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Jindal M, Neligan A, Rajakulendran S. Early and established status epilepticus: The impact of timing of intervention, treatment escalation and dosing on outcome. Seizure 2023; 111:98-102. [PMID: 37556986 DOI: 10.1016/j.seizure.2023.07.022] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2023] [Revised: 07/23/2023] [Accepted: 07/28/2023] [Indexed: 08/11/2023] Open
Abstract
OBJECTIVE We investigated the management and outcome of early and established status epilepticus including timing, dosing and selection of benzodiazepines along with the timing and efficacy of second line treatments. METHODS Retrospective single tertiary centre observational cohort study to identify all cases of SE between January 2019 and February 2022. RESULTS 252 cases were identified. Seizures terminated spontaneously in 136 (54%) cases. 116 (46%) were given benzodiazepines, of which 29 (25%) were given at least one benzodiazepine by family/carers, and 72 (62.1%) received benzodiazepines by ambulance services. Benzodiazepines terminated seizures in 83 (71.6%) cases. The commonest benzodiazepine used was buccal midazolam (35.5%). Median time to first benzodiazepine was 14.5 (6-27) minutes. There was a positive correlation between time to first benzodiazepine and time to seizure cessation, progression to second- and third-line treatment, and respiratory complications (p<0.05). 73 (62.9%) cases received a correct benzodiazepine dose. Benzodiazepine underdosing was associated with longer seizure duration (p<0.05). 33 (28.4%) cases progressed to second-line treatment where mean time to treatment was 59.4 min (±32.3 min). The commonest second-line treatment was Levetiracetam (53.8%), followed by Phenytoin (43.6%) with SE termination in 57.5% cases. 14 (12.1%) cases progressed to third-line treatment; mean time to treatment was 60.6 min (±22.24 min). Respiratory complications occurred in 17 (6.75%) cases; none due to benzodiazepines. There were two deaths in refractory SE. CONCLUSION Early administration of benzodiazepines and optimal dosing is associated with a higher rate of SE termination. Levetiracetam was the most commonly used second line treatment.
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Affiliation(s)
- Malaika Jindal
- UCL Queen Square Institute of Neurology, London, United Kingdom
| | - Aidan Neligan
- UCL Queen Square Institute of Neurology, London, United Kingdom; Homerton University Hospital NHS Foundation Trust, London, United Kingdom
| | - Sanjeev Rajakulendran
- UCL Queen Square Institute of Neurology, London, United Kingdom; National Hospital for Neurology & Neurosurgery, London WC1N 3BG United Kingdom; North Middlesex University Hospital, London, United Kingdom.
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Tharmaraja T, Ho JSY, Neligan A, Rajakulendran S. The etiology and mortality of new-onset refractory status epilepticus (NORSE) in adults: A systematic review and meta-analysis. Epilepsia 2023; 64:1113-1124. [PMID: 36727541 DOI: 10.1111/epi.17523] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Revised: 01/30/2023] [Accepted: 01/31/2023] [Indexed: 02/03/2023]
Abstract
New-onset refractory status epilepticus (NORSE) is a devastating neurological presentation. There is a paucity of large studies on NORSE as it is a relatively new clinical syndrome. The aim of this review was to summarize the etiologies and establish a mortality rate for NORSE. Two independent authors systematically searched the following electronic databases from January 1, 2005 April 20, 2021: PubMed, Embase, OVID, Scopus, Web of Science, "Clinicaltrials.gov," and the International Standard Randomised Controlled Trial Number (ISRCTN) registry. We included all primary research studies of NORSE in adults and excluded commentaries, reviews, pre-clinical studies, and pediatric populations. Etiology was extracted from all studies meeting eligibility criteria, whereas data relating to treatments, hospital stay, functional outcomes, and mortality were extracted from studies with sample size ≥5. We conducted a random-effects meta-analysis of mortality rate with meta-regression testing for significant covariates. Of 1482 studies, 109 case reports and case series met our criteria, comprising 395 cases of NORSE. The most common etiology was cryptogenic in 197 cases (49.9%), followed by autoimmune in 143 cases (36.2%). The pooled mortality rate was 22% (95% confidence interval 17%-27%; N studies = 15), with low heterogeneity ( I 2 = 0%). Meta-regression revealed that year of study, treatment with ketogenic diet or immunotherapy, percentage of cryptogenic cases, and length of intensive care unit stay were not significant covariates for mortality. Common treatments included antiseizure medications (median 5), general anesthesia, and immunotherapy such as corticosteroids, intravenous immunoglobulin, and plasma exchange. Mean length of intensive care admission was 33.4 days, with 52% of cases diagnosed with epilepsy on discharge. Neurocognitive impairment was a common sequela of NORSE. NORSE is associated with a high mortality. Half of cases remain cryptogenic, which presents a diagnostic challenge. Future focus should be on elucidating the underlying neurobiology and determining the most effective therapeutic interventions.
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Affiliation(s)
- Thahesh Tharmaraja
- Leonard Wolfson Experimental Neurology Centre, The National Hospital for Neurology and Neurosurgery, London, UK
| | - Jamie Sin Ying Ho
- Royal Free Hospital, Royal Free London NHS Foundation Trust, London, UK
| | - Aidan Neligan
- UCL Queen Square Institute of Neurology, London, UK
- Homerton University Hospital NHS Foundation Trust, London, UK
| | - Sanjeev Rajakulendran
- UCL Queen Square Institute of Neurology, London, UK
- The National Hospital for Neurology and Neurosurgery, London, UK
- The North Middlesex University Hospital, London, UK
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3
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Neligan A, Rajakulendran S. Has the mortality of status epilepticus changed over the past few decades? Epilepsy Behav 2023; 138:109050. [PMID: 36549100 DOI: 10.1016/j.yebeh.2022.109050] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 12/02/2022] [Accepted: 12/02/2022] [Indexed: 12/24/2022]
Abstract
Earlier and more aggressive treatment of status epilepticus has long been established orthodoxy. In addition to increasing therapeutic options, it is of critical importance to understand whether or not this has translated into improved prognosis. In this review, we examine the evidence as to whether the mortality of convulsive status epilepticus changed over the past few decades. In particular, we discuss a recent systematic review and meta-analysis examining this question and its implications. We discuss potential reasons why there is no evidence of improved prognosis in terms of mortality and ways in which this may be addressed. Finally, we advocate the urgent need for accurate data on functional outcomes in non-fatal cases of status epilepticus. This paper was presented at the 8th London-Innsbruck Colloquium on Status Epilepticus and Acute Seizures held in September 2022.
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Affiliation(s)
- A Neligan
- Homerton University Hospital NHS Foundation Trust, Homerton Row, London E9 6SR, UK; UCL Queen Square Institute of Neurology, Queen Square, London WC1N 3BG, UK.
| | - Sanjeev Rajakulendran
- UCL Queen Square Institute of Neurology, Queen Square, London WC1N 3BG, UK; National Hospital for Neurology & Neurosurgery, Queen Square, London WC1N 3BG, UK; North Middlesex University Hospital, Sterling Way, London N18 1QX, UK
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4
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Green SF, Hare N, Kassam M, Rugg-Gunn F, Koepp MJ, Sander JW, Rajakulendran S. Retention of brivaracetam in adults with drug-resistant epilepsy at a single tertiary care center. Epilepsy Behav 2022; 135:108868. [PMID: 35985166 DOI: 10.1016/j.yebeh.2022.108868] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Revised: 06/30/2022] [Accepted: 07/29/2022] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Brivaracetam (BRV) is licensed as an adjunctive treatment for focal epilepsy. We describe our clinical experience with BRV at a large UK tertiary center. METHODS Adults initiated on BRV between July 2015 and July 2020 were followed up until they discontinued BRV or September 2021. Data on epilepsy syndrome, duration, seizure types, concomitant and previous antiseizure medication (ASM) use, BRV dosing, efficacy, and side effects were recorded. Efficacy was categorized as temporary (minimum three months) or ongoing (at last follow-up) seizure freedom, ≥50% seizure reduction, or other benefits (e.g., no convulsions or daytime seizures). Brivaracetam retention was estimated using Kaplan-Meier survival analysis. RESULTS Two-hundred people were treated with BRV, of whom 81% had focal epilepsy. The mean (interquartile range [IQR]) follow-up time was 707 (688) days, and the dose range was 50-600 mg daily. The mean (IQR) of the previous number of used ASMs was 6.9 (6.0), and concomitant use was 2.2 (1.0). One-hundred and eighty-eight people (94%) had previously discontinued levetiracetam (LEV), mainly due to side effects. 13/200 (6.5%) were seizure free for a minimum of six months during treatment, and 46/200 (23%) had a ≥50% reduction in seizure frequency for six months or more. Retention rates were 83% at six months, 71% at 12 months, and 57% at 36 months. Brivaracetam was mostly discontinued due to side effects (38/75, 51%) or lack of efficacy (28/75, 37%). Concomitant use of carbamazepine significantly increased the hazard ratio of discontinuing BRV due to side effects (p = 0.006). The most commonly reported side effects were low mood (20.5%), fatigue (18%) and aggressive behavior (8.5%). These side effects were less prevalent than when the same individuals took LEV (low mood, 59%; aggressive behavior, 43%). Intellectual disability was a risk factor for behavioral side effects (p = 0.004), and a pre-existing mood disorder significantly increased the likelihood of further episodes of low mood (p = 0.019). CONCLUSIONS Brivaracetam was effective at a broad range of doses in managing drug-resistant epilepsy across various phenotypes, but less effective than LEV in those who switched due to poor tolerability on LEV. There were no new tolerability issues, but 77% of the individuals experiencing side effects on BRV also experienced similar side effects on LEV.
