1
|
Keeley J, Benson-Goldberg S, Saldaris J, Lariviere J, Leonard H, Marsh ED, Demarest ST, Benke TA, Jacoby P, Downs J. Communication of individuals with CDKL5 deficiency disorder as observed by caregivers: A descriptive qualitative study. Am J Med Genet A 2024:e63570. [PMID: 38425131 DOI: 10.1002/ajmg.a.63570] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Accepted: 02/02/2024] [Indexed: 03/02/2024]
Abstract
CDKL5 deficiency disorder (CDD) is a genetically caused developmental epileptic encephalopathy that causes severe communication impairments. Communication of individuals with CDD is not well understood in the literature and currently available measures are not well validated in this population. Accurate and sensitive measurement of the communication of individuals with CDD is important for understanding this condition, clinical practice, and upcoming interventional trials. The aim of this descriptive qualitative study was to understand how individuals with CDD communicate, as observed by caregivers. Participants were identified through the International CDKL5 Disorder Database and invited to take part if their child had a pathogenic variant of the CDKL5 gene and they had previously completed the Communication and Symbolic Behavior Checklist (CSBS-DP ITC). The sample comprised caregivers of 23 individuals with CDD, whose ages ranged from 2 to 30 years (median 13 years), 15 were female, and most did not use words. Semistructured interviews were conducted via videoconference and analyzed using a conventional content analysis. Three overarching categories were identified: mode, purpose and meaning, and reciprocal exchanges. These categories described the purposes and mechanism of how some individuals with CDD communicate, including underpinning influential factors. Novel categories included expressing a range of emotions, and reciprocal exchanges (two-way interactions that varied in complexity). Caregivers observed many communication modes for multiple purposes. Understanding how individuals with CDD communicate improves understanding of the condition and will guide research to develop accurate measurement for clinical practice and upcoming medication trials.
Collapse
Affiliation(s)
- Jessica Keeley
- Telethon Kids Institute, University of Western Australia, Perth, Western Australia, Australia
| | - Sofia Benson-Goldberg
- Center for Literacy and Disability Studies, Department of Health Sciences, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Jacinta Saldaris
- Telethon Kids Institute, University of Western Australia, Perth, Western Australia, Australia
| | - Judy Lariviere
- Assistive Tech 4 ALL, Inc., Rancho Cordova, California, USA
| | - Helen Leonard
- Telethon Kids Institute, University of Western Australia, Perth, Western Australia, Australia
| | - Eric D Marsh
- Division of Neurology, Children's Hospital of Philadelphia, School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Scott T Demarest
- Department of Pediatrics and Neurology, School of Medicine, University of Colorado Precision Medicine Institute, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Tim A Benke
- Children's Hospital Colorado, Paediatrics and Neurology, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Peter Jacoby
- Telethon Kids Institute, University of Western Australia, Perth, Western Australia, Australia
| | - Jenny Downs
- Telethon Kids Institute, University of Western Australia, Perth, Western Australia, Australia
- Curtin School of Allied Health, Faculty of Health Sciences, Curtin University, Perth, Western Australia, Australia
| |
Collapse
|
2
|
Stansauk J, Fidell A, Benke T, Schaffer M, Demarest ST. Analysis of electrocardiograms in individuals with CDKL5 deficiency disorder. Am J Med Genet A 2023; 191:108-111. [PMID: 36372969 PMCID: PMC9886132 DOI: 10.1002/ajmg.a.62995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Revised: 07/06/2022] [Accepted: 08/24/2022] [Indexed: 11/16/2022]
Abstract
CDKL5 deficiency disorder (CDD) is an epileptic encephalopathy associated with medically refractory epilepsy. We sought to determine whether prolonged corrected QT interval (QTc) or other cardiac conduction abnormalities were seen in CDD in a clinical cohort. A cohort of individuals with CDD was evaluated in the Children's Hospital Colorado's International Foundation for CDKL5 Research designated Center of Excellence clinic with routine electrocardiograms obtained as part of routine clinical care. Retrospective review of electrocardiograms was completed. ECGs from 44 individuals (7 male, 37 female, age range 0-34.5 years) with pathogenic mutations and findings consistent with CDD were evaluated. Multiple ECGs were available from the 44 individuals obtained from 1996 to 2020. Prolonged QTc was found in two individuals (4.5%) and either resolved or was not confirmed on Holter monitor; no additional interventions were performed. A total of 11 individuals had echocardiograms for a variety of indications including unexplained tachycardia and ECG abnormalities; all were normal. Two individuals in the cohort died during the study with no abnormal findings on ECG. The incidence of prolonged QTc or other significant actionable cardiac abnormalities was rare in a cohort of individuals with CDD though was higher than the prevalence seen within the general population. Further studies in a larger, confirmatory cohort over a longer period are needed.
