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Cameron T, Allan K, Kay Cooper. The use of ketogenic diets in children living with drug-resistant epilepsy, glucose transporter 1 deficiency syndrome and pyruvate dehydrogenase deficiency: A scoping review. J Hum Nutr Diet 2024; 37:827-846. [PMID: 38838079 DOI: 10.1111/jhn.13324] [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: 11/13/2023] [Accepted: 05/10/2024] [Indexed: 06/07/2024]
Abstract
BACKGROUND The ketogenic diet (KD) is a high fat, moderate protein and very low carbohydrate diet. It can be used as a medical treatment for drug-resistant epilepsy (DRE), glucose transporter 1 deficiency syndrome and pyruvate dehydrogenase deficiency. The aim of this scoping review was to map the KD literature, with a focus on epilepsy and associated metabolic conditions, to summarise the current evidence-base and identify any gaps. METHODS This review was conducted using JBI scoping review methodological guidance and the PRISMA extension for scoping reviews reporting guidance. A comprehensive literature search was conducted in September 2021 and updated in February 2024 using MEDLINE, CINAHL, AMED, EmBASE, CAB Abstracts, Scopus and Food Science Source databases. RESULTS The initial search yielded 2721 studies and ultimately, data were extracted from 320 studies that fulfilled inclusion criteria for the review. There were five qualitative studies, and the remainder were quantitative, including 23 randomised controlled trials (RCTs) and seven quasi-experimental studies. The USA published the highest number of KD studies followed by China, South Korea and the UK. Most studies focused on the classical KD and DRE. The studies key findings suggest that the KD is efficacious, safe and tolerable. CONCLUSIONS There are opportunities available to expand the scope of future KD research, particularly to conduct high-quality RCTs and further qualitative research focused on the child's needs and family support to improve the effectiveness of KDs.
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Affiliation(s)
- Tracy Cameron
- Royal Aberdeen Children's Hospital, NHS Grampian, Aberdeen, Scotland, UK
- School of Health Sciences, Robert Gordon University, Aberdeen, Scotland, UK
| | - Karen Allan
- School of Health Sciences, Robert Gordon University, Aberdeen, Scotland, UK
| | - Kay Cooper
- School of Health Sciences, Robert Gordon University, Aberdeen, Scotland, UK
- Scottish Centre for Evidence-based, Multi-professional Practice: A JBI Centre of Excellence, Aberdeen, Scotland, UK
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Liu Y, Fan L, Yang H, Wang D, Liu R, Shan T, Xia X. Ketogenic therapy towards precision medicine for brain diseases. Front Nutr 2024; 11:1266690. [PMID: 38450235 PMCID: PMC10915067 DOI: 10.3389/fnut.2024.1266690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 01/29/2024] [Indexed: 03/08/2024] Open
Abstract
Precision nutrition and nutrigenomics are emerging in the development of therapies for multiple diseases. The ketogenic diet (KD) is the most widely used clinical diet, providing high fat, low carbohydrate, and adequate protein. KD produces ketones and alters the metabolism of patients. Growing evidence suggests that KD has therapeutic effects in a wide range of neuronal diseases including epilepsy, neurodegeneration, cancer, and metabolic disorders. Although KD is considered to be a low-side-effect diet treatment, its therapeutic mechanism has not yet been fully elucidated. Also, its induced keto-response among different populations has not been elucidated. Understanding the ketone metabolism in health and disease is critical for the development of KD-associated therapeutics and synergistic therapy under any physiological background. Here, we review the current advances and known heterogeneity of the KD response and discuss the prospects for KD therapy from a precision nutrition perspective.
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Affiliation(s)
- Yang Liu
- Translational Medicine Center, Huaihe Hospital of Henan University, Henan University, Kaifeng, China
- Henan Key Laboratory of Brain Targeted Bio-nanomedicine, School of Life Sciences, Henan University, Kaifeng, China
| | - Linlin Fan
- Henan Key Laboratory of Brain Targeted Bio-nanomedicine, School of Life Sciences, Henan University, Kaifeng, China
| | - Haoying Yang
- Henan Key Laboratory of Brain Targeted Bio-nanomedicine, School of Life Sciences, Henan University, Kaifeng, China
| | - Danli Wang
- Zhoushan People’s Hospital, Zhoushan, China
| | - Runhan Liu
- Henan Key Laboratory of Brain Targeted Bio-nanomedicine, School of Life Sciences, Henan University, Kaifeng, China
| | - Tikun Shan
- Neurosurgery Department, The First Affiliated Hospital of Zhengzhou University, Zhengzhou University, Zhengzhou, China
| | - Xue Xia
- Henan Key Laboratory of Brain Targeted Bio-nanomedicine, School of Life Sciences, Henan University, Kaifeng, China
- School of Environmental and Life Sciences, College of Engineering, Science and Environment, University of Newcastle, Callaghan, NSW, Australia
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van Baalen A. Febrile infection-related epilepsy syndrome in childhood: A clinical review and practical approach. Seizure 2023; 111:215-222. [PMID: 37703593 DOI: 10.1016/j.seizure.2023.09.008] [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: 05/24/2023] [Revised: 09/04/2023] [Accepted: 09/06/2023] [Indexed: 09/15/2023] Open
Abstract
Febrile infection-related epilepsy syndrome (FIRES) of unknown aetiology is an extremely rare but severe epilepsy syndrome. It is characterized by a nonspecific febrile infection a few days before the onset of super-refractory status epilepticus, followed by refractory epilepsy and high morbidity in previously healthy children and young adults. To date, FIRES is incurable and irreversible. The clinical course may depend more on time than on therapy, while the outcome may depend more on the clinical spectrum than on therapy. Based on a literature search, retrospective data analysis, and personal observations, this review aimed to explore the clinical spectrum and therapeutic options for FIRES to improve outcomes by optimized and more standardized diagnosis and therapy, including adapted immunotherapy and a less aggressive approach to manage seizures, as seizure-freeness is difficult to achieve and, therefore, not the primary goal for cryptogenic FIRES.
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Affiliation(s)
- Andreas van Baalen
- Department of Neuropediatrics, University Medical Center Schleswig-Holstein, Kiel University (CAU), Arnold-Heller-Street 3, House C, Kiel 24105, Germany.
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Nagase H, Yamaguchi H, Tokumoto S, Ishida Y, Tomioka K, Nishiyama M, Nozu K, Maruyama A. Timing of therapeutic interventions against infection-triggered encephalopathy syndrome: a scoping review of the pediatric literature. Front Neurosci 2023; 17:1150868. [PMID: 37674514 PMCID: PMC10477367 DOI: 10.3389/fnins.2023.1150868] [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: 01/25/2023] [Accepted: 08/07/2023] [Indexed: 09/08/2023] Open
Abstract
Our goal was to conduct a scoping review of the literature on the treatment of infection-triggered encephalopathy syndrome/acute encephalopathy in children, focusing on treatment targets and treatment initiation timing. We performed literature searches using PubMed for articles reporting treatments of infection-triggered encephalopathy syndrome/acute encephalopathy. We included articles describing specific treatments for acute encephalopathy with control groups. For the purpose of searching new therapies only experimentally tried in the case series, we also included case series studies without control groups in this review, if the studies contained at least two cases with clear treatment goals. Therapies were classified based on their mechanisms of action into brain protection therapy, immunotherapy, and other therapies. We operationally categorized the timing of treatment initiation as T1 (6-12 h), T2 (12-24 h), T3 (24-48 h), and T4 (>48 h) after the onset of seizures and/or impaired consciousness. Thirty articles were included in this review; no randomized control study was found. Eleven retrospective/historical cohort studies and five case-control studies included control groups with or without specific therapies or outcomes. The targeted conditions and treatment timing varied widely across studies. However, the following three points were suggested to be effective in multiple studies: (1) Careful seizure management and targeted temperature management within 12 h (T1) of onset of febrile seizure/prolonged impaired consciousness without multiple organ failure may reduce the development of acute encephalopathy with biphasic seizures and late reduced diffusion; (2) immunotherapy using corticosteroids, tocilizumab, or plasma exchange within 24 h (T1-T2) of onset of acute necrotizing encephalopathy may reduce sequelae; and (3) anakinra therapy and ketogenic diet demonstrate little evidence of neurologic sequelae reduction, but may reduce seizure frequency and allow for weaning from barbiturates, even when administered weeks (T4) after onset in children with febrile infection-related epilepsy syndrome. Although available studies have no solid evidence in the treatment of infection-triggered encephalopathy syndrome/acute encephalopathy, this scoping review lays the groundwork for future prospective clinical trials.
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Affiliation(s)
- Hiroaki Nagase
- Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Hiroshi Yamaguchi
- Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Shoichi Tokumoto
- Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Yusuke Ishida
- Department of Neurology, Hyogo Prefectural Kobe Children’s Hospital, Kobe, Japan
- Department of Emergency and General Pediatrics, Hyogo Prefectural Kobe Children’s Hospital, Kobe, Japan
| | - Kazumi Tomioka
- Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Masahiro Nishiyama
- Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan
- Department of Neurology, Hyogo Prefectural Kobe Children’s Hospital, Kobe, Japan
| | - Kandai Nozu
- Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Azusa Maruyama
- Department of Neurology, Hyogo Prefectural Kobe Children’s Hospital, Kobe, Japan
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Sheikh Z, Hirsch LJ. A practical approach to in-hospital management of new-onset refractory status epilepticus/febrile infection related epilepsy syndrome. Front Neurol 2023; 14:1150496. [PMID: 37251223 PMCID: PMC10213694 DOI: 10.3389/fneur.2023.1150496] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Accepted: 04/12/2023] [Indexed: 05/31/2023] Open
Abstract
New-onset refractory status epilepticus (NORSE) is "a clinical presentation, not a specific diagnosis, in a patient without active epilepsy or other preexisting relevant neurological disorder, with new onset of refractory status epilepticus without a clear acute or active structural, toxic, or metabolic cause." Febrile infection related epilepsy syndrome (FIRES) is "a subcategory of NORSE that requires a prior febrile infection, with fever starting between 2 weeks and 24 h before the onset of refractory status epilepticus, with or without fever at the onset of status epilepticus." These apply to all ages. Extensive testing of blood and CSF for infectious, rheumatologic, and metabolic conditions, neuroimaging, EEG, autoimmune/paraneoplastic antibody evaluations, malignancy screen, genetic testing, and CSF metagenomics may reveal the etiology in some patients, while a significant proportion of patients' disease remains unexplained, known as NORSE of unknown etiology or cryptogenic NORSE. Seizures are refractory and usually super-refractory (i.e., persist despite 24 h of anesthesia), requiring a prolonged intensive care unit stay, often (but not always) with fair to poor outcomes. Management of seizures in the initial 24-48 h should be like any case of refractory status epilepticus. However, based on the published consensus recommendations, the first-line immunotherapy should begin within 72 h using steroids, intravenous immunoglobulins, or plasmapheresis. If there is no improvement, the ketogenic diet and second-line immunotherapy should start within seven days. Rituximab is recommended as the second-line treatment if there is a strong suggestion or proof of an antibody-mediated disease, while anakinra or tocilizumab are recommended for cryptogenic cases. Intensive motor and cognitive rehab are usually necessary after a prolonged hospital stay. Many patients will have pharmacoresistant epilepsy at discharge, and some may need continued immunologic treatments and an epilepsy surgery evaluation. Extensive research is in progress now via multinational consortia relating to the specific type(s) of inflammation involved, whether age and prior febrile illness affect this, and whether measuring and following serum and/or CSF cytokines can help determine the best treatment.
