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Kulkarni N, Nageotte RA, Klamer BG, Rekate HL, Bristol RE, Scharnweber T, Bobrowitz M, Kerrigan JF. Long term outcome after surgical treatment for hypothalamic hamartoma. Epilepsy Res 2023; 195:107186. [PMID: 37454523 DOI: 10.1016/j.eplepsyres.2023.107186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Revised: 04/03/2023] [Accepted: 07/03/2023] [Indexed: 07/18/2023]
Abstract
PURPOSE To determine long-term outcome for seizure control and clinical predictors for seizure freedom in patients undergoing surgical treatment for epilepsy associated with hypothalamic hamartoma (HH). METHODS 155 patients underwent surgical treatment for HHs and treatment-resistant epilepsy at one center (Barrow Neurological Institute at St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA) between February 2003 and June 2010. Data collection included medical record review and direct follow-up interviews to determine seizure outcome. Statistical analysis included descriptive summaries of patient characteristics and time-to-event analysis for seizure freedom. RESULTS Long-term survival with follow-up of at least five years since first surgical treatment was available for 108 patients (69.7% of the treatment cohort). The surgical approach for first HH intervention consisted of transventricular endoscopic resection (n = 57; 52.8%), transcallosal interforniceal resection (n = 35; 32.4%), pterional resection (n = 7; 6.5%), and gamma knife radiosurgery (n = 9; 8.3%). Multiple surgical procedures were required for 39 patients (36.1%). There were 10 known deaths from all causes in the treatment cohort (6.5%). Of these, one (0.6%) was related to immediate complications of HH surgery, three (1.9%) were attributed to Sudden Unexpected Death in Epileptic Persons (SUDEP), and one (0.6%) to complications of status epilepticus. For surviving patients with long-term follow-up, 55 (50.9%) were seizure-free for all seizure types. Univariable analysis showed that seizure-freedom was related to 1) absence of a pre-operative history for central precocious puberty (p = 0.01), and 2) higher percentage of HH lesion disconnection after surgery (p = 0.047). Kaplan-Meier survival analysis shows that long-term seizure outcome following HH surgery is comparable to short-term results. SUMMARY These uncontrolled observational results show that long-term seizure control following HH surgical treatment is comparable to other forms of epilepsy surgery. Late relapse (at least one year after surgery) and SUDEP do occur, but in a relatively small number of treated patients. These results inform clinical practice and serve as a comparable benchmark for newer technologies for HH surgery, such as magnetic resonance imaging-guided laser interstitial thermal therapy, where long-term outcome results are not yet available.
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Affiliation(s)
- Neil Kulkarni
- Division of Pediatric Neurology, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH, USA.
| | - Rachel Ayn Nageotte
- Department of Family Medicine, HonorHealth Scottsdale Osborn Medical Center, Scottsdale, AZ, USA
| | - Brett G Klamer
- Biostatistics Resource at Nationwide Children's Hospital, Columbus, OH, USA; Center for Biostatistics, Department of Biomedical Informatics, The Ohio State University, Columbus, OH, USA
| | - Harold L Rekate
- Long Island Jewish Medical Center, North Shore University Hospital, The Chiari Institute, Manhasset, NY, USA
| | - Ruth E Bristol
- Division of Neurosurgery, Barrow Neurological Institute at Phoenix Children's Hospital, University of Arizona College of Medicine, Phoenix, AZ, USA
| | - Travis Scharnweber
- Department of Neuroradiology, Barrow Neurological Institute at St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | - Margaret Bobrowitz
- Department of Neurosurgery, Barrow Neurological Institute at St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | - John F Kerrigan
- Division of Pediatric Neurology, Barrow Neurological Institute at Phoenix Children's Hospital, University of Arizona College of Medicine, Phoenix, AZ, USA
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Green TE, Motelow JE, Bennett MF, Ye Z, Bennett CA, Griffin NG, Damiano JA, Leventer RJ, Freeman JL, Harvey AS, Lockhart PJ, Sadleir LG, Boys A, Scheffer IE, Major H, Darbro BW, Bahlo M, Goldstein DB, Kerrigan JF, Heinzen EL, Berkovic SF, Hildebrand MS. Sporadic hypothalamic hamartoma is a ciliopathy with somatic and bi-allelic contributions. Hum Mol Genet 2022; 31:2307-2316. [PMID: 35137044 PMCID: PMC9307310 DOI: 10.1093/hmg/ddab366] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Revised: 12/02/2021] [Accepted: 12/15/2021] [Indexed: 11/13/2022] Open
Abstract
Hypothalamic hamartoma with gelastic seizures is a well-established cause of drug-resistant epilepsy in early life. The development of novel surgical techniques has permitted the genomic interrogation of hypothalamic hamartoma tissue. This has revealed causative mosaic variants within GLI3, OFD1 and other key regulators of the sonic-hedgehog pathway in a minority of cases. Sonic-hedgehog signalling proteins localize to the cellular organelle primary cilia. We therefore explored the hypothesis that cilia gene variants may underlie hitherto unsolved cases of sporadic hypothalamic hamartoma. We performed high-depth exome sequencing and chromosomal microarray on surgically resected hypothalamic hamartoma tissue and paired leukocyte-derived DNA from 27 patients. We searched for both germline and somatic variants under both dominant and bi-allelic genetic models. In hamartoma-derived DNA of seven patients we identified bi-allelic (one germline, one somatic) variants within one of four cilia genes-DYNC2I1, DYNC2H1, IFT140 or SMO. In eight patients, we identified single somatic variants in the previously established hypothalamic hamartoma disease genes GLI3 or OFD1. Overall, we established a plausible molecular cause for 15/27 (56%) patients. Here, we expand the genetic architecture beyond single variants within dominant disease genes that cause sporadic hypothalamic hamartoma to bi-allelic (one germline/one somatic) variants, implicate three novel cilia genes and reconceptualize the disorder as a ciliopathy.
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Affiliation(s)
- Timothy E Green
- Epilepsy Research Centre, Department of Medicine, The University of Melbourne, Austin Health, Heidelberg, VIC 3084, Australia
| | - Joshua E Motelow
- Institute for Genomic Medicine, Columbia University, New York, NY 10032, USA
| | - Mark F Bennett
- Epilepsy Research Centre, Department of Medicine, The University of Melbourne, Austin Health, Heidelberg, VIC 3084, Australia
- Population Health and Immunity Division, The Walter and Eliza Hall Institute of Medical Research, Melbourne, Victoria 3052, Australia
- Department of Medical Biology, University of Melbourne, Melbourne, Victoria 3052, Australia
| | - Zimeng Ye
- Epilepsy Research Centre, Department of Medicine, The University of Melbourne, Austin Health, Heidelberg, VIC 3084, Australia
| | - Caitlin A Bennett
- Epilepsy Research Centre, Department of Medicine, The University of Melbourne, Austin Health, Heidelberg, VIC 3084, Australia
| | - Nicole G Griffin
- Institute for Genomic Medicine, Columbia University, New York, NY 10032, USA
| | - John A Damiano
- Epilepsy Research Centre, Department of Medicine, The University of Melbourne, Austin Health, Heidelberg, VIC 3084, Australia
| | - Richard J Leventer
- Department of Neurology, The Royal Children’s Hospital, Parkville, VIC 3052, Australia
- Department of Paediatrics, University of Melbourne, Royal Children's Hospital, Parkville, VIC 3052, Australia
- Murdoch Children’s Research Institute, The Royal Children’s Hospital, Parkville, VIC 3052, Australia
| | - Jeremy L Freeman
- Department of Neurology, The Royal Children’s Hospital, Parkville, VIC 3052, Australia
- Murdoch Children’s Research Institute, The Royal Children’s Hospital, Parkville, VIC 3052, Australia
| | - A Simon Harvey
- Department of Neurology, The Royal Children’s Hospital, Parkville, VIC 3052, Australia
- Department of Paediatrics, University of Melbourne, Royal Children's Hospital, Parkville, VIC 3052, Australia
- Murdoch Children’s Research Institute, The Royal Children’s Hospital, Parkville, VIC 3052, Australia
| | - Paul J Lockhart
- Department of Paediatrics, University of Melbourne, Royal Children's Hospital, Parkville, VIC 3052, Australia
- Murdoch Children’s Research Institute, The Royal Children’s Hospital, Parkville, VIC 3052, Australia
| | - Lynette G Sadleir
- Department of Paediatrics and Child Health, University of Otago, Wellington 6242, New Zealand
| | - Amber Boys
- Victorian Clinical Genetics Services, Parkville, VIC 3052, Australia
| | - Ingrid E Scheffer
- Epilepsy Research Centre, Department of Medicine, The University of Melbourne, Austin Health, Heidelberg, VIC 3084, Australia
- Department of Neurology, The Royal Children’s Hospital, Parkville, VIC 3052, Australia
- Murdoch Children’s Research Institute, The Royal Children’s Hospital, Parkville, VIC 3052, Australia
- The Florey Institute of Neuroscience and Mental Health, Parkville, VIC 3052, Australia
| | - Heather Major
- Department of Pediatrics, The University of Iowa, Iowa City, IA 52246, USA
| | - Benjamin W Darbro
- Department of Pediatrics, The University of Iowa, Iowa City, IA 52246, USA
| | - Melanie Bahlo
- Population Health and Immunity Division, The Walter and Eliza Hall Institute of Medical Research, Melbourne, Victoria 3052, Australia
- Department of Medical Biology, University of Melbourne, Melbourne, Victoria 3052, Australia
| | - David B Goldstein
- Institute for Genomic Medicine, Columbia University, New York, NY 10032, USA
- Department of Genetics and Development, Columbia University, New York, NY 10032, USA
| | - John F Kerrigan
- Division of Pediatric Neurology, Barrow Neurological Institute, Phoenix Children's Hospital, Phoenix, AZ 85013, USA
| | - Erin L Heinzen
- Eshelman School of Pharmacy, Division of Pharmacotherapy and Experimental Therapeutics, and Department of Genetics, University of North Carolina, Chapel Hill, NC 27599, USA
| | - Samuel F Berkovic
- Epilepsy Research Centre, Department of Medicine, The University of Melbourne, Austin Health, Heidelberg, VIC 3084, Australia
| | - Michael S Hildebrand
- Epilepsy Research Centre, Department of Medicine, The University of Melbourne, Austin Health, Heidelberg, VIC 3084, Australia
- Murdoch Children’s Research Institute, The Royal Children’s Hospital, Parkville, VIC 3052, Australia
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Cohen NT, Cross JH, Arzimanoglou A, Berkovic SF, Kerrigan JF, Miller IP, Webster E, Soeby L, Cukiert A, Hesdorffer DK, Kroner BL, Saper CB, Schulze-Bonhage A, Gaillard WD. Hypothalamic Hamartomas: Evolving Understanding and Management. Neurology 2021; 97:864-873. [PMID: 34607926 PMCID: PMC8610628 DOI: 10.1212/wnl.0000000000012773] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 08/31/2021] [Indexed: 11/15/2022] Open
Abstract
Hypothalamic hamartomas (HH) are rare, basilar developmental lesions with widespread comorbidities often associated with refractory epilepsy and encephalopathy. Imaging advances allow for early, even prenatal, detection. Genetic studies suggest mutations in GLI3 and other patterning genes are involved in HH pathogenesis. About 50%-80% of children with HH have severe rage and aggression and a majority of patients exhibit externalizing disorders. Behavioral disruption and intellectual disability may predate epilepsy. Neuropsychological, sleep, and endocrine disorders are typical. The purpose of this article is to provide a summary of the current understanding of HH and to highlight opportunities for future research.
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Affiliation(s)
- Nathan T Cohen
- From the Center for Neuroscience Research (N.T.C., W.D.G.), Children's National Hospital, The George Washington University School of Medicine, Washington, DC; UCL NIHR BRC Great Ormond Street Institute of Child Health (J.H.C.), Member of ERN-EpiCARE, London; Great Ormond Street Hospital for Children (J.H.C.), NHS Trust, London; Young Epilepsy (J.H.C.), Lingfield, Surrey, UK; Department of Pediatric Clinical Epileptology (A.A.), Sleep Disorders and Functional Neurology, Member of ERN-EpiCARE; HFME (A.A.), Hospices Civils de Lyon, France; Epilepsy Research Unit (A.A.), Barcelona's Children Hospital San Juan de Dios, Member of the ERN EpiCARE, Spain; Epilepsy Research Centre (S.F.B.), University of Melbourne, Australia; Division of Pediatric Neurology (J.F.K.), Barrow Neurological Institute at Phoenix Children's Hospital; Hope for Hypothalamic Hamartomas (I.P.M., E.W., L.S.), Phoenix, AZ; Epilepsy Surgery Program (A.C.), Clinica de Epilepsia de Sao Paulo, Brazil; Department of Epidemiology (D.K.H.), Columbia University Medical Center, New York, NY; RTI International (B.L.K.), Rockville, MD; Department of Neurology (C.B.S.), Beth-Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; and Epilepsy Center (A.S.-B.), Faculty of Medicine, Medical Center-University of Freiburg, University of Freiburg, Germany.
