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Schiller K, Thomas J, Avigdor T, Mansilla D, Kortas A, Unterholzner G, Rauchenzauner M, Frauscher B. Pulsatile corticoid therapy reduces interictal epileptic activity burden in children with genetic drug-resistant epilepsy. Epilepsia Open 2024; 9:1265-1276. [PMID: 38831631 PMCID: PMC11296103 DOI: 10.1002/epi4.12947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Revised: 02/28/2024] [Accepted: 04/10/2024] [Indexed: 06/05/2024] Open
Abstract
OBJECTIVE Corticosteroids and adrenocorticotropic hormone (ACTH) are the therapy of choice to treat infantile spasms. However, systematic studies about their use in other types of childhood epilepsies remain rare and ACTH can have serious side effects. This study compares the interictal epileptic activity (IEA) burden (% of electroencephalography (EEG) time with IEDs) in children with genetic drug-resistant epilepsy before and after a standardized treatment with pulsatile corticoid therapy (PCT). METHODS Children with drug-resistant epilepsy underwent a standardized protocol for PCT with cycles of high-dose dexamethasone (20 mg/m2 body surface) intravenously. Patients were hospitalized for 3 days per PCT cycle and EEGs were obtained before initiation of treatment (baseline) and during the hospitalization around the time of every second cycle. EEG recordings during sleep and wakefulness were obtained. IEA burden was compared before and after PCT. Secondary outcome measures included the sleep spindle rate, the seizure frequency and subjective evaluation in a standardized interview. RESULTS In the cohort of 24 children (10 female, 6.2 ± 3.4 years), IEA burden was lower in the EEG after PCT compared to the baseline (baseline: 5.4% [0.7-97.3] vs. after PCT: 1.5% [0-96.9], p = 0.001, d = -0.41). Sleep physiology expressed by sleep spindles improved after PCT with enhanced fast spindle rates (0.8/min [0-2.2] vs. 1.5/min [0.2-3.4], p = 0.045, d = 0.36). Seizure frequency was decreased in 17 of the 24 patients (70.8%) with one patient achieving seizure freedom. The majority of patients improved in quality of life (79.2%), and sleep (81.3%). No serious adverse effects were documented. SIGNIFICANCE This study systematically assessed the effect of PCT in children with genetic / suspected genetic drug-resistant epilepsy. PCT was found to not only reduce the IEA burden but also increase sleep spindle rates, which are important for cognitive functioning. PLAIN LANGUAGE SUMMARY In this study, children with a form of epilepsy, which is resistant against antiseizure medication, received a systematic treatment with corticosteroids over multiple cycles in the hospital. It was found that not only the epileptic activity was reduced but also the sleep of the patients was improved after the treatment. These findings could provide the basis for extending the use of corticosteroids in children with epilepsy.
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Affiliation(s)
- Katharina Schiller
- Analytical Neurophysiology Lab, Department of Neurology and NeurosurgeryMontreal Neurological Hospital and InstituteMontrealQuebecCanada
- Department of NeurologyChildren's Hospital KaufbeurenKaufbeurenBavariaGermany
- Department of PeadiatricsMedical University InnsbruckInnsbruckAustria
| | - John Thomas
- Analytical Neurophysiology Lab, Department of Neurology and NeurosurgeryMontreal Neurological Hospital and InstituteMontrealQuebecCanada
| | - Tamir Avigdor
- Analytical Neurophysiology Lab, Department of Neurology and NeurosurgeryMontreal Neurological Hospital and InstituteMontrealQuebecCanada
| | - Daniel Mansilla
- Analytical Neurophysiology Lab, Department of Neurology and NeurosurgeryMontreal Neurological Hospital and InstituteMontrealQuebecCanada
| | - Aline Kortas
- Department of NeurologyChildren's Hospital KaufbeurenKaufbeurenBavariaGermany
| | | | - Markus Rauchenzauner
- Department of NeurologyChildren's Hospital KaufbeurenKaufbeurenBavariaGermany
- Department of PeadiatricsMedical University InnsbruckInnsbruckAustria
| | - Birgit Frauscher
- Analytical Neurophysiology Lab, Department of Neurology and NeurosurgeryMontreal Neurological Hospital and InstituteMontrealQuebecCanada
- Department of NeurologyDuke University Medical CenterDurhamNorth CarolinaUSA
- Department of Biomedical EngineeringDuke Pratt School of EngineeringDurhamNorth CarolinaUSA
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Zeng ML, Xu W. A Narrative Review of the Published Pre-Clinical Evaluations: Multiple Effects of Arachidonic Acid, its Metabolic Enzymes and Metabolites in Epilepsy. Mol Neurobiol 2024:10.1007/s12035-024-04274-6. [PMID: 38842673 DOI: 10.1007/s12035-024-04274-6] [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: 12/11/2023] [Accepted: 05/29/2024] [Indexed: 06/07/2024]
Abstract
Arachidonic acid (AA), an important polyunsaturated fatty acid in the brain, is hydrolyzed by a direct action of phospholipase A2 (PLA2) or through the combined action of phospholipase C and diacylglycerol lipase, and released into the cytoplasm. Various derivatives of AA can be synthesized mainly through the cyclooxygenase (COX), lipoxygenase (LOX) and cytochrome P450 (P450) enzyme pathways. AA and its metabolic enzymes and metabolites play important roles in a variety of neurophysiological activities. The abnormal metabolites and their catalytic enzymes in the AA cascade are related to the pathogenesis of various central nervous system (CNS) diseases, including epilepsy. Here, we systematically reviewed literatures in PubMed about the latest randomized controlled trials, animal studies and clinical studies concerning the known features of AA, its metabolic enzymes and metabolites, and their roles in epilepsy. The exclusion criteria include non-original studies and articles not in English.
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Affiliation(s)
- Meng-Liu Zeng
- Medical Science Research Center, Zhongnan Hospital of Wuhan University, Wuhan, 430071, China.
| | - Wei Xu
- Department of Pancreatic Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
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3
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Russo A, Mazzone S, Landolina L, Colucci R, Baccari F, Fetta A, Boni A, Cordelli DM. Efficacy and Safety of Pulse Intravenous Methylprednisolone in Pediatric Epileptic Encephalopathies: Timing and Networks Consideration. J Clin Med 2024; 13:2497. [PMID: 38731025 PMCID: PMC11084200 DOI: 10.3390/jcm13092497] [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: 03/05/2024] [Revised: 04/10/2024] [Accepted: 04/19/2024] [Indexed: 05/13/2024] Open
Abstract
Background: Epileptic encephalopathies (EE) are characterized by severe drug-resistant seizures, early onset, and unfavorable developmental outcomes. This article discusses the use of intravenous methylprednisolone (IVMP) pulse therapy in pediatric patients with EE to evaluate its efficacy and tolerability. Methods: This is a retrospective study from 2020 to 2023. Inclusion criteria were ≤18 years at the time of IVMP pulse therapy and at least 6 months of follow-up. Efficacy and outcome, defined as seizure reduction > 50% (responder rate), were evaluated at 6 and 9 months of therapy, and 6 months after therapy suspension; quality of life (QoL) was also assessed. Variables predicting positive post-IVMP outcomes were identified using statistical analysis. Results: The study included 21 patients, with a responder rate of 85.7% at 6 and 9 months of therapy, and 80.9% at 6 months after therapy suspension. Variables significantly predicting favorable outcome were etiology (p = 0.0475) and epilepsy type (p = 0.0475), with the best outcome achieved in patients with genetic epilepsy and those with encephalopathy related to electrical status epilepticus during slow-wave sleep (ESES). All patients evidenced improvements in QoL at the last follow-up, with no relevant adverse events reported. Conclusions: Our study confirmed the efficacy and high tolerability of IVMP pulse therapy in pediatric patients with EE. Genetic epilepsy and ESES were positive predictors of a favorable clinical outcome. QOL, EEG tracing, and postural-motor development showed an improving trend as well. IVMP pulse therapy should be considered earlier in patients with EE.
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Affiliation(s)
- Angelo Russo
- IRCCS, Istituto delle Scienze Neurologiche di Bologna, UOC Neuropsichiatria Dell’età Pediatrica, 40139 Bologna, Italy; (S.M.); (L.L.); (R.C.); (A.F.); (A.B.); (D.M.C.)
| | - Serena Mazzone
- IRCCS, Istituto delle Scienze Neurologiche di Bologna, UOC Neuropsichiatria Dell’età Pediatrica, 40139 Bologna, Italy; (S.M.); (L.L.); (R.C.); (A.F.); (A.B.); (D.M.C.)
| | - Laura Landolina
- IRCCS, Istituto delle Scienze Neurologiche di Bologna, UOC Neuropsichiatria Dell’età Pediatrica, 40139 Bologna, Italy; (S.M.); (L.L.); (R.C.); (A.F.); (A.B.); (D.M.C.)
- Dipartimento di Scienze Mediche e Chirurgiche (DIMEC), Università di Bologna, 40126 Bologna, Italy
| | - Roberta Colucci
- IRCCS, Istituto delle Scienze Neurologiche di Bologna, UOC Neuropsichiatria Dell’età Pediatrica, 40139 Bologna, Italy; (S.M.); (L.L.); (R.C.); (A.F.); (A.B.); (D.M.C.)
- Dipartimento di Scienze Mediche e Chirurgiche (DIMEC), Università di Bologna, 40126 Bologna, Italy
| | - Flavia Baccari
- IRCCS, Istituto delle Scienze Neurologiche di Bologna, UOS Epidemiologia e Biostatistica, 40139 Bologna, Italy;
| | - Anna Fetta
- IRCCS, Istituto delle Scienze Neurologiche di Bologna, UOC Neuropsichiatria Dell’età Pediatrica, 40139 Bologna, Italy; (S.M.); (L.L.); (R.C.); (A.F.); (A.B.); (D.M.C.)
- Dipartimento di Scienze Mediche e Chirurgiche (DIMEC), Università di Bologna, 40126 Bologna, Italy
| | - Antonella Boni
- IRCCS, Istituto delle Scienze Neurologiche di Bologna, UOC Neuropsichiatria Dell’età Pediatrica, 40139 Bologna, Italy; (S.M.); (L.L.); (R.C.); (A.F.); (A.B.); (D.M.C.)
| | - Duccio Maria Cordelli
- IRCCS, Istituto delle Scienze Neurologiche di Bologna, UOC Neuropsichiatria Dell’età Pediatrica, 40139 Bologna, Italy; (S.M.); (L.L.); (R.C.); (A.F.); (A.B.); (D.M.C.)
- Dipartimento di Scienze Mediche e Chirurgiche (DIMEC), Università di Bologna, 40126 Bologna, Italy
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Falsaperla R, Collotta AD, Marino SD, Sortino V, Leonardi R, Privitera GF, Pulvirenti A, Suppiej A, Vecchi M, Verrotti A, Farello G, Spalice A, Elia M, Spitaleri O, Micale M, Mailo J, Ruggieri M. Drug resistant epilepsies: A multicentre case series of steroid therapy. Seizure 2024; 117:115-125. [PMID: 38394725 DOI: 10.1016/j.seizure.2024.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Revised: 02/12/2024] [Accepted: 02/12/2024] [Indexed: 02/25/2024] Open
Abstract
PURPOSE Our study aimed to evaluate the effectiveness of corticosteroids on seizure control in drug-resistant epilepsies (DREs). Our primary goal was to assess the response to steroids for various underlying etiologies, interictal electroencephalographic (EEG) patterns and electroclinical seizure descriptions. Our second goal was to compare steroid responsiveness to different treatment protocols. METHODS This is a retrospective multicentre cohort study conducted according to the STROBE guidelines (Strengthening the Reporting of Observational Studies in Epidemiology). The following data were collected for each patient: epilepsy etiology, interictal EEG pattern, seizure types and type of steroid treatment protocol administered. RESULTS Thirty patients with DRE were included in the study. After 6 months of therapy, 62.7 % of patients experienced reduced seizure frequency by 50 %, and 6.6 % of patients experienced complete seizure cessation. Findings associated with favourable response to steroids included structural/lesional etiology of epilepsy, immune/infectious etiology and focal interictal abnormalities on EEG. Comparing four different steroid treatment protocols, the most effective for seizure control was treatment with methylprednisolone at the dose of 30 mg/kg/day administered for 3 days, leading to greater than 50 % seizure reduction at 6 months in 85.7 % of patients. Treatment with dexamethasone 6 mg/day for 5 days decreased seizure frequency in 71.4 % of patients. Hydrocortisone 10 mg/kg administered for 3 months showed a good response to treatment in 71 %. CONCLUSIONS In our study, two-thirds of patients with DRE experienced a significant seizure reduction following treatment with steroids. We suggest considering steroids as a potential therapeutic option in children with epilepsy not responding to conventional antiseizure medicines (ASM).