Collapse
Affiliation(s)
- Jessica Stansauk
- Section of Genetics and Metabolism, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, Colorado, USA,Section of Cardiology/Department of Pediatrics, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Andrea Fidell
- Section of Neurology, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Tim Benke
- Section of Neurology, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Michael Schaffer
- Section of Cardiology/Department of Pediatrics, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Scott T. Demarest
- Section of Neurology, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, Colorado, USA
| |
Collapse
|
3
|
Knight EMP, Amin S, Bahi-Buisson N, Benke TA, Cross JH, Demarest ST, Olson HE, Specchio N, Fleming TR, Aimetti AA, Gasior M, Devinsky O, Belyaev O, Ben-Zeev B, Brunklaus A, Ciliberto MA, Darra F, Davis R, De Giorgis V, Doronina O, Fahey M, Guerrini R, Heydemann P, Khaletskaya O, Lisewski P, Marsh ED, Moosa AN, Perry S, Philip S, Rajaraman RR, Renfroe B, Saneto RP, Scheffer IE, Sogawa Y, Suter B, Sweney MT, Tarquinio D, Veggiotti P, Wallace G, Weisenberg J, Wilfong A, Wirrell EC, Zafar M, Zolnowska M. Safety and efficacy of ganaxolone in patients with CDKL5 deficiency disorder: results from the double-blind phase of a randomised, placebo-controlled, phase 3 trial. Lancet Neurol 2022; 21:417-427. [PMID: 35429480 DOI: 10.1016/s1474-4422(22)00077-1] [Citation(s) in RCA: 57] [Impact Index Per Article: 28.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Revised: 02/01/2022] [Accepted: 02/09/2022] [Indexed: 12/27/2022]
Abstract
BACKGROUND CDKL5 deficiency disorder (CDD) is a rare, X-linked, developmental and epileptic encephalopathy characterised by severe global developmental impairment and seizures that can begin in the first few months after birth and are often treatment refractory. Ganaxolone, an investigational neuroactive steroid, reduced seizure frequency in an open-label, phase 2 trial that included patients with CDD. We aimed to further assess the efficacy and safety of ganaxolone in patients with CDD-associated refractory epilepsy. METHODS In the double-blind phase of this randomised, placebo-controlled, phase 3 trial, done at 39 outpatient clinics in eight countries (Australia, France, Israel, Italy, Poland, Russia, the UK, and the USA), patients were eligible if they were aged 2-21 years with a pathogenic or probably pathogenic CDKL5 variant and at least 16 major motor seizures (defined as bilateral tonic, generalised tonic-clonic, bilateral clonic, atonic, or focal to bilateral tonic-clonic) per 28 days in each 4-week period of an 8-week historical period. After a 6-week prospective baseline period, patients were randomly assigned (1:1) via an interactive web response system to receive either enteral adjunctive ganaxolone or matching enteral adjunctive placebo (maximum dose 63 mg/kg per day for patients weighing ≤28 kg or 1800 mg/day for patients weighing >28 kg) for 17 weeks. Patients, caregivers, investigators (including those analysing data), trial staff, and the sponsor (other than the investigational product manager) were masked to treatment allocation. The primary efficacy endpoint was percentage change in median 28-day major motor seizure frequency from the baseline period to the 17-week double-blind phase and was analysed (using a Wilcoxon-rank sum test) in all patients who received at least one dose of trial treatment and for whom baseline data were available. Safety (compared descriptively across groups) was analysed in all patients who received at least one dose of trial treatment. This study is registered with ClinicalTrials.gov, NCT03572933, and the open-label extension phase is ongoing. FINDINGS Between June 25, 2018, and July 2, 2020, 114 patients were screened for eligibility, of whom 101 (median age 6 years [IQR 3 to 10]) were randomly assigned to receive either ganaxolone (n=50) or placebo (n=51). All patients received at least one dose of a study drug, but seizure frequency for one patient in the ganaxolone group was not recorded at baseline and so the primary endpoint was analysed in a population of 100 patients. There was a median percentage change in 28-day major motor seizure frequency of -30·7% (IQR -49·5 to -1·9) in the ganaxolone group and of -6·9% (-24·1 to 39·7) in the placebo group (p=0·0036). The Hodges-Lehmann estimate of median difference in responses to ganaxolone versus placebo was -27·1% (95% CI -47·9 to - 9·6). Treatment-emergent adverse events occurred in 43 (86%) of 50 patients in the ganaxolone group and in 45 (88%) of 51 patients in the placebo group. Somnolence, pyrexia, and upper respiratory tract infections occurred in at least 10% of patients in the ganaxolone group and more frequently than in the placebo group. Serious adverse events occurred in six (12%) patients in the ganaxolone group and in five (10%) patients in the placebo group. Two (4%) patients in the ganaxolone group and four (8%) patients in the placebo group discontinued the trial. There were no deaths in the double-blind phase. INTERPRETATION Ganaxolone significantly reduced the frequency of CDD-associated seizures compared with placebo and was generally well tolerated. Results from what is, to our knowledge, the first controlled trial in CDD suggest a potential treatment benefit for ganaxolone. Long-term treatment is being assessed in the ongoing open-label extension phase of this trial. FUNDING Marinus Pharmaceuticals.