| | - J Helen Cross
- From the Center for Neuroscience Research (N.T.C., W.D.G.), Children's National Hospital, The George Washington University School of Medicine, Washington, DC; UCL NIHR BRC Great Ormond Street Institute of Child Health (J.H.C.), Member of ERN-EpiCARE, London; Great Ormond Street Hospital for Children (J.H.C.), NHS Trust, London; Young Epilepsy (J.H.C.), Lingfield, Surrey, UK; Department of Pediatric Clinical Epileptology (A.A.), Sleep Disorders and Functional Neurology, Member of ERN-EpiCARE; HFME (A.A.), Hospices Civils de Lyon, France; Epilepsy Research Unit (A.A.), Barcelona's Children Hospital San Juan de Dios, Member of the ERN EpiCARE, Spain; Epilepsy Research Centre (S.F.B.), University of Melbourne, Australia; Division of Pediatric Neurology (J.F.K.), Barrow Neurological Institute at Phoenix Children's Hospital; Hope for Hypothalamic Hamartomas (I.P.M., E.W., L.S.), Phoenix, AZ; Epilepsy Surgery Program (A.C.), Clinica de Epilepsia de Sao Paulo, Brazil; Department of Epidemiology (D.K.H.), Columbia University Medical Center, New York, NY; RTI International (B.L.K.), Rockville, MD; Department of Neurology (C.B.S.), Beth-Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; and Epilepsy Center (A.S.-B.), Faculty of Medicine, Medical Center-University of Freiburg, University of Freiburg, Germany
| | - Alexis Arzimanoglou
- From the Center for Neuroscience Research (N.T.C., W.D.G.), Children's National Hospital, The George Washington University School of Medicine, Washington, DC; UCL NIHR BRC Great Ormond Street Institute of Child Health (J.H.C.), Member of ERN-EpiCARE, London; Great Ormond Street Hospital for Children (J.H.C.), NHS Trust, London; Young Epilepsy (J.H.C.), Lingfield, Surrey, UK; Department of Pediatric Clinical Epileptology (A.A.), Sleep Disorders and Functional Neurology, Member of ERN-EpiCARE; HFME (A.A.), Hospices Civils de Lyon, France; Epilepsy Research Unit (A.A.), Barcelona's Children Hospital San Juan de Dios, Member of the ERN EpiCARE, Spain; Epilepsy Research Centre (S.F.B.), University of Melbourne, Australia; Division of Pediatric Neurology (J.F.K.), Barrow Neurological Institute at Phoenix Children's Hospital; Hope for Hypothalamic Hamartomas (I.P.M., E.W., L.S.), Phoenix, AZ; Epilepsy Surgery Program (A.C.), Clinica de Epilepsia de Sao Paulo, Brazil; Department of Epidemiology (D.K.H.), Columbia University Medical Center, New York, NY; RTI International (B.L.K.), Rockville, MD; Department of Neurology (C.B.S.), Beth-Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; and Epilepsy Center (A.S.-B.), Faculty of Medicine, Medical Center-University of Freiburg, University of Freiburg, Germany
| | - Samuel F Berkovic
- From the Center for Neuroscience Research (N.T.C., W.D.G.), Children's National Hospital, The George Washington University School of Medicine, Washington, DC; UCL NIHR BRC Great Ormond Street Institute of Child Health (J.H.C.), Member of ERN-EpiCARE, London; Great Ormond Street Hospital for Children (J.H.C.), NHS Trust, London; Young Epilepsy (J.H.C.), Lingfield, Surrey, UK; Department of Pediatric Clinical Epileptology (A.A.), Sleep Disorders and Functional Neurology, Member of ERN-EpiCARE; HFME (A.A.), Hospices Civils de Lyon, France; Epilepsy Research Unit (A.A.), Barcelona's Children Hospital San Juan de Dios, Member of the ERN EpiCARE, Spain; Epilepsy Research Centre (S.F.B.), University of Melbourne, Australia; Division of Pediatric Neurology (J.F.K.), Barrow Neurological Institute at Phoenix Children's Hospital; Hope for Hypothalamic Hamartomas (I.P.M., E.W., L.S.), Phoenix, AZ; Epilepsy Surgery Program (A.C.), Clinica de Epilepsia de Sao Paulo, Brazil; Department of Epidemiology (D.K.H.), Columbia University Medical Center, New York, NY; RTI International (B.L.K.), Rockville, MD; Department of Neurology (C.B.S.), Beth-Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; and Epilepsy Center (A.S.-B.), Faculty of Medicine, Medical Center-University of Freiburg, University of Freiburg, Germany
| | - John F Kerrigan
- From the Center for Neuroscience Research (N.T.C., W.D.G.), Children's National Hospital, The George Washington University School of Medicine, Washington, DC; UCL NIHR BRC Great Ormond Street Institute of Child Health (J.H.C.), Member of ERN-EpiCARE, London; Great Ormond Street Hospital for Children (J.H.C.), NHS Trust, London; Young Epilepsy (J.H.C.), Lingfield, Surrey, UK; Department of Pediatric Clinical Epileptology (A.A.), Sleep Disorders and Functional Neurology, Member of ERN-EpiCARE; HFME (A.A.), Hospices Civils de Lyon, France; Epilepsy Research Unit (A.A.), Barcelona's Children Hospital San Juan de Dios, Member of the ERN EpiCARE, Spain; Epilepsy Research Centre (S.F.B.), University of Melbourne, Australia; Division of Pediatric Neurology (J.F.K.), Barrow Neurological Institute at Phoenix Children's Hospital; Hope for Hypothalamic Hamartomas (I.P.M., E.W., L.S.), Phoenix, AZ; Epilepsy Surgery Program (A.C.), Clinica de Epilepsia de Sao Paulo, Brazil; Department of Epidemiology (D.K.H.), Columbia University Medical Center, New York, NY; RTI International (B.L.K.), Rockville, MD; Department of Neurology (C.B.S.), Beth-Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; and Epilepsy Center (A.S.-B.), Faculty of Medicine, Medical Center-University of Freiburg, University of Freiburg, Germany
| | - Ilene Penn Miller
- From the Center for Neuroscience Research (N.T.C., W.D.G.), Children's National Hospital, The George Washington University School of Medicine, Washington, DC; UCL NIHR BRC Great Ormond Street Institute of Child Health (J.H.C.), Member of ERN-EpiCARE, London; Great Ormond Street Hospital for Children (J.H.C.), NHS Trust, London; Young Epilepsy (J.H.C.), Lingfield, Surrey, UK; Department of Pediatric Clinical Epileptology (A.A.), Sleep Disorders and Functional Neurology, Member of ERN-EpiCARE; HFME (A.A.), Hospices Civils de Lyon, France; Epilepsy Research Unit (A.A.), Barcelona's Children Hospital San Juan de Dios, Member of the ERN EpiCARE, Spain; Epilepsy Research Centre (S.F.B.), University of Melbourne, Australia; Division of Pediatric Neurology (J.F.K.), Barrow Neurological Institute at Phoenix Children's Hospital; Hope for Hypothalamic Hamartomas (I.P.M., E.W., L.S.), Phoenix, AZ; Epilepsy Surgery Program (A.C.), Clinica de Epilepsia de Sao Paulo, Brazil; Department of Epidemiology (D.K.H.), Columbia University Medical Center, New York, NY; RTI International (B.L.K.), Rockville, MD; Department of Neurology (C.B.S.), Beth-Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; and Epilepsy Center (A.S.-B.), Faculty of Medicine, Medical Center-University of Freiburg, University of Freiburg, Germany
| | - Erica Webster
- From the Center for Neuroscience Research (N.T.C., W.D.G.), Children's National Hospital, The George Washington University School of Medicine, Washington, DC; UCL NIHR BRC Great Ormond Street Institute of Child Health (J.H.C.), Member of ERN-EpiCARE, London; Great Ormond Street Hospital for Children (J.H.C.), NHS Trust, London; Young Epilepsy (J.H.C.), Lingfield, Surrey, UK; Department of Pediatric Clinical Epileptology (A.A.), Sleep Disorders and Functional Neurology, Member of ERN-EpiCARE; HFME (A.A.), Hospices Civils de Lyon, France; Epilepsy Research Unit (A.A.), Barcelona's Children Hospital San Juan de Dios, Member of the ERN EpiCARE, Spain; Epilepsy Research Centre (S.F.B.), University of Melbourne, Australia; Division of Pediatric Neurology (J.F.K.), Barrow Neurological Institute at Phoenix Children's Hospital; Hope for Hypothalamic Hamartomas (I.P.M., E.W., L.S.), Phoenix, AZ; Epilepsy Surgery Program (A.C.), Clinica de Epilepsia de Sao Paulo, Brazil; Department of Epidemiology (D.K.H.), Columbia University Medical Center, New York, NY; RTI International (B.L.K.), Rockville, MD; Department of Neurology (C.B.S.), Beth-Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; and Epilepsy Center (A.S.-B.), Faculty of Medicine, Medical Center-University of Freiburg, University of Freiburg, Germany
| | - Lisa Soeby
- From the Center for Neuroscience Research (N.T.C., W.D.G.), Children's National Hospital, The George Washington University School of Medicine, Washington, DC; UCL NIHR BRC Great Ormond Street Institute of Child Health (J.H.C.), Member of ERN-EpiCARE, London; Great Ormond Street Hospital for Children (J.H.C.), NHS Trust, London; Young Epilepsy (J.H.C.), Lingfield, Surrey, UK; Department of Pediatric Clinical Epileptology (A.A.), Sleep Disorders and Functional Neurology, Member of ERN-EpiCARE; HFME (A.A.), Hospices Civils de Lyon, France; Epilepsy Research Unit (A.A.), Barcelona's Children Hospital San Juan de Dios, Member of the ERN EpiCARE, Spain; Epilepsy Research Centre (S.F.B.), University of Melbourne, Australia; Division of Pediatric Neurology (J.F.K.), Barrow Neurological Institute at Phoenix Children's Hospital; Hope for Hypothalamic Hamartomas (I.P.M., E.W., L.S.), Phoenix, AZ; Epilepsy Surgery Program (A.C.), Clinica de Epilepsia de Sao Paulo, Brazil; Department of Epidemiology (D.K.H.), Columbia University Medical Center, New York, NY; RTI International (B.L.K.), Rockville, MD; Department of Neurology (C.B.S.), Beth-Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; and Epilepsy Center (A.S.-B.), Faculty of Medicine, Medical Center-University of Freiburg, University of Freiburg, Germany
| | - Arthur Cukiert
- From the Center for Neuroscience Research (N.T.C., W.D.G.), Children's National Hospital, The George Washington University School of Medicine, Washington, DC; UCL NIHR BRC Great Ormond Street Institute of Child Health (J.H.C.), Member of ERN-EpiCARE, London; Great Ormond Street Hospital for Children (J.H.C.), NHS Trust, London; Young Epilepsy (J.H.C.), Lingfield, Surrey, UK; Department of Pediatric Clinical Epileptology (A.A.), Sleep Disorders and Functional Neurology, Member of ERN-EpiCARE; HFME (A.A.), Hospices Civils de Lyon, France; Epilepsy Research Unit (A.A.), Barcelona's Children Hospital San Juan de Dios, Member of the ERN EpiCARE, Spain; Epilepsy Research Centre (S.F.B.), University of Melbourne, Australia; Division of Pediatric Neurology (J.F.K.), Barrow Neurological Institute at Phoenix Children's Hospital; Hope for Hypothalamic Hamartomas (I.P.M., E.W., L.S.), Phoenix, AZ; Epilepsy Surgery Program (A.C.), Clinica de Epilepsia de Sao Paulo, Brazil; Department of Epidemiology (D.K.H.), Columbia University Medical Center, New York, NY; RTI International (B.L.K.), Rockville, MD; Department of Neurology (C.B.S.), Beth-Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; and Epilepsy Center (A.S.-B.), Faculty of Medicine, Medical Center-University of Freiburg, University of Freiburg, Germany
| | - Dale K Hesdorffer
- From the Center for Neuroscience Research (N.T.C., W.D.G.), Children's National Hospital, The George Washington University School of Medicine, Washington, DC; UCL NIHR BRC Great Ormond Street Institute of Child Health (J.H.C.), Member of ERN-EpiCARE, London; Great Ormond Street Hospital for Children (J.H.C.), NHS Trust, London; Young Epilepsy (J.H.C.), Lingfield, Surrey, UK; Department of Pediatric Clinical Epileptology (A.A.), Sleep Disorders and Functional Neurology, Member of ERN-EpiCARE; HFME (A.A.), Hospices Civils de Lyon, France; Epilepsy Research Unit (A.A.), Barcelona's Children Hospital San Juan de Dios, Member of the ERN EpiCARE, Spain; Epilepsy Research Centre (S.F.B.), University of Melbourne, Australia; Division of Pediatric Neurology (J.F.K.), Barrow Neurological Institute at Phoenix Children's Hospital; Hope for Hypothalamic Hamartomas (I.P.M., E.W., L.S.), Phoenix, AZ; Epilepsy Surgery Program (A.C.), Clinica de Epilepsia de Sao Paulo, Brazil; Department of Epidemiology (D.K.H.), Columbia University Medical Center, New York, NY; RTI International (B.L.K.), Rockville, MD; Department of Neurology (C.B.S.), Beth-Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; and Epilepsy Center (A.S.-B.), Faculty of Medicine, Medical Center-University of Freiburg, University of Freiburg, Germany
| | - Barbara L Kroner
- From the Center for Neuroscience Research (N.T.C., W.D.G.), Children's National Hospital, The George Washington University School of Medicine, Washington, DC; UCL NIHR BRC Great Ormond Street Institute of Child Health (J.H.C.), Member of ERN-EpiCARE, London; Great Ormond Street Hospital for Children (J.H.C.), NHS Trust, London; Young Epilepsy (J.H.C.), Lingfield, Surrey, UK; Department of Pediatric Clinical Epileptology (A.A.), Sleep Disorders and Functional Neurology, Member of ERN-EpiCARE; HFME (A.A.), Hospices Civils de Lyon, France; Epilepsy Research Unit (A.A.), Barcelona's Children Hospital San Juan de Dios, Member of the ERN EpiCARE, Spain; Epilepsy Research Centre (S.F.B.), University of Melbourne, Australia; Division of Pediatric Neurology (J.F.K.), Barrow Neurological Institute at Phoenix Children's Hospital; Hope for Hypothalamic Hamartomas (I.P.M., E.W., L.S.), Phoenix, AZ; Epilepsy Surgery Program (A.C.), Clinica de Epilepsia de Sao Paulo, Brazil; Department of Epidemiology (D.K.H.), Columbia University Medical Center, New York, NY; RTI International (B.L.K.), Rockville, MD; Department of Neurology (C.B.S.), Beth-Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; and Epilepsy Center (A.S.-B.), Faculty of Medicine, Medical Center-University of Freiburg, University of Freiburg, Germany
| | - Clifford B Saper
- From the Center for Neuroscience Research (N.T.C., W.D.G.), Children's National Hospital, The George Washington University School of Medicine, Washington, DC; UCL NIHR BRC Great Ormond Street Institute of Child Health (J.H.C.), Member of ERN-EpiCARE, London; Great Ormond Street Hospital for Children (J.H.C.), NHS Trust, London; Young Epilepsy (J.H.C.), Lingfield, Surrey, UK; Department of Pediatric Clinical Epileptology (A.A.), Sleep Disorders and Functional Neurology, Member of ERN-EpiCARE; HFME (A.A.), Hospices Civils de Lyon, France; Epilepsy Research Unit (A.A.), Barcelona's Children Hospital San Juan de Dios, Member of the ERN EpiCARE, Spain; Epilepsy Research Centre (S.F.B.), University of Melbourne, Australia; Division of Pediatric Neurology (J.F.K.), Barrow Neurological Institute at Phoenix Children's Hospital; Hope for Hypothalamic Hamartomas (I.P.M., E.W., L.S.), Phoenix, AZ; Epilepsy Surgery Program (A.C.), Clinica de Epilepsia de Sao Paulo, Brazil; Department of Epidemiology (D.K.H.), Columbia University Medical Center, New York, NY; RTI International (B.L.K.), Rockville, MD; Department of Neurology (C.B.S.), Beth-Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; and Epilepsy Center (A.S.-B.), Faculty of Medicine, Medical Center-University of Freiburg, University of Freiburg, Germany
| | - Andreas Schulze-Bonhage
- From the Center for Neuroscience Research (N.T.C., W.D.G.), Children's National Hospital, The George Washington University School of Medicine, Washington, DC; UCL NIHR BRC Great Ormond Street Institute of Child Health (J.H.C.), Member of ERN-EpiCARE, London; Great Ormond Street Hospital for Children (J.H.C.), NHS Trust, London; Young Epilepsy (J.H.C.), Lingfield, Surrey, UK; Department of Pediatric Clinical Epileptology (A.A.), Sleep Disorders and Functional Neurology, Member of ERN-EpiCARE; HFME (A.A.), Hospices Civils de Lyon, France; Epilepsy Research Unit (A.A.), Barcelona's Children Hospital San Juan de Dios, Member of the ERN EpiCARE, Spain; Epilepsy Research Centre (S.F.B.), University of Melbourne, Australia; Division of Pediatric Neurology (J.F.K.), Barrow Neurological Institute at Phoenix Children's Hospital; Hope for Hypothalamic Hamartomas (I.P.M., E.W., L.S.), Phoenix, AZ; Epilepsy Surgery Program (A.C.), Clinica de Epilepsia de Sao Paulo, Brazil; Department of Epidemiology (D.K.H.), Columbia University Medical Center, New York, NY; RTI International (B.L.K.), Rockville, MD; Department of Neurology (C.B.S.), Beth-Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; and Epilepsy Center (A.S.-B.), Faculty of Medicine, Medical Center-University of Freiburg, University of Freiburg, Germany
| | - William D Gaillard
- From the Center for Neuroscience Research (N.T.C., W.D.G.), Children's National Hospital, The George Washington University School of Medicine, Washington, DC; UCL NIHR BRC Great Ormond Street Institute of Child Health (J.H.C.), Member of ERN-EpiCARE, London; Great Ormond Street Hospital for Children (J.H.C.), NHS Trust, London; Young Epilepsy (J.H.C.), Lingfield, Surrey, UK; Department of Pediatric Clinical Epileptology (A.A.), Sleep Disorders and Functional Neurology, Member of ERN-EpiCARE; HFME (A.A.), Hospices Civils de Lyon, France; Epilepsy Research Unit (A.A.), Barcelona's Children Hospital San Juan de Dios, Member of the ERN EpiCARE, Spain; Epilepsy Research Centre (S.F.B.), University of Melbourne, Australia; Division of Pediatric Neurology (J.F.K.), Barrow Neurological Institute at Phoenix Children's Hospital; Hope for Hypothalamic Hamartomas (I.P.M., E.W., L.S.), Phoenix, AZ; Epilepsy Surgery Program (A.C.), Clinica de Epilepsia de Sao Paulo, Brazil; Department of Epidemiology (D.K.H.), Columbia University Medical Center, New York, NY; RTI International (B.L.K.), Rockville, MD; Department of Neurology (C.B.S.), Beth-Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; and Epilepsy Center (A.S.-B.), Faculty of Medicine, Medical Center-University of Freiburg, University of Freiburg, Germany
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Foldes ST, Munter BT, Appavu BL, Kerrigan JF, Adelson PD. Shift in electrocorticography electrode locations after surgical implantation in children. Epilepsy Res 2020; 167:106410. [PMID: 32758670 DOI: 10.1016/j.eplepsyres.2020.106410] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 06/05/2020] [Accepted: 06/27/2020] [Indexed: 10/24/2022]
Abstract
Interpreting electrocorticography (ECoG) in the context of neuroimaging requires that multimodal information be integrated accurately. However, the implantation of ECoG electrodes can shift the brain impacting the spatial interpretation of electrode locations in the context of pre-implant imaging. We characterized the amount of shift in ECoG electrode locations immediately after implant in a pediatric population. Electrode-shift was quantified as the difference in the electrode locations immediately after surgery (via post-operation CT) compared to the brain surface before the operation (pre-implant T1 MRI). A total of 1140 ECoG contracts were assessed across 18 patients ranging from 3 to 19 (12.1 ± 4.8) years of age who underwent intracranial monitoring in preparation for epilepsy resection surgery. Patients had an average of 63 channels assessed with an average of 5.64 ± 3.27 mm shift from the pre-implant brain surface within 24 h of implant. This shift significantly increased with estimated intracranial volume, but not age. Shift also varied significantly depending of the lobe the contact was over; where contacts on the temporal and frontal lobe had less shift than the parietal. Furthermore, contacts on strips had significantly less shift than those on grids. The shift in the brain surface due to ECoG implantation could lead to a misinterpretation of contact location particularly in patients with larger intracranial volume and for grid contacts over the parietal lobes.