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Affiliation(s)
- Raffaele Falsaperla
- Paediatric and Paediatric Emergency Department, University Hospital "Policlinico-San Marco", Catania, Italy; Unit of Intensive Care and Neonatology, University Hospital "Policlinico-San Marco", Catania, Italy.
| | - Ausilia Desiree Collotta
- Paediatric and Paediatric Emergency Department, University Hospital "Policlinico-San Marco", Catania, Italy; Department of Clinical and Experimental Medicine, Postgraduate Training Program in Pediatrics, University of Catania, Catania, Italy.
| | - Simona D Marino
- Paediatric and Paediatric Emergency Department, University Hospital "Policlinico-San Marco", Catania, Italy
| | - Vincenzo Sortino
- Paediatric and Paediatric Emergency Department, University Hospital "Policlinico-San Marco", Catania, Italy; Department of Clinical and Experimental Medicine, Postgraduate Training Program in Pediatrics, University of Catania, Catania, Italy
| | - Roberta Leonardi
- Department of Clinical and Experimental Medicine, Postgraduate Training Program in Pediatrics, University of Catania, Catania, Italy
| | - Grete Francesca Privitera
- Department of Mathematics and Computer Science, Department of Clinical and Experimental Medicine, University of Catania, c/o Viale A. Doria, 6, Catania 95125, Italy
| | - Alfredo Pulvirenti
- Department of Mathematics and Computer Science, Department of Clinical and Experimental Medicine, University of Catania, c/o Viale A. Doria, 6, Catania 95125, Italy
| | - Agnese Suppiej
- Medical Science Department (D.O.), Maternal and Child Department, Ferrara University Hospital, University of Ferrara, Italy
| | - Marilena Vecchi
- Paediatric Neurology and Neurophysiology Unit, Department of Women's and Children's Health, Padova University Hospital, Padova, Italy
| | - Alberto Verrotti
- Clinical Paediatric, University of Perugia, Hospital SM Della Misericordia, Perugia, Italy
| | - Giovanni Farello
- Clinical Paediatric, University of Perugia, Hospital SM Della Misericordia, Perugia, Italy
| | - Alberto Spalice
- Department of Paediatrics, Child Neurology and Psychiatry, Sapienza University of Rome, Rome, Italy
| | - Maurizio Elia
- Unit of Neurology and Clinical Neurophysiopathology, Oasi Research Institute, IRCCS, Troina, Italy
| | - Orazio Spitaleri
- Paediatric Neuropsychiatry Unit, Hospital " S.Marta e S.Venera", Acireale, Italy
| | - Marco Micale
- Paediatric Neuropsychiatry Unit, Maternal and Child Department, Arnas Civico, Palermo, Italy
| | - Janette Mailo
- Division of Paediatric Neurology, University of Alberta, Canada
| | - Martino Ruggieri
- Department of Clinical and Experimental Medicine, Unit of Clinical Pediatrics, Section of Pediatrics and Child Neuropsychiatry, University of Catania, Catania 95124, Italy
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Zhao L, McCann ME, Park RS, Pier DB, Bajic D. Acute Dystonic Reaction After Propofol Administration: A Pediatric Case Report. A A Pract 2023; 17:e01732. [PMID: 38078618 DOI: 10.1213/xaa.0000000000001732] [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: 12/18/2023]
Abstract
We present a case of a 12-year-old female with a history of infantile spasms who developed a propofol-associated acute dystonic reaction after emergence from general anesthesia for foot surgery. Uniquely, the patient's postoperative symptoms of an acute dystonic reaction were refractory to standard treatment with anticholinergics but were successfully treated with corticosteroids. The absence of any dystonic symptoms following subsequent foot surgery under general anesthesia without propofol supported a propofol-associated etiology. This case may contribute to a better understanding of the underlying mechanisms of propofol-associated acute dystonic reactions and adds a possible new treatment option.
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Affiliation(s)
- Lucy Zhao
- From the Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts
- Massachusetts Institute of Technology, Cambridge, Massachusetts
| | - Mary Ellen McCann
- From the Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts
- Department of Anaesthesia, Harvard Medical School, Boston, Massachusetts
| | - Raymond Seungjoon Park
- From the Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts
- Department of Anaesthesia, Harvard Medical School, Boston, Massachusetts
| | - Danielle Bennett Pier
- Department of Anaesthesia, Harvard Medical School, Boston, Massachusetts
- Division of Pediatric Neurology, Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts
| | - Dusica Bajic
- From the Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts
- Department of Anaesthesia, Harvard Medical School, Boston, Massachusetts
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6
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Kurt Gök D, İsmailoğulları S, Aldemir R, Tokmakçı M, Firat ST, Karaca Z, Keleştemur F, Zararsiz G. The effects of hypercortisolism on the frequency and magnitude of sleep EEG waves in patients with Cushing syndrome: A spectral analysis study. Neurophysiol Clin 2023; 53:102893. [PMID: 37657229 DOI: 10.1016/j.neucli.2023.102893] [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: 03/02/2023] [Revised: 06/28/2023] [Accepted: 06/29/2023] [Indexed: 09/03/2023] Open
Abstract
OBJECTIVES Our aim was to investigate the effects of endogenous chronic hypercortisolism on sleep electroencephalogram (EEG) and differences between the adrenocorticotropic hormone (ACTH)-dependent and independent Cushing Syndrome (CS) patients through a sleep spectral analysis program. METHODS A total of 32 patients diagnosed as having endogenous CS (12 ACTH-dependent and 20 ACTH-independent) and a control group comprising 16 healthy individuals were included in the study. Polysomnographic analysis was performed. Blood samples were collected at 08:00 AM for analysis of ACTH and basal cortisol, and at 00:00 AM for midnight cortisol levels. The frequency and power of the slow wave activity (SWA), theta, alpha, and beta waves of the first and last non-rapid eye movement (NREM) cycles were measured with a spectral analysis program. RESULTS The CS patient group had higher SWA power, especially in the first NREM cycle. In the ACTH-dependent group, SWA maximum and mean power values were higher in the frontal channels in the first NREM, compared to the last NREM sleep stage (p<0.05). CONCLUSION Cortisol has been found to be associated with SWA waves, making these waves higher in power, especially in the first NREM phase. This difference was much less pronounced in the final NREM sleep stage. The difference between the first and last NREM sleep stages with respect to the power of SWA in the frontal channel in the ACTH-dependent group suggests that not only cortisol but also high levels of ACTH affect the power of slow waves during sleep.
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Affiliation(s)
- Duygu Kurt Gök
- Department of Neurology, Kayseri City Education and Research Hospital, Kayseri, Turkey.
| | - Sevda İsmailoğulları
- Department of Neurology, Faculty of Medicine, Erciyes University, Kayseri, Turkey
| | - Ramazan Aldemir
- Department of Electronics and Automation, Biomedical Device Technology, Kayseri Vocational School of Higher Education, Kayseri University, City Kayseri, Turkey
| | - Mahmut Tokmakçı
- Department of Biomedical Engineering, Faculty of Engineering, Erciyes University, Kayseri, Turkey
| | - Sedat Tarik Firat
- Department of Medical Oncology, Kayseri City Education and Research Hospital, Kayseri, Turkey
| | - Züleyha Karaca
- Department of Endocrinology, Faculty of Medicine, Erciyes University, Kayseri, Turkey
| | - Fahrettin Keleştemur
- Department of Endocrinology, Faculty of Medicine, Yeditepe University, Istanbul, Turkey
| | - Gökmen Zararsiz
- Department of Biostatistics, Faculty of Medicine, Erciyes University, Kayseri, Turkey
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7
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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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Becker LL, Kaindl AM. Corticosteroids in childhood epilepsies: A systematic review. Front Neurol 2023; 14:1142253. [PMID: 36970534 PMCID: PMC10036579 DOI: 10.3389/fneur.2023.1142253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Accepted: 02/15/2023] [Indexed: 03/12/2023] Open
Abstract
Corticosteroids have been used for the treatment of patients with epilepsy for more than 6 decades, based on the hypothesis of inflammation in the genesis and/or promotion of epilepsy. We, therefore, aimed to provide a systematic overview of the use of corticosteroid regimes in childhood epilepsies in line with the PRISMA guidelines. We performed a structured literature search via PubMed and identified 160 papers with only three randomized controlled trials excluding the substantial trials on epileptic spasms. Corticosteroid regimes, duration of treatment (days to several months), and dosage protocols were highly variable in these studies. Evidence supports the use of steroids in epileptic spasms; however, there is only limited evidence for a positive effect for other epilepsy syndromes, e.g., epileptic encephalopathy with spike-and-wave activity in sleep [(D)EE-SWAS] or drug-resistant epilepsies (DREs). In (D)EE-SWAS (nine studies, 126 patients), 64% of patients showed an improvement either in the EEG or in their language/cognition following various steroid treatment regimes. In DRE (15 studies, 436 patients), a positive effect with a seizure reduction in 50% of pediatric and adult patients and seizure freedom in 15% was identified; however, no recommendation can be drawn due to the heterozygous cohort. This review highlights the immense need for controlled studies using steroids, especially in DRE, to offer patients new treatment options.
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Affiliation(s)
- Lena-Luise Becker
- Department of Pediatric Neurology, Charité – Universitätsmedizin Berlin, Berlin, Germany
- Center for Chronically Sick Children, Charité – Universitätsmedizin Berlin, Berlin, Germany
- German Epilepsy Center for Children and Adolescents, Charité – Universitätsmedizin Berlin, Berlin, Germany
- Institute of Cell- and Neurobiology, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Angela M. Kaindl
- Department of Pediatric Neurology, Charité – Universitätsmedizin Berlin, Berlin, Germany
- Center for Chronically Sick Children, Charité – Universitätsmedizin Berlin, Berlin, Germany
- German Epilepsy Center for Children and Adolescents, Charité – Universitätsmedizin Berlin, Berlin, Germany
- Institute of Cell- and Neurobiology, Charité – Universitätsmedizin Berlin, Berlin, Germany
- *Correspondence: Angela M. Kaindl
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9
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Operto FF, Pastorino GMG, Viggiano A, Dell’Isola GB, Dini G, Verrotti A, Coppola G. Epilepsy and Cognitive Impairment in Childhood and Adolescence: A Mini-Review. Curr Neuropharmacol 2023; 21:1646-1665. [PMID: 35794776 PMCID: PMC10514538 DOI: 10.2174/1570159x20666220706102708] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Revised: 02/28/2022] [Accepted: 04/26/2022] [Indexed: 11/22/2022] Open
Abstract
Managing epilepsy in people with an intellectual disability remains a therapeutic challenge and must take into account additional issues such as diagnostic difficulties and frequent drug resistance. Advances in genomic technologies improved our understanding of epilepsy and raised the possibility to develop patients-tailored treatments acting on the key molecular mechanisms involved in the development of the disease. In addition to conventional antiseizure medications (ASMs), ketogenic diet, hormone therapy and epilepsy surgery play an important role, especially in cases of drugresistance. This review aims to provide a comprehensive overview of the mainfactors influencing cognition in children and adolescents with epilepsy and the main therapeutic options available for the epilepsies associated with intellectual disability.
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Affiliation(s)
- Francesca Felicia Operto
- Child and Adolescent Neuropsychiatry Unit, Department of Medicine, Surgery and Dentistry, University of Salerno, Baronissi, SA, Italy
| | - Grazia Maria Giovanna Pastorino
- Child and Adolescent Neuropsychiatry Unit, Department of Medicine, Surgery and Dentistry, University of Salerno, Baronissi, SA, Italy
| | - Andrea Viggiano
- Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, University of Salerno, Baronissi, SA, Italy
| | | | - Gianluca Dini
- Department of Pediatrics, University of Perugia, Giorgio Menghini Square, 06129 Perugia, Italy
| | - Alberto Verrotti
- Department of Pediatrics, University of Perugia, Giorgio Menghini Square, 06129 Perugia, Italy
| | - Giangennaro Coppola
- Child and Adolescent Neuropsychiatry Unit, Department of Medicine, Surgery and Dentistry, University of Salerno, Baronissi, SA, Italy
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10
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An Italian consensus on the management of Lennox-Gastaut syndrome. Seizure 2022; 101:134-140. [DOI: 10.1016/j.seizure.2022.07.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Revised: 07/05/2022] [Accepted: 07/07/2022] [Indexed: 11/19/2022] Open
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11
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Glucocorticoid Receptor β Isoform Predominates in the Human Dysplastic Brain Region and Is Modulated by Age, Sex, and Antiseizure Medication. Int J Mol Sci 2022; 23:ijms23094940. [PMID: 35563330 PMCID: PMC9099578 DOI: 10.3390/ijms23094940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 04/28/2022] [Accepted: 04/28/2022] [Indexed: 12/10/2022] Open
Abstract
The glucocorticoid receptor (GR) at the blood−brain barrier (BBB) is involved in the pathogenesis of drug-resistant epilepsy with focal cortical dysplasia (FCD); however, the roles of GR isoforms GRα and GRβ in the dysplastic brain have not been revealed. We utilized dysplastic/epileptic and non-dysplastic brain tissue from patients who underwent resective epilepsy surgery to identify the GRα and GRβ levels, subcellular localization, and cellular specificity. BBB endothelial cells isolated from the dysplastic brain tissue (EPI-ECs) were used to decipher the key BBB proteins related to drug regulation and BBB integrity compared to control and transfected GRβ-overexpressed BBB endothelial cells. GRβ was upregulated in dysplastic compared to non-dysplastic tissues, and an imbalance of the GRα/GRβ ratio was significant in females vs. males and in patients > 45 years old. In EPI-ECs, the subcellular localization and expression patterns of GRβ, Hsp90, CYP3A4, and CYP2C9 were consistent with GRβ+ brain endothelial cells. Active matrix metalloproteinase levels and activity increased, whereas claudin-5 levels decreased in both EPI-ECs and GRβ+ endothelial cells. In conclusion, the GRβ has a major effect on dysplastic BBB functional proteins and is age and gender-dependent, suggesting a critical role of brain GRβ in dysplasia as a potential biomarker and therapeutic target in epilepsy.