Collapse
Affiliation(s)
- Elia M Pestana Knight
- Epilepsy Center, Cleveland Neurological Institute, Cleveland Clinic, Cleveland, OH, USA.
| | - Sam Amin
- Pediatric Neurology, University Hospitals Bristol and Weston, Bristol, UK
| | - Nadia Bahi-Buisson
- Pediatric Neurology, Necker Enfants Malades University Hospital, Paris, France
| | - Tim A Benke
- Department of Pediatrics and Neurology, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, CO, USA
| | - J Helen Cross
- UCL NIHR BRC Great Ormond Street Institute of Child Health, London, UK
| | - Scott T Demarest
- Department of Pediatrics and Neurology, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, CO, USA
| | - Heather E Olson
- Division of Epilepsy and Clinical Neurophysiology and Epilepsy Genetics Program, Department of Neurology, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | - Nicola Specchio
- Rare and Complex Epilepsy Unit, Department of Neuroscience, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Thomas R Fleming
- Department of Biostatistics, University of Washington, Seattle, WA, USA
| | | | | | - Orrin Devinsky
- New York University Langone Comprehensive Epilepsy Center, New York, NY, USA
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
4
|
Olson HE, Daniels CI, Haviland I, Swanson LC, Greene CA, Denny AMM, Demarest ST, Pestana-Knight E, Zhang X, Moosa AN, Fidell A, Weisenberg JL, Suter B, Fu C, Neul JL, Percy AK, Marsh ED, Benke TA, Poduri A. Current neurologic treatment and emerging therapies in CDKL5 deficiency disorder. J Neurodev Disord 2021; 13:40. [PMID: 34530725 PMCID: PMC8447578 DOI: 10.1186/s11689-021-09384-z] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Accepted: 08/16/2021] [Indexed: 12/05/2022] Open
Abstract
Background CDKL5 deficiency disorder (CDD) is associated with refractory infantile onset epilepsy, global developmental delay, and variable features that include sleep, behavioral disturbances, and movement disorders. Current treatment is primarily symptom-based and informed by experience in caring for this population. Methods We describe medication and non-medication approaches to treatment of epilepsy and additional key neurologic symptoms (sleep disturbances, behavioral issues, movement disorders, and swallowing dysfunction) in a cohort of 177 individuals meeting criteria for CDD, 154 evaluated at 4 CDKL5 Centers of Excellence in the USA and 40 identified through the NIH Natural History Study of Rett and Related Disorders. Results The four most frequently prescribed anti-seizure medications were broad spectrum, prescribed in over 50% of individuals. While the goal was not to ascertain efficacy, we obtained data from 86 individuals regarding response to treatment, with 2-week response achieved in 14–48% and sustained 3-month response in 5–36%, of those with known response. Additional treatments for seizures included cannabis derivatives, tried in over one-third of individuals, and clinical trial medications. In combination with pharmacological treatment, 50% of individuals were treated with ketogenic diet for attempted seizure control. Surgical approaches included vagus nerve stimulators, functional hemispherectomy, and corpus callosotomy, but numbers were too limited to assess response. Nearly one-third of individuals received pharmacologic treatment for sleep disturbances, 13% for behavioral dysregulation and movement disorders, and 43% had gastrostomy tubes. Conclusions Treatment for neurologic features of CDD is currently symptom-based and empiric rather than CDD-specific, though clinical trials for CDD are emerging. Epilepsy in this population is highly refractory, and no specific anti-seizure medication was associated with improved seizure control. Ketogenic diet is commonly used in patients with CDD. While behavioral interventions are commonly instituted, information on the use of medications for sleep, behavioral management, and movement disorders is sparse and would benefit from further characterization and optimization of treatment approaches. The heterogeneity in treatment approaches highlights the need for systematic review and guidelines for CDD. Additional disease-specific and disease-modifying treatments are in development. Supplementary Information The online version contains supplementary material available at 10.1186/s11689-021-09384-z.
Collapse
Affiliation(s)
- Heather E Olson
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, 300 Longwood Avenue, Mailstop 3063, Boston, MA, 02115, USA.
