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Pellinen J, Foster EC, Wilmshurst JM, Zuberi SM, French J. Improving epilepsy diagnosis across the lifespan: approaches and innovations. Lancet Neurol 2024; 23:511-521. [PMID: 38631767 DOI: 10.1016/s1474-4422(24)00079-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 10/30/2023] [Revised: 02/11/2024] [Accepted: 02/16/2024] [Indexed: 04/19/2024]
Abstract
Epilepsy diagnosis is often delayed or inaccurate, exposing people to ongoing seizures and their substantial consequences until effective treatment is initiated. Important factors contributing to this problem include delayed recognition of seizure symptoms by patients and eyewitnesses; cultural, geographical, and financial barriers to seeking health care; and missed or delayed diagnosis by health-care providers. Epilepsy diagnosis involves several steps. The first step is recognition of epileptic seizures; next is classification of epilepsy type and whether an epilepsy syndrome is present; finally, the underlying epilepsy-associated comorbidities and potential causes must be identified, which differ across the lifespan. Clinical history, elicited from patients and eyewitnesses, is a fundamental component of the diagnostic pathway. Recent technological advances, including smartphone videography and genetic testing, are increasingly used in routine practice. Innovations in technology, such as artificial intelligence, could provide new possibilities for directly and indirectly detecting epilepsy and might make valuable contributions to diagnostic algorithms in the future.
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Affiliation(s)
- Jacob Pellinen
- Department of Neurology, University of Colorado School of Medicine, Aurora, CO, USA.
| | - Emma C Foster
- Department of Neurosciences, Central Clinical School, Monash University, Melbourne, VIC, Australia
| | - Jo M Wilmshurst
- Red Cross War Memorial Children's Hospital and University of Cape Town Neuroscience Institute, Cape Town, South Africa
| | - Sameer M Zuberi
- Royal Hospital for Children and University of Glasgow School of Health & Wellbeing, Glasgow, UK
| | - Jacqueline French
- Comprehensive Epilepsy Center, New York University School of Medicine, New York, NY, USA
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Zuberi SM, Wirrell E, Tinuper P, Nabbout R. Response: Do all individuals with Dravet syndrome have intellectual disability? Epilepsia 2024. [PMID: 38597521 DOI: 10.1111/epi.17919] [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: 01/31/2024] [Accepted: 02/02/2024] [Indexed: 04/11/2024]
Affiliation(s)
- Sameer M Zuberi
- School of Health & Wellbeing, University of Glasgow, Glasgow, UK
- Paediatric Neurosciences, Royal Hospital for Children, Glasgow, UK
| | - Elaine Wirrell
- Divisions of Child & Adolescent Neurology and Epilepsy, Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Rima Nabbout
- Department of Pediatric Neurology, Reference Centre for Rare Epilepsies, Necker-Enfants Malades University Hospital, APHP, Member of European Reference Centre EpiCARE, Institut Imagine, INSERM, UMR 1163, Université Paris Cité, Paris, France
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Gallagher D, Pérez-Palma E, Bruenger T, Ghanty I, Brilstra E, Ceulemans B, Chemaly N, de Lange I, Depienne C, Guerrini R, Mei D, Møller RS, Nabbout R, Regan BM, Schneider AL, Scheffer IE, Schoonjans AS, Symonds JD, Weckhuysen S, Zuberi SM, Lal D, Brunklaus A. Genotype-phenotype associations in 1018 individuals with SCN1A-related epilepsies. Epilepsia 2024; 65:1046-1059. [PMID: 38410936 DOI: 10.1111/epi.17882] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2023] [Revised: 12/30/2023] [Accepted: 01/03/2024] [Indexed: 02/28/2024]
Abstract
OBJECTIVE SCN1A variants are associated with epilepsy syndromes ranging from mild genetic epilepsy with febrile seizures plus (GEFS+) to severe Dravet syndrome (DS). Many variants are de novo, making early phenotype prediction difficult, and genotype-phenotype associations remain poorly understood. METHODS We assessed data from a retrospective cohort of 1018 individuals with SCN1A-related epilepsies. We explored relationships between variant characteristics (position, in silico prediction scores: Combined Annotation Dependent Depletion (CADD), Rare Exome Variant Ensemble Learner (REVEL), SCN1A genetic score), seizure characteristics, and epilepsy phenotype. RESULTS DS had earlier seizure onset than other GEFS+ phenotypes (5.3 vs. 12.0 months, p < .001). In silico variant scores were higher in DS versus GEFS+ (p < .001). Patients with missense variants in functionally important regions (conserved N-terminus, S4-S6) exhibited earlier seizure onset (6.0 vs. 7.0 months, p = .003) and were more likely to have DS (280/340); those with missense variants in nonconserved regions had later onset (10.0 vs. 7.0 months, p = .036) and were more likely to have GEFS+ (15/29, χ2 = 19.16, p < .001). A minority of protein-truncating variants were associated with GEFS+ (10/393) and more likely to be located in the proximal first and last exon coding regions than elsewhere in the gene (9.7% vs. 1.0%, p < .001). Carriers of the same missense variant exhibited less variability in age at seizure onset compared with carriers of different missense variants for both DS (1.9 vs. 2.9 months, p = .001) and GEFS+ (8.0 vs. 11.0 months, p = .043). Status epilepticus as presenting seizure type is a highly specific (95.2%) but nonsensitive (32.7%) feature of DS. SIGNIFICANCE Understanding genotype-phenotype associations in SCN1A-related epilepsies is critical for early diagnosis and management. We demonstrate an earlier disease onset in patients with missense variants in important functional regions, the occurrence of GEFS+ truncating variants, and the value of in silico prediction scores. Status epilepticus as initial seizure type is a highly specific, but not sensitive, early feature of DS.
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Affiliation(s)
- Declan Gallagher
- School of Health and Wellbeing, University of Glasgow, Glasgow, UK
- Paediatric Neurosciences Research Group, Royal Hospital for Children, Glasgow, UK
| | - Eduardo Pérez-Palma
- Universidad del Desarrollo, Centro de Genética y Genómica, Facultad de Medicina Clínica Alemana, Santiago, Chile
- Cologne Center for Genomics, University of Cologne, Cologne, Germany
| | - Tobias Bruenger
- Cologne Center for Genomics, University of Cologne, Cologne, Germany
| | - Ismael Ghanty
- School of Health and Wellbeing, University of Glasgow, Glasgow, UK
- Paediatric Neurosciences Research Group, Royal Hospital for Children, Glasgow, UK
| | - Eva Brilstra
- Department of Genetics, University Medical Center, Utrecht, the Netherlands
| | - Berten Ceulemans
- Department of Child Neurology, University Hospital Antwerp, Antwerp, Belgium
| | - Nicole Chemaly
- Reference Center for Rare Epilepsies, Department of Pediatric Neurology, Hôpital Necker-Enfants Malades, Université de Paris, Paris, France
| | - Iris de Lange
- Department of Genetics, University Medical Center, Utrecht, the Netherlands
| | - Christel Depienne
- Institute of Human Genetics, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Renzo Guerrini
- Neuroscience Department, Children's Hospital A. Meyer Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) and University of Florence, Florence, Italy
| | - Davide Mei
- Neuroscience Department, Children's Hospital A. Meyer Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) and University of Florence, Florence, Italy
| | - Rikke S Møller
- Danish Epilepsy Center, Filadelfia, Dianalund, Denmark
- Department of Regional Health Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Rima Nabbout
- Reference Center for Rare Epilepsies, Department of Pediatric Neurology, Hôpital Necker-Enfants Malades, Université de Paris, Paris, France
| | - Brigid M Regan
- Department of Medicine, Epilepsy Research Centre, University of Melbourne, Austin Health, Melbourne, Victoria, Australia
| | - Amy L Schneider
- Department of Medicine, Epilepsy Research Centre, University of Melbourne, Austin Health, Melbourne, Victoria, Australia
| | - Ingrid E Scheffer
- Department of Medicine, Epilepsy Research Centre, University of Melbourne, Austin Health, Melbourne, Victoria, Australia
- University of Melbourne, Royal Children's Hospital, Florey and Murdoch Children's Research Institutes, Melbourne, Victoria, Australia
| | - An-Sofie Schoonjans
- Department of Child Neurology, University Hospital Antwerp, Antwerp, Belgium
| | - Joseph D Symonds
- School of Health and Wellbeing, University of Glasgow, Glasgow, UK
- Paediatric Neurosciences Research Group, Royal Hospital for Children, Glasgow, UK
| | - Sarah Weckhuysen
- Applied & Translational Neurogenomics Group, VIB Center for Molecular Neurology, Antwerp, Belgium
- Neurology Department, University Hospital Antwerp, Antwerp, Belgium
- Translational Neurosciences, University of Antwerp, Antwerp, Belgium
| | - Sameer M Zuberi
- School of Health and Wellbeing, University of Glasgow, Glasgow, UK
- Paediatric Neurosciences Research Group, Royal Hospital for Children, Glasgow, UK
| | - Dennis Lal
- Cologne Center for Genomics, University of Cologne, Cologne, Germany
- Epilepsy Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
- Stanley Center for Psychiatric Genetics, Broad Institute of MIT and Harvard, Cambridge, Massachusetts, USA
- Department of Neurology, McGovern Medical School, UTHealth Houston, Houston, Texas, USA
| | - Andreas Brunklaus
- School of Health and Wellbeing, University of Glasgow, Glasgow, UK
- Paediatric Neurosciences Research Group, Royal Hospital for Children, Glasgow, UK
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Eyre M, Thomas T, Ferrarin E, Khamis S, Zuberi SM, Sie A, Newlove-Delgado T, Morton M, Molteni E, Dale RC, Lim M, Nosadini M. Treatments and Outcomes Among Patients with Sydenham Chorea: A Meta-Analysis. JAMA Netw Open 2024; 7:e246792. [PMID: 38625703 PMCID: PMC11022117 DOI: 10.1001/jamanetworkopen.2024.6792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 12/07/2023] [Accepted: 02/17/2024] [Indexed: 04/17/2024] Open
Abstract
Importance Sydenham chorea is the most common acquired chorea of childhood worldwide; however, treatment is limited by a lack of high-quality evidence. Objectives To evaluate historical changes in the clinical characteristics of Sydenham chorea and identify clinical and treatment factors at disease onset associated with chorea duration, relapsing disease course, and functional outcome. Data Sources The systematic search for this meta-analysis was conducted in PubMed, Embase, CINAHL, Cochrane Library, and LILACS databases and registers of clinical trials from inception to November 1, 2022 (search terms: [Sydenham OR Sydenham's OR rheumatic OR minor] AND chorea). Study Selection Published articles that included patients with a final diagnosis of Sydenham chorea (in selected languages). Data Extraction and Synthesis This study followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline. Individual patient data on clinical characteristics, treatments, chorea duration, relapse, and final outcome were extracted. Data from patients in the modern era (1945 through 2022) were entered into multivariable models and stratified by corticosteroid duration for survival analysis of chorea duration. Main Outcomes and Measures The planned study outcomes were chorea duration at onset, monophasic course (absence of relapse after ≥24 months), and functional outcome (poor: modified Rankin Scale score 2-6 or persisting chorea, psychiatric, or behavioral symptoms at final follow-up after ≥6 months; good: modified Rankin Scale score 0-1 and no chorea, psychiatric, or behavioral symptoms at final follow-up). Results In total, 1479 patients were included (from 307 articles), 1325 since 1945 (median [IQR] age at onset, 10 [8-13] years; 875 of 1272 female [68.8%]). Immunotherapy was associated with shorter chorea duration (hazard ratio for chorea resolution, 1.51 [95% CI, 1.05-2.19]; P = .03). The median chorea duration in patients receiving 1 or more months of corticosteroids was 1.2 months (95% CI, 1.2-2.0) vs 2.8 months (95% CI, 2.0-3.0) for patients receiving none (P = .004). Treatment factors associated with monophasic disease course were antibiotics (odds ratio [OR] for relapse, 0.28 [95% CI, 0.09-0.85]; P = .02), corticosteroids (OR, 0.32 [95% CI, 0.15-0.67]; P = .003), and sodium valproate (OR, 0.33 [95% CI, 0.15-0.71]; P = .004). Patients receiving at least 1 month of corticosteroids had significantly lower odds of relapsing course (OR, 0.10 [95% CI, 0.04-0.25]; P < .001). No treatment factor was associated with good functional outcome. Conclusions and Relevance In this meta-analysis of treatments and outcomes in patients with Sydenham chorea, immunotherapy, in particular corticosteroid treatment, was associated with faster resolution of chorea. Antibiotics, corticosteroids and sodium valproate were associated with a monophasic disease course. This synthesis of retrospective data should support the development of evidence-based treatment guidelines for patients with Sydenham chorea.
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Affiliation(s)
- Michael Eyre
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London, United Kingdom
- Children’s Neurosciences, Evelina London Children’s Hospital at Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Terrence Thomas
- Department of Paediatrics, Neurology Service, KK Women’s and Children’s Hospital, Singapore
| | | | - Sonia Khamis
- Children’s Neurosciences, Evelina London Children’s Hospital at Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Sameer M. Zuberi
- Paediatric Neurosciences Research Group, Royal Hospital for Children, Glasgow, United Kingdom
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, United Kingdom
| | - Adrian Sie
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, United Kingdom
- NHS Lanarkshire, Bothwell, United Kingdom
| | - Tamsin Newlove-Delgado
- Children and Young People’s Mental Health (ChYMe) Research Collaboration, University of Exeter Medical School, Exeter, United Kingdom
| | - Michael Morton
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, United Kingdom
| | - Erika Molteni
- School of Biomedical Engineering and Imaging Sciences, King’s College London, United Kingdom
| | - Russell C. Dale
- Kids Neuroscience Centre, The Children’s Hospital at Westmead, Faculty of Medicine and Health, University of Sydney, Westmead, Australia
| | - Ming Lim
- Faculty of Life Sciences and Medicine, King’s College London, United Kingdom
- Children’s Neurosciences, Evelina London Children’s Hospital at Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Margherita Nosadini
- Paediatric Neurology and Neurophysiology Unit, Department of Women’s and Children’s Health, University Hospital of Padova, Padova, Italy
- Neuroimmunology Group, Paediatric Research Institute “Città della Speranza,” Padova, Italy
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Feng T, Makiello P, Dunwoody B, Steckler F, Symonds JD, Zuberi SM, Dorris L, Brunklaus A. Long-term predictors of developmental outcome and disease burden in SCN1A-positive Dravet syndrome. Brain Commun 2024; 6:fcae004. [PMID: 38229878 PMCID: PMC10789590 DOI: 10.1093/braincomms/fcae004] [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] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2023] [Revised: 11/25/2023] [Accepted: 01/05/2024] [Indexed: 01/18/2024] Open
Abstract
Dravet syndrome is a severe infantile onset developmental and epileptic encephalopathy associated with mutations in the sodium channel alpha 1 subunit gene SCN1A. Prospective data on long-term developmental and clinical outcomes are limited; this study seeks to evaluate the clinical course of Dravet syndrome over a 10-year period and identify predictors of developmental outcome. SCN1A mutation-positive Dravet syndrome patients were prospectively followed up in the UK from 2010 to 2020. Caregivers completed structured questionnaires on clinical features and disease burden; the Epilepsy & Learning Disability Quality of Life Questionnaire, the Adaptive Behavioural Assessment System-3 and the Sleep Disturbance Scale for Children. Sixty-eight of 113 caregivers (60%) returned posted questionnaires. Developmental outcome worsened at follow-up (4.45 [SD 0.65], profound cognitive impairment) compared to baseline (2.9 [SD 1.1], moderate cognitive impairment, P < 0.001), whereas epilepsy severity appeared less severe at 10-year follow-up (P = 0.042). Comorbidities were more apparent at 10-year outcome including an increase in autistic features (77% [48/62] versus 30% [17/57], χ2 = 19.9, P < 0.001), behavioural problems (81% [46/57] versus 38% [23/60], χ2 = 14.1, P < 0.001) and motor/mobility problems (80% [51/64] versus 41% [24/59], χ2 = 16.9, P < 0.001). Subgroup analysis demonstrated a more significant rise in comorbidities in younger compared to older patients. Predictors of worse long-term developmental outcome included poorer baseline language ability (P < 0.001), more severe baseline epilepsy severity (P = 0.003) and a worse SCN1A genetic score (P = 0.027). Sudden unexpected death in epilepsy had not been discussed with a medical professional in 35% (24/68) of participants. Over 90% of caregivers reported a negative impact on their own health and career opportunities. Our study identifies important predictors and potential biomarkers of developmental outcome in Dravet syndrome and emphasizes the significant caregiver burden of illness. The negative impact of epilepsy severity at baseline on long-term developmental outcomes highlights the importance of implementing early and focused therapies whilst the potential impact of newer anti-seizure medications requires further study.
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Affiliation(s)
- Tony Feng
- School of Health and Wellbeing, University of Glasgow, Clarice Pears Building, 90 Byres Road, Glasgow G12 8TB, UK
- The Paediatric Neurosciences Research Group, Royal Hospital for Children, Office Block, Level 0, Zone 1, 1345 Govan Road, Glasgow G51 4TF, UK
| | - Phoebe Makiello
- The Paediatric Neurosciences Research Group, Royal Hospital for Children, Office Block, Level 0, Zone 1, 1345 Govan Road, Glasgow G51 4TF, UK
| | - Benjamin Dunwoody
- The Paediatric Neurosciences Research Group, Royal Hospital for Children, Office Block, Level 0, Zone 1, 1345 Govan Road, Glasgow G51 4TF, UK
| | - Felix Steckler
- School of Health and Wellbeing, University of Glasgow, Clarice Pears Building, 90 Byres Road, Glasgow G12 8TB, UK
- The Paediatric Neurosciences Research Group, Royal Hospital for Children, Office Block, Level 0, Zone 1, 1345 Govan Road, Glasgow G51 4TF, UK
| | - Joseph D Symonds
- School of Health and Wellbeing, University of Glasgow, Clarice Pears Building, 90 Byres Road, Glasgow G12 8TB, UK
- The Paediatric Neurosciences Research Group, Royal Hospital for Children, Office Block, Level 0, Zone 1, 1345 Govan Road, Glasgow G51 4TF, UK
| | - Sameer M Zuberi
- School of Health and Wellbeing, University of Glasgow, Clarice Pears Building, 90 Byres Road, Glasgow G12 8TB, UK
- The Paediatric Neurosciences Research Group, Royal Hospital for Children, Office Block, Level 0, Zone 1, 1345 Govan Road, Glasgow G51 4TF, UK
| | - Liam Dorris
- School of Health and Wellbeing, University of Glasgow, Clarice Pears Building, 90 Byres Road, Glasgow G12 8TB, UK
- The Paediatric Neurosciences Research Group, Royal Hospital for Children, Office Block, Level 0, Zone 1, 1345 Govan Road, Glasgow G51 4TF, UK
| | - Andreas Brunklaus
- School of Health and Wellbeing, University of Glasgow, Clarice Pears Building, 90 Byres Road, Glasgow G12 8TB, UK
- The Paediatric Neurosciences Research Group, Royal Hospital for Children, Office Block, Level 0, Zone 1, 1345 Govan Road, Glasgow G51 4TF, UK
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Wirrell EC, Riney K, Specchio N, Zuberi SM. How have the recent updated epilepsy classifications impacted on diagnosis and treatment? Expert Rev Neurother 2023; 23:969-980. [PMID: 37676056 DOI: 10.1080/14737175.2023.2254937] [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: 07/19/2023] [Accepted: 08/30/2023] [Indexed: 09/08/2023]
Abstract
INTRODUCTION Epilepsies are a diverse group of disorders which differ regarding prognosis for seizure control and associated comorbidities. Accurate classification is critical to choose the highest yield investigations and best therapeutic options and to provide the most accurate prognoses regarding the expected degree of seizure control, possible remission, and risk of associated comorbidities to patients and their families. This article reviews the recent updates in epilepsy classification to illustrate how accurate classification impacts care for persons with epilepsy. AREAS COVERED The authors discuss the ILAE 2017 Classification of the Epilepsies along with the modification of the classification for neonatal seizures and epilepsies. They also discuss the ILAE position papers on Epilepsy syndromes in neonates and infants and children of variable age and the Idiopathic Generalized Epilepsies. EXPERT OPINION Accurate epilepsy classification allows selection of the highest yield investigations, choice of optimal therapies, and accurate prognostication of seizures (likelihood of response to antiseizure treatments and likelihood of remission with age), as well as comorbidities (likelihood, type, and severity). As we move into the era of disease modifying therapy, early accurate identification of underlying causes with timely introduction of specific treatments will be crucial to lessen the severity of epilepsy, with improved seizure control and attenuation of associated comorbidities.
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Affiliation(s)
- Elaine C Wirrell
- Divisions of Child and Adolescent Neurology and Epilepsy, Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | - Kate Riney
- Neurosciences Unit, Queensland Children's Hospital, Australia and Faculty of Medicine, University of St Lucia, Brisbane, Queensland, Australia
| | - Nicola Specchio
- Clinical and Experimental Neurology, Bambino Gesu Children's Hospital, IRCCS, Full Member of European Reference Network on Rare and Complex Epilepsies (EpiCARE), Rome, Italy
| | - Sameer M Zuberi
- School of Health and Wellbeing, University of Glasgow, Glasgow, UK
- Royal Hospital for Children, Glasgow, UK
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Owolabi MO, Leonardi M, Bassetti C, Jaarsma J, Hawrot T, Makanjuola AI, Dhamija RK, Feng W, Straub V, Camaradou J, Dodick DW, Sunna R, Menon B, Wright C, Lynch C, Chadha AS, Ferretti MT, Dé A, Catsman-Berrevoets CE, Gichu M, Tassorelli C, Oliver D, Paulus W, Mohammed RK, Charway-Felli A, Rostasy K, Feigin V, Craven A, Cunningham E, Galvin O, Perry AH, Fink EL, Baneke P, Helme A, Laurson-Doube J, Medina MT, Roa JD, Hogl B, O'Bryan A, Trenkwalder C, Wilmshurst J, Akinyemi RO, Yaria JO, Good DC, Hoemberg V, Boon P, Wiebe S, Cross JH, Haas M, Jabalpurwala I, Mojasevic M, DiLuca M, Barbarino P, Clarke S, Zuberi SM, Olowoyo P, Owolabi A, Oyesiku N, Maly-Sundgren PC, Norrving B, Soekadar SR, van Doorn PA, Lewis R, Solomon T, Servadei F. Global synergistic actions to improve brain health for human development. Nat Rev Neurol 2023; 19:371-383. [PMID: 37208496 PMCID: PMC10197060 DOI: 10.1038/s41582-023-00808-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [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] [Accepted: 03/29/2023] [Indexed: 05/21/2023]
Abstract
The global burden of neurological disorders is substantial and increasing, especially in low-resource settings. The current increased global interest in brain health and its impact on population wellbeing and economic growth, highlighted in the World Health Organization's new Intersectoral Global Action Plan on Epilepsy and other Neurological Disorders 2022-2031, presents an opportunity to rethink the delivery of neurological services. In this Perspective, we highlight the global burden of neurological disorders and propose pragmatic solutions to enhance neurological health, with an emphasis on building global synergies and fostering a 'neurological revolution' across four key pillars - surveillance, prevention, acute care and rehabilitation - termed the neurological quadrangle. Innovative strategies for achieving this transformation include the recognition and promotion of holistic, spiritual and planetary health. These strategies can be deployed through co-design and co-implementation to create equitable and inclusive access to services for the promotion, protection and recovery of neurological health in all human populations across the life course.
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Affiliation(s)
- Mayowa O Owolabi
- Center for Genomic and Precision Medicine, College of Medicine, University of Ibadan, Ibadan, Nigeria.
- Neurology Unit, Department of Medicine, College of Medicine, University of Ibadan, Ibadan, Nigeria.
- African Stroke Organization, Ibadan, Nigeria.
- World Federation for Neurorehabilitation, North Shields, UK.
- Lebanese American University of Beirut, Beirut, Lebanon.
- Blossom Specialist Medical Center, Ibadan, Nigeria.
| | - Matilde Leonardi
- Neurology, Public Health, Disability Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Claudio Bassetti
- Neurology Department Inselspital - University of Bern, Bern, Switzerland
- European Academy of Neurology, Vienna, Austria
| | - Joke Jaarsma
- European Federation of Neurological Associations, Brussels, Belgium
| | - Tadeusz Hawrot
- European Federation of Neurological Associations, Brussels, Belgium
| | | | | | - Wuwei Feng
- Department of Neurology, Duke University School of Medicine, Durham, NC, USA
| | - Volker Straub
- John Walton Muscular Dystrophy Research Center, Newcastle University, Newcastle, UK
| | - Jennifer Camaradou
- Faculty of Medicine and Health Sciences, University of East Anglia, Norwich, UK
- One Neurology Initiative, Brussels, Belgium
| | - David W Dodick
- Department of Neurology, Mayo Clinic, Phoenix, AZ, USA
- Atria Academy of Science and Medicine, New York, NY, USA
- American Brain Foundation, Minneapolis, MN, USA
| | - Rosita Sunna
- Tics and Tourette Across the Globe, Hannover, Germany
- Australian Clinical Psychology Association, Sydney, New South Wales, Australia
| | - Bindu Menon
- Department of Neurology, Apollo Specialty Hospitals, Nellore, India
| | | | - Chris Lynch
- Alzheimer's Disease International, London, UK
| | | | | | - Anna Dé
- Women's Brain Project, Guntershausen, Switzerland
| | - Coriene E Catsman-Berrevoets
- Department of Paediatric Neurology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
- European Paediatric Neurology Society, Bolton, UK
| | - Muthoni Gichu
- Department of Non-Communicable Diseases, Ministry of Health, Nairobi, Kenya
- Global Brain Health Institute, San Francisco, CA, USA
| | - Cristina Tassorelli
- Department of Brain and Behavioral Sciences of the University of Pavia, Pavia, Italy
- IRCCS C. Mondino Foundation Neurological Institute, Pavia, Italy
- International Headache Society, London, UK
| | - David Oliver
- University of Kent, Canterbury, UK
- International Neuro-Palliative Care Society, Roseville, MN, USA
| | - Walter Paulus
- Department of Neurology, Ludwig-Maximilians University Munich, Klinikum Großhadern, Munich, Germany
- International Federation of Clinical Neurophysiology, Milwaukee, WI, USA
| | - Ramla K Mohammed
- Amal Neuro Developmental Centres, Gudalur, India
- Al Ameen Educational Trust, Gudalur, India
| | | | - Kevin Rostasy
- European Paediatric Neurology Society, Bolton, UK
- Department of Paediatric Neurology, Children's Hospital Datteln, University Witten/Herdecke, Witten, Germany
| | - Valery Feigin
- National Institute for Stroke and Applied Neurosciences, Auckland University of Technology, Auckland, New Zealand
| | | | | | - Orla Galvin
- European Federation of Neurological Associations, Brussels, Belgium
| | | | - Ericka L Fink
- Department of Paediatric Neurology and Critical Care, University of Pittsburgh Medical Centre Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
- Safar Center for Resuscitation Research, University of Pittsburgh Medical Centre Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Peer Baneke
- Multiple Sclerosis International Federation, London, UK
| | - Anne Helme
- Multiple Sclerosis International Federation, London, UK
| | | | - Marco T Medina
- National Autonomous University of Honduras, Tegucigalpa, Honduras
- Pan-American Federation of Neurological Societies, Santiago de Chile, Chile
| | - Juan David Roa
- HOMI Fundacion Hospital Paediatrico la Misericordia, Bogota, Colombia
| | - Birgit Hogl
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
- World Sleep Society, Rochester, MN, USA
| | | | - Claudia Trenkwalder
- Paracelsus-Elena Hospital, Kassel, Department of Neurosurgery, University Medical Centre, Goettingen, Germany
| | - Jo Wilmshurst
- Department of Paediatrics and Child Health, Red Cross War Memorial Children's Hospital Neuroscience Institute, University of Cape Town, Cape Town, South Africa
- International Child Neurology Association, London, UK
| | - Rufus O Akinyemi
- African Stroke Organization, Ibadan, Nigeria
- Neuroscience and Ageing Research Unit, Institute for Advanced Medical Research and Training, College of Medicine, University of Ibadan, Ibadan, Nigeria
| | - Joseph O Yaria
- Department of Neurology, University College Hospital, Ibadan, Nigeria
| | - David C Good
- World Federation for Neurorehabilitation, North Shields, UK
- Department of Neurology, Pennsylvania State University College of Medicine, Hershey, PA, USA
| | - Volker Hoemberg
- World Federation for Neurorehabilitation, North Shields, UK
- SRH Neurorehabilitation Hospital Bad Wimpfen, Bad Wimpfen, Germany
| | - Paul Boon
- European Academy of Neurology, Vienna, Austria
- Department of Neurology, Ghent University Hospital, Ghent, Belgium
| | - Samuel Wiebe
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Alberta, Canada
- International League Against Epilepsy, Flower Mound, TX, USA
| | - J Helen Cross
- International League Against Epilepsy, Flower Mound, TX, USA
- Clinical Neurosciences Section, UCL Institute of Child Health, University College London, London, UK
| | - Magali Haas
- Cohen Veterans Bioscience, New York, NY, USA
| | | | | | - Monica DiLuca
- Department of Pharmacological and Biomolecular Sciences, University of Milan, Milan, Italy
- European Brain Council, Brussels, Belgium
| | | | - Stephanie Clarke
- World Federation for Neurorehabilitation, North Shields, UK
- Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Sameer M Zuberi
- European Paediatric Neurology Society, Bolton, UK
- Paediatric Neurosciences Research Group, School of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Paul Olowoyo
- Department of Medicine, Afe Babalola University, Ado-Ekiti, Nigeria
- Federal Teaching Hospital, Ido-Ekiti, Nigeria
| | | | - Nelson Oyesiku
- Department of Neurosurgery, University of North Carolina at Chapel Hill, North Carolina, NC, USA
- World Federation of Neurosurgical Societies, Prague, Czech Republic
| | - Pia C Maly-Sundgren
- Department of Clinical Sciences/Diagnostic Radiology, Lund University, Lund, Sweden
| | - Bo Norrving
- Department of Clinical Sciences/Neurology, Lund University, Lund, Sweden
| | - Surjo R Soekadar
- Clinical Neurotechnology Laboratory, Department of Psychiatry and Neurosciences, Charité Campus Mitte, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Pieter A van Doorn
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
- Peripheral Nerve Society, Roseville, MN, USA
| | - Richard Lewis
- Peripheral Nerve Society, Roseville, MN, USA
- Department of Neurology, Cedars Sinai Medical Center, Los Angeles, CA, USA
| | - Tom Solomon
- Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, UK
- Encephalitis Society, Malton, North Yorkshire, UK
| | - Franco Servadei
- World Federation of Neurosurgical Societies, Prague, Czech Republic
- Department of Neurosurgery, Humanitas Clinical and Research Center - IRCCS, Humanitas University, Milan, Italy
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8
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Strzelczyk A, Zuberi SM, Striano P, Rosenow F, Schubert-Bast S. The burden of illness in Lennox-Gastaut syndrome: a systematic literature review. Orphanet J Rare Dis 2023; 18:42. [PMID: 36859290 PMCID: PMC9979426 DOI: 10.1186/s13023-023-02626-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 02/06/2023] [Indexed: 03/03/2023] Open
Abstract
BACKGROUND Lennox-Gastaut syndrome (LGS) is a severe developmental and epileptic encephalopathy characterized by drug-resistant epilepsy with multiple seizure types starting in childhood, a typical slow spike-wave pattern on electroencephalogram, and cognitive dysfunction. METHODS We performed a systematic literature review according to the PRISMA guidelines to identify, synthesize and appraise the burden of illness in LGS (including "probable" LGS). Studies were identified by searching MEDLINE, Embase and APA PsychInfo, Cochrane's database of systematic reviews, and Epistemonikos. The outcomes were epidemiology (incidence, prevalence or mortality), direct and indirect costs, healthcare resource utilization, and patient and caregiver health-related quality of life (HRQoL). RESULTS The search identified 22 publications evaluating the epidemiology (n = 10), direct costs and resource (n = 10) and/or HRQoL (n = 5). No studies reporting on indirect costs were identified. With no specific ICD code for LGS in many regions, several studies had to rely upon indirect methods to identify their patient populations (e.g., algorithms to search insurance claims databases to identify "probable" LGS). There was heterogeneity between studies in how LGS was defined, the size of the populations, ages of the patients and length of the follow-up period. The prevalence varied from 4.2 to 60.8 per 100,000 people across studies for probable LGS and 2.9-28 per 100,000 for a confirmed/narrow definition of LGS. LGS was associated with high mortality rates compared to the general population and epilepsy population. Healthcare resource utilization and direct costs were substantial across all studies. Mean annual direct costs per person varied from $24,048 to $80,545 across studies, and home-based care and inpatient care were significant cost drivers. Studies showed that the HRQoL of patients and caregivers was adversely affected, although only a few studies were identified. In addition, studies suggested that seizure events were associated with higher costs and worse HRQoL. The risk of bias was low or moderate in most studies. CONCLUSIONS LGS is associated with a significant burden of illness featuring resistant seizures associated with higher costs and worse HRQoL. More research is needed, especially in evaluating indirect costs and caregiver burden, where there is a notable lack of studies.
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Affiliation(s)
- Adam Strzelczyk
- Epilepsy Center Frankfurt Rhine-Main, Center of Neurology and Neurosurgery, University Hospital and Goethe-University Frankfurt, Schleusenweg 2-16 (Haus 95), 60528, Frankfurt am Main, Germany.
- LOEWE Center for Personalized and Translational Epilepsy Research (CePTER), Goethe-University Frankfurt, Frankfurt am Main, Germany.
| | - Sameer M Zuberi
- Paediatric Neurosciences Research Group, Royal Hospital for Children, School of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Pasquale Striano
- IRCCS 'G. Gaslini' Institute, Genova, Italy
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa, Genova, Italy
| | - Felix Rosenow
- Epilepsy Center Frankfurt Rhine-Main, Center of Neurology and Neurosurgery, University Hospital and Goethe-University Frankfurt, Schleusenweg 2-16 (Haus 95), 60528, Frankfurt am Main, Germany
- LOEWE Center for Personalized and Translational Epilepsy Research (CePTER), Goethe-University Frankfurt, Frankfurt am Main, Germany
| | - Susanne Schubert-Bast
- Epilepsy Center Frankfurt Rhine-Main, Center of Neurology and Neurosurgery, University Hospital and Goethe-University Frankfurt, Schleusenweg 2-16 (Haus 95), 60528, Frankfurt am Main, Germany
- LOEWE Center for Personalized and Translational Epilepsy Research (CePTER), Goethe-University Frankfurt, Frankfurt am Main, Germany
- Department of Neuropediatrics, University Hospital and Goethe-University Frankfurt, Frankfurt am Main, Germany
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9
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Makiello P, Feng T, Dunwoody B, Steckler F, Symonds J, Zuberi SM, Dorris L, Brunklaus A. Comorbidities and predictors of health-related quality of life in Dravet syndrome: A 10-year, prospective follow-up study. Epilepsia 2023; 64:1012-1020. [PMID: 36740581 DOI: 10.1111/epi.17531] [Citation(s) in RCA: 4] [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] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Revised: 02/01/2023] [Accepted: 02/02/2023] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Dravet syndrome (DS) is a severe developmental and epileptic encephalopathy, leading to reduced health-related quality of life (HRQOL). Prospective outcome data on HRQOL are sparse, and this study investigated long-term predictors of HRQOL in DS. METHODS One hundred thirteen families of SCN1A-positive patients with DS, who were recruited as part of our 2010 study were contacted at 10-year follow-up, of which 68 (60%) responded. The mortality was 5.8%. Detailed clinical and demographic information was available for each patient. HRQOL was evaluated with two epilepsy-specific instruments, the Impact of Pediatric Epilepsy Scale (IPES) and the Epilepsy & Learning Disabilities Quality of Life Questionnaire (ELDQOL); a generic HRQOL instrument, the Pediatric Quality of Life Inventory (PedsQL); and a behavioral screening tool, the Strength and Difficulties Questionnaire (SDQ). RESULTS Twenty-eight patients were 10-15 years of age (0-5 years at baseline) and 40 were ≥16 years of age (≥6 years at baseline). Patients 0- to 5-years-old at baseline showed a significant decline in mean scores on the PedsQL total score (p = .004), physical score (p < .001), cognitive score (p = .011), social score (p = .003), and eating score (p = .030) at follow-up. On multivariate regression, lower baseline and follow-up HRQOL for the whole cohort were associated with worse epilepsy severity and a high SDQ total score (R2 = 33% and 18%, respectively). In the younger patient group, younger age at first seizure and increased severity of epilepsy were associated with a lower baseline HRQOL (R2 = 35%). In the older age group, worse epilepsy severity (F = 6.40, p = .016, R2 = 14%) and the use of sodium-channel blockers were independently associated with a lower HRQOL at 10-year follow-up (F = 4.13, p = .05, R2 = 8%). SIGNIFICANCE This 10-year, prospective follow-up study highlights the significant HRQOL-associated cognitive, social, and physical decline particularly affecting younger patients with DS. Sodium channel blocker use appears to negatively impact long-term HRQOL, highlighting the importance of early diagnosis and disease-specific management in DS.
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Affiliation(s)
- Phoebe Makiello
- The Paediatric Neurosciences Research Group, Royal Hospital for Children, Glasgow, UK
| | - Tony Feng
- The Paediatric Neurosciences Research Group, Royal Hospital for Children, Glasgow, UK
| | - Benjamin Dunwoody
- The Paediatric Neurosciences Research Group, Royal Hospital for Children, Glasgow, UK
| | - Felix Steckler
- The Paediatric Neurosciences Research Group, Royal Hospital for Children, Glasgow, UK
| | - Joseph Symonds
- The Paediatric Neurosciences Research Group, Royal Hospital for Children, Glasgow, UK.,School of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Sameer M Zuberi
- The Paediatric Neurosciences Research Group, Royal Hospital for Children, Glasgow, UK.,School of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Liam Dorris
- The Paediatric Neurosciences Research Group, Royal Hospital for Children, Glasgow, UK.,School of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Andreas Brunklaus
- The Paediatric Neurosciences Research Group, Royal Hospital for Children, Glasgow, UK.,School of Health and Wellbeing, University of Glasgow, Glasgow, UK
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10
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Knupp KG, Scheffer IE, Ceulemans B, Sullivan J, Nickels KC, Lagae L, Guerrini R, Zuberi SM, Nabbout R, Riney K, Agarwal A, Lock M, Dai D, Farfel GM, Galer BS, Gammaitoni AR, Polega S, Davis R, Gil-Nagel A. Fenfluramine provides clinically meaningful reduction in frequency of drop seizures in patients with Lennox-Gastaut syndrome: Interim analysis of an open-label extension study. Epilepsia 2023; 64:139-151. [PMID: 36196777 PMCID: PMC10099582 DOI: 10.1111/epi.17431] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [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: 06/15/2022] [Revised: 09/30/2022] [Accepted: 10/03/2022] [Indexed: 01/21/2023]
Abstract
OBJECTIVE This study was undertaken to evaluate the long-term safety and effectiveness of fenfluramine in patients with Lennox-Gastaut syndrome (LGS). METHODS Eligible patients with LGS who completed a 14-week phase 3 randomized clinical trial enrolled in an open-label extension (OLE; NCT03355209). All patients were initially started on .2 mg/kg/day fenfluramine and after 1 month were titrated by effectiveness and tolerability, which were assessed at 3-month intervals. The protocol-specified treatment duration was 12 months, but COVID-19-related delays resulted in 142 patients completing their final visit after 12 months. RESULTS As of October 19, 2020, 247 patients were enrolled in the OLE. Mean age was 14.3 ± 7.6 years (79 [32%] adults) and median fenfluramine treatment duration was 364 days; 88.3% of patients received 2-4 concomitant antiseizure medications. Median percentage change in monthly drop seizure frequency was -28.6% over the entire OLE (n = 241) and -50.5% at Month 15 (n = 142, p < .0001); 75 of 241 patients (31.1%) experienced ≥50% reduction in drop seizure frequency. Median percentage change in nondrop seizure frequency was -45.9% (n = 192, p = .0038). Generalized tonic-clonic seizures (GTCS) and tonic seizures were most responsive to treatment, with median reductions over the entire OLE of 48.8% (p < .0001, n = 106) and 35.8% (p < .0001, n = 186), respectively. A total of 37.6% (95% confidence interval [CI] = 31.4%-44.1%, n = 237) of investigators and 35.2% of caregivers (95% CI = 29.1%-41.8%, n = 230) rated patients as Much Improved/Very Much Improved on the Clinical Global Impression of Improvement scale. The most frequent treatment-emergent adverse events were decreased appetite (16.2%) and fatigue (13.4%). No cases of valvular heart disease (VHD) or pulmonary arterial hypertension (PAH) were observed. SIGNIFICANCE Patients with LGS experienced sustained reductions in drop seizure frequency on fenfluramine treatment, with a particularly robust reduction in frequency of GTCS, the key risk factor for sudden unexpected death in epilepsy. Fenfluramine was generally well tolerated; VHD or PAH was not observed long-term. Fenfluramine may provide an important long-term treatment option for LGS.
