) classification of status epilepticus, may be considered a spasm status.

Corpus Callosotomy for Controlling Epileptic Spasms: A Proposal for Surgical Selection

In 1940, van Wagenen and Herren first proposed the corpus callosotomy (CC) as a surgical procedure for epilepsy. CC has been mainly used to treat drop attacks, which are classified as generalized tonic or atonic seizures. Epileptic spasms (ESs) are a type of epileptic seizure characterized as brief muscle contractions with ictal polyphasic slow waves on an electroencephalogram and a main feature of West syndrome. Resection surgeries, including frontal/posterior disconnections and hemispherotomy, have been established for the treatment of medically intractable ES in patients with unilaterally localized epileptogenic regions. However, CC has also been adopted for ES treatment, with studies involving CC to treat ES having increased since 2010. In those studies, patients without lesions observed on magnetic resonance imaging or equally bilateral lesions predominated, in contrast to studies on resection surgeries. Here, we present a review of relevant literature concerning CC and relevant adaptations. We discuss history and adaptations of CC, and patient selection for epilepsy surgeries due to medically intractable ES, and compared resection surgeries with CC. We propose a surgical selection flow involving resection surgery or CC as first-line treatment for patients with ES who have been assessed as suitable candidates for surgery.

Efficacy of long term weekly ACTH therapy for intractable epilepsy

BACKGROUND

Adrenocorticotropic hormone (ACTH) therapy is the first-line therapy for infantile spasms, and is effective for many other intractable epilepsies. While spasms may respond to ACTH for weeks, a substantial proportion of patients develop recurrent seizures over a yearly period. To maintain efficacy, we treated two children with intractable epilepsy with weekly ACTH therapy for 1 year and described the changes in clinical seizures, electroencephalograms, developmental assessments and side effects.

SUBJECTS AND METHODS

A girl with infantile spasms due to lissencephaly and a boy with atypical absence seizures were studied. In both cases, seizures were frequent and resistant to antiepileptic drugs; electroencephalograms showed continuous epileptiform activities, and the patients' development was delayed and stagnant prior to ACTH treatment. The initial ACTH therapy (daily 0.015 mg/kg for 2 weeks, 0.015 mg/kg every 2 days for 1 week, 0.0075 mg/kg every 2 days for 1 week), was transiently effective in both cases. The second-round ACTH therapy consisted of the initial ACTH therapy protocol followed by weekly ACTH injections (0.015 mg/kg or 0.0075 mg/kg) for 1 year. Both cases were followed for at least 1 year after therapy.

RESULTS

In both patients, clinical seizures were completely controlled during and 1 year after the second-round AHCH therapy. Continuous epileptiform discharges disappeared, while intermittent interictal epileptiform discharges remained. Both patients showed some developmental gains after achieving seizure control. No serious side effects were recorded.

CONCLUSION

Further studies are warranted to determine if a long-term weekly ACTH is a safe and effective treatment for intractable epilepsy.

Study of epileptic drop attacks in symptomatic epilepsy of early childhood - differences from those in myoclonic-astatic epilepsy

OBJECTIVES

We studied epileptic drop attacks (EDA) in symptomatic epilepsy of early childhood by means of video-polygraphic recordings and compared clinico-electrical differences in EDA among patients with idiopathic myoclonic-astatic epilepsy (MAE).

SUBJECTS AND METHODS

Subjects consisted of 21 children with symptomatic epilepsy and 20 with idiopathic MAE whose EDA were documented at an age between 7 months and 6 years. The seizure types causing EDA as well as other demographic data were compared between the two epilepsy types.

RESULTS

A video-polygraphic study captured a total of 188 EDA (median: 8) in patients with symptomatic epilepsy and 182 EDA (median: 7) in those with idiopathic MAE. In the former, EDA were caused by epileptic spasms (ES) corresponding to generalized biphasic slow discharges, sharp-and-slow wave complexes, or the flattening of ongoing background activity in 15 patients, atonic seizures associated with runs of generalized spike-and-wave complexes in four patients, and myoclonic-atonic seizures in the remaining two patients. The mode of occurrence of EDA in ES was periodic clustering in eight of 15 patients. Interictal EEG revealed generalized irregular multiple spikes-and-waves with focal or multifocal accentuations. Sixteen idiopathic MAE patients had myoclonic-atonic seizures while the remaining four had myoclonic-flexor seizures, all corresponding to generalized high amplitude spikes or polyspike-and-wave complexes and occurring singly.

CONCLUSION

EDA often seen in young children with symptomatic epilepsy were most frequently caused by flexor type ES and rarely by myoclonic-atonic seizures, a hallmark seizure type of MAE. In a clinical setting, the occurrence of periodic clusters and independent focal or multifocal accentuations of generalized spike-and-wave complexes in interictal EEG may indicate EDA caused by ES.