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Affiliation(s)
- Zubeda Sheikh
- Department of Neurology, West Virginia University School of Medicine, Morgantown, WV, United States
- Epilepsy Division, Department of Neurology, Yale School of Medicine, New Haven, CT, United States
| | - Lawrence J. Hirsch
- Epilepsy Division, Department of Neurology, Yale School of Medicine, New Haven, CT, United States
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deCampo D, Xian J, Karlin A, Sullivan KR, Ruggiero SM, Galer P, Ramos M, Abend NS, Gonzalez A, Helbig I. Investigating the genetic contribution in febrile infection-related epilepsy syndrome and refractory status epilepticus. Front Neurol 2023; 14:1161161. [PMID: 37077567 PMCID: PMC10106651 DOI: 10.3389/fneur.2023.1161161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Accepted: 03/10/2023] [Indexed: 04/05/2023] Open
Abstract
IntroductionFebrile infection-related epilepsy syndrome (FIRES) is a severe childhood epilepsy with refractory status epilepticus after a typically mild febrile infection. The etiology of FIRES is largely unknown, and outcomes in most individuals with FIRES are poor.MethodsHere, we reviewed the current state-of-the art genetic testing strategies in individuals with FIRES. We performed a systematic computational analysis to identify individuals with FIRES and characterize the clinical landscape using the Electronic Medical Records (EMR). Among 25 individuals with a confirmed FIRES diagnosis over the last decade, we performed a comprehensive review of genetic testing and other diagnostic testing.ResultsManagement included use of steroids and intravenous immunoglobulin (IVIG) in most individuals, with an increased use of immunomodulatory agents, including IVIG, plasma exchange (PLEX) and immunosuppressants such as cytokine inhibitors, and the ketogenic diet after 2014. Genetic testing was performed on a clinical basis in almost all individuals and was non-diagnostic in all patients. We compared FIRES with both status epilepticus (SE) and refractory status epilepticus (RSE) as a broader comparison cohort and identified genetic causes in 36% of patients with RSE. The difference in genetic signatures between FIRES and RSE suggest distinct underlying etiologies. In summary, despite the absence of any identifiable etiologies in FIRES, we performed an unbiased analysis of the clinical landscape, identifying a heterogeneous range of treatment strategies and characterized real-world clinical practice.DiscussionFIRES remains one of the most enigmatic conditions in child neurology without any known etiologies to date despite significant efforts in the field, suggesting a clear need for further studies and novel diagnostic and treatment approaches.
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Affiliation(s)
- Danielle deCampo
- Division of Neurology, Children’s Hospital of Philadelphia, Philadelphia, PA, United States
- The Epilepsy NeuroGenetics Initiative (ENGIN), Children's Hospital of Philadelphia, Philadelphia, PA, United States
- Department of Biomedical and Health Informatics (DBHi), Children’s Hospital of Philadelphia, Philadelphia, PA, United States
| | - Julie Xian
- Division of Neurology, Children’s Hospital of Philadelphia, Philadelphia, PA, United States
- The Epilepsy NeuroGenetics Initiative (ENGIN), Children's Hospital of Philadelphia, Philadelphia, PA, United States
- Department of Biomedical and Health Informatics (DBHi), Children’s Hospital of Philadelphia, Philadelphia, PA, United States
| | - Alexis Karlin
- Division of Neurology, Children’s Hospital of Philadelphia, Philadelphia, PA, United States
- The Epilepsy NeuroGenetics Initiative (ENGIN), Children's Hospital of Philadelphia, Philadelphia, PA, United States
- Department of Biomedical and Health Informatics (DBHi), Children’s Hospital of Philadelphia, Philadelphia, PA, United States
| | - Katie R. Sullivan
- Division of Neurology, Children’s Hospital of Philadelphia, Philadelphia, PA, United States
- The Epilepsy NeuroGenetics Initiative (ENGIN), Children's Hospital of Philadelphia, Philadelphia, PA, United States
- Department of Biomedical and Health Informatics (DBHi), Children’s Hospital of Philadelphia, Philadelphia, PA, United States
| | - Sarah M. Ruggiero
- Division of Neurology, Children’s Hospital of Philadelphia, Philadelphia, PA, United States
- The Epilepsy NeuroGenetics Initiative (ENGIN), Children's Hospital of Philadelphia, Philadelphia, PA, United States
- Department of Biomedical and Health Informatics (DBHi), Children’s Hospital of Philadelphia, Philadelphia, PA, United States
| | - Peter Galer
- Division of Neurology, Children’s Hospital of Philadelphia, Philadelphia, PA, United States
- The Epilepsy NeuroGenetics Initiative (ENGIN), Children's Hospital of Philadelphia, Philadelphia, PA, United States
- Department of Biomedical and Health Informatics (DBHi), Children’s Hospital of Philadelphia, Philadelphia, PA, United States
| | - Mark Ramos
- Department of Biomedical and Health Informatics (DBHi), Children’s Hospital of Philadelphia, Philadelphia, PA, United States
| | - Nicholas S. Abend
- Division of Neurology, Children’s Hospital of Philadelphia, Philadelphia, PA, United States
- The Epilepsy NeuroGenetics Initiative (ENGIN), Children's Hospital of Philadelphia, Philadelphia, PA, United States
- Department of Biomedical and Health Informatics (DBHi), Children’s Hospital of Philadelphia, Philadelphia, PA, United States
| | - Alex Gonzalez
- Department of Biomedical and Health Informatics (DBHi), Children’s Hospital of Philadelphia, Philadelphia, PA, United States
| | - Ingo Helbig
- Division of Neurology, Children’s Hospital of Philadelphia, Philadelphia, PA, United States
- The Epilepsy NeuroGenetics Initiative (ENGIN), Children's Hospital of Philadelphia, Philadelphia, PA, United States
- Department of Biomedical and Health Informatics (DBHi), Children’s Hospital of Philadelphia, Philadelphia, PA, United States
- Department of Neurology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States
- *Correspondence: Ingo Helbig,
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Taraschenko O, Pavuluri S, Schmidt CM, Pulluru YR, Gupta N. Seizure burden and neuropsychological outcomes of new-onset refractory status epilepticus: Systematic review. Front Neurol 2023; 14:1095061. [PMID: 36761344 PMCID: PMC9902772 DOI: 10.3389/fneur.2023.1095061] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Accepted: 01/02/2023] [Indexed: 01/26/2023] Open
Abstract
Background Long-term sequelae of the new onset refractory status epilepticus (NORSE) include the development of epilepsy, cognitive deficits, and behavioral disturbances. The prevalence of these complications has been previously highlighted in case reports and case series: however, their full scope has not been comprehensively assessed. Methods We conducted a systematic review of the literature (PROSPERO ID CRD42022361142) regarding neurological and functional outcomes of NORSE at 30 days or longer following discharge from the hospital. A systematic review protocol was developed using guidance from the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Results Of the 1,602 records for unique publications, 33 reports on adults and 52 reports on children met our inclusion criteria. They contained the description of 280 adults and 587 children of whom only 75.7 and 85% of patients, respectively had data on long-term follow-up. The mean age of adult and pediatric patients was 34.3 and 7.9 years, respectively; and the longest duration of follow up were 11 and 20 years, respectively. Seizure outcomes received major attention and were highlighted for 93.4 and 96.6% of the adult and pediatric NORSE patients, respectively. Seizures remained medically refractory in 41.1% of adults and 57.7% of children, while seizure freedom was achieved in only 26 and 23.3% of these patients, respectively. The long-term cognitive outcome data was provided for just 10.4% of the adult patients. In contrast, cognitive health data were supplied for 68.9% of the described children of whom 31.9% were moderately or severely disabled. Long-term functional outcomes assessed with various standardized scales were reported in 62.2 and 25.5% of the adults and children, respectively with majority of patients not being able to return to a pre-morbid level of functioning. New onset psychiatric disorders were reported in 3.3% of adults and 11.2% of children recovering from NORSE. Conclusion These findings concur with previous observations that the majority of adult and pediatric patients continue to experience recurrent seizures and suffer from refractory epilepsy. Moderate to severe cognitive disability, loss of functional independence, and psychiatric disorders represent a hallmark of chronic NORSE signifying the major public health importance of this disorder.
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Affiliation(s)
- Olga Taraschenko
- Division of Epilepsy, Department of Neurological Sciences, University of Nebraska Medical Center, Omaha, NE, United States
| | - Spriha Pavuluri
- Division of Epilepsy, Department of Neurological Sciences, University of Nebraska Medical Center, Omaha, NE, United States
| | - Cynthia M. Schmidt
- Leon S. McGoogan Health Sciences Library, University of Nebraska Medical Center, Omaha, NE, United States
| | - Yashwanth Reddy Pulluru
- Division of Epilepsy, Department of Neurological Sciences, University of Nebraska Medical Center, Omaha, NE, United States
| | - Navnika Gupta
- Division of Epilepsy, Department of Neurological Sciences, University of Nebraska Medical Center, Omaha, NE, United States
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Nabbout R, Matricardi S, De Liso P, Dulac O, Oualha M. Ketogenic diet for super-refractory status epilepticus (SRSE) with NORSE and FIRES: Single tertiary center experience and literature data. Front Neurol 2023; 14:1134827. [PMID: 37122314 PMCID: PMC10133555 DOI: 10.3389/fneur.2023.1134827] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Accepted: 03/27/2023] [Indexed: 05/02/2023] Open
Abstract
Background and purpose Ketogenic diet (KD) is an emerging treatment option for super-refractory status epilepticus (SRSE). We evaluated the effectiveness of KD in patients presenting SRSE including NORSE (and its subcategory FIRES). Methods A retrospective review of the medical records was performed at the Necker Enfants Malades Hospital. All children with SRSE in whom KD was started during the last 10 years were included. A systematic search was carried out for all study designs, including at least one patient of any age with SRSE in whom KD was started. The primary outcome was the responder rate and Kaplan-Meier survival curves were generated for the time-to-KD response. As secondary outcomes, Cox proportional hazard models were created to assess the impact of NORSE-related factors on KD efficacy. Results Sixteen children received KD for treatment of SRSE, and three had NORSE presentation (one infectious etiology, two FIRES). In medical literature, 1,613 records were initially identified, and 75 were selected for review. We selected 276 patients receiving KD during SRSE. The most common etiology of SRSE was acute symptomatic (21.3%), among these patients, 67.7% presented with NORSE of immune and infectious etiologies. Other etiologies were remote symptomatic (6.8%), progressive symptomatic (6.1%), and SE in defined electroclinical syndromes (14.8%), including two patients with genetic etiology and NORSE presentation. The etiology was unknown in 50.7% of the patients presenting with cryptogenic NORSE, of which 102 presented with FIRES. Overall, most patients with NORSE benefit from KD (p < 0.004), but they needed a longer time to achieve RSE resolution after starting KD compared with other non-NORSE SRSE (p = 0.001). The response to KD in the NORSE group with identified etiology compared to the cryptogenic NORSE was significantly higher (p = 0.01), and the time to achieve SE resolution after starting KD was shorter (p = 0.04). Conclusions The search for underlying etiology should help to a better-targeted therapy. KD can have good efficacy in NORSE; however, the time to achieve SE resolution seems to be longer in cryptogenic cases. These findings highlight the therapeutic role of KD in NORSE, even though this favorable response needs to be better confirmed in prospective controlled studies.
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Affiliation(s)
- Rima Nabbout
- Reference Center for Rare Epilepsies, Department of Pediatric Neurology, Necker-Enfants Malades Hospital, Assistance Publique Hôpitaux de Paris, University Paris Cité, Member of ERN EpiCARE, Paris, France
- Imagine Institute, National Institute of Health and Medical Research, Mixed Unit of Research 1163, University Paris Cité, Paris, France
- *Correspondence: Rima Nabbout ;
| | - Sara Matricardi
- Reference Center for Rare Epilepsies, Department of Pediatric Neurology, Necker-Enfants Malades Hospital, Assistance Publique Hôpitaux de Paris, University Paris Cité, Member of ERN EpiCARE, Paris, France
- Department of Pediatrics, University of Chieti, Chieti, Italy
| | - Paola De Liso
- Neurology Unit, Department of Neuroscience, Bambino Gesù Children's Hospital, Member of ERN EpiCARE, Rome, Italy
| | - Olivier Dulac
- Reference Center for Rare Epilepsies, Department of Pediatric Neurology, Necker-Enfants Malades Hospital, Assistance Publique Hôpitaux de Paris, University Paris Cité, Member of ERN EpiCARE, Paris, France
| | - Mehdi Oualha
- Pediatric Intensive Care Unit, Necker-Enfants Malades Hospital, Assistance Publique Hôpitaux de Paris, Université de Paris, Paris, France
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Pavone P, Corsello G, Raucci U, Lubrano R, Parano E, Ruggieri M, Greco F, Marino S, Falsaperla R. Febrile infection-related Epilepsy Syndrome (FIRES): a severe encephalopathy with status epilepticus. Literature review and presentation of two new cases. Ital J Pediatr 2022; 48:199. [PMID: 36527084 PMCID: PMC9756623 DOI: 10.1186/s13052-022-01389-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 11/24/2022] [Indexed: 12/23/2022] Open
Abstract
FIRES is defined as a disorder that requires a prior febrile infection starting between 2 weeks and 24 h before the onset of the refractory status epilepticus with or without fever at the onset of status epilepticus. The patients, previously normal, present in the acute phase recurrent seizures and status epilepticus followed by a severe course with usually persistent seizures and residual cognitive impairment. Boundary with "new onset refractory status epilepticus (NORSE) has not clearly established. Pathogenetic hypothesis includes inflammatory or autoimmune mechanism with a possible genetic predisposition for an immune response dysfunction.Various types of treatment have been proposed for the treatment of the acute phase of the disorder to block the rapid seizures evolution to status epilepticus and to treat status epilepticus itself. Prognosis is usually severe both for control of the seizures and for cognitive involvement.FIRES is an uncommon but severe disorder which must be carefully considered in the differential diagnosis with other epileptic encephalopathy.