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Affiliation(s)
- Kelly G Knupp
- University of Colorado, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Ingrid E Scheffer
- University of Melbourne, Austin Hospital and Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Berten Ceulemans
- Department of Pediatric Neurology, Antwerp University Hospital, Antwerp, Belgium
| | - Joseph Sullivan
- University of California, San Francisco Weill Institute for Neurosciences, Benioff Children's Hospital, San Francisco, California, USA
| | | | - Lieven Lagae
- Member of the European Reference Network EpiCARE, Department of Pediatric Neurology, University of Leuven, Leuven, Belgium
| | - Renzo Guerrini
- Pediatric Neurology and Neurogenetics Unit, Anna Meyer Children's Hospital, University of Florence, Florence, Italy.,Stella Maris Foundation, Scientific Institute for Research and Health Care, Pisa, Italy
| | - Sameer M Zuberi
- Paediatric Neurosciences Research Group, Royal Hospital for Children, Glasgow, UK
| | - Rima Nabbout
- Reference Center for Rare Epilepsies, Necker-Sick Children University Hospital, Public Hospital Network of Paris, member of EpiCARE, Imagine Institute, Paris Cité University, Paris, France
| | - Kate Riney
- Neuroscience Unit, Queensland Children's Hospital, South Brisbane, Queensland, Australia.,School of Clinical Medicine, University of Queensland, St Lucia, Queensland, Australia
| | - Anupam Agarwal
- Zogenix (now a part of UCB), Emeryville, California, USA
| | - Michael Lock
- Independent Consultant, Zogenix (now a part of UCB), Haiku, Hawaii, USA
| | - David Dai
- Syneos Health, Morrisville, North Carolina, USA
| | - Gail M Farfel
- Zogenix (now a part of UCB), Emeryville, California, USA
| | | | | | - Shikha Polega
- Zogenix (now a part of UCB), Emeryville, California, USA
| | - Ronald Davis
- Neurology and Epilepsy Research Center, Orlando, Florida, USA
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11
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Brunklaus A, Feng T, Brünger T, Perez-Palma E, Heyne H, Matthews E, Semsarian C, Symonds JD, Zuberi SM, Lal D, Schorge S. Gene variant effects across sodium channelopathies predict function and guide precision therapy. Brain 2022; 145:4275-4286. [PMID: 35037686 PMCID: PMC9897196 DOI: 10.1093/brain/awac006] [Citation(s) in RCA: 32] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Revised: 11/27/2021] [Accepted: 12/10/2021] [Indexed: 11/14/2022] Open
Abstract
Pathogenic variants in the voltage-gated sodium channel gene family lead to early onset epilepsies, neurodevelopmental disorders, skeletal muscle channelopathies, peripheral neuropathies and cardiac arrhythmias. Disease-associated variants have diverse functional effects ranging from complete loss-of-function to marked gain-of-function. Therapeutic strategy is likely to depend on functional effect. Experimental studies offer important insights into channel function but are resource intensive and only performed in a minority of cases. Given the evolutionarily conserved nature of the sodium channel genes, we investigated whether similarities in biophysical properties between different voltage-gated sodium channels can predict function and inform precision treatment across sodium channelopathies. We performed a systematic literature search identifying functionally assessed variants in any of the nine voltage-gated sodium channel genes until 28 April 2021. We included missense variants that had been electrophysiologically characterized in mammalian cells in whole-cell patch-clamp recordings. We performed an alignment of linear protein sequences of all sodium channel genes and correlated variants by their overall functional effect on biophysical properties. Of 951 identified records, 437 sodium channel-variants met our inclusion criteria and were reviewed for functional properties. Of these, 141 variants were epilepsy-associated (SCN1/2/3/8A), 79 had a neuromuscular phenotype (SCN4/9/10/11A), 149 were associated with a cardiac phenotype (SCN5/10A) and 68 (16%) were considered benign. We detected 38 missense variant pairs with an identical disease-associated variant in a different sodium channel gene. Thirty-five out of 38 of those pairs resulted in similar functional consequences, indicating up to 92% biophysical agreement between corresponding sodium channel variants (odds ratio = 11.3; 95% confidence interval = 2.8 to 66.9; P < 0.001). Pathogenic missense variants were clustered in specific functional domains, whereas population variants were significantly more frequent across non-conserved domains (odds ratio = 18.6; 95% confidence interval = 10.9-34.4; P < 0.001). Pore-loop regions were frequently associated with loss-of-function variants, whereas inactivation sites were associated with gain-of-function (odds ratio = 42.1, 95% confidence interval = 14.5-122.4; P < 0.001), whilst variants occurring in voltage-sensing regions comprised a range of gain- and loss-of-function effects. Our findings suggest that biophysical characterisation of variants in one SCN-gene can predict channel function across different SCN-genes where experimental data are not available. The collected data represent the first gain- versus loss-of-function topological map of SCN proteins indicating shared patterns of biophysical effects aiding variant analysis and guiding precision therapy. We integrated our findings into a free online webtool to facilitate functional sodium channel gene variant interpretation (http://SCN-viewer.broadinstitute.org).
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Affiliation(s)
- Andreas Brunklaus
- Correspondence to: Dr Andreas Brunklaus, MD Fraser of Allander Neurosciences Unit Office Block, Ground Floor, Zone 2 Royal Hospital for Children 1345 Govan Road Glasgow G51 4TF, UK E-mail:
| | | | | | - Eduardo Perez-Palma
- Centro de Genética y Genómica, Facultad de Medicina Clínica Alemana, Universidad del Desarrollo, Santiago, Chile
| | - Henrike Heyne
- Genomic and Personalized Medicine, Digital Health Center, Hasso Plattner Institute, Potsdam, Germany
- Hasso Plattner Institute, Mount Sinai School of Medicine, New York, NY, USA
- Institute for Molecular Medicine Finland: FIMM, Helsinki, Finland
| | - Emma Matthews
- Atkinson Morley Neuromuscular Centre, St George’s University Hospitals NHS Foundation Trust, London, UK
- Molecular and Clinical Sciences Research Institute, St George’s University of London, London, UK
| | - Christopher Semsarian
- Agnes Ginges Centre for Molecular Cardiology at Centenary Institute, The University of Sydney, Sydney, Australia
- Sydney Medical School Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, Australia
| | - Joseph D Symonds
- The Paediatric Neurosciences Research Group, Royal Hospital for Children, Glasgow, UK
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Sameer M Zuberi
- The Paediatric Neurosciences Research Group, Royal Hospital for Children, Glasgow, UK
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Dennis Lal
- Epilepsy Center, Neurological Institute, Cleveland Clinic, Cleveland, USA
- Stanley Center for Psychiatric Genetics, Broad Institute of MIT and Harvard, Cambridge, MA, USA
| | - Stephanie Schorge
- Correspondence may also be addressed to: Professor Stephanie Schorge, PhD Department of Neuroscience Physiology and Pharmacology UCL, London WC1E 6BT, UK E-mail:
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12
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Brunklaus A, Brünger T, Feng T, Fons C, Lehikoinen A, Panagiotakaki E, Vintan MA, Symonds J, Andrew J, Arzimanoglou A, Delima S, Gallois J, Hanrahan D, Lesca G, MacLeod S, Marjanovic D, McTague A, Nuñez-Enamorado N, Perez-Palma E, Scott Perry M, Pysden K, Russ-Hall SJ, Scheffer IE, Sully K, Syrbe S, Vaher U, Velayutham M, Vogt J, Weiss S, Wirrell E, Zuberi SM, Lal D, Møller RS, Mantegazza M, Cestèle S. The gain of function SCN1A disorder spectrum: novel epilepsy phenotypes and therapeutic implications. Brain 2022; 145:3816-3831. [PMID: 35696452 PMCID: PMC9679167 DOI: 10.1093/brain/awac210] [Citation(s) in RCA: 33] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 04/14/2022] [Accepted: 05/26/2022] [Indexed: 11/29/2022] Open
Abstract
Brain voltage-gated sodium channel NaV1.1 (SCN1A) loss-of-function variants cause the severe epilepsy Dravet syndrome, as well as milder phenotypes associated with genetic epilepsy with febrile seizures plus. Gain of function SCN1A variants are associated with familial hemiplegic migraine type 3. Novel SCN1A-related phenotypes have been described including early infantile developmental and epileptic encephalopathy with movement disorder, and more recently neonatal presentations with arthrogryposis. Here we describe the clinical, genetic and functional evaluation of affected individuals. Thirty-five patients were ascertained via an international collaborative network using a structured clinical questionnaire and from the literature. We performed whole-cell voltage-clamp electrophysiological recordings comparing sodium channels containing wild-type versus variant NaV1.1 subunits. Findings were related to Dravet syndrome and familial hemiplegic migraine type 3 variants. We identified three distinct clinical presentations differing by age at onset and presence of arthrogryposis and/or movement disorder. The most severely affected infants (n = 13) presented with congenital arthrogryposis, neonatal onset epilepsy in the first 3 days of life, tonic seizures and apnoeas, accompanied by a significant movement disorder and profound intellectual disability. Twenty-one patients presented later, between 2 weeks and 3 months of age, with a severe early infantile developmental and epileptic encephalopathy and a movement disorder. One patient presented after 3 months with developmental and epileptic encephalopathy only. Associated SCN1A variants cluster in regions of channel inactivation associated with gain of function, different to Dravet syndrome variants (odds ratio = 17.8; confidence interval = 5.4-69.3; P = 1.3 × 10-7). Functional studies of both epilepsy and familial hemiplegic migraine type 3 variants reveal alterations of gating properties in keeping with neuronal hyperexcitability. While epilepsy variants result in a moderate increase in action current amplitude consistent with mild gain of function, familial hemiplegic migraine type 3 variants induce a larger effect on gating properties, in particular the increase of persistent current, resulting in a large increase of action current amplitude, consistent with stronger gain of function. Clinically, 13 out of 16 (81%) gain of function variants were associated with a reduction in seizures in response to sodium channel blocker treatment (carbamazepine, oxcarbazepine, phenytoin, lamotrigine or lacosamide) without evidence of symptom exacerbation. Our study expands the spectrum of gain of function SCN1A-related epilepsy phenotypes, defines key clinical features, provides novel insights into the underlying disease mechanisms between SCN1A-related epilepsy and familial hemiplegic migraine type 3, and identifies sodium channel blockers as potentially efficacious therapies. Gain of function disease should be considered in early onset epilepsies with a pathogenic SCN1A variant and non-Dravet syndrome phenotype.
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Affiliation(s)
- Andreas Brunklaus
- Correspondence to: Professor Andreas Brunklaus, MD Institute of Health and Wellbeing University of Glasgow Paediatric Neurosciences Research Group Office Block, Ground Floor, Zone 2 Royal Hospital for Children 1345 Govan Road, Glasgow G51 4TF, UK E-mail:
| | - Tobias Brünger
- Cologne Center for Genomics, University of Cologne, Cologne, Germany
| | - Tony Feng
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
- The Paediatric Neurosciences Research Group, Royal Hospital for Children, Member of the ERN EpiCARE, Glasgow, UK
| | - Carmen Fons
- Pediatric Neurology Department, CIBERER-ISCIII, Sant Joan de Déu Universitary Hospital, Institut de Recerca Sant Joan de Déu, Member of the ERN EpiCARE, Barcelona, Spain
| | - Anni Lehikoinen
- Pediatric Neurology Department, Kuopio University Hospital, Member of the ERN EpiCARE, Kuopio, Finland
| | - Eleni Panagiotakaki
- Department of Paediatric Clinical Epileptology, sleep disorders and functional neurology, Member of the ERN EpiCARE, University Hospitals of Lyon (HCL) and Inserm U1028/CNRS UMR5292, Lyon, France
| | - Mihaela-Adela Vintan
- ‘Iuliu Hatieganu’ University of Medicine and Pharmacy, Faculty of Medicine, Department of Neuroscience, Neurology and Pediatric Neurology, Victor Babes, 43, 400012 Cluj-Napoca, Romania
| | - Joseph Symonds
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
- The Paediatric Neurosciences Research Group, Royal Hospital for Children, Member of the ERN EpiCARE, Glasgow, UK
| | - James Andrew
- The Paediatric Neurosciences Research Group, Royal Hospital for Children, Member of the ERN EpiCARE, Glasgow, UK
| | - Alexis Arzimanoglou
- Pediatric Neurology Department, CIBERER-ISCIII, Sant Joan de Déu Universitary Hospital, Institut de Recerca Sant Joan de Déu, Member of the ERN EpiCARE, Barcelona, Spain
- Department of Paediatric Clinical Epileptology, sleep disorders and functional neurology, Member of the ERN EpiCARE, University Hospitals of Lyon (HCL) and Inserm U1028/CNRS UMR5292, Lyon, France
| | - Sarah Delima
- Indiana University School of Medicine, IU Health Riley Hospital for Children, Department of Neurology, Division of Pediatric Neurology, Indianapolis, IN, USA
| | - Julie Gallois
- Louisiana State University Health Sciences Center School of Medicine, New Orleans, LA, USA
| | - Donncha Hanrahan
- Department of Paediatric Neurology, Royal Belfast Hospital for Sick Children, Belfast, UK
| | - Gaetan Lesca
- Department of Medical Genetics, Lyon University Hospital, Member of the ERN EpiCARE, Université Claude Bernard Lyon 1, Lyon, France
| | - Stewart MacLeod
- The Paediatric Neurosciences Research Group, Royal Hospital for Children, Member of the ERN EpiCARE, Glasgow, UK
| | - Dragan Marjanovic
- The Danish Epilepsy Centre, Member of the ERN EpiCARE, Dianalund, Denmark
| | - Amy McTague
- Developmental Neurosciences, UCL Great Ormond Street Institute of Child Health, London, UK
- Department of Neurology, Great Ormond Street Hospital for Children, Member of the ERN EpiCARE, London, UK
| | | | - Eduardo Perez-Palma
- Universidad del Desarrollo, Centro de Genética y Genómica, Facultad de Medicina Clínica Alemana, Santiago, Chile
| | - M Scott Perry
- Jane and John Justin Neurosciences Center, Cook Children’s Medical Center, Ft Worth, TX, USA
| | - Karen Pysden
- Paediatric Neurology Department, Leeds Teaching Hospitals, Leeds General Infirmary, Leeds, UK
| | - Sophie J Russ-Hall
- Epilepsy Research Centre, Department of Medicine, University of Melbourne, Austin Health, Melbourne, Australia
| | - Ingrid E Scheffer
- Epilepsy Research Centre, Department of Medicine, University of Melbourne, Austin Health, Melbourne, Australia
- Florey Institute of Neuroscience and Mental Health, Melbourne, Australia
- Murdoch Children’s Research Institute and Department of Paediatrics, University of Melbourne, Royal Children’s Hospital, Melbourne, Australia
| | - Krystal Sully
- Baylor College of Medicine, Houston, TX, USA
- Texas Children’s Hospital, Houston, TX, USA
| | - Steffen Syrbe
- Division of Pediatric Epileptology, Center for Pediatrics and Adolescent Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Ulvi Vaher
- Children’s Clinic of Tartu University Hospital, Faculty of Medicine of Tartu University, Member of the ERN EpiCARE, Tartu, Estonia
| | | | - Julie Vogt
- West Midlands Regional Genetics Service, Birmingham Women’s and Children’s Hospital, Birmingham, UK
| | - Shelly Weiss
- Division of Neurology, SickKids, University of Toronto, Toronto, Canada
| | - Elaine Wirrell
- Divisions of Epilepsy and Child and Adolescent Neurology, Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | - Sameer M Zuberi
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
- The Paediatric Neurosciences Research Group, Royal Hospital for Children, Member of the ERN EpiCARE, Glasgow, UK
| | - Dennis Lal
- Cologne Center for Genomics, University of Cologne, Cologne, Germany
- Genomic Medicine Institute, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
- Epilepsy Center, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
- Stanley Center for Psychiatric Genetics, Broad Institute of MIT and Harvard, Cambridge, MA, USA
| | - Rikke S Møller
- Correspondence may also be addressed to: Professor Rikke Steensbjerre Møller, PhD E-mail: ; Professor Massimo Mantegazza, PhD E-mail: ; Professor Sandrine Cestèle, PhD E-mail:
| | - Massimo Mantegazza
- Correspondence may also be addressed to: Professor Rikke Steensbjerre Møller, PhD E-mail: ; Professor Massimo Mantegazza, PhD E-mail: ; Professor Sandrine Cestèle, PhD E-mail:
| | - Sandrine Cestèle
- Correspondence may also be addressed to: Professor Rikke Steensbjerre Møller, PhD E-mail: ; Professor Massimo Mantegazza, PhD E-mail: ; Professor Sandrine Cestèle, PhD E-mail:
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13
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Guerrini R, Specchio N, Aledo‐Serrano Á, Pringsheim M, Darra F, Mayer T, Gil‐Nagel A, Polster T, Zuberi SM, Lothe A, Gammaitoni A, Strzelczyk A. An examination of the efficacy and safety of fenfluramine in adults, children, and adolescents with Dravet syndrome in a real-world practice setting: A report from the Fenfluramine European Early Access Program. Epilepsia Open 2022; 7:578-587. [PMID: 35801621 PMCID: PMC9712464 DOI: 10.1002/epi4.12624] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [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: 04/08/2022] [Accepted: 07/03/2022] [Indexed: 12/30/2022] Open
Abstract
OBJECTIVE To examine the efficacy and safety of fenfluramine in patients with Dravet syndrome (DS) in three age groups: <6, 6-17, and ≥18 years old, treated in a real-world setting. METHODS Patients with DS were treated with fenfluramine in the European Union Early Access Program (EAP). Following a 28-day baseline period to establish the pretreatment monthly convulsive seizure frequency (MCSF), fenfluramine was started at a dose chosen by the treating physician and gradually titrated based on efficacy and tolerability up to a maximum of 0.7 mg/kg/day. Seizure incidence was recorded in a written diary, and adverse events (AEs) were reported at each patient visit. Cardiovascular safety was assessed by transthoracic echocardiography before treatment started and at least every 6 months thereafter. RESULTS A total of 149 patients have enrolled in the EAP and 63 were <6 years old, 62 were 6-17 years old, and 24 were ≥18 years old. After 3 months of treatment 62%, 53%, and 50% of patients demonstrated ≥75% reduction in MCSF in the <6, 6-17, and ≥18-year-old groups, respectively. This pattern of response was sustained through 12 months of treatment with 55%, 46%, and 80% of the <6, 6-17, and ≥18-year-old groups, respectively, experiencing a ≥75% reduction in MCSF. Most common AEs were loss of appetite (21%) and somnolence (16%). No valvular heart disease or pulmonary artery hypertension was observed. SIGNIFICANCE The magnitude, consistency, and durability of the response to add-on fenfluramine is consistent across age groups in patients with Dravet syndrome.
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Affiliation(s)
- Renzo Guerrini
- Children's Hospital A MeyerUniversity of Florence, Full Member of European Reference Network on Rare and Complex Epilepsies EpiCAREFlorenceItaly
| | - Nicola Specchio
- Rare and Complex Epilepsy Unit, Department of NeuroscienceBambino Gesù Children's Hospital IRCCS, Full Member of European Reference Network on Rare and Complex Epilepsies EpiCARERomeItaly
| | - Ángel Aledo‐Serrano
- Epilepsy Program, Department of NeurologyHospital Ruber InternacionalMadridSpain
| | - Milka Pringsheim
- Clinic for Neuropediatrics and Neurorehabilitation, Epilepsy Center for Children and AdolescentsSchön KlinikVogtareuthGermany,Department for Congenital Heart Disease and Pediatric CardiologyGerman Heart CenterMunichGermany,Research Institute for Rehabilitation, Transition and PalliationParacelsus Medical UniversitySalzburgAustria
| | - Francesca Darra
- Child Neuropsychiatry, Department of Surgical Sciences, Dentistry, Gynecology and PediatricsUniversity of Verona, Full Member of European Reference Network on Rare and Complex Epilepsies EpiCAREVeronaItaly
| | - Thomas Mayer
- Epilepsy Center KleinwachauDresden‐RadebergGermany
| | - Antonio Gil‐Nagel
- Epilepsy Program, Department of NeurologyHospital Ruber InternacionalMadridSpain
| | - Tilman Polster
- Krankenhaus Mara – Bethel Epilepsy Centre, Department of Epileptology, Medical SchoolBielefeld UniversityBielefeldGermany
| | - Sameer M. Zuberi
- Paediatric Neurosciences Research Group, Royal Hospital for Children & Institute of Health & WellbeingUniversity of GlasgowGlasgowUK
| | | | | | - Adam Strzelczyk
- Epilepsy Center Frankfurt Rhine‐Main and Department of NeurologyGoethe‐University FrankfurtFrankfurt am MainGermany
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14
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McTague A, Brunklaus A, Barcia G, Varadkar S, Zuberi SM, Chatron N, Parrini E, Mei D, Nabbout R, Lesca G. Defining causal variants in rare epilepsies: an essential team effort between biomedical scientists, geneticists and epileptologists. Eur J Med Genet 2022; 65:104531. [PMID: 35618197 DOI: 10.1016/j.ejmg.2022.104531] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Revised: 05/01/2022] [Accepted: 05/19/2022] [Indexed: 11/23/2022]
Abstract
In the last few years, with the advent of next generation sequencing (NGS), our knowledge of genes associated with monogenic epilepsies has significantly improved. NGS is also a powerful diagnostic tool for patients with epilepsy, through gene panels, exomes and genomes. This has improved diagnostic yield, reducing the time between the first seizure and a definitive molecular diagnosis. However, these developments have also increased the complexity of data interpretation, due to the large number of variants identified in a given patient and due to the phenotypic variability associated with many of the epilepsy-related genes. In this paper, we present examples of variant classification in "real life" clinic situations. We emphasize the importance of accurate phenotyping of the epilepsies including recognising variable/milder phenotypes and expansion of previously described phenotypes. There are some important issues specific to rare epilepsies - mosaicism and reduced penetrance - which affect genetic counselling. These challenges may be overcome through multidisciplinary meetings including epileptologists, pediatric neurologists, and clinical and molecular geneticists, in which every specialist learns from the others in a process which leads to for rapid and accurate diagnosis. This is an important milestone to achieve as targeted therapiesbased on the functional effects of pathogenic variants become available.
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Affiliation(s)
- Amy McTague
- Developmental Neurosciences, UCL Great Ormond Street Institute of Child Health, Member of the ERN EpiCARE, London, UK; Department of Neurology, Great Ormond Street Institute of Child Health, Member of the ERN EpiCARE, London, UK.
| | - Andreas Brunklaus
- The Pediatric Neurosciences Research Group, Royal Hospital for Children, Member of the ERN EpiCARE, Glasgow, UK; Institute of Health and Wellbeing, University of Glasgow, Member of the ERN EpiCARE, Glasgow, UK
| | - Giulia Barcia
- Department of Pediatric Neurology, Centre de Reference Epilepsies Rares, Hôpital Necker-Enfants Malades, Assistance Publique-Hôpitaux de Paris, Member of the ERN EpiCARE, Paris, France
| | - Sophia Varadkar
- Department of Neurology, Great Ormond Street Institute of Child Health, Member of the ERN EpiCARE, London, UK
| | - Sameer M Zuberi
- The Pediatric Neurosciences Research Group, Royal Hospital for Children, Member of the ERN EpiCARE, Glasgow, UK; Institute of Health and Wellbeing, University of Glasgow, Member of the ERN EpiCARE, Glasgow, UK
| | - Nicolas Chatron
- Department of Medical Genetics, Lyon University Hospital, Université Claude Bernard Lyon 1, Member of the ERN EpiCARE, Lyon, France
| | - Elena Parrini
- Pediatric Neurology, Neurogenetics, and Neurobiology Unit and Laboratories, Meyer Children's Hospital - University of Florence, Member of the ERN EpiCARE, Florence, Italy
| | - Davide Mei
- Pediatric Neurology, Neurogenetics, and Neurobiology Unit and Laboratories, Meyer Children's Hospital - University of Florence, Member of the ERN EpiCARE, Florence, Italy
| | - Rima Nabbout
- Department of Pediatric Neurology, Centre de Reference Epilepsies Rares, Hôpital Necker-Enfants Malades, Assistance Publique-Hôpitaux de Paris, Member of the ERN EpiCARE, Paris, France
| | - Gaetan Lesca
- Department of Medical Genetics, Lyon University Hospital, Université Claude Bernard Lyon 1, Member of the ERN EpiCARE, Lyon, France
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15
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Zuberi SM. Precision in child neurology: Networks, systems, and technology. Dev Med Child Neurol 2022; 64:673. [PMID: 35532050 DOI: 10.1111/dmcn.15222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 03/07/2022] [Indexed: 11/28/2022]
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16
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Hirsch E, French J, Scheffer IE, Bogacz A, Alsaadi T, Sperling MR, Abdulla F, Zuberi SM, Trinka E, Specchio N, Somerville E, Samia P, Riney K, Nabbout R, Jain S, Wilmshurst JM, Auvin S, Wiebe S, Perucca E, Moshé SL, Tinuper P, Wirrell EC. ILAE definition of the Idiopathic Generalized Epilepsy Syndromes: Position statement by the ILAE Task Force on Nosology and Definitions. Epilepsia 2022; 63:1475-1499. [PMID: 35503716 DOI: 10.1111/epi.17236] [Citation(s) in RCA: 121] [Impact Index Per Article: 60.5] [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: 04/23/2021] [Revised: 03/18/2022] [Accepted: 03/21/2022] [Indexed: 12/13/2022]
Abstract
In 2017, the International League Against Epilepsy (ILAE) Classification of Epilepsies described the "genetic generalized epilepsies" (GGEs), which contained the "idiopathic generalized epilepsies" (IGEs). The goal of this paper is to delineate the four syndromes comprising the IGEs, namely childhood absence epilepsy, juvenile absence epilepsy, juvenile myoclonic epilepsy, and epilepsy with generalized tonic-clonic seizures alone. We provide updated diagnostic criteria for these IGE syndromes determined by the expert consensus opinion of the ILAE's Task Force on Nosology and Definitions (2017-2021) and international external experts outside our Task Force. We incorporate current knowledge from recent advances in genetic, imaging, and electroencephalographic studies, together with current terminology and classification of seizures and epilepsies. Patients that do not fulfill criteria for one of these syndromes, but that have one, or a combination, of the following generalized seizure types: absence, myoclonic, tonic-clonic and myoclonic-tonic-clonic seizures, with 2.5-5.5 Hz generalized spike-wave should be classified as having GGE. Recognizing these four IGE syndromes as a special grouping among the GGEs is helpful, as they carry prognostic and therapeutic implications.
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Affiliation(s)
- Edouard Hirsch
- Francis Rohmer Neurology Epilepsy Units, National Institute of Health and Medical Research 1258, Federation of Translational Medicine of Strasbourg, Strasbourg University, Strasbourg, France
| | - Jacqueline French
- New York University Grossman School of Medicine and NYU Langone Health, New York, New York, USA
| | - Ingrid E Scheffer
- Austin Health and Royal Children's Hospital, Florey Institute, Murdoch Children's Research Institute, University of Melbourne, Melbourne, Victoria, Australia
| | - Alicia Bogacz
- Institute of Neurology, Clinical Hospital, Faculty of Medicine, University of the Republic, Montevideo, Uruguay
| | - Taoufik Alsaadi
- Department of Neurology, American Center for Psychiatry and Neurology, Abu Dhabi, United Arab Emirates
| | - Michael R Sperling
- Department of Neurology, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Fatema Abdulla
- Salmaniya Medical Complex-Government Hospital, Manama, Bahrain
| | - Sameer M Zuberi
- Paediatric Neurosciences Research Group, Royal Hospital for Children and Institute of Health & Wellbeing, University of Glasgow, member of EpiCARE, Glasgow, UK
| | - Eugen Trinka
- Department of Neurology and Neuroscience Institute, Christian Doppler University Hospital, Paracelsus Medical University, Center for Cognitive Neuroscience, member of EpiCARE, Salzburg, Austria.,Department of Public Health, Health Services Research, and Health Technology Assessment, University for Health Sciences, Medical Informatics, and Technology, Hall in Tirol, Austria
| | - Nicola Specchio
- Rare and Complex Epilepsy Unit, Department of Neuroscience, Bambino Gesù Children's Hospital, Scientific Institute for Research and Health Care, member of EpiCARE, Rome, Italy
| | - Ernest Somerville
- Prince of Wales Hospital, University of New South Wales, Sydney, New South Wales, Australia
| | - Pauline Samia
- Department of Pediatrics and Child Health, Aga Khan University, East Africa, Nairobi, Kenya
| | - Kate Riney
- Neurosciences Unit, Queensland Children's Hospital, South Brisbane, Queensland, Australia.,Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Rima Nabbout
- Reference Center for Rare Epilepsies, Department of Pediatric Neurology, Necker-Enfants Malades Hospital, Public Hospital Network of Paris, member of EpiCARE, Imagine Institute, National Institute of Health and Medical Research, Mixed Unit of Research 1163, University of Paris, Paris, France
| | | | - Jo M Wilmshurst
- Department of Paediatric Neurology, Red Cross War Memorial Children's Hospital, Neuroscience Institute, University of Cape Town, Cape Town, South Africa
| | - Stephane Auvin
- Pediatric Neurology, Public Hospital Network of Paris, Robert Debré Hospital, NeuroDiderot, National Institute of Health and Medical Research, Department Medico-Universitaire, Innovation Robert-Debré, University of Paris, Paris, France.,University Institute of France, Paris, France
| | - Samuel Wiebe
- Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
| | - Emilio Perucca
- Department of Neuroscience, Monash University, Melbourne, Victoria, Australia.,Department of Medicine, Austin Health, University of Melbourne, Heidelberg, Victoria, Australia
| | - Solomon L Moshé
- Isabelle Rapin Division of Child Neurology, Saul R. Korey Department of Neurology, and Departments of Neuroscience and Pediatrics, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, New York, USA
| | - Paolo Tinuper
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy.,Institute of Neurological Sciences, Scientific Institute for Research and Health Care, member of EpiCARE, Bologna, Italy
| | - Elaine C Wirrell
- Divisions of Child and Adolescent Neurology and Epilepsy, Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
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17
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Zuberi SM, Wirrell E, Yozawitz E, Wilmshurst JM, Specchio N, Riney K, Pressler R, Auvin S, Samia P, Hirsch E, Galicchio S, Triki C, Snead OC, Wiebe S, Cross JH, Tinuper P, Scheffer IE, Perucca E, Moshé SL, Nabbout R. ILAE classification and definition of epilepsy syndromes with onset in neonates and infants: Position statement by the ILAE Task Force on Nosology and Definitions. Epilepsia 2022; 63:1349-1397. [PMID: 35503712 DOI: 10.1111/epi.17239] [Citation(s) in RCA: 197] [Impact Index Per Article: 98.5] [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: 04/23/2021] [Revised: 03/20/2022] [Accepted: 03/21/2022] [Indexed: 12/20/2022]
Abstract
The International League Against Epilepsy (ILAE) Task Force on Nosology and Definitions proposes a classification and definition of epilepsy syndromes in the neonate and infant with seizure onset up to 2 years of age. The incidence of epilepsy is high in this age group and epilepsy is frequently associated with significant comorbidities and mortality. The licensing of syndrome specific antiseizure medications following randomized controlled trials and the development of precision, gene-related therapies are two of the drivers defining the electroclinical phenotypes of syndromes with onset in infancy. The principal aim of this proposal, consistent with the 2017 ILAE Classification of the Epilepsies, is to support epilepsy diagnosis and emphasize the importance of classifying epilepsy in an individual both by syndrome and etiology. For each syndrome, we report epidemiology, clinical course, seizure types, electroencephalography (EEG), neuroimaging, genetics, and differential diagnosis. Syndromes are separated into self-limited syndromes, where there is likely to be spontaneous remission and developmental and epileptic encephalopathies, diseases where there is developmental impairment related to both the underlying etiology independent of epileptiform activity and the epileptic encephalopathy. The emerging class of etiology-specific epilepsy syndromes, where there is a specific etiology for the epilepsy that is associated with a clearly defined, relatively uniform, and distinct clinical phenotype in most affected individuals as well as consistent EEG, neuroimaging, and/or genetic correlates, is presented. The number of etiology-defined syndromes will continue to increase, and these newly described syndromes will in time be incorporated into this classification. The tables summarize mandatory features, cautionary alerts, and exclusionary features for the common syndromes. Guidance is given on the criteria for syndrome diagnosis in resource-limited regions where laboratory confirmation, including EEG, MRI, and genetic testing, might not be available.
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Affiliation(s)
- Sameer M Zuberi
- Paediatric Neurosciences Research Group, Royal Hospital for Children, Institute of Health & Wellbeing, Collaborating Centre of European Reference Network EpiCARE, University of Glasgow, Glasgow, UK
| | - Elaine Wirrell
- Divisions of Child and Adolescent Neurology and Epilepsy, Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | - Elissa Yozawitz
- Isabelle Rapin Division of Child Neurology, Saul R. Korey Department of Neurology, Montefiore Medical Center, Bronx, New York, USA
| | - Jo M Wilmshurst
- Department of Paediatric Neurology, Red Cross War Memorial Children's Hospital, Neuroscience Institute, University of Cape Town, Cape Town, South Africa
| | - Nicola Specchio
- Rare and Complex Epilepsy Unit, Department of Neuroscience, Bambino Gesu' Children's Hospital, IRCCS, Member of European Reference Network EpiCARE, Rome, Italy
| | - Kate Riney
- Neurosciences Unit, Queensland Children's Hospital, South Brisbane, Queensland, Australia.,Faculty of Medicine, University of Queensland, St Lucia, Queensland, Australia
| | - Ronit Pressler
- Clinical Neuroscience, UCL- Great Ormond Street Institute of Child Health, London, UK.,Department of Clinical Neurophysiology, Great Ormond Street Hospital for Children NHS Foundation Trust, Member of European Reference Network EpiCARE, London, UK
| | - Stephane Auvin
- AP-HP, Hôpital Robert-Debré, INSERM NeuroDiderot, DMU Innov-RDB, Neurologie Pédiatrique, Member of European Reference Network EpiCARE, Université de Paris, Paris, France
| | - Pauline Samia
- Department of Paediatrics and Child Health, Aga Khan University, Nairobi, Kenya
| | - Edouard Hirsch
- Neurology Epilepsy Unit "Francis Rohmer", INSERM 1258, FMTS, Strasbourg University, Strasbourg, France
| | - Santiago Galicchio
- Child Neurology Department, Victor J Vilela Child Hospital of Rosario, Santa Fe, Argentina
| | - Chahnez Triki
- Child Neurology Department, LR19ES15 Neuropédiatrie, Sfax Medical School, University of Sfax, Sfax, Tunisia
| | - O Carter Snead
- Pediatric Neurology, Hospital for Sick Children, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Samuel Wiebe
- Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
| | - J Helen Cross
- Programme of Developmental Neurosciences, UCL NIHR BRC Great Ormond Street Institute of Child Health, Great Ormond Street Hospital for Children, Member of European Reference Network EpiCARE, London, UK.,Young Epilepsy, Lingfield, UK
| | - Paolo Tinuper
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy.,IRCCS Istituto delle Scienze Neurologiche, Bologna, Italy
| | - Ingrid E Scheffer
- Austin Health and Royal Children's Hospital, Florey Institute, Murdoch Children's Research Institute, University of Melbourne, Melbourne, Victoria, Australia
| | - Emilio Perucca
- Department of Neuroscience, Monash University, Melbourne, Victoria, Australia.,Department of Medicine, Austin Health, University of Melbourne, Heidelberg, Victoria, Australia
| | - Solomon L Moshé
- Isabelle Rapin Division of Child Neurology, Saul R. Korey Department of Neurology, Bronx, New York, USA.,Departments of Neuroscience and Pediatrics, Albert Einstein College of Medicine, Bronx, New York, USA.,Montefiore Medical Center, Bronx, New York, USA
| | - Rima Nabbout
- Reference Centre for Rare Epilepsies, Department of Pediatric Neurology, Necker-Enfants Malades University Hospital, APHP, Member of European Reference Network EpiCARE, Institut Imagine, INSERM, UMR 1163, Université Paris cité, Paris, France
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18
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Wirrell EC, Nabbout R, Scheffer IE, Alsaadi T, Bogacz A, French JA, Hirsch E, Jain S, Kaneko S, Riney K, Samia P, Snead OC, Somerville E, Specchio N, Trinka E, Zuberi SM, Balestrini S, Wiebe S, Cross JH, Perucca E, Moshé SL, Tinuper P. Methodology for classification and definition of epilepsy syndromes with list of syndromes: Report of the ILAE Task Force on Nosology and Definitions. Epilepsia 2022; 63:1333-1348. [PMID: 35503715 DOI: 10.1111/epi.17237] [Citation(s) in RCA: 60] [Impact Index Per Article: 30.0] [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: 04/23/2021] [Revised: 03/11/2022] [Accepted: 03/16/2022] [Indexed: 01/01/2023]
Abstract
Epilepsy syndromes have been recognized for >50 years, as distinct electroclinical phenotypes with therapeutic and prognostic implications. Nonetheless, no formally accepted International League Against Epilepsy (ILAE) classification of epilepsy syndromes has existed. The ILAE Task Force on Nosology and Definitions was established to reach consensus regarding which entities fulfilled criteria for an epilepsy syndrome and to provide definitions for each syndrome. We defined an epilepsy syndrome as "a characteristic cluster of clinical and electroencephalographic features, often supported by specific etiological findings (structural, genetic, metabolic, immune, and infectious)." The diagnosis of a syndrome in an individual with epilepsy frequently carries prognostic and treatment implications. Syndromes often have age-dependent presentations and a range of specific comorbidities. This paper describes the guiding principles and process for syndrome identification in both children and adults, and the template of clinical data included for each syndrome. We divided syndromes into typical age at onset, and further characterized them based on seizure and epilepsy types and association with developmental and/or epileptic encephalopathy or progressive neurological deterioration. Definitions for each specific syndrome are contained within the corresponding position papers.
