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Kanmaz S, Yılmaz S, Olculu CB, Toprak DE, Ince T, Yılmaz Ö, Atas Y, Sen G, Şimşek E, Serin HM, Durmuşalioğlu EA, Işık E, Atik T, Aktan G, Cogulu O, Gokben S, Ozkınay F, Tekgul H. The Utility of Genetic Testing in Infantile Epileptic Spasms Syndrome: A Step-Based Approach in the Next-Generation Sequencing Era. Pediatr Neurol 2024; 157:100-107. [PMID: 38905742 DOI: 10.1016/j.pediatrneurol.2024.05.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 04/29/2024] [Accepted: 05/27/2024] [Indexed: 06/23/2024]
Abstract
BACKGROUND To evaluate the utility of genetic testing for etiology-specific diagnosis (ESD) in infantile epileptic spasms syndrome (IESS) with a step-based diagnostic approach in the next-generation sequencing (NGS) era. METHODS The study cohort consisted of 314 patients with IESS, followed by the Pediatric Neurology Division of Ege University Hospital between 2005 and 2021. The ESD was evaluated using a step-based approach: step I (clinical phenomenology), step II (neuroimaging), step III (metabolic screening), and step IV (genetic testing). The diagnostic utility of genetic testing was evaluated to compare the early-NGS period (2005 to 2013, n = 183) and the NGS era (2014 to 2021, n = 131). RESULTS An ESD was established in 221 of 314 (70.4%) infants with IESS: structural, 40.8%; genetic, 17.2%; metabolic, 8.3%; immune-infectious, 4.1%. The diagnostic yield of genetic testing increased from 8.9% to 41.7% in the cohort during the four follow-up periods. The rate of unknown etiology decreased from 34.9% to 22.1% during the follow-up periods. The genetic ESD was established as 27.4% with genetic testing in the NGS era. The genetic testing in the NGS era increased dramatically in subgroups with unknown and structural etiologies. The diagnostic yields of the epilepsy panels increased from 7.6% to 19.2%. However, the diagnostic yield of whole exome sequencing remained at similar levels during the early-NGS period at 54.5% and in the NGS era at 59%. CONCLUSIONS The more genetic ESD (27.4%) was defined for IESS in the NGS era with the implication of precision therapy (37.7%).
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Affiliation(s)
- Seda Kanmaz
- Division of Child Neurology, Department of Pediatrics, Ege University Medical Faculty, Izmir, Turkiye
| | - Sanem Yılmaz
- Division of Child Neurology, Department of Pediatrics, Ege University Medical Faculty, Izmir, Turkiye.
| | - Cemile Büşra Olculu
- Division of Child Neurology, Department of Pediatrics, Ege University Medical Faculty, Izmir, Turkiye
| | - Dilara Ece Toprak
- Division of Child Neurology, Department of Pediatrics, Ege University Medical Faculty, Izmir, Turkiye
| | - Tuğçe Ince
- Division of Child Neurology, Department of Pediatrics, Ege University Medical Faculty, Izmir, Turkiye
| | - Özlem Yılmaz
- Division of Child Neurology, Department of Pediatrics, Ege University Medical Faculty, Izmir, Turkiye
| | - Yavuz Atas
- Division of Child Neurology, Department of Pediatrics, Ege University Medical Faculty, Izmir, Turkiye
| | - Gursel Sen
- Division of Child Neurology, Department of Pediatrics, Ege University Medical Faculty, Izmir, Turkiye
| | - Erdem Şimşek
- Division of Child Neurology, Department of Pediatrics, Ege University Medical Faculty, Izmir, Turkiye
| | - Hepsen Mine Serin
- Division of Child Neurology, Department of Pediatrics, Ege University Medical Faculty, Izmir, Turkiye
| | - Enise Avcı Durmuşalioğlu
- Division of Pediatric Genetics, Department of Pediatrics, Ege University Medical Faculty, Izmir, Turkiye
| | - Esra Işık
- Division of Pediatric Genetics, Department of Pediatrics, Ege University Medical Faculty, Izmir, Turkiye
| | - Tahir Atik
- Division of Pediatric Genetics, Department of Pediatrics, Ege University Medical Faculty, Izmir, Turkiye
| | - Gul Aktan
- Division of Child Neurology, Department of Pediatrics, Ege University Medical Faculty, Izmir, Turkiye
| | - Ozgur Cogulu
- Division of Pediatric Genetics, Department of Pediatrics, Ege University Medical Faculty, Izmir, Turkiye
| | - Sarenur Gokben
- Division of Child Neurology, Department of Pediatrics, Ege University Medical Faculty, Izmir, Turkiye
| | - Ferda Ozkınay
- Division of Pediatric Genetics, Department of Pediatrics, Ege University Medical Faculty, Izmir, Turkiye
| | - Hasan Tekgul
- Division of Child Neurology, Department of Pediatrics, Ege University Medical Faculty, Izmir, Turkiye
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Corrêa DG, Telles B, Freddi TDAL. The vigabatrin-associated brain abnormalities on MRI and their differential diagnosis. Clin Radiol 2024; 79:94-101. [PMID: 38092645 DOI: 10.1016/j.crad.2023.11.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Revised: 10/12/2023] [Accepted: 11/14/2023] [Indexed: 01/02/2024]
Abstract