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Affiliation(s)
- Piero Pavone
- Department of Clinical and Experimental Medicine, University Hospital "Policlinico-San Marco", Catania, Catania, Italy.
| | - Giovanni Corsello
- Department of Health Promotion, Mather and Child Care, Internal Medicine and Medical Specialities, University of Palermo, Palermo, Italy
| | - Umberto Raucci
- Department of Emergency and Clinical Pediatrics, Bambin Gesù Children's Hospital IRCCS, Rome, Italy
| | - Riccardo Lubrano
- Pediatrics and Neonatology Unit, Maternal-Child Department, Santa Maria Goretti Hospital, Sapienza University of Rome, Latina, Italy
| | - Enrico Parano
- Unit of Catania, Institute for Research and Biomedical Innovation (IRIB), National Council of Research, Catania, Italy
| | - Martino Ruggieri
- Department of Clinical and Experimental Medicine, University Hospital "Policlinico-San Marco", Catania, Catania, Italy
| | - Filippo Greco
- Department of Clinical and Experimental Medicine, University Hospital "Policlinico-San Marco", Catania, Catania, Italy
| | - Silvia Marino
- Unit of Pediatrics and Pediatric Emergency, AOU "Policlinico"- PO "San Marco", University of Catania, Catania, Italy
| | - Raffaele Falsaperla
- Unit of Pediatrics and Pediatric Emergency, AOU "Policlinico"- PO "San Marco", University of Catania, Catania, Italy
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Wickstrom R, Taraschenko O, Dilena R, Payne ET, Specchio N, Nabbout R, Koh S, Gaspard N, Hirsch LJ. International consensus recommendations for management of New Onset Refractory Status Epilepticus (NORSE) incl. Febrile Infection-Related Epilepsy Syndrome (FIRES): Statements and Supporting Evidence. Epilepsia 2022; 63:2840-2864. [PMID: 35997591 PMCID: PMC9828002 DOI: 10.1111/epi.17397] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Revised: 07/14/2022] [Accepted: 08/18/2022] [Indexed: 01/12/2023]
Abstract
OBJECTIVE To develop consensus-based recommendations for the management of adult and paediatric patients with NORSE/FIRES based on best evidence and experience. METHODS The Delphi methodology was followed. A facilitator group of 9 experts was established, who defined the scope, users and suggestions for recommendations. Following a review of the current literature, recommendation statements concerning diagnosis, treatment and research directions were generated which were then voted on a scale of 1 (strongly disagree) to 9 (strongly agree) by a panel of 48 experts in the field. Consensus that a statement was appropriate was reached if the median score was greater or equal to 7, and inappropriate if the median score was less than or equal to 3. The analysis of evidence was mapped to the results of each statement included in the Delphi survey. RESULTS Overall, 85 recommendation statements achieved consensus. The recommendations are divided into five sections: 1) disease characteristics, 2) diagnostic testing and sampling, 3) acute treatment, 4) treatment in the post-acute phase, and 5) research, registries and future directions in NORSE/FIRES. The detailed results and discussion of all 85 statements are outlined herein. A corresponding summary of findings and practical flowsheets are presented in a companion article. SIGNIFICANCE This detailed analysis offers insight into the supporting evidence and the current gaps in the literature that are associated with expert consensus statements related to NORSE/FIRES. The recommendations generated by this consensus can be used as a guide for the diagnosis, evaluation, and management of patients with NORSE/FIRES, and for planning of future research.
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Affiliation(s)
- Ronny Wickstrom
- Neuropaediatric UnitDepartment of Women's and Children's HealthKarolinska Institutet and Karolinska University HospitalStockholmSweden
| | - Olga Taraschenko
- Department of Neurological SciencesUniversity of Nebraska Medical CenterOmahaNebraskaUSA
| | - Robertino Dilena
- Neuropathophysiology UnitFoundation IRCCS Ca' Granda Ospedale Maggiore PoliclinicoMilanItaly
| | - Eric T. Payne
- Department of Pediatrics, Section of NeurologyAlberta Children's HospitalCalgaryAlbertaCanada
| | - Nicola Specchio
- Rare and Complex Epilepsy Unit, Department of NeurosciencesBambino Gesù Children's Hospital, IRCCS, Full Member of European Reference Network EpiCARERomeItaly
| | - Rima Nabbout
- Department of Pediatric Neurology, APHP, Member of EPICARE ERN, Centre de Reference Epilepsies RaresUniversite de Paris, Institut Imagine, INSERM 1163ParisFrance
| | - Sookyong Koh
- Department of Pediatrics, Children's Hospital and Medical CenterUniversity of NebraskaOmahaNebraskaUSA
| | | | - Lawrence J. Hirsch
- Department of Neurology, Comprehensive Epilepsy CenterYale UniversityNew HavenConnecticutUSA
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11
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Obara K, Ono T. Ketogenic Diet for a Young Adult Patient With Chronic-Phase Febrile Infection-Related Epilepsy Syndrome. Cureus 2022; 14:e22099. [PMID: 35165646 PMCID: PMC8830588 DOI: 10.7759/cureus.22099] [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] [Accepted: 02/10/2022] [Indexed: 11/06/2022] Open
Abstract
Febrile infection-related epilepsy syndrome (FIRES) is a rare disease, whereby refractory status epilepticus (a severe epileptic syndrome) occurs in previously healthy individuals following a febrile illness. Here, we report a patient with FIRES who received ketogenic diet (KD) therapy initiated in the chronic phase. A 21-year-old man presented with status epilepticus, following fever and headache. In the acute phase, his seizures were refractory to conventional antiepileptic drugs and were suppressed only by intravenous anesthetics. In the chronic phase, he showed frequent seizures with concurrent severe cognitive decline. Twenty-seven months after onset, the patient was started on KD. Consequently, his seizure frequency rapidly reduced while his cognitive function slowly improved, albeit incompletely. Recently, KD has been shown to both reduce seizures and improve cognitive prognoses in children with FIRES. Although early KD may help in both seizure control and cognitive prognosis, it is likely that KD can be applied to adult patients with chronic FIRES.
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12
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Sivathanu D, Kewalramani D, Kumar Manokaran R. Favorable response to classic ketogenic diet in a child with anti-GAD 65 antibody mediated super refractory status epilepticus. Epilepsy Behav Rep 2022; 19:100557. [PMID: 35789965 PMCID: PMC9250004 DOI: 10.1016/j.ebr.2022.100557] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Revised: 05/30/2022] [Accepted: 06/05/2022] [Indexed: 11/10/2022] Open
Abstract
Autoimmune encephalitis is a disease condition which presents with refractory seizures in children requiring immunotherapy. KD is a non-pharmacological treatment modality used worldwide in people with drug-resistant epilepsy. It acts through many anti-inflammatory mechanisms leading to seizure control. This article highlights the use of adjuvant effect of ketogenic diet in anti GAD-65 antibody positive autoimmune encephalitis. It is the need of the hour to formulate treatment protocols incorporating newer treatment strategies including KD.
Autoimmune encephalitis refers to a spectrum of inflammatory brain diseases which can present as drug-resistant seizures in children. Hereby, we report a case of anti-GAD-65 antibody encephalitis in a 7-year-old child who presented with superrefractory status epilepticus (SRSE). The traditional management with multiple anti-seizure medications at appropriate dosage and immunotherapy was tried despite which the child continued to have seizures. Hence the child was initiated on a classic ketogenic diet. He achieved ketosis within 48 h of diet initiation and there was a drastic reduction in the seizure frequency followed by a completed remission. Hence, this non-pharmacological intervention was an effective adjunct in achieving seizure control in our patient. A ketogenic diet has been sparingly used for the management of post-encephalitic epilepsy and autoimmune epilepsy. However, the data onthe effectiveness of the ketogenic diet in the management of autoimmune encephalitis is scarce. Starting KD early in the disease course helped not only in seizure control but also preserved the cognitive and neurological well-being of the child.
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13
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Kaul N, Laing J, Nicolo JP, Nation J, Kwan P, O'Brien TJ. Practical Considerations for Ketogenic Diet in Adults With Super-Refractory Status Epilepticus. Neurol Clin Pract 2021; 11:438-444. [PMID: 34840870 DOI: 10.1212/cpj.0000000000001009] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Accepted: 10/05/2020] [Indexed: 01/04/2023]
Abstract
Purpose of Review Ketogenic diet therapy can be used as an adjuvant treatment of super-refractory status epilepticus (SRSE). However, the drug and metabolic interactions with concomitant treatments present a challenge for clinicians. In this review, we focus on the practical considerations of implementing ketogenic dietary therapy in the acute setting, including the dietary composition, potential drug-diet interactions, and monitoring during ketogenic treatment. Recent Findings This report describes the ketogenic diet therapy protocol implemented for the treatment of SRSE and a review of the current evidence to support clinical practice. Summary The control of SRSE is critical in reducing morbidity and mortality. There is emerging evidence that ketogenic diet may be a safe and effective treatment option for these patients.
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Affiliation(s)
- Neha Kaul
- Department of Allied Health (Clinical Nutrition) (NK), Royal Melbourne Hospital; Department of Nutrition and Dietetics, (NK) Alfred Hospital; Departments of Medicine and Neurology (NK, J-PN, JN, PK, TJO), Royal Melbourne Hospital, University of Melbourne; and Departments of Neurosciences and Neurology (NK, JL, J-PN, PK, TJO), Alfred Hospital and Monash University, Melbourne, Australia
| | - Joshua Laing
- Department of Allied Health (Clinical Nutrition) (NK), Royal Melbourne Hospital; Department of Nutrition and Dietetics, (NK) Alfred Hospital; Departments of Medicine and Neurology (NK, J-PN, JN, PK, TJO), Royal Melbourne Hospital, University of Melbourne; and Departments of Neurosciences and Neurology (NK, JL, J-PN, PK, TJO), Alfred Hospital and Monash University, Melbourne, Australia
| | - John-Paul Nicolo
- Department of Allied Health (Clinical Nutrition) (NK), Royal Melbourne Hospital; Department of Nutrition and Dietetics, (NK) Alfred Hospital; Departments of Medicine and Neurology (NK, J-PN, JN, PK, TJO), Royal Melbourne Hospital, University of Melbourne; and Departments of Neurosciences and Neurology (NK, JL, J-PN, PK, TJO), Alfred Hospital and Monash University, Melbourne, Australia
| | - Judy Nation
- Department of Allied Health (Clinical Nutrition) (NK), Royal Melbourne Hospital; Department of Nutrition and Dietetics, (NK) Alfred Hospital; Departments of Medicine and Neurology (NK, J-PN, JN, PK, TJO), Royal Melbourne Hospital, University of Melbourne; and Departments of Neurosciences and Neurology (NK, JL, J-PN, PK, TJO), Alfred Hospital and Monash University, Melbourne, Australia
| | - Patrick Kwan
- Department of Allied Health (Clinical Nutrition) (NK), Royal Melbourne Hospital; Department of Nutrition and Dietetics, (NK) Alfred Hospital; Departments of Medicine and Neurology (NK, J-PN, JN, PK, TJO), Royal Melbourne Hospital, University of Melbourne; and Departments of Neurosciences and Neurology (NK, JL, J-PN, PK, TJO), Alfred Hospital and Monash University, Melbourne, Australia
| | - Terence J O'Brien
- Department of Allied Health (Clinical Nutrition) (NK), Royal Melbourne Hospital; Department of Nutrition and Dietetics, (NK) Alfred Hospital; Departments of Medicine and Neurology (NK, J-PN, JN, PK, TJO), Royal Melbourne Hospital, University of Melbourne; and Departments of Neurosciences and Neurology (NK, JL, J-PN, PK, TJO), Alfred Hospital and Monash University, Melbourne, Australia
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14
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Li WJ, Xue CL, Zhang Y, Wu LH, Chen DM, Chen F, Xu J, Li Z, Miao HJ. Ketogenic diet (KD) therapy in the acute phase of febrile infection-related epilepsy syndrome (FIRES): a case report. Transl Pediatr 2021; 10:2392-2397. [PMID: 34733679 PMCID: PMC8506052 DOI: 10.21037/tp-21-121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Accepted: 06/29/2021] [Indexed: 11/20/2022] Open
Abstract
Management of frequent epileptic seizures in febrile infection-related epilepsy (FIRES) is often challenging. FIRES is an uncommon disease condition. Children with FIRES develop refractory epilepsy with severe cognitive deficits that affect the function of the temporal and frontal lobes. However, better seizure control during the acute stage of FIRES could protect against injury to the nervous system. Ketogenic diet (KD) can effectively resolve super-refractory status epilepticus (SRSE) in the acute phase and improve the prognosis of FIRES. We present the case of a previously healthy 3-year-old male with new-onset status epilepticus (SE) admitted to the paediatric intensive care unit for 55 days. Despite treatment with multiple anti-epileptic agents in addition to IV anaesthetics, the patient remained in SRSE and continued to have generalised epileptic activity on electroencephalography (EEG). KD therapy was initiated on the 14th day of the onset, and the patient achieved complete neurological recovery following the KD. Throughout the remainder of admission, the patient was successfully weaned off the ventilator, tolerated oral meals, and worked with occupational and physical therapists to return to his baseline functional status. The convulsions were well controlled after discharge. We discuss the treatment strategies for FIRES and highlight the role of KD therapy in the acute phase to control disease progression and improve the prognosis, and early diagnosis of FIRES and early initiation of KD therapy combined with anti-epileptic drugs (AEDs) could improve the prognosis.