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Affiliation(s)
- Elaine C Wirrell
- Divisions of Child and Adolescent Neurology and Epilepsy, Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | - Rima Nabbout
- Reference Center for Rare Epilepsies, Department of Pediatric Neurology, Necker-Sick Children Hospital, Public Hospital Network of Paris, member of EpiCARE, Paris, France.,Imagine Institute, National Institute of Health and Medical Research, Mixed Unit of Research 1163, University of Paris, Paris, France
| | - Ingrid E Scheffer
- Austin Health and Royal Children's Hospital, Florey Institute, Murdoch Children's Research Institute, University of Melbourne, Melbourne, Victoria, Australia
| | - Taoufik Alsaadi
- Department of Neurology, American Center for Psychiatry and Neurology, Abu Dhabi, United Arab Emirates
| | - Alicia Bogacz
- Faculty of Medicine, Clinics Hospital, Institute of Neurology, University of the Republic, Montevideo, Uruguay
| | - Jacqueline A French
- New York University Grossman School of Medicine and NYU Langone Health, New York, New York, USA
| | - Edouard Hirsch
- Francis Rohmer Neurology Epilepsy Unit, National Institute of Health and Medical Research 1258, Federation of Translational Medicine of Strasbourg, Strasbourg University, Strasbourg, France
| | | | - Sunao Kaneko
- North Tohoku Epilepsy Center, Minato Hospital, Hachinohe, Japan
| | - Kate Riney
- Neurosciences Unit, Queensland Children's Hospital, South Brisbane, Queensland, Australia.,Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Pauline Samia
- Department of Pediatrics and Child Health, Aga Khan University, Nairobi, Kenya
| | - O Carter Snead
- Department Pediatrics [Neurology], Faculty of Medicine, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Ernest Somerville
- Prince of Wales Hospital and University of New South Wales, Sydney, New South Wales, Australia
| | - Nicola Specchio
- Rare and Complex Epilepsy Unit, Department of Neuroscience, Bambino Gesù Children's Hospital, Scientific Institute for Research and Health Care, member of EpiCARE, Rome, Italy
| | - Eugen Trinka
- Department of Neurology, Christian Doppler University Hospital, Paracelsus Medical University, Salzburg, Austria.,Center for Cognitive Neuroscience, member of EpiCARE, Salzburg, Austria.,Neuroscience Institute, Christian Doppler University Hospital, Paracelsus Medical University, Salzburg, Austria
| | - Sameer M Zuberi
- Paediatric Neurosciences Research Group, Royal Hospital for Children and Institute of Health & Wellbeing, University of Glasgow, Glasgow, UK.,Collaborating Centre of European Reference Network EpiCARE, Glasgow, UK
| | - Simona Balestrini
- Neuroscience Department, Meyer Children's Hospital-University of Florence, Florence, Italy.,Department of Clinical and Experimental Epilepsy, University College London Queen Square Institute of Neurology, London, UK.,Chalfont Centre for Epilepsy, Buckinghamshire, UK
| | - Samuel Wiebe
- Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
| | - J Helen Cross
- Programme of Developmental Neurosciences, University College London National Institute for Health Research Biomedical Research Centre Great Ormond Street Institute of Child Health, Great Ormond Street Hospital for Children, London, UK.,Young Epilepsy Lingfield, Lingfield, UK
| | - Emilio Perucca
- Department of Neurosciences, Monash University, Melbourne, Victoria, Australia.,Department of Medicine, Austin Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Solomon L Moshé
- Isabelle Rapin Division of Child Neurology, Saul R. Korey Department of Neurology, and Departments of Neuroscience and Pediatrics, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, New York, USA
| | - Paolo Tinuper
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy.,Institute of Neurological Sciences, Scientific Institute for Research and Health Care, Bologna, Italy
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19
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Riney K, Bogacz A, Somerville E, Hirsch E, Nabbout R, Scheffer IE, Zuberi SM, Alsaadi T, Jain S, French J, Specchio N, Trinka E, Wiebe S, Auvin S, Cabral-Lim L, Naidoo A, Perucca E, Moshé SL, Wirrell EC, Tinuper P. International League Against Epilepsy classification and definition of epilepsy syndromes with onset at a variable age: position statement by the ILAE Task Force on Nosology and Definitions. Epilepsia 2022; 63:1443-1474. [PMID: 35503725 DOI: 10.1111/epi.17240] [Citation(s) in RCA: 55] [Impact Index Per Article: 27.5] [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: 04/23/2021] [Revised: 03/12/2022] [Accepted: 03/16/2022] [Indexed: 01/15/2023]
Abstract
The goal of this paper is to provide updated diagnostic criteria for the epilepsy syndromes that have a variable age of onset, based on expert consensus of the International League Against Epilepsy Nosology and Definitions Taskforce (2017-2021). We use language consistent with current accepted epilepsy and seizure classifications and incorporate knowledge from advances in genetics, electroencephalography, and imaging. Our aim in delineating the epilepsy syndromes that present at a variable age is to aid diagnosis and to guide investigations for etiology and treatments for these patients.
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Affiliation(s)
- Kate Riney
- Neurosciences Unit, Queensland Children's Hospital, South Brisbane, Queensland, Australia.,Faculty of Medicine, University of Queensland, South Brisbane, Queensland, Australia
| | - Alicia Bogacz
- Institute of Neurology, University of the Republic, Montevideo, Uruguay
| | - Ernest Somerville
- Prince of Wales Hospital, Sydney, New South Wales, Australia.,University of New South Wales, Sydney, New South Wales, Australia
| | - Edouard Hirsch
- Francis Rohmer Epilepsy Unit, Hautepierre Hospital, Strasbourg, France.,National Institute of Health and Medical Research 1258, Strasbourg, France.,Federation of Translational Medicine of Strasbourg, University of Strasbourg, Strasbourg, France
| | - Rima Nabbout
- Reference Centre for Rare Epilepsies, Assistance Publique - Hôpitaux de Paris, Department of Pediatric Neurology, Necker-Enfants Malades Hospital, Member of Epicare, Paris, France.,Imagine Institute, National Institute of Health and Medical Research Mixed Unit of Research 1163, Paris, France.,University City University, Paris, France
| | - Ingrid E Scheffer
- Austin Health, Royal Children's Hospital, Florey Institute and Murdoch Children's Research Institute, University of Melbourne, Melbourne, Victoria, Australia
| | - Sameer M Zuberi
- University City University, Paris, France.,Paediatric Neurosciences Research Group, Royal Hospital for Children, Glasgow, UK.,Institute of Health & Wellbeing, University of Glasgow, Glasgow, UK
| | - Taoufik Alsaadi
- Department of Neurology, American Center for Psychiatry and Neurology, Abu Dhabi, United Arab Emirates
| | | | - Jacqueline French
- New York University Grossman School of Medicine and NYU Langone Health, New York, New York, USA
| | - Nicola Specchio
- Rare and Complex Epilepsy Unit, Department of Neuroscience, Bambino Gesù Children's Hospital, Scientific Institute for Research and Health Care, member of EpiCARE, Rome, Italy
| | - Eugen Trinka
- Department of Neurology, Christian Doppler University Hospital, Paracelsus Medical University, Center for Cognitive Neuroscience, member of EpiCARE, Salzburg, Austria.,Neuroscience Institute, Christian Doppler University Hospital, Center for Cognitive Neuroscience, Salzburg, Austria.,Department of Public Health, Health Services Research and Health Technology Assessment, University for Health Sciences, Medical Informatics, and Technology, Hall in Tirol, Austria
| | - Samuel Wiebe
- Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
| | - Stéphane Auvin
- Institut Universitaire de France, Paris, France.,Paediatric Neurology, Assistance Publique - Hôpitaux de Paris, Robert-Debré Hospital, Paris, France.,University of Paris, Paris, France
| | - Leonor Cabral-Lim
- Department of Neurosciences, College of Medicine and Philippine General Hospital, Health Sciences Center, University of the Philippines Manila, Manila, the Philippines
| | - Ansuya Naidoo
- Neurology Unit, Greys Hospital, Pietermaritzburg, South Africa.,Department of Neurology, University of KwaZulu Natal, KwaZulu Natal, South Africa
| | - Emilio Perucca
- Department of Medicine, Austin Health, University of Melbourne, Heidelberg, Victoria, Australia.,Department of Neuroscience, Monash University, Melbourne, Victoria, Australia
| | - Solomon L Moshé
- Isabelle Rapin Division of Child Neurology, Saul R. Korey Department of Neurology and Departments of Neuroscience and Pediatrics, Albert Einstein College of Medicine, New York, New York, USA.,Montefiore Medical Center, Bronx, New York, USA
| | - Elaine C Wirrell
- Divisions of Child and Adolescent Neurology and Epilepsy, Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | - Paolo Tinuper
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy.,Reference Centre for Rare and Complex Epilepsies, IRCCS Istituto delle Scienze Neurologiche, Bologna, Italy
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20
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Specchio N, Wirrell EC, Scheffer IE, Nabbout R, Riney K, Samia P, Guerreiro M, Gwer S, Zuberi SM, Wilmshurst JM, Yozawitz E, Pressler R, Hirsch E, Wiebe S, Cross HJ, Perucca E, Moshé SL, Tinuper P, Auvin S. International League Against Epilepsy classification and definition of epilepsy syndromes with onset in childhood: Position paper by the ILAE Task Force on Nosology and Definitions. Epilepsia 2022; 63:1398-1442. [PMID: 35503717 DOI: 10.1111/epi.17241] [Citation(s) in RCA: 209] [Impact Index Per Article: 104.5] [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: 04/24/2021] [Revised: 03/16/2022] [Accepted: 03/17/2022] [Indexed: 12/30/2022]
Abstract
The 2017 International League Against Epilepsy classification has defined a three-tier system with epilepsy syndrome identification at the third level. Although a syndrome cannot be determined in all children with epilepsy, identification of a specific syndrome provides guidance on management and prognosis. In this paper, we describe the childhood onset epilepsy syndromes, most of which have both mandatory seizure type(s) and interictal electroencephalographic (EEG) features. Based on the 2017 Classification of Seizures and Epilepsies, some syndrome names have been updated using terms directly describing the seizure semiology. Epilepsy syndromes beginning in childhood have been divided into three categories: (1) self-limited focal epilepsies, comprising four syndromes: self-limited epilepsy with centrotemporal spikes, self-limited epilepsy with autonomic seizures, childhood occipital visual epilepsy, and photosensitive occipital lobe epilepsy; (2) generalized epilepsies, comprising three syndromes: childhood absence epilepsy, epilepsy with myoclonic absence, and epilepsy with eyelid myoclonia; and (3) developmental and/or epileptic encephalopathies, comprising five syndromes: epilepsy with myoclonic-atonic seizures, Lennox-Gastaut syndrome, developmental and/or epileptic encephalopathy with spike-and-wave activation in sleep, hemiconvulsion-hemiplegia-epilepsy syndrome, and febrile infection-related epilepsy syndrome. We define each, highlighting the mandatory seizure(s), EEG features, phenotypic variations, and findings from key investigations.
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Affiliation(s)
- Nicola Specchio
- Rare and Complex Epilepsy Unit, Department of Neuroscience, Bambino Gesù Children's Hospital, Scientific Institute for Research and Health Care, Full Member of EpiCARE, Rome, Italy
| | - Elaine C Wirrell
- Divisions of Child and Adolescent Neurology and Epilepsy, Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | - Ingrid E Scheffer
- Austin Health and Royal Children's Hospital, Florey Institute, Murdoch Children's Research Institute, University of Melbourne, Melbourne, Victoria, Australia
| | - Rima Nabbout
- Reference Center for Rare Epilepsies, Department of Pediatric Neurology, Necker-Sick Children Hospital, Public Hospital Network of Paris, member of EpiCARE, Imagine Institute, National Institute of Health and Medical Research, Mixed Unit of Research 1163, University of Paris, Paris, France
| | - Kate Riney
- Neurosciences Unit, Queensland Children's Hospital, South Brisbane, Queensland, Australia.,Faculty of Medicine, University of Queensland, South Brisbane, Queensland, Australia
| | - Pauline Samia
- Department of Pediatrics and Child Health, Aga Khan University, Nairobi, Kenya
| | | | - Sam Gwer
- School of Medicine, Kenyatta University, and Afya Research Africa, Nairobi, Kenya
| | - Sameer M Zuberi
- Paediatric Neurosciences Research Group, Royal Hospital for Children and Institute of Health & Wellbeing, member of EpiCARE, University of Glasgow, Glasgow, UK
| | - Jo M Wilmshurst
- Department of Paediatric Neurology, Red Cross War Memorial Children's Hospital, Neuroscience Institute, University of Cape Town, Cape Town, South Africa
| | - Elissa Yozawitz
- Isabelle Rapin Division of Child Neurology of the Saul R. Korey Department of Neurology, Montefiore Medical Center, Bronx, New York, USA
| | - Ronit Pressler
- Programme of Developmental Neurosciences, University College London National Institute for Health Research Biomedical Research Centre Great Ormond Street Institute of Child Health, Department of Clinical Neurophysiology, Great Ormond Street Hospital for Children, London, UK
| | - Edouard Hirsch
- Neurology Epilepsy Units "Francis Rohmer", INSERM 1258, FMTS, Strasbourg University, Strasbourg, France
| | - Sam Wiebe
- Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
| | - Helen J Cross
- Programme of Developmental Neurosciences, University College London National Institute for Health Research Biomedical Research Centre Great Ormond Street Institute of Child Health, Great Ormond Street Hospital for Children, and Young Epilepsy Lingfield, London, UK
| | - Emilio Perucca
- Department of Neuroscience, Monash University, Melbourne, Victoria, Australia.,Department of Medicine, Austin Health, University of Melbourne, Heidelberg, Victoria, Australia
| | - Solomon L Moshé
- Isabelle Rapin Division of Child Neurology, Saul R. Korey Department of Neurology, and Departments of Neuroscience and Pediatrics, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, New York, USA
| | - Paolo Tinuper
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy.,Institute of Neurological Sciences, Scientific Institute for Research and Health Care, Bologna, Italy
| | - Stéphane Auvin
- Robert Debré Hospital, Public Hospital Network of Paris, NeuroDiderot, National Institute of Health and Medical Research, Department Medico-Universitaire Innovation Robert-Debré, Pediatric Neurology, University of Paris, Paris, France
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21
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Knupp KG, Scheffer IE, Ceulemans B, Sullivan JE, Nickels KC, Lagae L, Guerrini R, Zuberi SM, Nabbout R, Riney K, Shore S, Agarwal A, Lock M, Farfel GM, Galer BS, Gammaitoni AR, Davis R, Gil-Nagel A. Efficacy and Safety of Fenfluramine for the Treatment of Seizures Associated With Lennox-Gastaut Syndrome: A Randomized Clinical Trial. JAMA Neurol 2022; 79:554-564. [PMID: 35499850 PMCID: PMC9062770 DOI: 10.1001/jamaneurol.2022.0829] [Citation(s) in RCA: 33] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Question Is adjunctive fenfluramine effective in patients with Lennox-Gastaut syndrome (LGS)? Findings In this randomized clinical trial of 263 patients with LGS, use of 0.7-mg/kg/d fenfluramine resulted in a greater reduction in drop seizures than with placebo, more patients achieving a 50% or greater reduction in drop seizure frequency, and greater reduction in generalized tonic-clonic seizure frequency. Treatment-emergent adverse events included decreased appetite, but no patient developed valvular heart disease or pulmonary hypertension. Meaning Findings from this trial suggest that fenfluramine may be a safe and effective treatment option for patients with LGS. Importance New treatment options are needed for patients with Lennox-Gastaut syndrome (LGS), a profoundly impairing, treatment-resistant, developmental and epileptic encephalopathy. Objective To evaluate the efficacy and safety of fenfluramine in patients with LGS. Design, Setting, and Participants This multicenter, double-blind, placebo-controlled, parallel-group randomized clinical trial was conducted from November 27, 2017, to October 25, 2019, and had a 20-week trial duration. Patients were enrolled at 65 study sites in North America, Europe, and Australia. Included patients were aged 2 to 35 years with confirmed diagnosis of LGS and experienced 2 or more drop seizures per week during the 4-week baseline. Using a modified intent-to-treat method, data analysis was performed from November 27, 2017, to October 25, 2019. The database lock date was January 30, 2020, and the date of final report was September 11, 2021. Interventions Patients were randomized to receive either a 0.7-mg/kg/d or 0.2-mg/kg/d (maximum 26 mg/d) dose of fenfluramine or placebo. After titration (2-week period), patients were taking their randomized dose for 12 additional weeks. Main Outcomes and Measures Primary efficacy end point was percentage change from baseline in drop seizure frequency in patients who received 0.7 mg/kg/d of fenfluramine vs placebo. Results A total of 263 patients (median [range] age, 13 [2-35] years; 146 male patients [56%]) were randomized to the 0.7-mg/kg/d fenfluramine group (n = 87), 0.2-mg/kg/d fenfluramine group (n = 89), or placebo group (n = 87). The median percentage reduction in frequency of drop seizures was 26.5 percentage points in the 0.7-mg/kg/d fenfluramine group, 14.2 percentage points in the 0.2-mg/kg/d fenfluramine group, and 7.6 percentage points in the placebo group. The trial met its primary efficacy end point: patients in the 0.7-mg/kg/d fenfluramine group achieved a −19.9 percentage points (95% CI, −31.0 to −8.7 percentage points; P = .001) estimated median difference in drop seizures from baseline vs placebo. More patients in the 0.7-mg/kg/d fenfluramine group achieved a 50% or greater response (22 of 87 [25%]; P = .02) vs placebo (9 of 87 [10%]). Site investigators and caregivers gave a much improved or very much improved rating on the Clinical Global Impression of Improvement scale to more patients in the 0.7-mg/kg/d fenfluramine group than patients in the placebo group (21 [26%] vs 5 [6%]; P = .001). The seizure subtype that appeared most responsive to fenfluramine was generalized tonic-clonic seizure (120 of 263 [46%]), with a decrease in frequency of 45.7% in the 0.7-mg/kg/d fenfluramine group and 58.2% in the 0.2-mg/kg/d fenfluramine group compared with an increase of 3.7% in the placebo group. Most common treatment-emergent adverse events included decreased appetite (59 [22%]), somnolence (33 [13%]), and fatigue (33 [13%]). No cases of valvular heart disease or pulmonary arterial hypertension were observed. Conclusions and Relevance Results of this trial showed that, in patients with LGS, fenfluramine compared with placebo provided a significantly greater reduction in drop seizures and may be a particularly advantageous choice in patients who experience generalized tonic-clonic seizures. Trial Registration ClinicalTrials.gov Identifier: NCT03355209
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Affiliation(s)
- Kelly G Knupp
- Department of Neurology, Children's Hospital Colorado, Aurora
| | - Ingrid E Scheffer
- Austin Hospital and Royal Children's Hospital, University of Melbourne, Melbourne, Victoria, Australia
| | - Berten Ceulemans
- Department of Paediatric Neurology, Antwerp University Hospital, Antwerp, Belgium
| | - Joseph E Sullivan
- Weill Institute for Neurosciences, Benioff Children's Hospital, University of California San Francisco, San Francisco
| | | | - Lieven Lagae
- Steering Committee, European Reference Network EpiCARE, Lyon, France.,Department of Paediatric Neurology, KU Leuven, Leuven, Belgium
| | - Renzo Guerrini
- Pediatric Neurology and Neurogenetics Unit, Anna Meyer Children's Hospital, University of Florence, Florence, Italy.,Neurobiologia e Neurogenetica dei Disturbi del Neurosviluppo, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Fondazione Stella Maris, Pisa, Italy
| | - Sameer M Zuberi
- Paediatric Neurosciences Research Group, Royal Hospital for Children, Glasgow, United Kingdom
| | - Rima Nabbout
- Department of Pediatric Neurology, Reference Centre for Rare Epilepsies, Necker-Enfants Malades Hospital, Imagine Institute, University Paris Descartes, Paris, France
| | - Kate Riney
- Neuroscience Unit, Queensland Children's Hospital, South Brisbane, Queensland, Australia.,School of Clinical Medicine, University of Queensland, St Lucia, Queensland, Australia
| | - Svetlana Shore
- Zogenix Inc, Emeryville, California.,Now with Neurocrine Biosciences, San Diego, California
| | | | - Michael Lock
- Zogenix Inc, Emeryville, California.,Now with Zogenix Inc, Haiku, Hawaii
| | | | | | | | - Ronald Davis
- Neurology and Epilepsy Research Center, Orlando, Florida
| | - Antonio Gil-Nagel
- Department of Neurology, Epilepsy Program, Hospital Ruber Internacional, Madrid, Spain
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22
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Brunklaus A, Pérez-Palma E, Ghanty I, Xinge J, Brilstra E, Ceulemans B, Chemaly N, de Lange I, Depienne C, Guerrini R, Mei D, Møller RS, Nabbout R, Regan BM, Schneider AL, Scheffer IE, Schoonjans AS, Symonds JD, Weckhuysen S, Kattan MW, Zuberi SM, Lal D. Development and Validation of a Prediction Model for Early Diagnosis of SCN1A-Related Epilepsies. Neurology 2022; 98:e1163-e1174. [PMID: 35074891 PMCID: PMC8935441 DOI: 10.1212/wnl.0000000000200028] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 01/03/2022] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Pathogenic variants in the neuronal sodium channel α1 subunit gene (SCN1A) are the most frequent monogenic cause of epilepsy. Phenotypes comprise a wide clinical spectrum, including severe childhood epilepsy; Dravet syndrome, characterized by drug-resistant seizures, intellectual disability, and high mortality; and the milder genetic epilepsy with febrile seizures plus (GEFS+), characterized by normal cognition. Early recognition of a child's risk for developing Dravet syndrome vs GEFS+ is key for implementing disease-modifying therapies when available before cognitive impairment emerges. Our objective was to develop and validate a prediction model using clinical and genetic biomarkers for early diagnosis of SCN1A-related epilepsies. METHODS We performed a retrospective multicenter cohort study comprising data from patients with SCN1A-positive Dravet syndrome and patients with GEFS+ consecutively referred for genetic testing (March 2001-June 2020) including age at seizure onset and a newly developed SCN1A genetic score. A training cohort was used to develop multiple prediction models that were validated using 2 independent blinded cohorts. Primary outcome was the discriminative accuracy of the model predicting Dravet syndrome vs other GEFS+ phenotypes. RESULTS A total of 1,018 participants were included. The frequency of Dravet syndrome was 616/743 (83%) in the training cohort, 147/203 (72%) in validation cohort 1, and 60/72 (83%) in validation cohort 2. A high SCN1A genetic score (133.4 [SD 78.5] vs 52.0 [SD 57.5]; p < 0.001) and young age at onset (6.0 [SD 3.0] vs 14.8 [SD 11.8] months; p < 0.001) were each associated with Dravet syndrome vs GEFS+. A combined SCN1A genetic score and seizure onset model separated Dravet syndrome from GEFS+ more effectively (area under the curve [AUC] 0.89 [95% CI 0.86-0.92]) and outperformed all other models (AUC 0.79-0.85; p < 0.001). Model performance was replicated in both validation cohorts 1 (AUC 0.94 [95% CI 0.91-0.97]) and 2 (AUC 0.92 [95% CI 0.82-1.00]). DISCUSSION The prediction model allows objective estimation at disease onset whether a child will develop Dravet syndrome vs GEFS+, assisting clinicians with prognostic counseling and decisions on early institution of precision therapies (http://scn1a-prediction-model.broadinstitute.org/). CLASSIFICATION OF EVIDENCE This study provides Class II evidence that a combined SCN1A genetic score and seizure onset model distinguishes Dravet syndrome from other GEFS+ phenotypes.
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Affiliation(s)
- Andreas Brunklaus
- From the Pediatric Neurosciences Research Group (A.B., I.G., J.D.S., S.M.Z.), Royal Hospital for Children, Glasgow; Institute of Health and Wellbeing (A.B., I.G., J.D.S., S.M.Z.), University of Glasgow, UK; Centro de Genética y Genómica, Facultad de Medicina Clínica Alemana (E.P.-P.), Universidad del Desarrollo, Santiago, Chile; Genomic Medicine Institute, Lerner Research Institute (E.P.-P., D.L.), Department of Quantitative Health Sciences (J.X., M.W.K.), and Epilepsy Center, Neurological Institute (D.L.), Cleveland Clinic, OH; Department of Genetics (E.B., I.d.L.), University Medical Centre, Utrecht, the Netherlands; Department of Child Neurology (B.C., A.-S.S.), University Hospital Antwerp, Belgium; Reference Centre for Rare Epilepsies, Department of Pediatric Neurology (N.C., R.N.), Hôpital Necker-Enfants Malades, Université de Paris, France; Institute of Human Genetics (C.D.), University Hospital Essen, University of Duisburg-Essen, Germany; Neuroscience Department (R.G., D.M.), Children's Hospital A. Meyer-University of Florence, Italy; The Danish Epilepsy Centre (R.S.M.), Dianalund, Denmark; Institute for Regional Health Services (R.S.M.), University of Southern Denmark, Odense; Department of Medicine, Epilepsy Research Centre, Austin Health (B.M.R., A.L.S., I.E.S.), and Florey and Murdoch Children's Research Institutes, Royal Children's Hospital (I.E.S.), University of Melbourne, Australia; Applied and Translational Neurogenomics Group (S.W.), VIB-Center for Molecular Neurology, VIB, Antwerp; Neurology Department (S.W.), University Hospital Antwerp; Institute Born-Bunge (S.W.), University of Antwerp, Belgium; Cologne Center for Genomics (D.L.), University of Cologne, Germany; and Stanley Center for Psychiatric Genetics (D.L.), Broad Institute of MIT and Harvard, Cambridge, MA.
| | - Eduardo Pérez-Palma
- From the Pediatric Neurosciences Research Group (A.B., I.G., J.D.S., S.M.Z.), Royal Hospital for Children, Glasgow; Institute of Health and Wellbeing (A.B., I.G., J.D.S., S.M.Z.), University of Glasgow, UK; Centro de Genética y Genómica, Facultad de Medicina Clínica Alemana (E.P.-P.), Universidad del Desarrollo, Santiago, Chile; Genomic Medicine Institute, Lerner Research Institute (E.P.-P., D.L.), Department of Quantitative Health Sciences (J.X., M.W.K.), and Epilepsy Center, Neurological Institute (D.L.), Cleveland Clinic, OH; Department of Genetics (E.B., I.d.L.), University Medical Centre, Utrecht, the Netherlands; Department of Child Neurology (B.C., A.-S.S.), University Hospital Antwerp, Belgium; Reference Centre for Rare Epilepsies, Department of Pediatric Neurology (N.C., R.N.), Hôpital Necker-Enfants Malades, Université de Paris, France; Institute of Human Genetics (C.D.), University Hospital Essen, University of Duisburg-Essen, Germany; Neuroscience Department (R.G., D.M.), Children's Hospital A. Meyer-University of Florence, Italy; The Danish Epilepsy Centre (R.S.M.), Dianalund, Denmark; Institute for Regional Health Services (R.S.M.), University of Southern Denmark, Odense; Department of Medicine, Epilepsy Research Centre, Austin Health (B.M.R., A.L.S., I.E.S.), and Florey and Murdoch Children's Research Institutes, Royal Children's Hospital (I.E.S.), University of Melbourne, Australia; Applied and Translational Neurogenomics Group (S.W.), VIB-Center for Molecular Neurology, VIB, Antwerp; Neurology Department (S.W.), University Hospital Antwerp; Institute Born-Bunge (S.W.), University of Antwerp, Belgium; Cologne Center for Genomics (D.L.), University of Cologne, Germany; and Stanley Center for Psychiatric Genetics (D.L.), Broad Institute of MIT and Harvard, Cambridge, MA
| | - Ismael Ghanty
- From the Pediatric Neurosciences Research Group (A.B., I.G., J.D.S., S.M.Z.), Royal Hospital for Children, Glasgow; Institute of Health and Wellbeing (A.B., I.G., J.D.S., S.M.Z.), University of Glasgow, UK; Centro de Genética y Genómica, Facultad de Medicina Clínica Alemana (E.P.-P.), Universidad del Desarrollo, Santiago, Chile; Genomic Medicine Institute, Lerner Research Institute (E.P.-P., D.L.), Department of Quantitative Health Sciences (J.X., M.W.K.), and Epilepsy Center, Neurological Institute (D.L.), Cleveland Clinic, OH; Department of Genetics (E.B., I.d.L.), University Medical Centre, Utrecht, the Netherlands; Department of Child Neurology (B.C., A.-S.S.), University Hospital Antwerp, Belgium; Reference Centre for Rare Epilepsies, Department of Pediatric Neurology (N.C., R.N.), Hôpital Necker-Enfants Malades, Université de Paris, France; Institute of Human Genetics (C.D.), University Hospital Essen, University of Duisburg-Essen, Germany; Neuroscience Department (R.G., D.M.), Children's Hospital A. Meyer-University of Florence, Italy; The Danish Epilepsy Centre (R.S.M.), Dianalund, Denmark; Institute for Regional Health Services (R.S.M.), University of Southern Denmark, Odense; Department of Medicine, Epilepsy Research Centre, Austin Health (B.M.R., A.L.S., I.E.S.), and Florey and Murdoch Children's Research Institutes, Royal Children's Hospital (I.E.S.), University of Melbourne, Australia; Applied and Translational Neurogenomics Group (S.W.), VIB-Center for Molecular Neurology, VIB, Antwerp; Neurology Department (S.W.), University Hospital Antwerp; Institute Born-Bunge (S.W.), University of Antwerp, Belgium; Cologne Center for Genomics (D.L.), University of Cologne, Germany; and Stanley Center for Psychiatric Genetics (D.L.), Broad Institute of MIT and Harvard, Cambridge, MA
| | - Ji Xinge
- From the Pediatric Neurosciences Research Group (A.B., I.G., J.D.S., S.M.Z.), Royal Hospital for Children, Glasgow; Institute of Health and Wellbeing (A.B., I.G., J.D.S., S.M.Z.), University of Glasgow, UK; Centro de Genética y Genómica, Facultad de Medicina Clínica Alemana (E.P.-P.), Universidad del Desarrollo, Santiago, Chile; Genomic Medicine Institute, Lerner Research Institute (E.P.-P., D.L.), Department of Quantitative Health Sciences (J.X., M.W.K.), and Epilepsy Center, Neurological Institute (D.L.), Cleveland Clinic, OH; Department of Genetics (E.B., I.d.L.), University Medical Centre, Utrecht, the Netherlands; Department of Child Neurology (B.C., A.-S.S.), University Hospital Antwerp, Belgium; Reference Centre for Rare Epilepsies, Department of Pediatric Neurology (N.C., R.N.), Hôpital Necker-Enfants Malades, Université de Paris, France; Institute of Human Genetics (C.D.), University Hospital Essen, University of Duisburg-Essen, Germany; Neuroscience Department (R.G., D.M.), Children's Hospital A. Meyer-University of Florence, Italy; The Danish Epilepsy Centre (R.S.M.), Dianalund, Denmark; Institute for Regional Health Services (R.S.M.), University of Southern Denmark, Odense; Department of Medicine, Epilepsy Research Centre, Austin Health (B.M.R., A.L.S., I.E.S.), and Florey and Murdoch Children's Research Institutes, Royal Children's Hospital (I.E.S.), University of Melbourne, Australia; Applied and Translational Neurogenomics Group (S.W.), VIB-Center for Molecular Neurology, VIB, Antwerp; Neurology Department (S.W.), University Hospital Antwerp; Institute Born-Bunge (S.W.), University of Antwerp, Belgium; Cologne Center for Genomics (D.L.), University of Cologne, Germany; and Stanley Center for Psychiatric Genetics (D.L.), Broad Institute of MIT and Harvard, Cambridge, MA
| | - Eva Brilstra
- From the Pediatric Neurosciences Research Group (A.B., I.G., J.D.S., S.M.Z.), Royal Hospital for Children, Glasgow; Institute of Health and Wellbeing (A.B., I.G., J.D.S., S.M.Z.), University of Glasgow, UK; Centro de Genética y Genómica, Facultad de Medicina Clínica Alemana (E.P.-P.), Universidad del Desarrollo, Santiago, Chile; Genomic Medicine Institute, Lerner Research Institute (E.P.-P., D.L.), Department of Quantitative Health Sciences (J.X., M.W.K.), and Epilepsy Center, Neurological Institute (D.L.), Cleveland Clinic, OH; Department of Genetics (E.B., I.d.L.), University Medical Centre, Utrecht, the Netherlands; Department of Child Neurology (B.C., A.-S.S.), University Hospital Antwerp, Belgium; Reference Centre for Rare Epilepsies, Department of Pediatric Neurology (N.C., R.N.), Hôpital Necker-Enfants Malades, Université de Paris, France; Institute of Human Genetics (C.D.), University Hospital Essen, University of Duisburg-Essen, Germany; Neuroscience Department (R.G., D.M.), Children's Hospital A. Meyer-University of Florence, Italy; The Danish Epilepsy Centre (R.S.M.), Dianalund, Denmark; Institute for Regional Health Services (R.S.M.), University of Southern Denmark, Odense; Department of Medicine, Epilepsy Research Centre, Austin Health (B.M.R., A.L.S., I.E.S.), and Florey and Murdoch Children's Research Institutes, Royal Children's Hospital (I.E.S.), University of Melbourne, Australia; Applied and Translational Neurogenomics Group (S.W.), VIB-Center for Molecular Neurology, VIB, Antwerp; Neurology Department (S.W.), University Hospital Antwerp; Institute Born-Bunge (S.W.), University of Antwerp, Belgium; Cologne Center for Genomics (D.L.), University of Cologne, Germany; and Stanley Center for Psychiatric Genetics (D.L.), Broad Institute of MIT and Harvard, Cambridge, MA
| | - Berten Ceulemans
- From the Pediatric Neurosciences Research Group (A.B., I.G., J.D.S., S.M.Z.), Royal Hospital for Children, Glasgow; Institute of Health and Wellbeing (A.B., I.G., J.D.S., S.M.Z.), University of Glasgow, UK; Centro de Genética y Genómica, Facultad de Medicina Clínica Alemana (E.P.-P.), Universidad del Desarrollo, Santiago, Chile; Genomic Medicine Institute, Lerner Research Institute (E.P.-P., D.L.), Department of Quantitative Health Sciences (J.X., M.W.K.), and Epilepsy Center, Neurological Institute (D.L.), Cleveland Clinic, OH; Department of Genetics (E.B., I.d.L.), University Medical Centre, Utrecht, the Netherlands; Department of Child Neurology (B.C., A.-S.S.), University Hospital Antwerp, Belgium; Reference Centre for Rare Epilepsies, Department of Pediatric Neurology (N.C., R.N.), Hôpital Necker-Enfants Malades, Université de Paris, France; Institute of Human Genetics (C.D.), University Hospital Essen, University of Duisburg-Essen, Germany; Neuroscience Department (R.G., D.M.), Children's Hospital A. Meyer-University of Florence, Italy; The Danish Epilepsy Centre (R.S.M.), Dianalund, Denmark; Institute for Regional Health Services (R.S.M.), University of Southern Denmark, Odense; Department of Medicine, Epilepsy Research Centre, Austin Health (B.M.R., A.L.S., I.E.S.), and Florey and Murdoch Children's Research Institutes, Royal Children's Hospital (I.E.S.), University of Melbourne, Australia; Applied and Translational Neurogenomics Group (S.W.), VIB-Center for Molecular Neurology, VIB, Antwerp; Neurology Department (S.W.), University Hospital Antwerp; Institute Born-Bunge (S.W.), University of Antwerp, Belgium; Cologne Center for Genomics (D.L.), University of Cologne, Germany; and Stanley Center for Psychiatric Genetics (D.L.), Broad Institute of MIT and Harvard, Cambridge, MA
| | - Nicole Chemaly
- From the Pediatric Neurosciences Research Group (A.B., I.G., J.D.S., S.M.Z.), Royal Hospital for Children, Glasgow; Institute of Health and Wellbeing (A.B., I.G., J.D.S., S.M.Z.), University of Glasgow, UK; Centro de Genética y Genómica, Facultad de Medicina Clínica Alemana (E.P.-P.), Universidad del Desarrollo, Santiago, Chile; Genomic Medicine Institute, Lerner Research Institute (E.P.-P., D.L.), Department of Quantitative Health Sciences (J.X., M.W.K.), and Epilepsy Center, Neurological Institute (D.L.), Cleveland Clinic, OH; Department of Genetics (E.B., I.d.L.), University Medical Centre, Utrecht, the Netherlands; Department of Child Neurology (B.C., A.-S.S.), University Hospital Antwerp, Belgium; Reference Centre for Rare Epilepsies, Department of Pediatric Neurology (N.C., R.N.), Hôpital Necker-Enfants Malades, Université de Paris, France; Institute of Human Genetics (C.D.), University Hospital Essen, University of Duisburg-Essen, Germany; Neuroscience Department (R.G., D.M.), Children's Hospital A. Meyer-University of Florence, Italy; The Danish Epilepsy Centre (R.S.M.), Dianalund, Denmark; Institute for Regional Health Services (R.S.M.), University of Southern Denmark, Odense; Department of Medicine, Epilepsy Research Centre, Austin Health (B.M.R., A.L.S., I.E.S.), and Florey and Murdoch Children's Research Institutes, Royal Children's Hospital (I.E.S.), University of Melbourne, Australia; Applied and Translational Neurogenomics Group (S.W.), VIB-Center for Molecular Neurology, VIB, Antwerp; Neurology Department (S.W.), University Hospital Antwerp; Institute Born-Bunge (S.W.), University of Antwerp, Belgium; Cologne Center for Genomics (D.L.), University of Cologne, Germany; and Stanley Center for Psychiatric Genetics (D.L.), Broad Institute of MIT and Harvard, Cambridge, MA
| | - Iris de Lange
- From the Pediatric Neurosciences Research Group (A.B., I.G., J.D.S., S.M.Z.), Royal Hospital for Children, Glasgow; Institute of Health and Wellbeing (A.B., I.G., J.D.S., S.M.Z.), University of Glasgow, UK; Centro de Genética y Genómica, Facultad de Medicina Clínica Alemana (E.P.-P.), Universidad del Desarrollo, Santiago, Chile; Genomic Medicine Institute, Lerner Research Institute (E.P.-P., D.L.), Department of Quantitative Health Sciences (J.X., M.W.K.), and Epilepsy Center, Neurological Institute (D.L.), Cleveland Clinic, OH; Department of Genetics (E.B., I.d.L.), University Medical Centre, Utrecht, the Netherlands; Department of Child Neurology (B.C., A.-S.S.), University Hospital Antwerp, Belgium; Reference Centre for Rare Epilepsies, Department of Pediatric Neurology (N.C., R.N.), Hôpital Necker-Enfants Malades, Université de Paris, France; Institute of Human Genetics (C.D.), University Hospital Essen, University of Duisburg-Essen, Germany; Neuroscience Department (R.G., D.M.), Children's Hospital A. Meyer-University of Florence, Italy; The Danish Epilepsy Centre (R.S.M.), Dianalund, Denmark; Institute for Regional Health Services (R.S.M.), University of Southern Denmark, Odense; Department of Medicine, Epilepsy Research Centre, Austin Health (B.M.R., A.L.S., I.E.S.), and Florey and Murdoch Children's Research Institutes, Royal Children's Hospital (I.E.S.), University of Melbourne, Australia; Applied and Translational Neurogenomics Group (S.W.), VIB-Center for Molecular Neurology, VIB, Antwerp; Neurology Department (S.W.), University Hospital Antwerp; Institute Born-Bunge (S.W.), University of Antwerp, Belgium; Cologne Center for Genomics (D.L.), University of Cologne, Germany; and Stanley Center for Psychiatric Genetics (D.L.), Broad Institute of MIT and Harvard, Cambridge, MA
| | - Christel Depienne
- From the Pediatric Neurosciences Research Group (A.B., I.G., J.D.S., S.M.Z.), Royal Hospital for Children, Glasgow; Institute of Health and Wellbeing (A.B., I.G., J.D.S., S.M.Z.), University of Glasgow, UK; Centro de Genética y Genómica, Facultad de Medicina Clínica Alemana (E.P.-P.), Universidad del Desarrollo, Santiago, Chile; Genomic Medicine Institute, Lerner Research Institute (E.P.-P., D.L.), Department of Quantitative Health Sciences (J.X., M.W.K.), and Epilepsy Center, Neurological Institute (D.L.), Cleveland Clinic, OH; Department of Genetics (E.B., I.d.L.), University Medical Centre, Utrecht, the Netherlands; Department of Child Neurology (B.C., A.-S.S.), University Hospital Antwerp, Belgium; Reference Centre for Rare Epilepsies, Department of Pediatric Neurology (N.C., R.N.), Hôpital Necker-Enfants Malades, Université de Paris, France; Institute of Human Genetics (C.D.), University Hospital Essen, University of Duisburg-Essen, Germany; Neuroscience Department (R.G., D.M.), Children's Hospital A. Meyer-University of Florence, Italy; The Danish Epilepsy Centre (R.S.M.), Dianalund, Denmark; Institute for Regional Health Services (R.S.M.), University of Southern Denmark, Odense; Department of Medicine, Epilepsy Research Centre, Austin Health (B.M.R., A.L.S., I.E.S.), and Florey and Murdoch Children's Research Institutes, Royal Children's Hospital (I.E.S.), University of Melbourne, Australia; Applied and Translational Neurogenomics Group (S.W.), VIB-Center for Molecular Neurology, VIB, Antwerp; Neurology Department (S.W.), University Hospital Antwerp; Institute Born-Bunge (S.W.), University of Antwerp, Belgium; Cologne Center for Genomics (D.L.), University of Cologne, Germany; and Stanley Center for Psychiatric Genetics (D.L.), Broad Institute of MIT and Harvard, Cambridge, MA