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12
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Monitoring Glucose Concentrations in Children with Epilepsy on a Ketogenic Diet. Healthcare (Basel) 2022; 10:healthcare10020245. [PMID: 35206860 PMCID: PMC8872244 DOI: 10.3390/healthcare10020245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 01/16/2022] [Accepted: 01/24/2022] [Indexed: 12/04/2022] Open
Abstract
Ketogenic diet (KD) and pulsatile dexamethasone therapy (PDT) are commonly used in the treatment of children with drug resistant epilepsy. Potential side effects of the KD are hypoglycemia, whereas PDT might lead to hyperglycemia. One practical option to measure glucose concentrations regularly is the flash glucose monitoring system (FGM). In this single-center study in Germany, two pediatric patients with epilepsy (age: 6.0 and 6.8 years) received FGM from the beginning of the KD over six months, in the year 2020, and one patient (9.8 years) was observed for one month on PDT and switched to the KD thereafter. Glucose concentrations were measured by using an FGM system and capillary blood measurement. Seizure frequency, changes in cognition, motor performance, social behavior, and sleep quality were evaluated. The mean hypoglycemia rate per day (65 mg/dL and lower) declined significantly in patient 1 and 2 after three months. Patient 3 showed in total seven hyperglycemic events during PDT. Patient 1 became seizure free. Improvement of attention and memory performance were reported. FGM during the KD as a treatment for drug resistant epilepsies in childhood is a practical option to explore and to avoid hypoglycemia during the KD and hyperglycemia during PDT.
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Zhu HM, Yuan CH, Luo MQ, Deng XL, Huang S, Wu GF, Hu JS, Yao C, Liu ZS. Safety and Effectiveness of Oral Methylprednisolone Therapy in Comparison With Intramuscular Adrenocorticotropic Hormone and Oral Prednisolone in Children With Infantile Spasms. Front Neurol 2022; 12:756746. [PMID: 35002921 PMCID: PMC8727336 DOI: 10.3389/fneur.2021.756746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Accepted: 11/26/2021] [Indexed: 11/30/2022] Open
Abstract
Background and Purpose: To assess the safety and effectiveness of oral methylprednisolone (oMP) in comparison with intramuscular adrenocorticotropic hormone (imACTH) and oral prednisolone (oP) therapies in children with infantile spasms (IS). Methods: In this prospective, open-label, non-blinded, uncontrolled observational study, children (aged 2–24 months) with newly diagnosed IS presenting with hypsarrhythmia or its variants on electroencephalogram (EEG) were included. It was followed by imACTH, oP, or oMP (32–48 mg/day for 2 weeks followed by tapering) treatments. Electroclinical remission/spasm control, relapse, and adverse effects were evaluated in the short-term (days 14 and 42) and intermediary-term (3, 6, and 12 months) intervals. Results: A total of 320 pediatric patients were enrolled: 108, 107, and 105 in the imACTH, oMP, and oP groups, respectively. The proportion of children achieving electroclinical remission on days 14 and 42 was similar among the three groups (day 14: 53.70 vs. 60.75 vs. 51.43%, p = 0.362; day 42: 57.55 vs. 63.46 vs. 55.34%, p = 0.470). The time to response was significantly faster in the oMP group (6.5 [3.00, 10.00] days vs. 8.00 [5.00, 11.00] days for imACTH and 8.00 [5.00, 13.00] days for oP, p = 0.025). Spasm control at 3, 6, and 12 months was also similar in the three groups (P = 0.775, 0.667, and 0.779). The relapse rate in the imACTH group (24.10%) was lower than oMP (30.77%) and oP groups (33.33%), and the time taken for relapse in the imACTH group (79.00 [56.50, 152.00] days) was longer than oMP (62.50 [38.00, 121.75] days) and oP groups (71.50 [40.00, 99.75] days), but the differences were not statistically significant (p = 0.539 and 0.530, respectively). The occurrence of adverse effects was similar among the three groups. Conclusions: The short and intermediary-term efficacy and recurrence rates of oMP are not inferior to those of imACTH and oP for the treatment of IS. Significantly, the time to achieve electroclinical remission with oMP was quicker than that with imACTH and oP. Considering its convenience, affordability, and the absence of irreversible side effects, oMP can serve as a form of first-line treatment for newly diagnosed IS.
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Affiliation(s)
- Hong-Min Zhu
- Department of Neurology, Wuhan Children's Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Chun-Hui Yuan
- Department of Laboratory Medicine, Wuhan Children's Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Meng-Qing Luo
- Department of Neurology, Wuhan Children's Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Department of Rehabilitation Medicine, Wuhan First Hospital, Wuhan, China
| | - Xiao-Long Deng
- Department of Neurology, Wuhan Children's Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Sheng Huang
- Department of Neurology, Wuhan Children's Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ge-Fei Wu
- Department of Neurology, Wuhan Children's Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jia-Sheng Hu
- Department of Neurology, Wuhan Children's Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Cong Yao
- Health Care Department, Wuhan Children's Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Zhi-Sheng Liu
- Department of Neurology, Wuhan Children's Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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14
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Neuroinflammation and Proinflammatory Cytokines in Epileptogenesis. Mol Neurobiol 2022; 59:1724-1743. [PMID: 35015252 DOI: 10.1007/s12035-022-02725-6] [Citation(s) in RCA: 64] [Impact Index Per Article: 32.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 12/30/2021] [Indexed: 02/06/2023]
Abstract
Increasing evidence corroborates the fundamental role of neuroinflammation in the development of epilepsy. Proinflammatory cytokines (PICs) are crucial contributors to the inflammatory reactions in the brain. It is evidenced that epileptic seizures are associated with elevated levels of PICs, particularly interleukin-1β (IL-1β), IL-6, and tumor necrosis factor-α (TNF-α), which underscores the impact of neuroinflammation and PICs on hyperexcitability of the brain and epileptogenesis. Since the pathophysiology of epilepsy is unknown, determining the possible roles of PICs in epileptogenesis could facilitate unraveling the pathophysiology of epilepsy. About one-third of epileptic patients are drug-resistant, and existing treatments only resolve symptoms and do not inhibit epileptogenesis; thus, treatment of epilepsy is still challenging. Accordingly, understanding the function of PICs in epilepsy could provide us with promising targets for the treatment of epilepsy, especially drug-resistant type. In this review, we outline the role of neuroinflammation and its primary mediators, including IL-1β, IL-1α, IL-6, IL-17, IL-18, TNF-α, and interferon-γ (IFN-γ) in the pathophysiology of epilepsy. Furthermore, we discuss the potential therapeutic targeting of PICs and cytokine receptors in the treatment of epilepsy.
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15
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Yang D, Na JH, Kim SH, Kim HD, Lee JS, Kang HC. Efficacy and prognosis of long-term, high-dose steroid therapy for Lennox-Gastaut syndrome. Epilepsy Res 2022; 179:106847. [PMID: 34979339 DOI: 10.1016/j.eplepsyres.2021.106847] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Revised: 12/15/2021] [Accepted: 12/23/2021] [Indexed: 11/03/2022]
Abstract
OBJECTIVE Lennox-Gastaut syndrome (LGS) is a severe form of developmental and epileptic encephalopathy that is highly resistant to treatment with conventional anti-epileptic drugs and non-pharmacological therapies. In the present study, we aimed to investigate the efficacy of long-term, high-dose steroid therapy and its effect on prognosis in children with LGS. METHODS This prospective study included patients with LGS who received long-term, high-dose steroid therapy beginning in November 2016. Prednisolone (60 mg per day) was administered for 2 weeks, following which the dosage was reduced to 60 mg on alternate days for 12 weeks. The drug was then slowly tapered over the next 3 months. The primary outcome was a reduction in seizure frequency relative to baseline at 14 weeks. The secondary outcome was whether patients had become seizure-free at 1 year. RESULTS Among 44 patients, 30 (68.2%) experienced a reduction in seizure frequency of more than 50%, including 26 (59.1%) with complete seizure control who were classified as the responder group. The remaining 14 (31.8%) were classified as the non-responder group after 14 weeks of treatment. Twenty patients (45.5%, 20/44) remained seizure-free after 1 year of treatment. However, 10 patients (33.3%, 10/30) in the responder group relapsed within a year. Improvements in electroencephalography (EEG) findings tended to be consistent with seizure outcomes. All patients had side effects of weight gain and Cushing's face, but most adverse effects were mild and transient. CONCLUSION Long-term, high-dose steroid therapy can be considered an effective treatment option for children with intractable LGS.
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Affiliation(s)
- Donghwa Yang
- Divison of Pediatric Neurology, Department of Pediatrics, National Health Insurance Service Ilsan Hospital, Goyang-si, Gyunggi-do, Republic of Korea; Divison of Pediatric Neurology, Department of Pediatrics, Severance Children's Hospital, Yonsei University College of Medicine, Epilepsy Research Institute, Seoul, Republic of Korea
| | - Ji-Hoon Na
- Divison of Pediatric Neurology, Department of Pediatrics, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Se Hee Kim
- Divison of Pediatric Neurology, Department of Pediatrics, Severance Children's Hospital, Yonsei University College of Medicine, Epilepsy Research Institute, Seoul, Republic of Korea
| | - Heung Dong Kim
- Divison of Pediatric Neurology, Department of Pediatrics, Severance Children's Hospital, Yonsei University College of Medicine, Epilepsy Research Institute, Seoul, Republic of Korea
| | - Joon Soo Lee
- Divison of Pediatric Neurology, Department of Pediatrics, Severance Children's Hospital, Yonsei University College of Medicine, Epilepsy Research Institute, Seoul, Republic of Korea
| | - Hoon-Chul Kang
- Divison of Pediatric Neurology, Department of Pediatrics, Severance Children's Hospital, Yonsei University College of Medicine, Epilepsy Research Institute, Seoul, Republic of Korea.
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16
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The Endocannabinoid System in Glial Cells and Their Profitable Interactions to Treat Epilepsy: Evidence from Animal Models. Int J Mol Sci 2021; 22:ijms222413231. [PMID: 34948035 PMCID: PMC8709154 DOI: 10.3390/ijms222413231] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Revised: 12/03/2021] [Accepted: 12/06/2021] [Indexed: 12/11/2022] Open
Abstract
Epilepsy is one of the most common neurological conditions. Yearly, five million people are diagnosed with epileptic-related disorders. The neuroprotective and therapeutic effect of (endo)cannabinoid compounds has been extensively investigated in several models of epilepsy. Therefore, the study of specific cell-type-dependent mechanisms underlying cannabinoid effects is crucial to understanding epileptic disorders. It is estimated that about 100 billion neurons and a roughly equal number of glial cells co-exist in the human brain. The glial population is in charge of neuronal viability, and therefore, their participation in brain pathophysiology is crucial. Furthermore, glial malfunctioning occurs in a wide range of neurological disorders. However, little is known about the impact of the endocannabinoid system (ECS) regulation over glial cells, even less in pathological conditions such as epilepsy. In this review, we aim to compile the existing knowledge on the role of the ECS in different cell types, with a particular emphasis on glial cells and their impact on epilepsy. Thus, we propose that glial cells could be a novel target for cannabinoid agents for treating the etiology of epilepsy and managing seizure-like disorders.
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17
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Li H, Xu L, Yang F, Jia L, Cheng H, Liu W. Case Report: Hypopituitarism Presenting With Nonconvulsive Status Epilepticus. Front Neurol 2021; 12:715885. [PMID: 34630288 PMCID: PMC8493291 DOI: 10.3389/fneur.2021.715885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Accepted: 08/26/2021] [Indexed: 12/02/2022] Open
Abstract
Introduction: Hypopituitarism is defined as one or more partial or complete pituitary hormone deficiencies. Nonconvulsive status epilepticus (NCSE) refers to a state of continuous or repetitive seizures without convulsions. In this paper, we review a case of an old female patient with hypopituitarism who presented with NCSE, which is rare in the clinic. Case Report: This paper describes a 67-year-old female patient with hypopituitarism who presented as NCSE. She had surgical resection of pituitary tumor half a year before the seizures and did not get regular hormone replacement therapy. She presented general convulsive status epilepsy as the initial symptom and got sedation and antiepileptic drug in the emergency room. The seizure was terminated but the patient fell in coma in the following days. The patient had magnetic resonance imaging (MRI) and other inspects, and EEG showed epileptic discharges. Combining these clinical symptoms and examinations, we made the diagnosis of NCSE. Finally, she regained consciousness after the treatment with diazepam. Conclusion: This case report and literature review investigated the possible mechanism of hypopituitarism presenting with NCSE.