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Affiliation(s)
- Sebastian F Green
- Department of Clinical & Experimental Epilepsy, UCL Queen Square Institute of Neurology, London WC1N 3BG & Chalfont Centre for Epilepsy, Chalfont St Peter SL9 0RJ, United Kingdom; Southmead Hospital, North Bristol NHS Trust, Bristol, United Kingdom
| | - Nisha Hare
- Southmead Hospital, North Bristol NHS Trust, Bristol, United Kingdom
| | - Mehreen Kassam
- Department of Clinical & Experimental Epilepsy, UCL Queen Square Institute of Neurology, London WC1N 3BG & Chalfont Centre for Epilepsy, Chalfont St Peter SL9 0RJ, United Kingdom
| | - Fergus Rugg-Gunn
- Department of Clinical & Experimental Epilepsy, UCL Queen Square Institute of Neurology, London WC1N 3BG & Chalfont Centre for Epilepsy, Chalfont St Peter SL9 0RJ, United Kingdom
| | - Matthias J Koepp
- Department of Clinical & Experimental Epilepsy, UCL Queen Square Institute of Neurology, London WC1N 3BG & Chalfont Centre for Epilepsy, Chalfont St Peter SL9 0RJ, United Kingdom
| | - Josemir W Sander
- Department of Clinical & Experimental Epilepsy, UCL Queen Square Institute of Neurology, London WC1N 3BG & Chalfont Centre for Epilepsy, Chalfont St Peter SL9 0RJ, United Kingdom; Stichting Epilepsie Instellingen Nederland (SEIN), Heemstede, The Netherlands.
| | - Sanjeev Rajakulendran
- Department of Clinical & Experimental Epilepsy, UCL Queen Square Institute of Neurology, London WC1N 3BG & Chalfont Centre for Epilepsy, Chalfont St Peter SL9 0RJ, United Kingdom
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Nakajima M, Pauls M, Rajakulendran S. Extensive Medullo-Cervicothoracic Lesion in Acute Lymphoblastic Leukemia. J Clin Neurol 2022; 18:105-107. [PMID: 35021286 PMCID: PMC8762490 DOI: 10.3988/jcn.2022.18.1.105] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 08/25/2021] [Accepted: 08/26/2021] [Indexed: 11/23/2022] Open
Affiliation(s)
- Mitsuko Nakajima
- Department of Neurology, National Hospital for Neurology and Neurosurgery, London, UK
| | - Mathilde Pauls
- Department of Neurology, National Hospital for Neurology and Neurosurgery, London, UK
| | - Sanjeev Rajakulendran
- Department of Neurology, National Hospital for Neurology and Neurosurgery, London, UK.
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6
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Rajakulendran S, Belluzzo M, Novy J, Sisodiya SM, Koepp MJ, Duncan JS, Sander JW. Late-life terminal seizure freedom in drug-resistant epilepsy: "Burned-out epilepsy". J Neurol Sci 2021; 431:120043. [PMID: 34753039 DOI: 10.1016/j.jns.2021.120043] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [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: 04/26/2021] [Revised: 10/10/2021] [Accepted: 10/25/2021] [Indexed: 02/05/2023]
Abstract
The course of established epilepsy in late life is not fully known. One key question is whether the resolution of an epileptic diathesis is a natural outcome in some people with long-standing epilepsy. We investigated this with a view to generating a hypothesis. We retrospectively explored whether terminal seizure-freedom occurs in older people with previous drug-resistant epilepsy at the Chalfont Centre for Epilepsy over twenty years. Of the 226 people followed for a median period of 52 years, 39 (17%) achieved late-life terminal seizure-freedom of at least two years before death, which occurred at a median age of 68 years with a median duration of 7 years. Multivariate analysis suggests that a high initial seizure frequency was a negative predictor (p < 0.0005). Our findings indicate that the 'natural' course of long-standing epilepsy in some people is one of terminal seizure freedom. We also consider the concept of "remission" in epilepsy, its definition challenges, and the evolving terminology used to describe the state of seizure freedom. The intersection of ageing and seizure freedom is an essential avenue of future investigation, especially in light of current demographic trends. Gaining mechanistic insights into this phenomenon may help broaden our understanding of the neurobiology of epilepsy and potentially provide targets for therapeutic intervention.
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Affiliation(s)
- S Rajakulendran
- Department of Clinical and Experimental Epilepsy, UCL Queen Square Institute of Neurology, London WC1N 3BG & Chalfont Centre for Epilepsy, Chalfont St Peter SL9 0RJ, United Kingdom
| | - M Belluzzo
- Department of Clinical and Experimental Epilepsy, UCL Queen Square Institute of Neurology, London WC1N 3BG & Chalfont Centre for Epilepsy, Chalfont St Peter SL9 0RJ, United Kingdom; Department of Clinical Neurosciences, Neurology Unit, Santa Maria della Misericordia Hospital, Udine 33100, Italy
| | - J Novy
- Department of Clinical and Experimental Epilepsy, UCL Queen Square Institute of Neurology, London WC1N 3BG & Chalfont Centre for Epilepsy, Chalfont St Peter SL9 0RJ, United Kingdom; Department of Clinical Neurosciences, Neurology Service, Lausanne University Hospital (Vaud University Hospital Center) and University of Lausanne, Lausanne, Switzerland
| | - S M Sisodiya
- Department of Clinical and Experimental Epilepsy, UCL Queen Square Institute of Neurology, London WC1N 3BG & Chalfont Centre for Epilepsy, Chalfont St Peter SL9 0RJ, United Kingdom
| | - M J Koepp
- Department of Clinical and Experimental Epilepsy, UCL Queen Square Institute of Neurology, London WC1N 3BG & Chalfont Centre for Epilepsy, Chalfont St Peter SL9 0RJ, United Kingdom
| | - J S Duncan
- Department of Clinical and Experimental Epilepsy, UCL Queen Square Institute of Neurology, London WC1N 3BG & Chalfont Centre for Epilepsy, Chalfont St Peter SL9 0RJ, United Kingdom
| | - J W Sander
- Department of Clinical and Experimental Epilepsy, UCL Queen Square Institute of Neurology, London WC1N 3BG & Chalfont Centre for Epilepsy, Chalfont St Peter SL9 0RJ, United Kingdom; Stichting Epilepsie Instellingen Nederland (SEIN), Achterweg 5, Heemstede 2103SW, Netherlands; Department of Neurology, West China Hospital & Institute of Brain Science & Brain-inspired Technology, Sichuan University, Chengdu 610041, China.
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7
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Neligan A, Kerin B, Walker MC, Rajakulendran S. New-Onset Refractory Status Epilepticus (NORSE): The Queen Square Neuro-ICU experience. Epilepsy Behav 2021; 125:108387. [PMID: 34781063 DOI: 10.1016/j.yebeh.2021.108387] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [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: 07/18/2021] [Revised: 09/28/2021] [Accepted: 10/16/2021] [Indexed: 10/19/2022]
Abstract
The introduction and widespread adoption of the term 'NORSE' - new-onset refractory status epilepticus - raises both fundamental conceptual and pragmatic questions. We studied a cohort of patients with 'NORSE' at the National Hospital for Neurology and Neurosurgery to investigate the clinical features, treatment responses, and outcomes with a focus on sub-group analysis. We identified 26 cases of 'NORSE'. There was no difference in prognosis between 'NORSE' and non-'NORSE' RSE, nor in any sub-analysis in the 'NORSE' cohort. We discuss the utility and validity of the term NORSE as a descriptor for a subgroup with RSE in whom the underlying etiologies are heterogeneous and pathophysiological mechanisms are unknown.
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Affiliation(s)
- Aidan Neligan
- UCL Queen Square Institute of Neurology, London WC1N 3BG, UK; Homerton University Hospital NHS Foundation Trust, Homerton Row, London E9 6SR, UK.
| | - Bellami Kerin
- UCL Queen Square Institute of Neurology, London WC1N 3BG, UK
| | - Matthew C Walker
- UCL Queen Square Institute of Neurology, London WC1N 3BG, UK; The National Hospital for Neurology and Neurosurgery, Queen Square, London WC1N 3BG, UK
| | - Sanjeev Rajakulendran
- UCL Queen Square Institute of Neurology, London WC1N 3BG, UK; The National Hospital for Neurology and Neurosurgery, Queen Square, London WC1N 3BG, UK; North Middlesex University Hospital, Sterling Way, London N18 1QX, UK
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8
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Green SF, Loefflad N, Heaney DC, Rajakulendran S. New-onset seizures in older people: Clinical features, course and outcomes. J Neurol Sci 2021; 429:118065. [PMID: 34492571 DOI: 10.1016/j.jns.2021.118065] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [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: 05/05/2021] [Revised: 08/27/2021] [Accepted: 08/31/2021] [Indexed: 01/01/2023]
Abstract
OBJECTIVE The incidence of epilepsy increases with age. With current demographic trends, this presents a healthcare challenge. We investigated the clinical spectrum of first seizures, evaluated neuroimaging and EEG findings, and determined clinical outcomes, including anti-seizure medication (ASM) response in older people. In addition, we sought to understand the relative effects of age and frailty on ASM response. METHODS A retrospective single centre cohort study of 207 cases ≥60 years' old, 113 of whom were eventually diagnosed with a first seizure in a specialist epilepsy clinic. RESULTS 65/113 (57.5%) presented with either focal aware or focal impaired awareness seizures. Stroke was the most common aetiological association (31.9%, 36/113), and odds of seizure recurrence did not significantly differ between aetiologies. 55/86 (64.0%) who started an ASM had no seizure recurrence. 14/48 (29.2%) who underwent EEG had epileptiform abnormalities, however EEG result directly affected management in only 4/48 (8.3%). The most common MRI findings were small vessel disease (37/93, 39.8%), stroke (27/93, 29.0%) and global atrophy (14/93, 15.1%). Increasing age and frailty did not affect the odds of seizure recurrence or of experiencing ASM side effects. Severity of small vessel disease or atrophy did not affect odds of seizure recurrence. CONCLUSION Our data inform the management of first seizures in older people and provisionally support the use of ASMs in patients with increasing age and frailty, despite concerns over polypharmacy and comorbidity. Our findings should be replicated in larger cohorts.