| | - Renzo Guerrini
- From the Pediatric Neurosciences Research Group (A.B., I.G., J.D.S., S.M.Z.), Royal Hospital for Children, Glasgow; Institute of Health and Wellbeing (A.B., I.G., J.D.S., S.M.Z.), University of Glasgow, UK; Centro de Genética y Genómica, Facultad de Medicina Clínica Alemana (E.P.-P.), Universidad del Desarrollo, Santiago, Chile; Genomic Medicine Institute, Lerner Research Institute (E.P.-P., D.L.), Department of Quantitative Health Sciences (J.X., M.W.K.), and Epilepsy Center, Neurological Institute (D.L.), Cleveland Clinic, OH; Department of Genetics (E.B., I.d.L.), University Medical Centre, Utrecht, the Netherlands; Department of Child Neurology (B.C., A.-S.S.), University Hospital Antwerp, Belgium; Reference Centre for Rare Epilepsies, Department of Pediatric Neurology (N.C., R.N.), Hôpital Necker-Enfants Malades, Université de Paris, France; Institute of Human Genetics (C.D.), University Hospital Essen, University of Duisburg-Essen, Germany; Neuroscience Department (R.G., D.M.), Children's Hospital A. Meyer-University of Florence, Italy; The Danish Epilepsy Centre (R.S.M.), Dianalund, Denmark; Institute for Regional Health Services (R.S.M.), University of Southern Denmark, Odense; Department of Medicine, Epilepsy Research Centre, Austin Health (B.M.R., A.L.S., I.E.S.), and Florey and Murdoch Children's Research Institutes, Royal Children's Hospital (I.E.S.), University of Melbourne, Australia; Applied and Translational Neurogenomics Group (S.W.), VIB-Center for Molecular Neurology, VIB, Antwerp; Neurology Department (S.W.), University Hospital Antwerp; Institute Born-Bunge (S.W.), University of Antwerp, Belgium; Cologne Center for Genomics (D.L.), University of Cologne, Germany; and Stanley Center for Psychiatric Genetics (D.L.), Broad Institute of MIT and Harvard, Cambridge, MA
| | - Davide Mei
- From the Pediatric Neurosciences Research Group (A.B., I.G., J.D.S., S.M.Z.), Royal Hospital for Children, Glasgow; Institute of Health and Wellbeing (A.B., I.G., J.D.S., S.M.Z.), University of Glasgow, UK; Centro de Genética y Genómica, Facultad de Medicina Clínica Alemana (E.P.-P.), Universidad del Desarrollo, Santiago, Chile; Genomic Medicine Institute, Lerner Research Institute (E.P.-P., D.L.), Department of Quantitative Health Sciences (J.X., M.W.K.), and Epilepsy Center, Neurological Institute (D.L.), Cleveland Clinic, OH; Department of Genetics (E.B., I.d.L.), University Medical Centre, Utrecht, the Netherlands; Department of Child Neurology (B.C., A.-S.S.), University Hospital Antwerp, Belgium; Reference Centre for Rare Epilepsies, Department of Pediatric Neurology (N.C., R.N.), Hôpital Necker-Enfants Malades, Université de Paris, France; Institute of Human Genetics (C.D.), University Hospital Essen, University of Duisburg-Essen, Germany; Neuroscience Department (R.G., D.M.), Children's Hospital A. Meyer-University of Florence, Italy; The Danish Epilepsy Centre (R.S.M.), Dianalund, Denmark; Institute for Regional Health Services (R.S.M.), University of Southern Denmark, Odense; Department of Medicine, Epilepsy Research Centre, Austin Health (B.M.R., A.L.S., I.E.S.), and Florey and Murdoch Children's Research Institutes, Royal Children's Hospital (I.E.S.), University of Melbourne, Australia; Applied and Translational Neurogenomics Group (S.W.), VIB-Center for Molecular Neurology, VIB, Antwerp; Neurology Department (S.W.), University Hospital Antwerp; Institute Born-Bunge (S.W.), University of Antwerp, Belgium; Cologne Center for Genomics (D.L.), University of Cologne, Germany; and Stanley Center for Psychiatric Genetics (D.L.), Broad Institute of MIT and Harvard, Cambridge, MA
| | - Rikke S Møller
- From the Pediatric Neurosciences Research Group (A.B., I.G., J.D.S., S.M.Z.), Royal Hospital for Children, Glasgow; Institute of Health and Wellbeing (A.B., I.G., J.D.S., S.M.Z.), University of Glasgow, UK; Centro de Genética y Genómica, Facultad de Medicina Clínica Alemana (E.P.-P.), Universidad del Desarrollo, Santiago, Chile; Genomic Medicine Institute, Lerner Research Institute (E.P.-P., D.L.), Department of Quantitative Health Sciences (J.X., M.W.K.), and Epilepsy Center, Neurological Institute (D.L.), Cleveland Clinic, OH; Department of Genetics (E.B., I.d.L.), University Medical Centre, Utrecht, the Netherlands; Department of Child Neurology (B.C., A.-S.S.), University Hospital Antwerp, Belgium; Reference Centre for Rare Epilepsies, Department of Pediatric Neurology (N.C., R.N.), Hôpital Necker-Enfants Malades, Université de Paris, France; Institute of Human Genetics (C.D.), University Hospital Essen, University of Duisburg-Essen, Germany; Neuroscience Department (R.G., D.M.), Children's Hospital A. Meyer-University of Florence, Italy; The Danish Epilepsy Centre (R.S.M.), Dianalund, Denmark; Institute for Regional Health Services (R.S.M.), University of Southern Denmark, Odense; Department of Medicine, Epilepsy Research Centre, Austin Health (B.M.R., A.L.S., I.E.S.), and Florey and Murdoch Children's Research Institutes, Royal Children's Hospital (I.E.S.), University of Melbourne, Australia; Applied and Translational Neurogenomics Group (S.W.), VIB-Center for Molecular Neurology, VIB, Antwerp; Neurology Department (S.W.), University Hospital Antwerp; Institute Born-Bunge (S.W.), University of Antwerp, Belgium; Cologne Center for Genomics (D.L.), University of Cologne, Germany; and Stanley Center for Psychiatric Genetics (D.L.), Broad Institute of MIT and Harvard, Cambridge, MA
| | - Rima Nabbout
- From the Pediatric Neurosciences Research Group (A.B., I.G., J.D.S., S.M.Z.), Royal Hospital for Children, Glasgow; Institute of Health and Wellbeing (A.B., I.G., J.D.S., S.M.Z.), University of Glasgow, UK; Centro de Genética y Genómica, Facultad de Medicina Clínica Alemana (E.P.-P.), Universidad del Desarrollo, Santiago, Chile; Genomic Medicine Institute, Lerner Research Institute (E.P.-P., D.L.), Department of Quantitative Health Sciences (J.X., M.W.K.), and Epilepsy Center, Neurological Institute (D.L.), Cleveland Clinic, OH; Department of Genetics (E.B., I.d.L.), University Medical Centre, Utrecht, the Netherlands; Department of Child Neurology (B.C., A.-S.S.), University Hospital Antwerp, Belgium; Reference Centre for Rare Epilepsies, Department of Pediatric Neurology (N.C., R.N.), Hôpital Necker-Enfants Malades, Université de Paris, France; Institute of Human Genetics (C.D.), University Hospital Essen, University of Duisburg-Essen, Germany; Neuroscience Department (R.G., D.M.), Children's Hospital A. Meyer-University of Florence, Italy; The Danish Epilepsy Centre (R.S.M.), Dianalund, Denmark; Institute for Regional Health Services (R.S.M.), University of Southern Denmark, Odense; Department of Medicine, Epilepsy Research Centre, Austin Health (B.M.R., A.L.S., I.E.S.), and Florey and Murdoch Children's Research Institutes, Royal Children's Hospital (I.E.S.), University of Melbourne, Australia; Applied and Translational Neurogenomics Group (S.W.), VIB-Center for Molecular Neurology, VIB, Antwerp; Neurology Department (S.W.), University Hospital Antwerp; Institute Born-Bunge (S.W.), University of Antwerp, Belgium; Cologne Center for Genomics (D.L.), University of Cologne, Germany; and Stanley Center for Psychiatric Genetics (D.L.), Broad Institute of MIT and Harvard, Cambridge, MA
| | - Brigid M Regan
- From the Pediatric Neurosciences Research Group (A.B., I.G., J.D.S., S.M.Z.), Royal Hospital for Children, Glasgow; Institute of Health and Wellbeing (A.B., I.G., J.D.S., S.M.Z.), University of Glasgow, UK; Centro de Genética y Genómica, Facultad de Medicina Clínica Alemana (E.P.-P.), Universidad del Desarrollo, Santiago, Chile; Genomic Medicine Institute, Lerner Research Institute (E.P.-P., D.L.), Department of Quantitative Health Sciences (J.X., M.W.K.), and Epilepsy Center, Neurological Institute (D.L.), Cleveland Clinic, OH; Department of Genetics (E.B., I.d.L.), University Medical Centre, Utrecht, the Netherlands; Department of Child Neurology (B.C., A.-S.S.), University Hospital Antwerp, Belgium; Reference Centre for Rare Epilepsies, Department of Pediatric Neurology (N.C., R.N.), Hôpital Necker-Enfants Malades, Université de Paris, France; Institute of Human Genetics (C.D.), University Hospital Essen, University of Duisburg-Essen, Germany; Neuroscience Department (R.G., D.M.), Children's Hospital A. Meyer-University of Florence, Italy; The Danish Epilepsy Centre (R.S.M.), Dianalund, Denmark; Institute for Regional Health Services (R.S.M.), University of Southern Denmark, Odense; Department of Medicine, Epilepsy Research Centre, Austin Health (B.M.R., A.L.S., I.E.S.), and Florey and Murdoch Children's Research Institutes, Royal Children's Hospital (I.E.S.), University of Melbourne, Australia; Applied and Translational Neurogenomics Group (S.W.), VIB-Center for Molecular Neurology, VIB, Antwerp; Neurology Department (S.W.), University Hospital Antwerp; Institute Born-Bunge (S.W.), University of Antwerp, Belgium; Cologne Center for Genomics (D.L.), University of Cologne, Germany; and Stanley Center for Psychiatric Genetics (D.L.), Broad Institute of MIT and Harvard, Cambridge, MA
| | - Amy L Schneider
- From the Pediatric Neurosciences Research Group (A.B., I.G., J.D.S., S.M.Z.), Royal Hospital for Children, Glasgow; Institute of Health and Wellbeing (A.B., I.G., J.D.S., S.M.Z.), University of Glasgow, UK; Centro de Genética y Genómica, Facultad de Medicina Clínica Alemana (E.P.-P.), Universidad del Desarrollo, Santiago, Chile; Genomic Medicine Institute, Lerner Research Institute (E.P.-P., D.L.), Department of Quantitative Health Sciences (J.X., M.W.K.), and Epilepsy Center, Neurological Institute (D.L.), Cleveland Clinic, OH; Department of Genetics (E.B., I.d.L.), University Medical Centre, Utrecht, the Netherlands; Department of Child Neurology (B.C., A.-S.S.), University Hospital Antwerp, Belgium; Reference Centre for Rare Epilepsies, Department of Pediatric Neurology (N.C., R.N.), Hôpital Necker-Enfants Malades, Université de Paris, France; Institute of Human Genetics (C.D.), University Hospital Essen, University of Duisburg-Essen, Germany; Neuroscience Department (R.G., D.M.), Children's Hospital A. Meyer-University of Florence, Italy; The Danish Epilepsy Centre (R.S.M.), Dianalund, Denmark; Institute for Regional Health Services (R.S.M.), University of Southern Denmark, Odense; Department of Medicine, Epilepsy Research Centre, Austin Health (B.M.R., A.L.S., I.E.S.), and Florey and Murdoch Children's Research Institutes, Royal Children's Hospital (I.E.S.), University of Melbourne, Australia; Applied and Translational Neurogenomics Group (S.W.), VIB-Center for Molecular Neurology, VIB, Antwerp; Neurology Department (S.W.), University Hospital Antwerp; Institute Born-Bunge (S.W.), University of Antwerp, Belgium; Cologne Center for Genomics (D.L.), University of Cologne, Germany; and Stanley Center for Psychiatric Genetics (D.L.), Broad Institute of MIT and Harvard, Cambridge, MA
| | - Ingrid E Scheffer
- From the Pediatric Neurosciences Research Group (A.B., I.G., J.D.S., S.M.Z.), Royal Hospital for Children, Glasgow; Institute of Health and Wellbeing (A.B., I.G., J.D.S., S.M.Z.), University of Glasgow, UK; Centro de Genética y Genómica, Facultad de Medicina Clínica Alemana (E.P.-P.), Universidad del Desarrollo, Santiago, Chile; Genomic Medicine Institute, Lerner Research Institute (E.P.-P., D.L.), Department of Quantitative Health Sciences (J.X., M.W.K.), and Epilepsy Center, Neurological Institute (D.L.), Cleveland Clinic, OH; Department of Genetics (E.B., I.d.L.), University Medical Centre, Utrecht, the Netherlands; Department of Child Neurology (B.C., A.-S.S.), University Hospital Antwerp, Belgium; Reference Centre for Rare Epilepsies, Department of Pediatric Neurology (N.C., R.N.), Hôpital Necker-Enfants Malades, Université de Paris, France; Institute of Human Genetics (C.D.), University Hospital Essen, University of Duisburg-Essen, Germany; Neuroscience Department (R.G., D.M.), Children's Hospital A. Meyer-University of Florence, Italy; The Danish Epilepsy Centre (R.S.M.), Dianalund, Denmark; Institute for Regional Health Services (R.S.M.), University of Southern Denmark, Odense; Department of Medicine, Epilepsy Research Centre, Austin Health (B.M.R., A.L.S., I.E.S.), and Florey and Murdoch Children's Research Institutes, Royal Children's Hospital (I.E.S.), University of Melbourne, Australia; Applied and Translational Neurogenomics Group (S.W.), VIB-Center for Molecular Neurology, VIB, Antwerp; Neurology Department (S.W.), University Hospital Antwerp; Institute Born-Bunge (S.W.), University of Antwerp, Belgium; Cologne Center for Genomics (D.L.), University of Cologne, Germany; and Stanley Center for Psychiatric Genetics (D.L.), Broad Institute of MIT and Harvard, Cambridge, MA
| | - An-Sofie Schoonjans
- From the Pediatric Neurosciences Research Group (A.B., I.G., J.D.S., S.M.Z.), Royal Hospital for Children, Glasgow; Institute of Health and Wellbeing (A.B., I.G., J.D.S., S.M.Z.), University of Glasgow, UK; Centro de Genética y Genómica, Facultad de Medicina Clínica Alemana (E.P.-P.), Universidad del Desarrollo, Santiago, Chile; Genomic Medicine Institute, Lerner Research Institute (E.P.-P., D.L.), Department of Quantitative Health Sciences (J.X., M.W.K.), and Epilepsy Center, Neurological Institute (D.L.), Cleveland Clinic, OH; Department of Genetics (E.B., I.d.L.), University Medical Centre, Utrecht, the Netherlands; Department of Child Neurology (B.C., A.-S.S.), University Hospital Antwerp, Belgium; Reference Centre for Rare Epilepsies, Department of Pediatric Neurology (N.C., R.N.), Hôpital Necker-Enfants Malades, Université de Paris, France; Institute of Human Genetics (C.D.), University Hospital Essen, University of Duisburg-Essen, Germany; Neuroscience Department (R.G., D.M.), Children's Hospital A. Meyer-University of Florence, Italy; The Danish Epilepsy Centre (R.S.M.), Dianalund, Denmark; Institute for Regional Health Services (R.S.M.), University of Southern Denmark, Odense; Department of Medicine, Epilepsy Research Centre, Austin Health (B.M.R., A.L.S., I.E.S.), and Florey and Murdoch Children's Research Institutes, Royal Children's Hospital (I.E.S.), University of Melbourne, Australia; Applied and Translational Neurogenomics Group (S.W.), VIB-Center for Molecular Neurology, VIB, Antwerp; Neurology Department (S.W.), University Hospital Antwerp; Institute Born-Bunge (S.W.), University of Antwerp, Belgium; Cologne Center for Genomics (D.L.), University of Cologne, Germany; and Stanley Center for Psychiatric Genetics (D.L.), Broad Institute of MIT and Harvard, Cambridge, MA
| | - Joseph D Symonds
- From the Pediatric Neurosciences Research Group (A.B., I.G., J.D.S., S.M.Z.), Royal Hospital for Children, Glasgow; Institute of Health and Wellbeing (A.B., I.G., J.D.S., S.M.Z.), University of Glasgow, UK; Centro de Genética y Genómica, Facultad de Medicina Clínica Alemana (E.P.-P.), Universidad del Desarrollo, Santiago, Chile; Genomic Medicine Institute, Lerner Research Institute (E.P.-P., D.L.), Department of Quantitative Health Sciences (J.X., M.W.K.), and Epilepsy Center, Neurological Institute (D.L.), Cleveland Clinic, OH; Department of Genetics (E.B., I.d.L.), University Medical Centre, Utrecht, the Netherlands; Department of Child Neurology (B.C., A.-S.S.), University Hospital Antwerp, Belgium; Reference Centre for Rare Epilepsies, Department of Pediatric Neurology (N.C., R.N.), Hôpital Necker-Enfants Malades, Université de Paris, France; Institute of Human Genetics (C.D.), University Hospital Essen, University of Duisburg-Essen, Germany; Neuroscience Department (R.G., D.M.), Children's Hospital A. Meyer-University of Florence, Italy; The Danish Epilepsy Centre (R.S.M.), Dianalund, Denmark; Institute for Regional Health Services (R.S.M.), University of Southern Denmark, Odense; Department of Medicine, Epilepsy Research Centre, Austin Health (B.M.R., A.L.S., I.E.S.), and Florey and Murdoch Children's Research Institutes, Royal Children's Hospital (I.E.S.), University of Melbourne, Australia; Applied and Translational Neurogenomics Group (S.W.), VIB-Center for Molecular Neurology, VIB, Antwerp; Neurology Department (S.W.), University Hospital Antwerp; Institute Born-Bunge (S.W.), University of Antwerp, Belgium; Cologne Center for Genomics (D.L.), University of Cologne, Germany; and Stanley Center for Psychiatric Genetics (D.L.), Broad Institute of MIT and Harvard, Cambridge, MA
| | - Sarah Weckhuysen
- From the Pediatric Neurosciences Research Group (A.B., I.G., J.D.S., S.M.Z.), Royal Hospital for Children, Glasgow; Institute of Health and Wellbeing (A.B., I.G., J.D.S., S.M.Z.), University of Glasgow, UK; Centro de Genética y Genómica, Facultad de Medicina Clínica Alemana (E.P.-P.), Universidad del Desarrollo, Santiago, Chile; Genomic Medicine Institute, Lerner Research Institute (E.P.-P., D.L.), Department of Quantitative Health Sciences (J.X., M.W.K.), and Epilepsy Center, Neurological Institute (D.L.), Cleveland Clinic, OH; Department of Genetics (E.B., I.d.L.), University Medical Centre, Utrecht, the Netherlands; Department of Child Neurology (B.C., A.-S.S.), University Hospital Antwerp, Belgium; Reference Centre for Rare Epilepsies, Department of Pediatric Neurology (N.C., R.N.), Hôpital Necker-Enfants Malades, Université de Paris, France; Institute of Human Genetics (C.D.), University Hospital Essen, University of Duisburg-Essen, Germany; Neuroscience Department (R.G., D.M.), Children's Hospital A. Meyer-University of Florence, Italy; The Danish Epilepsy Centre (R.S.M.), Dianalund, Denmark; Institute for Regional Health Services (R.S.M.), University of Southern Denmark, Odense; Department of Medicine, Epilepsy Research Centre, Austin Health (B.M.R., A.L.S., I.E.S.), and Florey and Murdoch Children's Research Institutes, Royal Children's Hospital (I.E.S.), University of Melbourne, Australia; Applied and Translational Neurogenomics Group (S.W.), VIB-Center for Molecular Neurology, VIB, Antwerp; Neurology Department (S.W.), University Hospital Antwerp; Institute Born-Bunge (S.W.), University of Antwerp, Belgium; Cologne Center for Genomics (D.L.), University of Cologne, Germany; and Stanley Center for Psychiatric Genetics (D.L.), Broad Institute of MIT and Harvard, Cambridge, MA
| | - Michael W Kattan
- From the Pediatric Neurosciences Research Group (A.B., I.G., J.D.S., S.M.Z.), Royal Hospital for Children, Glasgow; Institute of Health and Wellbeing (A.B., I.G., J.D.S., S.M.Z.), University of Glasgow, UK; Centro de Genética y Genómica, Facultad de Medicina Clínica Alemana (E.P.-P.), Universidad del Desarrollo, Santiago, Chile; Genomic Medicine Institute, Lerner Research Institute (E.P.-P., D.L.), Department of Quantitative Health Sciences (J.X., M.W.K.), and Epilepsy Center, Neurological Institute (D.L.), Cleveland Clinic, OH; Department of Genetics (E.B., I.d.L.), University Medical Centre, Utrecht, the Netherlands; Department of Child Neurology (B.C., A.-S.S.), University Hospital Antwerp, Belgium; Reference Centre for Rare Epilepsies, Department of Pediatric Neurology (N.C., R.N.), Hôpital Necker-Enfants Malades, Université de Paris, France; Institute of Human Genetics (C.D.), University Hospital Essen, University of Duisburg-Essen, Germany; Neuroscience Department (R.G., D.M.), Children's Hospital A. Meyer-University of Florence, Italy; The Danish Epilepsy Centre (R.S.M.), Dianalund, Denmark; Institute for Regional Health Services (R.S.M.), University of Southern Denmark, Odense; Department of Medicine, Epilepsy Research Centre, Austin Health (B.M.R., A.L.S., I.E.S.), and Florey and Murdoch Children's Research Institutes, Royal Children's Hospital (I.E.S.), University of Melbourne, Australia; Applied and Translational Neurogenomics Group (S.W.), VIB-Center for Molecular Neurology, VIB, Antwerp; Neurology Department (S.W.), University Hospital Antwerp; Institute Born-Bunge (S.W.), University of Antwerp, Belgium; Cologne Center for Genomics (D.L.), University of Cologne, Germany; and Stanley Center for Psychiatric Genetics (D.L.), Broad Institute of MIT and Harvard, Cambridge, MA
| | - Sameer M Zuberi
- From the Pediatric Neurosciences Research Group (A.B., I.G., J.D.S., S.M.Z.), Royal Hospital for Children, Glasgow; Institute of Health and Wellbeing (A.B., I.G., J.D.S., S.M.Z.), University of Glasgow, UK; Centro de Genética y Genómica, Facultad de Medicina Clínica Alemana (E.P.-P.), Universidad del Desarrollo, Santiago, Chile; Genomic Medicine Institute, Lerner Research Institute (E.P.-P., D.L.), Department of Quantitative Health Sciences (J.X., M.W.K.), and Epilepsy Center, Neurological Institute (D.L.), Cleveland Clinic, OH; Department of Genetics (E.B., I.d.L.), University Medical Centre, Utrecht, the Netherlands; Department of Child Neurology (B.C., A.-S.S.), University Hospital Antwerp, Belgium; Reference Centre for Rare Epilepsies, Department of Pediatric Neurology (N.C., R.N.), Hôpital Necker-Enfants Malades, Université de Paris, France; Institute of Human Genetics (C.D.), University Hospital Essen, University of Duisburg-Essen, Germany; Neuroscience Department (R.G., D.M.), Children's Hospital A. Meyer-University of Florence, Italy; The Danish Epilepsy Centre (R.S.M.), Dianalund, Denmark; Institute for Regional Health Services (R.S.M.), University of Southern Denmark, Odense; Department of Medicine, Epilepsy Research Centre, Austin Health (B.M.R., A.L.S., I.E.S.), and Florey and Murdoch Children's Research Institutes, Royal Children's Hospital (I.E.S.), University of Melbourne, Australia; Applied and Translational Neurogenomics Group (S.W.), VIB-Center for Molecular Neurology, VIB, Antwerp; Neurology Department (S.W.), University Hospital Antwerp; Institute Born-Bunge (S.W.), University of Antwerp, Belgium; Cologne Center for Genomics (D.L.), University of Cologne, Germany; and Stanley Center for Psychiatric Genetics (D.L.), Broad Institute of MIT and Harvard, Cambridge, MA
| | - Dennis Lal
- From the Pediatric Neurosciences Research Group (A.B., I.G., J.D.S., S.M.Z.), Royal Hospital for Children, Glasgow; Institute of Health and Wellbeing (A.B., I.G., J.D.S., S.M.Z.), University of Glasgow, UK; Centro de Genética y Genómica, Facultad de Medicina Clínica Alemana (E.P.-P.), Universidad del Desarrollo, Santiago, Chile; Genomic Medicine Institute, Lerner Research Institute (E.P.-P., D.L.), Department of Quantitative Health Sciences (J.X., M.W.K.), and Epilepsy Center, Neurological Institute (D.L.), Cleveland Clinic, OH; Department of Genetics (E.B., I.d.L.), University Medical Centre, Utrecht, the Netherlands; Department of Child Neurology (B.C., A.-S.S.), University Hospital Antwerp, Belgium; Reference Centre for Rare Epilepsies, Department of Pediatric Neurology (N.C., R.N.), Hôpital Necker-Enfants Malades, Université de Paris, France; Institute of Human Genetics (C.D.), University Hospital Essen, University of Duisburg-Essen, Germany; Neuroscience Department (R.G., D.M.), Children's Hospital A. Meyer-University of Florence, Italy; The Danish Epilepsy Centre (R.S.M.), Dianalund, Denmark; Institute for Regional Health Services (R.S.M.), University of Southern Denmark, Odense; Department of Medicine, Epilepsy Research Centre, Austin Health (B.M.R., A.L.S., I.E.S.), and Florey and Murdoch Children's Research Institutes, Royal Children's Hospital (I.E.S.), University of Melbourne, Australia; Applied and Translational Neurogenomics Group (S.W.), VIB-Center for Molecular Neurology, VIB, Antwerp; Neurology Department (S.W.), University Hospital Antwerp; Institute Born-Bunge (S.W.), University of Antwerp, Belgium; Cologne Center for Genomics (D.L.), University of Cologne, Germany; and Stanley Center for Psychiatric Genetics (D.L.), Broad Institute of MIT and Harvard, Cambridge, MA
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23
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Craiu D, Rener Primec Z, Lagae L, Vigevano F, Trinka E, Specchio N, Bakhtadze S, Cazacu C, Golli T, Zuberi SM. Vaccination and childhood epilepsies. Eur J Paediatr Neurol 2022; 36:57-68. [PMID: 34922162 DOI: 10.1016/j.ejpn.2021.11.014] [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: 06/08/2021] [Revised: 11/08/2021] [Accepted: 11/24/2021] [Indexed: 10/19/2022]
Abstract
INTRODUCTION The evidence relating vaccination to febrile seizures and epilepsy is evaluated with an emphasis on febrile seizures (FS), Dravet syndrome (DS), West syndrome, and other developmental and epileptic encephalopathies. METHODS A systematic literature review using search words vaccination/immunization AND febrile seizures/epilepsy/Dravet/epileptic encephalopathy/developmental encephalopathy was performed. The role of vaccination as the cause/trigger/aggravation factor for FS or epilepsies and preventive measures were analyzed. RESULTS From 1428 results, 846 duplicates and 447 irrelevant articles were eliminated; 120 were analyzed. CONCLUSIONS There is no evidence that vaccinations cause epilepsy in healthy populations. Vaccinations do not cause epileptic encephalopathies but may be non-specific triggers to seizures in underlying structural or genetic etiologies. The first seizure in DS may be earlier in vaccinated versus non-vaccinated patients, but developmental outcome is similar in both groups. Children with a personal or family history of FS or epilepsy should receive all routine vaccinations. This recommendation includes DS. The known risks of the infectious diseases prevented by immunization are well established. Vaccination should be deferred in case of acute illness. Acellular pertussis DTaP (diphtheria-tetanus-pertussis) is recommended. The combination of certain vaccine types may increase the risk of febrile seizures however the public health benefit of separating immunizations has not been proven. Measles-containing vaccine should be administered at age 12-15 months. Routine prophylactic antipyretics are not indicated, as there is no evidence of decreased FS risk and they can attenuate the antibody response following vaccination. Prophylactic measures (preventive antipyretic medication) are recommended in DS due to the increased risk of prolonged seizures with fever.
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Affiliation(s)
- Dana Craiu
- Carol Davila University of Medicine and Pharmacy, Faculty of Medicine, Department of Neurosciences, Pediatric Neurology Discipline II, Strada Dionisie Lupu No. 37, postal code: 020021, Bucharest/S2, Romania; Pediatric Neurology Clinic, Center of Expertise for Rare Disorders in Pediatric Neurology, EpiCARE member, Sos. Berceni 10, Bucharest/S4, Romania.
| | - Zvonka Rener Primec
- Department of Child, Adolescent and Developmental Neurology, Children's Hospital, University Medical Center Ljubljana Bohoričeva 20, 1000, Ljubljana, Slovenia; Faculty of Medicine, University of Ljubljana, Vrazov trg 2, 1000, Ljubljana, Slovenia.
| | - Lieven Lagae
- University of Leuven, Department of Development and Regeneration, Section Paediatric Neurology, Herestraat 49, 3000, Leuven, Belgium.
| | - Federico Vigevano
- Department of Neuroscience, Bambino Gesù Children's Hospital, IRCCS, Full Member of European Reference Network EpiCARE, Piazza S. Onofrio, 4, 00151, Rome, Italy.
| | - Eugen Trinka
- Department of Neurology, Christian-Doppler Medical Centre, Paracelsus Medical University, Affiliated Member of the European Reference Network, EpiCARE, 5020, Salzburg, Austria; Neuroscience Institute, Christian-Doppler Medical Centre, Paracelsus Medical University Salzburg, Austria.
| | - Nicola Specchio
- Department of Neuroscience, Bambino Gesù Children's Hospital, IRCCS, Full Member of European Reference Network EpiCARE, Piazza S. Onofrio, 4, 00151, Rome, Italy.
| | - Sophia Bakhtadze
- Department of Paediatric Neurology, Tbilisi State Medical University, 0160, Tbilisi, Georgia.
| | - Cristina Cazacu
- Pediatric Neurology Clinic, Center of Expertise for Rare Disorders in Pediatric Neurology, EpiCARE member, Sos. Berceni 10, Bucharest/S4, Romania.
| | - Tanja Golli
- Department of Child, Adolescent and Developmental Neurology, Children's Hospital, University Medical Center Ljubljana Bohoričeva 20, 1000, Ljubljana, Slovenia; Faculty of Medicine, University of Ljubljana, Vrazov trg 2, 1000, Ljubljana, Slovenia.
| | - Sameer M Zuberi
- Paediatric Neurosciences, Royal Hospital for Children, Glasgow, UK; Institute of Health & Wellbeing, University of Glasgow, Glasgow, UK.
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24
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Cardenal-Muñoz E, Auvin S, Villanueva V, Cross JH, Zuberi SM, Lagae L, Aibar JÁ. Guidance on Dravet syndrome from infant to adult care: Road map for treatment planning in Europe. Epilepsia Open 2021; 7:11-26. [PMID: 34882995 PMCID: PMC8886070 DOI: 10.1002/epi4.12569] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [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: 06/27/2021] [Revised: 11/24/2021] [Accepted: 12/02/2021] [Indexed: 12/22/2022] Open
Abstract
Dravet syndrome (DS) is a severe, rare, and complex developmental and epileptic encephalopathy affecting 1 in 16 000 live births and characterized by a drug‐resistant epilepsy, cognitive, psychomotor, and language impairment, and behavioral disorders. Evidence suggests that optimal treatment of seizures in DS may improve outcomes, even though neurodevelopmental impairments are the likely result of both the underlying genetic variant and the epilepsy. We present an updated guideline for DS diagnosis and treatment, taking into consideration care of the adult patient and nonpharmaceutical therapeutic options for this disease. This up‐to‐date guideline, which is based on an extensive review of the literature and culminates with a new treatment algorithm for DS, is a European consensus developed through a survey involving 29 European clinical experts in DS. This guideline will serve professionals in their clinical practice and, as a consequence, will benefit DS patients and their families.
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Affiliation(s)
- Elena Cardenal-Muñoz
- Dravet Syndrome Foundation Spain, Member of the EpiCARE ePAG Group, Madrid, Spain
| | - Stéphane Auvin
- APHP. Service de Neurologie Pédiatrique, Hôpital Robert Debré, Paris, France.,INSERM NeuroDiderot, Université de Paris, Paris, France.,Institut Universitaire de France (IUF), Paris, France
| | - Vicente Villanueva
- Refractory Epilepsy Unit, Hospital Universitario y Politécnico La Fe, Member of the ERN EpiCARE, Valencia, Spain
| | - J Helen Cross
- Department of Developmental Neurosciences, UCL NIHR BRC Great Ormond Street Institute of Child Health, London, UK.,Department of Neurology, Great Ormond Street Hospital for Children, Member of the ERN EpiCARE, London, UK
| | - Sameer M Zuberi
- Paediatric Neurosciences Research Group, Royal Hospital for Children, Member of the ERN EpiCARE, Glasgow, UK.,Institute of Health & Wellbeing, University of Glasgow, Glasgow, UK
| | - Lieven Lagae
- Department of Development and Regeneration, KU Leuven, Member of the ERN EpiCARE, Leuven, Belgium
| | - José Ángel Aibar
- Dravet Syndrome Foundation Spain, Member of the EpiCARE ePAG Group, Madrid, Spain
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25
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Symonds JD, Elliott KS, Shetty J, Armstrong M, Brunklaus A, Cutcutache I, Diver LA, Dorris L, Gardiner S, Jollands A, Joss S, Kirkpatrick M, McLellan A, MacLeod S, O'Regan M, Page M, Pilley E, Pilz DT, Stephen E, Stewart K, Ashrafian H, Knight JC, Zuberi SM. Early childhood epilepsies: epidemiology, classification, aetiology, and socio-economic determinants. Brain 2021; 144:2879-2891. [PMID: 34687210 PMCID: PMC8557326 DOI: 10.1093/brain/awab162] [Citation(s) in RCA: 47] [Impact Index Per Article: 15.7] [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: 12/13/2020] [Revised: 02/22/2021] [Accepted: 03/24/2021] [Indexed: 11/14/2022] Open
Abstract
Epilepsies of early childhood are frequently resistant to therapy and often associated with cognitive and behavioural comorbidity. Aetiology focused precision medicine, notably gene-based therapies, may prevent seizures and comorbidities. Epidemiological data utilizing modern diagnostic techniques including whole genome sequencing and neuroimaging can inform diagnostic strategies and therapeutic trials. We present a 3-year, multicentre prospective cohort study, involving all children under 3 years of age in Scotland presenting with epilepsies. We used two independent sources for case identification: clinical reporting and EEG record review. Capture-recapture methodology was then used to improve the accuracy of incidence estimates. Socio-demographic and clinical details were obtained at presentation, and 24 months later. Children were extensively investigated for aetiology. Whole genome sequencing was offered for all patients with drug-resistant epilepsy for whom no aetiology could yet be identified. Multivariate logistic regression modelling was used to determine associations between clinical features, aetiology, and outcome. Three hundred and ninety children were recruited over 3 years. The adjusted incidence of epilepsies presenting in the first 3 years of life was 239 per 100 000 live births [95% confidence interval (CI) 216-263]. There was a socio-economic gradient to incidence, with a significantly higher incidence in the most deprived quintile (301 per 100 000 live births, 95% CI 251-357) compared with the least deprived quintile (182 per 100 000 live births, 95% CI 139-233), χ2 odds ratio = 1.7 (95% CI 1.3-2.2). The relationship between deprivation and incidence was only observed in the group without identified aetiology, suggesting that populations living in higher deprivation areas have greater multifactorial risk for epilepsy. Aetiology was determined in 54% of children, and epilepsy syndrome was classified in 54%. Thirty-one per cent had an identified genetic cause for their epilepsy. We present novel data on the aetiological spectrum of the most commonly presenting epilepsies of early childhood. Twenty-four months after presentation, 36% of children had drug-resistant epilepsy (DRE), and 49% had global developmental delay (GDD). Identification of an aetiology was the strongest determinant of both DRE and GDD. Aetiology was determined in 82% of those with DRE, and 75% of those with GDD. In young children with epilepsy, genetic testing should be prioritized as it has the highest yield of any investigation and is most likely to inform precision therapy and prognosis. Epilepsies in early childhood are 30% more common than previously reported. Epilepsies of undetermined aetiology present more frequently in deprived communities. This likely reflects increased multifactorial risk within these populations.
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Affiliation(s)
- Joseph D Symonds
- Paediatric Neurosciences Research Group, Royal Hospital for Children, Glasgow G51 4TF, UK.,Institute of Health and Wellbeing, University of Glasgow, Glasgow G12 8QQ, UK
| | - Katherine S Elliott
- Wellcome Centre for Human Genetics, University of Oxford, Oxford OX3 7BN, UK
| | - Jay Shetty
- Department of Paediatric Neurosciences, Royal Hospital for Sick Children, Sciennes Road, Edinburgh EH9 1LF, UK
| | | | - Andreas Brunklaus
- Paediatric Neurosciences Research Group, Royal Hospital for Children, Glasgow G51 4TF, UK.,Institute of Health and Wellbeing, University of Glasgow, Glasgow G12 8QQ, UK
| | | | - Louise A Diver
- West of Scotland Regional Genetics Service, Queen Elizabeth University Hospitals, Glasgow G51 4TF, UK
| | - Liam Dorris
- Paediatric Neurosciences Research Group, Royal Hospital for Children, Glasgow G51 4TF, UK.,Institute of Health and Wellbeing, University of Glasgow, Glasgow G12 8QQ, UK
| | - Sarah Gardiner
- West of Scotland Regional Genetics Service, Queen Elizabeth University Hospitals, Glasgow G51 4TF, UK
| | - Alice Jollands
- Paediatric Neurology, Tayside Children's Hospital, Dundee DD1 9SY, UK
| | - Shelagh Joss
- West of Scotland Regional Genetics Service, Queen Elizabeth University Hospitals, Glasgow G51 4TF, UK
| | - Martin Kirkpatrick
- Paediatric Neurology, Tayside Children's Hospital, Dundee DD1 9SY, UK.,School of Medicine, University of Dundee DD1 9SY, UK
| | - Ailsa McLellan
- Department of Paediatric Neurosciences, Royal Hospital for Sick Children, Sciennes Road, Edinburgh EH9 1LF, UK
| | - Stewart MacLeod
- Paediatric Neurosciences Research Group, Royal Hospital for Children, Glasgow G51 4TF, UK
| | - Mary O'Regan
- Paediatric Neurosciences Research Group, Royal Hospital for Children, Glasgow G51 4TF, UK.,Paediatric Neurology, Crumlin Children's Hospital, Cooley Rd, Crumlin, Dublin D12 N512, Ireland
| | | | - Elizabeth Pilley
- Department of Paediatric Neurosciences, Royal Hospital for Sick Children, Sciennes Road, Edinburgh EH9 1LF, UK.,Paediatric Neurology, Tayside Children's Hospital, Dundee DD1 9SY, UK
| | - Daniela T Pilz
- West of Scotland Regional Genetics Service, Queen Elizabeth University Hospitals, Glasgow G51 4TF, UK
| | - Elma Stephen
- Paediatric Neurology, Royal Aberdeen Children's Hospital, Aberdeen AB25 2ZG, UK
| | - Kirsty Stewart
- West of Scotland Regional Genetics Service, Queen Elizabeth University Hospitals, Glasgow G51 4TF, UK
| | - Houman Ashrafian
- Division of Cardiovascular Medicine, John Radcliffe Hospital, Oxford, UK.,Department of Experimental Therapeutics, Radcliffe Department of Medicine, John Radcliffe Hospital, Oxford, UK
| | - Julian C Knight
- Wellcome Centre for Human Genetics, University of Oxford, Oxford OX3 7BN, UK
| | - Sameer M Zuberi
- Paediatric Neurosciences Research Group, Royal Hospital for Children, Glasgow G51 4TF, UK.,Institute of Health and Wellbeing, University of Glasgow, Glasgow G12 8QQ, UK
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Madan Cohen J, Checketts D, Dunayevich E, Gunning B, Hyslop A, Madhavan D, Villanueva V, Zolnowska M, Zuberi SM. Time to onset of cannabidiol treatment effects in Dravet syndrome: Analysis from two randomized controlled trials. Epilepsia 2021; 62:2218-2227. [PMID: 34265088 PMCID: PMC8456817 DOI: 10.1111/epi.16974] [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] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Revised: 06/08/2021] [Accepted: 06/08/2021] [Indexed: 12/19/2022]
Abstract
OBJECTIVE We conducted a post hoc analysis of two randomized controlled trials, GWPCARE1 (NCT02091375) and GWPCARE2 (NCT02224703), to estimate the time to onset of cannabidiol (CBD) treatment effects (seizure reduction and adverse events [AEs]) in patients with Dravet syndrome (DS). METHODS Patients received either plant-derived highly purified CBD (Epidiolex in the United States; 100 mg/ml oral solution) 10 mg/kg/day (CBD10; GWPCARE2) or 20 mg/kg/day (CBD20; GWPCARE1&2), or matching placebo for 14 weeks. Treatment started at 2.5 mg/kg/day, reached 10 mg/kg/day on Day 7, and went up to 20 mg/kg/day on Day 11 during the 14-day titration period. Percentage change from baseline in convulsive seizure frequency was calculated by cumulative day (i.e., including all previous days). Time to onset and resolution of AEs were also evaluated. RESULTS Overall, 124 patients received placebo and 194 received CBD (CBD10, n = 64; CBD20, n = 130). Mean age was 9.5 years (range = 2.2-18.9). Patients had discontinued a median of four antiepileptic drugs (range = 0-26) and were currently taking a median of three (range = 1-5). Differences in convulsive seizure reduction between placebo and CBD emerged during titration and became nominally significant by Day 12 for CBD20 (p = .02) and Day 13 for CBD10 (p = .03). Additionally, differences in the 50% responder rate between placebo and CBD became apparent during titration. Onset of the first reported AE occurred during the titration period in 48.4% of placebo patients and 54.1% of CBD patients. The three most common AEs of somnolence, decreased appetite, and diarrhea resolved within 4 weeks of onset in the majority of CBD-treated patients (56.3%-72.9%). SIGNIFICANCE The therapeutic effect of CBD in DS may start within 2 weeks of treatment in some patients. Although AEs lasted longer for CBD than placebo, most resolved within the 14-week study period.