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Affiliation(s)
- Wen-Jing Li
- Department of Pharmacy, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Chun-Ling Xue
- Department of Emergency, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Yong Zhang
- Department of Pharmacy, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Li-Hui Wu
- Department of Emergency, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Dong-Mei Chen
- Department of Emergency, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Feng Chen
- Department of Pharmacy, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Jing Xu
- Department of Pharmacy, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Zhuo Li
- Department of Emergency, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Hong-Jun Miao
- Department of Emergency, Children's Hospital of Nanjing Medical University, Nanjing, China
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15
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Dramatic Course of Paediatric Cryptogenic Febrile Infection-Related Epilepsy Syndrome with Unusual Chronic Phase Presentation-A Case Report with Literature Study. Brain Sci 2021; 11:brainsci11081030. [PMID: 34439649 PMCID: PMC8392460 DOI: 10.3390/brainsci11081030] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 07/28/2021] [Accepted: 07/29/2021] [Indexed: 12/03/2022] Open
Abstract
Febrile Infection-Related Epilepsy Syndrome (FIRES) is a catastrophic, extremely rare epileptic encephalopathy. It strikes previously healthy school-aged children and is usually cryptogenic. Its dramatic onset with refractory status epilepticus is always preceded by a nonspecific febrile illness. The seizure activity in FIRES may last for several weeks with little to no response to antiepileptic treatment, usually resulting in the usage of anaesthetics. This acute phase is followed by a chronic, refractory epilepsy and cognitive deficit, that persist for the rest of the patient’s life. Still to this day no definite cause has been described. In this study we review the current finding in FIRES and describe a case of a 4-year-old patient with a dramatic course of the acute phase in FIRES and unusual presentation of the chronic phase, which is dominated by extrapyramidal symptoms such as dystonia. This case highlights that the clinical presentation of FIRES may differ from those frequently described in literature.
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16
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Shin YW. Understanding new-onset refractory status epilepticus from an immunological point of view. ENCEPHALITIS 2021; 1:61-67. [PMID: 37469848 PMCID: PMC10295883 DOI: 10.47936/encephalitis.2021.00045] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2021] [Revised: 04/11/2021] [Accepted: 05/21/2021] [Indexed: 07/21/2023] Open
Abstract
New-onset refractory status epilepticus (NORSE) is unexpected onset of refractory status epilepticus in individuals with no preexisting relevant neurologic condition. The etiologies remain largely cryptogenic; treatment is challenging after failure to control seizures despite use of multiple antiepileptic drugs and anesthetic agents. Frequent fever and other infectious prodromes, elevated proinflammatory cytokine/chemokine levels, and limbic or multifocal brain lesions indicate active inflammation in NORSE. Among identified causes, autoimmune encephalitis is the most common and accounts for more than one-third of all known NORSE cases, followed by infection-related etiologies. Although more evidence is needed, anti-cytokine therapies with tocilizumab and anakinra along with other immunotherapeutic agents used in autoimmune encephalitis can aid in alleviating or hindering the inflammatory cascade and controlling seizures.
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Affiliation(s)
- Yong-Won Shin
- Center for Hospital Medicine, Department of Neurosurgery, Seoul National University Hospital, Seoul, Korea
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17
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Lin WS, Hsu TR. Hypothesis: Febrile infection-related epilepsy syndrome is a microglial NLRP3 inflammasome/IL-1 axis-driven autoinflammatory syndrome. Clin Transl Immunology 2021; 10:e1299. [PMID: 34141434 PMCID: PMC8204115 DOI: 10.1002/cti2.1299] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Revised: 05/22/2021] [Accepted: 05/27/2021] [Indexed: 11/08/2022] Open
Abstract
FIRES (febrile infection-related epilepsy syndrome) is a protracted neuroinflammatory condition of obscure cause. It mainly afflicts school-age children and often leads to permanent neurological sequelae. Most treatments to date have been of limited efficacy, while ketogenic diet and anti-interleukin-1 therapy appear beneficial for some patients. Research into this clinical entity is hampered by its rarity and complexity. Nonetheless, accumulating evidence derived from basic investigations and clinical observations converges to implicate the autoinflammatory nature of this syndrome. A closer analysis of current literature suggests that microglia and the NLRP3 inflammasome might be the pivotal cellular and molecular players in FIRES pathogenesis, respectively. Through evidence synthesis, herein we formulate the working hypothesis of overactivation of microglial NLRP3 inflammasome/interleukin-1 axis as the driving event in FIRES by creating a proinflammatory and proconvulsive milieu. The reverberation between neuroinflammation and seizure forms a vicious cycle. The unique properties of microglia might also contribute to unopposed IL-1 signalling and incessant sterile neuroinflammation in this context. The potential therapeutic relevance of the proposed conceptual framework is discussed.
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Affiliation(s)
- Wei-Sheng Lin
- Department of Pediatrics Taipei Veterans General Hospital Taipei Taiwan.,Institute of Clinical Medicine and Faculty of Medicine National Yang Ming Chiao Tung University Taipei Taiwan
| | - Ting-Rong Hsu
- Department of Pediatrics Taipei Veterans General Hospital Taipei Taiwan.,Institute of Clinical Medicine and Faculty of Medicine National Yang Ming Chiao Tung University Taipei Taiwan
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18
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Baba S, Okanishi T, Ohsugi K, Suzumura R, Niimi K, Shimizu S, Sakihama H, Itamura S, Hirano K, Nishimura M, Fujimoto A, Enoki H. Possible Role of High-Dose Barbiturates and Early Administration of Parenteral Ketogenic Diet for Reducing Development of Chronic Epilepsy in Febrile Infection-Related Epilepsy Syndrome: A Case Report. Neuropediatrics 2021; 52:133-137. [PMID: 33231274 DOI: 10.1055/s-0040-1716903] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
We describe the efficacy of high-dose barbiturates and early administration of a parenteral ketogenic diet (KD) as initial treatments for acute status epilepticus (SE) in an 8-year-old girl with febrile infection-related epilepsy syndrome (FIRES). The patient was admitted to our hospital with refractory focal SE. Abundant epileptic discharges over the left frontal region were observed on electroencephalogram (EEG). Treatment with continuous infusion of thiamylal for 4 hours, increased incrementally to 40 mg/kg/h, successfully ended the clinical SE, and induced a burst-suppression coma. The infusion rate was then gradually decreased to 4 mg/kg/h over the next 12 hours. Parenteral KD was administered from days 6 to 21 of illness. Continuous infusion of thiamylal was switched to midazolam on day 10 without causing seizures or EEG exacerbations. The patient has remained seizure free in the 15 months since hospital discharge. The effectiveness of KD for the treatment of FIRES has attracted attention amongst clinicians, but KD treatment may need to last for 2 to 4 days before it can stop SE, a time period that could cause irreversible brain damage. Considering the severity of SE in our patient and the dose of barbiturates needed to treat it, we consider this case to have had a good clinical outcome. The results suggest that rapid termination of seizure using high-dose barbiturates in conjunction with early administration of parenteral KD could reduce the development of chronic epilepsy in patients with FIRES.
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Affiliation(s)
- Shimpei Baba
- Department of Child Neurology, Comprehensive Epilepsy Center, Seirei Hamamatsu General Hospital, Hamamatsu, Shizuoka, Japan
| | - Tohru Okanishi
- Department of Child Neurology, Comprehensive Epilepsy Center, Seirei Hamamatsu General Hospital, Hamamatsu, Shizuoka, Japan
| | - Koichi Ohsugi
- Department of Emergency & Critical Care Medicine, Seirei Hamamatsu General Hospital, Hamamatsu, Shizuoka, Japan
| | - Rika Suzumura
- Division of Nutrition, Seirei Hamamatsu General Hospital, Hamamatsu, Shizuoka, Japan
| | - Keiko Niimi
- Division of Rehabilitation, Seirei Hamamatsu General Hospital, Hamamatsu, Shizuoka, Japan
| | - Sayuri Shimizu
- Division of Rehabilitation, Seirei Hamamatsu General Hospital, Hamamatsu, Shizuoka, Japan
| | - Hiroshi Sakihama
- Department of Pediatrics, Seirei Hamamatsu General Hospital, Hamamatsu, Shizuoka, Japan
| | - Shinji Itamura
- Department of Child Neurology, Comprehensive Epilepsy Center, Seirei Hamamatsu General Hospital, Hamamatsu, Shizuoka, Japan
| | - Keiko Hirano
- Department of Pediatrics, Iwata City Hospital, Okubo, Iwata, Shizuoka, Japan
| | - Mitsuyo Nishimura
- Division of Clinical Laboratory, Seirei Hamamatsu General Hospital, Hamamatsu, Shizuoka, Japan
| | - Ayataka Fujimoto
- Department of Epilepsy and Surgery, Comprehensive Epilepsy Center, Seirei Hamamatsu General Hospital, Hamamatsu, Shizuoka, Japan
| | - Hideo Enoki
- Department of Child Neurology, Comprehensive Epilepsy Center, Seirei Hamamatsu General Hospital, Hamamatsu, Shizuoka, Japan
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19
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Schoeler NE, Simpson Z, Zhou R, Pujar S, Eltze C, Cross JH. Dietary Management of Children With Super-Refractory Status Epilepticus: A Systematic Review and Experience in a Single UK Tertiary Centre. Front Neurol 2021; 12:643105. [PMID: 33776895 PMCID: PMC7994594 DOI: 10.3389/fneur.2021.643105] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Accepted: 02/17/2021] [Indexed: 12/16/2022] Open
Abstract
Ketogenic diet therapies (KDT) are high-fat, low carbohydrate diets used as an effective treatment option for drug-resistant epilepsy. There is limited research on the efficacy of KDT for super-refractory status epilepticus (SRSE). We systematically review evidence for use of KDT in children with SRSE and present a single UK tertiary centre's experience. Thirty one articles were included, of which 24 were “medium” or “low” quality. One hundred and forty seven children with SRSE started KDT, of which 141 (96%) achieved ketosis. KDT was started mean 5.3 days (range 1–420) after status epilepticus (SE) started. SRSE resolved in 85/141 (60%) children after mean 6.3 days (range 0–19) post SE onset, but it is unclear whether further treatments were initiated post-KDT. 13/141 (9%) children died. Response to KDT was more likely when initiated earlier (p = 0.03) and in females (p = 0.01). Adverse side effects were reported in 48/141 (34%), mostly gastrointestinal; potentially serious adverse effects occurred in ≤4%. Eight children with SRSE, all diagnosed with febrile infection-related epilepsy syndrome, were treated with KDT at Great Ormond Street Hospital for Children. KDT was initiated enterally at mean day 13.6+/− 5.1 of admission. Seven of 8 (88%) children reported adverse side effects, which were potentially serious in 4/8 (50%), including metabolic acidosis, hypoglycaemia and raised amylase. SE ceased in 6/8 (75%) children after mean 25+/− 9.4 days post onset, but other treatments were often started concomitantly and all children started other treatments post-KDT. Two of 8 (25%) children died during admission and another died post-admission. Four of the remaining 5 children continue to have drug-resistant seizures, one of whom remains on KDT; seizure burden was unknown for one child. Our findings indicate that KDT is possible and safe in children with SRSE. Cessation of SRSE may occur in almost two-thirds of children initiated with KDT, but a causal effect is difficult to determine due to concomitant treatments, treatments started post-KDT and the variable length of time post-KDT onset when SRSE cessation occurs. Given that serious adverse side effects seem rare and response rates are (cautiously) favorable, KDT should be considered as an early treatment option in this group.
