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Kobayashi K, Shibata T, Tsuchiya H, Akiyama M, Akiyama T. Hypotheses of pathophysiological mechanisms in epileptic encephalopathies: A review. Brain Dev 2025; 47:104318. [PMID: 39787996 DOI: 10.1016/j.braindev.2024.104318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2024] [Revised: 12/25/2024] [Accepted: 12/26/2024] [Indexed: 01/12/2025]
Abstract
INTRODUCTION Epileptic encephalopathy (EE) is a serious clinical issue that manifests as part of developmental and epileptic encephalopathy (DEE), particularly in childhood epilepsy. In EE, neurocognitive functions and behavior are impaired by intense epileptiform electroencephalogram (EEG) activity. Hypotheses of pathophysiological mechanisms behind EE are reviewed to contribute to an effective solution for EE. REVIEW Current hypotheses are as follows: 1) neuronal dysfunction based on genetic abnormalities that may affect neurocognitive functions and epilepsy separately; 2) impairment of synaptic homeostasis during sleep that may be responsible for DEE/EE with spike-and-wave activation in sleep; 3) abnormal subcortical regulation of the cerebral cortex; 4) abnormal cortical metabolism and hemodynamics with impairment of the neural network including default mode network; 5) neurotransmitter imbalance and disordered neural excitability; 6) the effects of neuroinflammation that may be caused by epileptic seizures and in turn aggravate epileptogenesis; 7) the interaction between physiological and pathological high-frequency EEG activity; etc. The causal relationship between epileptiform EEG activity and neurocognitive dysfunctions is small in DEE based on genetic abnormalities and it is largely unestablished in the other hypothetical mechanisms. CONCLUSION We have not yet found answers to the question of whether the single-central or multiple derangements are present and what seizures and intense epileptiform EEG abnormalities mean in EE. We need to continue our best efforts in both aspects to elucidate the pathophysiological mechanisms of DEE/EE and further develop epilepsy treatment and precision medicine.
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Affiliation(s)
- Katsuhiro Kobayashi
- Department of Pediatrics, Asahigawaso Rehabilitation and Medical Center, Okayama, Japan.
| | - Takashi Shibata
- Department of Pediatric Neurology, Okayama University Hospital and Faculty of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Okayama, Japan
| | - Hiroki Tsuchiya
- Department of Pediatric Neurology, Okayama University Hospital and Faculty of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Okayama, Japan
| | - Mari Akiyama
- Department of Pediatric Neurology, Okayama University Hospital and Faculty of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Okayama, Japan
| | - Tomoyuki Akiyama
- Department of Pediatric Neurology, Okayama University Hospital and Faculty of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Okayama, Japan
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Mizuguchi M, Ichiyama T, Imataka G, Okumura A, Goto T, Sakuma H, Takanashi JI, Murayama K, Yamagata T, Yamanouchi H, Fukuda T, Maegaki Y. Guidelines for the diagnosis and treatment of acute encephalopathy in childhood. Brain Dev 2021; 43:2-31. [PMID: 32829972 DOI: 10.1016/j.braindev.2020.08.001] [Citation(s) in RCA: 84] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 08/04/2020] [Accepted: 08/04/2020] [Indexed: 12/16/2022]
Abstract
The cardinal symptom of acute encephalopathy is impairment of consciousness of acute onset during the course of an infectious disease, with duration and severity meeting defined criteria. Acute encephalopathy consists of multiple syndromes such as acute necrotizing encephalopathy, acute encephalopathy with biphasic seizures and late reduced diffusion and clinically mild encephalitis/encephalopathy with reversible splenial lesion. Among these syndromes, there are both similarities and differences. In 2016, the Japanese Society of Child Neurology published 'Guidelines for the Diagnosis and Treatment of Acute Encephalopathy in Childhood', which made recommendations and comments on the general aspects of acute encephalopathy in the first half, and on individual syndromes in the latter half. Since the guidelines were written in Japanese, this review article describes extracts from the recommendations and comments in English, in order to introduce the essence of the guidelines to international clinicians and researchers.