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Affiliation(s)
- Jennifer Madan Cohen
- Department of Pediatrics, Division of Neurology at Connecticut Children’sUniversity of ConnecticutHartfordConnecticutUSA
| | | | | | | | - Ann Hyslop
- Nicklaus Children’s HospitalMiamiFloridaUSA
| | | | | | | | - Sameer M. Zuberi
- Paediatric Neurosciences Research GroupRoyal Hospital for Children & College of Medical, Veterinary, and Life SciencesUniversity of GlasgowGlasgowUK
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27
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Baumgartner T, Carreño M, Rocamora R, Bisulli F, Boni A, Brázdil M, Horak O, Craiu D, Pereira C, Guerrini R, San Antonio‐Arce V, Schulze‐Bonhage A, Zuberi SM, Hallböök T, Kalviainen R, Lagae L, Nguyen S, Quintas S, Franco A, Cross JH, Walker M, Arzimanoglou A, Rheims S, Granata T, Canafoglia L, Johannessen Landmark C, Sen A, Rattihalli R, Nabbout R, Tartara E, Santos M, Rangel R, Krsek P, Marusic P, Specchio N, Braun KPJ, Smeyers P, Villanueva V, Kotulska K, Surges R. A survey of the European Reference Network EpiCARE on clinical practice for selected rare epilepsies. Epilepsia Open 2021; 6:160-170. [PMID: 33681659 PMCID: PMC7918306 DOI: 10.1002/epi4.12459] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 11/26/2020] [Accepted: 12/09/2020] [Indexed: 11/11/2022] Open
Abstract
Objective Clinical care of rare and complex epilepsies is challenging, because evidence-based treatment guidelines are scarce, the experience of many physicians is limited, and interdisciplinary treatment of comorbidities is required. The pathomechanisms of rare epilepsies are, however, increasingly understood, which potentially fosters novel targeted therapies. The objectives of our survey were to obtain an overview of the clinical practice in European tertiary epilepsy centers treating patients with 5 arbitrarily selected rare epilepsies and to get an estimate of potentially available patients for future studies. Methods Members of the European Reference Network for rare and complex epilepsies (EpiCARE) were invited to participate in a web-based survey on clinical practice of patients with Dravet syndrome, tuberous sclerosis complex (TSC), autoimmune encephalitis, and progressive myoclonic epilepsies including Unverricht Lundborg and Unverricht-like diseases. A consensus-based questionnaire was generated for each disease. Results Twenty-six of 30 invited epilepsy centers participated. Cohorts were present in most responding centers for TSC (87%), Dravet syndrome (85%), and autoimmune encephalitis (71%). Patients with TSC and Dravet syndrome represented the largest cohorts in these centers. The antiseizure drug treatments were rather consistent across the centers especially with regard to Dravet syndrome, infantile spasms in TSC, and Unverricht Lundborg / Unverricht-like disease. Available, widely used targeted therapies included everolimus in TSC and immunosuppressive therapies in autoimmune encephalitis. Screening for comorbidities was routinely done, but specific treatment protocols were lacking in most centers. Significance The survey summarizes the current clinical practice for selected rare epilepsies in tertiary European epilepsy centers and demonstrates consistency as well as heterogeneity in the treatment, underscoring the need for controlled trials and recommendations. The survey also provides estimates for potential participants of clinical trials recruited via EpiCARE, emphasizing the great potential of Reference Networks for future studies to evaluate new targeted therapies and to identify novel biomarkers.
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Affiliation(s)
| | - Mar Carreño
- Epilepsy UnitChild Neurology DepartmentHospital San Juan de DiosBarcelonaSpain
- Hospital Clinic de BarcelonaBarcelonaSpain
| | - Rodrigo Rocamora
- Epilepsy CentreFaculty of Health and Life SciencesHospital del Mar‐IMIMUniversitat Pompeu FabraBarcelonaSpain
| | | | - Antonella Boni
- IRCCS Istituto delle Scienze Neurologiche di BolognaBolognaItaly
| | - Milan Brázdil
- Brno Epilepsy CenterDepartment of NeurologySt. Anne´s University HospitalMedical Faculty of Masaryk UniversityBrnoCzech Republic
| | - Ondrej Horak
- Brno Epilepsy CenterDepartment of Child NeurologyBrno University HospitalMedical Faculty of Masaryk UniversityBrnoCzech Republic
| | - Dana Craiu
- Alexandru Obregia Clinical HospitalBucharestRomania
| | | | - Renzo Guerrini
- Children's Hospital A. Meyer‐University of FlorenceFlorenceItaly
| | - Victoria San Antonio‐Arce
- Epilepsy UnitChild Neurology DepartmentHospital San Juan de DiosBarcelonaSpain
- Epilepsy CenterFaculty of MedicineUniversity Medical CenterFreiburgGermany
| | | | | | - Tove Hallböök
- Department of PediatricsInstitute of Clinical SciencesSahlgrenska AcademyUniversity of Gothenburg and Queen Silvia Children’s HospitalSahlgrenska University HospitalGothenburgSweden
| | - Reetta Kalviainen
- Pohjois‐Savon SairaanhoitopiiriKuopio University Hospital, (KUH)KuopioFinland
| | - Lieven Lagae
- University Hospital Gasthuisberg KULeuvenBelgium
| | | | - Sofia Quintas
- Centro Hospitalar Universitário Lisboa Norte ‐ Hospital de Santa MariaLisboaPortugal
| | - Ana Franco
- Centro Hospitalar Universitário Lisboa Norte ‐ Hospital de Santa MariaLisboaPortugal
| | - J. Helen Cross
- Great Ormond Street Hospital for ChildrenNHS TrustLondonUK
| | - Matthew Walker
- University College London Hospitals NHS Foundation TrustLondonUK
| | - Alexis Arzimanoglou
- Epilepsy UnitChild Neurology DepartmentHospital San Juan de DiosBarcelonaSpain
- Department of Paediatric Clinical Epileptology, Sleep Disorders and Functional NeurologyUniversity Hospitals of Lyon (HCL)LyonFrance
| | - Sylvain Rheims
- Department of Functional Neurology and EpileptologyHospices Civils de LyonUniversity of LyonLyonFrance
| | - Tiziana Granata
- Department of PediatricNeuroscience FondazioneIRCCS Istituto Neurologico Carlo BestaMilanItaly
| | - Laura Canafoglia
- Epilepsy UnitFondazione IRCCS Istituto Neurologico Carlo BestaMilanItaly
| | - Cecilie Johannessen Landmark
- Department of PharmacologyOslo University HospitalThe National Center for EpilepsyOslo Metropolitan UniversityOsloNorway
| | - Arjune Sen
- Oxford Epilepsy Research GroupNIHR Oxford Biomedical Research CentreNuffield Department of Clinical NeurosciencesJohn Radcliffe HospitalOxfordUK
| | - Rohini Rattihalli
- Department of Paediatric NeurologyChildren's HospitalJohn Radcliffe HospitalOxfordUK
| | - Rima Nabbout
- Department of Pediatric NeurologyAPHP, Imagine InstituteReference Centre for Rare EpilepsiesParis Descartes UniversityParisFrance
| | | | | | - Rui Rangel
- Centro Hospitalar Universitário do PortoPortoPortugal
| | - Pavel Krsek
- Departement of NeurologyCharles UniversitySecond Faculty of Medicine and Motol University HospitalPragueCzech Republic
| | - Petr Marusic
- Departement of NeurologyCharles UniversitySecond Faculty of Medicine and Motol University HospitalPragueCzech Republic
| | - Nicola Specchio
- Rare and Complex Epilepsy UnitDepartment of NeuroscienceBambino Gesu’ Children’s Hospital, IRCCSRomeItaly
| | - Kees P. J. Braun
- Department of Child NeurologyUniversity Medical Center UtrechtUtrechtThe Netherlands
| | - Patricia Smeyers
- Refractory Epilepsy Unit of Hospital Universitario y Politécnico La FeValenciaSpain
| | - Vicente Villanueva
- Refractory Epilepsy Unit of Hospital Universitario y Politécnico La FeValenciaSpain
| | | | - Rainer Surges
- Department of EpileptologyUniversity Hospital BonnBonnGermany
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Gulcebi MI, Bartolini E, Lee O, Lisgaras CP, Onat F, Mifsud J, Striano P, Vezzani A, Hildebrand MS, Jimenez-Jimenez D, Junck L, Lewis-Smith D, Scheffer IE, Thijs RD, Zuberi SM, Blenkinsop S, Fowler HJ, Foley A, Sisodiya SM, Berkovic S, Cavalleri G, Correa DJ, Martins Custodio H, Galovic M, Guerrini R, Henshall D, Howard O, Hughes K, Katsarou A, Koeleman BP, Krause R, Lowenstein D, Mandelenaki D, Marini C, O'Brien TJ, Pace A, De Palma L, Perucca P, Pitkänen A, Quinn F, Selmer KK, Steward CA, Swanborough N, Thijs R, Tittensor P, Trivisano M, Weckhuysen S, Zara F. Climate change and epilepsy: Insights from clinical and basic science studies. Epilepsy Behav 2021; 116:107791. [PMID: 33578223 PMCID: PMC9386889 DOI: 10.1016/j.yebeh.2021.107791] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Revised: 12/24/2020] [Accepted: 01/03/2021] [Indexed: 12/23/2022]
Abstract
Climate change is with us. As professionals who place value on evidence-based practice, climate change is something we cannot ignore. The current pandemic of the novel coronavirus, SARS-CoV-2, has demonstrated how global crises can arise suddenly and have a significant impact on public health. Global warming, a chronic process punctuated by acute episodes of extreme weather events, is an insidious global health crisis needing at least as much attention. Many neurological diseases are complex chronic conditions influenced at many levels by changes in the environment. This review aimed to collate and evaluate reports from clinical and basic science about the relationship between climate change and epilepsy. The keywords climate change, seasonal variation, temperature, humidity, thermoregulation, biorhythm, gene, circadian rhythm, heat, and weather were used to search the published evidence. A number of climatic variables are associated with increased seizure frequency in people with epilepsy. Climate change-induced increase in seizure precipitants such as fevers, stress, and sleep deprivation (e.g. as a result of more frequent extreme weather events) or vector-borne infections may trigger or exacerbate seizures, lead to deterioration of seizure control, and affect neurological, cerebrovascular, or cardiovascular comorbidities and risk of sudden unexpected death in epilepsy. Risks are likely to be modified by many factors, ranging from individual genetic variation and temperature-dependent channel function, to housing quality and global supply chains. According to the results of the limited number of experimental studies with animal models of seizures or epilepsy, different seizure types appear to have distinct susceptibility to seasonal influences. Increased body temperature, whether in the context of fever or not, has a critical role in seizure threshold and seizure-related brain damage. Links between climate change and epilepsy are likely to be multifactorial, complex, and often indirect, which makes predictions difficult. We need more data on possible climate-driven altered risks for seizures, epilepsy, and epileptogenesis, to identify underlying mechanisms at systems, cellular, and molecular levels for better understanding of the impact of climate change on epilepsy. Further focussed data would help us to develop evidence for mitigation methods to do more to protect people with epilepsy from the effects of climate change.
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Affiliation(s)
- Medine I. Gulcebi
- Department of Medical Pharmacology, Marmara University, School of Medicine, Istanbul, Turkey
| | - Emanuele Bartolini
- USL Centro Toscana, Neurology Unit, Nuovo Ospedale Santo Stefano, Via Suor Niccolina Infermiera 20, 59100 Prato, Italy.
| | - Omay Lee
- Department of Neurology and Clinical Neurophysiology, St. George's University Hospitals NHS Foundation Trust, London, UK.
| | - Christos Panagiotis Lisgaras
- New York University Langone Health, 100 First Ave., New York, NY 10016, USA; The Nathan S. Kline Institute for Psychiatric Research, Center for Dementia Research, 140 Old Orangeburg Rd., Orangeburg, NY 10962, USA.
| | - Filiz Onat
- Department of Medical Pharmacology, Marmara University School of Medicine, Istanbul, Turkey,Department of Medical Pharmacology, Acibadem University School of Medicine, Istanbul, Turkey
| | - Janet Mifsud
- Department of Clinical Pharmacology and Therapeutics, University of Malta, Msida MSD2040, Malta.
| | - Pasquale Striano
- Paediatric Neurology and Muscular Diseases Unit, DINOGMI-Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa, IRCCS “Giannina Gaslini” Institute, Genova, Italy
| | - Annamaria Vezzani
- Laboratory of Experimental Neurology, Department of Neuroscience, IRCCS 'Mario Negri' Institute for Pharmacological Research, Milan, Italy.
| | - Michael S. Hildebrand
- Department of Medicine (Austin Health), University of Melbourne, and Murdoch Children’s Research Institute, Melbourne, Victoria, Australia
| | - Diego Jimenez-Jimenez
- Department of Clinical and Experimental Epilepsy, UCL Queen Square Institute of Neurology, London, WC1N 3BG, UK and Chalfont Centre for Epilepsy, Bucks, UK.
| | - Larry Junck
- Department of Neurology, University of Michigan, Ann Arbor, MI, USA.
| | - David Lewis-Smith
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK.
| | - Ingrid E. Scheffer
- University of Melbourne, Austin Health and Royal Children’s Hospital, Florey Institute and Murdoch Children’s Research Institute, Melbourne, Australia
| | - Roland D. Thijs
- Department of Neurology, Leiden University Medical Centre (LUMC), PO Box 9600, 2300 RC Leiden, the Netherlands
| | - Sameer M. Zuberi
- Paediatric Neurosciences Research Group, Royal Hospital for Children & Institute of Health & Wellbeing, University of Glasgow, Fraser of Allander Neurosciences Unit, Royal Hospital for Children, UK
| | | | - Hayley J. Fowler
- Centre for Earth Systems Engineering Research, School of Engineering, Newcastle University, UK
| | - Aideen Foley
- Department of Geography, Birkbeck College University of London, London, UK.
| | - Epilepsy Climate Change ConsortiumBalestriniSimonaaaBerkovicSamuelabCavalleriGianpieroacCorreaDaniel JoséadMartins CustodioHelenaaeGalovicMarianafGuerriniRenzoagHenshallDavidahHowardOlgaaiHughesKelvinajKatsarouAnnaakKoelemanBobby P.C.alKrauseRolandamLowensteinDanielanMandelenakiDespoinaaoMariniCarlaapO’BrienTerence J.aqPaceAdrianarDe PalmaLucaasPeruccaPieroatPitkänenAslaauQuinnFinolaavSelmerKaja KristineawStewardCharles A.axSwanboroughNicolaayThijsRolandazTittensorPhilbaTrivisanoMarinabbWeckhuysenSarahbcZaraFedericobdDepartment of Clinical and Experimental Epilepsy, UCL Queen Square Institute of Neurology, London, UK and Chalfont Centre for Epilepsy, Bucks, UKEpilepsy Research Centre, Department of Medicine, Austin Health, University of Melbourne, Melbourne, Victoria, AustraliaDepartment of Molecular and Cellular Therapeutics, The Royal College of Surgeons in Ireland, Dublin 2, Ireland; The FutureNeuro Research Centre, Dublin 2, IrelandSaul R. Korey Department of Neurology, Albert Einstein College of Medicine and Montefiore Medical Center, 1410 Pelham Parkway South, K-312, Bronx, NY 10461, USADepartment of Clinical and Experimental Epilepsy, UCL Queen Square Institute of Neurology, London, UK; Chalfont Centre for Epilepsy, Bucks, UKUniversity Hospital Zurich, SwitzerlandDepartment of Child Neurology and Psychiatry, University of Pisa and IRCCS Fondazione Stella Maris, 56018 Calambrone, Pisa, ItalyFutureNeuro SFI Research Centre, Royal College of Surgeons in Ireland, 123 St Stephen’s Green, Dublin D02 YN77, IrelandUCB Pharma Ltd, Slough, UKDravet Syndrome UK, UKLaboratory of Developmental Epilepsy, Saul R. Korey Department of Neurology, Albert Einstein College of Medicine, Bronx, New York, USAUniversity Medical Center, Utrecht, The NetherlandsLuxembourg Centre for Systems Biomedicine, University of Luxembourg, Esch-sur-Alzette, LuxembourgDepartment of Neurology, University of California, San Francisco, CA, USADepartment of Pediatric Neurology, Queen Fabiola Children’s University Hospital, Brussels, Brussels Capital Region, BelgiumNeuroscience Department, Children’s Hospital A. Meyer-University of Florence, Florence, ItalyMelbourne Brain Centre, Departments of Medicine and Neurology, Royal Melbourne Hospital, University of Melbourne, VIC, Australia; Departments of Neuroscience and Neurology, Central Clinical School, Monash University, The Alfred Hospital, Melbourne, VIC, AustraliaGozo General Hospital, MaltaNeurology Unit, Department of Neuroscience, Bambino Gesù Children's Hospital, IRCCS, Rome, ItalyDepartment of Neuroscience, Central Clinical School, Monash University, Melbourne, VIC, Australia; Departments of Medicine and Neurology, The Royal Melbourne Hospital, The University of Melbourne, Melbourne, VIC, Australia; Department of Neurology, Alfred Health, Melbourne, VIC, AustraliaA.I. Virtanen Institute for Molecular Sciences, University of Eastern Finland, PO Box 1627, FIN-70211 Kuopio, FinlandILAE-IBE Congress Secretariat, Dublin, IrelandNational Centre for Rare Epilepsy-related Disorders, Oslo University Hospital, Oslo, Norway; Department of Medical Genetics, Oslo University Hospital, University of Oslo, Oslo, NorwayCongenica Ltd, Wellcome Genome Campus, Hinxton, Cambridge, CB10 1DR, UK; Wellcome Sanger InstituteWellcome Genome Campus, Hinxton, Cambridge CB10 1SA, UKEpilepsy Society, Bucks, UKStichting Epilepsie Instellingen Nederland (SEIN), Heemstede, Netherlands; Department of Neurology, Leiden University Medical Centre, Leiden, Netherlands; NIHR University College London Hospitals Biomedical Research Centre, UCL Queen Square Institute of Neurology, London, UKRoyal Wolverhampton NHS Trust, Wolverhampton, UKRare and Complex Epilepsy Unit, Department of Neuroscience and Neurorehabilitation, Bambino Gesù Children’s Hospital, IRCCS, Rome, ItalyNeurogenetics Group, Center for Molecular Neurology, VIB, University of Antwerp, Antwerp 2610, BelgiumUnit of Medical Genetics, IRCCS Istituto Giannina Gaslini, Genoa, Italy; Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), University of Genoa, Italy
| | - Sanjay M. Sisodiya
- Department of Clinical and Experimental Epilepsy, UCL Queen Square Institute of Neurology, London, WC1N 3BG, UK and Chalfont Centre for Epilepsy, Bucks, UK,Corresponding author at: Department of Clinical and Experimental Epilepsy, UCL Queen Square Institute of Neurology, London, UK
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29
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Pressler RM, Cilio MR, Mizrahi EM, Moshé SL, Nunes ML, Plouin P, Vanhatalo S, Yozawitz E, de Vries LS, Puthenveettil Vinayan K, Triki CC, Wilmshurst JM, Yamamoto H, Zuberi SM. The ILAE classification of seizures and the epilepsies: Modification for seizures in the neonate. Position paper by the ILAE Task Force on Neonatal Seizures. Epilepsia 2021; 62:615-628. [PMID: 33522601 DOI: 10.1111/epi.16815] [Citation(s) in RCA: 131] [Impact Index Per Article: 43.7] [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: 08/08/2020] [Revised: 12/23/2020] [Accepted: 12/23/2020] [Indexed: 12/23/2022]
Abstract
Seizures are the most common neurological emergency in the neonatal period and in contrast to those in infancy and childhood, are often provoked seizures with an acute cause and may be electrographic-only. Hence, neonatal seizures may not fit easily into classification schemes for seizures and epilepsies primarily developed for older children and adults. A Neonatal Seizures Task Force was established by the International League Against Epilepsy (ILAE) to develop a modification of the 2017 ILAE Classification of Seizures and Epilepsies, relevant to neonates. The neonatal classification framework emphasizes the role of electroencephalography (EEG) in the diagnosis of seizures in the neonate and includes a classification of seizure types relevant to this age group. The seizure type is determined by the predominant clinical feature. Many neonatal seizures are electrographic-only with no evident clinical features; therefore, these are included in the proposed classification. Clinical events without an EEG correlate are not included. Because seizures in the neonatal period have been shown to have a focal onset, a division into focal and generalized is unnecessary. Seizures can have a motor (automatisms, clonic, epileptic spasms, myoclonic, tonic), non-motor (autonomic, behavior arrest), or sequential presentation. The classification allows the user to choose the level of detail when classifying seizures in this age group.
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Affiliation(s)
- Ronit M Pressler
- Clinical Neuroscience, UCL- Great Ormond Street Institute of Child Health, London, UK.,Department of Clinical Neurophysiology, Great Ormond Street Hospital for Children, NHS Foundation Trust, London, UK
| | - Maria Roberta Cilio
- Division of Pediatric Neurology, Institute for Experimental and Clinical Research, Saint-Luc University Hospital, Université Catholique de Louvain, Brussels, Belgium
| | - Eli M Mizrahi
- Departments of Neurology and Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Solomon L Moshé
- Isabelle Rapin Division of Child Neurology, Saul R. Korey Department of Neurology, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY, USA.,Department of Pediatrics, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY, USA
| | - Magda L Nunes
- Pontificia Universidade Catolica do Rio Grande do Sul - PUCRS School of Medicine and the Brain Institute, Porto Alegre, RS, Brazil
| | - Perrine Plouin
- Department of Clinical Neurophysiology, Hospital Necker Enfant Malades, Paris, France
| | - Sampsa Vanhatalo
- Department of Clinical Neurophysiology and BABA center Children's Hospital, HUS Imaging, Neuroscience Center, Helsinki Institute of Life Science, Helsinki University Central Hospital and University of Helsinki, Helsinki, Finland
| | - Elissa Yozawitz
- Isabelle Rapin Division of Child Neurology, Saul R. Korey Department of Neurology, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY, USA.,Department of Pediatrics, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY, USA
| | - Linda S de Vries
- Department of Neonatology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | | | - Chahnez C Triki
- Department of Child Neurology, Hedi Chaker Hospital, LR19ES15 Sfax University, Sfax, Tunisia
| | - Jo M Wilmshurst
- Department of Paediatric Neurology, Red Cross War Memorial Children's Hospital, Neuroscience Institute, University of Cape Town, Cape Town, South Africa
| | - Hitoshi Yamamoto
- Department of Pediatrics, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Sameer M Zuberi
- Paediatric Neurosciences Research Group, Royal Hospital for Children & Institute of Health & Wellbeing, University of Glasgow, Glasgow, UK
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30
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Coughlin CR, Tseng LA, Abdenur JE, Ashmore C, Boemer F, Bok LA, Boyer M, Buhas D, Clayton PT, Das A, Dekker H, Evangeliou A, Feillet F, Footitt EJ, Gospe SM, Hartmann H, Kara M, Kristensen E, Lee J, Lilje R, Longo N, Lunsing RJ, Mills P, Papadopoulou MT, Pearl PL, Piazzon F, Plecko B, Saini AG, Santra S, Sjarif DR, Stockler-Ipsiroglu S, Striano P, Van Hove JLK, Verhoeven-Duif NM, Wijburg FA, Zuberi SM, van Karnebeek CDM. Consensus guidelines for the diagnosis and management of pyridoxine-dependent epilepsy due to α-aminoadipic semialdehyde dehydrogenase deficiency. J Inherit Metab Dis 2021; 44:178-192. [PMID: 33200442 DOI: 10.1002/jimd.12332] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Revised: 10/21/2020] [Accepted: 11/13/2020] [Indexed: 12/19/2022]
Abstract
Pyridoxine-dependent epilepsy (PDE-ALDH7A1) is an autosomal recessive condition due to a deficiency of α-aminoadipic semialdehyde dehydrogenase, which is a key enzyme in lysine oxidation. PDE-ALDH7A1 is a developmental and epileptic encephalopathy that was historically and empirically treated with pharmacologic doses of pyridoxine. Despite adequate seizure control, most patients with PDE-ALDH7A1 were reported to have developmental delay and intellectual disability. To improve outcome, a lysine-restricted diet and competitive inhibition of lysine transport through the use of pharmacologic doses of arginine have been recommended as an adjunct therapy. These lysine-reduction therapies have resulted in improved biochemical parameters and cognitive development in many but not all patients. The goal of these consensus guidelines is to re-evaluate and update the two previously published recommendations for diagnosis, treatment, and follow-up of patients with PDE-ALDH7A1. Members of the International PDE Consortium initiated evidence and consensus-based process to review previous recommendations, new research findings, and relevant clinical aspects of PDE-ALDH7A1. The guideline development group included pediatric neurologists, biochemical geneticists, clinical geneticists, laboratory scientists, and metabolic dieticians representing 29 institutions from 16 countries. Consensus guidelines for the diagnosis and management of patients with PDE-ALDH7A1 are provided.
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Affiliation(s)
- Curtis R Coughlin
- Section of Clinical Genetics and Metabolism, Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Laura A Tseng
- Department of Pediatrics Emma Children's Hospital, Amsterdam University Medical Centre, Amsterdam, The Netherlands
| | - Jose E Abdenur
- Division of Metabolic Disorders, CHOC Children's Hospital, Orange, California, USA
| | - Catherine Ashmore
- Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - François Boemer
- Department of Human Genetics, Centre Hospitalier Universitaire Sart-Tilman, Liège, Belgium
| | - Levinus A Bok
- Department of Pediatrics and Neonatology, Máxima Medical Center, Veldhoven, The Netherlands
| | - Monica Boyer
- Division of Metabolic Disorders, CHOC Children's Hospital, Orange, California, USA
| | - Daniela Buhas
- Division of Medical Genetics, Department of Specialized Medicine, Montreal Children's Hospital, McGill University Health Centre, Québec, Canada
| | - Peter T Clayton
- Genetics and Genomic Medicine, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Anibh Das
- Clinic for Paediatric Kidney, Liver, and Metabolic Diseases, Hannover Medical School, Hannover, Germany
| | - Hanka Dekker
- VKS: Dutch Patient Organization for Metabolic Diseases, Zwolle, The Netherlands
| | - Athanasios Evangeliou
- Division of Child Neurology and Inherited Metabolic Disorders, 4th Department of Pediatrics, Aristotle University of Thessaloniki, General Hospital Papageorgiou, Thessaloniki, Greece
| | - François Feillet
- Reference Center for Inborn Errors of Metabolism, Pediatric Unit, University Hospital of Nancy, Nancy, France
- INSERM UMR S 1256, Nutrition, Genetics, and Environmental Risk Exposure (NGERE), Faculty of Medicine of Nancy, University of Lorraine, Nancy, France
| | - Emma J Footitt
- Department of Metabolic Paediatrics, Great Ormond Street Hospital, London, UK
| | - Sidney M Gospe
- Division of Pediatric Neurology, Departments of Neurology and Pediatrics, University of Washington, Seattle, Washington, USA
- Department of Pediatrics, Duke University, Durham, North Carolina, USA
| | - Hans Hartmann
- Clinic for Paediatric Kidney, Liver, and Metabolic Diseases, Hannover Medical School, Hannover, Germany
| | - Majdi Kara
- Department of Pediatrics, University of Tripoli, Tripoli, Libya
| | - Erle Kristensen
- National Management of Newborn Screening and Advanced Laboratory Diagnostics in Inborn Errors of Metabolism, Department of Children and Adolescent Medicine, Oslo University Hospital, Oslo, Norway
| | - Joy Lee
- Department of Metabolic Medicine, The Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Rina Lilje
- Department of Children and Adolescent Medicine, Oslo University Hospital, Oslo, Norway
| | - Nicola Longo
- Division of Medical Genetics, Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA
| | - Roelineke J Lunsing
- Department of Neurology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Philippa Mills
- Genetics and Genomic Medicine, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Maria T Papadopoulou
- Division of Child Neurology and Inherited Metabolic Disorders, 4th Department of Pediatrics, Aristotle University of Thessaloniki, General Hospital Papageorgiou, Thessaloniki, Greece
| | - Phillip L Pearl
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Flavia Piazzon
- Neurometabolic Clinic, Children's Institute, University of Sao Paulo, Brazil
| | - Barbara Plecko
- Division of General Pediatrics, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Arushi G Saini
- Pediatric Neurology Unit, Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Saikat Santra
- Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - Damayanti R Sjarif
- Department of Child Health, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
| | - Sylvia Stockler-Ipsiroglu
- Division of Biochemical Genetics, BC Children's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Pasquale Striano
- Pediatric Neurology and Muscular Diseases Unit, IRCCS "G. Gaslini" Institute, Genoa, Italy
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genova, Genoa, Italy
| | - Johan L K Van Hove
- Section of Clinical Genetics and Metabolism, Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | | | - Frits A Wijburg
- Department of Pediatrics Emma Children's Hospital, Amsterdam University Medical Centre, Amsterdam, The Netherlands
| | - Sameer M Zuberi
- Paediatric Neurosciences Research Group, Royal Hospital for Children & School of Medicine, University of Glasgow, Glasgow, UK
| | - Clara D M van Karnebeek
- Department of Pediatrics Emma Children's Hospital, Amsterdam University Medical Centre, Amsterdam, The Netherlands
- Department of Pediatrics, Amalia Children's Hospital, Radboud Centre for Mitochondrial Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
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31
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Stamberger H, Hammer TB, Gardella E, Vlaskamp DRM, Bertelsen B, Mandelstam S, de Lange I, Zhang J, Myers CT, Fenger C, Afawi Z, Almanza Fuerte EP, Andrade DM, Balcik Y, Ben Zeev B, Bennett MF, Berkovic SF, Isidor B, Bouman A, Brilstra E, Busk ØL, Cairns A, Caumes R, Chatron N, Dale RC, de Geus C, Edery P, Gill D, Granild-Jensen JB, Gunderson L, Gunning B, Heimer G, Helle JR, Hildebrand MS, Hollingsworth G, Kharytonov V, Klee EW, Koeleman BPC, Koolen DA, Korff C, Küry S, Lesca G, Lev D, Leventer RJ, Mackay MT, Macke EL, McEntagart M, Mohammad SS, Monin P, Montomoli M, Morava E, Moutton S, Muir AM, Parrini E, Procopis P, Ranza E, Reed L, Reif PS, Rosenow F, Rossi M, Sadleir LG, Sadoway T, Schelhaas HJ, Schneider AL, Shah K, Shalev R, Sisodiya SM, Smol T, Stumpel CTRM, Stuurman K, Symonds JD, Mau-Them FT, Verbeek N, Verhoeven JS, Wallace G, Yosovich K, Zarate YA, Zerem A, Zuberi SM, Guerrini R, Mefford HC, Patel C, Zhang YH, Møller RS, Scheffer IE. NEXMIF encephalopathy: an X-linked disorder with male and female phenotypic patterns. Genet Med 2020; 23:363-373. [PMID: 33144681 DOI: 10.1038/s41436-020-00988-9] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [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: 06/08/2020] [Revised: 09/21/2020] [Accepted: 09/21/2020] [Indexed: 11/09/2022] Open
Abstract
PURPOSE Pathogenic variants in the X-linked gene NEXMIF (previously KIAA2022) are associated with intellectual disability (ID), autism spectrum disorder, and epilepsy. We aimed to delineate the female and male phenotypic spectrum of NEXMIF encephalopathy. METHODS Through an international collaboration, we analyzed the phenotypes and genotypes of 87 patients with NEXMIF encephalopathy. RESULTS Sixty-three females and 24 males (46 new patients) with NEXMIF encephalopathy were studied, with 30 novel variants. Phenotypic features included developmental delay/ID in 86/87 (99%), seizures in 71/86 (83%) and multiple comorbidities. Generalized seizures predominated including myoclonic seizures and absence seizures (both 46/70, 66%), absence with eyelid myoclonia (17/70, 24%), and atonic seizures (30/70, 43%). Males had more severe developmental impairment; females had epilepsy more frequently, and varied from unaffected to severely affected. All NEXMIF pathogenic variants led to a premature stop codon or were deleterious structural variants. Most arose de novo, although X-linked segregation occurred for both sexes. Somatic mosaicism occurred in two males and a family with suspected parental mosaicism. CONCLUSION NEXMIF encephalopathy is an X-linked, generalized developmental and epileptic encephalopathy characterized by myoclonic-atonic epilepsy overlapping with eyelid myoclonia with absence. Some patients have developmental encephalopathy without epilepsy. Males have more severe developmental impairment. NEXMIF encephalopathy arises due to loss-of-function variants.