| | - Carolyn I Daniels
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, 300 Longwood Avenue, Mailstop 3063, Boston, MA, 02115, USA
| | - Isabel Haviland
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, 300 Longwood Avenue, Mailstop 3063, Boston, MA, 02115, USA
| | - Lindsay C Swanson
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, 300 Longwood Avenue, Mailstop 3063, Boston, MA, 02115, USA
| | - Caitlin A Greene
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, 300 Longwood Avenue, Mailstop 3063, Boston, MA, 02115, USA
| | - Anne Marie M Denny
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, 300 Longwood Avenue, Mailstop 3063, Boston, MA, 02115, USA.,Division of Pediatric Neurology, University of Saskatchewan, Saskatoon, SK, Canada
| | - Scott T Demarest
- Children's Hospital Colorado, University of Colorado, School of Medicine, Aurora, CO, USA.,Department of Pediatrics, School of Medicine, University of Colorado, Aurora, CO, USA
| | - Elia Pestana-Knight
- Epilepsy Center, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Xiaoming Zhang
- Epilepsy Center, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Ahsan N Moosa
- Epilepsy Center, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Andrea Fidell
- Children's Hospital Colorado, University of Colorado, School of Medicine, Aurora, CO, USA.,Department of Pediatrics, School of Medicine, University of Colorado, Aurora, CO, USA
| | - Judith L Weisenberg
- Department of Pediatric Neurology, Washington University School of Medicine, St. Louis, MO, USA
| | - Bernhard Suter
- Division of Child Neurology, Texas Children's Hospital, Departments of Neurology and Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Cary Fu
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jeffrey L Neul
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Alan K Percy
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Eric D Marsh
- Division of Child Neurology, Children's Hospital of Philadelphia, Departments of Neurology and Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Timothy A Benke
- Children's Hospital Colorado, University of Colorado, School of Medicine, Aurora, CO, USA.,Department of Pediatrics, School of Medicine, University of Colorado, Aurora, CO, USA.,Departments of Pharmacology, Neurology, and Otolaryngology, School of Medicine, University of Colorado, Aurora, CO, USA
| | - Annapurna Poduri
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, 300 Longwood Avenue, Mailstop 3063, Boston, MA, 02115, USA
| |
Collapse
|
5
|
MacKay CI, Wong K, Demarest ST, Benke TA, Downs J, Leonard H. Exploring genotype-phenotype relationships in the CDKL5 deficiency disorder using an international dataset. Clin Genet 2020; 99:157-165. [PMID: 33047306 DOI: 10.1111/cge.13862] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [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: 06/10/2020] [Revised: 09/20/2020] [Accepted: 10/09/2020] [Indexed: 12/24/2022]
Abstract
Characterized by early-onset seizures, global developmental delay and severe motor deficits, CDKL5 deficiency disorder is caused by pathogenic variants in the cyclin-dependent kinase-like 5 gene. Previous efforts to investigate genotype-phenotype relationships have been limited due to small numbers of recurrent mutations and small cohort sizes. Using data from the International CDKL5 Disorder Database we examined genotype-phenotype relationships for 13 recurrent CDKL5 variants and the previously analyzed historic variant groupings. We have applied the CDKL5 Developmental Score (CDS) and an adapted version of the CDKL5 Clinical Severity Assessment (CCSA), to grade the severity of phenotype and developmental outcomes for 285 individuals with CDKL5 variants. Comparisons of adapted CCSA and CDS between recurrent variants and variant groups were performed using multiple linear regression adjusting for age and sex. Individuals with the missense variant, p.Arg178Trp, had the highest mean adapted CCSA and lowest mean developmental scores. Other variants producing severe phenotypes included p.Arg559* and p.Arg178Gln. Variants producing milder phenotypes included p.Arg134*, p.Arg550*, and p.Glu55Argfs*20. There are observed differences in phenotype severity and developmental outcomes for individuals with different CDKL5 variants. However, the historic variant groupings did not seem to reflect differences in phenotype severity or developmental outcomes as clearly as analyzed by individual variants.
Collapse
Affiliation(s)
- Conor I MacKay
- Telethon Kids Institute, The University of Western Australia, Perth, Western Australia, Australia
| | - Kingsley Wong
- Telethon Kids Institute, The University of Western Australia, Perth, Western Australia, Australia
| | - Scott T Demarest
- Children's Hospital Colorado, Aurora, Colorado, USA.,Departments of Pediatrics and Neurology, University of Colorado at Denver, Aurora, Colorado, USA
| | - Tim A Benke
- Children's Hospital Colorado, Aurora, Colorado, USA.,Departments of Pediatrics, Pharmacology, Neurology and Otolaryngology, University of Colorado at Denver, Aurora, Colorado, USA
| | - Jenny Downs
- Telethon Kids Institute, The University of Western Australia, Perth, Western Australia, Australia.,School of Physiotherapy and Exercise Science, Curtin University, Perth, Western Australia, Australia
| | - Helen Leonard
- Telethon Kids Institute, The University of Western Australia, Perth, Western Australia, Australia
| |
Collapse
|
6
|
Olson HE, Demarest ST, Pestana-Knight EM, Swanson LC, Iqbal S, Lal D, Leonard H, Cross JH, Devinsky O, Benke TA. Cyclin-Dependent Kinase-Like 5 Deficiency Disorder: Clinical Review. Pediatr Neurol 2019; 97:18-25. [PMID: 30928302 PMCID: PMC7120929 DOI: 10.1016/j.pediatrneurol.2019.02.015] [Citation(s) in RCA: 127] [Impact Index Per Article: 25.4] [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: 01/06/2019] [Revised: 01/21/2019] [Accepted: 02/16/2019] [Indexed: 01/08/2023]
Abstract
Cyclin-dependent kinase-like 5 (CDKL5) deficiency disorder (CDD) is a developmental encephalopathy caused by pathogenic variants in the gene CDKL5. This unique disorder includes early infantile onset refractory epilepsy, hypotonia, developmental intellectual and motor disabilities, and cortical visual impairment. We review the clinical presentations and genetic variations in CDD based on a systematic literature review and experience in the CDKL5 Centers of Excellence. We propose minimum diagnostic criteria. Pathogenic variants include deletions, truncations, splice variants, and missense variants. Pathogenic missense variants occur exclusively within the kinase domain or affect splice sites. The CDKL5 protein is widely expressed in the brain, predominantly in neurons, with roles in cell proliferation, neuronal migration, axonal outgrowth, dendritic morphogenesis, and synapse development. The molecular biology of CDD is revealing opportunities in precision therapy, with phase 2 and 3 clinical trials underway or planned to assess disease specific and disease modifying treatments.