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Affiliation(s)
- Stephen T Foldes
- Barrow Neurological Institute, Phoenix Children's Hospital, Phoenix, AZ, United States; Department of Child Health, University of Arizona - College of Medicine, Phoenix, AZ, United States; School of Biological and Health Systems Engineering, Arizona State University, Tempe, AZ, United States.
| | - Bryce T Munter
- Department of Child Health, University of Arizona - College of Medicine, Phoenix, AZ, United States
| | - Brian L Appavu
- Barrow Neurological Institute, Phoenix Children's Hospital, Phoenix, AZ, United States; Department of Child Health, University of Arizona - College of Medicine, Phoenix, AZ, United States; School of Biological and Health Systems Engineering, Arizona State University, Tempe, AZ, United States
| | - John F Kerrigan
- Barrow Neurological Institute, Phoenix Children's Hospital, Phoenix, AZ, United States; Department of Child Health, University of Arizona - College of Medicine, Phoenix, AZ, United States
| | - P David Adelson
- Barrow Neurological Institute, Phoenix Children's Hospital, Phoenix, AZ, United States; Department of Child Health, University of Arizona - College of Medicine, Phoenix, AZ, United States; School of Biological and Health Systems Engineering, Arizona State University, Tempe, AZ, United States
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Yuen KCJ, Oatman O, Kerrigan JF. SUN-295 Prevalence of Self-Reported Endocrine Comorbidities in Hypothalamic Hamartoma Patients: Data from the Hope for Hypothalamic Hamartoma Survey. J Endocr Soc 2020. [PMCID: PMC7447015 DOI: 10.1210/jendso/bvaa046.683] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
Background: Hypothalamic hamartoma (HH) are rare, congenital, benign mass lesions in the ventral hypothalamus that can be asymptomatic or associated with gelastic seizures and treatment-resistant epilepsy. Central precocious puberty (CPP) is the main endocrine comorbidity (30-80% of cases). Other endocrine comorbidities have also been described that tends to occur after surgery. However, previous studies reporting its prevalence have shown inconsistent results because of the rarity of the disease, variability of follow-up, and lack of long-term endocrinologic assessment. Aims: To evaluate the self-reported prevalence of demographics and endocrine comorbidities in a large cohort of HH patients. Methods: Hope for HH is a volunteer-based nonprofit organization founded by parents of children with HH. This international survey was initiated, translated into multiple languages and distributed by mail and electronically to families of children with HH in the Hope for HH database after concerns were raised that there have been multiple ongoing comorbidities (including endocrine) that continues to be under-recognized. Results: In total, 257 HH patients (132M/125F, mainly between ages 4-35 years and from the US, Russia, UK, Australia, Canada, Germany and Kazakhstan) participated in the survey. Some patients had a secondary diagnosis of Pallister-Hall (7.0%), Lennox-Gastaut (1.95%), Prader-Willi (0.8%) and West (0.8%) syndromes. The majority of patients (n=163, 63.4%) underwent surgery (MRI-guided stereotactic laser ablation [n=61, 37.4%], endoscopic resection [n=31, 19.0%], transcallosal resection [n=30, 18.4%], stereotactic radiofrequency ablation [n=27, 16.6%], orbitozygomatic resection [n=9, 5.5%]) or gamma knife radiosurgery (n=28, 17.2%). After surgery and/or radiation, ~50% of patients were seizure-free but reported unchanged, poor or very poor quality of life (QoL), with fatigue (56.4%), heat intolerance (46.3%) and adipsia (21.8%) being the more common symptoms. Reported endocrine comorbidities include CPP (42%), hypothalamic obesity (35.0%), abnormal body composition (31.5%), central hypothyroidism (19.8%), osteopenia/osteoporosis with low BMD (12.8%), diabetes insipidus (11.3%), GH deficiency (10.5%), central adrenal insufficiency (10.5%), central hypogonadism (5.1%), and delayed puberty (4.7%), and 26.5% of patients were not seeing an endocrinologist. Conclusion: In contrast to previous studies reporting low prevalence, mild and transient endocrine comorbidities in HH patients (2,3), this survey suggests a greater prevalence of other non-CPP endocrine comorbidities with a substantial number of patients reporting unchanged or impaired QoL. Thus, long-term endocrinologic follow-up with the involvement of a multidiscliplinary team is essential to diagnose early and treat these comorbidities in these patients.
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Boerwinkle VL, Mirea L, Gaillard WD, Sussman BL, Larocque D, Bonnell A, Ronecker JS, Troester MM, Kerrigan JF, Foldes ST, Appavu B, Jarrar R, Williams K, Wilfong AA, Adelson PD. Resting-state functional MRI connectivity impact on epilepsy surgery plan and surgical candidacy: prospective clinical work. J Neurosurg Pediatr 2020; 25:1-8. [PMID: 32197251 DOI: 10.3171/2020.1.peds19695] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Accepted: 01/10/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The authors' goal was to prospectively quantify the impact of resting-state functional MRI (rs-fMRI) on pediatric epilepsy surgery planning. METHODS Fifty-one consecutive patients (3 months to 20 years old) with intractable epilepsy underwent rs-fMRI for presurgical evaluation. The team reviewed the following available diagnostic data: video-electroencephalography (n = 51), structural MRI (n = 51), FDG-PET (n = 42), magnetoencephalography (n = 5), and neuropsychological testing (n = 51) results to formulate an initial surgery plan blinded to the rs-fMRI findings. Subsequent to this discussion, the connectivity results were revealed and final recommendations were established. Changes between pre- and post-rs-fMRI treatment plans were determined, and changes in surgery recommendation were compared using McNemar's test. RESULTS Resting-state fMRI was successfully performed in 50 (98%) of 51 cases and changed the seizure onset zone localization in 44 (88%) of 50 patients. The connectivity results prompted 6 additional studies, eliminated the ordering of 11 further diagnostic studies, and changed the intracranial monitoring plan in 10 cases. The connectivity results significantly altered surgery planning with the addition of 13 surgeries, but it did not eliminate planned surgeries (p = 0.003). Among the 38 epilepsy surgeries performed, the final surgical approach changed due to rs-fMRI findings in 22 cases (58%), including 8 (28%) of 29 in which extraoperative direct electrical stimulation mapping was averted. CONCLUSIONS This study demonstrates the impact of rs-fMRI connectivity results on the decision-making for pediatric epilepsy surgery by providing new information about the location of eloquent cortex and the seizure onset zone. Additionally, connectivity results may increase the proportion of patients considered eligible for surgery while optimizing the need for further testing.
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Affiliation(s)
| | | | - William D Gaillard
- 3Department of Neurology, Children's National Medical Center, Washington, DC
| | | | | | | | - Jennifer S Ronecker
- 5Division of Pediatric Neurosurgery, Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, Arizona; and
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Boerwinkle VL, Cediel EG, Mirea L, Williams K, Kerrigan JF, Lam S, Raskin JS, Desai VR, Wilfong AA, Adelson PD, Curry DJ. Network-targeted approach and postoperative resting-state functional magnetic resonance imaging are associated with seizure outcome. Ann Neurol 2019; 86:344-356. [PMID: 31294865 DOI: 10.1002/ana.25547] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Revised: 07/08/2019] [Accepted: 07/09/2019] [Indexed: 12/25/2022]
Abstract
OBJECTIVE Postoperative resting-state functional magnetic resonance imaging (MRI) in children with intractable epilepsy has not been quantified in relation to seizure outcome. Therefore, its value as a biomarker for epileptogenic pathology is not well understood. METHODS In a sample of children with intractable epilepsy who underwent prospective resting-state seizure onset zone (SOZ)-targeted epilepsy surgery, postoperative resting-state functional MRI (rs-fMRI) was performed 6 to 12 months later. Graded normalization of the postoperative resting-state SOZ was compared to seizure outcomes, patient, surgery, and anatomical MRI characteristics. RESULTS A total of 64 cases were evaluated. Network-targeted surgery, followed by postoperative rs-fMRI normalization was significantly (p < 0.001) correlated with seizure reduction, with a Spearman rank correlation coefficient of 0.83. Of 39 cases with postoperative rs-fMRI SOZ normalization, 38 (97%) became completely seizure free. In contrast, of the 25 cases without complete rs-fMRI SOZ normalization, only 3 (5%) became seizure free. The accuracy of rs-fMRI as a biomarker predicting seizure freedom is 94%, with 96% sensitivity and 93% specificity. INTERPRETATION Among seizure localization techniques in pediatric epilepsy, network-targeted surgery, followed by postoperative rs-fMRI normalization, has high correlation with seizure freedom. This study shows that rs-fMRI SOZ can be used as a biomarker of the epileptogenic zone, and postoperative rs-fMRI normalization is a biomarker for SOZ quiescence. ANN NEUROL 2019;86:344-356.
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Affiliation(s)
- Varina L Boerwinkle
- Division of Pediatric Neurology, Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, AZ
| | - Emilio G Cediel
- Division of Pediatric Neurosurgery, Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, AZ
| | - Lucia Mirea
- Department of Research, Phoenix Children's Hospital, Phoenix, AZ
| | - Korwyn Williams
- Division of Pediatric Neurology, Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, AZ
| | - John F Kerrigan
- Division of Pediatric Neurology, Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, AZ
| | - Sandi Lam
- Section of Pediatric Neurosurgery, Riley Hospital for Children, Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Jeffrey S Raskin
- Section of Pediatric Neurosurgery, Riley Hospital for Children, Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Virendra R Desai
- Department of Neurosurgery, Houston Methodist Hospital, Houston, TX
| | - Angus A Wilfong
- Division of Pediatric Neurology, Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, AZ
| | - P David Adelson
- Division of Pediatric Neurology, Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, AZ.,Division of Pediatric Neurosurgery, Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, AZ
| | - Daniel J Curry
- Department of Pediatric Neurosurgery, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
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Boerwinkle VL, Foldes ST, Torrisi SJ, Temkit H, Gaillard WD, Kerrigan JF, Desai VR, Raskin JS, Vedantam A, Jarrar R, Williams K, Lam S, Ranjan M, Broderson JS, Adelson D, Wilfong AA, Curry DJ. Subcentimeter epilepsy surgery targets by resting state functional magnetic resonance imaging can improve outcomes in hypothalamic hamartoma. Epilepsia 2018; 59:2284-2295. [DOI: 10.1111/epi.14583] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Revised: 09/10/2018] [Accepted: 09/24/2018] [Indexed: 12/13/2022]
Affiliation(s)
- Varina L. Boerwinkle
- Division of Pediatric Neurology; Barrow Neurological Institute at Phoenix Children’s Hospital; Phoenix Arizona
| | - Stephen T. Foldes
- Neuroscience Research; Barrow Neurological Institute at Phoenix Children’s Hospital; Phoenix Arizona
| | - Salvatore J. Torrisi
- Section on the Neurobiology of Fear and Anxiety; National Institute of Mental Health; National Institutes of Health; Bethesda Maryland
| | - Hamy Temkit
- Department of Research; Phoenix Children’s Hospital; Phoenix Arizona
| | - William D. Gaillard
- Department of Neurology; Children’s National Medical Center; Washington District of Columbia
| | - John F. Kerrigan
- Division of Pediatric Neurology; Barrow Neurological Institute at Phoenix Children’s Hospital; Phoenix Arizona
| | - Virendra R. Desai
- Department of Neurosurgery; Houston Methodist Hospital; Houston Methodist Neurological Institute; Houston Texas
| | - Jeffrey S. Raskin
- Department of Pediatric Neurosurgery; Texas Children’s Hospital; Baylor College of Medicine; Houston Texas
| | - Aditya Vedantam
- Department of Pediatric Neurosurgery; Texas Children’s Hospital; Baylor College of Medicine; Houston Texas
| | - Randa Jarrar
- Division of Pediatric Neurology; Barrow Neurological Institute at Phoenix Children’s Hospital; Phoenix Arizona
| | - Korwyn Williams
- Division of Pediatric Neurology; Barrow Neurological Institute at Phoenix Children’s Hospital; Phoenix Arizona
| | - Sandi Lam
- Department of Pediatric Neurosurgery; Texas Children’s Hospital; Baylor College of Medicine; Houston Texas
| | - Manish Ranjan
- Division of Pediatric Neurosurgery; Barrow Neurological Institute at Phoenix Children’s Hospital; Phoenix Arizona
| | - Janna S. Broderson
- Division of Pediatric Neurology; Texas Children’s Hospital; Baylor College of Medicine; Houston Texas
| | - David Adelson
- Division of Pediatric Neurology; Barrow Neurological Institute at Phoenix Children’s Hospital; Phoenix Arizona
- Division of Pediatric Neurosurgery; Barrow Neurological Institute at Phoenix Children’s Hospital; Phoenix Arizona
| | - Angus A. Wilfong
- Division of Pediatric Neurology; Barrow Neurological Institute at Phoenix Children’s Hospital; Phoenix Arizona
| | - Daniel J. Curry
- Department of Pediatric Neurosurgery; Texas Children’s Hospital; Baylor College of Medicine; Houston Texas
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Abstract
We report a 10-month-old boy with treatment-resistant infantile spasms associated with hypothalamic hamartoma (HH). Electroencephalography before surgical treatment showed modified hypsarrhythmia. Transventricular endoscopic resection and disconnection resulted in immediate and enduring disappearance of the epileptic spasms and improvement in the postoperative electroencephalography. After 8 years of treatment, the patient has nondisabling gelastic seizures associated with a small amount of residual HH but no other seizure types. He is not taking any antiepilepsy drugs. He is academically and socially successful. We are not aware of any prior reports of surgical treatment of HH with concurrent infantile spasms as an uncontrolled seizure type. The immediate disappearance of infantile spasms demonstrates that the HH lesion itself is an active and necessary component within the epileptic network responsible for spasms in this particular condition. This case contributes to the recognition that focal pathologies can be responsible for infantile spasms with hypsarrhythmia and respond successfully to surgical intervention.