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Affiliation(s)
- Sebastian F Green
- Epilepsy Department, National Hospital for Neurology and Neurosurgery, London, UK; Institute of Clinical Neurosciences, North Bristol NHS Trust, Bristol, UK
| | | | - Dominic C Heaney
- Epilepsy Department, National Hospital for Neurology and Neurosurgery, London, UK
| | - Sanjeev Rajakulendran
- Epilepsy Department, National Hospital for Neurology and Neurosurgery, London, UK; UCL Queen Square Institute of Neurology, London, UK.
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9
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Neligan A, Walker M, Rajakulendran S. Challenge to levetiracetam's de facto position as generic first-line antiseizure medication. Pract Neurol 2021; 22:94-95. [PMID: 34611050 DOI: 10.1136/practneurol-2021-003217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/23/2021] [Indexed: 11/03/2022]
Affiliation(s)
- Aidan Neligan
- Neurology, Homerton University Hospital, London, UK .,DCEE, UCL Queen Square Institute of Neurology, London, UK
| | - Matthew Walker
- DCEE, UCL Queen Square Institute of Neurology, London, UK.,National Hospital for Neurology and Neurosurgery Queen Square, London, UK
| | - Sanjeev Rajakulendran
- DCEE, UCL Queen Square Institute of Neurology, London, UK.,National Hospital for Neurology and Neurosurgery Queen Square, London, UK
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10
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Neligan A, Rajakulendran S, Walker MC. Advances in the management of generalized convulsive status epilepticus: what have we learned? Brain 2021; 144:1336-1341. [PMID: 33778866 DOI: 10.1093/brain/awab049] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [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: 10/15/2020] [Revised: 11/18/2020] [Accepted: 12/09/2020] [Indexed: 12/15/2022] Open
Abstract
Convulsive status epilepticus is the most serious manifestation of an epileptic diathesis. In the early stages (5-30 min), there exists class A evidence to support the efficacy of benzodiazepines as first-line treatment. As status epilepticus progresses into the later stages, the evidence for treatment becomes less robust until we are depending upon short case series and case reports for the treatment of refractory status epilepticus. However, the past year saw the publication of three randomized controlled trials in the setting of benzodiazepine-resistant established convulsive status epilepticus: the EcLiPSE and ConSEPT studies, compared levetiracetam to phenytoin in children; and the ESETT study compared fosphenytoin, levetiracetam and sodium valproate in adults and children. In addition, the emergence of data from the SENSE study, a multicentre multinational prospective cohort study and the publication of a systematic review and meta-analysis of the mortality of status epilepticus over the past 30 years, has brought the treatment of status epilepticus into sharp focus. In this update we provide a detailed analysis of these studies and their impact on clinical practice. We review contentious areas of management in status epilepticus where a consensus is lacking and advance the case for more research on existing and alternative treatment strategies.
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Affiliation(s)
- Aidan Neligan
- Homerton University Hospital NHS Foundation Trust, Homerton Row, London E9 6SR, UK.,DCEE, UCL Queen Square Institute of Neurology, Queen Square, London WC1N 3BG, UK
| | - Sanjeev Rajakulendran
- DCEE, UCL Queen Square Institute of Neurology, Queen Square, London WC1N 3BG, UK.,National Hospital for Neurology and Neurosurgery, Queen Square, London WC1N 3BG, UK.,North Middlesex University Hospital, Sterling Way, London N18 1QX, UK
| | - Matthew C Walker
- DCEE, UCL Queen Square Institute of Neurology, Queen Square, London WC1N 3BG, UK.,National Hospital for Neurology and Neurosurgery, Queen Square, London WC1N 3BG, UK
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11
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Keddie S, Pakpoor J, Mousele C, Pipis M, Machado PM, Foster M, Record CJ, Keh RYS, Fehmi J, Paterson RW, Bharambe V, Clayton LM, Allen C, Price O, Wall J, Kiss-Csenki A, Rathnasabapathi DP, Geraldes R, Yermakova T, King-Robson J, Zosmer M, Rajakulendran S, Sumaria S, Farmer SF, Nortley R, Marshall CR, Newman EJ, Nirmalananthan N, Kumar G, Pinto AA, Holt J, Lavin TM, Brennan KM, Zandi MS, Jayaseelan DL, Pritchard J, Hadden RDM, Manji H, Willison HJ, Rinaldi S, Carr AS, Lunn MP. Epidemiological and cohort study finds no association between COVID-19 and Guillain-Barré syndrome. Brain 2021; 144:682-693. [PMID: 33313649 PMCID: PMC7799186 DOI: 10.1093/brain/awaa433] [Citation(s) in RCA: 154] [Impact Index Per Article: 51.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 11/06/2020] [Accepted: 11/19/2020] [Indexed: 02/06/2023] Open
Abstract
Reports of Guillain-Barré syndrome (GBS) have emerged during the Coronavirus disease 2019 (COVID-19) pandemic. This epidemiological and cohort study sought to investigate any causative association between COVID-19 infection and GBS. The epidemiology of GBS cases reported to the UK National Immunoglobulin Database was studied from 2016 to 2019 and compared to cases reported during the COVID-19 pandemic. Data were stratified by hospital trust and region, with numbers of reported cases per month. UK population data for COVID-19 infection were collated from UK public health bodies. In parallel, but separately, members of the British Peripheral Nerve Society prospectively reported incident cases of GBS during the pandemic at their hospitals to a central register. The clinical features, investigation findings and outcomes of COVID-19 (definite or probable) and non-COVID-19 associated GBS cases in his cohort were compared. The incidence of GBS treated in UK hospitals from 2016 to 2019 was 1.65–1.88 per 100 000 individuals per year. In 2020, GBS and COVID-19 incidences varied between regions and did not correlate with one another (r = 0.06, 95% confidence interval: −0.56 to 0.63, P = 0.86). GBS incidence fell between March and May 2020 compared to the same months of 2016–19. In an independent cohort study, 47 GBS cases were reported (COVID-19 status: 13 definite, 12 probable, 22 non-COVID-19). There were no significant differences in the pattern of weakness, time to nadir, neurophysiology, CSF findings or outcome between these groups. Intubation was more frequent in the COVID-19 affected cohort (7/13, 54% versus 5/22, 23% in COVID-19-negative) likely related to COVID-19 pulmonary involvement. Although it is not possible to entirely rule out the possibility of a link this study finds no epidemiological or phenotypic clues of SARS-CoV-2 being causative of GBS. GBS incidence has fallen during the pandemic, which may be the influence of lockdown measures reducing transmission of GBS inducing pathogens such as Campylobacter jejuni and respiratory viruses.