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Affiliation(s)
- Hannah Stamberger
- Epilepsy Research Centre, Department of Medicine, Austin Health, University of Melbourne, Melbourne, VIC, Australia.,Applied and Translational Neurogenomics group, Center for Molecular Neurology, VIB, and Department of Neurology, University Hospital of Antwerp, University of Antwerp, Antwerpen, Belgium
| | - Trine B Hammer
- Department of Epilepsy Genetics, Danish Epilepsy Centre Filadelfia, Dianalund, Denmark.,Clinical Genetic Department, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Elena Gardella
- Department of Epilepsy Genetics, Danish Epilepsy Centre Filadelfia, Dianalund, Denmark.,Institute for Regional Health Services Research, University of Southern Denmark, Odense, Denmark
| | - Danique R M Vlaskamp
- Epilepsy Research Centre, Department of Medicine, Austin Health, University of Melbourne, Melbourne, VIC, Australia.,University of Groningen, University Medical Center Groningen, Department of Neurology, Groningen, the Netherlands.,University of Groningen, University Medical Center Groningen, Department of Genetics, Groningen, The Netherlands
| | - Birgitte Bertelsen
- Center for Genomic Medicine, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Simone Mandelstam
- Royal Children's Hospital, Melbourne, VIC, Australia.,Murdoch Children's Research Institute, Melbourne, VIC, Australia.,Department of Pediatrics, University of Melbourne, Melbourne, VIC, Australia.,Department of Radiology, University of Melbourne, Melbourne, VIC, Australia.,Florey Institute of Neuroscience and Mental Health, Melbourne, VIC, Australia
| | - Iris de Lange
- Department of Genetics, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jing Zhang
- Department of Pediatrics, Peking University First Hospital, Beijing, China
| | - Candace T Myers
- Division of Genetic Medicine, Department of Pediatrics, University of Washington, Seattle, WA, USA
| | - Christina Fenger
- Department of Epilepsy Genetics, Danish Epilepsy Centre Filadelfia, Dianalund, Denmark
| | - Zaid Afawi
- Tel Aviv University Medical School, Tel Aviv, Israel
| | - Edith P Almanza Fuerte
- Division of Genetic Medicine, Department of Pediatrics, University of Washington, Seattle, WA, USA
| | - Danielle M Andrade
- Division of Neurology, Toronto Western Hospital, University of Toronto, Toronto, ON, Canada
| | - Yunus Balcik
- Epilepsy Center Frankfurt Rhine-Main, Center of Neurology and Neurosurgery, University Hospital Frankfurt, and Center for Personalized Translational Epilepsy Research (CePTER), Goethe-University Frankfurt, Frankfurt am Main, Germany
| | - Bruria Ben Zeev
- Edmond and Lily Safra Children's Hospital, Pediatric Neurology Unit, Tel-Hashomer, Israel.,Tel Aviv University, Sackler School of Medicine, Tel Aviv, Israel
| | - Mark F Bennett
- Epilepsy Research Centre, Department of Medicine, Austin Health, University of Melbourne, Melbourne, VIC, Australia.,The Walter and Eliza Hall Institute of Medical Research, Melbourne, VIC, Australia.,Department of Medical Biology University of Melbourne, Melbourne, VIC, Australia
| | - Samuel F Berkovic
- Epilepsy Research Centre, Department of Medicine, Austin Health, University of Melbourne, Melbourne, VIC, Australia
| | | | - Arjan Bouman
- Department of Clinical Genetics, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Eva Brilstra
- Department of Genetics, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Øyvind L Busk
- Section for Medical Genetics, Telemark Hospital, Skien, Norway
| | - Anita Cairns
- Department of Neurosciences, Queensland Children's Hospital, Brisbane, QLD, Australia
| | - Roseline Caumes
- Service de Neuropédiatrie, Pôle de Médecine et Spécialités Médicales, CHRU de Lille, Lille, France
| | - Nicolas Chatron
- Lyon University Hospitals, Departments of Genetics, Lyon, France
| | - Russell C Dale
- T.Y. Nelson Department of Neurology and Neurosurgery, The Children's Hospital at Westmead, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Christa de Geus
- University Medical Centre Groningen, Department of Genetics, Groningen, The Netherlands
| | - Patrick Edery
- Lyon University Hospitals, Departments of Genetics, Lyon, France.,INSERM U1028, CNRS UMR5292, Centre de Recherche en Neurosciences de Lyon, GENDEV Team, Bron, France
| | - Deepak Gill
- T.Y. Nelson Department of Neurology and Neurosurgery, The Children's Hospital at Westmead, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | | | - Lauren Gunderson
- Department of Clinical Genomics, Mayo Clinic, Rochester, MN, USA
| | | | - Gali Heimer
- Edmond and Lily Safra Children's Hospital, Pediatric Neurology Unit, Tel-Hashomer, Israel.,Tel Aviv University, Sackler School of Medicine, Tel Aviv, Israel
| | - Johan R Helle
- Section for Medical Genetics, Telemark Hospital, Skien, Norway
| | - Michael S Hildebrand
- Epilepsy Research Centre, Department of Medicine, Austin Health, University of Melbourne, Melbourne, VIC, Australia.,Murdoch Children's Research Institute, Melbourne, VIC, Australia
| | - Georgie Hollingsworth
- Epilepsy Research Centre, Department of Medicine, Austin Health, University of Melbourne, Melbourne, VIC, Australia
| | | | - Eric W Klee
- Department of Clinical Genomics, Mayo Clinic, Rochester, MN, USA.,Center for Individualized Medicine, Mayo Clinic, Rochester, MN, USA
| | - Bobby P C Koeleman
- Department of Genetics, University Medical Center Utrecht, Utrecht, The Netherlands
| | - David A Koolen
- Department of Human Genetics, Donders Institute for Brain, Cognition and Behavior, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Christian Korff
- Pediatric Neurology Unit, University Hospitals, Geneva, Switzerland
| | - Sébastien Küry
- Service de génétique médicale, CHU Nantes, Nantes, France
| | - Gaetan Lesca
- Lyon University Hospitals, Departments of Genetics, Lyon, France
| | - Dorit Lev
- Tel Aviv University, Sackler School of Medicine, Tel Aviv, Israel.,Institute of Medical Genetics, Wolfson Medical Center, Holon, Israel
| | - Richard J Leventer
- Royal Children's Hospital, Melbourne, VIC, Australia.,Murdoch Children's Research Institute, Melbourne, VIC, Australia.,Department of Pediatrics, University of Melbourne, Melbourne, VIC, Australia
| | - Mark T Mackay
- Royal Children's Hospital, Melbourne, VIC, Australia.,Murdoch Children's Research Institute, Melbourne, VIC, Australia.,Department of Pediatrics, University of Melbourne, Melbourne, VIC, Australia
| | - Erica L Macke
- Center for Individualized Medicine, Mayo Clinic, Rochester, MN, USA
| | - Meriel McEntagart
- Medical Genetics, St George's University Hospitals NHS FT, Cranmer Tce, London, United Kingdom
| | - Shekeeb S Mohammad
- T.Y. Nelson Department of Neurology and Neurosurgery, The Children's Hospital at Westmead, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Pauline Monin
- Lyon University Hospitals, Departments of Genetics, Lyon, France
| | - Martino Montomoli
- Department of Neuroscience, Pharmacology and Child Health, Children's Hospital A. Meyer and University of Florence, Florence, Italy
| | - Eva Morava
- Department of Clinical Genomics, Mayo Clinic, Rochester, MN, USA.,Center for Individualized Medicine, Mayo Clinic, Rochester, MN, USA
| | - Sebastien Moutton
- CPDPN, Pôle mère enfant, Maison de Santé Protestante Bordeaux Bagatelle, Talence, France.,INSERM UMR1231 GAD, FHU-TRANSLAD, Université de Bourgogne, Dijon, France
| | - Alison M Muir
- Division of Genetic Medicine, Department of Pediatrics, University of Washington, Seattle, WA, USA
| | - Elena Parrini
- Department of Neuroscience, Pharmacology and Child Health, Children's Hospital A. Meyer and University of Florence, Florence, Italy
| | - Peter Procopis
- T.Y. Nelson Department of Neurology and Neurosurgery, The Children's Hospital at Westmead, Faculty of Medicine and Health, University of Sydney, Sydney, Australia.,Discipline of Child and Adolescent Health, Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - Emmanuelle Ranza
- Medigenome, Swiss Institute of Genomic Medicine, Geneva, Switzerland
| | - Laura Reed
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Philipp S Reif
- Epilepsy Center Frankfurt Rhine-Main, Center of Neurology and Neurosurgery, University Hospital Frankfurt, and Center for Personalized Translational Epilepsy Research (CePTER), Goethe-University Frankfurt, Frankfurt am Main, Germany
| | - Felix Rosenow
- Epilepsy Center Frankfurt Rhine-Main, Center of Neurology and Neurosurgery, University Hospital Frankfurt, and Center for Personalized Translational Epilepsy Research (CePTER), Goethe-University Frankfurt, Frankfurt am Main, Germany
| | - Massimiliano Rossi
- Lyon University Hospitals, Departments of Genetics, Lyon, France.,INSERM U1028, CNRS UMR5292, Centre de Recherche en Neurosciences de Lyon, GENDEV Team, Bron, France
| | - Lynette G Sadleir
- Department of Paediatrics and Child Health, University of Otago Wellington, Wellington, New Zealand
| | - Tara Sadoway
- Division of Neurology, Toronto Western Hospital, University of Toronto, Toronto, ON, Canada
| | | | - Amy L Schneider
- Epilepsy Research Centre, Department of Medicine, Austin Health, University of Melbourne, Melbourne, VIC, Australia
| | | | - Ruth Shalev
- Neuropaediatric Unit, Shaare Zedek Medical Centre, Hebrew University School of Medicine, Jerusalem, Israel
| | - Sanjay M Sisodiya
- Department of Clinical and Experimental Epilepsy, UCL Queen Square Institute of Neurology, London, United Kingdom and Chalfont Centre for Epilepsy, Bucks, UK
| | - Thomas Smol
- Institut de Génétique Médicale, Hopital Jeanne de Flandre, Lille University Hospital, Lille, France
| | - Connie T R M Stumpel
- Department of Clinical Genetics and GROW-School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Kyra Stuurman
- Department of Clinical Genetics, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Joseph D Symonds
- Paediatric Neurosciences Research Group, Royal Hospital for Children, Glasgow, UK.,College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
| | - Frederic Tran Mau-Them
- UF Innovation en diagnostic genomique des maladies rares, CHU Dijon Bourgogne, Dijon, France.,INSERM UMR1231 GAD, Dijon, France
| | - Nienke Verbeek
- Department of Genetics, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Judith S Verhoeven
- Academic Center for Epileptology, Kempenhaege, Department of Neurology, Heeze, The Netherlands
| | - Geoffrey Wallace
- Department of Neurosciences, Queensland Children's Hospital, Brisbane, QLD, Australia.,School of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Keren Yosovich
- Molecular Genetics Lab, Wolfson Medical Center, Holon, Israel
| | - Yuri A Zarate
- Section of Genetics and Metabolism, Department of Pediatrics, University of Arkansas for Medical Sciences, Arkansas Children's Hospital, Little Rock, AR, USA
| | - Ayelet Zerem
- Tel Aviv University, Sackler School of Medicine, Tel Aviv, Israel.,White Matter Disease Care, Pediatric Neurology Unit, Dana-Dwak Children's Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Sameer M Zuberi
- Paediatric Neurosciences Research Group, Royal Hospital for Children, Glasgow, UK.,College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
| | - Renzo Guerrini
- Department of Neuroscience, Pharmacology and Child Health, Children's Hospital A. Meyer and University of Florence, Florence, Italy
| | - Heather C Mefford
- Division of Genetic Medicine, Department of Pediatrics, University of Washington, Seattle, WA, USA
| | - Chirag Patel
- Genetic Health Queensland, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia
| | - Yue-Hua Zhang
- Department of Pediatrics, Peking University First Hospital, Beijing, China
| | - Rikke S Møller
- Department of Epilepsy Genetics, Danish Epilepsy Centre Filadelfia, Dianalund, Denmark.,Institute for Regional Health Services Research, University of Southern Denmark, Odense, Denmark
| | - Ingrid E Scheffer
- Epilepsy Research Centre, Department of Medicine, Austin Health, University of Melbourne, Melbourne, VIC, Australia. .,Royal Children's Hospital, Melbourne, VIC, Australia. .,Murdoch Children's Research Institute, Melbourne, VIC, Australia. .,Department of Pediatrics, University of Melbourne, Melbourne, VIC, Australia. .,Florey Institute of Neuroscience and Mental Health, Melbourne, VIC, Australia.
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Zuberi SM. The training & organisation of paediatric neurology in Europe. Eur J Paediatr Neurol 2020; 28:1. [PMID: 32900594 PMCID: PMC7441983 DOI: 10.1016/j.ejpn.2020.08.007] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Klepper J, Akman C, Armeno M, Auvin S, Cervenka M, Cross HJ, De Giorgis V, Della Marina A, Engelstad K, Heussinger N, Kossoff EH, Leen WG, Leiendecker B, Monani UR, Oguni H, Neal E, Pascual JM, Pearson TS, Pons R, Scheffer IE, Veggiotti P, Willemsen M, Zuberi SM, De Vivo DC. Glut1 Deficiency Syndrome (Glut1DS): State of the art in 2020 and recommendations of the international Glut1DS study group. Epilepsia Open 2020; 5:354-365. [PMID: 32913944 PMCID: PMC7469861 DOI: 10.1002/epi4.12414] [Citation(s) in RCA: 111] [Impact Index Per Article: 27.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Revised: 06/13/2020] [Accepted: 06/16/2020] [Indexed: 12/14/2022] Open
Abstract
Glut1 deficiency syndrome (Glut1DS) is a brain energy failure syndrome caused by impaired glucose transport across brain tissue barriers. Glucose diffusion across tissue barriers is facilitated by a family of proteins including glucose transporter type 1 (Glut1). Patients are treated effectively with ketogenic diet therapies (KDT) that provide a supplemental fuel, namely ketone bodies, for brain energy metabolism. The increasing complexity of Glut1DS, since its original description in 1991, now demands an international consensus statement regarding diagnosis and treatment. International experts (n = 23) developed a consensus statement utilizing their collective professional experience, responses to a standardized questionnaire, and serial discussions of wide-ranging issues related to Glut1DS. Key clinical features signaling the onset of Glut1DS are eye-head movement abnormalities, seizures, neurodevelopmental impairment, deceleration of head growth, and movement disorders. Diagnosis is confirmed by the presence of these clinical signs, hypoglycorrhachia documented by lumbar puncture, and genetic analysis showing pathogenic SLC2A1 variants. KDT represent standard choices with Glut1DS-specific recommendations regarding duration, composition, and management. Ongoing research has identified future interventions to restore Glut1 protein content and function. Clinical manifestations are influenced by patient age, genetic complexity, and novel therapeutic interventions. All clinical phenotypes will benefit from a better understanding of Glut1DS natural history throughout the life cycle and from improved guidelines facilitating early diagnosis and prompt treatment. Often, the presenting seizures are treated initially with antiseizure drugs before the cause of the epilepsy is ascertained and appropriate KDT are initiated. Initial drug treatment fails to treat the underlying metabolic disturbance during early brain development, contributing to the long-term disease burden. Impaired development of the brain microvasculature is one such complication of delayed Glut1DS treatment in the postnatal period. This international consensus statement should facilitate prompt diagnosis and guide best standard of care for Glut1DS throughout the life cycle.
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Affiliation(s)
- Joerg Klepper
- Children's Hospital Aschaffenburg‐AlzenauAschaffenburgGermany
| | - Cigdem Akman
- Department of Neurology and PediatricsVagelos College of Physicians and Surgeons at Columbia UniversityNew YorkNYUSA
| | - Marisa Armeno
- Department of NutritionHospital Pediatria JP GarrahanBuenos AiresArgentina
| | - Stéphane Auvin
- Department of Pediatric NeurologyCHU Hôpital Robert DebreAPHPParisFrance
| | - Mackenzie Cervenka
- Department of NeurologyComprehensive Epilepsy CenterJohns Hopkins University School of MedicineBaltimoreMDUSA
| | - Helen J. Cross
- UCL NIHR BRC Great Ormond Street Institute of Child HealthLondonUK
| | | | - Adela Della Marina
- Department of Neuropediatrics, Developmental Neurology and Social Pediatrics, Centre for Neuromuscular Disorders in Children, University Hospital EssenUniversity of Duisburg‐EssenEssenGermany
| | - Kristin Engelstad
- Department of Neurology and PediatricsVagelos College of Physicians and Surgeons at Columbia UniversityNew YorkNYUSA
| | - Nicole Heussinger
- Department of Pediatric NeurologyParacelsus Medical Private UniversityNurembergGermany
| | - Eric H. Kossoff
- Departments of Neurology and PediatricsJohns Hopkins UniversityBaltimoreMDUSA
| | - Wilhelmina G. Leen
- Department of NeurologyCanisius Wilhemina HospitalNijmegenThe Netherlands
| | - Baerbel Leiendecker
- Department of Neuropediatrics, Developmental Neurology and Social Pediatrics, Centre for Neuromuscular Disorders in Children, University Hospital EssenUniversity of Duisburg‐EssenEssenGermany
| | - Umrao R. Monani
- Center for Motor Neuron Biology & DiseaseDepartments of Neurology and Pathology & Cell BiologyColumbia University Irving Medical CenterNew YorkNYUSA
| | - Hirokazu Oguni
- Department of PediatricsTokyo Women's Medical UniversityTokyoJapan
| | | | - Juan M. Pascual
- Departments of Neurology and Neurotherapeutics, Physiology and PediatricsEugene McDermott Center for Human Growth and DevelopmentThe University of Texas Southwestern Medical CenterDallasTXUSA
| | - Toni S. Pearson
- Mount Sinai Center for Headache & Pain MedicineNew YorkNYUSA
| | - Roser Pons
- First Department of PediatricsAgia Sofia HospitalUniversity of AthensAthensGreece
| | - Ingrid E. Scheffer
- Florey and Murdoch InstitutesAustin Health and Royal Children's HospitalThe University of MelbourneMelbourneVictoriaAustralia
| | - Pierangelo Veggiotti
- Pediatric Neurology V. Buzzi HospitalChild Neuropsychiatry University of MilanMilanItaly
| | - Michél Willemsen
- Department of Pediatric NeurologyRadboud University Medical CentreAmalia Children's HospitalNijmegenNetherlands
| | - Sameer M. Zuberi
- Royal Hospital for Children & College of Medical Veterinary & Life SciencesUniversity of GlasgowGlasgowUK
| | - Darryl C. De Vivo
- Department of Neurology and PediatricsVagelos College of Physicians and Surgeons at Columbia UniversityNew YorkNYUSA
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34
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Symonds JD, Moloney TC, Lang B, McLellan A, O'Regan ME, MacLeod S, Jollands A, Vincent A, Kirkpatrick M, Brunklaus A, Shetty J, Dorris L, Forbes K, Abu-Arafeh I, Andrew J, Brink P, Callaghan M, Cruden J, Findlay C, Grattan R, MacDonnell J, McKnight J, Morrison CA, Nairn L, Pilley E, Stephen E, Thomsen S, Webb A, Wilson M, Zuberi SM. Neuronal antibody prevalence in children with seizures under 3 years: A prospective national cohort. Neurology 2020; 95:e1590-e1598. [PMID: 32690789 DOI: 10.1212/wnl.0000000000010318] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Accepted: 03/30/2020] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To report the prevalence of anti-neuronal antibodies in a prospective whole-nation cohort of children presenting with seizures before their third birthday. METHODS This was a prospective population-based national cohort study involving all children presenting with new-onset epilepsy or complex febrile seizures before their third birthday over a 3-year period. Patients with previously identified structural, metabolic, or infectious cause for seizures were excluded. Serum samples were obtained at first presentation and tested for 7 neuronal antibodies using live cell-based assays. Clinical data were collected with structured proformas at recruitment and 24 months after presentation. In addition, patients with seizures and clinically suspected autoimmune encephalitis were independently identified by a review of the case records of all children <3 years of age in Scotland who had undergone EEG. RESULTS Two hundred ninety-eight patients were identified and recruited and underwent autoantibody testing. Antibody positivity was identified in 18 of 298 (6.0%). The antibodies identified were GABA receptor B (n = 8, 2.7%), contactin-associated protein 2 (n = 4, 1.3%), glycine receptor (n = 3, 1.0%), leucine-rich glioma inactivated 1 (n = 2, 0.7%), NMDA receptor (n = 1, 0.3%), and GABA receptor A (n = 1, 0.3%). None of these patients had a clinical picture of autoimmune encephalitis. Seizure classification and clinical phenotype did not correlate with antibody positivity. CONCLUSIONS Autoimmune encephalitis is very rare in early childhood. However serum neuronal antibodies are identified in 6.4% of children presenting with seizures at <3 years of age. Antibody testing should not be a routine clinical test in early childhood-onset epilepsy because, in the absence of other features of autoimmune encephalitis, antibody positivity is of doubtful clinical significance. Antibody testing should be reserved for patients with additional features of encephalitis.
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Affiliation(s)
- Joseph D Symonds
- From the Paediatric Neurosciences Research Group (J.D.S., M.E.O., S.M., A.B., L.D., M.W., S.M.Z.), Royal Hospital for Children; College of Medical, Veterinary & Life Sciences (J.D.S., A.B., L.D., S.M.Z.), University of Glasgow; Nuffield Department of Clinical Neurosciences (T.C.M., B.L., A.V., S.T.), John Radcliffe Hospital, Oxford; Department of Paediatric Neurosciences (A.M., J.S.), Royal Hospital for Sick Children, Edinburgh; Paediatric Neurology (A.J., M.K., P.B., E.P.), Tayside Children's Hospital, Dundee; Neuroradiology (K.F.), Queen Elizabeth University Hospitals, Glasgow; Department of Paediatrics (I.A.-A., R.G.), Forth Valley Royal Hospital, Larbert; Department of Paediatrics (J.A., M.C.), University Hospital Wishaw; Department of Paediatrics (J.C.), Victoria Hospital, Kirkcaldy; Department of Paediatrics (C.F., C.A.M.), University Hospital Crosshouse, Kilmarnock; Department of Paediatrics (J. MacDonnell), Borders General Hospital, Melrose; Department of Paediatrics (J. McKnight), Dumfries and Galloway Royal Infirmary; Department of Paediatrics (L.N.), Royal Alexandra Hospital, Paisley; Paediatric Neurology (E.S.), Royal Aberdeen Children's Hospital; and Department of Paediatrics (A.W.), Raigmore Hospital, Inverness, UK
| | - Teresa C Moloney
- From the Paediatric Neurosciences Research Group (J.D.S., M.E.O., S.M., A.B., L.D., M.W., S.M.Z.), Royal Hospital for Children; College of Medical, Veterinary & Life Sciences (J.D.S., A.B., L.D., S.M.Z.), University of Glasgow; Nuffield Department of Clinical Neurosciences (T.C.M., B.L., A.V., S.T.), John Radcliffe Hospital, Oxford; Department of Paediatric Neurosciences (A.M., J.S.), Royal Hospital for Sick Children, Edinburgh; Paediatric Neurology (A.J., M.K., P.B., E.P.), Tayside Children's Hospital, Dundee; Neuroradiology (K.F.), Queen Elizabeth University Hospitals, Glasgow; Department of Paediatrics (I.A.-A., R.G.), Forth Valley Royal Hospital, Larbert; Department of Paediatrics (J.A., M.C.), University Hospital Wishaw; Department of Paediatrics (J.C.), Victoria Hospital, Kirkcaldy; Department of Paediatrics (C.F., C.A.M.), University Hospital Crosshouse, Kilmarnock; Department of Paediatrics (J. MacDonnell), Borders General Hospital, Melrose; Department of Paediatrics (J. McKnight), Dumfries and Galloway Royal Infirmary; Department of Paediatrics (L.N.), Royal Alexandra Hospital, Paisley; Paediatric Neurology (E.S.), Royal Aberdeen Children's Hospital; and Department of Paediatrics (A.W.), Raigmore Hospital, Inverness, UK
| | - Bethan Lang
- From the Paediatric Neurosciences Research Group (J.D.S., M.E.O., S.M., A.B., L.D., M.W., S.M.Z.), Royal Hospital for Children; College of Medical, Veterinary & Life Sciences (J.D.S., A.B., L.D., S.M.Z.), University of Glasgow; Nuffield Department of Clinical Neurosciences (T.C.M., B.L., A.V., S.T.), John Radcliffe Hospital, Oxford; Department of Paediatric Neurosciences (A.M., J.S.), Royal Hospital for Sick Children, Edinburgh; Paediatric Neurology (A.J., M.K., P.B., E.P.), Tayside Children's Hospital, Dundee; Neuroradiology (K.F.), Queen Elizabeth University Hospitals, Glasgow; Department of Paediatrics (I.A.-A., R.G.), Forth Valley Royal Hospital, Larbert; Department of Paediatrics (J.A., M.C.), University Hospital Wishaw; Department of Paediatrics (J.C.), Victoria Hospital, Kirkcaldy; Department of Paediatrics (C.F., C.A.M.), University Hospital Crosshouse, Kilmarnock; Department of Paediatrics (J. MacDonnell), Borders General Hospital, Melrose; Department of Paediatrics (J. McKnight), Dumfries and Galloway Royal Infirmary; Department of Paediatrics (L.N.), Royal Alexandra Hospital, Paisley; Paediatric Neurology (E.S.), Royal Aberdeen Children's Hospital; and Department of Paediatrics (A.W.), Raigmore Hospital, Inverness, UK
| | - Ailsa McLellan
- From the Paediatric Neurosciences Research Group (J.D.S., M.E.O., S.M., A.B., L.D., M.W., S.M.Z.), Royal Hospital for Children; College of Medical, Veterinary & Life Sciences (J.D.S., A.B., L.D., S.M.Z.), University of Glasgow; Nuffield Department of Clinical Neurosciences (T.C.M., B.L., A.V., S.T.), John Radcliffe Hospital, Oxford; Department of Paediatric Neurosciences (A.M., J.S.), Royal Hospital for Sick Children, Edinburgh; Paediatric Neurology (A.J., M.K., P.B., E.P.), Tayside Children's Hospital, Dundee; Neuroradiology (K.F.), Queen Elizabeth University Hospitals, Glasgow; Department of Paediatrics (I.A.-A., R.G.), Forth Valley Royal Hospital, Larbert; Department of Paediatrics (J.A., M.C.), University Hospital Wishaw; Department of Paediatrics (J.C.), Victoria Hospital, Kirkcaldy; Department of Paediatrics (C.F., C.A.M.), University Hospital Crosshouse, Kilmarnock; Department of Paediatrics (J. MacDonnell), Borders General Hospital, Melrose; Department of Paediatrics (J. McKnight), Dumfries and Galloway Royal Infirmary; Department of Paediatrics (L.N.), Royal Alexandra Hospital, Paisley; Paediatric Neurology (E.S.), Royal Aberdeen Children's Hospital; and Department of Paediatrics (A.W.), Raigmore Hospital, Inverness, UK
| | - Mary E O'Regan
- From the Paediatric Neurosciences Research Group (J.D.S., M.E.O., S.M., A.B., L.D., M.W., S.M.Z.), Royal Hospital for Children; College of Medical, Veterinary & Life Sciences (J.D.S., A.B., L.D., S.M.Z.), University of Glasgow; Nuffield Department of Clinical Neurosciences (T.C.M., B.L., A.V., S.T.), John Radcliffe Hospital, Oxford; Department of Paediatric Neurosciences (A.M., J.S.), Royal Hospital for Sick Children, Edinburgh; Paediatric Neurology (A.J., M.K., P.B., E.P.), Tayside Children's Hospital, Dundee; Neuroradiology (K.F.), Queen Elizabeth University Hospitals, Glasgow; Department of Paediatrics (I.A.-A., R.G.), Forth Valley Royal Hospital, Larbert; Department of Paediatrics (J.A., M.C.), University Hospital Wishaw; Department of Paediatrics (J.C.), Victoria Hospital, Kirkcaldy; Department of Paediatrics (C.F., C.A.M.), University Hospital Crosshouse, Kilmarnock; Department of Paediatrics (J. MacDonnell), Borders General Hospital, Melrose; Department of Paediatrics (J. McKnight), Dumfries and Galloway Royal Infirmary; Department of Paediatrics (L.N.), Royal Alexandra Hospital, Paisley; Paediatric Neurology (E.S.), Royal Aberdeen Children's Hospital; and Department of Paediatrics (A.W.), Raigmore Hospital, Inverness, UK
| | - Stewart MacLeod
- From the Paediatric Neurosciences Research Group (J.D.S., M.E.O., S.M., A.B., L.D., M.W., S.M.Z.), Royal Hospital for Children; College of Medical, Veterinary & Life Sciences (J.D.S., A.B., L.D., S.M.Z.), University of Glasgow; Nuffield Department of Clinical Neurosciences (T.C.M., B.L., A.V., S.T.), John Radcliffe Hospital, Oxford; Department of Paediatric Neurosciences (A.M., J.S.), Royal Hospital for Sick Children, Edinburgh; Paediatric Neurology (A.J., M.K., P.B., E.P.), Tayside Children's Hospital, Dundee; Neuroradiology (K.F.), Queen Elizabeth University Hospitals, Glasgow; Department of Paediatrics (I.A.-A., R.G.), Forth Valley Royal Hospital, Larbert; Department of Paediatrics (J.A., M.C.), University Hospital Wishaw; Department of Paediatrics (J.C.), Victoria Hospital, Kirkcaldy; Department of Paediatrics (C.F., C.A.M.), University Hospital Crosshouse, Kilmarnock; Department of Paediatrics (J. MacDonnell), Borders General Hospital, Melrose; Department of Paediatrics (J. McKnight), Dumfries and Galloway Royal Infirmary; Department of Paediatrics (L.N.), Royal Alexandra Hospital, Paisley; Paediatric Neurology (E.S.), Royal Aberdeen Children's Hospital; and Department of Paediatrics (A.W.), Raigmore Hospital, Inverness, UK
| | - Alice Jollands
- From the Paediatric Neurosciences Research Group (J.D.S., M.E.O., S.M., A.B., L.D., M.W., S.M.Z.), Royal Hospital for Children; College of Medical, Veterinary & Life Sciences (J.D.S., A.B., L.D., S.M.Z.), University of Glasgow; Nuffield Department of Clinical Neurosciences (T.C.M., B.L., A.V., S.T.), John Radcliffe Hospital, Oxford; Department of Paediatric Neurosciences (A.M., J.S.), Royal Hospital for Sick Children, Edinburgh; Paediatric Neurology (A.J., M.K., P.B., E.P.), Tayside Children's Hospital, Dundee; Neuroradiology (K.F.), Queen Elizabeth University Hospitals, Glasgow; Department of Paediatrics (I.A.-A., R.G.), Forth Valley Royal Hospital, Larbert; Department of Paediatrics (J.A., M.C.), University Hospital Wishaw; Department of Paediatrics (J.C.), Victoria Hospital, Kirkcaldy; Department of Paediatrics (C.F., C.A.M.), University Hospital Crosshouse, Kilmarnock; Department of Paediatrics (J. MacDonnell), Borders General Hospital, Melrose; Department of Paediatrics (J. McKnight), Dumfries and Galloway Royal Infirmary; Department of Paediatrics (L.N.), Royal Alexandra Hospital, Paisley; Paediatric Neurology (E.S.), Royal Aberdeen Children's Hospital; and Department of Paediatrics (A.W.), Raigmore Hospital, Inverness, UK
| | - Angela Vincent
- From the Paediatric Neurosciences Research Group (J.D.S., M.E.O., S.M., A.B., L.D., M.W., S.M.Z.), Royal Hospital for Children; College of Medical, Veterinary & Life Sciences (J.D.S., A.B., L.D., S.M.Z.), University of Glasgow; Nuffield Department of Clinical Neurosciences (T.C.M., B.L., A.V., S.T.), John Radcliffe Hospital, Oxford; Department of Paediatric Neurosciences (A.M., J.S.), Royal Hospital for Sick Children, Edinburgh; Paediatric Neurology (A.J., M.K., P.B., E.P.), Tayside Children's Hospital, Dundee; Neuroradiology (K.F.), Queen Elizabeth University Hospitals, Glasgow; Department of Paediatrics (I.A.-A., R.G.), Forth Valley Royal Hospital, Larbert; Department of Paediatrics (J.A., M.C.), University Hospital Wishaw; Department of Paediatrics (J.C.), Victoria Hospital, Kirkcaldy; Department of Paediatrics (C.F., C.A.M.), University Hospital Crosshouse, Kilmarnock; Department of Paediatrics (J. MacDonnell), Borders General Hospital, Melrose; Department of Paediatrics (J. McKnight), Dumfries and Galloway Royal Infirmary; Department of Paediatrics (L.N.), Royal Alexandra Hospital, Paisley; Paediatric Neurology (E.S.), Royal Aberdeen Children's Hospital; and Department of Paediatrics (A.W.), Raigmore Hospital, Inverness, UK
| | - Martin Kirkpatrick
- From the Paediatric Neurosciences Research Group (J.D.S., M.E.O., S.M., A.B., L.D., M.W., S.M.Z.), Royal Hospital for Children; College of Medical, Veterinary & Life Sciences (J.D.S., A.B., L.D., S.M.Z.), University of Glasgow; Nuffield Department of Clinical Neurosciences (T.C.M., B.L., A.V., S.T.), John Radcliffe Hospital, Oxford; Department of Paediatric Neurosciences (A.M., J.S.), Royal Hospital for Sick Children, Edinburgh; Paediatric Neurology (A.J., M.K., P.B., E.P.), Tayside Children's Hospital, Dundee; Neuroradiology (K.F.), Queen Elizabeth University Hospitals, Glasgow; Department of Paediatrics (I.A.-A., R.G.), Forth Valley Royal Hospital, Larbert; Department of Paediatrics (J.A., M.C.), University Hospital Wishaw; Department of Paediatrics (J.C.), Victoria Hospital, Kirkcaldy; Department of Paediatrics (C.F., C.A.M.), University Hospital Crosshouse, Kilmarnock; Department of Paediatrics (J. MacDonnell), Borders General Hospital, Melrose; Department of Paediatrics (J. McKnight), Dumfries and Galloway Royal Infirmary; Department of Paediatrics (L.N.), Royal Alexandra Hospital, Paisley; Paediatric Neurology (E.S.), Royal Aberdeen Children's Hospital; and Department of Paediatrics (A.W.), Raigmore Hospital, Inverness, UK
| | - Andreas Brunklaus
- From the Paediatric Neurosciences Research Group (J.D.S., M.E.O., S.M., A.B., L.D., M.W., S.M.Z.), Royal Hospital for Children; College of Medical, Veterinary & Life Sciences (J.D.S., A.B., L.D., S.M.Z.), University of Glasgow; Nuffield Department of Clinical Neurosciences (T.C.M., B.L., A.V., S.T.), John Radcliffe Hospital, Oxford; Department of Paediatric Neurosciences (A.M., J.S.), Royal Hospital for Sick Children, Edinburgh; Paediatric Neurology (A.J., M.K., P.B., E.P.), Tayside Children's Hospital, Dundee; Neuroradiology (K.F.), Queen Elizabeth University Hospitals, Glasgow; Department of Paediatrics (I.A.-A., R.G.), Forth Valley Royal Hospital, Larbert; Department of Paediatrics (J.A., M.C.), University Hospital Wishaw; Department of Paediatrics (J.C.), Victoria Hospital, Kirkcaldy; Department of Paediatrics (C.F., C.A.M.), University Hospital Crosshouse, Kilmarnock; Department of Paediatrics (J. MacDonnell), Borders General Hospital, Melrose; Department of Paediatrics (J. McKnight), Dumfries and Galloway Royal Infirmary; Department of Paediatrics (L.N.), Royal Alexandra Hospital, Paisley; Paediatric Neurology (E.S.), Royal Aberdeen Children's Hospital; and Department of Paediatrics (A.W.), Raigmore Hospital, Inverness, UK
| | - Jayakara Shetty
- From the Paediatric Neurosciences Research Group (J.D.S., M.E.O., S.M., A.B., L.D., M.W., S.M.Z.), Royal Hospital for Children; College of Medical, Veterinary & Life Sciences (J.D.S., A.B., L.D., S.M.Z.), University of Glasgow; Nuffield Department of Clinical Neurosciences (T.C.M., B.L., A.V., S.T.), John Radcliffe Hospital, Oxford; Department of Paediatric Neurosciences (A.M., J.S.), Royal Hospital for Sick Children, Edinburgh; Paediatric Neurology (A.J., M.K., P.B., E.P.), Tayside Children's Hospital, Dundee; Neuroradiology (K.F.), Queen Elizabeth University Hospitals, Glasgow; Department of Paediatrics (I.A.-A., R.G.), Forth Valley Royal Hospital, Larbert; Department of Paediatrics (J.A., M.C.), University Hospital Wishaw; Department of Paediatrics (J.C.), Victoria Hospital, Kirkcaldy; Department of Paediatrics (C.F., C.A.M.), University Hospital Crosshouse, Kilmarnock; Department of Paediatrics (J. MacDonnell), Borders General Hospital, Melrose; Department of Paediatrics (J. McKnight), Dumfries and Galloway Royal Infirmary; Department of Paediatrics (L.N.), Royal Alexandra Hospital, Paisley; Paediatric Neurology (E.S.), Royal Aberdeen Children's Hospital; and Department of Paediatrics (A.W.), Raigmore Hospital, Inverness, UK
| | - Liam Dorris
- From the Paediatric Neurosciences Research Group (J.D.S., M.E.O., S.M., A.B., L.D., M.W., S.M.Z.), Royal Hospital for Children; College of Medical, Veterinary & Life Sciences (J.D.S., A.B., L.D., S.M.Z.), University of Glasgow; Nuffield Department of Clinical Neurosciences (T.C.M., B.L., A.V., S.T.), John Radcliffe Hospital, Oxford; Department of Paediatric Neurosciences (A.M., J.S.), Royal Hospital for Sick Children, Edinburgh; Paediatric Neurology (A.J., M.K., P.B., E.P.), Tayside Children's Hospital, Dundee; Neuroradiology (K.F.), Queen Elizabeth University Hospitals, Glasgow; Department of Paediatrics (I.A.-A., R.G.), Forth Valley Royal Hospital, Larbert; Department of Paediatrics (J.A., M.C.), University Hospital Wishaw; Department of Paediatrics (J.C.), Victoria Hospital, Kirkcaldy; Department of Paediatrics (C.F., C.A.M.), University Hospital Crosshouse, Kilmarnock; Department of Paediatrics (J. MacDonnell), Borders General Hospital, Melrose; Department of Paediatrics (J. McKnight), Dumfries and Galloway Royal Infirmary; Department of Paediatrics (L.N.), Royal Alexandra Hospital, Paisley; Paediatric Neurology (E.S.), Royal Aberdeen Children's Hospital; and Department of Paediatrics (A.W.), Raigmore Hospital, Inverness, UK
| | - Kirsten Forbes
- From the Paediatric Neurosciences Research Group (J.D.S., M.E.O., S.M., A.B., L.D., M.W., S.M.Z.), Royal Hospital for Children; College of Medical, Veterinary & Life Sciences (J.D.S., A.B., L.D., S.M.Z.), University of Glasgow; Nuffield Department of Clinical Neurosciences (T.C.M., B.L., A.V., S.T.), John Radcliffe Hospital, Oxford; Department of Paediatric Neurosciences (A.M., J.S.), Royal Hospital for Sick Children, Edinburgh; Paediatric Neurology (A.J., M.K., P.B., E.P.), Tayside Children's Hospital, Dundee; Neuroradiology (K.F.), Queen Elizabeth University Hospitals, Glasgow; Department of Paediatrics (I.A.-A., R.G.), Forth Valley Royal Hospital, Larbert; Department of Paediatrics (J.A., M.C.), University Hospital Wishaw; Department of Paediatrics (J.C.), Victoria Hospital, Kirkcaldy; Department of Paediatrics (C.F., C.A.M.), University Hospital Crosshouse, Kilmarnock; Department of Paediatrics (J. MacDonnell), Borders General Hospital, Melrose; Department of Paediatrics (J. McKnight), Dumfries and Galloway Royal Infirmary; Department of Paediatrics (L.N.), Royal Alexandra Hospital, Paisley; Paediatric Neurology (E.S.), Royal Aberdeen Children's Hospital; and Department of Paediatrics (A.W.), Raigmore Hospital, Inverness, UK
| | - Ishaq Abu-Arafeh
- From the Paediatric Neurosciences Research Group (J.D.S., M.E.O., S.M., A.B., L.D., M.W., S.M.Z.), Royal Hospital for Children; College of Medical, Veterinary & Life Sciences (J.D.S., A.B., L.D., S.M.Z.), University of Glasgow; Nuffield Department of Clinical Neurosciences (T.C.M., B.L., A.V., S.T.), John Radcliffe Hospital, Oxford; Department of Paediatric Neurosciences (A.M., J.S.), Royal Hospital for Sick Children, Edinburgh; Paediatric Neurology (A.J., M.K., P.B., E.P.), Tayside Children's Hospital, Dundee; Neuroradiology (K.F.), Queen Elizabeth University Hospitals, Glasgow; Department of Paediatrics (I.A.-A., R.G.), Forth Valley Royal Hospital, Larbert; Department of Paediatrics (J.A., M.C.), University Hospital Wishaw; Department of Paediatrics (J.C.), Victoria Hospital, Kirkcaldy; Department of Paediatrics (C.F., C.A.M.), University Hospital Crosshouse, Kilmarnock; Department of Paediatrics (J. MacDonnell), Borders General Hospital, Melrose; Department of Paediatrics (J. McKnight), Dumfries and Galloway Royal Infirmary; Department of Paediatrics (L.N.), Royal Alexandra Hospital, Paisley; Paediatric Neurology (E.S.), Royal Aberdeen Children's Hospital; and Department of Paediatrics (A.W.), Raigmore Hospital, Inverness, UK
| | - Jamie Andrew
- From the Paediatric Neurosciences Research Group (J.D.S., M.E.O., S.M., A.B., L.D., M.W., S.M.Z.), Royal Hospital for Children; College of Medical, Veterinary & Life Sciences (J.D.S., A.B., L.D., S.M.Z.), University of Glasgow; Nuffield Department of Clinical Neurosciences (T.C.M., B.L., A.V., S.T.), John Radcliffe Hospital, Oxford; Department of Paediatric Neurosciences (A.M., J.S.), Royal Hospital for Sick Children, Edinburgh; Paediatric Neurology (A.J., M.K., P.B., E.P.), Tayside Children's Hospital, Dundee; Neuroradiology (K.F.), Queen Elizabeth University Hospitals, Glasgow; Department of Paediatrics (I.A.-A., R.G.), Forth Valley Royal Hospital, Larbert; Department of Paediatrics (J.A., M.C.), University Hospital Wishaw; Department of Paediatrics (J.C.), Victoria Hospital, Kirkcaldy; Department of Paediatrics (C.F., C.A.M.), University Hospital Crosshouse, Kilmarnock; Department of Paediatrics (J. MacDonnell), Borders General Hospital, Melrose; Department of Paediatrics (J. McKnight), Dumfries and Galloway Royal Infirmary; Department of Paediatrics (L.N.), Royal Alexandra Hospital, Paisley; Paediatric Neurology (E.S.), Royal Aberdeen Children's Hospital; and Department of Paediatrics (A.W.), Raigmore Hospital, Inverness, UK