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Affiliation(s)
- Jordana Fox
- Division of Pediatric Neurology, Hypothalamic Hamartoma Program, Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, AZ
| | - Shaun Hussain
- Division of Pediatric Neurology, Pediatric Epilepsy Program, Department of Pediatrics, UCLA School of Medicine, Mattel Children's Hospital, Los Angeles, CA
| | - Raman Sankar
- Division of Pediatric Neurology, Pediatric Epilepsy Program, Department of Pediatrics, UCLA School of Medicine, Mattel Children's Hospital, Los Angeles, CA
| | - John F Kerrigan
- Division of Pediatric Neurology, Hypothalamic Hamartoma Program, Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, AZ.
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Xu DS, Chen T, Hlubek RJ, Bristol RE, Smith KA, Ponce FA, Kerrigan JF, Nakaji P. Magnetic Resonance Imaging-Guided Laser Interstitial Thermal Therapy for the Treatment of Hypothalamic Hamartomas: A Retrospective Review. Neurosurgery 2018; 83:1183-1192. [DOI: 10.1093/neuros/nyx604] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2016] [Accepted: 11/27/2017] [Indexed: 11/13/2022] Open
Affiliation(s)
- David S Xu
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Tsinsue Chen
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Randall J Hlubek
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Ruth E Bristol
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix Children's Hospital, Phoenix, Arizona
| | - Kris A Smith
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Francisco A Ponce
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - John F Kerrigan
- Department of Pediatric Neurology, Barrow Neurological Institute, Phoenix Children's Hospital, Phoenix, Arizona
| | - Peter Nakaji
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
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Abstract
OBJECTIVE We conducted a systematic review of the English-language literature to identify clinical features associated with a higher risk of psychiatric symptoms (aggression and rage behaviors) in patients with hypothalamic hamartoma (HH) and epilepsy. METHODS Two publicly-accessible databases (PubMed and Cochrane Library) were searched for Hypothalamic Hamartoma AND Epilepsy. We identified peer-reviewed original research publications (case reports or clinical series; N=19) in which clinical data was provided on an individual basis. Subjects were cohorted into those with (N=51) and without (N=68) behavioral aggression. Multiple clinical features were collated and subjected to univariate analysis to determine possible differences between these two cohorts. RESULTS The presence of aggression significantly correlated with 1) male gender, 2) younger age at time of first seizure onset, 3) the presence of intellectual disability, and 4) the presence of multiple seizure types (versus gelastic seizures only). For those patients undergoing surgical treatment, aggression also correlated with younger age at the time of surgical intervention. CONCLUSION Possible predictive clinical features for the presence of aggression and rage behaviors in patients with hypothalamic hamartoma and epilepsy are identified. These results may contribute to the complex treatment decisions that are unique to this population.
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Affiliation(s)
- Zachary Killeen
- University of Arizona College of Medicine, Phoenix, AZ, United States
| | - Raymond Bunch
- Division of Psychiatry and Hypothalamic Hamartoma Program, Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, AZ, United States
| | - John F Kerrigan
- Division of Pediatric Neurology and Hypothalamic Hamartoma Program, Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, AZ, United States.
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12
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Abstract
The most common, and usually the only, endocrine disturbance in patients with hypothalamic hamartoma (HH) and epilepsy is central precocious puberty (CPP). The mechanism for CPP associated with HH may relate to ectopic generation and pulsatile release of gonadotropin-releasing hormone (GnRH) from the HH, but this remains an unproven hypothesis. Possible regulators of GnRH release that are intrinsic to HH tissue include the following: (1) glial factors (such as transforming growth factor α[TGFα) and (2) γ-aminobutyric acid (GABA)-mediated excitation. Both are known to be present in surgically-resected HH tissue, but are present in patients with and without a history of CPP, suggesting the possibility that symptoms related to HH are directly associated with the region of anatomic attachment of the HH to the hypothalamus, which determines functional network connections, rather than to differences in HH tissue expression or pathophysiology. CPP associated with HH presents with isosexual development prior to the age of 8 years in girls and 9 years in boys. It is not uncommon for CPP with HH to present in children at an earlier age in comparison to other causes of CPP, including in infancy. Surgical resection of the HH can be effective for treating CPP, but is reserved for patients with intractable epilepsy, since GnRH agonists are widely available and effective treatment. Other endocrine disturbances with HH are rare, but can include growth hormone deficiency, hypothyroidism, and adrenal insufficiency. Diabetes insipidus is commonly encountered postoperatively, but is not observed with HH prior to surgical intervention.
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Affiliation(s)
- Victor S Harrison
- Division of Endocrinology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, U.S.A
| | - Oliver Oatman
- Division of Endocrinology and Hypothalamic Hamartoma Program, Phoenix Children's Hospital, Phoenix, Arizona, U.S.A
| | - John F Kerrigan
- Pediatric Neurology Division and Hypothalamic Hamartoma Program, Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, Arizona, U.S.A
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Régis J, Helen Cross J, Kerrigan JF. Achieving a cure for hypothalamic hamartomas: a Sisyphean quest? Epilepsia 2017; 58 Suppl 2:7-11. [DOI: 10.1111/epi.13773] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/30/2017] [Indexed: 02/06/2023]
Affiliation(s)
- Jean Régis
- Inserm UMR1106; Aix-Marseille University; Marseille France
- Functional and Stereotactic Neurosurgery Service and Gamma Knife Unit; Timone University Hospital; Marseille France
| | - J. Helen Cross
- The Prince of Wales's Chair of Childhood Epilepsy; UCL-Institute of Child Health; Great Ormond Street Hospital for Children; London United Kingdom
- Young Epilepsy; Lingfield United Kingdom
| | - John F. Kerrigan
- Pediatric Neurology Division and Hypothalamic Hamartoma Program; Barrow Neurological Institute at Phoenix Children's Hospital; Phoenix Arizona U.S.A
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Wagner K, Wethe JV, Schulze-Bonhage A, Trippel M, Rekate H, Prigatano GP, Kerrigan JF. Cognition in epilepsy patients with hypothalamic hamartomas. Epilepsia 2017; 58 Suppl 2:85-93. [DOI: 10.1111/epi.13759] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/09/2017] [Indexed: 11/30/2022]
Affiliation(s)
- Kathrin Wagner
- Epilepsy Centre; Medical Center - University of Freiburg; Freiburg Germany
| | - Jennifer V. Wethe
- Division of Psychology; Mayo Clinic College of Medicine; Scottsdale Arizona U.S.A
| | | | - Michael Trippel
- Department of Stereotactic and Functional Neurosurgery; Medical Center - University of Freiburg; Freiburg Germany
| | - Harold Rekate
- The Chiari Institute; Neurosurgery; Great Neck New York U.S.A
| | - George P. Prigatano
- Department of Clinical Neuropsychology; Barrow Neurological Institute; St. Joseph's Hospital and Medical Center; Phoenix Arizona U.S.A
| | - John F. Kerrigan
- Division of Neurology; Barrow Neurological Institute at Phoenix Children's Hospital; Phoenix Arizona U.S.A
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15
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Kerrigan JF, Parsons A, Tsang C, Simeone K, Coons S, Wu J. Hypothalamic hamartoma: Neuropathology and epileptogenesis. Epilepsia 2017; 58 Suppl 2:22-31. [DOI: 10.1111/epi.13752] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/09/2016] [Indexed: 01/06/2023]
Affiliation(s)
- John F. Kerrigan
- Hypothalamic Hamartoma Program and Pediatric Neurology Division; Barrow Neurological Institute at Phoenix Children's Hospital; Phoenix Children's Hospital; Phoenix Arizona U.S.A
- Hypothalamic Hamartoma Tissue Research Laboratory; Barrow Neurological Institute; St. Joseph's Hospital and Medical Center; Phoenix Arizona U.S.A
| | - Angela Parsons
- Hypothalamic Hamartoma Tissue Research Laboratory; Barrow Neurological Institute; St. Joseph's Hospital and Medical Center; Phoenix Arizona U.S.A
| | - Candy Tsang
- Hypothalamic Hamartoma Tissue Research Laboratory; Barrow Neurological Institute; St. Joseph's Hospital and Medical Center; Phoenix Arizona U.S.A
| | - Kristina Simeone
- Department of Pharmacology; Creighton University School of Medicine; Omaha Nebraska U.S.A
| | - Stephen Coons
- Division of Neuropathology; Barrow Neurological Institute; St. Joseph's Hospital and Medical Center; Phoenix Arizona U.S.A
| | - Jie Wu
- Hypothalamic Hamartoma Program and Division of Neurology; Barrow Neurological Institute; St. Joseph's Hospital and Medical Center; Phoenix Arizona U.S.A
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Appavu B, Vanatta L, Condie J, Kerrigan JF, Jarrar R. Ketogenic diet treatment for pediatric super-refractory status epilepticus. Seizure 2016; 41:62-5. [PMID: 27475280 DOI: 10.1016/j.seizure.2016.07.006] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2016] [Revised: 06/18/2016] [Accepted: 07/14/2016] [Indexed: 11/29/2022] Open
Abstract
PURPOSE We aimed to study whether ketogenic diet (KD) therapy leads to resolution of super-refractory status epilepticus in pediatric patients without significant harm. METHOD A retrospective review was performed at Phoenix Children's Hospital on patients with super-refractory status epilepticus undergoing ketogenic diet therapy from 2011 to 2015. RESULTS Ten children with super-refractory status epilepticus, ages 2-16 years, were identified. 4/10 patients had immune mediated encephalitis, including Rasmussen encephalitis, anti-N-methyl-d-aspartate receptor encephalitis, and post-infectious mycoplasma encephalitis. Other etiologies included Lennox Gastaut Syndrome, non-ketotic hyperglycinemia, PCDH19 and GABRG2 genetic epilepsy, New Onset Refractory Status Epilepticus, and Febrile Infection-Related Epilepsy Syndrome. 4/10 patients' EEG features suggested focal with status epilepticus, and 6/10 suggested generalized with status epilepticus. Median hospital length was 61days and median ICU length was 27days. The median number of antiepileptic medications prior to diet initiation was 3.0 drugs, and the median after ketogenic diet treatment was 3.5 drugs. Median duration of status epilepticus prior to KD was 18days. 9/10 patients had resolution of super-refractory status epilepticus in a median of 7days after diet initiation. 8/9 patients were weaned off anesthesia within 15days of diet initiation, and within 1day of achieving ketonuria. 1/10 patients experienced side effects on the diet requiring supplementation. CONCLUSION Most patients achieved resolution of status epilepticus on KD therapy, suggesting it could be an effective therapy that can be utilized early in the treatment of children with super refractory status epilepticus.
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Affiliation(s)
- Brian Appavu
- Barrow Neurological Institute at Phoenix Children's Hospital, 1919 E. Thomas Road, Ambulatory Building, 3rd Floor, Phoenix, AZ 85016, United States.
| | - Lisa Vanatta
- Barrow Neurological Institute at Phoenix Children's Hospital, 1919 E. Thomas Road, Ambulatory Building, 3rd Floor, Phoenix, AZ 85016, United States.
| | - John Condie
- Barrow Neurological Institute at Phoenix Children's Hospital, 1919 E. Thomas Road, Ambulatory Building, 3rd Floor, Phoenix, AZ 85016, United States.
| | - John F Kerrigan
- Barrow Neurological Institute at Phoenix Children's Hospital, 1919 E. Thomas Road, Ambulatory Building, 3rd Floor, Phoenix, AZ 85016, United States.
| | - Randa Jarrar
- Barrow Neurological Institute at Phoenix Children's Hospital, 1919 E. Thomas Road, Ambulatory Building, 3rd Floor, Phoenix, AZ 85016, United States.