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Affiliation(s)
- Huimin Li
- Jincheng People's Hospital Affiliated to Shanxi Medical University, Jincheng, China
| | - Lina Xu
- Jincheng People's Hospital Affiliated to Shanxi Medical University, Jincheng, China
| | - Fengbing Yang
- Jincheng People's Hospital Affiliated to Shanxi Medical University, Jincheng, China
| | - Longbin Jia
- Jincheng People's Hospital Affiliated to Shanxi Medical University, Jincheng, China
| | - Hongjiang Cheng
- Jincheng People's Hospital Affiliated to Shanxi Medical University, Jincheng, China
| | - Wei Liu
- Jincheng People's Hospital Affiliated to Shanxi Medical University, Jincheng, China
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18
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Kapoor D, Sharma S, Garg D, Samaddar S, Panda I, Patra B, Mukherjee SB, Pemde HK. Intravenous Methylprednisolone Versus Oral Prednisolone for West Syndrome: A Randomized Open-Label Trial. Indian J Pediatr 2021; 88:778-784. [PMID: 33575989 PMCID: PMC7877308 DOI: 10.1007/s12098-020-03630-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Accepted: 12/16/2020] [Indexed: 12/22/2022]
Abstract
OBJECTIVE To compare intravenous methylprednisolone (IVMP) with oral prednisolone (OP) for the treatment of West syndrome. METHODS In this randomized, open-label trial, children aged 2 to 30 mo presenting with epileptic spasms with hypsarrhythmia or its variants on EEG were randomized to receive either IVMP (30 mg/kg/d for 3 d followed by oral prednisolone taper) or OP (4 mg/kg/d for two weeks followed by taper). The primary outcome measure was spasms cessation on day 14. Secondary outcomes included time to response, electroclinical remission at 2 and 6 wk, and frequency of adverse effects. ( ClinicalTrials.gov Identifier: NCT03876444). RESULTS Sixty children were enrolled; 31 in the IVMP and 29 in the OP arm. Proportion of children achieving spasms cessation at day 14 was similar in both groups (54.8% versus 68.9%, p = 0.26). Time to achieve remission was lower in the IVMP group (mean 5.4 ± 0.9 versus 9.5 ± 2.6 d, p < 0.0001). Electroclinical remission at 2 wk was similar in both groups (51.6% versus 44.8%, p = 0.59) but lower at 6 wk in the IVMP group (45.2% versus 75.9%, p < 0.015). Adverse effects like sleep disturbance, irritability and hypertension were more common in IVMP group whereas weight gain was more common in the OP group. CONCLUSIONS There was no significant difference in spasms cessation between the groups on day 14 although remission was higher at 6 wk in OP group. Our study suggests that OP was better than IVMP in efficacy and sustained remission with fewer adverse effects.
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Affiliation(s)
- Dipti Kapoor
- Division of Neurology, Department of Pediatrics, Kalawati Saran Children's Hospital and Lady Hardinge Medical College, New Delhi, 110001, India
| | - Suvasini Sharma
- Division of Neurology, Department of Pediatrics, Kalawati Saran Children's Hospital and Lady Hardinge Medical College, New Delhi, 110001, India.
| | - Divyani Garg
- Department of Neurology, Smt. Sucheta Kriplani Hospital and Lady Hardinge Medical College, New Delhi, India
| | - Sukla Samaddar
- Division of Neurology, Department of Pediatrics, Kalawati Saran Children's Hospital and Lady Hardinge Medical College, New Delhi, 110001, India
| | - Isha Panda
- Division of Neurology, Department of Pediatrics, Kalawati Saran Children's Hospital and Lady Hardinge Medical College, New Delhi, 110001, India
| | - Bijoy Patra
- Division of Neurology, Department of Pediatrics, Kalawati Saran Children's Hospital and Lady Hardinge Medical College, New Delhi, 110001, India
| | - Sharmila B Mukherjee
- Division of Neurology, Department of Pediatrics, Kalawati Saran Children's Hospital and Lady Hardinge Medical College, New Delhi, 110001, India
| | - Harish K Pemde
- Division of Neurology, Department of Pediatrics, Kalawati Saran Children's Hospital and Lady Hardinge Medical College, New Delhi, 110001, India
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Safety, Feasibility and Effectiveness of Pulse Methylprednisolone Therapy in Comparison with Intramuscular Adrenocorticotropic Hormone in Children with West Syndrome. Indian J Pediatr 2021; 88:663-667. [PMID: 33103229 DOI: 10.1007/s12098-020-03521-7] [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] [Received: 04/18/2020] [Accepted: 09/28/2020] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To assess the feasibility, effectiveness, and safety of pulse methylprednisolone in comparison with intramuscular adrenocorticotropic hormone (ACTH) therapy in children with West syndrome (WS). METHODS This open-label, pilot study with a parallel-group assignment included 44 recently diagnosed children with WS. Methylprednisolone therapy was given as intravenous infusion at a dose of 30 mg/kg/d for five days followed by oral steroids 1 mg/kg gradually tapered over 5-6 wk. The efficacy outcomes included a cessation of epileptic spasms (as per caregiver reporting) and resolution of hypsarrhythmia on electroencephalogram; safety outcome was the frequency of various adverse effects. RESULTS By day 14 of therapy, 6/18 (33.3%) children in the methylprednisolone group and 10/26 (38.5%) children in the ACTH group achieved cessation of epileptic spasms [group difference - 5.2%; confidence interval (CI) -30.7 to 22.8; p = 0.73]. However, by six weeks of therapy, 4/18 (22.2%) children in the methylprednisolone group and 11/26 (42.3%) children in the ACTH group had cessation of epileptic spasms (group difference - 20.1%; CI -43.0 to 8.4; p = 0.17). Hypertension was more commonly observed in the ACTH group (10 children) than in the methylprednisolone group (2 children; p = 0.046). Pulse methylprednisolone therapy was relatively safe. CONCLUSIONS The study observed limited effectiveness of both ACTH and pulse methylprednisolone therapy, which may partially be due to preponderance of structural etiology and a long treatment lag. However, pulse methylprednisolone therapy appeared to be safe, tolerable, and feasible for management of WS.
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20
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Chatterjee A, Mundlamuri RC, Kenchaiah R, Asranna A, Nagappa M, Bindu PS, Seshagiri DV, Viswanathan LG, Shreedhar AS, Duble S, Rangarajan A, Khilari M, Bharath RD, Saini J, Thennarasu K, Taly AB, Sinha S. Role of pulse methylprednisolone in epileptic encephalopathy: A retrospective observational analysis. Epilepsy Res 2021; 173:106611. [PMID: 33740698 DOI: 10.1016/j.eplepsyres.2021.106611] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 03/02/2021] [Accepted: 03/09/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVES To study the effect of monthly pulses of intravenous methylprednisolone (IVMP) on seizure and global outcomes in children with epileptic encephalopathy (EE). METHODS This retrospective study was undertaken in a tertiary care epilepsy center in India. Consecutive patients with EE who had received IVMP as adjunctive therapy for a minimum of 3 months and had at least one pre-and post-steroid EEG each, were identified and a structured questionnaire was used to collect information including outcomes at 3 months post-steroid course completion and beyond, as available. RESULTS Ninety-seven patients (M:F=71:26) fulfilling the inclusion criteria with a mean age at onset of seizures being 20.52 ± 25.69 months were included. Commonest seizure types were myoclonic (66%); Lennaux-Gastaut and West Syndromes accounted for 57 % and 24 % patients respectively. The etiology was unknown in 52 %. All children were on a combination of standard anti-seizure drugs. The duration of IVMP pulse therapy was 7.72 ± 6.25 months. One-fourth (26 %) patients experienced minor adverse events. Greater than 50 % seizure burden reduction was seen in 66 % patients at 3 months with seizure-freedom in 25 %. A total of 45 (46 %) patients became seizure-free in the cohort eventually with continuation of steroids beyond 3 months. Children with idiopathic EEs, normal neuroimaging, myoclonic jerks, and West syndrome showed the best response. The presence of burst-suppression and generalized paroxysmal fast activity (GPFA) predicted inadequate response. CONCLUSIONS Adjunct pulse doses of IVMP are safe, well-tolerated, and effective in reducing seizures and improving global outcomes in children with idiopathic EEs, West syndrome, normal neuroimaging, and myoclonic jerks. Seizure freedom might be delayed in a subset of these patients, hence duration of therapy beyond 3 months may be warranted.
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Affiliation(s)
- Aparajita Chatterjee
- Department of Neurology, National Institute of Mental Health and Neurosciences, Bangalore, 560011, India
| | | | - Raghavendra Kenchaiah
- Department of Neurology, National Institute of Mental Health and Neurosciences, Bangalore, 560011, India
| | - Ajay Asranna
- Department of Neurology, National Institute of Mental Health and Neurosciences, Bangalore, 560011, India
| | - M Nagappa
- Department of Neurology, National Institute of Mental Health and Neurosciences, Bangalore, 560011, India
| | - P S Bindu
- Department of Neurology, National Institute of Mental Health and Neurosciences, Bangalore, 560011, India
| | - D V Seshagiri
- Department of Neurology, National Institute of Mental Health and Neurosciences, Bangalore, 560011, India
| | | | - A S Shreedhar
- Department of Neurology, National Institute of Mental Health and Neurosciences, Bangalore, 560011, India
| | - Sisir Duble
- Department of Neurology, National Institute of Mental Health and Neurosciences, Bangalore, 560011, India
| | - Anush Rangarajan
- Department of Neurology, National Institute of Mental Health and Neurosciences, Bangalore, 560011, India
| | - Madhuri Khilari
- Department of Neurology, National Institute of Mental Health and Neurosciences, Bangalore, 560011, India
| | - Rose Dawn Bharath
- Department of Neuroimaging and Interventional Radiology, National Institute of Mental Health and Neurosciences, Bangalore, 560011, India
| | - Jitender Saini
- Department of Neuroimaging and Interventional Radiology, National Institute of Mental Health and Neurosciences, Bangalore, 560011, India
| | - K Thennarasu
- Department of Biostatistics, National Institute of Mental Health and Neurosciences, Bangalore, 560011, India
| | - Arun B Taly
- Department of Neurology, National Institute of Mental Health and Neurosciences, Bangalore, 560011, India
| | - Sanjib Sinha
- Department of Neurology, National Institute of Mental Health and Neurosciences, Bangalore, 560011, India.
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21
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The role of inflammatory mediators in epilepsy: Focus on developmental and epileptic encephalopathies and therapeutic implications. Epilepsy Res 2021; 172:106588. [PMID: 33721708 DOI: 10.1016/j.eplepsyres.2021.106588] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 01/28/2021] [Accepted: 02/16/2021] [Indexed: 02/06/2023]
Abstract
In recent years, there has been an increasing interest in the potential involvement of neuroinflammation in the pathogenesis of epilepsy. Specifically, the role of innate immunity (that includes cytokines and chemokines) has been extensively investigated either in animal models of epilepsy and in clinical settings. Developmental and epileptic encephalopathies (DEE) are a heterogeneous group of epileptic disorders, in which uncontrolled epileptic activity results in cognitive, motor and behavioral impairment. By definition, epilepsy in DEE is poorly controlled by common antiepileptic drugs but may respond to alternative treatments, including steroids and immunomodulatory drugs. In this review, we will focus on how cytokines and chemokines play a role in the pathogenesis of DEE and why expanding our knowledge about the role of neuroinflammation in DEE may be crucial to develop new and effective targeted therapeutic strategies to prevent seizure recurrence and developmental regression.
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22
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Basu T, Maguire J, Salpekar JA. Hypothalamic-pituitary-adrenal axis targets for the treatment of epilepsy. Neurosci Lett 2021; 746:135618. [PMID: 33429002 DOI: 10.1016/j.neulet.2020.135618] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 12/25/2020] [Accepted: 12/29/2020] [Indexed: 12/20/2022]
Abstract
Stress is a common seizure trigger in persons with epilepsy. The body's physiological response to stress is mediated by the hypothalamic-pituitary-adrenal (HPA) axis and involves a hormonal cascade that includes corticotropin releasing hormone (CRH), adrenocorticotropin releasing hormone (ACTH) and the release of cortisol (in humans and primates) or corticosterone (in rodents). The prolonged exposure to stress hormones may not only exacerbate pre-existing medical conditions including epilepsy, but may also increase the predisposition to psychiatric comorbidities. Hyperactivity of the HPA axis negatively impacts the structure and function of the temporal lobe of the brain, a region that is heavily involved in epilepsy and mood disorders like anxiety and depression. Seizures themselves damage temporal lobe structures, further disinhibiting the HPA axis, setting off a vicious cycle of neuronal damage and increasing susceptibility for subsequent seizures and psychiatric comorbidity. Treatments targeting the HPA axis may be beneficial both for epilepsy and for associated stress-related comorbidities such as anxiety or depression. This paper will highlight the evidence demonstrating dysfunction in the HPA axis associated with epilepsy which may contribute to the comorbidity of psychiatric disorders and epilepsy, and propose treatment strategies that may dually improve seizure control as well as alleviate stress related psychiatric comorbidities.