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Affiliation(s)
- Masashi Mizuguchi
- Committee for the Compilation of Guidelines for the Diagnosis and Treatment of Acute Encephalopathy in Childhood, Japanese Society of Child Neurology, Tokyo, Japan; Department of Developmental Medical Sciences, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.
| | - Takashi Ichiyama
- Committee for the Compilation of Guidelines for the Diagnosis and Treatment of Acute Encephalopathy in Childhood, Japanese Society of Child Neurology, Tokyo, Japan; Division of Pediatrics, Tsudumigaura Medical Center for Children with Disabilities, Yamaguchi, Japan
| | - George Imataka
- Committee for the Compilation of Guidelines for the Diagnosis and Treatment of Acute Encephalopathy in Childhood, Japanese Society of Child Neurology, Tokyo, Japan; Department of Pediatrics, Dokkyo Medical University, Tochigi, Japan
| | - Akihisa Okumura
- Committee for the Compilation of Guidelines for the Diagnosis and Treatment of Acute Encephalopathy in Childhood, Japanese Society of Child Neurology, Tokyo, Japan; Department of Pediatrics, Aichi Medical University, Aichi, Japan
| | - Tomohide Goto
- Committee for the Compilation of Guidelines for the Diagnosis and Treatment of Acute Encephalopathy in Childhood, Japanese Society of Child Neurology, Tokyo, Japan; Division of Neurology, Kanagawa Children's Medical Center, Kanagawa, Japan
| | - Hiroshi Sakuma
- Committee for the Compilation of Guidelines for the Diagnosis and Treatment of Acute Encephalopathy in Childhood, Japanese Society of Child Neurology, Tokyo, Japan; Department of Brain and Neurosciences, Tokyo Metropolitan Institute of Medical Science, Tokyo, Japan
| | - Jun-Ichi Takanashi
- Committee for the Compilation of Guidelines for the Diagnosis and Treatment of Acute Encephalopathy in Childhood, Japanese Society of Child Neurology, Tokyo, Japan; Department of Pediatrics, Tokyo Women's Medical University Yachiyo Medical Center, Yachiyo, Japan
| | - Kei Murayama
- Committee for the Compilation of Guidelines for the Diagnosis and Treatment of Acute Encephalopathy in Childhood, Japanese Society of Child Neurology, Tokyo, Japan; Department of Metabolism, Chiba Children's Hospital, Chiba, Japan
| | - Takanori Yamagata
- Committee for the Compilation of Guidelines for the Diagnosis and Treatment of Acute Encephalopathy in Childhood, Japanese Society of Child Neurology, Tokyo, Japan; Department of Pediatrics, Jichi Medical University, Tochigi, Japan
| | - Hideo Yamanouchi
- Committee for the Compilation of Guidelines for the Diagnosis and Treatment of Acute Encephalopathy in Childhood, Japanese Society of Child Neurology, Tokyo, Japan; Department of Pediatrics, Comprehensive Epilepsy Center, Saitama Medical University, Saitama, Japan
| | - Tokiko Fukuda
- Department of Pediatrics, Hamamatsu University School of Medicine, Hamamatsu, Japan; Committee for the Integration of Guidelines, Japanese Society of Child Neurology, Tokyo, Japan
| | - Yoshihiro Maegaki
- Committee for the Integration of Guidelines, Japanese Society of Child Neurology, Tokyo, Japan; Division of Child Neurology, Department of Brain and Neurosciences, Faculty of Medicine, Tottori University, Yonago, Japan
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Kessi M, Liu F, Zhan Y, Tang Y, Wu L, Yang L, Zhang CL, Yin F, Peng J. Efficacy of different treatment modalities for acute and chronic phases of the febrile infection-related epilepsy syndrome: A systematic review. Seizure 2020; 79:61-68. [DOI: 10.1016/j.seizure.2020.04.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Revised: 04/23/2020] [Accepted: 04/30/2020] [Indexed: 01/17/2023] Open
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Sakuma H, Horino A, Kuki I. Neurocritical care and target immunotherapy for febrile infection-related epilepsy syndrome. Biomed J 2020; 43:205-210. [PMID: 32330681 PMCID: PMC7424090 DOI: 10.1016/j.bj.2020.03.009] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 03/29/2020] [Accepted: 03/30/2020] [Indexed: 01/15/2023] Open
Abstract