Collapse
Affiliation(s)
- Heather E Olson
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Boston, Massachusetts.
| | - Scott T Demarest
- Children's Hospital Colorado, University of Colorado, School of Medicine, Aurora, Colorado; Department of Pediatrics, University of Colorado, School of Medicine, Aurora, Colorado
| | - Elia M Pestana-Knight
- Cleveland Clinic Neurological Institute Epilepsy Center, Cleveland Clinic Neurological Institute Pediatric Neurology Department, Neurogenetics, Cleveland Clinic Children's, Cleveland, Ohio
| | - Lindsay C Swanson
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Boston, Massachusetts
| | - Sumaiya Iqbal
- Stanley Center for Psychiatric Research, Broad Institute of MIT and Harvard, Cambridge, Massachusetts; Analytic and Translational Genetics Unit, Massachusetts General Hospital, Boston, Massachusetts
| | - Dennis Lal
- Stanley Center for Psychiatric Research, Broad Institute of MIT and Harvard, Cambridge, Massachusetts; Genomic Medicine Institute, Cleveland Clinic, Cleveland, Ohio; Neurological Institute, Cleveland Clinic, Cleveland, Ohio
| | - Helen Leonard
- Telethon Kids Institute, University of Western Australia, Perth, WA, Australia
| | - J Helen Cross
- UCL Great Ormond Street NIHR BRC Institute of Child Health, London, UK
| | - Orrin Devinsky
- Department of Neurology, NYU Langone Health, New York, New York
| | - Tim A Benke
- Children's Hospital Colorado, University of Colorado, School of Medicine, Aurora, Colorado; Department of Pediatrics, University of Colorado, School of Medicine, Aurora, Colorado; Department of Pharmacology, University of Colorado, School of Medicine, Aurora, Colorado; Department of Neurology, University of Colorado, School of Medicine, Aurora, Colorado; Department of Otolaryngology, University of Colorado, School of Medicine, Aurora, Colorado
| |
Collapse
|
7
|
Demarest ST, Olson HE, Moss A, Pestana-Knight E, Zhang X, Parikh S, Swanson LC, Riley KD, Bazin GA, Angione K, Niestroj LM, Lal D, Juarez-Colunga E, Benke TA. CDKL5 deficiency disorder: Relationship between genotype, epilepsy, cortical visual impairment, and development. Epilepsia 2019; 60:1733-1742. [PMID: 31313283 PMCID: PMC7098045 DOI: 10.1111/epi.16285] [Citation(s) in RCA: 85] [Impact Index Per Article: 17.0] [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: 12/13/2018] [Revised: 06/20/2019] [Accepted: 06/20/2019] [Indexed: 01/15/2023]
Abstract
OBJECTIVE The cyclin-dependent kinase like 5 (CDKL5) gene is a known cause of early onset developmental and epileptic encephalopathy, also known as CDKL5 deficiency disorder (CDD). We sought to (1) provide a description of seizure types in patients with CDD, (2) provide an assessment of the frequency of seizure-free periods and cortical visual impairment (CVI), (3) correlate these features with genotype and gender, and (4) correlate these features with developmental milestones. METHODS This is a cohort study of patients with CDD. Phenotypic features were explored and correlated with gene variant grouping and gender. A developmental score was created based on achieving seven primary milestones. Phenotypic variables were correlated with the developmental score to explore markers of better developmental outcomes. Multivariate linear regression was used to account for age at last visit. RESULTS Ninety-two patients with CDD were seen during the enrollment period. Eighteen were male (19%); median age at last visit was 5 years (interquartile range = 2.0-11.0). Eighty-one percent of patients developed epileptic spasms, but only 47% of those also had hypsarrhythmia. Previously described hypermotor-tonic-spasms sequence was seen in only 24% of patients, but 56% of patients had seizures with multiple phases (often tonic and spasms). Forty-three percent of patients experienced a seizure-free period ranging from 1 to >12 months, but only 6% were still seizure-free at the last visit. CVI was present in 75% of all CDD patients. None of these features was associated with genotype group or gender. CVI was correlated with reduced milestone achievement after adjusting for age at last visit and a history of hypsarrhythmia. SIGNIFICANCE The most common seizure types in CDD are epileptic spasms (often without hypsarrhythmia) and tonic seizures that may cluster together. CVI is a common feature in CDD and is correlated with achieving fewer milestones.