Vigabatrin is an anti-epileptic drug that inhibits the enzyme γ-aminobutyric acid (GABA)-transaminase. The anticonvulsant effect of vigabatrin involves increasing GABA levels and attenuating glutamate-glutamine cycling. Vigabatrin indications include infantile spasms and refractory focal seizures. Despite having a significant role in paediatric epileptology, vigabatrin has adverse effects, such as retinal toxicity, in up to 30% of patients after 1 year of use and brain abnormalities on magnetic resonance imaging (MRI). The percentage of patients with brain abnormalities on MRI varies between 22-32% of children using vigabatrin to treat infantile spasms. Risk factors for presenting these imaging abnormalities are cryptogenic infantile spasms, age <12 months old, high dosage, and possible concomitant hormonal therapy. Clinically, these abnormalities are usually asymptomatic. Histopathological analysis reveals white matter vacuolation and intramyelinic oedema. The typical findings of vigabatrin-associated brain abnormalities on MRI are bilateral and have a symmetrical hyperintense signal on T2-weighted imaging, with diffusion restriction, that often compromise the globi pallidi, thalami, subthalamic nuclei, cerebral peduncles, midbrain, dorsal brainstem, including the medial longitudinal fasciculi, and dentate nuclei of the cerebellum. In this article, the authors intend to review the clinical manifestations, histopathological features, imaging aspects, and differential diagnosis of vigabatrin-associated brain abnormalities on MRI.
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Affiliation(s)
- D G Corrêa
- Department of Radiology, Clínica de Diagnóstico por Imagem (CDPI)/DASA, Avenida das Américas, 4666, 302A, 303, 307, 325, 326, Barra da Tijuca, Rio de Janeiro, RJ 2640-102, Brazil; Department of Radiology, Rio de Janeiro State University, Boulevard 28 de Setembro, 77, Vila Isabel, Rio de Janeiro, RJ 20551-030, Brazil.
| | - B Telles
- Department of Radiology, Curitiba Institute of Neurology, Rua Jeremias Maciel Perretto, 300, Campo Comprido, Curitiba, PR 81210-310, Brazil; Department of Radiology, Hospital Pequeno Príncipe, Rua Desembargador Motta, 1070, Água Verde, Curitiba, PR 80250-060, Brazil
| | - T de A L Freddi
- Department of Radiology, Hcor, Rua Desembargador Eliseu Guilherme, 147, Paraíso, São Paulo, SP 04004-030, Brazil
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3
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Zuberi SM, Wirrell E, Yozawitz E, Wilmshurst JM, Specchio N, Riney K, Pressler R, Auvin S, Samia P, Hirsch E, Galicchio S, Triki C, Snead OC, Wiebe S, Cross JH, Tinuper P, Scheffer IE, Perucca E, Moshé SL, Nabbout R. ILAE classification and definition of epilepsy syndromes with onset in neonates and infants: Position statement by the ILAE Task Force on Nosology and Definitions. Epilepsia 2022; 63:1349-1397. [PMID: 35503712 DOI: 10.1111/epi.17239] [Citation(s) in RCA: 220] [Impact Index Per Article: 110.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Revised: 03/20/2022] [Accepted: 03/21/2022] [Indexed: 12/20/2022]
Abstract
The International League Against Epilepsy (ILAE) Task Force on Nosology and Definitions proposes a classification and definition of epilepsy syndromes in the neonate and infant with seizure onset up to 2 years of age. The incidence of epilepsy is high in this age group and epilepsy is frequently associated with significant comorbidities and mortality. The licensing of syndrome specific antiseizure medications following randomized controlled trials and the development of precision, gene-related therapies are two of the drivers defining the electroclinical phenotypes of syndromes with onset in infancy. The principal aim of this proposal, consistent with the 2017 ILAE Classification of the Epilepsies, is to support epilepsy diagnosis and emphasize the importance of classifying epilepsy in an individual both by syndrome and etiology. For each syndrome, we report epidemiology, clinical course, seizure types, electroencephalography (EEG), neuroimaging, genetics, and differential diagnosis. Syndromes are separated into self-limited syndromes, where there is likely to be spontaneous remission and developmental and epileptic encephalopathies, diseases where there is developmental impairment related to both the underlying etiology independent of epileptiform activity and the epileptic encephalopathy. The emerging class of etiology-specific epilepsy syndromes, where there is a specific etiology for the epilepsy that is associated with a clearly defined, relatively uniform, and distinct clinical phenotype in most affected individuals as well as consistent EEG, neuroimaging, and/or genetic correlates, is presented. The number of etiology-defined syndromes will continue to increase, and these newly described syndromes will in time be incorporated into this classification. The tables summarize mandatory features, cautionary alerts, and exclusionary features for the common syndromes. Guidance is given on the criteria for syndrome diagnosis in resource-limited regions where laboratory confirmation, including EEG, MRI, and genetic testing, might not be available.