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Affiliation(s)
- Natasha E Schoeler
- Developmental Neurosciences Research and Teaching Department, University College London Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Zoe Simpson
- Department of Dietetics, Great Ormond Street Hospital for Children, London, United Kingdom
| | - Runming Zhou
- Developmental Neurosciences Research and Teaching Department, University College London Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Suresh Pujar
- Department of Paediatric and Neurology, Great Ormond Street Hospital for Children, London, United Kingdom
| | - Christin Eltze
- Department of Paediatric and Neurology, Great Ormond Street Hospital for Children, London, United Kingdom
| | - J H Cross
- Developmental Neurosciences Research and Teaching Department, University College London Great Ormond Street Institute of Child Health, London, United Kingdom.,Department of Paediatric and Neurology, Great Ormond Street Hospital for Children, London, United Kingdom.,Young Epilepsy, Lingfield, United Kingdom
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20
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Koh S, Wirrell E, Vezzani A, Nabbout R, Muscal E, Kaliakatsos M, Wickström R, Riviello JJ, Brunklaus A, Payne E, Valentin A, Wells E, Carpenter JL, Lee K, Lai Y, Eschbach K, Press CA, Gorman M, Stredny CM, Roche W, Mangum T. Proposal to optimize evaluation and treatment of Febrile infection-related epilepsy syndrome (FIRES): A Report from FIRES workshop. Epilepsia Open 2021; 6:62-72. [PMID: 33681649 PMCID: PMC7918329 DOI: 10.1002/epi4.12447] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Revised: 11/03/2020] [Accepted: 11/13/2020] [Indexed: 12/23/2022] Open
Abstract
Febrile infection-related epilepsy syndrome (FIRES) is a rare catastrophic epileptic encephalopathy that presents suddenly in otherwise normal children and young adults causing significant neurological disability, chronic epilepsy, and high rates of mortality. To suggest a therapy protocol to improve outcome of FIRES, workshops were held in conjunction with American Epilepsy Society annual meeting between 2017 and 2019. An international group of pediatric epileptologists, pediatric neurointensivists, rheumatologists and basic scientists with interest and expertise in FIRES convened to propose an algorithm for a standardized approach to the diagnosis and treatment of FIRES. The broad differential for refractory status epilepticus (RSE) should include FIRES, to allow empiric therapies to be started early in the clinical course. FIRES should be considered in all previously healthy patients older than two years of age who present with explosive onset of seizures rapidly progressing to RSE, following a febrile illness in the preceding two weeks. Once FIRES is suspected, early administrations of ketogenic diet and anakinra (the IL-1 receptor antagonist that blocks biologic activity of IL-1β) are recommended.
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Affiliation(s)
- Sookyong Koh
- Department of PediatricsEmory University School of MedicineAtlantaGAUSA
| | - Elaine Wirrell
- Child and Adolescent Neurology and EpilepsyMayo ClinicRochesterMNUSA
| | - Annamaria Vezzani
- Department of NeuroscienceInstituto di Ricerche Farmacologiche Mario Negri IRCCSMilanItaly
| | - Rima Nabbout
- Reference Centre for Rare EpilepsiesDepartment of Pediatric NeurologyNecker Enfants Malades Hospital, APHPImagine InstituteParis Descartes UniversityParisFrance
| | - Eyal Muscal
- Department of PediatricsSection of Pediatric, RheumatologyBaylor College of MedicineHoustonTXUSA
| | - Marios Kaliakatsos
- Department of NeurologyGreat Ormond Street Hospital for ChildrenLondonUK
| | - Ronny Wickström
- Neuropediatric UnitDepartment of Women's and Children's HealthKarolinska InstituteStockholmSweden
| | | | - Andreas Brunklaus
- Paediatric Neurosciences Research GroupRoyal Hospital for ChildrenGlasgowUK
| | - Eric Payne
- Child and Adolescent Neurology and EpilepsyMayo ClinicRochesterMNUSA
| | - Antonio Valentin
- Department of Basic and Clinical Neuroscience, Psychology and NeuroscienceDepartment of Clinical NeurophysiologyKing's College Hospital NHS TrustLondonUK
| | - Elizabeth Wells
- Center for Neuroscience and Behavioral MedicineChildren’s National Health SystemWashingtonDCUSA
| | - Jessica L. Carpenter
- Center for Neuroscience and Behavioral MedicineChildren’s National Health SystemWashingtonDCUSA
| | - Kihyeong Lee
- Comprehensive Epilepsy CenterAdvent Health for ChildrenOrlandoFLUSA
| | - Yi‐Chen Lai
- Jan and Dan Duncan Neurological Research InstituteBaylor College of MedicineHoustonTXUSA
| | - Krista Eschbach
- Department of PediatricsSection of NeurologyUniversity of Colorado DenverDenverCOUSA
| | - Craig A. Press
- Department of PediatricsSection of NeurologyUniversity of Colorado DenverDenverCOUSA
| | - Mark Gorman
- Department of NeurologyBoston Children’s HospitalBostonMAUSA
| | | | - William Roche
- Department of PediatricsEmory University School of MedicineAtlantaGAUSA
| | - Tara Mangum
- Department of PediatricsPhoenix Children’s HospitalPhoenixAZUSA
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21
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Koh S, Dupuis N, Auvin S. Ketogenic diet and Neuroinflammation. Epilepsy Res 2020; 167:106454. [DOI: 10.1016/j.eplepsyres.2020.106454] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 07/26/2020] [Accepted: 09/01/2020] [Indexed: 12/13/2022]
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22
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Diet in the Treatment of Epilepsy: What We Know So Far. Nutrients 2020; 12:nu12092645. [PMID: 32872661 PMCID: PMC7551815 DOI: 10.3390/nu12092645] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2020] [Revised: 08/26/2020] [Accepted: 08/28/2020] [Indexed: 02/07/2023] Open
Abstract
Epilepsy is a chronic and debilitating neurological disorder, with a worldwide prevalence of 0.5–1% and a lifetime incidence of 1–3%. An estimated 30% of epileptic patients continue to experience seizures throughout life, despite adequate drug therapy or surgery, with a major impact on society and global health. In recent decades, dietary regimens have been used effectively in the treatment of drug-resistant epilepsy, following the path of a non-pharmacological approach. The ketogenic diet and its variants (e.g., the modified Atkins diet) have an established role in contrasting epileptogenesis through the production of a series of cascading events induced by physiological ketosis. Other dietary regimens, such as caloric restriction and a gluten free diet, can also exert beneficial effects on neuroprotection and, therefore, on refractory epilepsy. The purpose of this review was to analyze the evidence from the literature about the possible efficacy of different dietary regimens on epilepsy, focusing on the underlying pathophysiological mechanisms, safety, and tolerability both in pediatric and adult population. We believe that a better knowledge of the cellular and molecular biochemical processes behind the anticonvulsant effects of alimentary therapies may lead to the development of personalized dietary intervention protocols.
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Kessi M, Liu F, Zhan Y, Tang Y, Wu L, Yang L, Zhang CL, Yin F, Peng J. Efficacy of different treatment modalities for acute and chronic phases of the febrile infection-related epilepsy syndrome: A systematic review. Seizure 2020; 79:61-68. [DOI: 10.1016/j.seizure.2020.04.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Revised: 04/23/2020] [Accepted: 04/30/2020] [Indexed: 01/17/2023] Open
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Sakuma H, Horino A, Kuki I. Neurocritical care and target immunotherapy for febrile infection-related epilepsy syndrome. Biomed J 2020; 43:205-210. [PMID: 32330681 PMCID: PMC7424090 DOI: 10.1016/j.bj.2020.03.009] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 03/29/2020] [Accepted: 03/30/2020] [Indexed: 01/15/2023] Open
Abstract
Febrile infection-related epilepsy syndrome (FIRES) is an intractable neurological disease characterized by an unexplained refractory status epilepticus triggered by febrile infection. A Consensus definition of FIRES was proposed in 2018, and its clinical features and prognosis are gradually being clarified. However, the development of effective treatments has been hindered as the etiology of this rare disease is as yet unelucidated. The basic approach to the management of FIRES, like other forms of epilepsy, is based on the control of seizures, however seizures are extremely intractable and require intravenous administration of large doses of anticonvulsants, mainly barbiturates. This treatment strategy produces various complications including respiratory depression and drug hypersensitivity syndrome, which make it more difficult to control seizures. Consequently, it is crucial to predict these events and to formulate a planned treatment strategy. As well, it is important to grow out of conventional treatment strategies that rely on only anticonvulsants, and alternative therapies are gradually being developed. One such example is the adoption of a ketogenic diet which may lead to reduced convulsions as well as improve intellectual prognosis. Further, overproduction of inflammatory cytokines in the central nervous system has been shown to be strongly related to the pathology of FIRES which has led to attempts at immunomodulation therapy including anti-cytokine therapy.
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Affiliation(s)
- Hiroshi Sakuma
- Department of Brain Development and Neural Regeneration, Tokyo Metropolitan Institute of Medical Science, Tokyo, Japan.
| | - Asako Horino
- Department of Brain Development and Neural Regeneration, Tokyo Metropolitan Institute of Medical Science, Tokyo, Japan; Department of Pediatric Neurology, Children's Medical Center, Osaka City General Hospital, Osaka, Japan
| | - Ichiro Kuki
- Department of Pediatric Neurology, Children's Medical Center, Osaka City General Hospital, Osaka, Japan
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Armeno M, Caraballo R. The evolving indications of KD therapy. Epilepsy Res 2020; 163:106340. [PMID: 32330835 DOI: 10.1016/j.eplepsyres.2020.106340] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Revised: 03/14/2020] [Accepted: 04/08/2020] [Indexed: 02/06/2023]
Abstract
Despite the rapid increase of clinical and basic-science knowledge on ketogenic diet therapies over the past years, it has not always been easy to determine the adequate indications of this treatment. Over the nearly 100 years of use, from being a last resource in the therapeutic algorithm, the diet has become one of the four main treatments for patients with difficult-to-control epilepsy together with antiepileptic drugs, surgery, and vagus nerve stimulation. The use of the diet has also changed. The current paper will briefly discuss the history of the diet together with a review of the literature regarding its most important indications and how they have evolved. The concept of the importance of defining the type of seizure, type of syndrome, and etiology in the selection of patients and timing of diet initiation has been gaining importance. This paper explores how the indications of the diet changed together with the shifting focus of epilepsy teams towards its use in different types of epilepsy and epilepsy syndromes and according to etiologies and as an alternative option in refractory and superrefractory status epilepticus.