Collapse
Affiliation(s)
- Scott T Demarest
- Children's Hospital Colorado, Aurora, Colorado
- Adult and Child Consortium for Health Outcomes Research and Delivery Science, Aurora, Colorado
- University of Colorado School of Medicine, Aurora, Colorado
- Department of Pediatrics, Colorado School of Public Health, Aurora, Colorado
- Department of Neurology, Colorado School of Public Health, Aurora, Colorado
| | - Heather E Olson
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Boston, Massachusetts
| | - Angela Moss
- Adult and Child Consortium for Health Outcomes Research and Delivery Science, Aurora, Colorado
| | - Elia Pestana-Knight
- Epilepsy Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
- Department of Neurology, Lerner Research Institute, Cleveland, Ohio
- Genomic Medicine Institute, Lerner Research Institute, Cleveland, Ohio
| | - Xiaoming Zhang
- Epilepsy Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
- Department of Neurology, Lerner Research Institute, Cleveland, Ohio
- Genomic Medicine Institute, Lerner Research Institute, Cleveland, Ohio
| | - Sumit Parikh
- Genomic Medicine Institute, Lerner Research Institute, Cleveland, Ohio
- Department of Neurogenetics, Lerner Research Institute, Cleveland, Ohio
| | - Lindsay C Swanson
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Boston, Massachusetts
| | - Katherine D Riley
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Boston, Massachusetts
| | - Grace A Bazin
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Boston, Massachusetts
| | - Katie Angione
- Children's Hospital Colorado, Aurora, Colorado
- University of Colorado School of Medicine, Aurora, Colorado
| | | | - Dennis Lal
- Epilepsy Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
- Genomic Medicine Institute, Lerner Research Institute, Cleveland, Ohio
- Cologne Center for Genomics, University of Cologne, Cologne, Germany
- Cleveland Clinic Children's, Cleveland, Ohio
- Stanley Center for Psychiatric Research, Cambridge, Massachusetts
- Broad Institute of Massachusetts Institute of Technology and Harvard, Cambridge, Massachusetts
| | - Elizabeth Juarez-Colunga
- Adult and Child Consortium for Health Outcomes Research and Delivery Science, Aurora, Colorado
- Department of Biostatistics and Informatics, Colorado School of Public Health, Aurora, Colorado
| | - Tim A Benke
- Children's Hospital Colorado, Aurora, Colorado
- University of Colorado School of Medicine, Aurora, Colorado
- Department of Pediatrics, Colorado School of Public Health, Aurora, Colorado
- Department of Neurology, Colorado School of Public Health, Aurora, Colorado
- Department of Pharmacology, Colorado School of Public Health, Aurora, Colorado
- Department of Otolaryngology, Colorado School of Public Health, Aurora, Colorado
| |
Collapse
|
8
|
Eschbach K, Moss A, Joshi C, Angione K, Smith G, Dempsey A, Juarez-Colunga E, Demarest ST. Diagnosis switching and outcomes in a cohort of patients with potential epilepsy with myoclonic-atonic seizures. Epilepsy Res 2018; 147:95-101. [PMID: 30286391 DOI: 10.1016/j.eplepsyres.2018.09.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [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: 08/17/2018] [Revised: 09/06/2018] [Accepted: 09/21/2018] [Indexed: 12/22/2022]
Abstract
INTRODUCTION There is overlap in the electroclinical features of many childhood epilepsy syndromes, especially those presenting with multiple seizure types, such as epilepsy with myoclonic-atonic seizures (EMAS) and Lennox-Gastaut syndrome (LGS). This study aimed to determine the frequency of diagnosis switching and the factors influencing epilepsy syndrome diagnosis in a cohort of children with possible EMAS, as well as to explore the relationship between epilepsy syndrome diagnoses, key electroclinical features, and clinically relevant outcomes. METHODS This is a cross-sectional retrospective chart review of children treated at the Children's Hospital of Colorado with a potential diagnosis of EMAS. RESULTS There were 77 patients that met eligibility criteria, including 39% (n = 30) with an initial diagnosis of EMAS and 74% (n = 57) with a final diagnosis of EMAS. On average, for the 65% of patients who received more than one epilepsy diagnosis, the first, second, and third diagnoses were received within one year, three years, and ten years after epilepsy onset, respectively. Final diagnosis was significantly related to obtaining at least a six-month period of seizure freedom, p = 0.03. Classic LGS traits, including paroxysmal fast activity, slow spike-and-wave, and tonic seizures were present in 50% of the overall cohort, although a minority of these patients had a final diagnosis of LGS. However, the presence of more LGS traits was associated with a higher likelihood of ongoing seizures. Adjusted for age of epilepsy onset, seizure freedom was half as likely for every additional LGS trait observed (0.49[0.31, 0.77], p = 0.002). CONCLUSION Current epilepsy syndrome classification has reduced applicability due to overlapping features. This results in diagnosis switching and limited prognostic value for patients with an overlapping clinical phenotype. Future studies should attempt to stratify patients based not only on epilepsy syndrome diagnosis, but also on the presence of various electroclinical traits to more accurately predict outcome.