Febrile infection-related epilepsy syndrome (FIRES) is an intractable neurological disease characterized by an unexplained refractory status epilepticus triggered by febrile infection. A Consensus definition of FIRES was proposed in 2018, and its clinical features and prognosis are gradually being clarified. However, the development of effective treatments has been hindered as the etiology of this rare disease is as yet unelucidated. The basic approach to the management of FIRES, like other forms of epilepsy, is based on the control of seizures, however seizures are extremely intractable and require intravenous administration of large doses of anticonvulsants, mainly barbiturates. This treatment strategy produces various complications including respiratory depression and drug hypersensitivity syndrome, which make it more difficult to control seizures. Consequently, it is crucial to predict these events and to formulate a planned treatment strategy. As well, it is important to grow out of conventional treatment strategies that rely on only anticonvulsants, and alternative therapies are gradually being developed. One such example is the adoption of a ketogenic diet which may lead to reduced convulsions as well as improve intellectual prognosis. Further, overproduction of inflammatory cytokines in the central nervous system has been shown to be strongly related to the pathology of FIRES which has led to attempts at immunomodulation therapy including anti-cytokine therapy.
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Affiliation(s)
- Hiroshi Sakuma
- Department of Brain Development and Neural Regeneration, Tokyo Metropolitan Institute of Medical Science, Tokyo, Japan.
| | - Asako Horino
- Department of Brain Development and Neural Regeneration, Tokyo Metropolitan Institute of Medical Science, Tokyo, Japan; Department of Pediatric Neurology, Children's Medical Center, Osaka City General Hospital, Osaka, Japan
| | - Ichiro Kuki
- Department of Pediatric Neurology, Children's Medical Center, Osaka City General Hospital, Osaka, Japan
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Early risk factors for mortality in children with seizure and/or impaired consciousness accompanied by fever without known etiology. Brain Dev 2018; 40:552-557. [PMID: 29567266 DOI: 10.1016/j.braindev.2018.02.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Revised: 02/27/2018] [Accepted: 02/28/2018] [Indexed: 12/14/2022]
Abstract
BACKGROUND Children who present with seizure and/or impaired consciousness accompanied by fever without known etiology (SICF) may be diagnosed with either acute encephalopathy (AE) or febrile seizure (FS). Although approximately 5% of AE cases are fatal, it is difficult to identify fatal cases among children with SICF, which are often critical by the time of diagnosis. Thus, early prediction of outcomes for children with SICF, prior to diagnosis, may help to reduce mortality associated with AE. The aim of the present study was to identify clinical and laboratory risk factors for mortality acquired within 6 h of onset among children with SICF. METHODS We retrospectively reviewed the medical records of children who had been admitted to Kobe Children's Hospital (Kobe, Japan) with SICF between October 2002 and September 2015. We compared clinical and laboratory characteristics acquired within 6 h of onset and outcomes between survivors and non-survivors using univariate and multivariate analyses. RESULTS The survivor and non-survivor groups included 659 and nine patients, respectively. All patients in the non-survivor group received a final diagnosis of AE. Univariate analysis revealed significant differences between the groups with regard to seizure duration and the following laboratory parameters: aspartate transaminase (AST), alanine aminotransferase, lactate dehydrogenase, sodium, and lactate. The multivariate analysis identified AST as a significant independent factor associated with mortality. CONCLUSIONS Elevation of AST within 6 h of onset is independently correlated with mortality in children with SICF. Our result may elucidate earlier intervention for patients with high risk of mortality.