Effect of adrenocorticotropic hormone therapy for epileptic spasms developing after the age of 1 year

PURPOSE

Epileptic spasms sometimes begin after the first year of life, and such seizures are recognized as late-onset spasms (LOS). The prognosis of LOS is poor, and a treatment strategy has not been established. This study aimed to assess the short- and long-term effects of adrenocorticotropic hormone (ACTH) therapy for LOS.

METHODS

We investigated the rate of LOS in 22 patients (14 boys and 8 girls) treated with ACTH therapy. The age at onset of LOS and at the start of ACTH therapy ranged from 12 to 94 months (median, 31.6 ± 22.1 months) and from 12.5 to 116 months (median, 37.5 ± 23.7 months), respectively. We investigated the response rate of LOS treated with ACTH therapy, and compared the clinical features between responders (short-term) and nonresponders.

RESULTS

Nine (41%) of the 22 patients showed cessation of epileptic spasms within 3 months. The epileptic spasms ceased in four of these nine patients for more than 1 year. The age at onset of LOS was significantly associated with short-term seizure cessation (p<0.05). Patients who achieved short-term cessation of seizures received ACTH therapy within 6 months from the onset of LOS.

CONCLUSION

ACTH therapy is a potentially effective treatment when started within 6 months from the onset of LOS. A younger age at onset of LOS is associated with a favorable outcome.

A long-term, clinical study on symptomatic infantile spasms with focal features

BACKGROUND

We studied the clinical, neuroradiological and EEG characteristics of patients with infantile spasms (IS) who showed focal features to reveal their long-term prognoses and treatment responses.

SUBJECTS AND METHODS

Subjects included 69 patients with IS who consecutively visited our hospital. We tentatively classified the subjects into focal IS (fIS) and diffuse WS (dIS) groups based on the presence and absence of more than two of the following findings, respectively: (1) epileptic spasms (ES) that were asymmetric, (2) a focal epileptic EEG abnormality, (3) a lateralized neurological abnormality, (4) a focal brain MRI and (5) a focal SPECT abnormality.

RESULTS

We found 23 cases with fIS and 46 cases with dIS. ES responded more frequently in fIS than dIS group (100% vs. 80%; P=0.02) to the initial ACTH trial although the subsequent seizure relapse occurred more frequently in fIS than dIS group (74% vs. 38%; P=0.0006). The second course of ACTH trial brought a short as well as long-term remission in both groups (6/8 cases vs. 5/6 cases). Later in the clinical course, the fIS patients tended to display a focal epileptic EEG abnormality and to develop focal seizures. In our series, approximately one-third of patients with fIS later showed either only a focal epileptic EEG abnormality, a focal epileptic EEG abnormality with focal seizures, or bilateral asymmetric EEG foci with disabling seizures, respectively.

CONCLUSION

It is useful to classify patients with IS into fIS and dIS groups based on various lateralizing signs because the classification provides practical information regarding the long-term outcome and treatment strategy.

Infantile spams without hypsarrhythmia: a study of 16 cases

In this study, we present the electroclinical features and evolution of patients with epileptic spasms (ES) in clusters without hypsarrhythmia and with or without focal or generalized paroxysmal discharges on the interictal EEG. We also discuss how to nosologically define these cases.

METHODS

Between February 1, 1990, and December, 2009, sixteen patients met the electroclinical diagnostic criteria of ES in clusters without hypsarrhythmia.

RESULTS

ES were cryptogenic in thirteen patients and symptomatic in three. Age at onset of ES was between 4 months and 30 months, with a mean age of 9 months and a median age of 7 months. Seven patients had seizures before the onset of ES. Focal spikes were observed in seven patients, bilateral spikes and spikes and waves in five, multifocal spikes in two, and two patients had a normal EEG. The ictal EEG recording showed diffuse high-amplitude slow waves in ten patients, diffuse slow waves followed by voltage attenuation in four patients, and diffuse fast rhythms in two. ES were cured in five patients. Mean follow-up was 6 years. Neuropsychological development has been normal in the five latter patients. Eleven patients continue with seizures refractory to antiepileptic drugs after a mean follow-up of 10 years. Of these eleven patients, five have severe mental retardation, three have moderate mental retardation, and two have mild mental retardation. All of them show behavioral disturbances.

CONCLUSION

The patients in this series may be considered to have a variant of West syndrome rather than an electroclinically distinct epileptic syndrome.

Epileptic spasms after stem cell transplantation for chronic Epstein-Barr virus infection

Stem cell transplantation has been performed for various diseases, contributing to a markedly improved prognosis in some cases. However, several complications, including posterior reversible encephalopathy syndrome, have been evident. Although posterior reversible encephalopathy syndrome was originally defined as a reversible disease, it has become clear that it is not reversible in all patients. Epstein-Barr virus causes a wide spectrum of neurologic disorders, including epilepsy. To our knowledge, Epstein-Barr virus was not previously reported to cause epileptic spasms. We describe a girl with epileptic spasms after posterior reversible encephalopathy syndrome associated with stem cell transplantation for chronic Epstein-Barr virus infection. Although direct correlation was not clarified, this is a rare case that may contribute to our understanding of the neurologic complications of stem cell transplantation for chronic Epstein-Barr virus infection.