Collapse
Affiliation(s)
- Krista Eschbach
- Department of Pediatrics, Section of Neurology, Children's Hospital of Colorado, University of Colorado Anschutz Medical Campus, Aurora, CO, USA.
| | - Angela Moss
- Adult and Child Center for Health Outcomes and Delivery Science, University of Colorado Anschutz Medical Campus, Colorado School of Public Health, Aurora, CO, USA.
| | - Charuta Joshi
- Department of Pediatrics, Section of Neurology, Children's Hospital of Colorado, University of Colorado Anschutz Medical Campus, Aurora, CO, USA.
| | - Katie Angione
- Department of Pediatrics, Section of Neurology, Children's Hospital of Colorado, University of Colorado Anschutz Medical Campus, Aurora, CO, USA.
| | - Garnett Smith
- Department of Pediatrics, Section of Neurology, Children's Hospital of Colorado, University of Colorado Anschutz Medical Campus, Aurora, CO, USA.
| | - Amanda Dempsey
- Adult and Child Center for Health Outcomes and Delivery Science, University of Colorado Anschutz Medical Campus, Colorado School of Public Health, Aurora, CO, USA; Department of Pediatrics, Children's Hospital of Colorado, University of Colorado Anschutz Medical Campus, Aurora, CO, USA.
| | - Elizabeth Juarez-Colunga
- Adult and Child Center for Health Outcomes and Delivery Science, University of Colorado Anschutz Medical Campus, Colorado School of Public Health, Aurora, CO, USA.
| | - Scott T Demarest
- Department of Pediatrics, Section of Neurology, Children's Hospital of Colorado, University of Colorado Anschutz Medical Campus, Aurora, CO, USA.
| |
Collapse
|
9
|
Demarest ST, Shellhaas RA, Gaillard WD, Keator C, Nickels KC, Hussain SA, Loddenkemper T, Patel AD, Saneto RP, Wirrell E, Sánchez Fernández I, Chu CJ, Grinspan Z, Wusthoff CJ, Joshi S, Mohamed IS, Stafstrom CE, Stack CV, Yozawitz E, Bluvstein JS, Singh RK, Knupp KG. The impact of hypsarrhythmia on infantile spasms treatment response: Observational cohort study from the National Infantile Spasms Consortium. Epilepsia 2017; 58:2098-2103. [PMID: 29105055 DOI: 10.1111/epi.13937] [Citation(s) in RCA: 42] [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] [Accepted: 10/02/2017] [Indexed: 12/31/2022]
Abstract
OBJECTIVE The multicenter National Infantile Spasms Consortium prospective cohort was used to compare outcomes and phenotypic features of patients with infantile spasms with and without hypsarrhythmia. METHODS Patients aged 2 months to 2 years were enrolled prospectively with new-onset infantile spasms. Treatment choice and categorization of hypsarrhythmia were determined clinically at each site. Response to therapy was defined as resolution of clinical spasms (and hypsarrhythmia if present) without relapse 3 months after initiation. RESULTS Eighty-two percent of patients had hypsarrhythmia, but this was not associated with gender, mean age, preexisting developmental delay or epilepsy, etiology, or response to first-line therapy. Infants with hypsarrhythmia were more likely to receive standard treatment (adrenocorticotropic hormone, prednisolone, or vigabatrin [odds ratio (OR) 2.6, 95% confidence interval (CI) 1.4-4.7] and preexisting epilepsy reduced the likelihood of standard treatment (OR 3.2, 95% CI 1.9-5.4). Hypsarrhythmia was not a determinant of response to treatment. A logistic regression model demonstrated that later age of onset (OR 1.09 per month, 95% CI 1.03-1.15) and absence of preexisting epilepsy (OR 1.7, 95% CI 1.06-2.81) had a small impact on the likelihood of responding to the first-line treatment. However, receiving standard first-line treatment increased the likelihood of responding dramatically: vigabatrin (OR 5.2 ,95% CI 2-13.7), prednisolone (OR 8, 95% CI 3.1-20.6), and adrenocorticotropic hormone (ACTH; OR 10.2, 95% CI 4.1-25.8) . SIGNIFICANCE First-line treatment with standard therapy was by far the most important variable in determining likelihood of response to treatment of infantile spasms with or without hypsarrhythmia.