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Affiliation(s)
- Sameer M Zuberi
- Paediatric Neurosciences Research Group, Royal Hospital for Children, Institute of Health & Wellbeing, Collaborating Centre of European Reference Network EpiCARE, University of Glasgow, Glasgow, UK
| | - Elaine Wirrell
- Divisions of Child and Adolescent Neurology and Epilepsy, Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | - Elissa Yozawitz
- Isabelle Rapin Division of Child Neurology, Saul R. Korey Department of Neurology, Montefiore Medical Center, Bronx, New York, USA
| | - Jo M Wilmshurst
- Department of Paediatric Neurology, Red Cross War Memorial Children's Hospital, Neuroscience Institute, University of Cape Town, Cape Town, South Africa
| | - Nicola Specchio
- Rare and Complex Epilepsy Unit, Department of Neuroscience, Bambino Gesu' Children's Hospital, IRCCS, Member of European Reference Network EpiCARE, Rome, Italy
| | - Kate Riney
- Neurosciences Unit, Queensland Children's Hospital, South Brisbane, Queensland, Australia.,Faculty of Medicine, University of Queensland, St Lucia, Queensland, Australia
| | - Ronit Pressler
- Clinical Neuroscience, UCL- Great Ormond Street Institute of Child Health, London, UK.,Department of Clinical Neurophysiology, Great Ormond Street Hospital for Children NHS Foundation Trust, Member of European Reference Network EpiCARE, London, UK
| | - Stephane Auvin
- AP-HP, Hôpital Robert-Debré, INSERM NeuroDiderot, DMU Innov-RDB, Neurologie Pédiatrique, Member of European Reference Network EpiCARE, Université de Paris, Paris, France
| | - Pauline Samia
- Department of Paediatrics and Child Health, Aga Khan University, Nairobi, Kenya
| | - Edouard Hirsch
- Neurology Epilepsy Unit "Francis Rohmer", INSERM 1258, FMTS, Strasbourg University, Strasbourg, France
| | - Santiago Galicchio
- Child Neurology Department, Victor J Vilela Child Hospital of Rosario, Santa Fe, Argentina
| | - Chahnez Triki
- Child Neurology Department, LR19ES15 Neuropédiatrie, Sfax Medical School, University of Sfax, Sfax, Tunisia
| | - O Carter Snead
- Pediatric Neurology, Hospital for Sick Children, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Samuel Wiebe
- Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
| | - J Helen Cross
- Programme of Developmental Neurosciences, UCL NIHR BRC Great Ormond Street Institute of Child Health, Great Ormond Street Hospital for Children, Member of European Reference Network EpiCARE, London, UK.,Young Epilepsy, Lingfield, UK
| | - Paolo Tinuper
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy.,IRCCS Istituto delle Scienze Neurologiche, Bologna, Italy
| | - Ingrid E Scheffer
- Austin Health and Royal Children's Hospital, Florey Institute, Murdoch Children's Research Institute, University of Melbourne, Melbourne, Victoria, Australia
| | - Emilio Perucca
- Department of Neuroscience, Monash University, Melbourne, Victoria, Australia.,Department of Medicine, Austin Health, University of Melbourne, Heidelberg, Victoria, Australia
| | - Solomon L Moshé
- Isabelle Rapin Division of Child Neurology, Saul R. Korey Department of Neurology, Bronx, New York, USA.,Departments of Neuroscience and Pediatrics, Albert Einstein College of Medicine, Bronx, New York, USA.,Montefiore Medical Center, Bronx, New York, USA
| | - Rima Nabbout
- Reference Centre for Rare Epilepsies, Department of Pediatric Neurology, Necker-Enfants Malades University Hospital, APHP, Member of European Reference Network EpiCARE, Institut Imagine, INSERM, UMR 1163, Université Paris cité, Paris, France