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Gaspard N, Hirsch LJ, Sculier C, Loddenkemper T, van Baalen A, Lancrenon J, Emmery M, Specchio N, Farias-Moeller R, Wong N, Nabbout R. New-onset refractory status epilepticus (NORSE) and febrile infection-related epilepsy syndrome (FIRES): State of the art and perspectives. Epilepsia 2018; 59:745-752. [DOI: 10.1111/epi.14022] [Citation(s) in RCA: 129] [Impact Index Per Article: 18.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/19/2018] [Indexed: 12/14/2022]
Affiliation(s)
- Nicolas Gaspard
- Service de Neurologie et Centre de Référence pour le Traitement de l'Epilepsie Réfractaire; Université Libre de Bruxelles - Hôpital Erasme; Bruxelles Belgique
- Department of Neurology; Comprehensive Epilepsy Center; Yale University School of Medicine; New Haven CT USA
| | - Lawrence J. Hirsch
- Department of Neurology; Comprehensive Epilepsy Center; Yale University School of Medicine; New Haven CT USA
| | - Claudine Sculier
- Service de Neurologie et Centre de Référence pour le Traitement de l'Epilepsie Réfractaire; Université Libre de Bruxelles - Hôpital Erasme; Bruxelles Belgique
- Division of Epilepsy and Clinical Neurophysiology; Department of Neurology; Boston Children's Hospital and Harvard Medical School; Boston MA USA
| | - Tobias Loddenkemper
- Division of Epilepsy and Clinical Neurophysiology; Department of Neurology; Boston Children's Hospital and Harvard Medical School; Boston MA USA
| | - Andreas van Baalen
- Department of Neuropediatrics; University Medical Center Schleswig-Holstein; Kiel Germany
| | - Judette Lancrenon
- Association Paratonnerre - European Association of Persons Affected by F.I.R.E.S; Lyon France
| | - Michel Emmery
- Association Paratonnerre - European Association of Persons Affected by F.I.R.E.S; Lyon France
| | - Nicola Specchio
- Rare and Complex Epilepsies Unit; Department of Neuroscience; Bambino Gesù Children's Hospital, IRCCS; Rome Italy
| | - Raquel Farias-Moeller
- Center for Neuroscience; Children's National Health System; George Washington University; Washington DC USA
| | | | - Rima Nabbout
- Department of Pediatric Neurology; Centre de Reference Epilepsies Rares; Necker-Enfants Malades Hospital; Inserm U1129, Imagine Institute, Paris Descartes University; Paris France
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Morita M, Fujimoto A, Okanishi T, Nishimura M, Sato K, Kanai S, Enoki H. Vagus nerve stimulation therapy improved refractory epilepsy secondary to acute encephalitis with refractory, repetitive partial seizures (AERRPS). INTERDISCIPLINARY NEUROSURGERY-ADVANCED TECHNIQUES AND CASE MANAGEMENT 2017. [DOI: 10.1016/j.inat.2017.03.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Zhang B, Wang L. Acute encephalitis with refractory, repetitive partial seizures: A case report and literature review. Exp Ther Med 2016; 12:3401-3404. [DOI: 10.3892/etm.2016.3750] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2015] [Accepted: 05/12/2016] [Indexed: 11/06/2022] Open
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Sato Y, Numata-Uematsu Y, Uematsu M, Kikuchi A, Nakayama T, Kakisaka Y, Kobayashi T, Hino-Fukuyo N, Suzuki H, Takahashi Y, Saito Y, Tanuma N, Hayashi M, Iwasaki M, Haginoya K, Kure S. Acute encephalitis with refractory, repetitive partial seizures: Pathological findings and a new therapeutic approach using tacrolimus. Brain Dev 2016; 38:772-6. [PMID: 26906012 DOI: 10.1016/j.braindev.2016.02.006] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2015] [Revised: 02/08/2016] [Accepted: 02/09/2016] [Indexed: 11/28/2022]
Abstract
Acute encephalitis with refractory, repetitive partial seizures (AERRPS) is characterized by prolonged severe seizures and a high-grade fever. We experienced a boy with severe AERRPS with frequent partial seizures that exhibited right-side predominance. The patient required the continuous intravenous administration of many antiepileptic drugs and respirator management for several months. Methylprednisolone pulse therapy and intravenous immunoglobulin administration were only temporarily effective. The MRI and EEG showed the abnormality in the left occipital lobe. Although occipital lobectomy was performed, his seizures continued. His cerebrospinal fluid exhibited elevated protein