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Wu J, Gao M, Rice SG, Tsang C, Beggs J, Turner D, Li G, Yang B, Xia K, Gao F, Qiu S, Liu Q, Kerrigan JF. Gap Junctions Contribute to Ictal/Interictal Genesis in Human Hypothalamic Hamartomas. EBioMedicine 2016; 8:96-102. [PMID: 27428422 PMCID: PMC4919609 DOI: 10.1016/j.ebiom.2016.04.026] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2016] [Revised: 04/21/2016] [Accepted: 04/21/2016] [Indexed: 11/28/2022] Open
Abstract
Human hypothalamic hamartoma (HH) is a rare subcortical lesion associated with treatment-resistant epilepsy. Cellular mechanisms responsible for epileptogenesis are unknown. We hypothesized that neuronal gap junctions contribute to epileptogenesis through synchronous activity within the neuron networks in HH tissue. We studied surgically resected HH tissue with Western-blot analysis, immunohistochemistry, electron microscopy, biocytin microinjection of recorded HH neurons, and microelectrode patch clamp recordings with and without pharmacological blockade of gap junctions. Normal human hypothalamus tissue was used as a control. Western blots showed increased expression of both connexin-36 (Cx36) and connexin-43 (Cx43) in HH tissue compared with normal human mammillary body tissue. Immunohistochemistry demonstrated that Cx36 and Cx43 are expressed in HH tissue, but Cx36 was mainly expressed within neuron clusters while Cx43 was mainly expressed outside of neuron clusters. Gap-junction profiles were observed between small HH neurons with electron microscopy. Biocytin injection into single recorded small HH neurons showed labeling of adjacent neurons, which was not observed in the presence of a neuronal gap-junction blocker, mefloquine. Microelectrode field recordings from freshly resected HH slices demonstrated spontaneous ictal/interictal-like discharges in most slices. Bath-application of gap-junction blockers significantly reduced ictal/interictal-like discharges in a concentration-dependent manner, while not affecting the action-potential firing of small gamma-aminobutyric acid (GABA) neurons observed with whole-cell patch-clamp recordings from the same patient's HH tissue. These results suggest that neuronal gap junctions between small GABAergic HH neurons participate in the genesis of epileptic-like discharges. Blockade of gap junctions may be a new therapeutic strategy for controlling seizure activity in HH patients. Neuronal-type functional gap junctions are present in HH tissue. Expression of neuronal-type gap junctions is more abundant in HH tissue relative to normal hypothalamus (mammillary body). In HH slices, pharmacological block of neuronal-type gap junctions significantly reduces seizure-like discharges.
This paper evaluates the role that gap junctions contribute to seizure activity utilized human hypothalamic hamartoma (HH) tissue after surgical resection. We find that 1) gap junctions are present in HH tissue, 2) gap junctions are more abundant in HH tissue relative to normal hypothalamus (mammillary body), and 3) pharmacological blockade of gap junctions in freshly-resected HH tissue slices can decrease the seizure-like discharges. These results provide evidence that gap junctions participate in the generation of seizures from HH tissue and suggest further research into the possibility that gap junction blocking medications may improve seizures in patients with HH.
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Affiliation(s)
- Jie Wu
- The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan 450052, China; Division of Neurology, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ 85013, USA; Department of Pharmacology, Shantou University of Medical College, Guangdong, Shantou 815041, China.
| | - Ming Gao
- Division of Neurology, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ 85013, USA
| | - Stephen G Rice
- Division of Pediatric Neurology, Barrow Neurological Institute, Phoenix Children's Hospital, Phoenix, AZ 85016, USA
| | - Candy Tsang
- Division of Pediatric Neurology, Barrow Neurological Institute, Phoenix Children's Hospital, Phoenix, AZ 85016, USA
| | - John Beggs
- Division of Neurology, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ 85013, USA
| | - Dharshaun Turner
- Division of Neurology, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ 85013, USA
| | - Guohui Li
- Division of Neurology, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ 85013, USA
| | - Bo Yang
- The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan 450052, China
| | - Kunkun Xia
- The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan 450052, China; Division of Neurology, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ 85013, USA
| | - Fenfei Gao
- Department of Pharmacology, Shantou University of Medical College, Guangdong, Shantou 815041, China
| | - Shenfeng Qiu
- Department of Basic Medical Sciences, University of Arizona College of Medicine, Phoenix, AZ 85004, USA
| | - Qiang Liu
- Division of Neurology, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ 85013, USA
| | - John F Kerrigan
- Division of Pediatric Neurology, Barrow Neurological Institute, Phoenix Children's Hospital, Phoenix, AZ 85016, USA
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Semaan S, Wu J, Gan Y, Jin Y, Li GH, Kerrigan JF, Chang YC, Huang Y. Hyperactivation of BDNF-TrkB signaling cascades in human hypothalamic hamartoma (HH): a potential mechanism contributing to epileptogenesis. CNS Neurosci Ther 2015; 21:164-72. [PMID: 25307426 PMCID: PMC6495156 DOI: 10.1111/cns.12331] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2014] [Revised: 08/20/2014] [Accepted: 09/04/2014] [Indexed: 01/26/2023] Open
Abstract
AIMS Although compelling evidence suggests that human hypothalamic hamartoma (HH) is intrinsically epileptogenic for gelastic seizures, the molecular mechanisms responsible for epileptogenesis within HH remain to be elucidated. The aim of this study was to test the hypothesis that hyperactivation of BDNF-TrkB signaling pathways in surgically resected HH tissue is a possible mechanism for downregulation of KCC2 expression, which in turn underlies GABA-mediated excitation within HH. METHODS Activation of three major BDNF-TrkB signaling pathways including MAPKs, Akt, and PLCγ1 were evaluated in surgically resected HH tissue (n = 14) versus human hypothalamic control tissue (n = 8) using combined methodologies of biochemistry, molecular biology, cell biology, and electrophysiology. RESULTS Our data show that compared with hypothalamic control tissue, in HH tissue, (i) activation of TrkB and expression of mature BDNF are elevated; (ii) MAPKs (including ERK1/2, p38, and JNK), Akt, and PLCγ1 are highly activated; (iii) KCC2 expression is downregulated; and (iv) pharmacological manipulation of TrkB signaling alters HH neuronal firing rate. CONCLUSION Our findings suggest that multiple BDNF-TrkB signaling pathways are activated in HH. They act independently or collaboratively to downregulate KCC2 expression, which is the key component for GABA-mediated excitation associated with gelastic seizures.
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Affiliation(s)
- Suzan Semaan
- St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
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Wu J, Gao M, Shen JX, Qiu SF, Kerrigan JF. Mechanisms of intrinsic epileptogenesis in human gelastic seizures with hypothalamic hamartoma. CNS Neurosci Ther 2014; 21:104-11. [PMID: 25495642 DOI: 10.1111/cns.12348] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2014] [Revised: 10/07/2014] [Accepted: 10/08/2014] [Indexed: 12/24/2022] Open
Abstract
Human hypothalamic hamartoma (HH) is a rare developmental malformation often characterized by gelastic seizures, which are refractory to medical therapy. Ictal EEG recordings from the HH have demonstrated that the epileptic source of gelastic seizures lies within the HH lesion itself. Recent advances in surgical techniques targeting HH have led to dramatic improvements in seizure control, which further supports the hypothesis that gelastic seizures originate within the HH. However, the basic cellular and molecular mechanisms of epileptogenesis in this subcortical lesion are poorly understood. Since 2003, Barrow Neurological Institute has maintained a multidisciplinary clinical program to evaluate and treat patients with HH. This program has provided a unique opportunity to investigate the basic mechanisms of epileptogenesis using surgically resected HH tissue. The first report on the electrophysiological properties of HH neurons was published in 2005. Since then, ongoing research has provided additional insights into the mechanisms by which HH generate seizure activity. In this review, we summarize this progress and propose a cellular model that suggests that GABA-mediated excitation contributes to epileptogenesis in HH lesions.
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Affiliation(s)
- Jie Wu
- Division of Neurology, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA; Department of Physiology, Shantou University of Medical College, Shantou, Guangdong, China; Department of Basic Medical Sciences, University of Arizona College of Medicine-Phoenix, Phoenix, AZ, USA
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Kerrigan JF, Chrisman C, Rastogi RG. Unilateral visual loss in a previously healthy 15-year-old girl: monosymptomatic neuromyelitis optica? Semin Pediatr Neurol 2014; 21:145-51. [PMID: 25149951 DOI: 10.1016/j.spen.2014.04.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
We report a previously healthy 15 year old girl with acute onset of unilateral visual loss consistent with a diagnosis of monosymptomatic optic neuritis. Her symptoms responded well to the use of high-dose intravenous methylprednisolone. With very brief follow-up (2 months) she has had no subsequent difficulties. However, testing was positive for the presence of anti-aquaporin-4 antibodies in both serum and cerebrospinal fluid, which have been associated with neuromyelitis optica (NMO). While NMO antibodies lack complete sensitivity, there is high degree of specificity. Our patient does not meet currently accepted diagnostic criteria for NMO, but is likely at high-risk to develop myelitis or recurrent optic neuritis. There are no evidence-based guidelines for whether this patient should undergo disease-modifying treatment. Based upon the high-risk for clinical relapse, we have recommended immunosuppressive therapy with rituximab (anti-B cell monoclonal antibodies). While randomized trials for patients with this clinical scenario are unlikely, observational studies of a cohort of such patients would provide better guidance on the natural history and merits of disease-modifying therapy.
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Affiliation(s)
- John F Kerrigan
- Division of Pediatric Neurology, Barrow Neurological Institute, Phoenix Children's Hospital, Phoenix, AZ.
| | - Christina Chrisman
- Division of Neurology, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ
| | - Reena Gogia Rastogi
- Division of Pediatric Neurology, Barrow Neurological Institute, Phoenix Children's Hospital, Phoenix, AZ
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Steinmetz PN, Wait SD, Lekovic GP, Rekate HL, Kerrigan JF. Firing behavior and network activity of single neurons in human epileptic hypothalamic hamartoma. Front Neurol 2013; 4:210. [PMID: 24409165 PMCID: PMC3873534 DOI: 10.3389/fneur.2013.00210] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2013] [Accepted: 12/11/2013] [Indexed: 12/04/2022] Open
Abstract
OBJECTIVE Human hypothalamic hamartomas (HH) are intrinsically epileptogenic and are associated with treatment-resistant gelastic seizures. The basic cellular mechanisms responsible for seizure onset within HH are unknown. We used intra-operative microwire recordings of single neuron activity to measure the spontaneous firing rate of neurons and the degree of functional connection between neurons within the tumor. TECHNIQUE Fourteen patients underwent transventricular endoscopic resection of HH for treatment-resistant epilepsy. Prior to surgical resection, single neuron recordings from bundled microwires (total of nine contacts) were obtained from HH tissue. Spontaneous activity was recorded for two or three 5-min epochs under steady-state general anesthesia. Off-line analysis included cluster analysis of single unit activity and probability analysis of firing relationships between pairs of neurons. RESULTS Altogether, 222 neurons were identified (mean 6 neurons per recording epoch). Cluster analysis of single neuron firing utilizing a mixture of Gaussians model identified two distinct populations on the basis of firing rate (median firing frequency 0.6 versus 15.0 spikes per second; p < 10(-5)). Cluster analysis identified three populations determined by levels of burst firing (median burst indices of 0.015, 0.18, and 0.39; p < 10(-15)). Unbiased analysis of spontaneous single unit behavior showed that 51% of all possible neuron pairs within each recording epoch had a significant level of firing synchrony (p < 10(-15)). The subgroup of neurons with higher median firing frequencies was more likely to demonstrate synchronous firing (p < 10(-7)). CONCLUSION Hypothalamic hamartoma tissue in vivo contains neurons which fire spontaneously. The activity of single neurons is diverse but distributes into at least two electrophysiological phenoytpes. Functional linkage between single neurons suggests that HH neurons exist within local networks that may contribute to ictogenesis.
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Affiliation(s)
- Peter N. Steinmetz
- Comprehensive Epilepsy Center, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ, USA
| | - Scott D. Wait
- Carolina Neurosurgery and Spine Associates, Levine Children’s Hospital, Carolinas Medical Center, Charlotte, NC, USA
| | - Gregory P. Lekovic
- House Ear Institute, University of Southern California School of Medicine, Los Angeles, CA, USA
| | - Harold L. Rekate
- The Chiari Institute, Hofstra Northshore LIJ College of Medicine, Great Neck, NY, USA
| | - John F. Kerrigan
- Comprehensive Epilepsy Center, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ, USA
- Division of Pediatric Neurology, Barrow Neurological Institute at Phoenix Children’s Hospital, Phoenix, AZ, USA
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Wethe JV, Prigatano GP, Gray J, Chapple K, Rekate HL, Kerrigan JF. Cognitive functioning before and after surgical resection for hypothalamic hamartoma and epilepsy. Neurology 2013; 81:1044-50. [PMID: 23946307 DOI: 10.1212/wnl.0b013e3182a4a3e3] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVE To determine whether patients with hypothalamic hamartoma (HH) improve in their cognitive functioning after neurosurgical resection of their HH and explore what variables correlate with cognitive outcome. METHODS Thirty-two patients underwent preoperative and postoperative neuropsychological testing. The age range of patients was between 3.3 and 39.3 years (mean 12.2 years, SD 7.0). The average time interval between surgery and postoperative neuropsychological testing was 23.4 months (range 5.1-47.2 months). Tests administered varied on the basis of the patient's age and clinical condition. RESULTS As a group, measures of overall intelligence showed improvement postsurgery, with associated improvement in processing speed. Memory scores did not demonstrate consistent improvement or decline. Duration of epilepsy, age at surgery, and level of neurocognitive functioning prior to surgery were correlated with postsurgical cognitive status. Patients who had mental retardation but were testable generally showed the greatest gains. CONCLUSIONS Despite the great variability in level of cognitive impairment in patients with HH and refractory epilepsy, level of intelligence may show mild to moderate improvements postsurgery if no surgical complications occur. The variables that predict cognitive outcome are not fully delineated, but testable individuals with the greatest presurgical cognitive impairment and those with the shortest duration of epilepsy appear to make the greatest gains in intellectual functioning. CLASSIFICATION OF EVIDENCE This study provides Class IV evidence that single surgical resection for HH was associated with improvement in some subset measures of intellectual functioning, but not memory. Factors that predict better outcomes cannot be determined.
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Affiliation(s)
- Jennifer V Wethe
- From the Divisions of Neurology and Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ
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Abstract
We evaluated health-related quality of life in patients with hypothalamic hamartoma, to see how it differs from that of children with more common neurologic disorders. We used the PedsQL 4.0, along with the Child Behavior Checklist, Hague Seizure Severity Scale, and Side Effects Scale, to evaluate presurgical patients with hypothalamic hamartoma and epilepsy (n = 21). The results were compared with those of age-matched cohorts with migraine (n = 19) and Benign Epilepsy with Central Temporal Spikes (n = 11). In comparison with the migraine group, the patients with hypothalamic hamartoma had decreased health-related quality of life across all domains of the PedsQL 4.0. Compared with the benign epilepsy group, the hypothalamic hamartoma cohort has a significantly lower score in School Function. Comorbid psychomotor retardation was predictive of lower quality of life. Research examining the efficacy of recently developed surgical treatments for hypothalamic hamartoma should include health-related quality of life as an outcome measure.
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Affiliation(s)
- Cleo Park
- Division of Pediatric Neurology and Hypothalamic Hamartoma Program, Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix Children's Hospital, Phoenix, AZ, USA.