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Affiliation(s)
- Trina Basu
- Department of Neuroscience, Tufts University School of Medicine, Boston, MA 02111, United States
| | - Jamie Maguire
- Department of Neuroscience, Tufts University School of Medicine, Boston, MA 02111, United States
| | - Jay A Salpekar
- Kennedy Krieger Institute, Johns Hopkins University Medical School, Baltimore, MD 21205, United States.
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Shin HJ, Na JH, Lee H, Lee YM. High-Dose Prednisolone Therapy for Lennox–Gastaut Syndrome Caused by Fentanyl Intoxication-Induced Toxic Leukoencephalopathy. ANNALS OF CHILD NEUROLOGY 2021. [DOI: 10.26815/acn.2021.00465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
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Dexamethasone after early-life seizures attenuates increased susceptibility to seizures, seizure-induced microglia activation and neuronal injury later in life. Neurosci Lett 2020; 728:134953. [DOI: 10.1016/j.neulet.2020.134953] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Revised: 03/26/2020] [Accepted: 03/31/2020] [Indexed: 12/29/2022]
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Taalab YM, Fathi Mohammed W, Helmy MA, Othman AA, Darwish M, Hassan I, Abbas M. Cannabis Influences the Putative Cytokines-Related Pathway of Epilepsy among Egyptian Epileptic Patients. Brain Sci 2019; 9:brainsci9120332. [PMID: 31757102 PMCID: PMC6955862 DOI: 10.3390/brainsci9120332] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Revised: 11/11/2019] [Accepted: 11/18/2019] [Indexed: 12/21/2022] Open
Abstract
The study aims to investigate: (1) the prevalence of cannabis among epileptic patients seen at Mansoura University Hospital, (2) serum levels and gene expression of cytokines in epilepsy patients and the controls. and (3) the possibility that cannabis use affects the cytokine levels in epilepsy patients, triggering its future use in treatment. We recruited 440 epilepsy patients and 200 controls matched for age, gender, and ethnicity. Of the epileptic patients, 37.5% demonstrated lifetime cannabis use with a mean duration of 15 ± 73 years. Serum levels of interleukin IL-1α, IL-1β, IL-2, IL-4, IL-6, IL-8, IL-10, and tumor necrosis factor-α (TNF-α), were analyzed and gene expression analysis was conducted only for those cytokines that were different between groups in the serum analysis. The “Epilepsy-only” patients had significantly higher serum and mRNA levels of IL-1α, β, IL-2,6,8, and TNF-α compared to the controls and the “Cannabis+Epilepsy” group (p = 0.0001). IL-10 showed significantly lower levels in the “Epilepsy-only” patients compared to the controls and “Cannabis+Epilepsy” (p = 0.0001). Cannabis use is prevalent among epilepsy patients. Epilepsy is characterized by a pro-inflammatory state supported by high serum and gene expression levels. Cannabis users demonstrated significantly lower levels of inflammatory cytokines compared to epilepsy non-cannabis users which might contribute to its use in the treatment of resistant epilepsy.
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Affiliation(s)
- Yasmeen M. Taalab
- Forensic Medicine and Clinical Toxicology Department, Faculty of Medicine, Mansoura University, El-Mansoura 35516, Egypt; (Y.M.T.); (M.A.H.)
- Institute of Forensic and Traffic Medicine, University of Heidelberg, 69115 Heidelberg, Germany
| | - Wessam Fathi Mohammed
- Neurology Department, Faculty of Medicine, Mansoura University, El-Mansoura 35516, Egypt; (W.F.M.); (M.A.)
| | - Manar A. Helmy
- Forensic Medicine and Clinical Toxicology Department, Faculty of Medicine, Mansoura University, El-Mansoura 35516, Egypt; (Y.M.T.); (M.A.H.)
| | - Alyaa A.A. Othman
- Forensic Medicine and Clinical Toxicology Department, Faculty of Medicine, Mansoura University, El-Mansoura 35516, Egypt; (Y.M.T.); (M.A.H.)
| | - Mohamed Darwish
- Clinical Pathology Department, Faculty of Medicine, Mansoura University, El-Mansoura 35516, Egypt;
| | - Ibrahim Hassan
- Movement and Training Science Department, Institute of Sports Sciences, Johannes Gutenberg University of Mainz, 55128 Mainz, Germany
- Correspondence: ; Tel.: +491-630-803-435
| | - Mohammed Abbas
- Neurology Department, Faculty of Medicine, Mansoura University, El-Mansoura 35516, Egypt; (W.F.M.); (M.A.)
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Abstract
A rapidly growing body of evidence supports the premise that neuroinflammation plays an important role in initiating and sustaining seizures in a range of pediatric epilepsies. Clinical and experimental evidence indicate that neuroinflammation is both an outcome and a contributor to seizures. In this manner, seizures that arise from an initial insult (e.g. infection, trauma, genetic mutation) contribute to an inflammatory response that subsequently promotes recurrent seizures. This cyclical relationship between seizures and neuroinflammation has been described as a 'vicious cycle.' Studies of human tissue resected for surgical treatment of refractory epilepsy have reported activated inflammatory and immune signaling pathways, while animal models have been used to demonstrate that key inflammatory mediators lead to increased seizure susceptibility. Further characterization of the molecular mechanisms involved in this cycle may ultimately enable the development of new therapeutic approaches for the treatment of epilepsy. In this brief review we focus on key inflammatory mediators that have become prominent in recent literature of epilepsy, including newly characterized microRNAs and their potential role in neuroinflammatory signaling.
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Affiliation(s)
- Shruti Bagla
- Division of Hematology/Oncology, Department of Pediatrics, Room 3L22, Children's Hospital of Michigan, 3901 Beaubien Blvd, Detroit, MI 48201, USA
| | - Alan A Dombkowski
- Division of Clinical Pharmacology and Toxicology, Department of Pediatrics, Room 3L22, Children's Hospital of Michigan, 3901 Beaubien Blvd, Detroit, MI 48201, USA
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Post JM, Loch S, Lerner R, Remmers F, Lomazzo E, Lutz B, Bindila L. Antiepileptogenic Effect of Subchronic Palmitoylethanolamide Treatment in a Mouse Model of Acute Epilepsy. Front Mol Neurosci 2018; 11:67. [PMID: 29593494 PMCID: PMC5861196 DOI: 10.3389/fnmol.2018.00067] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Accepted: 02/16/2018] [Indexed: 12/16/2022] Open
Abstract
Research on the antiepileptic effects of (endo-)cannabinoids has remarkably progressed in the years following the discovery of fundamental role of the endocannabinoid (eCB) system in controlling neural excitability. Moreover, an increasing number of well-documented cases of epilepsy patients exhibiting multi-drug resistance report beneficial effects of cannabis use. Pre-clinical and clinical research has increasingly focused on the antiepileptic effectiveness of exogenous administration of cannabinoids and/or pharmacologically induced increase of eCBs such as anandamide (also known as arachidonoylethanolamide [AEA]). Concomitant research has uncovered the contribution of neuroinflammatory processes and peripheral immunity to the onset and progression of epilepsy. Accordingly, modulation of inflammatory pathways such as cyclooxygenase-2 (COX-2) was pursued as alternative therapeutic strategy for epilepsy. Palmitoylethanolamide (PEA) is an endogenous fatty acid amide related to the centrally and peripherally present eCB AEA, and is a naturally occurring nutrient that has long been recognized for its analgesic and anti-inflammatory properties. Neuroprotective and anti-hyperalgesic properties of PEA were evidenced in neurodegenerative diseases, and antiepileptic effects in pentylenetetrazol (PTZ), maximal electroshock (MES) and amygdaloid kindling models of epileptic seizures. Moreover, numerous clinical trials in chronic pain revealed that PEA treatment is devoid of addiction potential, dose limiting side effects and psychoactive effects, rendering PEA an appealing candidate as antiepileptic compound or adjuvant. In the present study, we aimed at assessing antiepileptic properties of PEA in a mouse model of acute epileptic seizures induced by systemic administration of kainic acid (KA). KA-induced epilepsy in rodents is assumed to resemble to different extents human temporal lobe epilepsy (TLE) depending on the route of KA administration; intracerebral (i.c.) injection was recently shown to most closely mimic human TLE, while systemic KA administration causes more widespread pathological damage, both in brain and periphery. To explore the potential of PEA to exert therapeutic effects both in brain and periphery, acute and subchronic administration of PEA by intraperitoneal (i.p.) injection was assessed on mice with systemically administered KA. Specifically, we investigated: (i) neuroprotective and anticonvulsant properties of acute and subchronic PEA treatment in KA-induced seizure models, and (ii) temporal dynamics of eCB and eicosanoid (eiC) levels in hippocampus and plasma over 180 min post seizure induction in PEA-treated and non-treated KA-injected mice vs. vehicle injected mice. Finally, we compared the systemic PEA treatment with, and in combination with, pharmacological blockade of fatty acid amide hydrolase (FAAH) in brain and periphery, in terms of anticonvulsant properties and modulation of eCBs and eiCs. Here, we demonstrate that subchronic administration of PEA significantly alleviates seizure intensity, promotes neuroprotection and induces modulation of the plasma and hippocampal eCB and eiC levels in systemic KA-injected mice.
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Affiliation(s)
- Julia M Post
- Institute of Physiological Chemistry, University Medical Center of the Johannes Gutenberg University of Mainz, Mainz, Germany
| | - Sebastian Loch
- Institute of Physiological Chemistry, University Medical Center of the Johannes Gutenberg University of Mainz, Mainz, Germany
| | - Raissa Lerner
- Institute of Physiological Chemistry, University Medical Center of the Johannes Gutenberg University of Mainz, Mainz, Germany
| | - Floortje Remmers
- Institute of Physiological Chemistry, University Medical Center of the Johannes Gutenberg University of Mainz, Mainz, Germany
| | - Ermelinda Lomazzo
- Institute of Physiological Chemistry, University Medical Center of the Johannes Gutenberg University of Mainz, Mainz, Germany
| | - Beat Lutz
- Institute of Physiological Chemistry, University Medical Center of the Johannes Gutenberg University of Mainz, Mainz, Germany
| | - Laura Bindila
- Institute of Physiological Chemistry, University Medical Center of the Johannes Gutenberg University of Mainz, Mainz, Germany
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28
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Wanigasinghe J, Arambepola C, Ranganathan SS, Sumanasena S. Randomized, Single-Blind, Parallel Clinical Trial on Efficacy of Oral Prednisolone Versus Intramuscular Corticotropin: A 12-Month Assessment of Spasm Control in West Syndrome. Pediatr Neurol 2017; 76:14-19. [PMID: 28927673 DOI: 10.1016/j.pediatrneurol.2017.07.008] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2017] [Revised: 07/09/2017] [Accepted: 07/11/2017] [Indexed: 11/25/2022]
Abstract
OBJECTIVE We earlier completed a single-blind, parallel-group, randomized clinical trial to test the null hypothesis that adrenocorticotropic hormone (ACTH) is not superior to high-dose prednisolone for short-term control of West syndrome. We now present long-term follow-up data for spasm control for individuals who completed this earlier trial. METHODS Infants with untreated West syndrome were randomized to receive 14 days of prednisolone (40 to 60 mg/day) or intramuscular long-acting ACTH (40 to 60 IU every other day). They were evaluated at three, six, and 12 months to evaluate long-term spasm control. RESULTS The total number of infants treated was 97 (48 prednisolone; 49 ACTH). All completed the treatment course. Eighty-five, 82, and 76 children were available for follow-up at three, six, and 12 months. The number lost to follow-up at each interval was not statistically different. Likelihood of spasm freedom at three months was significantly higher for prednisolone (64.6%) than for ACTH (38.8%) (P = 0.01; odds ratio = 2.9; 95% confidence interval = 1.3 to 6.6). At six months (P = 0.19) and twelve months (P = 0.13), the control of spasms was not statistically different, although a trend in favor of prednisolone was documented at both of these time points (58.3% versus 44.9% for ACTH at six months and 56.2% versus 40.8% with ACTH at 12 months). After initial remission by day 14 (n = 46), the likelihood of a relapse within the next 12 months was not statistically different between the two treatment groups (P = 0.1). CONCLUSIONS Control of spasms at three months was significantly better if initially treated with prednisolone. Control of spasms at six and 12 months was not significantly different despite a trend favoring prednisolone. Risk of relapse following initial remission was similar in the two groups.