Collapse
Affiliation(s)
- Scott T Demarest
- Departments of Pediatrics and Neurology, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, U.S.A
| | - Renée A Shellhaas
- Departments of Pediatrics & Communicable Diseases (Division of Pediatric Neurology), University of Michigan, Ann Arbor, Michigan, U.S.A
| | - William D Gaillard
- Center for Neuroscience, Children's National Health System, Washington, District of Columbia, U.S.A
| | - Cynthia Keator
- Jane and John Justin Neurosciences Department, Cook Children's Hospital, Fort Worth, Texas, U.S.A
| | - Katherine C Nickels
- Departments of Neurology and Pediatrics, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Shaun A Hussain
- Department of Pediatric Neurology, Mattel Children's Hospital at UCLA, Los Angeles, California, U.S.A
| | - Tobias Loddenkemper
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Boston, Massachusetts, U.S.A
| | - Anup D Patel
- Departments of Neurology and Pediatrics, Nationwide Children's Hospital and the Ohio State University College of Medicine, Columbus, Ohio, U.S.A
| | - Russell P Saneto
- Department of Neurology/Division of Pediatric Neurology, Seattle Children's Hospital University of Washington, Seattle, Washington, U.S.A
| | - Elaine Wirrell
- Departments of Neurology and Pediatrics, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Iván Sánchez Fernández
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Boston, Massachusetts, U.S.A
| | - Catherine J Chu
- Department of Neurology, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts, U.S.A
| | - Zachary Grinspan
- Departments of Healthcare Policy & Research and Department of Pediatrics, Weill Cornell Medical Center, New York, New York, U.S.A
| | - Courtney J Wusthoff
- Division of Child Neurology, Stanford University, Palo Alto, California, U.S.A
| | - Sucheta Joshi
- Departments of Pediatrics & Communicable Diseases (Division of Pediatric Neurology), University of Michigan, Ann Arbor, Michigan, U.S.A
| | - Ismail S Mohamed
- Division of Neurology, Department of Pediatrics, University of Alabama, Birmingham, Alabama, U.S.A
| | - Carl E Stafstrom
- Departments of Neurology and Pediatrics, Johns Hopkins Hospital, Baltimore, Maryland, U.S.A
| | - Cynthia V Stack
- Departments of Pediatrics and Neurology, Division of Child Neurology, Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois, U.S.A
| | - Elissa Yozawitz
- Departments of Neurology and Pediatrics, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, U.S.A
| | - Judith S Bluvstein
- Departments of Neurology and Pediatrics, NYU School of Medicine, New York, New York, U.S.A
| | - Rani K Singh
- Department of Neurology, Carolinas Healthcare System, Charlotte, North Carolina, U.S.A
| | - Kelly G Knupp
- Departments of Pediatrics and Neurology, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, U.S.A
| | | |
Collapse
|
10
|
Demarest ST, Whitehead MT, Turnacioglu S, Pearl PL, Gropman AL. Phenotypic analysis of epilepsy in the mitochondrial encephalomyopathy, lactic acidosis, and strokelike episodes-associated mitochondrial DNA A3243G mutation. J Child Neurol 2014; 29:1249-56. [PMID: 25038129 DOI: 10.1177/0883073814538511] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
The A to G mitochondrial DNA point mutation at position 3243 (A3243G) is the most common cause of mitochondrial encephalomyopathy, lactic acidosis, and strokelike episodes (MELAS), a systemic multiorgan disease. Epilepsy is a common finding but there is wide phenotypic variation that has not been thoroughly explored. We report the epilepsy phenotypes of 7 patients with the A3243G mutation. Most presented with typical MELAS and epilepsy characterized by infrequent prolonged focal seizures, including epilepsia partialis continua, hemiclonic status epilepticus, nonconvulsive status, and occipital status epilepticus. Seizures usually occurred during the acute phase of a strokelike episode. Periodic lateralized epileptiform discharges may be seen electrographically. Some patients with this mutation are completely asymptomatic or have mild symptoms typical for mitochondrial diseases. Slow spike-wave activity consistent with Lennox-Gastaut syndrome and electrographic status epilepticus was seen in 1 patient who responded to ethosuximide.
Collapse
Affiliation(s)
- Scott T Demarest
- Children's National Medical Center, The George Washington University School of Medicine, Washington, DC, USA
| | - Matthew T Whitehead
- Children's National Medical Center, The George Washington University School of Medicine, Washington, DC, USA
| | - Sinan Turnacioglu
- Children's National Medical Center, The George Washington University School of Medicine, Washington, DC, USA
| | - Phillip L Pearl
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Andrea L Gropman
- Children's National Medical Center, The George Washington University School of Medicine, Washington, DC, USA
| |
Collapse
|