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Affiliation(s)
- Stephen Keddie
- Department of Neuromuscular Diseases, University College London, London, UK.,National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Foundation Trust, London, UK
| | | | - Christina Mousele
- National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Foundation Trust, London, UK
| | - Menelaos Pipis
- Department of Neuromuscular Diseases, University College London, London, UK.,National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Foundation Trust, London, UK
| | - Pedro M Machado
- Department of Neuromuscular Diseases, University College London, London, UK.,National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Foundation Trust, London, UK
| | - Mark Foster
- National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Foundation Trust, London, UK
| | | | - Ryan Y S Keh
- Lancashire Teaching Hospitals NHS Foundation Trust, UK
| | - Janev Fehmi
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Ross W Paterson
- National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Foundation Trust, London, UK.,Darent Valley Hospital, Dartford, UK
| | - Viraj Bharambe
- The Walton Centre National Health Service (NHS) Foundation Trust, Liverpool, UK
| | | | | | - Olivia Price
- Basildon and Thurrock University Hospital Trust, Basildon, UK
| | - Jasmine Wall
- Lancashire Teaching Hospitals NHS Foundation Trust, UK
| | | | | | - Ruth Geraldes
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK.,Wexham Park Hospital, Frimley Health Foundation Trust, Berkshire, UK
| | | | | | - Maya Zosmer
- North Middlesex University Hospital NHS Trust, London, UK
| | - Sanjeev Rajakulendran
- National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Foundation Trust, London, UK.,North Middlesex University Hospital NHS Trust, London, UK
| | - Sheetal Sumaria
- National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Foundation Trust, London, UK
| | - Simon F Farmer
- National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Foundation Trust, London, UK
| | - Ross Nortley
- National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Foundation Trust, London, UK.,Wexham Park Hospital, Frimley Health Foundation Trust, Berkshire, UK
| | | | | | | | | | - Ashwin A Pinto
- Wessex Neurological Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - James Holt
- The Walton Centre National Health Service (NHS) Foundation Trust, Liverpool, UK
| | - Tim M Lavin
- Manchester Centre for Clinical Neuroscience, Salford Royal Hospital NHS Foundation Trust, Manchester, UK
| | | | - Michael S Zandi
- National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Foundation Trust, London, UK
| | - Dipa L Jayaseelan
- National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Foundation Trust, London, UK.,West Hertfordshire Hospitals NHS Trust, Watford, UK
| | | | | | - Hadi Manji
- Department of Neuromuscular Diseases, University College London, London, UK.,National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Foundation Trust, London, UK
| | | | - Simon Rinaldi
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Aisling S Carr
- National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Foundation Trust, London, UK
| | - Michael P Lunn
- Department of Neuromuscular Diseases, University College London, London, UK.,National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Foundation Trust, London, UK
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Allard J, Lawthom C, Henley W, Mclean B, Hudson S, Tittensor P, Rajakulendran S, Ellawela S, Pace A, Shankar R. Eslicarbazepine acetate response in intellectual disability population versus general population. Acta Neurol Scand 2021; 143:256-260. [PMID: 33131083 DOI: 10.1111/ane.13368] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [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: 09/08/2020] [Revised: 10/21/2020] [Accepted: 10/24/2020] [Indexed: 02/05/2023]
Abstract
BACKGROUND A quarter of people with intellectual disability (ID) have epilepsy, compared to approximately one in a hundred across the general population. Evidence for the safe and effective prescribing of antiepileptic drugs (AEDs) for those with ID is, however, limited. AIMS OF STUDY This study seeks to strengthen the research evidence around Eslicarbazepine Acetate (ESL), a new AED, by comparing response of individuals with ID to those from the general population who do not have ID. METHODS A single data set was created through retrospective data collection from English and Welsh NHS Trusts. The UK-based Epilepsy Database Research Register (Ep-ID) data collection and analysis method were used. RESULTS Data were collected for 93 people (36 ID and 57 'no ID'). Seizure improvement of '>50%' was higher at 12 months for 'no ID' participants (56%), compared to ID participants (35%). Retention rates were slightly higher for those with ID (56% compared to 53%). Neither difference was significant. CONCLUSIONS Tolerance and Efficacy for ID and 'no ID' people in our data set were similar. Seizure improvement and retention rates were slightly lower than that found in other European data sets, but findings strengthen the evidence for the use of ESL in the ID population.
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Affiliation(s)
- Jon Allard
- Cornwall Intellectual Disability & Epilepsy Research (CIDER) Centre Cornwall Partnership NHS Foundation Trust Bodmin UK
| | - Charlotte Lawthom
- Swansea University Swansea UK
- Aneurin Bevan University Health Board Newport UK
| | | | | | - Sharon Hudson
- Cornwall Intellectual Disability & Epilepsy Research (CIDER) Centre Cornwall Partnership NHS Foundation Trust Bodmin UK
| | | | - Sanjeev Rajakulendran
- The National Hospital for Neurology and Neurosurgery University College Hospitals NHS Foundation Trust London UK
| | - Shan Ellawela
- The Newcastle upon Tyne Hospitals NHS Foundation Trust Newcastle Upon Tyne UK
| | - Adrian Pace
- Salford Royal NHS Foundation Trust Salford UK
| | - Rohit Shankar
- Cornwall Intellectual Disability & Epilepsy Research (CIDER) Centre Cornwall Partnership NHS Foundation Trust Bodmin UK
- University of Exeter Medical School Truro UK
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Neligan A, Heaney D, Rajakulendran S. Is a separate clinical pathway for first seizures justified? Appraisal of the first seizure pathway at a tertiary neuroscience centre. Seizure 2020; 84:108-111. [PMID: 33310677 DOI: 10.1016/j.seizure.2020.11.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [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: 09/28/2020] [Revised: 11/26/2020] [Accepted: 11/28/2020] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVES To investigate the clinical characteristics, final diagnosis, investigation results, management, response to anti-seizure medications (ASMs) and clinical outcomes of individuals assessed in a First Seizure service over a 5-year period. METHODS Retrospective analysis of 772 individuals who were clinically assessed in a dedicated First Seizure service at National Hospital for Neurology & Neurosurgery (NHNN), Queen Square over a 5-year period. RESULTS 772 individuals were assessed following a suspected or reported first seizure (median age of 54, average age of 39.4, range 16-96). 393 (50.9 %) were ultimately diagnosed with a definite seizure of which 183 (46.5 %) had experienced seizures previously which had not been recognised or diagnosed. 250 (32 %) had vasovagal syncope and 69 (18.2 %) were diagnosed with psychogenic non-epileptic seizures. EEGs in 16.6 % of individuals who had a first unprovoked seizure demonstrated epileptiform discharges, whilst 33.6 % had abnormal MRI findings felt to be clinically relevant. CONCLUSIONS Seizure mimics represent a significant proportion of attendees to a 'first seizure' service. Improved recognition and more education of this issue could facilitate earlier management of these other diagnostic entities and ensure that only appropriate cases are referred to the first seizure service. Almost half of 'first seizure' cases had previous seizures, highlighting the importance of obtaining this relevant history and in reviewing ASM-naive individuals in a timely manner with the primary aim of preventing further recurrences.
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Affiliation(s)
- A Neligan
- Homerton University Hospital Foundation Trust, Homerton Row, London E9 6SR, UK; UCL Queen Square Institute of Neurology, Queen Square, London WC1N 3BG, UK
| | - D Heaney
- UCL Queen Square Institute of Neurology, Queen Square, London WC1N 3BG, UK; The National Hospital for Neurology and Neurosurgery and UCL Institute of Neurology, Queen Square, London WC1N 3BG, UK
| | - S Rajakulendran
- UCL Queen Square Institute of Neurology, Queen Square, London WC1N 3BG, UK; The National Hospital for Neurology and Neurosurgery and UCL Institute of Neurology, Queen Square, London WC1N 3BG, UK; North Middlesex University Hospital, Sterling Way, London N18 1QX, UK.
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Green SF, Nguyen P, Kaalund-Hansen K, Rajakulendran S, Murphy E. Effectiveness, retention, and safety of modified ketogenic diet in adults with epilepsy at a tertiary-care centre in the UK. J Neurol 2020; 267:1171-1178. [PMID: 31925498 PMCID: PMC7109193 DOI: 10.1007/s00415-019-09658-6] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Revised: 11/24/2019] [Accepted: 11/27/2019] [Indexed: 01/25/2023]
Abstract
With the rising demand for ketogenic diet therapy in adult epilepsy, there is a need for research describing the real-life effectiveness, retention, and safety of relevant services. In this 1-year prospective cohort study we present outcomes of the first 100 referrals for modified ketogenic diet (MKD) at the UK's largest tertiary-care epilepsy centre, where patients received dietetic review up to twice per week. Of the first 100 referrals, 42 (31 females, 11 males; mean age 36.8 [SD ± 11.4 years]) commenced MKD, having used a mean of 4 (SD ± 3) previous antiepileptic drugs. Retention rates were: 60% at 3 months, 43% at 6 months, and 29% at 12 months. 60% of patients reported an improvement in seizure frequency, 38% reported a > 50% reduction, and 13% reported a period of seizure freedom; 30% reported a worsening in seizure frequency at some point during MKD therapy. The most common reasons for discontinuing MKD were side effects and diet restrictiveness. The most common side effects were weight loss, gastrointestinal symptoms and low mood. The likelihood of discontinuing MKD was significantly decreased by experiencing an improvement in seizure frequency (p ≤ 0.001). This study demonstrates that MKD can be effective in adults, although, even with regular dietetic support, retention rates remain low, and periods of worsening seizure frequency are common.
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Affiliation(s)
- S F Green
- Epilepsy Department, The National Hospital for Neurology and Neurosurgery, Queen Square, London, WC1N 3BG, UK
| | - P Nguyen
- Charles Dent Metabolic Unit, The National Hospital for Neurology and Neurosurgery, Queen Square, London, WC1N 3BG, UK
| | - K Kaalund-Hansen
- Charles Dent Metabolic Unit, The National Hospital for Neurology and Neurosurgery, Queen Square, London, WC1N 3BG, UK
| | - S Rajakulendran
- Epilepsy Department, The National Hospital for Neurology and Neurosurgery, Queen Square, London, WC1N 3BG, UK
| | - Elaine Murphy
- Charles Dent Metabolic Unit, The National Hospital for Neurology and Neurosurgery, Queen Square, London, WC1N 3BG, UK.
- University College London, London, UK.