ACTH therapy in refractory generalized epilepsy

Adrenocorticotropic hormone (ACTH) has a long track record for the treatment of infantile spasms. However, there is paucity of data on the use of ACTH in the treatment of epilepsy beyond infantile spasms. We report the use of ACTH in two children with refractory generalized epilepsy. Both patients responded well. ACTH may be considered as a useful adjunctive therapy in patients with intractable generalized seizures. Side effects and cost however, remain important concerns.

Epileptic spasms: a variety of etiologies and associated syndromes

Epileptic spasms have been described as a paroxysmal epileptic seizure type that consists of a series of motor movements, involving sudden flexion or extension predominantly of axial and/or proximal limb muscles, occurring with a noticeable periodicity, outside the age of infantile spasms, but have otherwise not been well characterized or described. The purpose of this study was to evaluate patients with epileptic spasms to describe the etiology and best treatment regimen for this seizure type. Twenty-eight children fit the selection criteria for this study, and their charts and electroencephalography (EEG) results were reviewed. Data regarding onset of seizures, characteristics of seizures, duration of seizures, activity at onset, treatments tried and/or failed, genetic or metabolic workup, and results of any imaging studies were collected. The results indicate that the genetic and metabolic workups that were done were most often negative or unrevealing. In addition, treatment regimens varied greatly from patient to patient, and it is evident that these seizures are refractory to many standard anticonvulsants, as well as the ketogenic diet. The results of imaging from this series point to a variety of structural abnormalities that could possibly explain a structural versus metabolic etiology for epileptic spasms. In conclusion, epileptic spasms remain an elusive seizure type to classify, diagnose, and treat. The results of the current series show a relationship between structural abnormalities on magnetic resonance imaging (MRI) and resultant epileptic spasms, which has further implications regarding surgical treatment of these seizures as opposed to the traditional treatment with anticonvulsants, to which epileptic spasms remain refractory.

ACTH therapy for generalized seizures other than spasms

PURPOSE

We reviewed our experience with ACTH for the treatment of intractable generalized seizures other than spasms.

METHODS

Efficacy and adverse effects of ACTH against intractable generalized seizures other than spasms were retrospectively investigated in 15 patients treated between 1991 and 2003. The median age of the patients at ACTH therapy was 42 months. The targeted type of seizure was brief tonic in 6, atypical absence in 6, atonic in 2, and myoclonic in 1. The dose of ACTH was 0.01-0.015 mg/kg in most patients. The effect of ACTH was determined at the end of ACTH therapy, and 3 months and 1 year after ACTH therapy.

RESULTS

Seizure freedom was obtained in 13 of 15 patients. However, 6 of them had a recurrence of seizures within 3 months after ACTH therapy. ACTH was the most effective in patients with atypical absence seizures. Statistical analysis showed that the number of injection and total dose of ACTH were smaller in patients with atypical absence seizures than in those with brief tonic seizures. Adverse effects were frequent but serious one was not observed.

CONCLUSION

ACTH therapy was effective in patients with intractable generalized seizures other than spasms. However, its efficacy was often transient. ACTH can be useful for generalized seizures other than spasms but its limitation should be considered.

Diagnostic issues and treatment of cryptogenic or symptomatic generalized epilepsies

To clarify the diagnostic issues and treatment of patients with cryptogenic or symptomatic generalized epilepsies, not including West syndrome (WS), we investigated electroclinical change during the clinical course, and treatment effects in these patients. The selection criteria were minor generalized seizures as their main seizure type and diffuse epileptic discharges as their main EEG findings. Regarding EEG, we included EEGs that predominantly displayed multifocal spike-waves because of the inclusion of severe epilepsy with multiple independent spike foci (SE-MISF). We divided the subjects into two groups according to their main seizure types: Group A (54 patients) with brief tonic seizures and Group B (24 patients) with myoclonic seizures and/or atypical absences. The main epileptic syndromes were considered to be Lennox-Gastaut syndrome and SE-MISF in Group A, and epilepsy with myoclonic-astatic seizures in Group B. A history of WS was often seen in Group A, but it was exceptional in Group B. During the clinical course, seizure types did not basically change in Group A. EEG patterns were changeable in both groups. Although there was some overlap in electroclinical manifestations among epileptic syndromes, a transition between the two groups was not seen. High-dose valproate and ethosuximide were the most effective in Groups A and B, respectively. Long-term prognosis was significantly more favorable in Group B than in Group A.