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Affiliation(s)
| | - Carukshi Arambepola
- Department of Community Medicine, Faculty of Medicine, University of Colombo, Sri Lanka
| | | | - Samanmali Sumanasena
- Department of Disability Studies, Faculty of Medicine, University of Kelaniya, Sri Lanka
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Shachor-Meyouhas Y, Ravid S, Hanna S, Yaacoby-Bianu K, Kassis I. Legionella pneumophila Pneumonia in Two Infants Treated with Adrenocorticotropic Hormone. J Pediatr 2017; 186:186-188.e1. [PMID: 28336145 DOI: 10.1016/j.jpeds.2017.02.063] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2016] [Revised: 02/17/2017] [Accepted: 02/23/2017] [Indexed: 11/29/2022]
Abstract
Patients with infantile spasms, an intractable epileptic disorder, often are treated with adrenocorticotropic hormone. Legionella pneumophila is a rare cause of pneumonia in children. We describe 2 infants with Legionella pneumonia whose infection occurred within 1 month after starting adrenocorticotropic hormone.
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Affiliation(s)
- Yael Shachor-Meyouhas
- Pediatric Infectious Diseases Unit, Ruth Rappaport Children's Hospital, Rambam Health Care Campus, Haifa, Israel.
| | - Sarit Ravid
- Pediatric Neurology Unit, Ruth Rappaport Children's Hospital, Rambam Health Care Campus, Haifa, Israel
| | - Suheir Hanna
- Department of Pediatrics A, Ruth Rappaport Children's Hospital, Rambam Health Care Campus, Haifa, Israel
| | - Karin Yaacoby-Bianu
- Pediatric Pulmonary Institute, Ruth Rappaport Children's Hospital, Rambam Health Care Campus, Haifa, Israel
| | - Imad Kassis
- Pediatric Infectious Diseases Unit, Ruth Rappaport Children's Hospital, Rambam Health Care Campus, Haifa, Israel
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30
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Kotwas I, McGonigal A, Bastien-Toniazzo M, Bartolomei F, Micoulaud-Franchi JA. Stress regulation in drug-resistant epilepsy. Epilepsy Behav 2017; 71:39-50. [PMID: 28494323 DOI: 10.1016/j.yebeh.2017.01.025] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2016] [Revised: 12/29/2016] [Accepted: 01/25/2017] [Indexed: 12/17/2022]
Abstract
The prevalence of psychological distress, especially depressive and anxiety disorders, is higher in epilepsy than in other chronic health conditions. These comorbid conditions contribute even more than epileptic seizures themselves to impaired quality of life in patients with epilepsy (PWE). The link between these comorbidities and epilepsy appears to have a neurobiological basis, which is at least partly mediated by stress through psychological and pathophysiological pathways. The impact of stress in PWE is also particularly important because it is the most frequently reported seizure trigger. It is therefore crucial for clinicians to take stress-related conditions and psychiatric comorbidities into account when managing PWE and to propose clinical support to enhance self-control of stress. Screening tools have been specially designed and validated in PWE for depressive disorders and anxiety disorders (e.g. NDDI-E, GAD-7). Other instruments are useful for measuring stress-related variables (e.g. SRRS, PSS, SCS, MHLCS, DSR-15, ERP-R, QOLIE-31) in order to help characterize the individual "stress profile" and thus orientate patients towards the most appropriate treatment. Management includes both pharmacological treatment and nonpharmacological methods for enhancing self-management of stress (e.g. mindfulness-based therapies, yoga, cognitive-behavioral therapies, biofeedback), which may not only protect against psychiatric comorbidities but also reduce seizure frequency.
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Affiliation(s)
- Iliana Kotwas
- Laboratoire Parole et Langage UMR 7309, Aix-Marseille Université, Marseille, France.
| | - Aileen McGonigal
- Service de Neurophysiologie Clinique, Centre Hospitalo Universitaire de la Timone, 264, rue Saint-Pierre, 13005 Marseille, France; Unité mixte INSERM Epilepsie et Cognition UMR 751, 27 Bd Jean Moulin, 13385 Marseille Cedex 05, France
| | | | - Fabrice Bartolomei
- Service de Neurophysiologie Clinique, Centre Hospitalo Universitaire de la Timone, 264, rue Saint-Pierre, 13005 Marseille, France; Unité mixte INSERM Epilepsie et Cognition UMR 751, 27 Bd Jean Moulin, 13385 Marseille Cedex 05, France
| | - Jean-Arthur Micoulaud-Franchi
- Service d'explorations fonctionnelles du système nerveux, Clinique du sommeil, CHU de, Bordeaux, Place Amélie Raba-Léon, 33076 Bordeaux, France; USR CNRS 3413 SANPSY, CHU Pellegrin, Université de Bordeaux, France
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31
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Up-regulated BAFF and BAFF receptor expression in patients with intractable temporal lobe epilepsy and a pilocarpine-induced epilepsy rat model. Seizure 2017; 48:79-88. [DOI: 10.1016/j.seizure.2017.03.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Revised: 03/23/2017] [Accepted: 03/25/2017] [Indexed: 11/20/2022] Open
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Pera MC, Randazzo G, Masnada S, Dontin SD, De Giorgis V, Balottin U, Veggiotti P. Intravenous methylprednisolone pulse therapy for children with epileptic encephalopathy. FUNCTIONAL NEUROLOGY 2016; 30:173-9. [PMID: 26910177 DOI: 10.11138/fneur/2015.30.3.173] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The aim of this retrospective study of children affected by epileptic encephalopathy was to evaluate seizure frequency, electroencephalographic pattern and neuropsychological status, before and after intravenous methylprednisolone therapy. Eleven children with epileptic encephalopathy were administered one cycle of intravenous methylprednisolone (15-30 mg/kg/day for three consecutive days, once a month for four months) in addition to constant dosages of their regular antiepileptic drugs. The treatment resulted in statistically significant reductions of generalized slow spike-and-wave discharges (p<0.0028) and seizure frequency (p<0.013), which persisted even after methylprednisolone pulse therapy was stopped. A globally positive outcome was noted in 9/11 patients (81.8%). This methylprednisolone treatment regimen did not cause significant or persistent adverse effects. We suggest that children with epileptic encephalopathy without an underlying structural lesion could be the best candidates for intravenous methylprednisolone pulse therapy.
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Current understanding and neurobiology of epileptic encephalopathies. Neurobiol Dis 2016; 92:72-89. [DOI: 10.1016/j.nbd.2016.03.007] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Revised: 03/01/2016] [Accepted: 03/09/2016] [Indexed: 12/25/2022] Open
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de Vries EE, van den Munckhof B, Braun KPJ, van Royen-Kerkhof A, de Jager W, Jansen FE. Inflammatory mediators in human epilepsy: A systematic review and meta-analysis. Neurosci Biobehav Rev 2016; 63:177-90. [PMID: 26877106 DOI: 10.1016/j.neubiorev.2016.02.007] [Citation(s) in RCA: 157] [Impact Index Per Article: 19.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2015] [Revised: 01/07/2016] [Accepted: 02/08/2016] [Indexed: 12/13/2022]
Abstract
BACKGROUND Accumulating evidence suggests a role for inflammation in the pathophysiology of epilepsy. METHODS We performed a systematic review and meta-analysis of studies that investigated inflammatory mediators in human epilepsy. Studies reporting on inflammatory mediators in serum, cerebrospinal fluid or brain tissue of epilepsy patients were included. Studies comparing patients to controls were included in a meta-analysis. RESULTS 66 articles reporting on 1934 patients were included. IL-1ra, IL-1β, IL-6, IL-10, IFN-γ and TNF-α were the most extensively investigated proteins. Elevated levels for IL-1ra, IL-1β, IL-6 and CXCL8/IL-8 were reported in several different epilepsy etiologies and media, while other proteins were specifically increased for one etiology. IL-1α, IL-7 and IL-13, as well as the chemokines CCL2-5, -19 and -22, were increased exclusively in brain tissue. In an aggregate meta-analysis, we found significantly different protein levels for serum IL-6, IL-17 and CSF IL-1β and IL-10. CONCLUSION Inflammatory pathways are involved in epilepsy. Future studies may further clarify their role, and prove potential of targeted anti-inflammatory treatment.
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Affiliation(s)
- Evelien E de Vries
- Brain Center Rudolf Magnus, Department of Pediatric Neurology, University Medical Center Utrecht, Utrecht, The Netherlands.
| | - Bart van den Munckhof
- Brain Center Rudolf Magnus, Department of Pediatric Neurology, University Medical Center Utrecht, Utrecht, The Netherlands.
| | - Kees P J Braun
- Brain Center Rudolf Magnus, Department of Pediatric Neurology, University Medical Center Utrecht, Utrecht, The Netherlands.
| | - Annet van Royen-Kerkhof
- Department of Pediatric Immunology, Laboratory of Translational Immunology, University Medical Centre Utrecht, Utrecht, The Netherlands.
| | - Wilco de Jager
- Department of Pediatric Immunology, Laboratory of Translational Immunology, University Medical Centre Utrecht, Utrecht, The Netherlands.
| | - Floor E Jansen
- Brain Center Rudolf Magnus, Department of Pediatric Neurology, University Medical Center Utrecht, Utrecht, The Netherlands.
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Chen J, Cai F, Jiang L, Hu Y, Feng C. A prospective study of dexamethasone therapy in refractory epileptic encephalopathy with continuous spike-and-wave during sleep. Epilepsy Behav 2016; 55:1-5. [PMID: 26720702 DOI: 10.1016/j.yebeh.2015.10.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2015] [Revised: 10/01/2015] [Accepted: 10/05/2015] [Indexed: 10/22/2022]
Abstract
PURPOSE Epileptic encephalopathy with continuous spike-and-wave during sleep (CSWS) is an intractable form of epilepsy that has no consensus protocol for corticosteroid therapy. This prospective study aimed to evaluate the efficacy and tolerability of dexamethasone for the treatment of CSWS. METHODS Patients (age: 4 years to 12 years and 5 months) with CSWS that failed to respond to several antiepileptic drugs and prednisolone at our pediatric neurology outpatient clinic between 2007 and 2015 were treated with dexamethasone and prospectively analyzed. An initial 4-week dexamethasone (0.15 mg/kg/day p.o.) scheme was employed, and response was assessed. If effective, dexamethasone was maintained for 2-3 months and then slowly weaned over several months, depending on individual patient response at each follow-up. Systemic evaluations (clinical evaluations, electroencephalography recordings, and analysis of side effects) were performed regularly thereafter. RESULTS Among 15 patients, 7 were defined as initial responders after 4-week dexamethasone treatment based on comprehensive clinical and electroencephalogram evaluations. The duration of dexamethasone treatment (including weaning) in these 7 patients was 6 to 10 months, and the follow-up duration was 6 months to 7 years. Three patients had no relapse after dexamethasone withdrawal at last follow-up. Among the other 4 patients, relapse was observed during dexamethasone withdrawal (n=1) or at 2-6 months after discontinuation of dexamethasone therapy (n=3). There were no serious or life-threatening side effects, and all observed side effects were reversible after discontinuation of dexamethasone. CONCLUSIONS Continuous oral dexamethasone treatment is an effective and tolerable therapy and should be an option for the treatment of CSWS.
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Affiliation(s)
- Jin Chen
- Department of Neurology, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Fangcheng Cai
- Pediatric Research Institute, Chongqing Medical University, Chongqing, China.
| | - Li Jiang
- Department of Neurology, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Yue Hu
- Department of Neurology, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Chenggong Feng
- Department of Neurology, Children's Hospital of Chongqing Medical University, Chongqing, China
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36
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Galtrey CM, Cock HR. Stress and Epilepsy. NEUROPSYCHIATRIC SYMPTOMS OF NEUROLOGICAL DISEASE 2016. [DOI: 10.1007/978-3-319-22159-5_15] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
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Bakker DP, Catsman-Berrevoets CE, Neuteboom RF. Effectiveness of a hybrid corticosteroid treatment regimen on refractory childhood seizures and a review of other corticosteroid treatments. Eur J Paediatr Neurol 2015; 19:553-60. [PMID: 25976064 DOI: 10.1016/j.ejpn.2015.04.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2014] [Revised: 02/20/2015] [Accepted: 04/11/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Many different corticosteroid treatment schedules have been used in order to treat refractory epileptic seizures with encouraging effects on seizure reduction in many epileptic syndromes. OBJECTIVE The objective is to report our experience with a hybrid treatment regimen for refractory seizures in children with epilepsies other than West and Landau-Kleffner syndrome. We hypothesized that a pulse of corticosteroids effectively reduces seizures while low-dosage maintenance treatment reduces side effects. The results are compared with results from a review of reported corticosteroid and ACTH treatments. METHODS In this retrospective observational study, 26 children diagnosed with epilepsy with refractory seizures other than West syndrome and Landau-Kleffner syndrome were eligible for a treatment regimen consisting of three days intravenous methylprednisolone (20 mg per kilogram per day) followed by twelve weeks oral prednisolone (0.5 mg per kilogram on alternate days), concluded with a taper phase. Data on effectiveness and side effects were obtained. End-points were the percentages of patients who became seizure free or responded well. RESULTS Twenty-one patients received the study treatment. Nine (43%) responded well and 6 (29%) became seizure free. All but one patient had a relapse of seizures. Four patients had reversible adverse effects. Data extracted from the literature were consistent with a good response in 48% of 192 children treated with different corticosteroids and in 69% of 103 patients treated with ACTH. CONCLUSION This new hybrid therapy of a pulse of intravenous methylprednisolone and alternate day oral prednisolone is effective with a favourable side effect profile. Results on efficacy and safety justify a randomized controlled trial.