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Kerrigan JF, Parsons A, Rice SG, Simeone K, Shetter AG, Abla AA, Prenger E, Coons SW. Hypothalamic Hamartomas: Neuropathological Features with and without Prior Gamma Knife Radiosurgery. Stereotact Funct Neurosurg 2013. [DOI: 10.1159/000341076] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Drees C, Chapman K, Prenger E, Baxter L, Maganti R, Rekate H, Shetter A, Bobrowitz M, Kerrigan JF. Seizure outcome and complications following hypothalamic hamartoma treatment in adults: endoscopic, open, and Gamma Knife procedures. J Neurosurg 2012; 117:255-61. [PMID: 22680243 DOI: 10.3171/2012.5.jns112256] [Citation(s) in RCA: 69] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECT This study aimed at identifying outcomes with respect to seizures, morbidity, and mortality in adult patients undergoing resective or Gamma Knife surgery (GKS) to treat intractable epilepsy associated with hypothalamic hamartoma (HH). METHODS Adult patients undergoing surgical treatment for HH-related epilepsy were prospectively monitored at a single center for complications and seizure outcome by using a proprietary database. Preintervention and postintervention data for patients 18 years of age and older, and with at least 1 year of follow-up, were analyzed, with specific attention to seizure control, complications, hormonal status, and death. RESULTS Forty adult patients were found in the database (21 were women). The median HH volume was 0.54 cm(3). In 70% of patients, it was located inside the third ventricle, attached unilaterally and vertically to the hypothalamus (Delalande Type II). Most patients (26) underwent an endoscopic resection, 10 patients had a transcallosal or other type of open (pterional or orbitozygomatic) resection, and 4 patients chose GKS. Twenty-nine percent became seizure free in the long term, and overall a majority of patients (55%) reported at least > 90% seizure improvement. Only 3 patients were ultimately able to discontinue anticonvulsants, whereas most patients were taking an average of 2 antiepileptic drugs pre- and postoperatively. The only factor significantly correlated with seizure-free outcome was the absence of mental retardation. The HH volume, HH type, and amount of resection or disconnection were not correlated to seizure freedom. A total of 4 patients (10%) died, 2 immediately after surgery and 2 later. All of them had undergone a resection, as opposed to GKS, and still had seizures. Postoperatively, persistent neurological deficits were seen in 1 patient; 34% of patients had mild hormonal problems; and 59% experienced weight gain of at least 6.8 kg (average gain 12.7 kg). CONCLUSIONS Surgical or GKS procedures in adults with HH provided seizure freedom in one-third of patients. The only significant favorable prognostic factor was the absence of mental retardation. The overall mortality rate was high, at 10%. Other important morbidities were persistent hormonal disturbances and weight gain.
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Affiliation(s)
- Cornelia Drees
- Department of Neurology, University of Colorado School of Medicine, Aurora, Colorado 80045, USA.
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Troester M, Haine-Schlagel R, Ng YT, Chapman K, Chung S, Drees C, Prenger E, Rekate H, Kerrigan JF. EEG and video-EEG seizure monitoring has limited utility in patients with hypothalamic hamartoma and epilepsy. Epilepsia 2011; 52:1137-43. [DOI: 10.1111/j.1528-1167.2011.03095.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Abla AA, Wait SD, Forbes JA, Pati S, Johnsonbaugh RE, Kerrigan JF, Ng YT. Syndrome of alternating hypernatremia and hyponatremia after hypothalamic hamartoma surgery. Neurosurg Focus 2011; 30:E6. [PMID: 21284452 DOI: 10.3171/2010.12.focus10235] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT In this paper, the authors' goal was to describe the occurrence of alternating hypernatremia and hyponatremia in pediatric patients who underwent resection of hypothalamic hamartomas (HHs) for epilepsy. Hypernatremia in patients after pituitary or hypothalamic surgery can be caused by diabetes insipidus (DI), whereas hyponatremia can occur due to a syndrome of inappropriate antidiuretic hormone, cerebral salt wasting, or excessive administration of desmopressin (DDAVP). The triphasic response after surgery in the pituitary region can also explain variations in sodium parameters in such cases. METHODS One hundred fifty-three patients with HH who underwent surgery were enrolled in a prospective study to monitor outcomes. Of these, 4 patients (2.6%) were noted to experience dramatic alterations in serum sodium values. The medical records of these patients were identified and evaluated. RESULTS Patients' ages at surgery ranged from 1.2 to 6.0 years. All patients were girls. Two patients had Delalande Type IV lesions (of 16 total Type IV lesions surgically treated) and 2 had Type III lesions (of 39 total Type III lesions). All patients had a history of gelastic seizures refractory to medication. Seizure frequency ranged from 3 to 300 per day. After surgery, all patients experienced hypernatremia and hyponatremia. The largest fluctuation in serum sodium concentration during hospitalization in a single patient was 53 mEq/L (range 123-176 mEq/L). The mean absolute difference in maximum and minimum sodium values was 38.2 mEq/L. All patients exhibited an initial period of immediate DI (independent of treatment) after surgery followed by a period of hyponatremia (independent of treatment), with a minimum value occurring between postoperative Days 5 and 8. All patients then returned to a hypernatremic state of DI, and 3 patients still require DDAVP for DI management. A second occurrence of hyponatremia lasting several days without DDAVP administration occurred in 2 patients during their hospitalization between periods of hypernatremia. One patient stabilized in the normal range of sodium values prior to discharge from rehabilitation without the need for further intervention. At last follow-up, 3 patients are seizure-free. CONCLUSIONS Severe instability of sodium homeostasis with hypernatremia and hyponatremia is seen in up to 2.6% of children undergoing open resection of HH. This risk appears to be related to HH type, with a higher risk for Types III (2 [5.1%] of 39) and IV (2 [12.5%] of 16) lesions. Here, the authors describe alternating episodes of hypernatremia and hyponatremia in the postoperative period following HH surgery. Management of this entity requires careful serial assessment of volume status and urine concentration and will often require alternating salt replacement therapy with DDAVP administration.
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Affiliation(s)
- Adib A Abla
- Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona 85013, USA.
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Li G, Yang K, Zheng C, Liu Q, Chang Y, Kerrigan JF, Wu J. Functional rundown of gamma-aminobutyric acid(A) receptors in human hypothalamic hamartomas. Ann Neurol 2011; 69:664-72. [PMID: 21391233 DOI: 10.1002/ana.22298] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2010] [Revised: 08/23/2010] [Accepted: 09/17/2010] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Human hypothalamic hamartomas (HHs) are highly associated with treatment-resistant gelastic seizures. HHs are intrinsically epileptogenic, although the basic cellular mechanisms responsible for seizure activity are unknown. Altered gamma-aminobutyric acid (GABA) function can contribute to epileptogenesis in humans and animal models. Recently, functional GABA(A) receptor (GABA(A) R) rundown has been described in surgically resected human temporal lobe epilepsy tissue. We asked whether functional GABA(A) R rundown also occurs in human HH neurons. METHODS GABA(A) R-mediated currents were measured using perforated patch-clamp recordings in single neurons acutely dissociated from surgically resected HH tissue. In addition, functional GABA(A) Rs were expressed in Xenopus oocytes after microinjection with membrane fractions from either HH or control hypothalamus, and were studied with 2-electrode voltage-clamp recordings. RESULTS Perforated patch-clamp recordings in dissociated HH neurons showed that repetitive exposure to GABA (5 consecutive exposures to 0.1 mM GABA with 1-second duration and at 20-second intervals) induced a time-dependent rundown of whole-cell currents in small HH neurons, whereas large HH neurons showed much less rundown using the same protocol. Functional rundown was not observed in HH neurons with repetitive exposure to glycine or glutamate. Two-electrode voltage-clamp recordings (6 consecutive exposures to 1 mM GABA with 10-second duration and at 40-second intervals) induced GABA current rundown in Xenopus oocytes microinjected with HH membrane proteins, but not in the oocytes expressing hypothalamic membrane proteins derived from human autopsy controls. Functional rundown of GABA currents was significantly attenuated by intracellular application of adenosine triphosphate or the nonspecific phosphatase inhibitor, okadaic acid. INTERPRETATION Neurons from surgically resected human HH demonstrate functional rundown of GABA(A) R-mediated transmembrane currents in response to GABA agonist exposure. Rundown may be a marker for impaired GABAergic function and a contributing mechanism for seizure genesis within HH tissue.
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Affiliation(s)
- Guohui Li
- Division of Neurology, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
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Chapman KE, Kim DY, Rho JM, Ng YT, Kerrigan JF. Ketogenic diet in the treatment of seizures associated with hypothalamic hamartomas. Epilepsy Res 2011; 94:218-21. [PMID: 21377333 DOI: 10.1016/j.eplepsyres.2011.02.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2010] [Revised: 01/23/2011] [Accepted: 02/06/2011] [Indexed: 10/18/2022]
Abstract
Seizures associated with hypothalamic hamartoma (HH) are notoriously intractable to medical therapy, and while surgical resection affords most affected patients with complete or near seizure-freedom, there remains a need to identify alternative treatments. In this retrospective study, we identified six patients from a large cohort of 220 patients with HH who were treated with the ketogenic diet (KD). Four patients had a 50-90% reduction in multiple seizure types (including gelastic, partial-onset and atonic seizures), and two individuals failed to respond. In order to study possible mechanisms, we then performed microelectrode recordings of small neurons in surgically resected HH tissue slices. Exposure to ketone bodies decreased spontaneous firing in 5 of 7 small HH neurons. These preliminary results suggest that seizures associated with HH may respond favorably to the KD, and that ketone bodies might directly modulate the intrinsic epileptogenicity of HH tissue.
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Affiliation(s)
- Kevin E Chapman
- Barrow Neurological Institute and St. Joseph's Hospital & Medical Center, Phoenix, AZ 85013, USA
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31
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Simeone KA, Sabesan S, Kim DY, Kerrigan JF, Rho JM, Simeone TA. L-Type calcium channel blockade reduces network activity in human epileptic hypothalamic hamartoma tissue. Epilepsia 2011; 52:531-40. [PMID: 21269296 PMCID: PMC3071288 DOI: 10.1111/j.1528-1167.2010.02942.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Purpose Human hypothalamic hamartomas (HHs) are associated with gelastic seizures, intrinsically epileptogenic, and notoriously refractory to medical therapy. We previously reported that the L-type calcium channel antagonist nifedipine blocks spontaneous firing and γ-aminobutyric acid (GABA)A–induced depolarization of single cells in HH tissue slices. In this study, we examined whether blocking L-type calcium channels attenuates emergent activity of HH neuronal networks. Methods A high-density multielectrode array was used to record extracellular signals from surgically resected HH tissue slices. High-frequency oscillations (HFOs, ripples and fast ripples), field potentials, and multiunit activity (MUA) were studied (1) under normal and provoked [4-aminopyridine (4-AP)] conditions; and (2) following nifedipine treatment. Key Findings Spontaneous activity occurred during normal artificial cerebrospinal fluid (aCSF) conditions. Nifedipine reduced the total number and duration of HFOs, abolished the association of HFOs with field potentials, and increased the inter-HFO burst intervals. Notably, the number of active regions was decreased by 45 ± 9% (mean ± SEM) after nifedipine treatment. When considering electrodes that detected activity, nifedipine increased MUA in 58% of electrodes and reduced the number of field potentials in 67% of electrodes. Provocation with 4-AP increased the number of events and, as the number of electrodes that detected activity increased 248 ± 62%, promoted tissue-wide propagation of activity. During provocation with 4-AP, nifedipine effectively reduced HFOs, the association of HFOs with field potentials, field potentials, MUA, and the number of active regions, and limited propagation. Significance This is the first study to report (1) the presence of HFOs in human subcortical epileptic brain tissue in vitro; (2) the modulation of “pathologic” high-frequency oscillations (i.e., fast ripples) in human epileptic tissue by L-type calcium channel blockers; and (3) the modulation of network physiology and synchrony of emergent activity in human epileptic tissue following blockade of L-type calcium channels. Attenuation of activity in HH tissue during normal and provoked conditions supports a potential therapeutic usefulness of L-type calcium channel blockers in epileptic patients with HH.
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Affiliation(s)
- Kristina A Simeone
- Divisions of Neurology and Pediatric Neurology, Barrow Neurological Institute, St Joseph's Hospital and Medical Center, Phoenix, Arizona, USA.
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Ng YT, Hastriter EV, Wethe J, Chapman KE, Prenger EC, Prigatano GP, Oppenheim T, Varland M, Rekate HL, Kerrigan JF. Surgical resection of hypothalamic hamartomas for severe behavioral symptoms. Epilepsy Behav 2011; 20:75-8. [PMID: 21130692 DOI: 10.1016/j.yebeh.2010.10.027] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2010] [Revised: 10/21/2010] [Accepted: 10/26/2010] [Indexed: 10/18/2022]
Abstract
Hypothalamic hamartomas (HHs) are associated with treatment-resistant epilepsy. Many patients also experience severe and sometimes disabling psychiatric problems. The most common behavioral symptoms consist of paroxysms of uncontrolled anger related to poor frustration tolerance. These can include violence, resulting in disrupted family or school relationships, and legal consequences including incarceration. In a large cohort of patients undergoing surgical resection of HHs for refractory epilepsy, 88% of families described an improvement in overall behavioral functioning [1]. Here, we describe four patients (three males, mean age=11.9 years) who underwent surgical resection of HHs largely for behavioral indications. Three patients had relatively well controlled seizures, and one had no history of epilepsy. All patients had striking improvement in their psychiatric comorbidity. HH resection can result in significant improvement in behavioral functioning, even in patients with relatively infrequent seizures. Further investigation under approved human research protocols is warranted.
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Affiliation(s)
- Yu-tze Ng
- Division of Pediatric Neurology, Barrow Neurological Institute, Phoenix, AZ 85013, USA
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Abla AA, Shetter AG, Chang SW, Wait SD, Brachman DG, Ng YT, Rekate HL, Kerrigan JF. Gamma Knife surgery for hypothalamic hamartomas and epilepsy: patient selection and outcomes. J Neurosurg 2010; 113 Suppl:207-14. [PMID: 21121803 DOI: 10.3171/2010.8.gks101027] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
The authors present outcomes obtained in patients who underwent Gamma Knife surgery (GKS) at 1 institution as part of a multimodal treatment of refractory epilepsy caused by hypothalamic hamartomas (HHs).
Methods
Between 2003 and 2010, 19 patients with HH underwent GKS. Eight patients had follow-up for less than 1 year, and 1 patient was lost to follow-up. The 10 remaining patients (mean age 15.1 years, range 5.7–29.3 years) had a mean follow-up of 43 months (range 18–81 months) and are the focus of this report. Five patients had undergone a total of 6 prior surgeries: 1 transcallosal resection of the HH, 2 endoscopic transventricular resections of the HH, 2 temporal lobectomies, and 1 arachnoid cyst evacuation. In an institutional review board–approved study, postoperative complications and long-term outcome measures were monitored prospectively with the use of a proprietary database. Seven patients harbored Delalande Type II lesions; the remainder harbored Type III or IV lesions. Seizure frequency ranged from 1–2 monthly to as many as 100 gelastic seizures daily. The mean lesion volume was 695 mm3 (range 169–3000 mm3, median 265 mm3). The mean/median dose directed to the 50% isodose line was 18 Gy (range 16–20 Gy). The mean maximum point dose to the optic chiasm was 7.5 Gy (range 5–10 Gy). Three patients underwent additional resection 14.5, 21, and 32 months after GKS.