and proinflammatory cytokine levels, and was positive for anti-glutamate receptor ε2 antibodies. Pathological examination showed infiltration of many neutrophilic leukocytes, T cells, and microglia in the area exhibiting severe spongiosis. We thought that the exaggerated microglia and T-cell responses were related to the pathogenesis of the patient's seizures, and we therefore initiated treatment with tacrolimus. As a result, many of the daily seizure clusters were ameliorated, and the patient was discharged. We attempted to discontinue the tacrolimus twice, but the patient's seizure clusters recurred each time. This is the first case report of the pathological findings of AERRPS and showing an effective therapeutic approach using tacrolimus. Tacrolimus may be an effective immunosuppressant, especially for patients with severe AERRPS.
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Affiliation(s)
- Yuko Sato
- Department of Pediatrics, Tohoku University School of Medicine, Sendai, Japan
| | | | - Mitsugu Uematsu
- Department of Pediatrics, Tohoku University School of Medicine, Sendai, Japan.
| | - Atsuo Kikuchi
- Department of Pediatrics, Tohoku University School of Medicine, Sendai, Japan
| | - Tojo Nakayama
- Department of Pediatrics, Tohoku University School of Medicine, Sendai, Japan
| | - Yosuke Kakisaka
- Department of Pediatrics, Tohoku University School of Medicine, Sendai, Japan
| | - Tomoko Kobayashi
- Department of Pediatrics, Tohoku University School of Medicine, Sendai, Japan
| | - Naomi Hino-Fukuyo
- Department of Pediatrics, Tohoku University School of Medicine, Sendai, Japan
| | - Hiroyoshi Suzuki
- Department of Clinical Pathology and Laboratory, National Hospital Organization Sendai Medical Center, Sendai, Japan
| | - Yukitoshi Takahashi
- National Epilepsy Center, Shizuoka Institute of Epilepsy and Neurological Disorders, Shizuoka, Japan
| | - Yoshiaki Saito
- Division of Child Neurology, Department of Brain and Neurosciances, Faculty of Medicine, Tottori University, Yonago, Japan
| | - Naoyuki Tanuma
- Department of Brain Development and Neural Regeneration, Tokyo Metropolitan Institute of Medical Science, Tokyo, Japan
| | - Masaharu Hayashi
- Department of Pediatrics, Tokyo Metropolitan Fuchu Medical Center for the Disabled, Tokyo, Japan
| | - Masaki Iwasaki
- Department of Neurosurgery, Tohoku University School of Medicine, Sendai, Japan
| | - Kazuhiro Haginoya
- Department of Pediatrics, Tohoku University School of Medicine, Sendai, Japan; Department of Pediatric Neurology, Takuto Rehabilitation Center for Children, Sendai, Japan
| | - Shigeo Kure
- Department of Pediatrics, Tohoku University School of Medicine, Sendai, Japan
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Uchida T, Takayanagi M, Kitamura T, Nishio T, Numata Y, Endo W, Haginoya K, Ohura T. High-dose phenobarbital with intermittent short-acting barbiturates for acute encephalitis with refractory, repetitive partial seizures. Pediatr Int 2016; 58:750-3. [PMID: 27273286 DOI: 10.1111/ped.12934] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2014] [Revised: 11/25/2015] [Accepted: 01/26/2016] [Indexed: 11/30/2022]
Abstract
Acute encephalitis with refractory, repetitive partial seizures (AERRPS) is characterized by repetitive seizures during the acute and chronic phases and has a poor neurological outcome. Burst-suppression coma via continuous i.v. infusion of a short-acting barbiturate is used to terminate refractory seizures, but the severe side-effects of short-acting barbiturates are problematic. We report on a 9-year-old boy with AERRPS who was effectively treated with very-high-dose phenobarbital (VHDPB) combined with intermittent short-acting barbiturates. VHDPB side-effects were mild, especially compared with those associated with continuous i.v. infusion of short-acting barbiturates (dosage, 40-75 mg/kg/day; maximum blood level, 290 μg/mL). Using VHDPB as the main treatment, short-acting barbiturates were used intermittently and in small amounts. This is the first report to show that VHDPB, combined with intermittent short-acting barbiturates, can effectively treat AERRPS. After treatment, convulsions were suppressed and daily life continued, but intellectual impairment and high-level dysfunction remained.