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Affiliation(s)
- Dewi P Bakker
- Erasmus University Hospital-Sophia Children's Hospital, The Netherlands
| | | | - Rinze F Neuteboom
- Erasmus University Hospital-Sophia Children's Hospital, The Netherlands.
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Abstract
Lennox-Gastaut syndrome (LGS) is a severe pediatric epilepsy syndrome characterized by mixed seizures, cognitive decline, and generalized slow (<3 Hz) spike wave discharges on electroencephalography. Atonic seizures result in dangerous drop attacks with risks of injury and impairment of the quality of life. The seizures are frequently resistant to multiple antiepileptic (AED) drugs. Newer AEDs, such as rufinamide, are now available. When multiple AED trials fail, non-pharmacological treatments such as the ketogenic diet, vagus nerve stimulation, and epilepsy surgery, should be considered. The aim of this review is to present an updated outline of LGS and the available treatments. Although the prognosis for complete seizure control remains poor, the addition of newer therapies provides an improved hope for some of these patients and their families. Further long term randomized controlled trials are required to compare different therapeutic interventions in terms of efficacy and tolerability.
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Affiliation(s)
- Muradi H Al-Banji
- Department of Pediatrics, King Abdulaziz University Hospital, Jeddah, Kingdom of Saudi Arabia
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Mehta V, Ferrie CD, Cross JH, Vadlamani G. Corticosteroids including ACTH for childhood epilepsy other than epileptic spasms. Cochrane Database Syst Rev 2015; 2015:CD005222. [PMID: 26086765 PMCID: PMC7390481 DOI: 10.1002/14651858.cd005222.pub3] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND This is an updated version of the original Cochrane review published in Issue 1, 2007.Epilepsy is a disorder with recurrent epileptic seizures. Corticosteroids have been used in the treatment of children with epilepsy and have significant adverse effects. Their efficacy and tolerability have not been clearly established. OBJECTIVES To determine the efficacy, in terms of seizure control, improvements in cognition and in quality of life and tolerability of steroids compared to placebo or other antiepileptic drugs in children with epilepsy, excluding epileptic spasms. SEARCH METHODS We searched the following databases: The Cochrane Epilepsy Group Specialized Register (1 August 2014); CENTRAL, (The Cochrane Library Issue 7, July 2014); MEDLINE (1946 to 1 August 2014); EMBASE (1966 to December 2004); Database of Abstracts of Reviews of Effectiveness (DARE; Issue 3 of the database published in The Cochrane Library Issue 7, July 2014); ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform ICTRP (1 August 2014).We checked the reference lists of retrieved studies for additional reports of relevant studies. SELECTION CRITERIA All randomised controlled trials of administration of corticosteroids to children (less than 16 years) with epilepsy. DATA COLLECTION AND ANALYSIS For this update two review authors independently selected trials for inclusion and extracted data. Outcomes included cessation of seizures, reduction in seizure frequency, improvement in cognition, quality of life and adverse effects of steroids. MAIN RESULTS A single RCT was included that recruited five children in a double blind cross-over trial. One child was withdrawn prematurely from the study and another had infantile spasms and hence was excluded from further analysis. Adrenocorticotrophin hormone (ACTH 4-9) was administered. Of the three children analysed, one showed a reduction in seizures of 25% to 50% at both the low and higher doses of corticosteroids compared to placebo; one child showed a reduction in seizures at the higher dose only and one child showed no reduction in seizures at either dose. No adverse effects were reported. AUTHORS' CONCLUSIONS Since the last version of this review no new evidence has been found for the efficacy of corticosteroids in treating childhood epilepsies. Clinicians using steroids in childhood epilepsies, other than for epileptic spasms, should take this into account before using these agents.
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Affiliation(s)
- Vishal Mehta
- Hull and East Yorkshire Hospitals NHS TrustDepartment of PaediatricsAnlaby RoadHullWest YorkshireUKHU3 2JZ
| | - Colin D Ferrie
- Leeds General InfirmaryDepartment of Paediatric NeurologyClarendon WingBelmont GroveLeedsUKLS2 9NS
| | - J Helen Cross
- UCL Institute of Child Health4/5 Long YardLondonUKWC1N 3LU
- The Neville Childhood Epilepsy CentreSt Piers LaneLingfieldSurreyUKRH7 6PW
| | - Gayatri Vadlamani
- Leeds General InfirmaryDepartment of Paediatric NeurologyClarendon WingBelmont GroveLeedsUKLS2 9NS
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Yuan Q, Li F, Zhong H. Early diagnosis, treatment and prognosis of epilepsy with continuous spikes and waves during slow sleep. Int J Clin Exp Med 2015; 8:4052-4058. [PMID: 26064309 PMCID: PMC4443143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2014] [Accepted: 02/27/2015] [Indexed: 06/04/2023]
Abstract
The study is to investigate the importance of early diagnosis and treatment to the prognosis of epilepsy with continuous spikes and waves during slow sleep (CSWS). A total of 8 cases of CSWS children were followed up for 6 months to 4 years. Retrospective analysis of the clinical and electroencephalographic (EEG) characteristics, treatment and prognosis was performed in these 8 cases. Of the 8 cases of CSWS patients, 5 were males and 3 were females. Epilepsy onset ages were from 3 years and 1 month to 10 years and 6 months. Five cases of the patients were with brain lesions while the other 3 cases appeared normally by imaging detection. After treatment with valproic acid, clonazepam, lamotrigine and hormone for 3 months, clinical symptoms and EEG were improved significantly in 7 cases. Two cases relapsed at 6 months after comprehensive treatment. For atypical early performance of CSWS, early diagnosis and regular treatment could improve the condition of children with seizures and effectively inhibit the epileptic activity with good prognosis.
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Affiliation(s)
- Qiang Yuan
- Department of Pediatrics, Shanxi Province People’s HospitalXi’an 710068, P. R. China
| | - Fengtong Li
- Department of Pediatrics, Shanxi Province People’s HospitalXi’an 710068, P. R. China
| | - Hongping Zhong
- Department of Paediatrics, Yan’an University Affiliated HospitalYan’an 716000, P. R. China
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Higurashi N, Takahashi Y, Kashimada A, Sugawara Y, Sakuma H, Tomonoh Y, Inoue T, Hoshina M, Satomi R, Ohfu M, Itomi K, Takano K, Kirino T, Hirose S. Immediate suppression of seizure clusters by corticosteroids in PCDH19 female epilepsy. Seizure 2015; 27:1-5. [PMID: 25891919 DOI: 10.1016/j.seizure.2015.02.006] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2014] [Revised: 02/02/2015] [Accepted: 02/05/2015] [Indexed: 11/19/2022] Open
Abstract
PURPOSE The pathomechanism and treatment of PCDH19 female epilepsy (PCDH19-FE) remain unclear. Here, we report that corticosteroids are effective for control of the seizure clusters or other acute symptoms of PCDH19-FE and argue for the possible involvement of a compromised blood-brain barrier (BBB) in its pathogenesis. METHODS The efficacy of corticosteroids was retrospectively reviewed in five Japanese patients with PCDH19-FE. The results of antibody assays against the N-methyl-d-aspartate-type glutamate receptor (abs-NR) in serum/cerebrospinal fluid were also compiled. RESULTS Corticosteroid treatments significantly improved the acute symptoms, including seizure clusters, in all cases, most often immediately after the initial administration. However, the effect was transient, and some seizures recurred within a few weeks, especially in association with fever. Serum and/or cerebrospinal fluid abs-NR were detected in all patients. Target sequences of the detected antibodies were multiple, and the titers tended to decrease over time. In one patient, immunohistochemical analysis using rat hippocampal slices also revealed serum antibodies targeting an unknown epitope in neuronal cytoplasm. CONCLUSION Our findings imply an involvement of inflammatory processes in the pathogenesis of PCDH19-FE and therapeutic utility for corticosteroids as an adjunctive option in acute treatment. PCDH19 is well expressed in brain microvascular endothelial cells and thus its impairment may cause BBB vulnerability, which may be ameliorated by corticosteroids. The abs-NR detected in our patients may not indicate an autoimmune pathomechanism, but may rather represent non-specific sensitization to degraded neuronal components entering the general circulation, the latter process facilitated by the BBB vulnerability.
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Affiliation(s)
- Norimichi Higurashi
- Department of Pediatrics, Jikei University School of Medicine, 3-25-8, Nishi-Shimbashi, Minato-ku, Tokyo 105-8461, Japan; Central Research Institute for the Pathomechanisms of Epilepsy, Fukuoka University, 7-45-1, Nanakuma, Jonan-ku, Fukuoka 814-0180, Japan
| | - Yukitoshi Takahashi
- National Epilepsy Center, Shizuoka Institute of Epilepsy and Neurological Disorders, Urushiyama 886, Aoi-ku, Shizuoka 420-8688, Japan
| | - Ayako Kashimada
- Department of Pediatrics, Tokyo Medical and Dental University, 1-5-45, Yushima, Bunkyo-ku, Tokyo 113-8510, Japan
| | - Yuji Sugawara
- Department of Pediatrics, Tokyo Medical and Dental University, 1-5-45, Yushima, Bunkyo-ku, Tokyo 113-8510, Japan
| | - Hiroshi Sakuma
- Department of Brain Development and Neural Regeneration, Tokyo Metropolitan Institute of Medical Science, 2-1-6, Kamikitazawa, Setagaya-ku, Tokyo 156-8506, Japan
| | - Yuko Tomonoh
- Department of Pediatrics, Fukuoka University School of Medicine, 7-45-1, Nanakuma, Jonan-ku, Fukuoka 814-0180, Japan
| | - Takahito Inoue
- Department of Pediatrics, Fukuoka University School of Medicine, 7-45-1, Nanakuma, Jonan-ku, Fukuoka 814-0180, Japan
| | - Megumi Hoshina
- Department of Pediatrics, Ohara General Hospital, 6-11, Omachi, Fukushima 960-8611, Japan
| | - Ruri Satomi
- Department of Pediatrics, JA Toride Medical Center, 2-1-1, Hongo, Toride, Ibaraki 302-0022, Japan
| | - Masaharu Ohfu
- Division of Child Neurology, Okinawa Prefectural Southern Medical Center & Children's Medical Center, 118-1, Aza Arakawa, Haebaru-cho, Shimajiri-gun, Okinawa 901-1193, Japan
| | - Kazuya Itomi
- Division of Neurology, Aichi Children's Health and Medical Center, 1-2, Osakada Morioka-cho, Obu, Aichi 474-8710, Japan
| | - Kyoko Takano
- Department of Medical Genetics, Shinshu University School of Medicine, 3-1-1, Asahi, Matsumoto, Nagano 390-8621, Japan
| | - Tomoko Kirino
- Department of Pediatrics, Shikoku Medical Center for Children and Adults, 2-1-1, Senyu-cho, Zentsuji, Kagawa 765-8507, Japan
| | - Shinichi Hirose
- Central Research Institute for the Pathomechanisms of Epilepsy, Fukuoka University, 7-45-1, Nanakuma, Jonan-ku, Fukuoka 814-0180, Japan; Department of Pediatrics, Fukuoka University School of Medicine, 7-45-1, Nanakuma, Jonan-ku, Fukuoka 814-0180, Japan.