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Erdemir G, Pestana-Knight E, Honomichl R, Thompson NR, Lachhwani D, Kotagal P, Wyllie E, Gupta A, Bingaman WE, Moosa ANV. Surgical candidates in children with epileptic spasms can be selected without invasive monitoring: A report of 70 cases. Epilepsy Res 2021; 176:106731. [PMID: 34339941 DOI: 10.1016/j.eplepsyres.2021.106731] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 07/14/2021] [Accepted: 07/23/2021] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Prior surgical series in children with drug-resistant epileptic spasms have reported use of intracranial EEG monitoring in up to two-third of patients. We report outcome after epilepsy surgery for drug-resistant epileptic spasms in a cohort of children without the use of intracranial EEG monitoring in any of the patients. METHODS Medical records of all consecutive children aged 5 years or under who had epilepsy surgery for epileptic spasms at Cleveland Clinic between 2000 and 2018 were reviewed. Post-operative seizure outcome and predictors of prognosis of seizure outcome were analyzed. RESULTS Seventy children with active epileptic spasms underwent surgical resections during the study period. Mean age at seizure onset was 6.8 (+9.31) months and median age at surgery was 18.5 months. An epileptogenic lesion was identified on brain MRI in all patients; 17 (24%) had bilateral abnormalities. Etiologies included malformations of cortical development (58%), perinatal infarct/encephalomalacia (39%), and tumor (3%). None of the patients had intracranial EEG. Surgical procedures included hemispherectomy (44%), lobectomy/ lesionectomy (33%), and multilobar resections (23%). Twelve children needed repeat surgery; six (50%) became seizure free after the second surgery. At six months follow-up, 73% (51/70) were seizure-free since surgery. At a mean follow-up of 4.7 years, 60% (42/70) had Engel 1 outcome. In those with seizure recurrence, 17 (60%) reported improvement. Shorter epilepsy duration (p = 0.05) and lobar or sub-lobar epileptogenic lesions (p = 0.02) predicted favorable seizure outcome at 6 months after surgery. For long term outcome, patients with bilateral abnormalities on MRI (p = 0.001), and multilobar extent on MRI (p = 0.02) were at higher risk for recurrence. SIGNIFICANCE Children with drug-resistant epileptic spasms secondary to an epileptogenic lesion detected on MRI could be selected for epilepsy surgery without undergoing intracranial EEG monitoring. A surgical selection paradigm without intracranial monitoring may allow early surgery without the risks of invasive monitoring.
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Affiliation(s)
- Gozde Erdemir
- Epilepsy Center, Cleveland Clinic, Cleveland, OH, 44195, United States; Division of Pediatric Neurology, University of Maryland, Baltimore, MD, United States
| | | | - Ryan Honomichl
- Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, United States
| | - Nicolas R Thompson
- Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, United States
| | - Deepak Lachhwani
- Epilepsy Center, Cleveland Clinic, Cleveland, OH, 44195, United States
| | - Prakash Kotagal
- Epilepsy Center, Cleveland Clinic, Cleveland, OH, 44195, United States
| | - Elaine Wyllie
- Epilepsy Center, Cleveland Clinic, Cleveland, OH, 44195, United States
| | - Ajay Gupta
- Epilepsy Center, Cleveland Clinic, Cleveland, OH, 44195, United States
| | | | - Ahsan N V Moosa
- Epilepsy Center, Cleveland Clinic, Cleveland, OH, 44195, United States.