| | - Philip Brink
- From the Paediatric Neurosciences Research Group (J.D.S., M.E.O., S.M., A.B., L.D., M.W., S.M.Z.), Royal Hospital for Children; College of Medical, Veterinary & Life Sciences (J.D.S., A.B., L.D., S.M.Z.), University of Glasgow; Nuffield Department of Clinical Neurosciences (T.C.M., B.L., A.V., S.T.), John Radcliffe Hospital, Oxford; Department of Paediatric Neurosciences (A.M., J.S.), Royal Hospital for Sick Children, Edinburgh; Paediatric Neurology (A.J., M.K., P.B., E.P.), Tayside Children's Hospital, Dundee; Neuroradiology (K.F.), Queen Elizabeth University Hospitals, Glasgow; Department of Paediatrics (I.A.-A., R.G.), Forth Valley Royal Hospital, Larbert; Department of Paediatrics (J.A., M.C.), University Hospital Wishaw; Department of Paediatrics (J.C.), Victoria Hospital, Kirkcaldy; Department of Paediatrics (C.F., C.A.M.), University Hospital Crosshouse, Kilmarnock; Department of Paediatrics (J. MacDonnell), Borders General Hospital, Melrose; Department of Paediatrics (J. McKnight), Dumfries and Galloway Royal Infirmary; Department of Paediatrics (L.N.), Royal Alexandra Hospital, Paisley; Paediatric Neurology (E.S.), Royal Aberdeen Children's Hospital; and Department of Paediatrics (A.W.), Raigmore Hospital, Inverness, UK
| | - Mary Callaghan
- From the Paediatric Neurosciences Research Group (J.D.S., M.E.O., S.M., A.B., L.D., M.W., S.M.Z.), Royal Hospital for Children; College of Medical, Veterinary & Life Sciences (J.D.S., A.B., L.D., S.M.Z.), University of Glasgow; Nuffield Department of Clinical Neurosciences (T.C.M., B.L., A.V., S.T.), John Radcliffe Hospital, Oxford; Department of Paediatric Neurosciences (A.M., J.S.), Royal Hospital for Sick Children, Edinburgh; Paediatric Neurology (A.J., M.K., P.B., E.P.), Tayside Children's Hospital, Dundee; Neuroradiology (K.F.), Queen Elizabeth University Hospitals, Glasgow; Department of Paediatrics (I.A.-A., R.G.), Forth Valley Royal Hospital, Larbert; Department of Paediatrics (J.A., M.C.), University Hospital Wishaw; Department of Paediatrics (J.C.), Victoria Hospital, Kirkcaldy; Department of Paediatrics (C.F., C.A.M.), University Hospital Crosshouse, Kilmarnock; Department of Paediatrics (J. MacDonnell), Borders General Hospital, Melrose; Department of Paediatrics (J. McKnight), Dumfries and Galloway Royal Infirmary; Department of Paediatrics (L.N.), Royal Alexandra Hospital, Paisley; Paediatric Neurology (E.S.), Royal Aberdeen Children's Hospital; and Department of Paediatrics (A.W.), Raigmore Hospital, Inverness, UK
| | - Jamie Cruden
- From the Paediatric Neurosciences Research Group (J.D.S., M.E.O., S.M., A.B., L.D., M.W., S.M.Z.), Royal Hospital for Children; College of Medical, Veterinary & Life Sciences (J.D.S., A.B., L.D., S.M.Z.), University of Glasgow; Nuffield Department of Clinical Neurosciences (T.C.M., B.L., A.V., S.T.), John Radcliffe Hospital, Oxford; Department of Paediatric Neurosciences (A.M., J.S.), Royal Hospital for Sick Children, Edinburgh; Paediatric Neurology (A.J., M.K., P.B., E.P.), Tayside Children's Hospital, Dundee; Neuroradiology (K.F.), Queen Elizabeth University Hospitals, Glasgow; Department of Paediatrics (I.A.-A., R.G.), Forth Valley Royal Hospital, Larbert; Department of Paediatrics (J.A., M.C.), University Hospital Wishaw; Department of Paediatrics (J.C.), Victoria Hospital, Kirkcaldy; Department of Paediatrics (C.F., C.A.M.), University Hospital Crosshouse, Kilmarnock; Department of Paediatrics (J. MacDonnell), Borders General Hospital, Melrose; Department of Paediatrics (J. McKnight), Dumfries and Galloway Royal Infirmary; Department of Paediatrics (L.N.), Royal Alexandra Hospital, Paisley; Paediatric Neurology (E.S.), Royal Aberdeen Children's Hospital; and Department of Paediatrics (A.W.), Raigmore Hospital, Inverness, UK
| | - Christine Findlay
- From the Paediatric Neurosciences Research Group (J.D.S., M.E.O., S.M., A.B., L.D., M.W., S.M.Z.), Royal Hospital for Children; College of Medical, Veterinary & Life Sciences (J.D.S., A.B., L.D., S.M.Z.), University of Glasgow; Nuffield Department of Clinical Neurosciences (T.C.M., B.L., A.V., S.T.), John Radcliffe Hospital, Oxford; Department of Paediatric Neurosciences (A.M., J.S.), Royal Hospital for Sick Children, Edinburgh; Paediatric Neurology (A.J., M.K., P.B., E.P.), Tayside Children's Hospital, Dundee; Neuroradiology (K.F.), Queen Elizabeth University Hospitals, Glasgow; Department of Paediatrics (I.A.-A., R.G.), Forth Valley Royal Hospital, Larbert; Department of Paediatrics (J.A., M.C.), University Hospital Wishaw; Department of Paediatrics (J.C.), Victoria Hospital, Kirkcaldy; Department of Paediatrics (C.F., C.A.M.), University Hospital Crosshouse, Kilmarnock; Department of Paediatrics (J. MacDonnell), Borders General Hospital, Melrose; Department of Paediatrics (J. McKnight), Dumfries and Galloway Royal Infirmary; Department of Paediatrics (L.N.), Royal Alexandra Hospital, Paisley; Paediatric Neurology (E.S.), Royal Aberdeen Children's Hospital; and Department of Paediatrics (A.W.), Raigmore Hospital, Inverness, UK
| | - Rosemary Grattan
- From the Paediatric Neurosciences Research Group (J.D.S., M.E.O., S.M., A.B., L.D., M.W., S.M.Z.), Royal Hospital for Children; College of Medical, Veterinary & Life Sciences (J.D.S., A.B., L.D., S.M.Z.), University of Glasgow; Nuffield Department of Clinical Neurosciences (T.C.M., B.L., A.V., S.T.), John Radcliffe Hospital, Oxford; Department of Paediatric Neurosciences (A.M., J.S.), Royal Hospital for Sick Children, Edinburgh; Paediatric Neurology (A.J., M.K., P.B., E.P.), Tayside Children's Hospital, Dundee; Neuroradiology (K.F.), Queen Elizabeth University Hospitals, Glasgow; Department of Paediatrics (I.A.-A., R.G.), Forth Valley Royal Hospital, Larbert; Department of Paediatrics (J.A., M.C.), University Hospital Wishaw; Department of Paediatrics (J.C.), Victoria Hospital, Kirkcaldy; Department of Paediatrics (C.F., C.A.M.), University Hospital Crosshouse, Kilmarnock; Department of Paediatrics (J. MacDonnell), Borders General Hospital, Melrose; Department of Paediatrics (J. McKnight), Dumfries and Galloway Royal Infirmary; Department of Paediatrics (L.N.), Royal Alexandra Hospital, Paisley; Paediatric Neurology (E.S.), Royal Aberdeen Children's Hospital; and Department of Paediatrics (A.W.), Raigmore Hospital, Inverness, UK
| | - Jane MacDonnell
- From the Paediatric Neurosciences Research Group (J.D.S., M.E.O., S.M., A.B., L.D., M.W., S.M.Z.), Royal Hospital for Children; College of Medical, Veterinary & Life Sciences (J.D.S., A.B., L.D., S.M.Z.), University of Glasgow; Nuffield Department of Clinical Neurosciences (T.C.M., B.L., A.V., S.T.), John Radcliffe Hospital, Oxford; Department of Paediatric Neurosciences (A.M., J.S.), Royal Hospital for Sick Children, Edinburgh; Paediatric Neurology (A.J., M.K., P.B., E.P.), Tayside Children's Hospital, Dundee; Neuroradiology (K.F.), Queen Elizabeth University Hospitals, Glasgow; Department of Paediatrics (I.A.-A., R.G.), Forth Valley Royal Hospital, Larbert; Department of Paediatrics (J.A., M.C.), University Hospital Wishaw; Department of Paediatrics (J.C.), Victoria Hospital, Kirkcaldy; Department of Paediatrics (C.F., C.A.M.), University Hospital Crosshouse, Kilmarnock; Department of Paediatrics (J. MacDonnell), Borders General Hospital, Melrose; Department of Paediatrics (J. McKnight), Dumfries and Galloway Royal Infirmary; Department of Paediatrics (L.N.), Royal Alexandra Hospital, Paisley; Paediatric Neurology (E.S.), Royal Aberdeen Children's Hospital; and Department of Paediatrics (A.W.), Raigmore Hospital, Inverness, UK
| | - Jean McKnight
- From the Paediatric Neurosciences Research Group (J.D.S., M.E.O., S.M., A.B., L.D., M.W., S.M.Z.), Royal Hospital for Children; College of Medical, Veterinary & Life Sciences (J.D.S., A.B., L.D., S.M.Z.), University of Glasgow; Nuffield Department of Clinical Neurosciences (T.C.M., B.L., A.V., S.T.), John Radcliffe Hospital, Oxford; Department of Paediatric Neurosciences (A.M., J.S.), Royal Hospital for Sick Children, Edinburgh; Paediatric Neurology (A.J., M.K., P.B., E.P.), Tayside Children's Hospital, Dundee; Neuroradiology (K.F.), Queen Elizabeth University Hospitals, Glasgow; Department of Paediatrics (I.A.-A., R.G.), Forth Valley Royal Hospital, Larbert; Department of Paediatrics (J.A., M.C.), University Hospital Wishaw; Department of Paediatrics (J.C.), Victoria Hospital, Kirkcaldy; Department of Paediatrics (C.F., C.A.M.), University Hospital Crosshouse, Kilmarnock; Department of Paediatrics (J. MacDonnell), Borders General Hospital, Melrose; Department of Paediatrics (J. McKnight), Dumfries and Galloway Royal Infirmary; Department of Paediatrics (L.N.), Royal Alexandra Hospital, Paisley; Paediatric Neurology (E.S.), Royal Aberdeen Children's Hospital; and Department of Paediatrics (A.W.), Raigmore Hospital, Inverness, UK
| | - Calum A Morrison
- From the Paediatric Neurosciences Research Group (J.D.S., M.E.O., S.M., A.B., L.D., M.W., S.M.Z.), Royal Hospital for Children; College of Medical, Veterinary & Life Sciences (J.D.S., A.B., L.D., S.M.Z.), University of Glasgow; Nuffield Department of Clinical Neurosciences (T.C.M., B.L., A.V., S.T.), John Radcliffe Hospital, Oxford; Department of Paediatric Neurosciences (A.M., J.S.), Royal Hospital for Sick Children, Edinburgh; Paediatric Neurology (A.J., M.K., P.B., E.P.), Tayside Children's Hospital, Dundee; Neuroradiology (K.F.), Queen Elizabeth University Hospitals, Glasgow; Department of Paediatrics (I.A.-A., R.G.), Forth Valley Royal Hospital, Larbert; Department of Paediatrics (J.A., M.C.), University Hospital Wishaw; Department of Paediatrics (J.C.), Victoria Hospital, Kirkcaldy; Department of Paediatrics (C.F., C.A.M.), University Hospital Crosshouse, Kilmarnock; Department of Paediatrics (J. MacDonnell), Borders General Hospital, Melrose; Department of Paediatrics (J. McKnight), Dumfries and Galloway Royal Infirmary; Department of Paediatrics (L.N.), Royal Alexandra Hospital, Paisley; Paediatric Neurology (E.S.), Royal Aberdeen Children's Hospital; and Department of Paediatrics (A.W.), Raigmore Hospital, Inverness, UK
| | - Lesley Nairn
- From the Paediatric Neurosciences Research Group (J.D.S., M.E.O., S.M., A.B., L.D., M.W., S.M.Z.), Royal Hospital for Children; College of Medical, Veterinary & Life Sciences (J.D.S., A.B., L.D., S.M.Z.), University of Glasgow; Nuffield Department of Clinical Neurosciences (T.C.M., B.L., A.V., S.T.), John Radcliffe Hospital, Oxford; Department of Paediatric Neurosciences (A.M., J.S.), Royal Hospital for Sick Children, Edinburgh; Paediatric Neurology (A.J., M.K., P.B., E.P.), Tayside Children's Hospital, Dundee; Neuroradiology (K.F.), Queen Elizabeth University Hospitals, Glasgow; Department of Paediatrics (I.A.-A., R.G.), Forth Valley Royal Hospital, Larbert; Department of Paediatrics (J.A., M.C.), University Hospital Wishaw; Department of Paediatrics (J.C.), Victoria Hospital, Kirkcaldy; Department of Paediatrics (C.F., C.A.M.), University Hospital Crosshouse, Kilmarnock; Department of Paediatrics (J. MacDonnell), Borders General Hospital, Melrose; Department of Paediatrics (J. McKnight), Dumfries and Galloway Royal Infirmary; Department of Paediatrics (L.N.), Royal Alexandra Hospital, Paisley; Paediatric Neurology (E.S.), Royal Aberdeen Children's Hospital; and Department of Paediatrics (A.W.), Raigmore Hospital, Inverness, UK
| | - Elizabeth Pilley
- From the Paediatric Neurosciences Research Group (J.D.S., M.E.O., S.M., A.B., L.D., M.W., S.M.Z.), Royal Hospital for Children; College of Medical, Veterinary & Life Sciences (J.D.S., A.B., L.D., S.M.Z.), University of Glasgow; Nuffield Department of Clinical Neurosciences (T.C.M., B.L., A.V., S.T.), John Radcliffe Hospital, Oxford; Department of Paediatric Neurosciences (A.M., J.S.), Royal Hospital for Sick Children, Edinburgh; Paediatric Neurology (A.J., M.K., P.B., E.P.), Tayside Children's Hospital, Dundee; Neuroradiology (K.F.), Queen Elizabeth University Hospitals, Glasgow; Department of Paediatrics (I.A.-A., R.G.), Forth Valley Royal Hospital, Larbert; Department of Paediatrics (J.A., M.C.), University Hospital Wishaw; Department of Paediatrics (J.C.), Victoria Hospital, Kirkcaldy; Department of Paediatrics (C.F., C.A.M.), University Hospital Crosshouse, Kilmarnock; Department of Paediatrics (J. MacDonnell), Borders General Hospital, Melrose; Department of Paediatrics (J. McKnight), Dumfries and Galloway Royal Infirmary; Department of Paediatrics (L.N.), Royal Alexandra Hospital, Paisley; Paediatric Neurology (E.S.), Royal Aberdeen Children's Hospital; and Department of Paediatrics (A.W.), Raigmore Hospital, Inverness, UK
| | - Elma Stephen
- From the Paediatric Neurosciences Research Group (J.D.S., M.E.O., S.M., A.B., L.D., M.W., S.M.Z.), Royal Hospital for Children; College of Medical, Veterinary & Life Sciences (J.D.S., A.B., L.D., S.M.Z.), University of Glasgow; Nuffield Department of Clinical Neurosciences (T.C.M., B.L., A.V., S.T.), John Radcliffe Hospital, Oxford; Department of Paediatric Neurosciences (A.M., J.S.), Royal Hospital for Sick Children, Edinburgh; Paediatric Neurology (A.J., M.K., P.B., E.P.), Tayside Children's Hospital, Dundee; Neuroradiology (K.F.), Queen Elizabeth University Hospitals, Glasgow; Department of Paediatrics (I.A.-A., R.G.), Forth Valley Royal Hospital, Larbert; Department of Paediatrics (J.A., M.C.), University Hospital Wishaw; Department of Paediatrics (J.C.), Victoria Hospital, Kirkcaldy; Department of Paediatrics (C.F., C.A.M.), University Hospital Crosshouse, Kilmarnock; Department of Paediatrics (J. MacDonnell), Borders General Hospital, Melrose; Department of Paediatrics (J. McKnight), Dumfries and Galloway Royal Infirmary; Department of Paediatrics (L.N.), Royal Alexandra Hospital, Paisley; Paediatric Neurology (E.S.), Royal Aberdeen Children's Hospital; and Department of Paediatrics (A.W.), Raigmore Hospital, Inverness, UK
| | - Selina Thomsen
- From the Paediatric Neurosciences Research Group (J.D.S., M.E.O., S.M., A.B., L.D., M.W., S.M.Z.), Royal Hospital for Children; College of Medical, Veterinary & Life Sciences (J.D.S., A.B., L.D., S.M.Z.), University of Glasgow; Nuffield Department of Clinical Neurosciences (T.C.M., B.L., A.V., S.T.), John Radcliffe Hospital, Oxford; Department of Paediatric Neurosciences (A.M., J.S.), Royal Hospital for Sick Children, Edinburgh; Paediatric Neurology (A.J., M.K., P.B., E.P.), Tayside Children's Hospital, Dundee; Neuroradiology (K.F.), Queen Elizabeth University Hospitals, Glasgow; Department of Paediatrics (I.A.-A., R.G.), Forth Valley Royal Hospital, Larbert; Department of Paediatrics (J.A., M.C.), University Hospital Wishaw; Department of Paediatrics (J.C.), Victoria Hospital, Kirkcaldy; Department of Paediatrics (C.F., C.A.M.), University Hospital Crosshouse, Kilmarnock; Department of Paediatrics (J. MacDonnell), Borders General Hospital, Melrose; Department of Paediatrics (J. McKnight), Dumfries and Galloway Royal Infirmary; Department of Paediatrics (L.N.), Royal Alexandra Hospital, Paisley; Paediatric Neurology (E.S.), Royal Aberdeen Children's Hospital; and Department of Paediatrics (A.W.), Raigmore Hospital, Inverness, UK
| | - Alan Webb
- From the Paediatric Neurosciences Research Group (J.D.S., M.E.O., S.M., A.B., L.D., M.W., S.M.Z.), Royal Hospital for Children; College of Medical, Veterinary & Life Sciences (J.D.S., A.B., L.D., S.M.Z.), University of Glasgow; Nuffield Department of Clinical Neurosciences (T.C.M., B.L., A.V., S.T.), John Radcliffe Hospital, Oxford; Department of Paediatric Neurosciences (A.M., J.S.), Royal Hospital for Sick Children, Edinburgh; Paediatric Neurology (A.J., M.K., P.B., E.P.), Tayside Children's Hospital, Dundee; Neuroradiology (K.F.), Queen Elizabeth University Hospitals, Glasgow; Department of Paediatrics (I.A.-A., R.G.), Forth Valley Royal Hospital, Larbert; Department of Paediatrics (J.A., M.C.), University Hospital Wishaw; Department of Paediatrics (J.C.), Victoria Hospital, Kirkcaldy; Department of Paediatrics (C.F., C.A.M.), University Hospital Crosshouse, Kilmarnock; Department of Paediatrics (J. MacDonnell), Borders General Hospital, Melrose; Department of Paediatrics (J. McKnight), Dumfries and Galloway Royal Infirmary; Department of Paediatrics (L.N.), Royal Alexandra Hospital, Paisley; Paediatric Neurology (E.S.), Royal Aberdeen Children's Hospital; and Department of Paediatrics (A.W.), Raigmore Hospital, Inverness, UK
| | - Margaret Wilson
- From the Paediatric Neurosciences Research Group (J.D.S., M.E.O., S.M., A.B., L.D., M.W., S.M.Z.), Royal Hospital for Children; College of Medical, Veterinary & Life Sciences (J.D.S., A.B., L.D., S.M.Z.), University of Glasgow; Nuffield Department of Clinical Neurosciences (T.C.M., B.L., A.V., S.T.), John Radcliffe Hospital, Oxford; Department of Paediatric Neurosciences (A.M., J.S.), Royal Hospital for Sick Children, Edinburgh; Paediatric Neurology (A.J., M.K., P.B., E.P.), Tayside Children's Hospital, Dundee; Neuroradiology (K.F.), Queen Elizabeth University Hospitals, Glasgow; Department of Paediatrics (I.A.-A., R.G.), Forth Valley Royal Hospital, Larbert; Department of Paediatrics (J.A., M.C.), University Hospital Wishaw; Department of Paediatrics (J.C.), Victoria Hospital, Kirkcaldy; Department of Paediatrics (C.F., C.A.M.), University Hospital Crosshouse, Kilmarnock; Department of Paediatrics (J. MacDonnell), Borders General Hospital, Melrose; Department of Paediatrics (J. McKnight), Dumfries and Galloway Royal Infirmary; Department of Paediatrics (L.N.), Royal Alexandra Hospital, Paisley; Paediatric Neurology (E.S.), Royal Aberdeen Children's Hospital; and Department of Paediatrics (A.W.), Raigmore Hospital, Inverness, UK
| | - Sameer M Zuberi
- From the Paediatric Neurosciences Research Group (J.D.S., M.E.O., S.M., A.B., L.D., M.W., S.M.Z.), Royal Hospital for Children; College of Medical, Veterinary & Life Sciences (J.D.S., A.B., L.D., S.M.Z.), University of Glasgow; Nuffield Department of Clinical Neurosciences (T.C.M., B.L., A.V., S.T.), John Radcliffe Hospital, Oxford; Department of Paediatric Neurosciences (A.M., J.S.), Royal Hospital for Sick Children, Edinburgh; Paediatric Neurology (A.J., M.K., P.B., E.P.), Tayside Children's Hospital, Dundee; Neuroradiology (K.F.), Queen Elizabeth University Hospitals, Glasgow; Department of Paediatrics (I.A.-A., R.G.), Forth Valley Royal Hospital, Larbert; Department of Paediatrics (J.A., M.C.), University Hospital Wishaw; Department of Paediatrics (J.C.), Victoria Hospital, Kirkcaldy; Department of Paediatrics (C.F., C.A.M.), University Hospital Crosshouse, Kilmarnock; Department of Paediatrics (J. MacDonnell), Borders General Hospital, Melrose; Department of Paediatrics (J. McKnight), Dumfries and Galloway Royal Infirmary; Department of Paediatrics (L.N.), Royal Alexandra Hospital, Paisley; Paediatric Neurology (E.S.), Royal Aberdeen Children's Hospital; and Department of Paediatrics (A.W.), Raigmore Hospital, Inverness, UK.
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35
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Symonds JD, Zuberi SM, Stewart K, McLellan A, O'Regan M, MacLeod S, Jollands A, Joss S, Kirkpatrick M, Brunklaus A, Pilz DT, Shetty J, Dorris L, Abu-Arafeh I, Andrew J, Brink P, Callaghan M, Cruden J, Diver LA, Findlay C, Gardiner S, Grattan R, Lang B, MacDonnell J, McKnight J, Morrison CA, Nairn L, Slean MM, Stephen E, Webb A, Vincent A, Wilson M. Incidence and phenotypes of childhood-onset genetic epilepsies: a prospective population-based national cohort. Brain 2020; 142:2303-2318. [PMID: 31302675 PMCID: PMC6658850 DOI: 10.1093/brain/awz195] [Citation(s) in RCA: 211] [Impact Index Per Article: 52.8] [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: 09/15/2018] [Revised: 04/19/2019] [Accepted: 05/06/2019] [Indexed: 01/24/2023] Open
Abstract
Epilepsy is common in early childhood. In this age group it is associated with high rates of therapy-resistance, and with cognitive, motor, and behavioural comorbidity. A large number of genes, with wide ranging functions, are implicated in its aetiology, especially in those with therapy-resistant seizures. Identifying the more common single-gene epilepsies will aid in targeting resources, the prioritization of diagnostic testing and development of precision therapy. Previous studies of genetic testing in epilepsy have not been prospective and population-based. Therefore, the population-incidence of common genetic epilepsies remains unknown. The objective of this study was to describe the incidence and phenotypic spectrum of the most common single-gene epilepsies in young children, and to calculate what proportion are amenable to precision therapy. This was a prospective national epidemiological cohort study. All children presenting with epilepsy before 36 months of age were eligible. Children presenting with recurrent prolonged (>10 min) febrile seizures; febrile or afebrile status epilepticus (>30 min); or with clusters of two or more febrile or afebrile seizures within a 24-h period were also eligible. Participants were recruited from all 20 regional paediatric departments and four tertiary children’s hospitals in Scotland over a 3-year period. DNA samples were tested on a custom-designed 104-gene epilepsy panel. Detailed clinical information was systematically gathered at initial presentation and during follow-up. Clinical and genetic data were reviewed by a multidisciplinary team of clinicians and genetic scientists. The pathogenic significance of the genetic variants was assessed in accordance with the guidelines of UK Association of Clinical Genetic Science (ACGS). Of the 343 patients who met inclusion criteria, 333 completed genetic testing, and 80/333 (24%) had a diagnostic genetic finding. The overall estimated annual incidence of single-gene epilepsies in this well-defined population was 1 per 2120 live births (47.2/100 000; 95% confidence interval 36.9–57.5). PRRT2 was the most common single-gene epilepsy with an incidence of 1 per 9970 live births (10.0/100 000; 95% confidence interval 5.26–14.8) followed by SCN1A: 1 per 12 200 (8.26/100 000; 95% confidence interval 3.93–12.6); KCNQ2: 1 per 17 000 (5.89/100 000; 95% confidence interval 2.24–9.56) and SLC2A1: 1 per 24 300 (4.13/100 000; 95% confidence interval 1.07–7.19). Presentation before the age of 6 months, and presentation with afebrile focal seizures were significantly associated with genetic diagnosis. Single-gene disorders accounted for a quarter of the seizure disorders in this cohort. Genetic testing is recommended to identify children who may benefit from precision treatment and should be mainstream practice in early childhood onset epilepsy.
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Affiliation(s)
- Joseph D Symonds
- Paediatric Neurosciences Research Group, Royal Hospital for Children, Glasgow, UK.,College of Medical, Veterinary and Life Sciences, University of Glasgow, UK
| | - Sameer M Zuberi
- Paediatric Neurosciences Research Group, Royal Hospital for Children, Glasgow, UK.,College of Medical, Veterinary and Life Sciences, University of Glasgow, UK
| | - Kirsty Stewart
- West of Scotland Regional Genetics Service, Queen Elizabeth University Hospitals, Glasgow, UK
| | - Ailsa McLellan
- Department of Paediatric Neurosciences, Royal Hospital for Sick Children, Sciennes Road, Edinburgh, UK
| | - Mary O'Regan
- Paediatric Neurosciences Research Group, Royal Hospital for Children, Glasgow, UK
| | - Stewart MacLeod
- Paediatric Neurosciences Research Group, Royal Hospital for Children, Glasgow, UK
| | - Alice Jollands
- Paediatric Neurology, Tayside Children's Hospital, Dundee, UK
| | - Shelagh Joss
- West of Scotland Regional Genetics Service, Queen Elizabeth University Hospitals, Glasgow, UK
| | | | - Andreas Brunklaus
- Paediatric Neurosciences Research Group, Royal Hospital for Children, Glasgow, UK.,College of Medical, Veterinary and Life Sciences, University of Glasgow, UK
| | - Daniela T Pilz
- West of Scotland Regional Genetics Service, Queen Elizabeth University Hospitals, Glasgow, UK
| | - Jay Shetty
- Department of Paediatric Neurosciences, Royal Hospital for Sick Children, Sciennes Road, Edinburgh, UK
| | - Liam Dorris
- Paediatric Neurosciences Research Group, Royal Hospital for Children, Glasgow, UK.,College of Medical, Veterinary and Life Sciences, University of Glasgow, UK
| | - Ishaq Abu-Arafeh
- Department of Paediatrics, Forth Valley Royal Hospital, Larbert, UK
| | - Jamie Andrew
- Department of Paediatrics, University Hospital Wishaw, Netherton Street, Wishaw, UK
| | - Philip Brink
- Paediatric Neurology, Tayside Children's Hospital, Dundee, UK
| | - Mary Callaghan
- Department of Paediatrics, University Hospital Wishaw, Netherton Street, Wishaw, UK
| | - Jamie Cruden
- Department of Paediatrics, Victoria Hospital, Kirkcaldy, UK
| | - Louise A Diver
- West of Scotland Regional Genetics Service, Queen Elizabeth University Hospitals, Glasgow, UK
| | - Christine Findlay
- Department of Paediatrics, University Hospital Crosshouse, Kilmarnock, UK
| | - Sarah Gardiner
- West of Scotland Regional Genetics Service, Queen Elizabeth University Hospitals, Glasgow, UK
| | - Rosemary Grattan
- Department of Paediatrics, Forth Valley Royal Hospital, Larbert, UK
| | - Bethan Lang
- Nuffield Department of Clinical Neurosciences, Level 6, West Wing, John Radcliffe Hospital, Oxford, UK
| | - Jane MacDonnell
- Department of Paediatrics, Borders General Hospital, Melrose, UK
| | - Jean McKnight
- Department of Paediatrics, Dumfries and Galloway Royal Infirmary, Dumfries, UK
| | - Calum A Morrison
- Department of Paediatrics, University Hospital Crosshouse, Kilmarnock, UK
| | - Lesley Nairn
- Department of Paediatrics, Royal Alexandra Hospital, Paisley, UK
| | - Meghan M Slean
- College of Medical, Veterinary and Life Sciences, University of Glasgow, UK
| | - Elma Stephen
- Department of Paediatrics, Royal Aberdeen Children's Hospital, Aberdeen, UK
| | - Alan Webb
- Department of Paediatrics, Raigmore Hospital, Inverness, UK
| | - Angela Vincent
- Nuffield Department of Clinical Neurosciences, Level 6, West Wing, John Radcliffe Hospital, Oxford, UK
| | - Margaret Wilson
- Paediatric Neurosciences Research Group, Royal Hospital for Children, Glasgow, UK
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36
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Wolff M, Brunklaus A, Zuberi SM. Phenotypic spectrum and genetics of SCN2A-related disorders, treatment options, and outcomes in epilepsy and beyond. Epilepsia 2020; 60 Suppl 3:S59-S67. [PMID: 31904126 DOI: 10.1111/epi.14935] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [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: 02/22/2019] [Revised: 04/12/2019] [Accepted: 04/12/2019] [Indexed: 12/25/2022]
Abstract
Pathogenic variants in the SCN2A gene are associated with a variety of neurodevelopmental phenotypes, defined in recent years through multicenter collaboration. Phenotypes include benign (self-limited) neonatal and infantile epilepsy and more severe developmental and epileptic encephalopathies also presenting in early infancy. There is increasing evidence that an important phenotype linked to the gene is autism and intellectual disability without epilepsy or with rare seizures in later childhood. Other associations of SCN2A include the movement disorders chorea and episodic ataxia. It is likely that as genetic testing enters mainstream practice that new phenotypic associations will be identified. Some missense, gain of function variants tend to present in early infancy with epilepsy, whereas other missense or truncating, loss of function variants present with later-onset epilepsies or intellectual disability only. Knowledge of both mutation type and functional consequences can guide precision therapy. Sodium channel blockers may be effective antiepileptic medications in gain of function, neonatal and infantile presentations.
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Affiliation(s)
- Markus Wolff
- Pediatric Neurology, Vivantes Hospital Neukoelln, Berlin, Germany
| | - Andreas Brunklaus
- Paediatric Neurosciences Research Group, Royal Hospital for Children & School of Medicine, University of Glasgow, Glasgow, UK
| | - Sameer M Zuberi
- Paediatric Neurosciences Research Group, Royal Hospital for Children & School of Medicine, University of Glasgow, Glasgow, UK
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37
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Brunklaus A, Du J, Steckler F, Ghanty II, Johannesen KM, Fenger CD, Schorge S, Baez-Nieto D, Wang HR, Allen A, Pan JQ, Lerche H, Heyne H, Symonds JD, Zuberi SM, Sanders S, Sheidley BR, Craiu D, Olson HE, Weckhuysen S, DeJonge P, Helbig I, Van Esch H, Busa T, Milh M, Isidor B, Depienne C, Poduri A, Campbell AJ, Dimidschstein J, Møller RS, Lal D. Biological concepts in human sodium channel epilepsies and their relevance in clinical practice. Epilepsia 2020; 61:387-399. [PMID: 32090326 DOI: 10.1111/epi.16438] [Citation(s) in RCA: 53] [Impact Index Per Article: 13.3] [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: 09/09/2019] [Revised: 01/06/2020] [Accepted: 01/06/2020] [Indexed: 01/07/2023]
Abstract
OBJECTIVE Voltage-gated sodium channels (SCNs) share similar amino acid sequence, structure, and function. Genetic variants in the four human brain-expressed SCN genes SCN1A/2A/3A/8A have been associated with heterogeneous epilepsy phenotypes and neurodevelopmental disorders. To better understand the biology of seizure susceptibility in SCN-related epilepsies, our aim was to determine similarities and differences between sodium channel disorders, allowing us to develop a broader perspective on precision treatment than on an individual gene level alone. METHODS We analyzed genotype-phenotype correlations in large SCN-patient cohorts and applied variant constraint analysis to identify severe sodium channel disease. We examined temporal patterns of human SCN expression and correlated functional data from in vitro studies with clinical phenotypes across different sodium channel disorders. RESULTS Comparing 865 epilepsy patients (504 SCN1A, 140 SCN2A, 171 SCN8A, four SCN3A, 46 copy number variation [CNV] cases) and analysis of 114 functional studies allowed us to identify common patterns of presentation. All four epilepsy-associated SCN genes demonstrated significant constraint in both protein truncating and missense variation when compared to other SCN genes. We observed that age at seizure onset is related to SCN gene expression over time. Individuals with gain-of-function SCN2A/3A/8A missense variants or CNV duplications share similar characteristics, most frequently present with early onset epilepsy (<3 months), and demonstrate good response to sodium channel blockers (SCBs). Direct comparison of corresponding SCN variants across different SCN subtypes illustrates that the functional effects of variants in corresponding channel locations are similar; however, their clinical manifestation differs, depending on their role in different types of neurons in which they are expressed. SIGNIFICANCE Variant function and location within one channel can serve as a surrogate for variant effects across related sodium channels. Taking a broader view on precision treatment suggests that in those patients with a suspected underlying genetic epilepsy presenting with neonatal or early onset seizures (<3 months), SCBs should be considered.
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Affiliation(s)
- Andreas Brunklaus
- Paediatric Neurosciences Research Group, Royal Hospital for Children, Glasgow, UK.,School of Medicine, University of Glasgow, Glasgow, UK
| | - Juanjiangmeng Du
- Cologne Center for Genomics, University of Cologne, University Hospital Cologne, Cologne, Germany
| | - Felix Steckler
- Paediatric Neurosciences Research Group, Royal Hospital for Children, Glasgow, UK.,School of Medicine, University of Glasgow, Glasgow, UK
| | - Ismael I Ghanty
- Paediatric Neurosciences Research Group, Royal Hospital for Children, Glasgow, UK.,School of Medicine, University of Glasgow, Glasgow, UK
| | - Katrine M Johannesen
- Deparment of Epilepsy Genetics and Personalized Medicine, Danish Epilepsy Center Filadelfia, Dianalund, Denmark.,Institute for Regional Health Services, University of Southern Denmark, Odense, Denmark
| | - Christina Dühring Fenger
- Deparment of Epilepsy Genetics and Personalized Medicine, Danish Epilepsy Center Filadelfia, Dianalund, Denmark.,Amplexa Genetics, Odense, Denmark
| | - Stephanie Schorge
- Department of Clinical and Experimental Epilepsy, Institute of Neurology, University College London, London, UK.,School of Pharmacy, University College London, London, UK
| | - David Baez-Nieto
- Stanley Center for Psychiatric Research, Broad Institute of Massachusetts Institute of Technology and Harvard, Cambridge, Massachusetts
| | - Hao-Ran Wang
- Stanley Center for Psychiatric Research, Broad Institute of Massachusetts Institute of Technology and Harvard, Cambridge, Massachusetts
| | - Andrew Allen
- Stanley Center for Psychiatric Research, Broad Institute of Massachusetts Institute of Technology and Harvard, Cambridge, Massachusetts
| | - Jen Q Pan
- Stanley Center for Psychiatric Research, Broad Institute of Massachusetts Institute of Technology and Harvard, Cambridge, Massachusetts
| | - Holger Lerche
- Department of Neurology and Epileptology, Hertie Institute for Clinical Brain Research, University of Tübingen, Germany
| | - Henrike Heyne
- Stanley Center for Psychiatric Research, Broad Institute of Massachusetts Institute of Technology and Harvard, Cambridge, Massachusetts.,Analytic and Translational Genetics Unit, Massachusetts General Hospital, Boston, Massachusetts.,Institute for Molecular Medicine Finland, University of Helsinki, Helsinki, Finland
| | - Joseph D Symonds
- Paediatric Neurosciences Research Group, Royal Hospital for Children, Glasgow, UK.,School of Medicine, University of Glasgow, Glasgow, UK
| | - Sameer M Zuberi
- Paediatric Neurosciences Research Group, Royal Hospital for Children, Glasgow, UK.,School of Medicine, University of Glasgow, Glasgow, UK
| | - Stephan Sanders
- Department of Psychiatry, UCSF Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, California
| | - Beth R Sheidley
- Epilepsy Genetics Program, Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Boston, Massachusetts
| | - Dana Craiu
- Carol Davila University of Medicine, Department of Clinical Neurosciences, Pediatric Neurology Discipline, Bucharest, Romania.,Alexandru Obregia Hospital, Pediatric Neurology Clinic, Bucharest, Romania
| | - Heather E Olson
- Epilepsy Genetics Program, Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Boston, Massachusetts
| | - Sarah Weckhuysen
- Neurogenetics Group, Center for Molecular Neurology, VIB, Antwerp, Belgium.,Laboratory of Neurogenetics, Institute Born-Bunge, University of Antwerp, Antwerp, Belgium.,Department of Neurology, University Hospital Antwerp, Antwerp, Belgium
| | - Peter DeJonge
- Neurogenetics Group, Center for Molecular Neurology, VIB, Antwerp, Belgium.,Laboratory of Neurogenetics, Institute Born-Bunge, University of Antwerp, Antwerp, Belgium.,Department of Neurology, University Hospital Antwerp, Antwerp, Belgium
| | - Ingo Helbig
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Epilepsy NeuroGenetics Initiative, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.,Department of Neuropediatrics, University of Kiel, Kiel, Germany
| | - Hilde Van Esch
- Department of Human Genetics and Center for Human Genetics, Laboratory for Genetics of Cognition, University Hospitals Leuven, Leuven, Belgium
| | - Tiffany Busa
- Genetics Department, Timone Enfants University Hospital Center, Public Assistance-Marseille Hospitals, Marseille, France
| | - Matthieu Milh
- Medical Genetics and Functional Genomics, National Institute of Health and Medical Research, Mixed Unit of Research S910, Aix-Marseille University, Marseille, France.,Hematology Laboratory, Le Mans Hospital Center, Le Mans, France
| | - Bertrand Isidor
- Medical Genetics Department, Nantes University Hospital Center, Nantes, France
| | - Christel Depienne
- Institute of Human Genetics, Essen University Hospital, Essen, Germany.,Brain and Spinal Cord Institute, National Institute of Health and Medical Research, Unit 1127, National Center for Scientific Research, Mixed Unit of Research 7225, Sorbonne Universities, Pierre and Marie Curie University, Mixed Unit of Research S 1127, Brain & Spine Institute, Paris, France
| | - Annapurna Poduri
- Epilepsy Genetics Program, Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | | | - Jordane Dimidschstein
- Stanley Center for Psychiatric Research, Broad Institute of Massachusetts Institute of Technology and Harvard, Cambridge, Massachusetts
| | - Rikke S Møller
- Deparment of Epilepsy Genetics and Personalized Medicine, Danish Epilepsy Center Filadelfia, Dianalund, Denmark.,Institute for Regional Health Services, University of Southern Denmark, Odense, Denmark
| | - Dennis Lal
- Cologne Center for Genomics, University of Cologne, University Hospital Cologne, Cologne, Germany.,Stanley Center for Psychiatric Research, Broad Institute of Massachusetts Institute of Technology and Harvard, Cambridge, Massachusetts.,Analytic and Translational Genetics Unit, Massachusetts General Hospital, Boston, Massachusetts.,Epilepsy Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio.,Genomic Medicine Institute, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
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38
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Rice GI, Park S, Gavazzi F, Adang LA, Ayuk LA, Van Eyck L, Seabra L, Barrea C, Battini R, Belot A, Berg S, Billette de Villemeur T, Bley AE, Blumkin L, Boespflug-Tanguy O, Briggs TA, Brimble E, Dale RC, Darin N, Debray FG, De Giorgis V, Denecke J, Doummar D, Drake Af Hagelsrum G, Eleftheriou D, Estienne M, Fazzi E, Feillet F, Galli J, Hartog N, Harvengt J, Heron B, Heron D, Kelly DA, Lev D, Levrat V, Livingston JH, Marti I, Mignot C, Mochel F, Nougues MC, Oppermann I, Pérez-Dueñas B, Popp B, Rodero MP, Rodriguez D, Saletti V, Sharpe C, Tonduti D, Vadlamani G, Van Haren K, Tomas Vila M, Vogt J, Wassmer E, Wiedemann A, Wilson CJ, Zerem A, Zweier C, Zuberi SM, Orcesi S, Vanderver AL, Hur S, Crow YJ. Genetic and phenotypic spectrum associated with IFIH1 gain-of-function. Hum Mutat 2020; 41:837-849. [PMID: 31898846 PMCID: PMC7457149 DOI: 10.1002/humu.23975] [Citation(s) in RCA: 58] [Impact Index Per Article: 14.5] [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: 10/15/2019] [Revised: 12/11/2019] [Accepted: 12/30/2019] [Indexed: 12/04/2022]
Abstract
IFIH1 gain-of-function has been reported as a cause of a type I interferonopathy encompassing a spectrum of autoinflammatory phenotypes including Aicardi–Goutières syndrome and Singleton Merten syndrome. Ascertaining patients through a European and North American collaboration, we set out to describe the molecular, clinical and interferon status of a cohort of individuals with pathogenic heterozygous mutations in IFIH1. We identified 74 individuals from 51 families segregating a total of 27 likely pathogenic mutations in IFIH1. Ten adult individuals, 13.5% of all mutation carriers, were clinically asymptomatic (with seven of these aged over 50 years). All mutations were associated with enhanced type I interferon signaling, including six variants (22%) which were predicted as benign according to multiple in silico pathogenicity programs. The identified mutations cluster close to the ATP binding region of the protein. These data confirm variable expression and nonpenetrance as important characteristics of the IFIH1 genotype, a consistent association with enhanced type I interferon signaling, and a common mutational mechanism involving increased RNA binding affinity or decreased efficiency of ATP hydrolysis and filament disassembly rate.