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Affiliation(s)
- Marisa Armeno
- Department of Nutrition, Hospital de Pediatria Juan P Garrahan, Combate de los Pozos 1881, C1245 CABA, Buenos Aires, Argentina.
| | - Roberto Caraballo
- Department of Neurology, Hospital de Pediatria Juan P Garrahan, Combate de los Pozos 1881, C1245 CABA, Buenos Aires, Argentina
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Lee YJ. Febrile Infection-Related Epilepsy Syndrome: Refractory Status Epilepticus and Management Strategies. ANNALS OF CHILD NEUROLOGY 2020. [DOI: 10.26815/acn.2019.00283] [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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Mahmoud SH, Ho-Huang E, Buhler J. Systematic review of ketogenic diet use in adult patients with status epilepticus. Epilepsia Open 2019; 5:10-21. [PMID: 32140640 PMCID: PMC7049803 DOI: 10.1002/epi4.12370] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Revised: 10/30/2019] [Accepted: 11/06/2019] [Indexed: 12/12/2022] Open
Abstract
Status epilepticus (SE) is a medical emergency that is associated with a significant morbidity and mortality. Recently, there has been significant interest in the use of ketogenic diets (KD) in the management of SE. KD is a high‐fat, low‐carbohydrate, and adequate protein diet that has been shown to be a safe and effective adjuvant to present SE management in patients with refractory epilepsy. Many case reports and case series have demonstrated the potential safety and effectiveness of KD for the acute treatment of SE; however, quality studies remain scarce on this topic. The purpose of this systematic review is to summarize the available evidence for the safety and effectiveness of KD in adults with SE. A literature search was performed in MEDLINE, EMBASE, Cochrane Library, and CINAHL (September 14, 2018). The search was repeated on March 27, 2019, to include any studies published since the original search. Keywords related to KD and SE were used. Studies were selected based on the reported use of the KD in SE. The search resulted in a total of 954 records. After screening and full‐text review, 17 articles were included in this review: four observational studies, 10 case reports, and 3 case series. Based on the observational studies, a total of 38 Patients with SE have been reported. KD was successful in achieving cessation of SE in 31 Patients (82%). The most common adverse effects reported were metabolic acidosis, hyperlipidemia, and hypoglycemia. The current limited evidence suggests that KD might be considered as an option for adult patients with SE. Although promising, the results need to be interpreted with caution due to the inherent bias, confounding and small sample size of the included studies. A randomized controlled trial is recommended to establish role of KD in the management of SE in adults.
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Affiliation(s)
- Sherif Hanafy Mahmoud
- Faculty of Pharmacy and Pharmaceutical Sciences University of Alberta Edmonton AB Canada
| | - Ethos Ho-Huang
- Faculty of Pharmacy and Pharmaceutical Sciences University of Alberta Edmonton AB Canada
| | - Jessica Buhler
- Faculty of Pharmacy and Pharmaceutical Sciences University of Alberta Edmonton AB Canada
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Peng P, Peng J, Yin F, Deng X, Chen C, He F, Wang X, Guang S, Mao L. Ketogenic Diet as a Treatment for Super-Refractory Status Epilepticus in Febrile Infection-Related Epilepsy Syndrome. Front Neurol 2019; 10:423. [PMID: 31105638 PMCID: PMC6498987 DOI: 10.3389/fneur.2019.00423] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Accepted: 04/08/2019] [Indexed: 12/28/2022] Open
Abstract
Background: Febrile infection-related epilepsy syndrome (FIRES) is a fatal epileptic encephalopathy associated with super-refractory status epilepticus (SRSE). Several treatment strategies have been proposed for this condition although the clinical outcomes are poor. Huge efforts from neurointensivists have been focused on identifying the characteristics of FIRES and treatment to reduce the mortality associated with this condition. However, the role of ketogenic diet (KD) in FIRES is not fully understood. Methods: We performed a retrospective review of patients who met the diagnostic criteria of FIRES, SRSE, and were treated with KD between 2015 and 2018 at the Department of Pediatrics, Xiangya Hospital of Central South University. The following data were recorded: demographic features, clinical presentation, anticonvulsant treatment, timing and duration of KD and follow-up information. Electroencephalography recordings were reviewed and analyzed. Results: Seven patients with FIRES were put on KD (5 via enteral route, and 2 via intravenous line) for SRSE in the PICU. The median age was 8. Four patients were male and 3 were female. Although patients underwent treatment with a median of 4 antiepileptic drugs and 2 anesthetic agents, the status epilepticus (SE) persisted for 7–31 days before KD initiation. After KD initiation, all patients achieved ketosis and SE disappeared within an average of 5 days (IQR 3.5), although there were minor side effects. In 6 patients, a unique pattern was identified in the EEG recording at the peak period. After initiation of KD, the number of seizures reduced, the duration of seizure shortened, the background recovered and sleep architecture normalized in the EEG recordings. The early initiation of KD (at the onset of SE) in the acute phase of patients decreased the mRS score in the subsequent period (p = 0.012, r = 0.866). Conclusions: The characteristic EEG pattern in the acute phase promoted timely diagnosis of FIRES. Our data suggest that KD may be a safe and promising therapy for FIRES with SRSE, and that early initiation of KD produces a favorable prognosis. Therefore, KD should be applied earlier in the course of FIRES. Intravenous KD can be an effective alternative route of administration for patients who may not take KD enterally.
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Affiliation(s)
- Pan Peng
- Department of Pediatrics, Xiangya Hospital of Central South University, Changsha, China
| | - Jing Peng
- Department of Pediatrics, Xiangya Hospital of Central South University, Changsha, China
| | - Fei Yin
- Department of Pediatrics, Xiangya Hospital of Central South University, Changsha, China.,Hunan Intellectual and Developmental Disabilities Research Center, Xiangya Hospital of Central South University, Changsha, China
| | - Xiaolu Deng
- Department of Pediatrics, Xiangya Hospital of Central South University, Changsha, China
| | - Chen Chen
- Department of Pediatrics, Xiangya Hospital of Central South University, Changsha, China
| | - Fang He
- Department of Pediatrics, Xiangya Hospital of Central South University, Changsha, China
| | - Xiaole Wang
- Department of Pediatrics, Xiangya Hospital of Central South University, Changsha, China
| | - Shiqi Guang
- Department of Pediatrics, Xiangya Hospital of Central South University, Changsha, China
| | - Leilei Mao
- Department of Pediatrics, Xiangya Hospital of Central South University, Changsha, China
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Fessas P, Duret A. Question 1: Is there a role for the ketogenic diet in refractory status epilepticus? Arch Dis Child 2018; 103:994-997. [PMID: 30104393 DOI: 10.1136/archdischild-2018-315755] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Revised: 07/20/2018] [Accepted: 07/20/2018] [Indexed: 12/25/2022]
Affiliation(s)
- Petros Fessas
- School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Amedine Duret
- School of Clinical Medicine, University of Cambridge, Cambridge, UK
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New onset refractory status epilepticus (NORSE). Seizure 2018; 68:72-78. [PMID: 30482654 DOI: 10.1016/j.seizure.2018.09.018] [Citation(s) in RCA: 77] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2018] [Revised: 08/03/2018] [Accepted: 09/22/2018] [Indexed: 12/28/2022] Open
Abstract
PURPOSE To summarize the clinical features, suggested work-up, treatment and prognosis of new-onset refractory status epilepticus (NORSE), a condition recently defined as the occurrence of refractory status epilepticus (RSE) in a patient without active epilepsy, and without a clear acute or active structural, toxic or metabolic cause; and of the related syndrome of febrile infection-related epilepsy syndrome (FIRES), also recently defined as a subgroup of NORSE preceded by a febrile illness between 2 weeks and 24 h prior to the onset of RSE. METHOD Narrative review of the medical literature about NORSE and FIRES. RESULTS NORSE and FIRES mainly affect school-age children and young adults. A prodromal phase with flu-like symptoms precedes the SE onset in two third of NORSE cases, and by definition in all FIRES. Status epilepticus usually starts with repeated focal seizures with secondary bilateralization. Most cases evolve to super RSE (SRSE) and have unfavorable outcome, with short-term mortality of 12-27%, long-term disability and epilepsy. No specific imaging or laboratory abnormalities have been identified so far that allows an early diagnosis and half of adult cases remain of unknown etiology. A standardized diagnostic algorithm is provided and. Autoimmune encephalitis is the most frequent identified cause. In the absence of specific diagnosis, immunotherapy could be tried in addition to antiepileptic treatment. CONCLUSIONS This review presents the rare but devastating syndrome of NORSE, including the subcategory of FIRES. Early recognition with complete work-up is primordial to identify the underlying cause and promptly start appropriate treatment.
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Chen W, Su Y, Jiang M, Liu G, Tian F, Ren G. Status epilepticus associated with acute encephalitis: long‐term follow‐up of functional and cognitive outcomes in 72 patients. Eur J Neurol 2018; 25:1228-1234. [PMID: 29751371 DOI: 10.1111/ene.13678] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Accepted: 05/03/2018] [Indexed: 11/29/2022]
Affiliation(s)
- W. Chen
- Department of Neurology Xuanwu Hospital Capital Medical University Beijing China
| | - Y. Su
- Department of Neurology Xuanwu Hospital Capital Medical University Beijing China
| | - M. Jiang
- Department of Neurology Xuanwu Hospital Capital Medical University Beijing China
| | - G. Liu
- Department of Neurology Xuanwu Hospital Capital Medical University Beijing China
| | - F. Tian
- Department of Neurology Xuanwu Hospital Capital Medical University Beijing China
| | - G. Ren
- Department of Neurology Xuanwu Hospital Capital Medical University Beijing China
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32
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Kossoff EH, Zupec-Kania BA, Auvin S, Ballaban-Gil KR, Christina Bergqvist AG, Blackford R, Buchhalter JR, Caraballo RH, Cross JH, Dahlin MG, Donner EJ, Guzel O, Jehle RS, Klepper J, Kang HC, Lambrechts DA, Liu YMC, Nathan JK, Nordli DR, Pfeifer HH, Rho JM, Scheffer IE, Sharma S, Stafstrom CE, Thiele EA, Turner Z, Vaccarezza MM, van der Louw EJTM, Veggiotti P, Wheless JW, Wirrell EC. Optimal clinical management of children receiving dietary therapies for epilepsy: Updated recommendations of the International Ketogenic Diet Study Group. Epilepsia Open 2018; 3:175-192. [PMID: 29881797 PMCID: PMC5983110 DOI: 10.1002/epi4.12225] [Citation(s) in RCA: 358] [Impact Index Per Article: 59.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/16/2018] [Indexed: 12/14/2022] Open
Abstract
Ketogenic dietary therapies (KDTs) are established, effective nonpharmacologic treatments for intractable childhood epilepsy. For many years KDTs were implemented differently throughout the world due to lack of consistent protocols. In 2009, an expert consensus guideline for the management of children on KDT was published, focusing on topics of patient selection, pre‐KDT counseling and evaluation, diet choice and attributes, implementation, supplementation, follow‐up, side events, and KDT discontinuation. It has been helpful in outlining a state‐of‐the‐art protocol, standardizing KDT for multicenter clinical trials, and identifying areas of controversy and uncertainty for future research. Now one decade later, the organizers and authors of this guideline present a revised version with additional authors, in order to include recent research, especially regarding other dietary treatments, clarifying indications for use, side effects during initiation and ongoing use, value of supplements, and methods of KDT discontinuation. In addition, authors completed a survey of their institution's practices, which was compared to responses from the original consensus survey, to show trends in management over the last 10 years.