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5
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Trowbridge SK, Yuskaitis CJ, Baumer N, Libenson M, Prabhu SP, Harini C. Brain MRI abnormalities in patients with infantile spasms and Down syndrome. Epilepsy Behav 2019; 92:57-60. [PMID: 30616066 DOI: 10.1016/j.yebeh.2018.12.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Revised: 12/14/2018] [Accepted: 12/15/2018] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Infantile spasms (IS) are the most frequent epilepsy syndrome in children with Down syndrome (DS). In DS, cellular (synaptic/dendritic changes) and molecular mechanisms are believed to contribute to epileptogenesis, rather than gross structural anomalies. Neuroimaging is a standard part of the evaluation of newly diagnosed infantile epilepsy including IS and, in this age group, often requires sedation. It is unclear if neuroimaging provides additional clinically useful etiologic information in IS associated with DS. METHODS We conducted a retrospective chart review and detailed neuroimaging review in 36 patients (24 males) with IS and DS, cared for at Boston Children's Hospital. RESULTS Incidental imaging abnormalities were common (42%), but potentially relevant etiologic abnormalities were rare (16%). Structural congenital or acquired abnormalities were associated with ongoing antiepileptic drug (AED) use (p = 0.02), as well as refractory epilepsy (p = 0.04). However, neuroimaging did not alter the treatment plan for any of these patients. CONCLUSIONS Clinicians must carefully weigh the benefits and risks of neuroimaging in infants with DS and IS, as neuroimaging did not lead to any changes in clinical management in our patients but may offer information regarding prognosis.
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Affiliation(s)
- Sara K Trowbridge
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Christopher J Yuskaitis
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Nicole Baumer
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA; Down Syndrome Program, Developmental Medicine Center, Boston Children's Hospital, Boston, MA, USA
| | - Mark Libenson
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Sanjay P Prabhu
- Neuroradiology Division, Department of Radiology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA.
| | - Chellamani Harini
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
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6
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Harini C, Sharda S, Bergin AM, Poduri A, Yuskaitis CJ, Peters JM, Rakesh K, Kapur K, Pearl PL, Prabhu SP. Detailed Magnetic Resonance Imaging (MRI) Analysis in Infantile Spasms. J Child Neurol 2018; 33:405-412. [PMID: 29575949 DOI: 10.1177/0883073818760424] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
PURPOSE To evaluate initial magnetic resonance imaging (MRI) abnormalities in infantile spasms, correlate them to clinical characteristics, and describe repeat imaging findings. METHODS A retrospective review of infantile spasm patients was conducted, classifying abnormal MRI into developmental, acquired, and nonspecific subgroups. RESULTS MRIs were abnormal in 52 of 71 infantile spasm patients (23 developmental, 23 acquired, and 6 nonspecific) with no correlation to the clinical infantile spasm characteristics. Both developmental and acquired subgroups exhibited cortical gray and/or white matter abnormalities. Additional abnormalities of deep gray structures, brain stem, callosum, and volume loss occurred in the structural acquired subgroup. Repeat MRI showed better definition of the extent of existing malformations. CONCLUSION In structural infantile spasms, developmental/acquired subgroups showed differences in pattern of MRI abnormalities but did not correlate with clinical characteristics.
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Affiliation(s)
- Chellamani Harini
- 1 Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Ann Marie Bergin
- 1 Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Annapurna Poduri
- 1 Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA.,3 Epilepsy Genetics Program, Boston Children's Hospital, Boston, MA, USA
| | - Christopher J Yuskaitis
- 1 Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Jurriaan M Peters
- 1 Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Kshitiz Rakesh
- 1 Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Kush Kapur
- 1 Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Phillip L Pearl
- 1 Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Sanjay P Prabhu
- 4 Neuroradiology Division, Department of Radiology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
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Abstract
West syndrome, or infantile spasms syndrome is a frequently catastrophic infantile epileptic encephalopathy with a variety of etiologies. Despite the heterogeneous nature of causes of infantile spasms, a careful diagnostic evaluation can lead to diagnosis in many patients and may guide treatment choices. Magnetic resonance imaging (MRI) brain remains the highest yield initial study in determining the etiology in infantile spasms. Treatment of infantile spasms has little class I data, but adrenocorticotropic hormone (ACTH), prednisolone and vigabatrin have the best evidence as first-line medications. Other therapies including the ketogenic diet and other anti-epileptics medications may also prove useful in the treatment of infantile spasms. In general, more studies are needed to determine the best treatment regimen for this condition. Prognosis is generally poor, with the majority of patients having some or profound neurocognitive delays. Patients without delays at diagnosis and without an identifiable etiology, if treated appropriately, have the greatest likelihood of a normal outcome.