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Almaabdi KH, Alshehri RO, Althubiti AA, Alsharef ZH, Mulla SN, Alshaer DS, Alfaidi NS, Jan MM. Intravenous methylprednisolone for intractable childhood epilepsy. Pediatr Neurol 2014; 50:334-6. [PMID: 24507698 DOI: 10.1016/j.pediatrneurol.2013.12.015] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2013] [Revised: 12/11/2013] [Accepted: 12/12/2013] [Indexed: 10/25/2022]
Abstract
BACKGROUND Steroids have been used for the treatment of certain epilepsy types, such as infantile spasms; however, the use in the treatment of other intractable epilepsies has received limited study. We report our experience with intravenous methylprednisolone in children with epilepsy refractory to multiple antiepileptic drugs. METHODS A series of consecutive children were analyzed retrospectively. Patients with infantile spasms, progressive degenerative, or metabolic disorders were excluded. RESULTS Seventeen children aged 2-14 (mean 5.3) years were included. Associated cognitive and motor deficits were recognized in 82%. Most children (88%) had daily seizures and 13 (76%) were admitted previously with status epilepticus. The epilepsy was cryptogenic (unknown etiology) in 47% and the seizures were mixed in 41%. Intravenous methylprednisolone was given at 15 mg/kg per day followed by a weaning dose of oral prednisolone for 2-8 weeks (mean 3 weeks). Children were followed for 6-24 months (mean 18). Six (35%) children became completely seizure free; however, three of them later developed recurrent seizures. At 6 months posttreatment, improved seizure control was noted in 10 (59%) children. Children with mixed seizures were more likely to have a favorable response than those with one seizure type (49% vs 31%, P = 0.02). No major side effects were noted, and 35% of the parents reported improvements in their child's alertness and appetite. CONCLUSION Add-on steroid treatment for children with intractable epilepsy is safe and may be effective in some children when used in a short course.
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Affiliation(s)
- Kholoud H Almaabdi
- Department of Pediatrics, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Rawan O Alshehri
- Department of Pediatrics, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Areej A Althubiti
- Department of Pediatrics, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Zainab H Alsharef
- Department of Pediatrics, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Sara N Mulla
- Department of Pediatrics, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Dareen S Alshaer
- Department of Pediatrics, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Nouf S Alfaidi
- Department of Pediatrics, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Mohammed M Jan
- Department of Pediatrics, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia.
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Seizure precipitants (triggering factors) in patients with epilepsy. Epilepsy Behav 2014; 33:101-5. [PMID: 24632482 DOI: 10.1016/j.yebeh.2014.02.019] [Citation(s) in RCA: 81] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2013] [Revised: 02/13/2014] [Accepted: 02/16/2014] [Indexed: 11/23/2022]
Abstract
AIM adult epilepsy clinic population: (a) to identify the frequency of seizure precipitants (triggering factors) and their relative frequency in those with psychiatric disorders, and in those in remission or with active epilepsy, differences in frequency with regard to gender, seizure duration, number of drugs taken; (b) to determine which precipitants patients most commonly report; and (c) to identify differences in the distribution of precipitants among generalized, temporal, and extratemporal epilepsies. METHODS Consecutive patients attending a tertiary-care epilepsy clinic were prospectively and an open personal interview to identify and characterize seizure precipitants. Information about the epilepsy and clinical characteristics of patients was collected during the interview and from medical records. RESULTS Of 104 patients, 97% cited at least one precipitant. Stress, sleep deprivation, and fatigue were the most frequently reported precipitants. Patients with psychological comorbidities reported a greater percentage of seizures with seizure precipitants. Patients with idiopathic generalized epilepsy seemed to be more sensitive to seizures during awakening and sleep deprivation, patients with extratemporal epilepsy reported more frequent seizures during sleep. There were no differences in frequency or type of seizure precipitants with regard to gender, seizure duration or frequency, and the number of antiepileptic drugs taken. CONCLUSION The findings may have implications for the better management of epilepsy by increasing a focus on nonpharmacological therapy. The implications of the findings for nosology and causation of epilepsy are also briefly discussed.
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Holtman L, van Vliet EA, Appeldoorn C, Gaillard PJ, de Boer M, Dorland R, Wadman WJ, Gorter JA. Glutathione pegylated liposomal methylprednisolone administration after the early phase of status epilepticus did not modify epileptogenesis in the rat. Epilepsy Res 2014; 108:396-404. [DOI: 10.1016/j.eplepsyres.2014.01.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2013] [Revised: 12/02/2013] [Accepted: 01/06/2014] [Indexed: 01/23/2023]
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Hernan AE, Alexander A, Lenck-Santini PP, Scott RC, Holmes GL. Attention deficit associated with early life interictal spikes in a rat model is improved with ACTH. PLoS One 2014; 9:e89812. [PMID: 24587054 PMCID: PMC3933669 DOI: 10.1371/journal.pone.0089812] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2013] [Accepted: 01/26/2014] [Indexed: 12/02/2022] Open
Abstract
Children with epilepsy often present with pervasive cognitive and behavioral comorbidities including working memory impairments, attention deficit hyperactivity disorder (ADHD) and autism spectrum disorder. These non-seizure characteristics are severely detrimental to overall quality of life. Some of these children, particularly those with epilepsies classified as Landau-Kleffner Syndrome or continuous spike and wave during sleep, have infrequent seizure activity but frequent focal epileptiform activity. This frequent epileptiform activity is thought to be detrimental to cognitive development; however, it is also possible that these IIS events initiate pathophysiological pathways in the developing brain that may be independently associated with cognitive deficits. These hypotheses are difficult to address due to the previous lack of an appropriate animal model. To this end, we have recently developed a rat model to test the role of frequent focal epileptiform activity in the prefrontal cortex. Using microinjections of a GABA(A) antagonist (bicuculline methiodine) delivered multiple times per day from postnatal day (p) 21 to p25, we showed that rat pups experiencing frequent, focal, recurrent epileptiform activity in the form of interictal spikes during neurodevelopment have significant long-term deficits in attention and sociability that persist into adulthood. To determine if treatment with ACTH, a drug widely used to treat early-life seizures, altered outcome we administered ACTH once per day subcutaneously during the time of the induced interictal spike activity. We show a modest amelioration of the attention deficit seen in animals with a history of early life interictal spikes with ACTH, in the absence of alteration of interictal spike activity. These results suggest that pharmacological intervention that is not targeted to the interictal spike activity is worthy of future study as it may be beneficial for preventing or ameliorating adverse cognitive outcomes.
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Affiliation(s)
- Amanda E. Hernan
- Department of Neurology, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, United States of America
- Department of Neurological Sciences, University of Vermont College of Medicine, Burlington, Vermont, United States of America
| | - Abigail Alexander
- Department of Neurology, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, United States of America
| | - Pierre-Pascal Lenck-Santini
- Department of Neurological Sciences, University of Vermont College of Medicine, Burlington, Vermont, United States of America
| | - Rod C. Scott
- Institute of Child Health, University College London, London, United Kingdom
- Department of Neurological Sciences, University of Vermont College of Medicine, Burlington, Vermont, United States of America
| | - Gregory L. Holmes
- Department of Neurological Sciences, University of Vermont College of Medicine, Burlington, Vermont, United States of America
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Jia F, Jiang H, Du L, Li N, Sun J, Niu C. An effective initial polytherapy for children with West syndrome. Neural Regen Res 2013; 8:1623-30. [PMID: 25206459 PMCID: PMC4145964 DOI: 10.3969/j.issn.1673-5374.2013.17.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2012] [Accepted: 03/16/2013] [Indexed: 11/18/2022] Open
Abstract
Adrenocorticotropic hormone is recommended worldwide as an initial therapy for infantile spasms. However, infantile spasms in about 50% of children cannot be fully controlled by adrenocorticotropic hormone monotherapy, seizures recur in 33% of patients who initially respond to adrenocorticotropic hormone monotherapy, and side effects are relatively common during adrenocorticotropic hormone treatment. Topiramate, vitamin B6, and immunoglobulin are effective in some children with infantile spasms. In the present study, we hypothesized that combined therapy with adrenocorticotropic hormone, topiramate, vitamin B6, and immunoglobulin would effectively treat infantile spasms and have mild adverse effects. Thus, 51 children newly diagnosed with West syndrome including infantile spasms were enrolled and underwent polytherapy with the four drugs. Electroencephalographic hypsarrhythmia was significantly improved in a majority of patients, and these patients were seizure-free, had mild side effects, and low recurrence rates. The overall rates of effective treatment and loss of seizures were significantly higher in cryptogenic children compared with symptomatic children. The mean time to loss of seizures in cryptogenic children was significantly shorter than in symptomatic patients. These findings indicate that initial polytherapy with adrenocorticotropic hormone, topiramate, vitamin B6, and immunoglobulin effectively improves the prognosis of infantile spasms, and its effects were superior in cryptogenic children to symptomatic children.
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Affiliation(s)
- Feiyong Jia
- Department of Pediatric Neurorehabilitation, Second Part of First Hospital, Jilin University, Changchun 130031, Jilin Province, China
| | - Huiyi Jiang
- Department of Pediatric Neurorehabilitation, Second Part of First Hospital, Jilin University, Changchun 130031, Jilin Province, China
| | - Lin Du
- Department of Pediatric Neurorehabilitation, Second Part of First Hospital, Jilin University, Changchun 130031, Jilin Province, China
| | - Ning Li
- Department of Pediatric Neurorehabilitation, Second Part of First Hospital, Jilin University, Changchun 130031, Jilin Province, China
| | - Ji Sun
- Department of Pediatric Neurorehabilitation, Second Part of First Hospital, Jilin University, Changchun 130031, Jilin Province, China
| | - Chunbo Niu
- Department of Pathology, China-Japan Union Hospital of Jilin University, Changchun 130033, Jilin Province, China
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Oh YJ, Kim HN, Jeong JH, Park DK, Park KH, Ko JS, Kim DS. Altered expression of adrenocorticotropic hormone in the epileptic gerbil hippocampus following spontaneous seizure. BMB Rep 2013; 46:80-5. [PMID: 23433109 PMCID: PMC4133853 DOI: 10.5483/bmbrep.2013.46.2.149] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
We investigated the temporal alterations of adrenocorticotropic hormone (ACTH) immunoreactivity in the hippocampus after seizure onset. Expression of ACTH was observed within interneurons in the pre-seizure group of seizure sensitive gerbils, whereas its immunoreactivities were rarely detected in seizure resistant gerbil. Three hr after the seizure, ACTH immunoreactivity was significantly increased in interneurons within all hippocampal regions. On the basis of their localization and morphology through immunofluorescence staining, these cells were identified as GABAA α1-containing interneurons. At the 12 hr postictal period, ACTH expression in these regions was down-regulated, in a similar manner to the pre-seizure group of gerbils. These findings support the increase in ACTH synthesis that contributes to a reduction of corticotrophin-releasing factor via the negative feedback system which in turn provides an opportunity to enhance the excitability of GABAergic interneurons. Therefore, ACTH may play an important role in the reduction of excitotoxicity in all hippocampal regions. [BMB Reports 2013; 46(2): 80-85]
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Affiliation(s)
- Yun-Jung Oh
- Department of Anatomy, College of Medicine, Soonchunhyang University, Cheonan 330-090, Korea
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Heyman E, Lahat E, Gandelman-Marton R. Interictal encephalography can influence patient selection for methylprednisolone therapy in pediatric refractory epilepsy. J Child Neurol 2012; 27:162-7. [PMID: 21881006 DOI: 10.1177/0883073811414905] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
We describe our experience with intravenous methylprednisolone pulse therapy in older children with refractory epilepsy. Patients with refractory epilepsy, who were treated with steroids between 2005 and 2010, were retrospectively selected from the database of the pediatric epilepsy clinic at Assaf Harofeh Medical Center. Eight patients (5 boys) aged 1.1 to 9 years (5.2 ± 2.6) were identified. Intravenous methylprednisolone 30 mg/kg/d was given to all patients for 5 days in addition to a stable dosage of the regular antiepileptic drugs. Transient side effects were reported in 4 of the patients during pulse therapy. Significant clinical improvement was noted in 4 patients, accompanied by a significant reduction of the amplitude of the spike-slow wave discharges on the electroencephalogram (EEG). Children with refractory epilepsy, abnormal EEG background, and high-amplitude spike-slow wave discharges appear to be the best candidates for intravenous methylprednisolone pulse therapy.
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Affiliation(s)
- Eli Heyman
- Department of Pediatric Neurology, Assaf Harofeh Medical Center, Zerifin, Israel
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Braun S, Kottwitz D, Nuber UA. Pharmacological interference with the glucocorticoid system influences symptoms and lifespan in a mouse model of Rett syndrome. Hum Mol Genet 2011; 21:1673-80. [DOI: 10.1093/hmg/ddr602] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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The etiological role of blood-brain barrier dysfunction in seizure disorders. Cardiovasc Psychiatry Neurol 2011; 2011:482415. [PMID: 21541221 PMCID: PMC3085334 DOI: 10.1155/2011/482415] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2010] [Accepted: 01/28/2011] [Indexed: 11/18/2022] Open
Abstract
A wind of change characterizes epilepsy research efforts. The traditional approach, based on a neurocentric view of seizure generation, promoted understanding of the neuronal mechanisms of seizures; this resulted in the development of potent anti-epileptic drugs (AEDs). The fact that a significant number of individuals with epilepsy still fail to respond to available AEDs restates the need for an alternative approach. Blood-brain barrier (BBB) dysfunction is an important etiological player in seizure disorders, and combination therapies utilizing an AED in conjunction with a “cerebrovascular” drug could be used to control seizures more effectively than AED therapy alone. The fact that the BBB plays an etiologic role in other neurological diseases will be discussed in the context of a more “holistic” approach to the patient with epilepsy, where comorbidity variables are also encompassed by drug therapy.
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