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Affiliation(s)
- Eric H Kossoff
- Departments of Neurology and Pediatrics Johns Hopkins Outpatient Center Baltimore Maryland U.S.A
| | | | - Stéphane Auvin
- Department of Pediatric Neurology CHU Hôpital Robert Debré Paris France
| | - Karen R Ballaban-Gil
- Department of Neurology and Pediatrics Montefiore Medical Center/Albert Einstein College of Medicine Bronx New York U.S.A
| | - A G Christina Bergqvist
- Department of Neurology The Childrens Hospital of Philadelphia Philadelphia Pennsylvania U.S.A
| | - Robyn Blackford
- Department of Nutrition Lurie Children's Hospital Chicago Illinois U.S.A
| | | | - Roberto H Caraballo
- Department of Neurology Hospital J P Garrahan, Capital Federal Buenos Aires Argentina
| | - J Helen Cross
- Department of Clinical & Experimental Epilepsy Great Ormond Street Hospital University College London London United Kingdom
| | - Maria G Dahlin
- Department of Clinical Neuroscience, Women's and Children's Health Karolinska Institute Stockholm Sweden
| | - Elizabeth J Donner
- Division of Neurology The Hospital for Sick Children Toronto Ontario Canada
| | - Orkide Guzel
- Department of Pediatric Neurology Izmir Dr. Behcet Uz Children's Hospital Izmir Turkey
| | - Rana S Jehle
- Department of Neurology Montefiore Medical Center Bronx New York U.S.A
| | - Joerg Klepper
- Department of Pediatrics and Neuropediatrics Children's Hospital Aschaffenburg Aschaffenburg Germany
| | - Hoon-Chul Kang
- Department of Pediatrics Pediatric Epilepsy Clinic Severance Children's Hospital Seoul Korea
| | | | - Y M Christiana Liu
- Department of Neurology The Hospital for Sick Children Toronto Ontario Canada
| | - Janak K Nathan
- Department of Child Neurology Shushrusha Hospital Mumbai India
| | - Douglas R Nordli
- Department of Neurology Children's Hospital of Los Angeles Los Angeles California U.S.A
| | - Heidi H Pfeifer
- Department of Neurology Massachusetts General Hospital Boston Massachusetts U.S.A
| | - Jong M Rho
- Department of Paediatrics Alberta Children's Hospital Calgary Alberta Canada
| | - Ingrid E Scheffer
- Epilepsy Research Centre The University of Melbourne Austin Health Heidelberg Victoria Australia
| | - Suvasini Sharma
- Department of Pediatrics Lady Hardinge Medical College New Delhi India
| | - Carl E Stafstrom
- Departments of Pediatrics and Neurology Johns Hopkins Hospital Baltimore Maryland U.S.A
| | - Elizabeth A Thiele
- Department of Neurology Massachusetts General Hospital Boston Massachusetts U.S.A
| | - Zahava Turner
- Department of Pediatrics The Johns Hopkins University Baltimore Maryland U.S.A
| | - Maria M Vaccarezza
- Department of Neurology Hospital Italiano de Buenos Aires Buenos Aires Argentina
| | - Elles J T M van der Louw
- Department of Dietetics Sophia Children's Hospital Erasmus Medical Centre Rotterdam The Netherlands
| | - Pierangelo Veggiotti
- Infantile Neuropsychiatry Neurological Institute Foundation Casimiro Mondino Pavia Italy
| | - James W Wheless
- Department of Pediatric Neurology University of Tennessee Memphis Tennessee U.S.A
| | - Elaine C Wirrell
- Department of Neurology, Child and Adolescent Neurology Mayo Clinic Rochester Minnesota U.S.A
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Vasquez A, Farias-Moeller R, Tatum W. Pediatric refractory and super-refractory status epilepticus. Seizure 2018; 68:62-71. [PMID: 29941225 DOI: 10.1016/j.seizure.2018.05.012] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Revised: 05/17/2018] [Accepted: 05/19/2018] [Indexed: 01/01/2023] Open
Abstract
PURPOSE To summarize the available evidence related to pediatric refractory status epilepticus (RSE) and super-refractory status epilepticus (SRSE), with emphasis on epidemiology, etiologies, therapeutic approaches, and clinical outcomes. METHODS Narrative review of the medical literature using MEDLINE database. RESULTS RSE is defined as status epilepticus (SE) that fails to respond to adequately used first- and second-line antiepileptic drugs. SRSE occurs when SE persist for 24 h or more after administration of anesthesia, or recurs after its withdrawal. RSE and SRSE represent complex neurological emergencies associated with long-term neurological dysfunction and high mortality. Challenges in management arise as the underlying etiology is not always promptly recognized and therapeutic options become limited with prolonged seizures. Treatment decisions mainly rely on case series or experts' opinions. The comparative effectiveness of different treatment strategies has not been evaluated in large prospective series or randomized clinical trials. Continuous infusion of anesthetic agents is the most common treatment for RSE and SRSE, although many questions on optimal dosing and rate of administration remain unanswered. The use of non-pharmacological therapies is documented in case series or reports with low level of evidence. In addition to neurological complications resulting from prolonged seizures, children with RSE/SRSE often develop systemic complications associated with polypharmacy and prolonged hospital stay. CONCLUSION RSE and SRSE are neurological emergencies with limited therapeutic options. Multi-national collaborative efforts are desirable to evaluate the safety and efficacy of current RSE/SRSE therapies, and potentially impact patients' outcomes.
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Affiliation(s)
- Alejandra Vasquez
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, United States.
| | - Raquel Farias-Moeller
- Department of Neurology, Division of Pediatric Neurology, Children's Hospital of Wisconsin, Medical College of Wisconsin, Milwaukee, WI, United States.
| | - William Tatum
- Department of Neurology, Mayo Clinic Florida, 4500 San Pablo Rd, Jacksonville, FL, 32224, United States.
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Febrile infection-related epilepsy syndrome (FIRES): therapeutic complications, long-term neurological and neuroimaging follow-up. Seizure 2018; 56:53-59. [DOI: 10.1016/j.seizure.2018.02.003] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2016] [Revised: 02/02/2018] [Accepted: 02/06/2018] [Indexed: 11/22/2022] Open
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Aponte-Puerto A, Rozo-Osorio JD, Guzman-Porras JJ, Patiño-Moncayo AD, Amortegui-Beltrán JA, Uscategui AM. Febrile Infection-Related Epilepsy Syndrome (FIRES), a possible cause of super-refractory status epilepticus. Case report. CASE REPORTS 2018. [DOI: 10.15446/cr.v4n1.61288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Introducción: El estado epiléptico superrefractario (EES) es una patología con importante morbimortalidad que afecta el ambiente neuronal según el tipo y duración de las crisis.Presentación del caso: Se presenta el caso de un escolar con estado epiléptico superrefractario y crisis multifocales. Se descartaron causas metabólicas, estructurales, infecciosas, toxicológicas y autoinmunes y se utilizaron diferentes manejos anticonvulsivantes sin respuesta, lográndose control de las crisis 6 semanas después del ingreso a UCI. Se realizó un seguimiento de 12 años, periodo en el que el paciente presentó múltiples recaídas del estado epiléptico asociadas a la presencia de epilepsia refractaria con múltiples tipos de crisis, en su mayoría vegetativas; además se dio involución cognitiva.Discusión: Esta forma de estado epiléptico corresponde al síndrome de estado epiléptico facilitado por fiebre (FIRES), entidad de posible origen inmunológico conocida por ser refractaria al tratamiento agudo y al manejo cró- nico de la epilepsia y que se presenta como secuela. Su evolución no se ha descrito a largo plazo y por tanto no hay consenso sobre el manejo en la fase crónica.Conclusión: Es importante considerar esta etiología en estado epiléptico superrefractario para utilizar de forma temprana diferentes estrategias terapéuticas, como la dieta cetogénica, que permitan, por un lado, controlar su condición crítica y las crisis epilépticas a largo plazo y, por el otro, mejorar el pronóstico cognitivo, logrando así un impacto en la calidad de vida.
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Farias-Moeller R, Bartolini L, Staso K, Schreiber JM, Carpenter JL. Early ictal and interictal patterns in FIRES: The sparks before the blaze. Epilepsia 2017; 58:1340-1348. [DOI: 10.1111/epi.13801] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/20/2017] [Indexed: 12/28/2022]
Affiliation(s)
- Raquel Farias-Moeller
- Center for Neuroscience; Children's National Health System; George Washington University; Washington District of Columbia U.S.A
| | - Luca Bartolini
- Center for Neuroscience; Children's National Health System; George Washington University; Washington District of Columbia U.S.A
| | - Katelyn Staso
- Center for Neuroscience; Children's National Health System; George Washington University; Washington District of Columbia U.S.A
| | - John M. Schreiber
- Center for Neuroscience; Children's National Health System; George Washington University; Washington District of Columbia U.S.A
| | - Jessica L. Carpenter
- Center for Neuroscience; Children's National Health System; George Washington University; Washington District of Columbia U.S.A
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O'Connell BK, Gloss D, Devinsky O. Cannabinoids in treatment-resistant epilepsy: A review. Epilepsy Behav 2017; 70:341-348. [PMID: 28188044 DOI: 10.1016/j.yebeh.2016.11.012] [Citation(s) in RCA: 130] [Impact Index Per Article: 18.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2016] [Revised: 11/07/2016] [Accepted: 11/07/2016] [Indexed: 02/03/2023]
Abstract
Treatment-resistant epilepsy (TRE) affects 30% of epilepsy patients and is associated with severe morbidity and increased mortality. Cannabis-based therapies have been used to treat epilepsy for millennia, but only in the last few years have we begun to collect data from adequately powered placebo-controlled, randomized trials (RCTs) with cannabidiol (CBD), a cannabis derivative. Previously, information was limited to case reports, small series, and surveys reporting on the use of CBD and diverse medical marijuana (MMJ) preparations containing: tetrahydrocannabinol (THC), CBD, and many other cannabinoids in differing combinations. These RCTs have studied the safety and explored the potential efficacy of CBD use in children with Dravet Syndrome (DS) and Lennox-Gastaut Syndrome (LGS). The role of the placebo response is of paramount importance in studying medical cannabis products given the intense social and traditional media attention, as well as the strong beliefs held by many parents and patients that a natural product is safer and more effective than FDA-approved pharmaceutical agents. We lack valid data on the safety, efficacy, and dosing of artisanal preparations available from dispensaries in the 25 states and District of Columbia with MMJ programs and online sources of CBD and other cannabinoids. On the other hand, open-label studies with 100mg/ml CBD (Epidiolex®, GW Pharmaceuticals) have provided additional evidence of its efficacy along with an adequate safety profile (including certain drug interactions) in children and young adults with a spectrum of TREs. Further, Phase 3 RCTs with Epidiolex support efficacy and adequate safety profiles for children with DS and LGS at doses of 10- and 20-mg/kg/day. This article is part of a Special Issue titled "Cannabinoids and Epilepsy".
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Abstract
Febrile infection-related epilepsy syndrome (FIRES) is a form of epileptic encephalopathy with severe refractory epilepsy that presents in previously healthy, school-aged children after significant febrile illness with concomitant rise in body temperature. Suspected causes include genetic or acquired channelopathies, as well as mitochondrial disturbances. In FIRES, the EEG shows diffuse slowing, generalized, and/or multifocal discharges. Seizures are present and resistant to treatment. Moyamoya angiopathy (MMA) is characterized by progressive stenosis of cerebral arteries and subsequent development of a network of collateral circulation that is prone to rupture. We present here a case of a 6-year-old patient with a postfebrile illness, acute and explosive bilateral independent seizure onset that was most consistent with FIRES, but also with imaging evidence of right-sided-only MMA. Our patient demonstrated two diseases not described together previously in the literature. It is unknown whether this patient's MMA is related to FIRES. In spite of successful corrective surgery (encephaloduroarteriosynangiosis), the patient continues to suffer from intractable seizures (mostly on the right) and apparent mild encephalopathy. The impact of our interventions (surgery, antiepileptic medication) is unclear. In this article, we describe a case of MMA and FIRES, and the history, physical, laboratory, imaging, and developmental elements of the 6-year-old patient with previously normal development.
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Affiliation(s)
- Taylor Kaufman
- a Denver Health and Hospital Authority , Denver , Colorado
- b Department of Neurology , University of Colorado Health Sciences Center , Aurora , Colorado
| | - Andrew White
- a Denver Health and Hospital Authority , Denver , Colorado
- c Children's Hospital of Colorado , Aurora , Colorado
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Kenney-Jung DL, Vezzani A, Kahoud RJ, LaFrance-Corey RG, Ho ML, Muskardin TW, Wirrell EC, Howe CL, Payne ET. Febrile infection-related epilepsy syndrome treated with anakinra. Ann Neurol 2016; 80:939-945. [PMID: 27770579 DOI: 10.1002/ana.24806] [Citation(s) in RCA: 174] [Impact Index Per Article: 21.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Revised: 10/18/2016] [Accepted: 10/18/2016] [Indexed: 12/12/2022]
Abstract
Febrile infection-related epilepsy syndrome (FIRES) is a devastating epileptic encephalopathy with limited treatment options and an unclear etiology. Anakinra is a recombinant version of the human interleukin-1 receptor antagonist used to treat autoinflammatory disorders. This is the first report of anakinra for treatment of a child with super-refractory status epilepticus secondary to FIRES. Anakinra was well tolerated and effective. Cerebral spinal fluid analysis revealed elevated levels of proinflammatory cytokines before treatment that normalized on anakinra, suggesting a potential pathogenic role for neuroinflammation in FIRES. Further studies are required to assess anakinra efficacy and dosing, and to further delineate disease etiology. Ann Neurol 2016;80:939-945.