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Affiliation(s)
- Gary Rex Nelson
- Division of Child Neurology, University of Utah School of Medicine, Salt Lake City, USA
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Fong CY, Harvey AS. Variable outcome for epilepsy after neonatal hypoglycaemia. Dev Med Child Neurol 2014; 56:1093-9. [PMID: 24861161 DOI: 10.1111/dmcn.12496] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/28/2014] [Indexed: 11/28/2022]
Abstract
AIM To evaluate the electroclinical features of epilepsy secondary to neonatal hypoglycaemia. METHOD This was a retrospective study of children who had seizures beyond infancy after neonatal hypoglycaemia treated at The Royal Children's Hospital, Melbourne between 1996 and 2012. Patients with perinatal asphyxia were excluded. Clinical details were obtained from medical records. Digital electroencephalography (EEG) and brain magnetic resonance imaging (MRI) were reviewed. Eleven patients met the inclusion criteria (six males, five females; mean age 10y 5mo, range 4-18y at the time of review). RESULTS Age at seizure onset ranged from 4 months to 5 years. Seizures were focal occipital in nine and generalized tonic in two patients. MRI showed gliosis with or without cortical atrophy in the occipital lobe with or without parietal lobe in all. Predominant EEG findings were stereotyped occipital sharp-slow discharges in five, polymorphic occipital spike-wave or paroxysmal fast activity in three, and generalized slow spike-wave and fast activity in two. Seizures were infrequent or remitted in six of the nine children with focal occipital seizures, and frequent and refractory in both children with generalized seizures. INTERPRETATION Despite the common antecedent and bilateral occipital lobe injury, the seizure manifestations and course of epilepsy after neonatal hypoglycaemia were variable, with mild occipital, refractory occipital, and symptomatic generalized epilepsy recognized.
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Affiliation(s)
- Choong Yi Fong
- Department of Neurology, The Royal Children's Hospital Melbourne, Melbourne, Vic., Australia; Division of Paediatric Neurology, Department of Paediatrics, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
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Abstract
Infantile spasms are a unique disorder of infancy and early childhood. The average age at onset of infantile spasms is 6 months and the average incidence of the disorder is approximately 0.31 per 1000 live births. Approximately one-quarter of patients will spontaneously stop having spasms within 1 year of onset. There are three main types of epileptic spasms: flexor, extensor, and mixed flexor-extensor. Spasms frequently occur in clusters and commonly occur upon arousal from sleep. The motor spasms are frequently confused with other normal and abnormal infant behaviors. Typically, the interictal EEG reveals hypsarrhythmia or one of its variants. A variety of ictal EEG patterns may be seen, the most common of which is a generalized slow-wave transient followed by an attenuation of the background activity in all regions. The primary treatment objective is to improve the EEG and stop the spasms as soon as possible and to avoid prolonged treatment durations with any form of therapy. Currently, there is no conclusive evidence that medical or surgical treatment of infantile spasms significantly alters long-term outcome. Although the pathophysiological mechanism underlying infantile spasms is unknown, several animal models of infantile spasms have been developed in recent years.
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Affiliation(s)
- Richard A Hrachovy
- Peter Kellaway Section of Neurophysiology, Department of Neurology, Baylor College of Medicine, Houston, TX, USA; Michael E. DeBakey VA Medical Center, Houston, TX, USA.
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10
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Elucidating the Complex Interactions between Stress and Epileptogenic Pathways. Cardiovasc Psychiatry Neurol 2011; 2011:461263. [PMID: 21547249 PMCID: PMC3085328 DOI: 10.1155/2011/461263] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2010] [Accepted: 01/22/2011] [Indexed: 11/24/2022] Open
Abstract
Clinical and experimental data suggest that stress contributes to the pathology of epilepsy. We review mechanisms by which stress, primarily via stress hormones, may exacerbate epilepsy, focusing on the intersection between stress-induced pathways and the progression of pathological events that occur before, during, and after the onset of epileptogenesis. In addition to this temporal nuance, we discuss other complexities in stress-epilepsy interactions, including the role of blood-brain barrier dysfunction, neuron-glia interactions, and inflammatory/cytokine pathways that may be protective or damaging depending on context. We advocate the use of global analytical tools, such as microarray, in support of a shift away from a narrow focus on seizures and towards profiling the complex, early process of epileptogenesis, in which multiple pathways may interact to dictate the ultimate onset of chronic, recurring seizures.