Results
Of the 10 patients included in this study, 6 are seizure free (2 after they underwent additional surgery), 1 has a 50%–90% reduction in seizure frequency, 2 have a 50% reduction in seizure frequency, and 1 has observed no change in seizure frequency. Overall quality of life, based on data obtained from follow-up telephone conversations and/or surveys, improved in 9 patients and was due to improvements in seizure control (9 patients), short-term memory loss (3 patients), and behavioral symptoms (5 patients); in 1 patient, quality of life remains minimally affected. Incidences of morbidity were all temporary and included poikilothermia (1 patient), increased depression (1 patient), weight gain/increased appetite (2 patients), and anxiety (1 patient) after GKS.
Conclusions
Of the approximately 150 patients at Barrow Neurological Institute who have undergone treatment for HH, the authors have reserved GKS for treatment of small HHs located distal from radiosensitive structures in patients with high cognitive function and a stable clinical picture, which allows time for the effects of radiosurgery to occur without further deterioration. The lack of significant morbidity and the clinical outcomes achieved in this study demonstrated a low risk of GKS for HH with results comparable to those of previous series.
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Affiliation(s)
| | | | | | | | | | - Yu-Tze Ng
- 3Neurology, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | | | - John F. Kerrigan
- 3Neurology, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
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Chan YM, Fenoglio-Simeone KA, Paraschos S, Muhammad L, Troester MM, Ng YT, Johnsonbaugh RE, Coons SW, Prenger EC, Kerrigan JF, Seminara SB. Central precocious puberty due to hypothalamic hamartomas correlates with anatomic features but not with expression of GnRH, TGFalpha, or KISS1. Horm Res Paediatr 2010; 73:312-9. [PMID: 20389100 PMCID: PMC2868525 DOI: 10.1159/000308162] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2009] [Accepted: 06/17/2009] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND/AIMS Hypothalamic hamartomas are the most common identifiable cause of central precocious puberty (CPP). Hamartoma characteristics proposed to be associated with CPP include specific anatomic features and expression of molecules such as gonadotropin-releasing hormone (GnRH), transforming growth factor alpha (TGFalpha), and GRM1A, which encodes the type 1 metabotropic glutamate receptor alpha isoform. We sought to determine whether hamartomas that cause CPP could be distinguished by anatomic features, expression of these molecules, or expression of KISS1, whose products signal through the receptor GPR54 to stimulate GnRH release. METHODS Clinical records and radiologic images were reviewed for 18 patients who underwent hamartoma resection for intractable seizures; 7 had precocious puberty. Resected tissue was examined for expression of GnRH, GnRH receptor (GnRHR), TGFalpha, KISS1, GPR54, and GRM1A. RESULTS Hypothalamic hamartomas associated with CPP were more likely to contact the infundibulum or tuber cinereum and were larger than hamartomas not associated with CPP. GnRH, TGFalpha, and GnRHR were expressed by all hamartomas studied. Expression of KISS1, GPR54, and GRM1A did not differ significantly between hamartomas associated and not associated with CPP. CONCLUSION Anatomic features rather than expression patterns of candidate molecules distinguish hypothalamic hamartomas that are associated with CPP from those that are not.
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Affiliation(s)
- Yee-Ming Chan
- Harvard Reproductive Sciences Center and Reproductive Endocrine Unit, Department of Medicine, Massachusetts General Hospital, Boston, MA 02114, USA.
| | - Kristina A. Fenoglio-Simeone
- Divisions of Neurology and Pediatric Neurology, Barrow Neurological Institute and Children's Health Center, St. Joseph's Hospital and Medical Center, Phoenix, Ariz., USA
| | - Sophia Paraschos
- Harvard Reproductive Sciences Center and Reproductive Endocrine Unit, Department of Medicine, Massachusetts General Hospital Boston, Boston, Mass., USA
| | - Laura Muhammad
- Divisions of Neurology and Pediatric Neurology, Barrow Neurological Institute and Children's Health Center, St. Joseph's Hospital and Medical Center, Phoenix, Ariz., USA
| | - Matthew M. Troester
- Divisions of Neurology and Pediatric Neurology, Barrow Neurological Institute and Children's Health Center, St. Joseph's Hospital and Medical Center, Phoenix, Ariz., USA
| | - Yu-tze Ng
- Divisions of Neurology and Pediatric Neurology, Barrow Neurological Institute and Children's Health Center, St. Joseph's Hospital and Medical Center, Phoenix, Ariz., USA
| | | | | | - Erin C. Prenger
- Neuroimaging, Barrow Neurological Institute, Phoenix, Ariz., USA
| | - John F. Kerrigan
- Divisions of Neurology and Pediatric Neurology, Barrow Neurological Institute and Children's Health Center, St. Joseph's Hospital and Medical Center, Phoenix, Ariz., USA
| | - Stephanie B. Seminara
- Harvard Reproductive Sciences Center and Reproductive Endocrine Unit, Department of Medicine, Massachusetts General Hospital Boston, Boston, Mass., USA
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Kerrigan JF. Editorial comment. Semin Pediatr Neurol 2010; 17:15-6. [PMID: 20434686 DOI: 10.1016/j.spen.2010.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Munoz M, Kerrigan JF. Neonatal hypoxic-ischemic encephalopathy and total-body cooling. Semin Pediatr Neurol 2010; 17:82-6. [PMID: 20434705 DOI: 10.1016/j.spen.2010.02.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Maya Munoz
- Children's Health Center, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ 85013, USA
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Lekovic GP, Kerrigan JF, Wait S, Rekate HL, Steinmetz PN. IN SITU SINGLE-UNIT RECORDING OF HYPOTHALAMIC HAMARTOMAS UNDER ENDOSCOPIC DIRECT VISUALIZATION. Neurosurgery 2009; 65:E1195-6; discussion E1196. [DOI: 10.1227/01.neu.0000359531.45021.52] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
OBJECTIVE
Hypothalamic hamartomas (HHs) are associated with refractory epilepsy and are amenable to surgical treatment. The gelastic seizures associated with HHs originate within the HH lesion, but the responsible cellular mechanisms are unknown. Microelectrode patch-clamp recordings from HH neurons in resected slice preparations show that small HH neurons spontaneously fire with intrinsic pacemaker-like activity. We questioned whether spontaneous firing of HH neurons was present in situ, and we hypothesized that single-unit field recordings from HH tissue could be obtained with instrumentation passed through the endoscope before surgical resection.
TECHNIQUE
After informed consent was obtained, patients undergoing transventricular, endoscopic resection of an HH for intractable epilepsy were eligible for study. After placement of the endoscope, a bundled microwire (total of 9 contacts) was placed into the HH under direct visualization. Spontaneous activity was recorded for two or three 5-minute epochs, under steady-state general anesthesia. The wire was advanced 0.5 to 1 mm within the lesion between recording epochs.
RESULTS
A total of thirteen 5-minute recordings were obtained from 5 patients. Noise levels were comparable to extraoperative microwire recordings for temporal lobe epilepsy. Single-neuron spike activity was isolated from a total of 5 channels obtained during recording of 3 sessions in 3 patients.
CONCLUSION
We have shown that single-unit recordings from HH lesions can be successfully obtained in situ under direct endoscopic visualization. We believe that this is the first report using the working channel of a neuroendoscope to make physiological recordings of deep structures in humans.
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Affiliation(s)
- Gregory P. Lekovic
- Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - John F. Kerrigan
- Division of Neurology, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Scott Wait
- Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Harold L. Rekate
- Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Peter N. Steinmetz
- Divisions of Neurological Surgery and Neurology, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
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Wu J, DeChon J, Xue F, Li G, Ellsworth K, Gao M, Liu Q, Yang K, Zheng C, He P, Tu J, Kim DY, Rho JM, Rekate H, Kerrigan JF, Chang Y. GABA(A) receptor-mediated excitation in dissociated neurons from human hypothalamic hamartomas. Exp Neurol 2008; 213:397-404. [PMID: 18675803 DOI: 10.1016/j.expneurol.2008.07.004] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2008] [Revised: 05/30/2008] [Accepted: 07/01/2008] [Indexed: 11/19/2022]
Abstract
The cellular mechanisms underlying intrinsic epileptogenesis in human hypothalamic hamartoma (HH) are unknown. We previously reported that HH tissue is composed predominantly of GABAergic neurons, but how GABAergic-neuron-rich HH tissue is intrinsically epileptogenic is unclear. Here, we tested the hypotheses that some HH neurons exhibit immature features and that GABA excites these neurons via activation of GABA(A) receptors (GABA(A)Rs). Gramicidin-perforated and cell-attached patch-clamp recordings were performed using freshly-dissociated HH neurons to evaluate GABA(A)R-mediated currents, Cl(-) equilibrium potentials, and intracellular Cl(-) concentrations. Single-cell RT-PCR and immunocytochemical techniques were used to examine cation-Cl(-) co-transporter (NKCC1 and KCC2) gene and KCC2 protein expression and molecular markers of maturation. From a total of 93 acutely-dissociated HH neurons from 34 patients, 76% were small (soma: 6-9 microm) and 24% were large (soma: >20 microm) in size. Under gramicidin-perforated patch recording conditions, GABA(A)R activation depolarized/excited large but hyperpolarized/inhibited small HH neurons in most cases. Compared to small HH neurons, large HH neurons exhibited more positive Cl(-) equilibrium potentials, higher intracellular Cl(-) concentrations, lower KCC2 expression, and an immature phenotype, consistent with GABA(A)R-mediated excitation. Taken collectively, we provide novel evidence for and mechanistic insights into HH epileptogenicity: GABA(A)R-mediated excitation.
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Affiliation(s)
- Jie Wu
- Division of Neurology, NRC 445, Barrow Neurological Institute, St Joseph's Hospital and Medical Center, Phoenix, AZ 85013-4496, USA.
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Kim DY, Fenoglio KA, Simeone TA, Coons SW, Wu J, Chang Y, Kerrigan JF, Rho JM. GABAA receptor-mediated activation of L-type calcium channels induces neuronal excitation in surgically resected human hypothalamic hamartomas. Epilepsia 2008; 49:861-71. [PMID: 18076645 DOI: 10.1111/j.1528-1167.2007.01455.x] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
PURPOSE The human hypothalamic hamartoma (HH) is a rare, intrinsically epileptogenic lesion associated with gelastic seizures, but the underlying mechanisms remain unclear. Here, we examined the role of GABAA receptors in surgically resected HH tissue. METHODS HH tissue slices (350 microm) were studied using cellular electrophysiological, calcium imaging, and immunocytochemical techniques. RESULTS Two neuronal cell types were seen: small (10-16 microm) spontaneously firing GABAergic neurons and large (20-28 microm) quiescent neurons. In gramicidin-perforated patch recordings, muscimol (30 microM) induced membrane depolarization in 70% of large (but not small) neurons and a concomitant rise in intracellular calcium. These responses were blocked by bicuculline methiodide (50 microM). Depolarizing neurons also exhibited more positive reversal potentials (Emuscimol) and significantly higher intracellular chloride concentrations compared to those that hyperpolarized. The cation chloride co-transporters NKCC1 and KCC2 were coexpressed in the majority of large neurons, but fluorometric measurements revealed that 84% of large HH neurons expressed solely or relatively more NKCC1. Bumetanide (20 microM), a NKCC1 antagonist, partially suppressed muscimol-induced excitation in large neurons. Concordant with robust expression of CaV1.2 and CaV1.3 subunits in HH neurons, the L-type calcium channel blocker nifedipine (100 microM) prevented muscimol-induced neuronal excitation. CONCLUSIONS GABAA receptor-mediated excitation, due in part to differential expression of NKCC1 and KCC2 and subsequent activation of L-type calcium channels, may contribute to seizure genesis in HH tissue. Given the ready availability of L-type calcium channel blockers, our results have clinical ramifications for the treatment of seizures associated with HH lesions.
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MESH Headings
- Action Potentials/drug effects
- Action Potentials/physiology
- Adolescent
- Adult
- Calcium Channels, L-Type/drug effects
- Calcium Channels, L-Type/metabolism
- Calcium Channels, L-Type/physiology
- Child, Preschool
- Chloride Channels/metabolism
- Epilepsies, Partial/metabolism
- Epilepsies, Partial/physiopathology
- Female
- Hamartoma/metabolism
- Hamartoma/physiopathology
- Hamartoma/surgery
- Humans
- Hypothalamic Diseases/metabolism
- Hypothalamic Diseases/physiopathology
- Hypothalamic Diseases/surgery
- Immunohistochemistry
- Infant
- Male
- Membrane Potentials/drug effects
- Membrane Potentials/physiology
- Models, Neurological
- Muscimol/pharmacology
- Neurons/drug effects
- Neurons/metabolism
- Neurons/physiology
- Nifedipine/pharmacology
- Patch-Clamp Techniques
- Receptors, GABA-A/drug effects
- Receptors, GABA-A/metabolism
- Receptors, GABA-A/physiology
- Sodium-Potassium-Chloride Symporters/metabolism
- Solute Carrier Family 12, Member 2
- Symporters/drug effects
- Symporters/metabolism
- K Cl- Cotransporters
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Affiliation(s)
- Do Young Kim
- Division of Pediatric Neurology, Barrow Neurological Institute, St. Joseph's Hospital & Medical Center, Phoenix, AZ 85013, USA
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Craig DW, Itty A, Panganiban C, Szelinger S, Kruer MC, Sekar A, Reiman D, Narayanan V, Stephan DA, Kerrigan JF. Identification of somatic chromosomal abnormalities in hypothalamic hamartoma tissue at the GLI3 locus. Am J Hum Genet 2008; 82:366-74. [PMID: 18252217 DOI: 10.1016/j.ajhg.2007.10.006] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2007] [Revised: 10/04/2007] [Accepted: 10/15/2007] [Indexed: 10/22/2022] Open
Abstract
Hypothalamic hamartomas (HH) are rare, benign congenital tumors associated with intractable epilepsy. Most cases are sporadic and nonsyndromic. Approximately 5% of HH cases are associated with Pallister-Hall syndrome (PHS), which is caused by haploinsufficiency of GLI3. We have investigated the possibility that HH pathogenesis in sporadic cases is due to a somatic (tumor-only) mutation in GLI3. We isolated genomic DNA from peripheral blood and surgically resected HH tissue in 55 patients with sporadic HH and intractable epilepsy. A genome-wide screen for loss of heterozygosity (LOH) and chromosomal abnormalities was performed with parallel analysis of blood and HH tissue with Affymetrix 10K SNP microarrays. Additionally, resequencing and fine mapping with SNP genotyping were completed for the GLI3 gene with comparisons between peripheral blood and HH tissue pairs. By analyzing chromosomal copy-number data for paired samples on the Affymetrix 10K array, we identified a somatic chromosomal abnormality on chromosome 7p in one HH tissue sample. Resequencing of GLI3 did not identify causative germline mutations but did identify LOH within the GLI3 gene in the HH tissue samples of three patients. Further genotyping of 28 SNPs within and surrounding GLI3 identified five additional patients exhibiting LOH. Together, these data provide evidence that the development of chromosomal abnormalities within GLI3 is associated with the pathogenesis of HH lesions in sporadic, nonsyndromic patients with HH and intractable epilepsy. Chromosomal abnormalities including the GLI3 locus were seen in 8 of 55 (15%) of the resected HH tissue samples. These somatic mutations appear to be highly variable.