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Affiliation(s)
- Daniel L Kenney-Jung
- Departments of Neurology, Mayo Clinic, Rochester, MN.,Departments of Pediatrics, Mayo Clinic, Rochester, MN
| | - Annamaria Vezzani
- Institute of Hospitalization and Scientific Care-Mario Negri Institute of Pharmacological Research, Milan, Italy
| | - Robert J Kahoud
- Departments of Neurology, Mayo Clinic, Rochester, MN.,Departments of Pediatrics, Mayo Clinic, Rochester, MN
| | | | - Mai-Lan Ho
- Departments of Radiology, Mayo Clinic, Rochester, MN
| | | | - Elaine C Wirrell
- Departments of Neurology, Mayo Clinic, Rochester, MN.,Departments of Pediatrics, Mayo Clinic, Rochester, MN
| | - Charles L Howe
- Departments of Neurology, Mayo Clinic, Rochester, MN.,Departments of Neuroscience, Mayo Clinic, Rochester, MN.,Departments of Immunology, Mayo Clinic, Rochester, MN
| | - Eric T Payne
- Departments of Neurology, Mayo Clinic, Rochester, MN.,Departments of Pediatrics, Mayo Clinic, Rochester, MN
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Abstract
A 3-state syndromic surveillance system documented reduction and emergence of neurologic infectious diseases. Encephalitis is a devastating illness that commonly causes neurologic disability and has a case fatality rate >5% in the United States. An etiologic agent is identified in <50% of cases, making diagnosis challenging. The Centers for Disease Control and Prevention Emerging Infections Program (EIP) Encephalitis Project established syndromic surveillance for encephalitis in New York, California, and Tennessee, with the primary goal of increased identification of causative agents and secondary goals of improvements in treatment and outcome. The project represents the largest cohort of patients with encephalitis studied to date and has influenced case definition and diagnostic evaluation of this condition. Results of this project have provided insight into well-established causal pathogens and identified newer causes of infectious and autoimmune encephalitis. The recognition of a possible relationship between enterovirus D68 and acute flaccid paralysis with myelitis underscores the need for ongoing vigilance for emerging causes of neurologic disease.
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Abstract
Investigators from the University of Alabama, Birmingham, AL, and University of Michigan, Ann Arbor, MI, report 2 children who presented with FIRES and prolonged AED-resistant status epilepticus.
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Affiliation(s)
- John J Millichap
- Division of Neurology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL; Departments of Pediatrics and Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - J Gordon Millichap
- Division of Neurology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL; Departments of Pediatrics and Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL
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Yum MS, Lee M, Woo DC, Kim DW, Ko TS, Velíšek L. β-Hydroxybutyrate attenuates NMDA-induced spasms in rats with evidence of neuronal stabilization on MR spectroscopy. Epilepsy Res 2015; 117:125-32. [PMID: 26452206 DOI: 10.1016/j.eplepsyres.2015.08.005] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2015] [Revised: 07/15/2015] [Accepted: 08/06/2015] [Indexed: 01/04/2023]
Abstract
BACKGROUND Infantile spasms (IS) is a devastating epileptic encephalopathy. The ketogenic diet (KD) has been successfully used as a treatment for IS. This study was designed to test whether beta-hydroxybutyrate (BHB), a major metabolite of the KD, is effective in an animal model of IS. METHODS Pregnant rats received betamethasone on gestational day 15. The offspring received either single [30min prior to NMDA-triggered spasms on postnatal day (P) 15] or prolonged (three per day from P12 to P15) i.p. BHB. An additional experiment used repeated bouts of spasms on P12, P13, and P15 with randomized prolonged BHB treatment initiated after the first spasms. We determined the latency to onset of spasms and the number of spasms after the NMDA injection on P15. The rats that received randomized BHB treatment were also monitored with open field, sociability, and fear-conditioning tests and underwent in vivo (1)H MR imaging on a 9.4T MR system after NMDA-induced spasms. The acquired (1)H MR spectra were quantified using LC model. RESULTS Single-dose BHB pretreatment had no effect on spasms. In contrast, prolonged pretreatment with BHB significantly delayed the onset and decreased the frequency of spasms. In addition, randomized prolonged BHB treatment resulted in a significant reduction in number of spasms at P15. BHB treatment had no significant effect on motor activities, but significantly decreased the interactions with strangers and increased the contextual memory. On MR spectroscopic analysis of randomized prolonged BHB-treated rats at 24h after the cluster of spasms, the elevation of GABA, glutamine, glutamate, total creatine, macromolecule-plus lipids, and N-acetylaspartate levels after spasms were significantly attenuated by randomized BHB treatment (p<0.05). SIGNIFICANCE Prolonged administration of BHB directly suppresses development of spasms in a rat model of IS with acute stabilization of brain metabolites. Additionally, BHB appears to decrease the interests to other rats and improve memory responses.
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Affiliation(s)
- Mi-Sun Yum
- Department of Pediatrics, Asan Medical Center, College of Medicine Ulsan University, Seoul, South Korea.
| | - Minyoung Lee
- Department of Pediatrics, Asan Medical Center, College of Medicine Ulsan University, Seoul, South Korea.
| | - Dong-Cheol Woo
- Asan Institute for Life Sciences, University of Ulsan College of Medicine, Seoul, South Korea.
| | - Dong Wook Kim
- Department of Pediatrics, Ilsan Paik Hospital, Inje University College of Medicine, Goyang, South Korea.
| | - Tae-Sung Ko
- Department of Pediatrics, Asan Medical Center, College of Medicine Ulsan University, Seoul, South Korea.
| | - Libor Velíšek
- Departments of Cell Biology & Anatomy, Pediatrics and Neurology, New York Medical College, Valhalla, NY, United States.
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Jung DE, Joshi SM, Berg AT. How do you keto? Survey of North American pediatric ketogenic diet centers. J Child Neurol 2015; 30:868-73. [PMID: 25143482 DOI: 10.1177/0883073814545115] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2014] [Accepted: 07/06/2014] [Indexed: 01/01/2023]
Abstract
We surveyed ketogenic diet centers in North America about their practices surrounding the ketogenic diet. An internet survey was disseminated via REDCap(©) to North American ketogenic diet centers identified from the Charlie Foundation and Ketocal(©) websites. Fifty-six centers responded. In addition to physicians, nurses and dieticians, ketogenic teams included social workers (39%), feeding specialists (14%), educational liaisons (4%), psychologists (5%), and pharmacists (36%). A child attending school (2%), non-English speaking family (19%), single-parent family (0%), and oral feeding (6%) were rarely considered barriers. Overall, the diet was considered the first or second (0%), third or fourth (67%), fifth or sixth (29%), and last resort treatment (4%) by centers. It was considered the first or second treatment for GLUT1 disease (86%) and third or fourth for Dravet (63%), West (71%), and Doose (65%) syndromes. Ketogenic diet is no longer a last resort option. Traditional barriers do not influence its use.
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Affiliation(s)
- Da Eun Jung
- Department of Pediatrics, Ajou University School of Medicine, Suwon, Korea Department of Pediatrics, Epilepsy Center, Ann & Robert H. Lurie Children's Hospital of Chicago, and the Northwestern Memorial Feinberg School of Medicine, Chicago, IL, USA
| | - Sucheta M Joshi
- Division of Pediatric Neurology, Department of Pediatrics and Communicable Diseases, University of Michigan, Ann Arbor, MI, USA
| | - Anne T Berg
- Department of Pediatrics, Epilepsy Center, Ann & Robert H. Lurie Children's Hospital of Chicago, and the Northwestern Memorial Feinberg School of Medicine, Chicago, IL, USA
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Blaise JH, Ruskin DN, Koranda JL, Masino SA. Effects of a ketogenic diet on hippocampal plasticity in freely moving juvenile rats. Physiol Rep 2015; 3:3/5/e12411. [PMID: 26009636 PMCID: PMC4463838 DOI: 10.14814/phy2.12411] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Ketogenic diets are low-carbohydrate, sufficient protein, high-fat diets with anticonvulsant activity used primarily as a treatment for pediatric epilepsy. The anticonvulsant mechanism is thought to involve elevating inhibition and/or otherwise limiting excitability in the brain. Such a mechanism, however, might also significantly affect normal brain activity and limit synaptic plasticity, effects that would be important to consider in the developing brain. To assess ketogenic diet effects on synaptic transmission and plasticity, electrophysiological recordings were performed at the perforant path/dentate gyrus synapse in awake, freely-behaving juvenile male rats. Electrodes were implanted 1 week prior to recording. Animals were fed regular chow or a ketogenic diet ad libitum for 3 weeks before recording. Although the ketogenic diet did not significantly alter baseline excitability (assessed by input–output curves) or short-term plasticity (using the paired-pulse ratio), it did reduce the magnitude of long-term potentiation at all poststimulation timepoints out to the last time measured (48 h). The results suggest an effect of ketogenic diet-feeding on the induction magnitude but not the maintenance of long-term potentiation. The lack of effect of the diet on baseline transmission and the paired-pulse ratio suggests a mechanism that limits excitation preferentially in conditions of strong stimulation, consonant with clinical reports in which the ketogenic diet alleviates seizures without a major impact on normal brain activity. Limiting plasticity in a seizure-susceptible network may limit seizure-induced epileptogenesis which may subserve the ongoing benefit of the ketogenic diet in epilepsy.
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Affiliation(s)
- J Harry Blaise
- Department of Engineering, Trinity College, Hartford, Connecticut Neuroscience Program, Trinity College, Hartford, Connecticut
| | - David N Ruskin
- Neuroscience Program, Trinity College, Hartford, Connecticut Department of Psychology, Trinity College, Hartford, Connecticut
| | | | - Susan A Masino
- Neuroscience Program, Trinity College, Hartford, Connecticut Department of Psychology, Trinity College, Hartford, Connecticut
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Dupuis N, Curatolo N, Benoist JF, Auvin S. Ketogenic diet exhibits anti-inflammatory properties. Epilepsia 2015; 56:e95-8. [DOI: 10.1111/epi.13038] [Citation(s) in RCA: 115] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/21/2015] [Indexed: 12/16/2022]
Affiliation(s)
- Nina Dupuis
- INSERM, U1141; Paris France
- INSERM UMR1141; Paris Diderot University; Paris France
| | | | - Jean-François Benoist
- INSERM, U1141; Paris France
- AP-HP; Biochemistery Department; Robert Debre Univeristy Hospital; Paris France
| | - Stéphane Auvin
- INSERM, U1141; Paris France
- INSERM UMR1141; Paris Diderot University; Paris France
- AP-HP; Pediatric Neurology Department; Robert Debre University Hospital; Paris France
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Fleck J, Marafiga JR, Jesse AC, Ribeiro LR, Rambo LM, Mello CF. Montelukast potentiates the anticonvulsant effect of phenobarbital in mice: an isobolographic analysis. Pharmacol Res 2015; 94:34-41. [PMID: 25684626 DOI: 10.1016/j.phrs.2015.02.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2014] [Revised: 01/29/2015] [Accepted: 02/04/2015] [Indexed: 11/24/2022]
Abstract
Although leukotrienes have been implicated in seizures, no study has systematically investigated whether the blockade of CysLT1 receptors synergistically increases the anticonvulsant action of classic antiepileptics. In this study, behavioral and electroencephalographic methods, as well as isobolographic analysis, are used to show that the CysLT1 inverse agonist montelukast synergistically increases the anticonvulsant action of phenobarbital against pentylenetetrazole-induced seizures. Moreover, it is shown that LTD4 reverses the effect of montelukast. The experimentally derived ED50mix value for a fixed-ratio combination (1:1 proportion) of montelukast plus phenobarbital was 0.06±0.02 μmol, whereas the additively calculated ED50add value was 0.49±0.03 μmol. The calculated interaction index was 0.12, indicating a synergistic interaction. The association of montelukast significantly decreased the antiseizure ED50 for phenobarbital (0.74 and 0.04 μmol in the absence and presence of montelukast, respectively) and, consequently, phenobarbital-induced sedation at equieffective doses. The demonstration of a strong synergism between montelukast and phenobarbital is particularly relevant because both drugs are already used in the clinics, foreseeing an immediate translational application for epileptic patients who have drug-resistant seizures.
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Affiliation(s)
- Juliana Fleck
- Graduate Program in Pharmacology, Federal University of Santa Maria, Santa Maria, RS, Brazil; University Hospital of Santa Maria, Federal University of Santa Maria, Santa Maria, RS, Brazil; Pharmacy Department, Center of Health Sciences, Franciscan University Center, RS, Brazil
| | - Joseane Righes Marafiga
- Graduate Program in Pharmacology, Federal University of Santa Maria, Santa Maria, RS, Brazil
| | - Ana Cláudia Jesse
- Graduate Program in Pharmacology, Federal University of Santa Maria, Santa Maria, RS, Brazil
| | - Leandro Rodrigo Ribeiro
- Graduate Program in Pharmacology, Federal University of Santa Maria, Santa Maria, RS, Brazil
| | - Leonardo Magno Rambo
- Graduate Program in Pharmacology, Federal University of Santa Maria, Santa Maria, RS, Brazil
| | - Carlos Fernando Mello
- Graduate Program in Pharmacology, Federal University of Santa Maria, Santa Maria, RS, Brazil.
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