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Aizaki K, Sugai K, Saito Y, Nakagawa E, Sasaki M, Aoki Y, Matsubara Y. Cardio-facio-cutaneous syndrome with infantile spasms and delayed myelination. Brain Dev 2011; 33:166-9. [PMID: 20395089 DOI: 10.1016/j.braindev.2010.03.008] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2010] [Revised: 02/25/2010] [Accepted: 03/23/2010] [Indexed: 10/19/2022]
Abstract
A girl with cardio-facio-cutaneous (CFC) syndrome due to a BRAF gene mutation (c.1454T→C, p.L485S) experienced repetitive epileptic spasms at the corrected age of 4 months. Electroencephalograms revealed hypsarrhythmia, and magnetic resonance imaging identified delayed myelination and a hypoplastic corpus callosum. Various antiepileptic treatments, including adrenocorticotropic hormone therapy, were ineffective, although transient seizure control was achieved by a ketogenic diet and clorazepate dipotassium. However, seizures with epileptic foci at the bilateral posterior temporal areas re-aggravated and remained intractable; severe psychomotor delay persisted. This case indicated that infantile spasms in CFC syndrome can be difficult to control and may be accompanied by severe psychomotor retardation and abnormal myelination.
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Affiliation(s)
- Koichi Aizaki
- Department of Child Neurology, National Center Hospital, National Center of Neurology and Psychiatry, Kodaira, Tokyo, Japan
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Pellock JM, Hrachovy R, Shinnar S, Baram TZ, Bettis D, Dlugos DJ, Gaillard WD, Gibson PA, Holmes GL, Nordli DR, O’Dell C, Shields WD, Trevathan E, Wheless JW. Infantile spasms: A U.S. consensus report. Epilepsia 2010; 51:2175-89. [DOI: 10.1111/j.1528-1167.2010.02657.x] [Citation(s) in RCA: 328] [Impact Index Per Article: 23.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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Abstract
This epileptic disorder has become a classic topic for neuropediatricians and the interest is documented by the large number of publications on this subject.The relative frequency among the epileptic syndromes is an another reason why not only neuropediatricians but also general pediatricians must be fully informed about diagnostic, clinical, imaging and genetic aspects.Early diagnosis is of paramount importance in order to obtain even complete results in patients with so called idiopathic situations. A number of problems are still to be solved. There is no agreement on the type and the schedule of treatment. A common denominator about this problem is not jet available even if some advances in this regard have been accomplished. Of paramount importance is an accurate clinical and laboratory examination as a prerequisite regarding prognosis and results of therapy in every single case.However, even if more than 170 years have elapsed since the first communication of dr. West on the peculiar syndrome that his child was suffering of, the interest of scientists on this subject has now been enriched and rewarded.
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Affiliation(s)
- Alberto Fois
- Institute of Clinical Pediatrics, University of Siena, Siena, Italy.
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Marshall CR, Young EJ, Pani AM, Freckmann ML, Lacassie Y, Howald C, Fitzgerald KK, Peippo M, Morris CA, Shane K, Priolo M, Morimoto M, Kondo I, Manguoglu E, Berker-Karauzum S, Edery P, Hobart HH, Mervis CB, Zuffardi O, Reymond A, Kaplan P, Tassabehji M, Gregg RG, Scherer SW, Osborne LR. Infantile spasms is associated with deletion of the MAGI2 gene on chromosome 7q11.23-q21.11. Am J Hum Genet 2008; 83:106-11. [PMID: 18565486 DOI: 10.1016/j.ajhg.2008.06.001] [Citation(s) in RCA: 86] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2008] [Revised: 05/29/2008] [Accepted: 06/02/2008] [Indexed: 01/14/2023] Open
Abstract
Infantile spasms (IS) is the most severe and common form of epilepsy occurring in the first year of life. At least half of IS cases are idiopathic in origin, with others presumed to arise because of brain insult or malformation. Here, we identify a locus for IS by high-resolution mapping of 7q11.23-q21.1 interstitial deletions in patients. The breakpoints delineate a 500 kb interval within the MAGI2 gene (1.4 Mb in size) that is hemizygously disrupted in 15 of 16 participants with IS or childhood epilepsy, but remains intact in 11 of 12 participants with no seizure history. MAGI2 encodes the synaptic scaffolding protein membrane-associated guanylate kinase inverted-2 that interacts with Stargazin, a protein also associated with epilepsy in the stargazer mouse.