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15
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Allard J, Henley W, Mclean B, Sellers A, Hudson S, Rajakulendran S, Pace A, Pashley S, Maguire M, Mohan M, Ellawela S, Tittensor P, Ram S, Bagary M, Shankar R. Lacosamide in the general population and in people with intellectual disability: Similar responses? Seizure 2020; 76:161-166. [PMID: 32106016 PMCID: PMC7113834 DOI: 10.1016/j.seizure.2020.02.013] [Citation(s) in RCA: 8] [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: 01/14/2020] [Accepted: 02/18/2020] [Indexed: 11/30/2022] Open
Abstract
PURPOSE Epilepsy prevalence is significantly higher in people with Intellectual Disability (ID) compared to people with epilepsy (PWE) from the general population. Increased psychological and behavioural problems, healthcare costs, morbidity, mortality and treatment resistance to antiepileptic drugs (AEDs) is associated with epilepsy in ID populations. Prescribing AEDs for PWE and ID is challenging and influenced heavily by studies conducted with the general population. Our study compares Lacosamide (LCM) response for the ID population to those from the general population; using data from an UK based epilepsy database register (EP ID/PDD AED Register). METHODS Pooled retrospective case notes data for PWE prescribed LCM at 11 UK NHS Trusts were analysed. Participants were classified as per WHO guidance into groups of moderate-profound ID, mild ID and General population. Demographics, concomitant AEDs, starting and maximum dosage, exposure length, adverse effects, dropout rates, seizure frequency were collected. Group differences were reported as odds ratios estimated from univariable logistic regression models. RESULTS Of 232 consented participants, 156 were from the general population and 76 had ID (24 mild, 52 moderate-profound). Twelve month withdrawal rates and reasons, efficacy, side-effects, start and maximum doses were similar between the groups. Dose titration between baseline and three months was significantly slower in the ID group (p = 0.02). CONCLUSION There were no differences for LCM outcomes between general and ID groups. Slower LCM titration in ID populations in the first 3 months was associated with higher retention and lower behavioural side effects as compared to similar European studies.
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Affiliation(s)
- Jon Allard
- Cornwall Partnership NHS Foundation Trust, United Kingdom
| | | | - Brendan Mclean
- Royal Cornwall Hospital NHS Foundation Trust, United Kingdom
| | - Adrian Sellers
- Cornwall Partnership NHS Foundation Trust, United Kingdom
| | - Sharon Hudson
- Cornwall Partnership NHS Foundation Trust, United Kingdom
| | - Sanjeev Rajakulendran
- National Centre for Neurology and Neurosurgery, University College Hospitals NHS Foundation Trust, United Kingdom
| | - Adrian Pace
- Salford Royal NHS Foundation Trust, United Kingdom
| | - Sarah Pashley
- Nottinghamshire Healthcare NHS Foundation Trust, United Kingdom
| | | | | | - Shan Ellawela
- The Newcastle upon Tyne Hospitals NHS Foundation Trust, United Kingdom
| | | | - Sunil Ram
- Somerset Partnership NHS Foundation Trust, United Kingdom
| | - Manny Bagary
- Birmingham and Solihull Mental Health NHS Foundation Trust, United Kingdom
| | - Rohit Shankar
- Cornwall Partnership NHS Foundation Trust, United Kingdom; University of Exeter Medical School, United Kingdom.
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16
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El Tawil S, Morris R, Mullatti N, Nashef L, Rajakulendran S. Adult onset Rasmussen’s encephalitis associated with reflex language induced seizures responsive to Rituximab therapy. Seizure 2016; 42:60-62. [DOI: 10.1016/j.seizure.2016.09.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2016] [Revised: 09/16/2016] [Accepted: 09/18/2016] [Indexed: 10/20/2022] Open
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17
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Rajakulendran S, Pitceathly RDS, Taanman JW, Costello H, Sweeney MG, Woodward CE, Jaunmuktane Z, Holton JL, Jacques TS, Harding BN, Fratter C, Hanna MG, Rahman S. A Clinical, Neuropathological and Genetic Study of Homozygous A467T POLG-Related Mitochondrial Disease. PLoS One 2016; 11:e0145500. [PMID: 26735972 PMCID: PMC4703200 DOI: 10.1371/journal.pone.0145500] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2015] [Accepted: 12/06/2015] [Indexed: 02/06/2023] Open
Abstract
Mutations in the nuclear gene POLG (encoding the catalytic subunit of DNA polymerase gamma) are an important cause of mitochondrial disease. The most common POLG mutation, A467T, appears to exhibit considerable phenotypic heterogeneity. The mechanism by which this single genetic defect results in such clinical diversity remains unclear. In this study we evaluate the clinical, neuropathological and mitochondrial genetic features of four unrelated patients with homozygous A467T mutations. One patient presented with the severe and lethal Alpers-Huttenlocher syndrome, which was confirmed on neuropathology, and was found to have a depletion of mitochondrial DNA (mtDNA). Of the remaining three patients, one presented with mitochondrial encephalomyopathy, lactic acidosis and stroke-like episodes (MELAS), one with a phenotype in the Myoclonic Epilepsy, Myopathy and Sensory Ataxia (MEMSA) spectrum and one with Sensory Ataxic Neuropathy, Dysarthria and Ophthalmoplegia (SANDO). All three had secondary accumulation of multiple mtDNA deletions. Complete sequence analysis of muscle mtDNA using the MitoChip resequencing chip in all four cases demonstrated significant variation in mtDNA, including a pathogenic MT-ND5 mutation in one patient. These data highlight the variable and overlapping clinical and neuropathological phenotypes and downstream molecular defects caused by the A467T mutation, which may result from factors such as the mtDNA genetic background, nuclear genetic modifiers and environmental stressors.
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Affiliation(s)
- Sanjeev Rajakulendran
- UCL Institute of Neurology and National Hospital for Neurology and Neurosurgery and the MRC Centre for Neuromuscular Diseases, Queen Square, London WC1N 3BG, United Kingdom
| | - Robert D. S. Pitceathly
- UCL Institute of Neurology and National Hospital for Neurology and Neurosurgery, Queen Square, London WC1N 3BG, United Kingdom and Department of Basic and Clinical Neuroscience, Institute of Psychiatry, Psychology and Neuroscience, King’s College London SE5 8AF, United Kingdom
| | - Jan-Willem Taanman
- Department of Clinical Neurosciences, UCL Institute of Neurology, London NW3 2PF, United Kingdom
| | - Harry Costello
- Mitochondrial Research Group, Genetics and Genomic Medicine, UCL Institute of Child Health, London WC1N 1EH, United Kingdom
| | - Mary G. Sweeney
- Department of Neurogenetics, UCL Institute of Neurology and National Hospital for Neurology, Queen Square, London WC1N 3BG, United Kingdom
| | - Cathy E. Woodward
- Department of Neurogenetics, UCL Institute of Neurology and National Hospital for Neurology, Queen Square, London WC1N 3BG, United Kingdom
| | - Zane Jaunmuktane
- Division of Neuropathology, UCL Institute of Neurology and National Hospital for Neurology, Queen Square, London WC1N 3BG, United Kingdom
| | - Janice L. Holton
- Division of Neuropathology, UCL Institute of Neurology and National Hospital for Neurology, Queen Square, London WC1N 3BG, United Kingdom
| | - Thomas S. Jacques
- Developmental Biology and Cancer Programme, UCL Institute of Child Health and Department of Histopathology, Great Ormond Street Hospital for Children Foundation Trust, London WC1N 1EH, United Kingdom
| | - Brian N. Harding
- Division of Neuropathology, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, United States of America
| | - Carl Fratter
- Oxford Medical Genetics Laboratories, Oxford University Hospitals NHS Trust, Churchill Hospital, Oxford OX3 7LE, United Kingdom
| | - Michael G. Hanna
- UCL Institute of Neurology and National Hospital for Neurology and Neurosurgery and the MRC Centre for Neuromuscular Diseases, Queen Square, London WC1N 3BG, United Kingdom
| | - Shamima Rahman
- Mitochondrial Research Group, Genetics and Genomic Medicine, UCL Institute of Child Health, London WC1N 1EH, United Kingdom
- Metabolic Unit, Great Ormond Street Hospital, London WC1N 3JH, United Kingdom
- * E-mail:
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18
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Abstract
A central theme in the quest to unravel the genetic basis of epilepsy has been the effort to elucidate the roles played by inherited defects in ion channels. The ubiquitous expression of voltage-gated calcium channels (VGCCs) throughout the central nervous system (CNS), along with their involvement in fundamental processes, such as neuronal excitability and synaptic transmission, has made them attractive candidates. Recent insights provided by the identification of mutations in the P/Q-type calcium channel in humans and rodents with epilepsy and the finding of thalamic T-type calcium channel dysfunction in the absence of seizures have raised expectations of a causal role of calcium channels in the polygenic inheritance of idiopathic epilepsy. In this review, we consider how genetic variation in neuronal VGCCs may influence the development of epilepsy.
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Affiliation(s)
- Sanjeev Rajakulendran
- UCL-Institute of Neurology, MRC Centre for Neuromuscular Diseases, Queen Square, London WC1N 3BG, United Kingdom
| | - Michael G Hanna
- UCL-Institute of Neurology, MRC Centre for Neuromuscular Diseases, Queen Square, London WC1N 3BG, United Kingdom
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19
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Koa-Wing M, Jamil-Copley S, Ariff B, Kojodjojo P, Lim PB, Whinnett Z, Rajakulendran S, Malhotra P, Lefroy D, Peters NS, Davies DW, Kanagaratnam P. Haemorrhagic cerebral air embolism from an atrio-oesophageal fistula following atrial fibrillation ablation. Perfusion 2014; 30:484-6. [PMID: 25475690 DOI: 10.1177/0267659114562102] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
We report the case of a man found unconscious three weeks following atrial fibrillation (AF) ablation. Cranial and thoracic imaging demonstrated multiple areas of pneumo-embolic infarction secondary to an atrio-oesophageal fistula (AEF). AEF is a recognised, but rare, complication of AF ablation.(1-8) Early recognition is critical as the mortality is 100% without surgical intervention. We consider the postulated mechanisms of AEF formation, the spectrum of clinical presentation, investigations and treatment.
