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Pujar S, Cross JH. Diagnosis of Lennox-Gastaut syndrome and strategies for early recognition. Expert Rev Neurother 2024; 24:383-389. [PMID: 38415629 DOI: 10.1080/14737175.2024.2323568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2024] [Accepted: 02/22/2024] [Indexed: 02/29/2024]
Abstract
INTRODUCTION Lennox Gastaut syndrome (LGS) as an electroclinical diagnosis has been utilized as a clinical entity for more than 70 years. However, with the recognition of other distinct electroclinical epilepsy syndromes, no consistent single etiology, and the variability of criteria used in clinical trials, the clinical utility of such a diagnosis has been questioned. Recently, the International League Against Epilepsy for the first time defined diagnostic criteria for epilepsy syndromes, thereby allowing consistent language and inclusion criteria to be utilized. AREAS COVERED Recent diagnostic criteria for syndrome diagnosis are explored as defined by the International League Against Epilepsy, with further literature reviewed to highlight relevant features, and differential diagnosis explored. EXPERT OPINION Developmental and Epileptic Encephalopathy (DEE) is an overall term that may be descriptive of many different epilepsies, most of early onset, whether electroclinically or etiologically defined, of which LGS is one. Although we have moved forward in defining an increasing number of etiologically specific syndromes, this to date remains a minority of the DEEs. Although there is progress with precision medicine targeted at specific causes, the term LGS still remains useful as a diagnosis in defining treatment options, as well as overall prognosis.
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Affiliation(s)
- Suresh Pujar
- Paediatric Neurosciences Department, Great Ormond Street Hospital for Children, London, UK
- Developmental Neurosciences Research & Teaching Department, University College London NIHR BRC Great Ormond Street Institute of Child Health, London, UK
| | - J Helen Cross
- Paediatric Neurosciences Department, Great Ormond Street Hospital for Children, London, UK
- Developmental Neurosciences Research & Teaching Department, University College London NIHR BRC Great Ormond Street Institute of Child Health, London, UK
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Ketogenic Diets in the Management of Lennox-Gastaut Syndrome-Review of Literature. Nutrients 2022; 14:nu14234977. [PMID: 36501006 PMCID: PMC9740154 DOI: 10.3390/nu14234977] [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: 10/28/2022] [Revised: 11/16/2022] [Accepted: 11/20/2022] [Indexed: 11/25/2022] Open
Abstract
Epilepsy is an important medical problem with approximately 50 million patients globally. No more than 70% of epileptic patients will achieve seizure control after antiepileptic drugs, and several epileptic syndromes, including Lennox-Gastaut syndrome (LGS), are predisposed to more frequent pharmacoresistance. Ketogenic dietary therapies (KDTs) are a form of non-pharmacological treatments used in attempts to provide seizure control for LGS patients who experience pharmacoresistance. Our review aimed to evaluate the efficacy and practicalities concerning the use of KDTs in LGS. In general, KDTs are diets rich in fat and low in carbohydrates that put the organism into the state of ketosis. A classic ketogenic diet (cKD) is the best-evaluated KDT, while alternative KDTs, such as the medium-chain triglyceride diet (MCT), modified Atkins diet (MAD), and low glycemic index treatment (LGIT) present several advantages due to their better tolerability and easier administration. The literature reports regarding LGS suggest that KDTs can provide ≥50% seizure reduction and seizure-free status in a considerable percentage of the patients. The most commonly reported adverse effects are constipation, diarrhea, and vomiting, while severe adverse effects such as nephrolithiasis or osteopenia are rarely reported. The literature review suggests that KDTs can be applied safely and are effective in LGS treatment.
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Dalvi A, Ravi PR, Uppuluri CT. Design and evaluation of rufinamide nanocrystals loaded thermoresponsive nasal in situ gelling system for improved drug distribution to brain. Front Pharmacol 2022; 13:943772. [PMID: 36267292 PMCID: PMC9577085 DOI: 10.3389/fphar.2022.943772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2022] [Accepted: 09/20/2022] [Indexed: 11/13/2022] Open
Abstract
Rufinamide (Rufi) is an antiepileptic drug used to manage Lennox-Gastaut Syndrome and partial seizures. The oral bioavailability of Rufi is less due to its poor solubility and low dissolution rate in the gastrointestinal fluids. This results in less amount of drug reaching the brain following the oral administration of drug. Oral formulations of Rufi are prescribed at a high dose and dosing frequency to increase its distribution to the brain. A Rufi loaded thermoresponsive nasal in situ gel which showed significantly high brain concentrations compared to aqueous suspension of Rufi administered through nasal route was developed by our research group and published. In the current work, we have formulated nanocrystals of Rufi and suspended them in a xyloglucan based thermoresponsive gel to improve the nose-to-brain distribution. The particle size, polydispersity index, and yield (%) of the optimized Rufi nanocrystals were 261.2 ± 2.1 nm, 0.28 ± 0.08, and 89.6 ± 2.0 respectively. The narrow PDI indicates that the manufacturing process is reproducible and reliable. Higher % yield suggested that the method of preparation is efficient. The sol-to-gel transition of in situ gel loaded with Rufi nanocrystals was at 32°C which suggested that the formulation transforms into gel at nasal epithelial temperatures. The nasal pharmacokinetic studies showed that Rufi nanocrystals loaded in situ gel produced higher concentration of the drug in brain (higher brain Cmax) and maintained the drug concentrations for longer duration (higher mean residence time) compared to aqueous suspension of Rufi nanocrystals as well aqueous suspension of Rufi and Rufi loaded in situ gel, reported previously. Nanometric size of the Rufi nanocrystals combined with the in situ gelling properties helped the optimized formulation achieve higher brain distribution and also sustain the drug concentrations in brain for longer duration compared to any of the formulations studied by our research group.