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Tohyama J, Akasaka N, Osaka H, Maegaki Y, Kato M, Saito N, Yamashita S, Ohno K. Early onset West syndrome with cerebral hypomyelination and reduced cerebral white matter. Brain Dev 2008; 30:349-55. [PMID: 18065176 DOI: 10.1016/j.braindev.2007.10.006] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2007] [Revised: 10/08/2007] [Accepted: 10/13/2007] [Indexed: 10/22/2022]
Abstract
Numerous numbers of pre-, peri- and postnatal damages cause West syndrome in early infancy, however, etiology in many cases are not still elucidated despite intensive biochemical and neuroradiologic investigations. We described four patients having early onset epileptic encephalopathy with severe hypomyelination and reduction in cerebral white matter. The clinical symptoms of these patients are impaired visual attention, acquired microcephaly, spastic tetraplegia, profound psychomotor delay and infantile spasms since early infancy. All patients had striking hypomyelination of cerebrum, reduced volume of white matter and cortical atrophy on MRI. Serial MRI investigations in three patients showed absence of myelination of the white matter. On EEG, one patient revealed suppression-burst and other three had hypsarrhythmia. Despite having intractable seizures, no patient showed deterioration of neurological development. The group of these findings is mimicking to clinical manifestations of 3-phosphoglycerate dehydrogenase deficiency, and has some overlap with progressive encephalopathy with edema, hypsarrhythmia, and optic atrophy (PEHO) like syndrome, however it is not compatible with these two conditions. The findings observed in our patients can be regarded as a new clinical condition associated with early onset West syndrome.
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Affiliation(s)
- Jun Tohyama
- Department of Pediatrics, Epilepsy Center, Nishi-Niigata Chuo National Hospital, 1-14-1 Masago, Nishi-ku, Niigata-city, Niigata 950-2085, Japan.
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Desguerre I, Marti I, Valayannopoulos V, Bahi-Buisson N, Dulac O, Plouin P, Delonlay P, Hertz-Pannier L, Boddaert N. Transient magnetic resonance diffusion abnormalities in West syndrome: the radiological expression of non-convulsive status epilepticus? Dev Med Child Neurol 2008; 50:112-6. [PMID: 18201300 DOI: 10.1111/j.1469-8749.2007.02017.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
The purpose of this study was to report patients with pharmacoresistant West syndrome of unknown cause whose magnetic resonance imaging (MRI) with diffusion weighted imaging (DWI) showed a transient decrease of diffusion in subcortical structures. Of 20 patients investigated over a 2-year period, three males and three females constitute the present series. They had daily clusters of infantile spasms with hypsarrhythmia for 4 to 24 months before the first investigation. Four were severely hypotonic. All aetiological studies involving intermediary metabolism, peroxysomes, mitochondria, and neurotransmitters in cerebrospinal fluid were negative. Patients underwent DWI when first examined at the mean age of 13 months, and on follow-up examination 6 to 18 months later. Diffusion was decreased in the pallidi and posterior brainstem. It was also decreased for five patients in thalami and for three in dentate nuclei. Repeat MRI, performed when spasms were still present but hypsarrhythmia had ceased, did not show the same abnormalities. Because of recruitment bias, this series probably overestimates the true incidence of such DWI abnormalities. The eventuality of toxic lesions, including some inborn error of metabolism or drug toxicity, is considered unlikely although it could not be excluded. The contribution of the epileptic encephalopathy itself appears the most likely course.
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Affiliation(s)
- Isabelle Desguerre
- Department of Neuropaediatrics, APHP, Necker-Enfants Malades Hospital, Paris, France.
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Takano T, Hayashi A, Sokoda T, Sawai C, Sakaue Y, Takeuchi Y. Delayed myelination at the onset of cryptogenic West syndrome. Pediatr Neurol 2007; 37:417-20. [PMID: 18021923 DOI: 10.1016/j.pediatrneurol.2007.06.021] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2007] [Revised: 06/07/2007] [Accepted: 06/27/2007] [Indexed: 10/22/2022]
Abstract
To evaluate the prognostic value of delayed myelination at the onset of cryptogenic West syndrome, the relationship between the seizure or developmental outcome and myelination was examined. Cranial magnetic resonance imaging studies were performed in nine cryptogenic cases. Infantile spasms were controlled in all patients, but three cases showed a mild developmental delay at 2 years after onset. Delayed myelination was observed in three cases (33.3%) on T(1)-weighted images and in two cases (22.2%) on T(2)-weighted images. In the present study, neither the seizure outcome nor developmental status was positively correlated with the existence of delayed myelination at the onset of cryptogenic West syndrome.
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Affiliation(s)
- Tomoyuki Takano
- Department of Pediatrics, Shiga University of Medical Science, Seta-Tsukinowa, Otsu, Japan.
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