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Affiliation(s)
- M Koa-Wing
- Imperial College Healthcare NHS Trust, St Mary's Hospital, London, UK
| | - S Jamil-Copley
- Imperial College Healthcare NHS Trust, St Mary's Hospital, London, UK
| | - B Ariff
- Imperial College Healthcare NHS Trust, St Mary's Hospital, London, UK
| | - P Kojodjojo
- Imperial College Healthcare NHS Trust, St Mary's Hospital, London, UK
| | - P B Lim
- Imperial College Healthcare NHS Trust, St Mary's Hospital, London, UK
| | - Z Whinnett
- Imperial College Healthcare NHS Trust, St Mary's Hospital, London, UK
| | - S Rajakulendran
- Imperial College Healthcare NHS Trust, St Mary's Hospital, London, UK
| | - P Malhotra
- Imperial College Healthcare NHS Trust, St Mary's Hospital, London, UK
| | - D Lefroy
- Imperial College Healthcare NHS Trust, St Mary's Hospital, London, UK
| | - N S Peters
- Imperial College Healthcare NHS Trust, St Mary's Hospital, London, UK
| | - D W Davies
- Imperial College Healthcare NHS Trust, St Mary's Hospital, London, UK
| | - P Kanagaratnam
- Imperial College Healthcare NHS Trust, St Mary's Hospital, London, UK
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Rajakulendran S, Dua T, Harper M, Shakir R. The classification of neurological disorders in the 11th revision of the International Classification of Diseases (ICD-11). J Neurol Neurosurg Psychiatry 2014; 85:952-3. [PMID: 24249782 DOI: 10.1136/jnnp-2013-307093] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
| | - Tarun Dua
- Department of Mental Health and Substance Abuse, World Health Organization, Geneva, Switzerland
| | - Melissa Harper
- Department of Mental Health and Substance Abuse, World Health Organization, Geneva, Switzerland
| | - Raad Shakir
- Imperial College NHS Healthcare Trust, Charing Cross Hospital, London, UK
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21
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Neligan A, Rajakulendran S, Nortley R, Manji H. Extensive Cerebral Microhemorrhages Caused by Acute Disseminated Intravascular Coagulation Secondary to Sepsis. JAMA Neurol 2014; 71:510-1. [DOI: 10.1001/jamaneurol.2013.223] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Aidan Neligan
- National Hospital for Neurology and Neurosurgery, London, England
| | | | - Ross Nortley
- National Hospital for Neurology and Neurosurgery, London, England
| | - Hadi Manji
- National Hospital for Neurology and Neurosurgery, London, England
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22
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Affiliation(s)
- Raad Shakir
- Imperial College Healthcare NHS Trust, Charing Cross Hospital, London, United Kingdom
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23
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Rajakulendran S, Roberts J, Koltzenburg M, Hanna MG, Stewart H. Deletion of chromosome 12q21 affecting KCNC2 and ATXN7L3B in a family with neurodevelopmental delay and ataxia. J Neurol Neurosurg Psychiatry 2013; 84:1255-7. [PMID: 23475819 DOI: 10.1136/jnnp-2012-304555] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [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] [Indexed: 01/10/2023]
Abstract
OBJECTIVE To describe the clinical and genetic findings in a family affected by neurodevelopmental delay and cerebellar ataxia. METHODS The affected mother and her two children underwent clinical assessments followed by radiological, neurophysiological and cytogenetic investigations. RESULTS All three affected members exhibited varying degrees of delay in attaining motor and cognitive milestones, along with learning difficulties and cerebellar ataxia. All three harboured a new 670 kb deletion of chromosome 12q21. Two genes, KCNC2 and ATXN7L3B, lie within the deleted region. CONCLUSIONS This family's complex phenotype is associated with a new chromosomal deletion, which suggests potential roles for the two genes, KCNC2 and ATXN7L3B, in human neurological disease.
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Tomlinson SE, Rajakulendran S, Tan SV, Graves TD, Bamiou DE, Labrum RW, Burke D, Sue CM, Giunti P, Schorge S, Kullmann DM, Hanna MG. Clinical, genetic, neurophysiological and functional study of new mutations in episodic ataxia type 1. J Neurol Neurosurg Psychiatry 2013; 84:1107-12. [PMID: 23349320 PMCID: PMC4332158 DOI: 10.1136/jnnp-2012-304131] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND AND OBJECTIVE Heterozygous mutations in KCNA1 cause episodic ataxia type 1 (EA1), an ion channel disorder characterised by brief paroxysms of cerebellar dysfunction and persistent neuromyotonia. This paper describes four previously unreported families with EA1, with the aim of understanding the phenotypic spectrum associated with different mutations. METHODS 15 affected individuals from four families underwent clinical, genetic and neurophysiological evaluation. The functional impact of new mutations identified in the KCNA1 gene was investigated with in vitro electrophysiology and immunocytochemistry. RESULTS Detailed clinical documentation, dating back to 1928 in one family, indicates that all patients manifested episodic ataxia of varying severity. Four subjects from three families reported hearing impairment, which has not previously been reported in association with EA1. New mutations (R167M, C185W and I407M) were identified in three out of the four families. When expressed in human embryonic kidney cells, all three new mutations resulted in a loss of K(v)1.1 channel function. The fourth family harboured a previously reported A242P mutation, which has not been previously described in association with ataxia. CONCLUSIONS The genetic basis of EA1 in four families is established and this report presents the earliest documented case from 1928. All three new mutations caused a loss of K(v)1.1 channel function. The finding of deafness in four individuals raises the possibility of a link between K(v)1.1 dysfunction and hearing impairment. Our findings broaden the phenotypic range associated with mutations in KCNA1.
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Rajakulendran S, Pathak S, Tai YF, Sanderson F, Davies NWS. VZV uveoretino meningitis following dental treatment. J Neurovirol 2013; 19:188-9. [PMID: 23508283 DOI: 10.1007/s13365-013-0159-9] [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] [Received: 11/10/2012] [Revised: 02/09/2013] [Accepted: 02/25/2013] [Indexed: 11/24/2022]
Affiliation(s)
- Sanjeev Rajakulendran
- Charing Cross Hospital, Imperial College NHS Healthcare Trust, Fulham Palace Road, London, W6 8RF, UK
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Rajakulendran S, Roncaroli F, Wise R. Brainstem syndrome in a man with diabetes receiving haemodialysis. J Clin Neurosci 2012; 19:1427; answer 1469. [PMID: 23139938 DOI: 10.1016/j.jocn.2012.01.031] [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: 11/25/2022]
Affiliation(s)
- Sanjeev Rajakulendran
- Imperial College Hospital NHS Trust, Charing Cross Hospital, Fulham Palace Road, London W6 8RF, UK.
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Rajakulendran S, Stewart H, Koltzenburg M, Hanna MG. DELETION OF THE POTASSIUM CHANNEL GENE KCNC2 IN A FAMILY WITH NEURODEVELOPMENTAL DELAY AND ATAXIA. J Neurol Neurosurg Psychiatry 2012. [DOI: 10.1136/jnnp-2012-304200a.50] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Rajakulendran S, Roncaroli F, Wise R. Brainstem syndrome in a man with diabetes receiving haemodialysis. J Clin Neurosci 2012. [DOI: 10.1016/j.jocn.2012.01.030] [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: 11/29/2022]
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Affiliation(s)
- Roberto J Guiloff
- West London Neurosciences Centre, Charing Cross Hospital, Imperial College Healthcare National Health Service Trust, London, England.
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Abstract
The past two decades have witnessed the emergence of a new and expanding field of neurological diseases--the genetic ion channelopathies. These disorders arise from mutations in genes that encode ion channel subunits, and manifest as paroxysmal attacks involving the brain or spinal cord, and/or muscle. The voltage-gated P/Q-type calcium channel (P/Q channel) is highly expressed in the cerebellum, hippocampus and cortex of the mammalian brain. The P/Q channel has a fundamental role in mediating fast synaptic transmission at central and peripheral nerve terminals. Autosomal dominant mutations in the CACNA1A gene, which encodes voltage-gated P/Q-type calcium channel subunit α(1) (the principal pore-forming subunit of the P/Q channel) are associated with episodic and progressive forms of cerebellar ataxia, familial hemiplegic migraine, vertigo and epilepsy. This Review considers, from both a clinical and genetic perspective, the various neurological phenotypes arising from inherited P/Q channel dysfunction, with a focus on recent advances in the understanding of the pathogenetic mechanisms underlying these disorders.