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Alanazi RF, Alkhani AM. Management of Lennox-Gastaut syndrome with deep brain stimulation: A systematic literature review. NEUROSCIENCES (RIYADH, SAUDI ARABIA) 2022; 27:216-220. [PMID: 36252974 PMCID: PMC9749582 DOI: 10.17712/nsj.2022.4.20220043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/17/2022] [Accepted: 07/06/2022] [Indexed: 12/31/2022]
Abstract
OBJECTIVES To review the current literature regarding the efficacy and safety of deep brain stimulation (DBS) in Lennox-Gastaut syndrome (LGS). METHODS The authors conducted a systematic review of PubMed databases using keywords relevant to the objective of this research. Titles and abstracts were reviewed, after which studies that met the inclusion criteria were selected. Findings were reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. RESULTS Thirteen studies were identified, and only 3 studies that reported 50 patients (age range from 3 to 65 years) met the inclusion criteria of DBS for LGS. Radiological imaging findings and neurophysiological findings were described in all studies. The thalamus nuclei, particularly the centromedian thalamic nucleus (CMN), were found to be highly active in LGS. By targeting this brain region, patients showed favorable outcomes. Overall, the mean seizure reduction was more than 50% in all patients (among whom 2 were seizure free) at a mean follow-up of 15 (12-18) months. CONCLUSION According to this systemic review, DBS for LGS showed satisfactory outcomes, indicating that DBS should be considered a valid treatment option. However, more studies are needed to ensure the role of DBS in LGS by establishing accurate targeting of the CMN using proper lead positioning and radiological imaging, a standard DBS intervention, and long-term outcomes.
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Affiliation(s)
- Rahaf F. Alanazi
- From the College of Medicine (Alanazi), King Saud Bin Abdulaziz University for Health Sciences, and from the Division of Neurosurgery (Alkhani), Department of Surgery, King Abdulaziz Medical City, Ministry of the National Guard–Health Affairs, Riyadh, Kingdom of Saudi Arabia.,Address correspondence and reprint request to: Dr. Rahaf F. Alanazi, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Kingdom of Saudi Arabia. E-mail: ORCID ID: https://orcid.org/0000-0003-0094-5453
| | - Ahmed M. Alkhani
- From the College of Medicine (Alanazi), King Saud Bin Abdulaziz University for Health Sciences, and from the Division of Neurosurgery (Alkhani), Department of Surgery, King Abdulaziz Medical City, Ministry of the National Guard–Health Affairs, Riyadh, Kingdom of Saudi Arabia.
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Yang JO, Choi MH, Yoon JY, Lee JJ, Nam SO, Jun SY, Kwon HH, Yun S, Jeon SJ, Byeon I, Halder D, Kong J, Lee B, Lee J, Kang JW, Kim NS. Characteristics of Genetic Variations Associated With Lennox-Gastaut Syndrome in Korean Families. Front Genet 2021; 11:590924. [PMID: 33584793 PMCID: PMC7874053 DOI: 10.3389/fgene.2020.590924] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 12/31/2020] [Indexed: 12/21/2022] Open
Abstract
Lennox-Gastaut syndrome (LGS) is a severe type of childhood-onset epilepsy characterized by multiple types of seizures, specific discharges on electroencephalography, and intellectual disability. Most patients with LGS do not respond well to drug treatment and show poor long-term prognosis. Approximately 30% of patients without brain abnormalities have unidentifiable causes. Therefore, accurate diagnosis and treatment of LGS remain challenging. To identify causative mutations of LGS, we analyzed the whole-exome sequencing data of 17 unrelated Korean families, including patients with LGS and LGS-like epilepsy without brain abnormalities, using the Genome Analysis Toolkit. We identified 14 mutations in 14 genes as causes of LGS or LGS-like epilepsy. 64 percent of the identified genes were reported as LGS or epilepsy-related genes. Many of these variations were novel and considered as pathogenic or likely pathogenic. Network analysis was performed to classify the identified genes into two network clusters: neuronal signal transmission or neuronal development. Additionally, knockdown of two candidate genes with insufficient evidence of neuronal functions, SLC25A39 and TBC1D8, decreased neurite outgrowth and the expression level of MAP2, a neuronal marker. These results expand the spectrum of genetic variations and may aid the diagnosis and management of individuals with LGS.