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Affiliation(s)
- Gillian I Rice
- Division of Evolution and Genomic Sciences, Faculty of Biology, Medicine and Health, School of Biological Sciences, Manchester Academic Health Science Centre, University of Manchester, Manchester, United Kingdom
| | - Sehoon Park
- Department of Biological Chemistry and Molecular Pharmacology, Harvard Medical School, Boston, Massachusetts.,Program in Cellular and Molecular Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Francesco Gavazzi
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Laura A Adang
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Loveline A Ayuk
- Paediatric Department, Dumfries and Galloway Royal Infirmary, Cargenbridge, United Kingdom
| | - Lien Van Eyck
- Laboratory of Neurogenetics and Neuroinflammation, Institut Imagine, Paris, France
| | - Luis Seabra
- Laboratory of Neurogenetics and Neuroinflammation, Institut Imagine, Paris, France
| | - Christophe Barrea
- Department of Neuropaediatrics, CHU & University of Liège, Liege, Belgium
| | - Roberta Battini
- Department Clinical and Experimental Medicine, University of Pisa, Pisa, Italy.,IRCCS Fondazione Stella Maris, Pisa, Italy
| | - Alexandre Belot
- Université de Lyon, INSERM U1111, CIRI, Lyon, France.,Centre International de Recherche en Infectiologie, CIRI, Inserm, U1111, École Normale Supérieure de Lyon, Université Claude Bernard Lyon 1, Université de Lyon, Lyon, France
| | - Stefan Berg
- Pediatric Immunology and Rheumatology, The Queen Silvia Children's Hospital, Goteborg, Sweden
| | | | - Annette E Bley
- University Children's Hospital, University Medical Center Hamburg Eppendorf, Hamburg, Germany
| | - Lubov Blumkin
- Pediatric Neurology Unit, Metabolic Neurogenetic Service, Wolfson Medical Center, Holon, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Odile Boespflug-Tanguy
- Génétique Médicale, Université Paris Diderot, Paris, France.,Service de Neuropédiatrie et des Maladies Métaboliques, Centre de Référence Maladies Rares "Leucodystrophies", Hopital Robert Debré, Paris, France
| | - Tracy A Briggs
- Division of Evolution and Genomic Sciences, Faculty of Biology, Medicine and Health, School of Biological Sciences, Manchester Academic Health Science Centre, University of Manchester, Manchester, United Kingdom.,Manchester Centre for Genomic Medicine, St Mary's Hospital, Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - Elise Brimble
- Department of Neurology, Stanford University School of Medicine, Stanford, California
| | - Russell C Dale
- Faculty of Medicine and Health, Kids Neuroscience Centre, Brain and Mind Centre, Children's Hospital at Westmead, University of Sydney, Sydney, Australia
| | - Niklas Darin
- Department of Pediatrics, Institute of Clinical Sciences, Sahlgrenska University Hospital, University of Gothenburg, Gothenburg, Sweden.,The Queen Silvia Children's Hospital, Sahlgrenska University Hospital, Gothenburg, Sweden
| | | | | | - Jonas Denecke
- University Children's Hospital, University Medical Center Hamburg Eppendorf, Hamburg, Germany
| | - Diane Doummar
- GHUEP, département de neuropédiatrie, Centre de référence neurogénétique mouvement anormaux de l'enfant, Hôpital Armand Trousseau, Paris, France
| | | | - Despina Eleftheriou
- Paediatric Rheumatology, ARUK Centre for Adolescent Rheumatology, Institute of Child Health, University College London (UCL) Great Ormond Street Hospital, London, United Kingdom
| | - Margherita Estienne
- U.O. Neuropsichiatria Infantile, Fondazione IRCCS, Istituto Neurologico Carlo Besta, Milan, Italy
| | - Elisa Fazzi
- Unit of Child Neurology and Psichiatry, ASST Spedali Civili of Brescia, Brescia, Italy.,Department of Experimental and Clinical Sciences, University of Brescia, Brescia, Italy
| | - François Feillet
- Service de Médecine Infantile, Centre de Référence des maladies métaboliques de Nancy, CHU Brabois Enfants, Unité INSERM NGERE U1256, Nancy, France
| | - Jessica Galli
- Unit of Child Neurology and Psichiatry, ASST Spedali Civili of Brescia, Brescia, Italy.,Department of Experimental and Clinical Sciences, University of Brescia, Brescia, Italy
| | - Nicholas Hartog
- Department of Allergy/Immunology, Spectrum Health Helen Devos Children's Hospital, Michigan State University College of Human Medicine, East Lansing, Michigan
| | - Julie Harvengt
- Department of Medical Genetics, CHU & University of Liège, Gembloux, Belgium
| | - Bénédicte Heron
- Service de Neuropédiatrie, Centre Référence des Maladies Lysosomales, Hôpital Trousseau, Paris, France
| | - Delphine Heron
- UF Génétique Médicale et Centre de Référence "Déficiences Intellectuelles", Groupe Hospitalier Pitié-Salpêtrière, Paris, France
| | - Diedre A Kelly
- The Liver Unit, Birmingham Women's and Children's Hospital NHS Foundation Trust, Birmingham, United Kingdom
| | - Dorit Lev
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel.,Metabolic Neurogenetic Service, Wolfson Medical Center, The Rina Mor Institute of Medical Genetics, Holon, Israel
| | - Virginie Levrat
- Service de pédiatrie, Centre Hospitalier Annecy Genevois, Pringy, France
| | - John H Livingston
- Department of Paediatric Neurology, Leeds General Infirmary, Leeds, United Kingdom
| | - Itxaso Marti
- Pediatric Neurology, Hospital Universitario Donostia, Universidad del País Vasco UPV-EHU, San Sebastian, Spain
| | - Cyril Mignot
- Departement de Génétique & Centre de Référence Déficience Intellectuelle de cause rare, GH Pitié-Sapêtrière, Paris, France
| | - Fanny Mochel
- Institut du Cerveau et de la Moelle épinière, INSERM U 1127, Sorbonne Universités, Paris, France
| | | | - Ilena Oppermann
- University Children's Hospital, University Medical Center Hamburg Eppendorf, Hamburg, Germany
| | - Belén Pérez-Dueñas
- Pediatric Neurology Research Group, Hospital Vall d'Hebron-Research Institute (VHIR), Universitat Autonoma de Barcelona, Barcelona, Spain
| | - Bernt Popp
- Institute of Human Genetics, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Mathieu P Rodero
- Laboratory of Neurogenetics and Neuroinflammation, Institut Imagine, Paris, France
| | - Diana Rodriguez
- GRC n°19, pathologies Congénitales du Cervelet-LeucoDystrophies, CRMR maladies neurogénétiques, Sorbonne Université, Paris, France.,Service de Neuropédiatrie, Hôpital Trousseau, Groupe Hospitalier HUEP, Inserm U1141, Paris, France
| | - Veronica Saletti
- Developmental Neurology Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Cia Sharpe
- Paediatric Neurology, Starship Children's Hospital, Auckland, New Zealand
| | - Davide Tonduti
- Pediatric Neurology Unit, V. Buzzi Children's Hospital, Milan, Italy
| | - Gayatri Vadlamani
- Department of Paediatric Neurology, Leeds General Infirmary, Leeds, United Kingdom
| | - Keith Van Haren
- Department of Neurology, Stanford University School of Medicine, Stanford, California
| | - Miguel Tomas Vila
- Neuropediatría, Hospital Universitari i Pôlitecnic La Fe, Valencia, Spain
| | - Julie Vogt
- West Midlands Regional Clinical Genetics Service and Birmingham Health Partners, Birmingham Women's and Children's Hospitals NHS Foundation Trust, Birmingham, United Kingdom
| | - Evangeline Wassmer
- Department of Paediatric Neurology, Birmingham Women's and Children's Hospitals NHS Foundation Trust, Birmingham, United Kingdom
| | - Arnaud Wiedemann
- Service de Médecine Infantile, Centre de Référence des maladies métaboliques de Nancy, CHU Brabois Enfants, Unité INSERM NGERE U1256, Nancy, France
| | - Callum J Wilson
- National Metabolic Service, Starship Children's Hospital, Auckland, New Zealand
| | - Ayelet Zerem
- Pediatric Neurology Unit, Metabolic Neurogenetic Service, Wolfson Medical Center, Holon, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Christiane Zweier
- Institute of Human Genetics, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Sameer M Zuberi
- Paediatric Neurosciences Research Group, Royal Hospital for Children, Glasgow, United Kingdom.,School of Medicine, University of Glasgow, Glasgow, United Kingdom
| | - Simona Orcesi
- Child Neurology and Psychiatry Unit, IRCCS Mondino Foundation, Pavia, Italy.,Department of Brain and Behavioural Sciences, University of Pavia, Pavia, Italy
| | - Adeline L Vanderver
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Sun Hur
- Department of Biological Chemistry and Molecular Pharmacology, Harvard Medical School, Boston, Massachusetts.,Program in Cellular and Molecular Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Yanick J Crow
- Laboratory of Neurogenetics and Neuroinflammation, Institut Imagine, Paris, France.,Sorbonne-Paris-Cité, Institut Imagine, Paris Descartes University, Paris, France.,Centre for Genomic and Experimental Medicine, MRC Institute of Genetics and Molecular Medicine, University of Edinburgh, Edinburgh, United Kingdom
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Zuberi SM. Introduction to the special issue on epilepsy & neurodevelopmental disorders. Eur J Paediatr Neurol 2020; 24:1. [PMID: 31973985 DOI: 10.1016/j.ejpn.2020.01.007] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Brunklaus A, Schorge S, Smith AD, Ghanty I, Stewart K, Gardiner S, Du J, Pérez‐Palma E, Symonds JD, Collier AC, Lal D, Zuberi SM. SCN1A
variants from bench to bedside—improved clinical prediction from functional characterization. Hum Mutat 2019; 41:363-374. [PMID: 31782251 DOI: 10.1002/humu.23943] [Citation(s) in RCA: 30] [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: 04/16/2019] [Revised: 10/10/2019] [Accepted: 10/31/2019] [Indexed: 12/18/2022]
Affiliation(s)
- Andreas Brunklaus
- The Paediatric Neurosciences Research GroupRoyal Hospital for ChildrenGlasgow UK
- School of MedicineUniversity of GlasgowGlasgow UK
| | - Stephanie Schorge
- Department of Clinical and Experimental Epilepsy, Institute of NeurologyUniversity College LondonLondon UK
- School of PharmacyUniversity College LondonLondon UK
| | - Alexander D. Smith
- Faculty of Pharmaceutical SciencesThe University of British ColumbiaVancouver British Columbia Canada
| | - Ismael Ghanty
- The Paediatric Neurosciences Research GroupRoyal Hospital for ChildrenGlasgow UK
- School of MedicineUniversity of GlasgowGlasgow UK
| | - Kirsty Stewart
- West of Scotland Genetic Services, Level 2B, Laboratory MedicineQueen Elizabeth University HospitalGlasgow UK
| | - Sarah Gardiner
- West of Scotland Genetic Services, Level 2B, Laboratory MedicineQueen Elizabeth University HospitalGlasgow UK
| | - Juanjiangmeng Du
- Cologne Center for Genomics, University Hospital CologneUniversity of CologneCologne Germany
| | - Eduardo Pérez‐Palma
- Cologne Center for Genomics, University Hospital CologneUniversity of CologneCologne Germany
| | - Joseph D. Symonds
- The Paediatric Neurosciences Research GroupRoyal Hospital for ChildrenGlasgow UK
- School of MedicineUniversity of GlasgowGlasgow UK
| | - Abby C. Collier
- Faculty of Pharmaceutical SciencesThe University of British ColumbiaVancouver British Columbia Canada
| | - Dennis Lal
- Cologne Center for Genomics, University Hospital CologneUniversity of CologneCologne Germany
- Stanley Center for Psychiatric ResearchBroad Institute of MIT and HarvardCambridge Massachusetts
- Analytic and Translational Genetics UnitMassachusetts General HospitalBoston Massachusetts
- Epilepsy Center, Neurological InstituteCleveland ClinicCleveland Ohio
- Genomic Medicine InstituteLerner Research Institute Cleveland ClinicCleveland Ohio
| | - Sameer M. Zuberi
- The Paediatric Neurosciences Research GroupRoyal Hospital for ChildrenGlasgow UK
- School of MedicineUniversity of GlasgowGlasgow UK
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Nagyova R, Horsburgh G, Robertson A, Zuberi SM. The clinical utility of ambulatory EEG in childhood. Seizure 2019; 64:45-49. [DOI: 10.1016/j.seizure.2018.11.020] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Revised: 11/27/2018] [Accepted: 11/29/2018] [Indexed: 11/29/2022] Open
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Fisher RS, Cross JH, French JA, Higurashi N, Hirsch E, Jansen FE, Lagae L, Moshé SL, Peltola J, Roulet Perez E, Scheffer IE, Zuberi SM. Operationale Klassifikation der Anfallsformen durch die Internationale Liga gegen Epilepsie: Positionspapier der ILAE-Klassifikations- und Terminologiekommission. Z Epileptol 2018. [DOI: 10.1007/s10309-018-0216-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Scheffer IE, Berkovic S, Capovilla G, Connolly MB, French J, Guilhoto L, Hirsch E, Jain S, Mathern GW, Moshé SL, Nordli DR, Perucca E, Tomson T, Wiebe S, Zhang YH, Zuberi SM. ILAE-Klassifikation der Epilepsien: Positionspapier der ILAE-Kommission für Klassifikation und Terminologie. Z Epileptol 2018. [DOI: 10.1007/s10309-018-0218-6] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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Chitre M, Nahorski MS, Stouffer K, Dunning-Davies B, Houston H, Wakeling EL, Brady AF, Zuberi SM, Suri M, Parker APJ, Woods CG. PEHO syndrome: the endpoint of different genetic epilepsies. J Med Genet 2018; 55:803-813. [DOI: 10.1136/jmedgenet-2018-105288] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Revised: 07/10/2018] [Accepted: 08/17/2018] [Indexed: 01/08/2023]
Abstract
BackgroundProgressive encephalopathy, hypsarrhythmia and optic atrophy (PEHO) has been described as a clinically distinct syndrome. It has been postulated that it is an autosomal recessive condition. However, the aetiology is poorly understood, and the genetic basis of the condition has not been fully elucidated. Our objective was to discover if PEHO syndrome is a single gene disorder.MethodChildren with PEHO and PEHO-like syndrome were recruited. Clinical, neurological and dysmorphic features were recorded; EEG reports and MRI scans were reviewed. Where possible, exome sequencing was carried out first to seek mutations in known early infantile developmental and epileptic encephalopathy (DEE) genes and then to use an agnostic approach to seek novel candidate genes. We sought intra–interfamilial phenotypic correlations and genotype–phenotype correlations when pathological mutations were identified.ResultsTwenty-three children were recruited from a diverse ethnic background, 19 of which were suitable for inclusion. They were similar in many of the core and the supporting features of PEHO, but there was significant variation in MRI and ophthalmological findings, even between siblings with the same mutation. A pathogenic genetic variant was identified in 15 of the 19 children. One further girl’s DNA failed analysis, but her two affected sisters shared confirmed variants. Pathogenic variants were identified in seven different genes.ConclusionsWe found significant clinical and genetic heterogeneity. Given the intrafamily variation demonstrated, we question whether the diagnostic criteria for MRI and ophthalmic findings should be altered. We also question whether PEHO and PEHO-like syndrome represent differing points on a clinical spectrum of the DEE. We conclude that PEHO and PEHO-like syndrome are clinically and genetically diverse entities—and are phenotypic endpoints of many severe genetic encephalopathies.
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Affiliation(s)
- Sameer M Zuberi
- Paediatric Neurosciences Research Group, Royal Hospital for Children & School of Medicine, University of Glasgow, Glasgow G51 4TF, UK.
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Myers KA, Bello-Espinosa LE, Symonds JD, Zuberi SM, Clegg R, Sadleir LG, Buchhalter J, Scheffer IE. Heart rate variability in epilepsy: A potential biomarker of sudden unexpected death in epilepsy risk. Epilepsia 2018; 59:1372-1380. [PMID: 29873813 DOI: 10.1111/epi.14438] [Citation(s) in RCA: 82] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/09/2018] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Sudden unexpected death in epilepsy (SUDEP) is a tragic and devastating event for which the underlying pathophysiology remains poorly understood; this study investigated whether abnormalities in heart rate variability (HRV) are linked to SUDEP in patients with epilepsy due to mutations in sodium channel (SCN) genes. METHODS We retrospectively evaluated HRV in epilepsy patients using electroencephalographic studies to study the potential contribution of autonomic dysregulation to SUDEP risk. We extracted HRV data, in wakefulness and sleep, from 80 patients with drug-resistant epilepsy, including 40 patients with mutations in SCN genes and 40 control patients with non-SCN drug-resistant epilepsy. From the SCN group, 10 patients had died of SUDEP. We compared HRV between SUDEP and non-SUDEP groups, specifically studying awake HRV and sleep:awake HRV ratios. RESULTS The SUDEP patients had the most severe autonomic dysregulation, showing lower awake HRV and either extremely high or extremely low ratios of sleep-to-awake HRV in a subgroup analysis. A secondary analysis comparing the SCN and non-SCN groups indicated that autonomic dysfunction was slightly worse in the SCN epilepsy group. SIGNIFICANCE These findings suggest that autonomic dysfunction is associated with SUDEP risk in patients with epilepsy due to sodium channel mutations. The relationship of HRV to SUDEP merits further study; HRV may eventually have potential as a biomarker of SUDEP risk, which would allow for more informed counseling of patients and families, and also serve as a useful outcome measure for research aimed at developing therapies and interventions to reduce SUDEP risk.
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Affiliation(s)
- Kenneth A Myers
- Department of Medicine, Epilepsy Research Centre, Austin Health, University of Melbourne, Heidelberg, Victoria, Australia.,Department of Pediatrics, Section of Neurology, Alberta Children's Hospital, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Pediatrics, Faculty of Medicine, McGill University, Montreal, Quebec, Canada.,Division of Child Neurology, Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | - Luis E Bello-Espinosa
- Department of Pediatrics, Section of Neurology, Alberta Children's Hospital, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Joseph D Symonds
- College of Medicine, Veterinary, and Life Sciences, School of Medicine, University of Glasgow, Glasgow, UK.,Paediatric Neurosciences Research Group, Royal Hospital for Sick Children, Glasgow, UK
| | - Sameer M Zuberi
- College of Medicine, Veterinary, and Life Sciences, School of Medicine, University of Glasgow, Glasgow, UK.,Paediatric Neurosciences Research Group, Royal Hospital for Sick Children, Glasgow, UK
| | - Robin Clegg
- Department of Pediatrics, Section of Cardiology, Alberta Children's Hospital, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Lynette G Sadleir
- Department of Paediatrics and Child Health, University of Otago Wellington, Wellington, New Zealand
| | - Jeffrey Buchhalter
- Department of Pediatrics, Section of Neurology, Alberta Children's Hospital, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Ingrid E Scheffer
- Department of Medicine, Epilepsy Research Centre, Austin Health, University of Melbourne, Heidelberg, Victoria, Australia.,Department of Paediatrics, Royal Children's Hospital, University of Melbourne, Flemington, Victoria, Australia.,Florey Institute of Neuroscience and Mental Health, Heidelberg, Victoria, Australia
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Devinsky O, Patel AD, Cross JH, Villanueva V, Wirrell EC, Privitera M, Greenwood SM, Roberts C, Checketts D, VanLandingham KE, Zuberi SM. Effect of Cannabidiol on Drop Seizures in the Lennox-Gastaut Syndrome. N Engl J Med 2018; 378:1888-1897. [PMID: 29768152 DOI: 10.1056/nejmoa1714631] [Citation(s) in RCA: 504] [Impact Index Per Article: 84.0] [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] [Indexed: 11/19/2022]
Abstract
BACKGROUND Cannabidiol has been used for treatment-resistant seizures in patients with severe early-onset epilepsy. We investigated the efficacy and safety of cannabidiol added to a regimen of conventional antiepileptic medication to treat drop seizures in patients with the Lennox-Gastaut syndrome, a severe developmental epileptic encephalopathy. METHODS In this double-blind, placebo-controlled trial conducted at 30 clinical centers, we randomly assigned patients with the Lennox-Gastaut syndrome (age range, 2 to 55 years) who had had two or more drop seizures per week during a 28-day baseline period to receive cannabidiol oral solution at a dose of either 20 mg per kilogram of body weight (20-mg cannabidiol group) or 10 mg per kilogram (10-mg cannabidiol group) or matching placebo, administered in two equally divided doses daily for 14 weeks. The primary outcome was the percentage change from baseline in the frequency of drop seizures (average per 28 days) during the treatment period. RESULTS A total of 225 patients were enrolled; 76 patients were assigned to the 20-mg cannabidiol group, 73 to the 10-mg cannabidiol group, and 76 to the placebo group. During the 28-day baseline period, the median number of drop seizures was 85 in all trial groups combined. The median percent reduction from baseline in drop-seizure frequency during the treatment period was 41.9% in the 20-mg cannabidiol group, 37.2% in the 10-mg cannabidiol group, and 17.2% in the placebo group (P=0.005 for the 20-mg cannabidiol group vs. placebo group, and P=0.002 for the 10-mg cannabidiol group vs. placebo group). The most common adverse events among the patients in the cannabidiol groups were somnolence, decreased appetite, and diarrhea; these events occurred more frequently in the higher-dose group. Six patients in the 20-mg cannabidiol group and 1 patient in the 10-mg cannabidiol group discontinued the trial medication because of adverse events and were withdrawn from the trial. Fourteen patients who received cannabidiol (9%) had elevated liver aminotransferase concentrations. CONCLUSIONS Among children and adults with the Lennox-Gastaut syndrome, the addition of cannabidiol at a dose of 10 mg or 20 mg per kilogram per day to a conventional antiepileptic regimen resulted in greater reductions in the frequency of drop seizures than placebo. Adverse events with cannabidiol included elevated liver aminotransferase concentrations. (Funded by GW Pharmaceuticals; GWPCARE3 ClinicalTrials.gov number, NCT02224560 .).
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Affiliation(s)
- Orrin Devinsky
- From New York University Langone Comprehensive Epilepsy Center, New York (O.D.); Nationwide Children's Hospital and the Ohio State University College of Medicine, Columbus (A.D.P.), and the University of Cincinnati Medical Center, Department of Neurology, Cincinnati (M.P.) - all in Ohio; UCL Great Ormond Street Institute of Child Health, London (J.H.C.), GW Research Ltd., Cambridge (S.M.G., C.R., D.C.), and the Royal Hospital for Children and School of Medicine, University of Glasgow, Glasgow (S.M.Z.) - all in the United Kingdom; Refractory Epilepsy Unit, Neurology Service, Hospital Universitario y Politécnico La Fe, Valencia, Spain (V.V.); the Divisions of Child and Adolescent Neurology and Epilepsy, Department of Neurology, Mayo Clinic, Rochester, MN (E.C.W.); and Greenwich Biosciences, Carlsbad, CA (K.E.V.)
| | - Anup D Patel
- From New York University Langone Comprehensive Epilepsy Center, New York (O.D.); Nationwide Children's Hospital and the Ohio State University College of Medicine, Columbus (A.D.P.), and the University of Cincinnati Medical Center, Department of Neurology, Cincinnati (M.P.) - all in Ohio; UCL Great Ormond Street Institute of Child Health, London (J.H.C.), GW Research Ltd., Cambridge (S.M.G., C.R., D.C.), and the Royal Hospital for Children and School of Medicine, University of Glasgow, Glasgow (S.M.Z.) - all in the United Kingdom; Refractory Epilepsy Unit, Neurology Service, Hospital Universitario y Politécnico La Fe, Valencia, Spain (V.V.); the Divisions of Child and Adolescent Neurology and Epilepsy, Department of Neurology, Mayo Clinic, Rochester, MN (E.C.W.); and Greenwich Biosciences, Carlsbad, CA (K.E.V.)
| | - J Helen Cross
- From New York University Langone Comprehensive Epilepsy Center, New York (O.D.); Nationwide Children's Hospital and the Ohio State University College of Medicine, Columbus (A.D.P.), and the University of Cincinnati Medical Center, Department of Neurology, Cincinnati (M.P.) - all in Ohio; UCL Great Ormond Street Institute of Child Health, London (J.H.C.), GW Research Ltd., Cambridge (S.M.G., C.R., D.C.), and the Royal Hospital for Children and School of Medicine, University of Glasgow, Glasgow (S.M.Z.) - all in the United Kingdom; Refractory Epilepsy Unit, Neurology Service, Hospital Universitario y Politécnico La Fe, Valencia, Spain (V.V.); the Divisions of Child and Adolescent Neurology and Epilepsy, Department of Neurology, Mayo Clinic, Rochester, MN (E.C.W.); and Greenwich Biosciences, Carlsbad, CA (K.E.V.)
| | - Vicente Villanueva
- From New York University Langone Comprehensive Epilepsy Center, New York (O.D.); Nationwide Children's Hospital and the Ohio State University College of Medicine, Columbus (A.D.P.), and the University of Cincinnati Medical Center, Department of Neurology, Cincinnati (M.P.) - all in Ohio; UCL Great Ormond Street Institute of Child Health, London (J.H.C.), GW Research Ltd., Cambridge (S.M.G., C.R., D.C.), and the Royal Hospital for Children and School of Medicine, University of Glasgow, Glasgow (S.M.Z.) - all in the United Kingdom; Refractory Epilepsy Unit, Neurology Service, Hospital Universitario y Politécnico La Fe, Valencia, Spain (V.V.); the Divisions of Child and Adolescent Neurology and Epilepsy, Department of Neurology, Mayo Clinic, Rochester, MN (E.C.W.); and Greenwich Biosciences, Carlsbad, CA (K.E.V.)
| | - Elaine C Wirrell
- From New York University Langone Comprehensive Epilepsy Center, New York (O.D.); Nationwide Children's Hospital and the Ohio State University College of Medicine, Columbus (A.D.P.), and the University of Cincinnati Medical Center, Department of Neurology, Cincinnati (M.P.) - all in Ohio; UCL Great Ormond Street Institute of Child Health, London (J.H.C.), GW Research Ltd., Cambridge (S.M.G., C.R., D.C.), and the Royal Hospital for Children and School of Medicine, University of Glasgow, Glasgow (S.M.Z.) - all in the United Kingdom; Refractory Epilepsy Unit, Neurology Service, Hospital Universitario y Politécnico La Fe, Valencia, Spain (V.V.); the Divisions of Child and Adolescent Neurology and Epilepsy, Department of Neurology, Mayo Clinic, Rochester, MN (E.C.W.); and Greenwich Biosciences, Carlsbad, CA (K.E.V.)
| | - Michael Privitera
- From New York University Langone Comprehensive Epilepsy Center, New York (O.D.); Nationwide Children's Hospital and the Ohio State University College of Medicine, Columbus (A.D.P.), and the University of Cincinnati Medical Center, Department of Neurology, Cincinnati (M.P.) - all in Ohio; UCL Great Ormond Street Institute of Child Health, London (J.H.C.), GW Research Ltd., Cambridge (S.M.G., C.R., D.C.), and the Royal Hospital for Children and School of Medicine, University of Glasgow, Glasgow (S.M.Z.) - all in the United Kingdom; Refractory Epilepsy Unit, Neurology Service, Hospital Universitario y Politécnico La Fe, Valencia, Spain (V.V.); the Divisions of Child and Adolescent Neurology and Epilepsy, Department of Neurology, Mayo Clinic, Rochester, MN (E.C.W.); and Greenwich Biosciences, Carlsbad, CA (K.E.V.)
| | - Sam M Greenwood
- From New York University Langone Comprehensive Epilepsy Center, New York (O.D.); Nationwide Children's Hospital and the Ohio State University College of Medicine, Columbus (A.D.P.), and the University of Cincinnati Medical Center, Department of Neurology, Cincinnati (M.P.) - all in Ohio; UCL Great Ormond Street Institute of Child Health, London (J.H.C.), GW Research Ltd., Cambridge (S.M.G., C.R., D.C.), and the Royal Hospital for Children and School of Medicine, University of Glasgow, Glasgow (S.M.Z.) - all in the United Kingdom; Refractory Epilepsy Unit, Neurology Service, Hospital Universitario y Politécnico La Fe, Valencia, Spain (V.V.); the Divisions of Child and Adolescent Neurology and Epilepsy, Department of Neurology, Mayo Clinic, Rochester, MN (E.C.W.); and Greenwich Biosciences, Carlsbad, CA (K.E.V.)
| | - Claire Roberts
- From New York University Langone Comprehensive Epilepsy Center, New York (O.D.); Nationwide Children's Hospital and the Ohio State University College of Medicine, Columbus (A.D.P.), and the University of Cincinnati Medical Center, Department of Neurology, Cincinnati (M.P.) - all in Ohio; UCL Great Ormond Street Institute of Child Health, London (J.H.C.), GW Research Ltd., Cambridge (S.M.G., C.R., D.C.), and the Royal Hospital for Children and School of Medicine, University of Glasgow, Glasgow (S.M.Z.) - all in the United Kingdom; Refractory Epilepsy Unit, Neurology Service, Hospital Universitario y Politécnico La Fe, Valencia, Spain (V.V.); the Divisions of Child and Adolescent Neurology and Epilepsy, Department of Neurology, Mayo Clinic, Rochester, MN (E.C.W.); and Greenwich Biosciences, Carlsbad, CA (K.E.V.)
| | - Daniel Checketts
- From New York University Langone Comprehensive Epilepsy Center, New York (O.D.); Nationwide Children's Hospital and the Ohio State University College of Medicine, Columbus (A.D.P.), and the University of Cincinnati Medical Center, Department of Neurology, Cincinnati (M.P.) - all in Ohio; UCL Great Ormond Street Institute of Child Health, London (J.H.C.), GW Research Ltd., Cambridge (S.M.G., C.R., D.C.), and the Royal Hospital for Children and School of Medicine, University of Glasgow, Glasgow (S.M.Z.) - all in the United Kingdom; Refractory Epilepsy Unit, Neurology Service, Hospital Universitario y Politécnico La Fe, Valencia, Spain (V.V.); the Divisions of Child and Adolescent Neurology and Epilepsy, Department of Neurology, Mayo Clinic, Rochester, MN (E.C.W.); and Greenwich Biosciences, Carlsbad, CA (K.E.V.)
| | - Kevan E VanLandingham
- From New York University Langone Comprehensive Epilepsy Center, New York (O.D.); Nationwide Children's Hospital and the Ohio State University College of Medicine, Columbus (A.D.P.), and the University of Cincinnati Medical Center, Department of Neurology, Cincinnati (M.P.) - all in Ohio; UCL Great Ormond Street Institute of Child Health, London (J.H.C.), GW Research Ltd., Cambridge (S.M.G., C.R., D.C.), and the Royal Hospital for Children and School of Medicine, University of Glasgow, Glasgow (S.M.Z.) - all in the United Kingdom; Refractory Epilepsy Unit, Neurology Service, Hospital Universitario y Politécnico La Fe, Valencia, Spain (V.V.); the Divisions of Child and Adolescent Neurology and Epilepsy, Department of Neurology, Mayo Clinic, Rochester, MN (E.C.W.); and Greenwich Biosciences, Carlsbad, CA (K.E.V.)
| | - Sameer M Zuberi
- From New York University Langone Comprehensive Epilepsy Center, New York (O.D.); Nationwide Children's Hospital and the Ohio State University College of Medicine, Columbus (A.D.P.), and the University of Cincinnati Medical Center, Department of Neurology, Cincinnati (M.P.) - all in Ohio; UCL Great Ormond Street Institute of Child Health, London (J.H.C.), GW Research Ltd., Cambridge (S.M.G., C.R., D.C.), and the Royal Hospital for Children and School of Medicine, University of Glasgow, Glasgow (S.M.Z.) - all in the United Kingdom; Refractory Epilepsy Unit, Neurology Service, Hospital Universitario y Politécnico La Fe, Valencia, Spain (V.V.); the Divisions of Child and Adolescent Neurology and Epilepsy, Department of Neurology, Mayo Clinic, Rochester, MN (E.C.W.); and Greenwich Biosciences, Carlsbad, CA (K.E.V.)
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Snijders Blok L, Hiatt SM, Bowling KM, Prokop JW, Engel KL, Cochran JN, Bebin EM, Bijlsma EK, Ruivenkamp CAL, Terhal P, Simon MEH, Smith R, Hurst JA, McLaughlin H, Person R, Crunk A, Wangler MF, Streff H, Symonds JD, Zuberi SM, Elliott KS, Sanders VR, Masunga A, Hopkin RJ, Dubbs HA, Ortiz-Gonzalez XR, Pfundt R, Brunner HG, Fisher SE, Kleefstra T, Cooper GM. De novo mutations in MED13, a component of the Mediator complex, are associated with a novel neurodevelopmental disorder. Hum Genet 2018; 137:375-388. [PMID: 29740699 PMCID: PMC5973976 DOI: 10.1007/s00439-018-1887-y] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [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: 12/29/2017] [Accepted: 04/21/2018] [Indexed: 01/15/2023]
Abstract
Many genetic causes of developmental delay and/or intellectual disability (DD/ID) are extremely rare, and robust discovery of these requires both large-scale DNA sequencing and data sharing. Here we describe a GeneMatcher collaboration which led to a cohort of 13 affected individuals harboring protein-altering variants, 11 of which are de novo, in MED13; the only inherited variant was transmitted to an affected child from an affected mother. All patients had intellectual disability and/or developmental delays, including speech delays or disorders. Other features that were reported in two or more patients include autism spectrum disorder, attention deficit hyperactivity disorder, optic nerve abnormalities, Duane anomaly, hypotonia, mild congenital heart abnormalities, and dysmorphisms. Six affected individuals had mutations that are predicted to truncate the MED13 protein, six had missense mutations, and one had an in-frame-deletion of one amino acid. Out of the seven non-truncating mutations, six clustered in two specific locations of the MED13 protein: an N-terminal and C-terminal region. The four N-terminal clustering mutations affect two adjacent amino acids that are known to be involved in MED13 ubiquitination and degradation, p.Thr326 and p.Pro327. MED13 is a component of the CDK8-kinase module that can reversibly bind Mediator, a multi-protein complex that is required for Polymerase II transcription initiation. Mutations in several other genes encoding subunits of Mediator have been previously shown to associate with DD/ID, including MED13L, a paralog of MED13. Thus, our findings add MED13 to the group of CDK8-kinase module-associated disease genes.
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Affiliation(s)
- Lot Snijders Blok
- Human Genetics Department, Radboud University Medical Center, PO Box 9101, 6500 HB, Nijmegen, The Netherlands
- Language and Genetics Department, Max Planck Institute for Psycholinguistics, Nijmegen, The Netherlands
- Donders Institute for Brain, Cognition and Behaviour, Nijmegen, The Netherlands
| | - Susan M Hiatt
- HudsonAlpha Institute for Biotechnology, 601 Genome Way, Huntsville, AL, 35806, USA
| | - Kevin M Bowling
- HudsonAlpha Institute for Biotechnology, 601 Genome Way, Huntsville, AL, 35806, USA
| | - Jeremy W Prokop
- HudsonAlpha Institute for Biotechnology, 601 Genome Way, Huntsville, AL, 35806, USA
| | - Krysta L Engel
- HudsonAlpha Institute for Biotechnology, 601 Genome Way, Huntsville, AL, 35806, USA
| | - J Nicholas Cochran
- HudsonAlpha Institute for Biotechnology, 601 Genome Way, Huntsville, AL, 35806, USA
| | | | - Emilia K Bijlsma
- Department of Clinical Genetics, Leiden University Medical Center, Leiden, The Netherlands
| | - Claudia A L Ruivenkamp
- Department of Clinical Genetics, Leiden University Medical Center, Leiden, The Netherlands
| | - Paulien Terhal
- Department of Genetics, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Marleen E H Simon
- Department of Genetics, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Rosemarie Smith
- Division of Genetics, Department of Pediatrics, Maine Medical Center, Portland, ME, USA
| | - Jane A Hurst
- Great Ormond Street Hospital for Children, London, UK
| | | | | | - Amy Crunk
- GeneDx, 207 Perry Parkway, Gaithersburg, MD, 20877, USA
| | - Michael F Wangler
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX, USA
| | - Haley Streff
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX, USA
| | - Joseph D Symonds
- Paediatric Neurosciences Research Group, University of Glasgow and Royal Hospital for Children, Glasgow, G51 4TF, UK
| | - Sameer M Zuberi
- Paediatric Neurosciences Research Group, University of Glasgow and Royal Hospital for Children, Glasgow, G51 4TF, UK
| | | | - Victoria R Sanders
- Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Abigail Masunga
- Division of Human Genetics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Robert J Hopkin
- Division of Human Genetics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Holly A Dubbs
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | | | - Rolph Pfundt
- Human Genetics Department, Radboud University Medical Center, PO Box 9101, 6500 HB, Nijmegen, The Netherlands
| | - Han G Brunner
- Human Genetics Department, Radboud University Medical Center, PO Box 9101, 6500 HB, Nijmegen, The Netherlands
- Donders Institute for Brain, Cognition and Behaviour, Nijmegen, The Netherlands
- Department of Clinical Genetics, GROW School for Oncology and Developmental Biology, Maastricht UMC, Maastricht, The Netherlands
| | - Simon E Fisher
- Language and Genetics Department, Max Planck Institute for Psycholinguistics, Nijmegen, The Netherlands
- Donders Institute for Brain, Cognition and Behaviour, Nijmegen, The Netherlands
| | - Tjitske Kleefstra
- Human Genetics Department, Radboud University Medical Center, PO Box 9101, 6500 HB, Nijmegen, The Netherlands.
- Donders Institute for Brain, Cognition and Behaviour, Nijmegen, The Netherlands.
| | - Gregory M Cooper
- HudsonAlpha Institute for Biotechnology, 601 Genome Way, Huntsville, AL, 35806, USA.
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Zuberi SM. Sleep, oxygen saturation, and seizures in Dravet syndrome. Dev Med Child Neurol 2018; 60:118. [PMID: 29238957 DOI: 10.1111/dmcn.13644] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Sameer M Zuberi
- Paediatric Neurosciences Research Group, Royal Hospital for Children Glasgow, Glasgow, UK
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50
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Symonds JD, Zuberi SM. Genetics update: Monogenetics, polygene disorders and the quest for modifying genes. Neuropharmacology 2017; 132:3-19. [PMID: 29037745 DOI: 10.1016/j.neuropharm.2017.10.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [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: 01/31/2017] [Revised: 10/09/2017] [Accepted: 10/11/2017] [Indexed: 12/19/2022]
Abstract
The genetic channelopathies are a broad collection of diseases. Many ion channel genes demonstrate wide phenotypic pleiotropy, but nonetheless concerted efforts have been made to characterise genotype-phenotype relationships. In this review we give an overview of the factors that influence genotype-phenotype relationships across this group of diseases as a whole, using specific individual channelopathies as examples. We suggest reasons for the limitations observed in these relationships. We discuss the role of ion channel variation in polygenic disease and highlight research that has contributed to unravelling the complex aetiological nature of these conditions. We focus specifically on the quest for modifying genes in inherited channelopathies, using the voltage-gated sodium channels as an example. Epilepsy related to genetic channelopathy is one area in which precision medicine is showing promise. We will discuss the successes and limitations of precision medicine in these conditions. This article is part of the Special Issue entitled 'Channelopathies.'
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Affiliation(s)
- Joseph D Symonds
- The Paediatric Neurosciences Research Group, Royal Hospital for Children, Queen Elizabeth University Hospitals, Glasgow, UK; School of Medicine, University of Glasgow, Glasgow, UK
| | - Sameer M Zuberi
- The Paediatric Neurosciences Research Group, Royal Hospital for Children, Queen Elizabeth University Hospitals, Glasgow, UK; School of Medicine, University of Glasgow, Glasgow, UK.
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