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Baxter L, Spencer B, Kerrigan JF. Clinical application of functional MRI for memory using emotional enhancement: deficit and recovery with limbic encephalitis. Epilepsy Behav 2007; 11:454-9. [PMID: 17709301 DOI: 10.1016/j.yebeh.2007.04.022] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2007] [Revised: 04/12/2007] [Accepted: 04/13/2007] [Indexed: 11/19/2022]
Abstract
Although some functional MRI memory studies show reliable neural activity in the hippocampus and mesial temporal lobe (MTL), most typically report results from group studies. However, fMRI memory probes need to be robust enough to show MTL activity in individual patients to be helpful in diagnosis and treatment planning. We present the case of a patient with non-paraneoplastic limbic encephalitis who had severe anterograde amnesia with subsequent recovery to illustrate a fMRI probe of MTL activity that is easily administered to neurological patients. The task uses emotionally positive and affiliative stimuli to elicit responsivity in the amygdala-hippocampus region. In this patient, weak bilateral hippocampal activation was observed in the acute stage that increased after recovery, paralleling findings on structural MRI and neuropsychological memory assessment. This case study demonstrates that using emotional stimuli to enhance memory responsivity may be an effective way to visualize clinical changes in individual patients.
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Affiliation(s)
- Leslie Baxter
- Department of Neuropsychology, Barrow Neurological Institute, St Joseph's Hospital and Medical Center, Phoenix, AZ 85013, USA
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42
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Little AS, Ng YT, Kerrigan JF, Treiman DM, Fram E, Rekate HL. Anterior motor strip displacement in a boy with right frontal gray matter heterotopia undergoing epilepsy surgery. Epilepsy Behav 2007; 11:241-6. [PMID: 17681862 DOI: 10.1016/j.yebeh.2007.05.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2007] [Revised: 05/07/2007] [Accepted: 05/12/2007] [Indexed: 11/17/2022]
Abstract
The case of a 14-year-old boy with behavioral problems and medically refractory epilepsy related to symptomatic gray matter heterotopia in the right frontal lobe is reported. The patient underwent subdural cortical grid placement for seizure localization and functional mapping prior to lesionectomy. On the basis of the patient's MRI scan, it was predicted that the motor cortex was located adjacent to the abnormality, well anterior to its expected location. This prediction was confirmed by stimulation mapping. The patient underwent successful resection of the lesion under the guidance of the cortical map. Postoperatively, his seizures and behavior improved markedly. This case highlights how eloquent cortex can rarely be drawn toward a region of gray matter heterotopia. In addition, he is one of the few reported cases of focal cortical dysplasia resection with resultant improved behavior. These observations of unusual cortical representations have implications in epilepsy surgery planning.
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Affiliation(s)
- Andrew S Little
- Division of Neurological Surgery, Barrow Neurological Institute, St Joseph's Hospital and Medical Center, Phoenix, AZ 85013, USA
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43
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Little AS, Kerrigan JF, McDougall CG, Zabramski JM, Albuquerque FC, Nakaji P, Spetzler RF. Nonconvulsive status epilepticus in patients suffering spontaneous subarachnoid hemorrhage. J Neurosurg 2007; 106:805-11. [PMID: 17542523 DOI: 10.3171/jns.2007.106.5.805] [Citation(s) in RCA: 74] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Nonconvulsive status epilepticus (NCSE) is an underrecognized and poorly understood complication of aneurysmal subarachnoid hemorrhage (SAH). The authors evaluated the risk factors, electroencephalographic (EEG) characteristics, hospital course, and clinical outcomes associated with NCSE in a population with SAH treated at a single institution. METHODS The hospitalization and outcome data were reviewed in 11 patients who had received a diagnosis of NCSE and SAH. The study included individuals from a cohort of 389 consecutive patients with SAH who were treated between March 2003 and June 2005, and who were analyzed retrospectively. The patients' medical history, neurological grade, events of hospitalization, EEG morphological patterns, and disposition were analyzed. Advanced age, female sex, need for ventriculostomy, poor neurological grade (Hunt and Hess Grade III, IV, or V), thick cisternal blood clots, and structural lesions (intracerebral hemorrhage and stroke) were common in the population with NCSE. Patients with normal results on angiograms, good neurological grade (Hunt and Hess Grade I or II), and minimal SAH (Fisher Grade 1 or 2) were at lower risk. The most common ictal patterns were intermittent, and consisted of generalized periodic epileptiform discharges. Medical complications were also frequent, and the outcome of these patients was poor despite aggressive treatment regimens. CONCLUSIONS Nonconvulsive status epilepticus is a devastating complication of SAH with a high rate of associated morbidity. Based on these findings it appears that the patients at highest risk for NCSE can be identified, and this should provide a basis for further studies designed to determine the clinical significance of various EEG patterns and to develop preventative strategies.
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Affiliation(s)
- Andrew S Little
- Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona 85013, USA
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Fenoglio KA, Wu J, Kim DY, Simeone TA, Coons SW, Rekate H, Rho JM, Kerrigan JF. Hypothalamic hamartoma: basic mechanisms of intrinsic epileptogenesis. Semin Pediatr Neurol 2007; 14:51-9. [PMID: 17544947 DOI: 10.1016/j.spen.2007.03.002] [Citation(s) in RCA: 75] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The hypothalamic hamartoma (HH) is a rare developmental malformation commonly associated with gelastic seizures that are notoriously refractory to medical therapy. Recent evidence supports the intrinsic seizure propensity of HH. Despite increasing clinical recognition of this condition, the mechanisms of seizure genesis in HH tissue remain unclear. This review summarizes the histochemical and electrophysiological properties of HH neurons, and relates these findings to those characteristics identified in other types of epileptic tissue. Initial studies have revealed two distinct populations of neurons in surgically resected HH tissue. One group consisted of small gamma-aminobutyric acid (GABA)-expressing neurons that occurred principally in clusters and displayed spontaneous rhythmic firing. The second group was composed of large, quiescent, pyramidal-like neurons with more extensive dendritic and axonal arborization. We propose that the small, spontaneously firing GABAergic neurons send inhibitory projections to and drive the synchrony of large output neurons. These observations constitute the basis for future investigations aimed at elucidating the mechanisms of subcortical epileptogenesis.
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Affiliation(s)
- Kristina A Fenoglio
- Division of Neurology and Pediatric Neurology, Barrow Neurological Institute and Children's Health Center, St. Joseph's Hospital and Medical Center, Phoenix, AZ 85013, USA.
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Kerrigan JF, Kruer MC, Corneveaux J, Panganiban CB, Itty A, Reiman D, Ng YT, Stephan DA, Craig DW. Chromosomal abnormality at 6p25.1-25.3 identifies a susceptibility locus for hypothalamic hamartoma associated with epilepsy. Epilepsy Res 2007; 75:70-3. [PMID: 17512701 DOI: 10.1016/j.eplepsyres.2007.04.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2006] [Revised: 02/27/2007] [Accepted: 04/13/2007] [Indexed: 12/11/2022]
Abstract
The pathogenesis of hypothalamic hamartoma (HH) associated with epilepsy is unknown. We have identified an individual with HH and refractory epilepsy exhibiting subtle dysmorphic features. High-resolution karyotype identified a duplication of the terminal end of 6p (6p25.1-25.3), confirmed by fluorescent in situ-hybridization (FISH). Copy number analysis with high-density (250K) single nucleotide polymorphism (SNP) genotyping microarrays characterized the abnormality as a series of amplified regions between 1.4 Mb and 10.2 Mb, with a small tandem deletion from 8.8 Mb to 9.7 Mb. There are 38 RefSeq genes within the duplicated regions, and no known coding sequences within the deletion. This unique patient helps identify 6p25.1-25.3 as a possible susceptibility locus for sporadic HH.
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Affiliation(s)
- John F Kerrigan
- Epilepsy Center and Division of Pediatric Neurology, Barrow Neurological Institute and Children's Health Center, St. Joseph's Hospital and Medical Center, Phoenix, AZ 85013, USA.
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Abstract
Gastroesophageal reflux disease can have variable manifestations including regurgitation, irritability, arching, choking, and apnea. The disorder is also frequently mistaken for seizures (Sandifer syndrome). We report 6 patients in whom the opposite phenomenon occurred: their seizures were mistaken for gastroesophageal reflux disease. Six of 77 patients (6.8%) with gelastic seizures and epilepsy symptomatic of hypothalamic hamartomas were noted to be misdiagnosed with gastroesophageal reflux disease in infancy. As is typical in these patients, gelastic seizures were not diagnosed until months, or often years, later. Delayed diagnosis of hypothalamic hamartomas can lead to a potentially deleterious syndrome involving refractory epilepsy, developmental problems, and precocious puberty. Gelastic seizures should be considered among the conditions that can mimic reflux symptoms.
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Affiliation(s)
- Laura L Sweetman
- Division of Pediatric Neurology, Barrow Neurological Institute and Children's Health Center, St. Joseph's Hospital and Medical Center, Phoenix, Arizona 85013, USA
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Wu J, Chang Y, Li G, Xue F, DeChon J, Ellsworth K, Liu Q, Yang K, Bahadroani N, Zheng C, Zhang J, Rekate H, Rho JM, Kerrigan JF. Electrophysiological properties and subunit composition of GABAA receptors in patients with gelastic seizures and hypothalamic hamartoma. J Neurophysiol 2007; 98:5-15. [PMID: 17428906 DOI: 10.1152/jn.00165.2007] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Abnormalities in GABA(A) receptor structure and/or function have been associated with various forms of epilepsy in both humans and animals. Whether this is true for patients with gelastic seizures and hypothalamic hamartoma (HH) is unknown. In this study, we characterized the pharmacological properties and native subunit composition of GABA(A) receptors on acutely dissociated single neurons from surgically resected HH tissues using patch-clamp, immunocytochemical, and RT-PCR techniques. We found that 1) GABA induced an inward current (I(GABA)) at a holding potential of -60 mV; 2) I(GABA) was mimicked by the GABA(A) receptor agonist muscimol and blocked by the GABA(A) receptor antagonist bicuculline, suggesting that I(GABA) was mediated principally through the GABA(A) receptor; 3) the EC(50) and Hill coefficient derived from the I(GABA) concentration-response curve were 6.8 muM and 1.9, respectively; 4) the current-voltage curve was linear at a reversal potential close to zero; and 5) I(GABA) exhibited low sensitivity to zinc and diazepam but higher sensitivity to pentobarbital and pregnanolone. Additionally, using Xenopus oocytes microtransplanted with normal human hypothalamic tissue, we confirmed that the functional properties of GABA(A) receptors were similar to those seen in small isolated HH neurons. Finally, the expression profile of GABA(A) receptor subunits obtained from normal control human hypothalamic tissue was identical to that from surgically resected human HH tissue. Taken together, our data indicate that GABA(A) receptors on small HH neurons exhibit normal pharmacosensitivity and subunit composition. These findings bear relevance to a broader understanding of inhibitory neurotransmission in human HH tissue.
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Affiliation(s)
- Jie Wu
- Neurophysiology Lab, Div of Neurology, Barrow Neurological Inst, St Joseph's Hospital and Medical Center, Phoenix, AZ 85013-4496, USA.
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Abstract
OBJECT The purpose of this study was to report the cases of five patients with status epilepticus who were treated successfully with neurosurgery. METHODS Five children presented with refractory status epilepticus, including complex partial status epilepticus, epilepsia partialis continua and "status gelasticus." Multiple medical therapies had failed to control the seizures, and focal resection was performed. Seizures were fully controlled in four patients, and in one patient seizure frequency was reduced by more than 90%. CONCLUSIONS Refractory status epilepticus is associated with a high mortality rate and by definition does not respond well to medical treatment, even optimal medical treatment. Neurosurgical treatment should be considered as another therapeutic option once medical management has failed, and neurosurgery should not necessarily be a last resort.
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Affiliation(s)
- Yu-Tze Ng
- Department of Pediatric Neurology, Barrow Neurological Institute, Phoenix, Arizona 85013, USA.
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Abstract
Hypothalamic hamartomas (HHs) are rare developmental tumors that cause seizures or pituitary axis dysfunction, usually beginning in childhood. We analyzed HH tissue from 57 patients whose tumors were resected through recently developed transcallosal interforniceal and transventricular endoscopic surgical approaches. All cases were composed of abnormally distributed but cytologically normal neurons and glia, including fibrillary astrocytes and oligodendrocytes. Neuronal elements predominated in most cases, but a relative increase in astrocytic elements was seen with increasing age. All had various sized nodular foci of neurons as well as areas of diffusely distributed neurons with interspersed glial cells. Smaller neurons predominated, and most cases had only a few interspersed large ganglion cells. Immunohistochemistry demonstrated extensive production of synapse-associated proteins. Immunohistochemistry for phosphorylated and nonphosphorylated neurofilament and alpha-internexin demonstrated staining patterns consistent with mature neurons. In contrast to cortical dysplasia, atypical large ganglion-like balloon cells were almost never seen. In summary, although their number and distribution vary, mature smaller neurons were the most prominent and most consistent histologic feature of HH. Nodules of these small neurons were a universal feature of the microarchitecture of HH lesions associated with epilepsy. Characterization of these neurons may aid in understanding the mechanism of seizure development in HH.
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Affiliation(s)
- Stephen W Coons
- Division of Neuropathology, Barrow Neurological Institute, Phoenix, Arizona 85013, USA
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Abstract
PURPOSE A small number of patients with hypothalamic hamartoma (HH) present with infantile spasms (IS) as an initial or early seizure type. We describe the clinical features of IS associated with HH. METHODS Our series of patients with HH and epilepsy was reviewed to identify cases with a history of IS. The clinical features and neuroradiological findings in this study group were compared to a control group of patients with HH and refractory epilepsy, but without a history of IS. RESULTS We identified six patients with HH and a history of IS in this series (n = 122, 4.9%). Five of the six are male. Four of the six patients (67%) developed IS as their first seizure type. The mean age for onset of IS was 6.2 months (range 4-9 months). Results of electroencephalographic (EEG) study at the time of IS diagnosis showed hypsarrhythmia in two (33%). Five patients were treated with adrenocorticotropic hormone (ACTH), and four of the five (80%) responded with control of IS. However, these patients developed other seizure types, and were ultimately refractory to medical management. Aside from the IS, no significant differences in clinical and imaging features were determined between the study group and the control group. CONCLUSIONS HH should be included in the differential diagnosis for infants presenting with IS. These patients may have hypsarrhythmia on initial EEG, and may respond to ACTH treatment with improvement of IS. However, all became refractory with other seizure types, more commonly seen in HH patients. Focal pathologies associated with IS may be subcortical, as well as cortical, in nature. We have not identified any predictive features for the occurrence of IS in the HH population.
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Affiliation(s)
- John F Kerrigan
- Epilepsy Center and Division of Pediatric Neurology, Barrow Neurological Institute and Children's Health Center, St Joseph's Hospital and Medical Center, Phoenix, Arizona, USA.
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