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Affiliation(s)
- Sanjeev Rajakulendran
- Medical Research Council Center for Neuromuscular Diseases, Box 102, National Hospital for Neurology and Neurosurgery, Queen Square, London WC1N 3BG, UK
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Becker EBE, Fogel BL, Rajakulendran S, Dulneva A, Hanna MG, Perlman SL, Geschwind DH, Davies KE. Candidate screening of the TRPC3 gene in cerebellar ataxia. Cerebellum 2011; 10:296-9. [PMID: 21321808 PMCID: PMC3114078 DOI: 10.1007/s12311-011-0253-6] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The hereditary cerebellar ataxias are a diverse group of neurodegenerative disorders primarily characterised by loss of balance and coordination due to dysfunction of the cerebellum and its associated pathways. Although many genetic mutations causing inherited cerebellar ataxia have been identified, a significant percentage of patients remain whose cause is unknown. The transient receptor potential (TRP) family member TRPC3 is a non-selective cation channel linked to key signalling pathways that are affected in cerebellar ataxia. Furthermore, genetic mouse models of TRPC3 dysfunction display cerebellar ataxia, making the TRPC3 gene an excellent candidate for screening ataxic patients with unknown genetic aetiology. Here, we report a genetic screen for TRPC3 mutations in a cohort of 98 patients with genetically undefined late-onset cerebellar ataxia and further ten patients with undefined episodic ataxia. We identified a number of variants but no causative mutations in TRPC3. Our findings suggest that mutations in TRPC3 do not significantly contribute to the cause of late-onset and episodic human cerebellar ataxias.
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Affiliation(s)
- Esther B E Becker
- MRC Functional Genomics Unit, Department of Physiology, Anatomy and Genetics, University of Oxford, South Parks Road, Oxford, OX1 3QX, UK.
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Rajakulendran S, Parton M, Holton JL, Hanna MG. Clinical and pathological heterogeneity in late-onset partial merosin deficiency. Muscle Nerve 2011; 44:590-3. [DOI: 10.1002/mus.22196] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Angus-Leppan H, Rajakulendran S, Guiloff RJ. PO.09 Syncope and Raynaud's disease. Journal of Neurology, Neurosurgery & Psychiatry 2011. [DOI: 10.1136/jnnp-2011-300645.21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Fenton J, Rajakulendran S, Chinn R, Janssen JC. Subacute combined degeneration of the spinal cord due to vitamin B12 deficiency. BMJ Case Rep 2011; 2011:bcr.03.2011.4030. [PMID: 22687663 DOI: 10.1136/bcr.03.2011.4030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Jon Fenton
- Medicine, Chelsea and Westminster NHS Foundation Trust, London, UK
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Rajakulendran S, Paisán-Ruiz C, Houlden H. Thinning of the corpus callosum and cerebellar atrophy is correlated with phenotypic severity in a family with spastic paraplegia type 11. J Clin Neurol 2011; 7:102-4. [PMID: 21779300 PMCID: PMC3131536 DOI: 10.3988/jcn.2011.7.2.102] [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] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2010] [Revised: 10/14/2010] [Accepted: 10/14/2010] [Indexed: 12/12/2022] Open
Abstract
Background Mutations in the spatacsin gene are associated with spastic paraplegia type 11 (SPG11), which is the most-common cause of autosomal recessive hereditary spastic paraplegia. Although SPG11 has diverse phenotypes, thinning of the corpus callosum is an important feature. Case Report Clinical, genetic, and radiological evaluations were undertaken in a large family from Gujarat in North India with hereditary spastic paraplegia, whose affected members presented with varying degrees of spasticity, ataxia, and cognitive impairment. The clinical severity and the degree of corpus callosum and cerebellar atrophy varied among the four affected individuals in the family. Genetic testing of the affected members revealed recessive mutations in the spatacsin gene, consistent with a diagnosis of SPG11. Conclusions We believe that the extent of corpus callosum thinning and cerebellar atrophy is correlated with disease severity in affected patients. The addition of extrapyramidal features in the most-affected members suggests that SPG11 exhibits considerable phenotypic heterogeneity.
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Affiliation(s)
- Sanjeev Rajakulendran
- Department of Molecular Neurosciences and MRC Centre for Neuromuscular Diseases, UCL-Institute of Neurology, Queen Square, London, UK
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Auce P, Rajakulendran S, Nesbitt A, Chinn R, Kennedy A. Neurological picture. Internuclear ophthalmoplegia following African tick bite fever. J Neurol Neurosurg Psychiatry 2011; 82:681. [PMID: 21421770 DOI: 10.1136/jnnp.2010.236216] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Affiliation(s)
- Pauls Auce
- Department of Neurology, Chelsea and Westminster Hospital, London, UK
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Tan SV, Matthews E, Barber M, Burge JA, Rajakulendran S, Fialho D, Sud R, Haworth A, Koltzenburg M, Hanna MG. Refined exercise testing can aid DNA-based diagnosis in muscle channelopathies. Ann Neurol 2011; 69:328-40. [PMID: 21387378 DOI: 10.1002/ana.22238] [Citation(s) in RCA: 74] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To improve the accuracy of genotype prediction and guide genetic testing in patients with muscle channelopathies we applied and refined specialized electrophysiological exercise test parameters. METHODS We studied 56 genetically confirmed patients and 65 controls using needle electromyography, the long exercise test, and short exercise tests at room temperature, after cooling, and rewarming. RESULTS Concordant amplitude-and-area decrements were more reliable than amplitude-only measurements when interpreting patterns of change during the short exercise tests. Concordant amplitude-and-area pattern I and pattern II decrements of >20% were 100% specific for paramyotonia congenita and myotonia congenita, respectively. When decrements at room temperature and after cooling were <20%, a repeat short exercise test after rewarming was useful in patients with myotonia congenita. Area measurements and rewarming distinguished true temperature sensitivity from amplitude reduction due to cold-induced slowing of muscle fiber conduction. In patients with negative short exercise tests, symptomatic eye closure myotonia predicted sodium channel myotonia over myotonia congenita. Distinctive "tornado-shaped" neuromyotonia-like discharges may be seen in patients with paramyotonia congenita. In the long exercise test, area decrements from pre-exercise baseline were more sensitive than amplitude decrements-from-maximum-compound muscle action potential (CMAP) in patients with Andersen-Tawil syndrome. Possible ethnic differences in the normative data of the long exercise test argue for the use of appropriate ethnically-matched controls. INTERPRETATION Concordant CMAP amplitude-and-area decrements of >20% allow more reliable interpretation of the short exercise tests and aid accurate DNA-based diagnosis. In patients with negative exercise tests, specific clinical features are helpful in differentiating sodium from chloride channel myotonia. A modified algorithm is suggested.
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Affiliation(s)
- S Veronica Tan
- Medical Research Council Centre for Neuromuscular Diseases, National Hospital for Neurology and Neurosurgery, University College London, Institute of Neurology London, UK.
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Rajakulendran S, Andole S, Kennedy A. Familial cerebral cavernomas due to a KRIT1 mutation presenting with epilepsy. BMJ Case Rep 2011; 2011:2011/mar16_1/bcr0120113784. [PMID: 22699465 DOI: 10.1136/bcr.01.2011.3784] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
The authors present the case of a 25-year-old individual who presented acutely following a generalised tonic-clonic seizure. Brain MRI of the individual demonstrated the classical appearance of multiple cerebral cavernous haemangiomas (cavernomas). There was an autosomal dominant family history. Genetic testing identified a truncating mutation in the KRIT1 gene in the individual and confirmed the diagnosis of familial cerebral cavernomas as the cause of epilepsy in the family.
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Affiliation(s)
- Sanjeev Rajakulendran
- Department of Neurology, Chelsea and Westminster Hospital, Barnet Hospital, Barnet, UK
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Abstract
'Ion channelopathies' have emerged in the past decade as a new cause of several neurological diseases. These Mendelian disorders are caused by mutations in genes that encode ion channel subunits and are often characterised by paroxysmal attacks of brain or muscle dysfunction, interspersed with periods of clinical normality. Andersen-Tawil syndrome is one of the rarest and is characterised clinically by the triad of periodic paralysis, cardiac dysrhythmias and skeletal abnormalities. Mutations in a potassium channel gene, KCNJ2 which encodes the potassium channel, Kir2.1, underlie the disorder. Here, the authors describe a patient and review the clinical spectrum and genetic features of the disorder.
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Affiliation(s)
- S Rajakulendran
- Institute of Neurology, University College of London, London WC1N 3BG, UK
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Rayan DR, Matthews E, Rajakulendran S, Barreto G, Tan S, Dewar L, Burge J, Griggs R, Barohn R, Hanna M. P27 Genotype-phenotype correlation and longitudinal three year natural history study in the non-dystrophic myotonias in the UK. Neuromuscul Disord 2011. [DOI: 10.1016/s0960-8966(11)70046-3] [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: 11/15/2022]
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Rajakulendran S, Labrum RW, Graves TD, Tomlinson S, Eunson LH, Davis MB, Schorge S, Kullmann DM, Hanna MG. PAW31 Clinical and genetic spectrum of the episodic ataxias: the UK perspective. Journal of Neurology, Neurosurgery & Psychiatry 2010. [DOI: 10.1136/jnnp.2010.226340.59] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Rajakulendran S, Matthews E, Graves TD, Tan SV, Dewar L, Griggs RC, Hanna MG. POG07 Natural history trials of neurological channelopathies. J Neurol Psychiatry 2010. [DOI: 10.1136/jnnp.2010.226340.129] [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: 11/03/2022]
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Graves TD, Rajakulendran S, Zuberi SM, Morris HR, Schorge S, Hanna MG, Kullmann DM. Nongenetic factors influence severity of episodic ataxia type 1 in monozygotic twins. Neurology 2010; 75:367-72. [PMID: 20660867 DOI: 10.1212/wnl.0b013e3181ea9ee3] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE Episodic ataxia type 1 (EA1) is a monogenic channelopathy caused by mutations of the potassium channel gene KCNA1. Affected individuals carrying the same mutation can exhibit considerable variability in the severity of ataxia, neuromyotonia, and other associated features. We investigated the phenotypic heterogeneity of EA1 in 2 sets of identical twins to determine the contribution of environmental factors to disease severity. One of the mutations was also found in a distantly related family, providing evidence of the influence of genetic background on the EA1 phenotype. METHODS We evaluated 3 families with an EA1 phenotype, 2 of which included monozygotic twins. We sequenced the KCNA1 gene and studied the biophysical consequences of the mutations in HEK cells. RESULTS We identified a new KCNA1 mutation in each pair of twins. Both pairs reported striking differences in the clinical severity of symptoms. The F414S mutation identified in one set of twins also occurred in a distantly related family in which seizures complicated the EA1 phenotype. The other twins had an R307C mutation, the first EA1 mutation to affect an arginine residue in the voltage-sensor domain. Both mutants when expressed exerted a dominant-negative effect on wild-type channels. CONCLUSION These results broaden the range of KCNA1 mutations and reveal an unexpectedly large contribution of nongenetic factors to phenotypic variability in EA1. The occurrence of epilepsy in 1 of 2 families with the F414S mutation suggests an interplay of KCNA1 with other genetic factors.