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Affiliation(s)
- Takashi Uchida
- Division of Pediatrics, Sendai City Hospital, Sendai, Japan
| | | | - Taro Kitamura
- Division of Pediatrics, Sendai City Hospital, Sendai, Japan
| | | | - Yurika Numata
- Department of Pediatrics, Ishinomaki Red Cross Hospital, Ishinomaki, Japan
| | - Wakaba Endo
- Department of Pediatric Neurology, Takuto Rehabilitation Center for Children, Sendai, Japan
| | - Kazuhiro Haginoya
- Department of Pediatric Neurology, Takuto Rehabilitation Center for Children, Sendai, Japan
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Saitoh M, Kobayashi K, Ohmori I, Tanaka Y, Tanaka K, Inoue T, Horino A, Ohmura K, Kumakura A, Takei Y, Hirabayashi S, Kajimoto M, Uchida T, Yamazaki S, Shiihara T, Kumagai T, Kasai M, Terashima H, Kubota M, Mizuguchi M. Cytokine-related and sodium channel polymorphism as candidate predisposing factors for childhood encephalopathy FIRES/AERRPS. J Neurol Sci 2016; 368:272-6. [PMID: 27538648 DOI: 10.1016/j.jns.2016.07.040] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2016] [Revised: 07/13/2016] [Accepted: 07/14/2016] [Indexed: 11/15/2022]
Abstract
Febrile infection-related epilepsy syndrome (FIRES), or acute encephalitis with refractory, repetitive partial seizures (AERRPS), is an epileptic encephalopathy beginning with fever-mediated seizures. The etiology remains unclear. To elucidate the genetic background of FIRES/AERRPS (hereafter FIRES), we recruited 19 Japanese patients, genotyped polymorphisms of the IL1B, IL6, IL10, TNFA, IL1RN, SCN1A and SCN2A genes, and compared their frequency between the patients and controls. For IL1RN, the frequency of a variable number of tandem repeat (VNTR) allele, RN2, was significantly higher in the patients than in controls (p=0.0067), and A allele at rs4251981 in 5' upstream of IL1RN with borderline significance (p=0.015). Haplotype containing RN2 was associated with an increased risk of FIRES (OR 3.88, 95%CI 1.40-10.8, p=0.0057). For SCN1A, no polymorphisms showed a significant association, whereas a missense mutation, R1575C, was found in two patients. For SCN2A, the minor allele frequency of G allele at rs1864885 was higher in patients with borderline significance (p=0.011). We demonstrated the association of IL1RN haplotype containing RN2 with FIRES, and showed a possible association of IL1RN rs4251981 G>A and SCN2A rs1864885 A>G, in Japanese patients. These preliminary findings suggest the involvement of multiple genetic factors in FIRES, which needs to be confirmed by future studies in a larger number of FIRES cases.