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Affiliation(s)
- Jin Ok Yang
- Korea BioInformation Center, Korea Research Institute of Bioscience and Biotechnology, Daejeon, South Korea.,Department of Bio and Brain Engineering, Korea Advanced Institute of Science and Technology, Daejeon, South Korea
| | - Min-Hyuk Choi
- Rare-Disease Research Center, Korea Research Institute of Bioscience and Biotechnology, Daejeon, South Korea.,Department of Functional Genomics, Korea University of Science and Technology, Daejeon, South Korea
| | - Ji-Yong Yoon
- Rare-Disease Research Center, Korea Research Institute of Bioscience and Biotechnology, Daejeon, South Korea
| | - Jeong-Ju Lee
- Rare-Disease Research Center, Korea Research Institute of Bioscience and Biotechnology, Daejeon, South Korea
| | - Sang Ook Nam
- Department of Pediatrics, Pusan National University Children's Hospital, Pusan National University School of Medicine, Yangsan, South Korea
| | - Soo Young Jun
- Rare-Disease Research Center, Korea Research Institute of Bioscience and Biotechnology, Daejeon, South Korea
| | - Hyeok Hee Kwon
- Department of Medical Science and Anatomy, Chungnam National University, Daejeon, South Korea
| | - Sohyun Yun
- Rare-Disease Research Center, Korea Research Institute of Bioscience and Biotechnology, Daejeon, South Korea
| | - Su-Jin Jeon
- Rare-Disease Research Center, Korea Research Institute of Bioscience and Biotechnology, Daejeon, South Korea.,Department of Functional Genomics, Korea University of Science and Technology, Daejeon, South Korea
| | - Iksu Byeon
- Department of Bio and Brain Engineering, Korea Advanced Institute of Science and Technology, Daejeon, South Korea
| | - Debasish Halder
- Rare-Disease Research Center, Korea Research Institute of Bioscience and Biotechnology, Daejeon, South Korea
| | - Juhyun Kong
- Department of Pediatrics, Pusan National University Children's Hospital, Pusan National University School of Medicine, Yangsan, South Korea
| | - Byungwook Lee
- Department of Bio and Brain Engineering, Korea Advanced Institute of Science and Technology, Daejeon, South Korea
| | - Jeehun Lee
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Joon-Won Kang
- Department of Pediatrics and Medical Science, Chungnam National University Hospital, College of Medicine, Chungnam National University, Daejeon, South Korea
| | - Nam-Soon Kim
- Rare-Disease Research Center, Korea Research Institute of Bioscience and Biotechnology, Daejeon, South Korea.,Department of Functional Genomics, Korea University of Science and Technology, Daejeon, South Korea
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Belousova ED, Gorchanova ZK, Dorofeeva MY. [Why the diagnosis of Lennox-Gastaut syndrome is a rare one?]. Zh Nevrol Psikhiatr Im S S Korsakova 2019; 119:41-47. [PMID: 32207730 DOI: 10.17116/jnevro201911911241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The review addresses the problem of the diagnosis of Lennox-Gastaut syndrome, a severe epileptic encephalopathy. Despite the presence of a vivid clinical and encephalographic picture, classical Lennox-Gastaut syndrome, which meets all of its diagnostic criteria, is quite rare. Many authors believe that the diagnosis of the syndrome is possible if the patient has tonic seizures and typical ictal and interictal patterns on the electroencephalogram (EEG). The diagnosis of the syndrome is considered probable if there are typical EEG patterns of wakefulness and sleep, but no tonic seizures are recorded. Diagnosis of the syndrome is complicated by its polyetiology (clinical and EEG manifestations can vary significantly), the evolution of seizure types and EEG characteristics as the patient matures, the presence of other epileptic syndromes similar to Lennox-Gastaut syndrome.
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Affiliation(s)
- E D Belousova
- Veltischev Research and Clinical Institute of Pediatrics, Pirogov Russian National Research Medical University, Moscow, Russia
| | - Z K Gorchanova
- Veltischev Research and Clinical Institute of Pediatrics, Pirogov Russian National Research Medical University, Moscow, Russia
| | - M Yu Dorofeeva
- Veltischev Research and Clinical Institute of Pediatrics, Pirogov Russian National Research Medical University, Moscow, Russia
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