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Affiliation(s)
- T D Graves
- MRC Centre for Neuromuscular Diseases, UCL Institute of Neurology, University College London, Queen Square, London, United Kingdom
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Rajakulendran S, Kuntzer T, Dunand M, Yau SC, Ashton EJ, Storey H, McCauley J, Abbs S, Thonney F, Leturcq F, Lobrinus JA, Yousry T, Farmer S, Holton JL, Hanna MG. Marked Hemiatrophy in Carriers of Duchenne Muscular Dystrophy. ACTA ACUST UNITED AC 2010; 67:497-500. [DOI: 10.1001/archneurol.2010.58] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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Rajakulendran S, Matthews E, Tan S, Dewar L, Griggs R, Hanna M, the CINCH group. P44 The genetic skeletal muscle channelopathies: genotype–phenotype correlation and longitudinal studies. Neuromuscul Disord 2010. [DOI: 10.1016/s0960-8966(10)70059-6] [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: 10/19/2022]
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Rajakulendran S, Graves TD, Labrum RW, Kotzadimitriou D, Eunson L, Davis MB, Davies R, Wood NW, Kullmann DM, Hanna MG, Schorge S. Genetic and functional characterisation of the P/Q calcium channel in episodic ataxia with epilepsy. J Physiol 2010; 588:1905-13. [PMID: 20156848 DOI: 10.1113/jphysiol.2009.186437] [Citation(s) in RCA: 72] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Mutations in CACNA1A, which encodes the principal subunit of the P/Q calcium channel, underlie episodic ataxia type 2 (EA2). In addition, some patients with episodic ataxia complicated by epilepsy have been shown to harbour CACNA1A mutations, raising the possibility that P/Q channel dysfunction may be linked to human epilepsy. We undertook a review of all published CACNA1A EA2 cases and this showed that 7% have epilepsy--representing a sevenfold increased epilepsy risk compared to the background population risk (P<0.001). We also studied a series of 17 individuals with episodic ataxia accompanied by epilepsy and/or clearly epileptiform electroencephalograms (EEGs). We screened the entire coding region of CACNA1A for point mutations and rearrangements to determine if genetic variation in the gene is associated with the epilepsy phenotype, and measured the functional impact of all missense variations on heterologously expressed P/Q channels. We identified two large scale deletions and two new missense mutations in CACNA1A. When expressed, L621R had little detectable effect on P/Q channel function, while the other missense change, G540R, caused an approximately 30% reduction in current density. In nine patients we also identified the previously reported non-synonymous coding variants (E921D and E993V) which also resulted in impairment of P/Q channel function. Taken together, 12 of the 17 patients have genetic changes which decrease P/Q channel function. We conclude that variants in the coding region of CACNA1A that confer a loss of P/Q-type channel function are associated with episodic ataxia and epilepsy. Our data suggest that functional stratification of all variants, including common polymorphisms, rare variants and novel mutations, may provide new insights into the mechanisms of channelopathies.
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Affiliation(s)
- Sanjeev Rajakulendran
- MRC Centre for Neuromuscular Diseases, Department of Molecular Neuroscience, University College London, Institute of Neurology, London WC1N 3BG, UK
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Abstract
Mutations in the CACNA1A gene are associated with episodic ataxia type 2 (EA2) and spinocerebellar ataxia type 6 (SCA6). CACNA1A encodes the α-subunit of the P/Q-type calcium channel or CaV2.1, which is highly enriched in the cerebellum. It is one of the main channels linked to synaptic transmission throughout the human central nervous system. Here, we compare recent advances in the understanding of the genetic changes that underlie EA2 and SCA6 and what these new findings suggest about the mechanism of the disease.
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Affiliation(s)
- Sanjeev Rajakulendran
- MRC Centre for Neuromuscular Diseases, Institute of Neurology, University College London Queen Square, London WC1N 3BG UK
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Rajakulendran S, Tan SV, Matthews E, Tomlinson SE, Labrum R, Sud R, Kullmann DM, Schorge S, Hanna MG. A patient with episodic ataxia and paramyotonia congenita due to mutations in KCNA1 and SCN4A. Neurology 2009; 73:993-5. [PMID: 19770477 DOI: 10.1212/wnl.0b013e3181b87959] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- S Rajakulendran
- Medical Research Council Centre for Neuromuscular Disease, Queen Square, London, WC1N 3BG, UK
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Heeroma JH, Henneberger C, Rajakulendran S, Hanna MG, Schorge S, Kullmann DM. Episodic ataxia type 1 mutations differentially affect neuronal excitability and transmitter release. Dis Model Mech 2009; 2:612-9. [PMID: 19779067 DOI: 10.1242/dmm.003582] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Heterozygous mutations of KCNA1, the gene encoding potassium channel Kv1.1 subunits, cause episodic ataxia type 1 (EA1), which is characterized by paroxysmal cerebellar incoordination and interictal myokymia. Some mutations are also associated with epilepsy. Although Kv1.1-containing potassium channels play important roles in neuronal excitability and neurotransmitter release, it is not known how mutations associated with different clinical features affect the input-output relationships of individual neurons. We transduced rat hippocampal neurons, which were cultured on glial micro-islands, with lentiviruses expressing wild-type or mutant human KCNA1, and injected either depolarizing currents to evoke action potentials or depolarizing voltage commands to evoke autaptic currents. alpha-Dendrotoxin and tetraethylammonium allowed a pharmacological dissection of potassium currents underlying excitability and neurotransmission. Overexpression of wild-type Kv1.1 decreased both neuronal excitability and neurotransmitter release. By contrast, the C-terminus-truncated R417stop mutant, which is associated with severe drug-resistant EA1, had the opposite effect: increased excitability and release probability. Another mutant, T226R, which is associated with EA1 that is complicated by contractures and epilepsy, had no detectable effect on neuronal excitability; however, in common with R417stop, it markedly enhanced neurotransmitter release. The results provide direct evidence that EA1 mutations increase neurotransmitter release, and provide an insight into mechanisms underlying the phenotypic differences that are associated with different mutations.
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Affiliation(s)
- Joost H Heeroma
- Department of Clinical and Experimental Epilepsy, Department of Molecular Neuroscience and MRC Centre for Neuromuscular Diseases, UCL Institute of Neurology, London, UK
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Labrum RW, Rajakulendran S, Graves TD, Eunson LH, Bevan R, Sweeney MG, Hammans SR, Tubridy N, Britton T, Carr LJ, Ostergaard JR, Kennedy CR, Al-Memar A, Kullmann DM, Schorge S, Temple K, Davis MB, Hanna MG. Large scale calcium channel gene rearrangements in episodic ataxia and hemiplegic migraine: implications for diagnostic testing. J Med Genet 2009; 46:786-91. [PMID: 19586927 DOI: 10.1136/jmg.2009.067967] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND Episodic ataxia type 2 (EA2) and familial hemiplegic migraine type 1 (FHM1) are autosomal dominant disorders characterised by paroxysmal ataxia and migraine, respectively. Point mutations in CACNA1A, which encodes the neuronal P/Q-type calcium channel, have been detected in many cases of EA2 and FHM1. The genetic basis of typical cases without CACNA1A point mutations is not fully known. Standard DNA sequencing methods may miss large scale genetic rearrangements such as deletions and duplications. The authors investigated whether large scale genetic rearrangements in CACNA1A can cause EA2 and FHM1. METHODS The authors used multiplex ligation dependent probe amplification (MLPA) to screen for intragenic CACNA1A rearrangements. RESULTS The authors identified five previously unreported large scale deletions in CACNA1A in seven families with episodic ataxia and in one case with hemiplegic migraine. One of the deletions (exon 6 of CACNA1A) segregated with episodic ataxia in a four generation family with eight affected individuals previously mapped to 19p13. In addition, the authors identified the first pathogenic duplication in CACNA1A in an index case with isolated episodic diplopia without ataxia and in a first degree relative with episodic ataxia. CONCLUSIONS Large scale deletions and duplications can cause CACNA1A associated channelopathies. Direct DNA sequencing alone is not sufficient as a diagnostic screening test.
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Affiliation(s)
- R W Labrum
- MRC Centre for Neuromuscular Diseases, Institute of Neurology, UCL, London WC1N 3BG, UK
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