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Affiliation(s)
- M Saitoh
- Department of Developmental Medical Sciences, Graduate School of Medicine, The University of Tokyo, Japan.
| | - K Kobayashi
- Department of Child Neurology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Japan
| | - I Ohmori
- Department of Special Needs Education, Graduate School of Education, Okayama University, Japan
| | - Y Tanaka
- Department of Pediatrics, Ohta Nishinouchi General Hospital, Japan
| | - K Tanaka
- Department of Pediatrics, Ohta Nishinouchi General Hospital, Japan
| | - T Inoue
- Department of Pediatrics, Child Medical Center, Osaka City General Hospital, Japan
| | - A Horino
- Department of Pediatrics, Child Medical Center, Osaka City General Hospital, Japan
| | - K Ohmura
- Department of Pediatrics, Kishiwada City Hospital, Japan
| | - A Kumakura
- Department of Pediatrics, Kitano Hospital, Japan
| | - Y Takei
- Division of Neurology, Nagano Childrens' Hospital, Japan
| | - S Hirabayashi
- Division of Neurology, Nagano Childrens' Hospital, Japan
| | - M Kajimoto
- Department of Pediatrics, Yamaguchi University, Japan
| | - T Uchida
- Department of Pediatrics, Sendai City, Hospital, Japan
| | - S Yamazaki
- Department of Pediatrics, Niigata City Hospital, Japan
| | - T Shiihara
- Department of Neurology, Gunma Children's Medical Center, Japan
| | - T Kumagai
- Division of Neurology, National Center for Child Health and Development, Japan
| | - M Kasai
- Division of Neurology, National Center for Child Health and Development, Japan
| | - H Terashima
- Division of Neurology, National Center for Child Health and Development, Japan
| | - M Kubota
- Division of Neurology, National Center for Child Health and Development, Japan
| | - M Mizuguchi
- Department of Developmental Medical Sciences, Graduate School of Medicine, The University of Tokyo, Japan
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Abstract
Autoimmune neurologic diseases are of major clinical importance in children. Antibody-mediated diseases of the central nervous system are now increasingly recognized in childhood, where the antibodies bind to cell surface epitopes on neuronal or glial proteins, and the patients demonstrate either focal or more generalized clinical signs depending on the extent of brain regions targeted by the antibodies. The antibodies are directed towards ion channels, receptors, and membrane proteins; and the diseases include limbic encephalitis and N-methyl-d-aspartate receptor-antibody encephalitis, among many others. Additionally there are conditions where the wider immune system is implicated. Neurologic features like seizures, movement disorders, autonomic dysfunction, and sleep disorders, with neuroimaging and electrophysiologic features, may indicate a specific antibody-mediated or immune disorder. Often, phenotypic overlap is observed between these conditions, and phenotypic variation seen in children with the same condition. Nevertheless, many patients benefit from immunotherapy with substantial improvement, although huge efforts are still required to optimize the outcome for many patients. In many patients no antibodies have yet been identified, even though they respond to immunotherapies. Here we describe the known antibodies and associated diseases, discuss conditions that are thought to be immune-mediated but have no known immunologic biomarker, and provide guidelines for the investigation and classification of these disorders.
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Esposito S, Di Pietro GM, Madini B, Mastrolia MV, Rigante D. A spectrum of inflammation and demyelination in acute disseminated encephalomyelitis (ADEM) of children. Autoimmun Rev 2015; 14:923-929. [PMID: 26079482 PMCID: PMC7105213 DOI: 10.1016/j.autrev.2015.06.002] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2015] [Accepted: 06/09/2015] [Indexed: 11/15/2022]
Abstract
Acute disseminated encephalomyelitis (ADEM) is an inflammatory demyelinating disease of the central nervous system that involves multifocal areas of the white matter, rarely the gray matter and spinal cord, mainly affecting children and mostly occurring 1-2weeks after infections or more rarely after vaccinations. Though a specific etiologic agent is not constantly identified, to evaluate carefully patient's clinical history and obtain adequate samples for the search of a potential ADEM causal agent is crucial. In the case of a prompt diagnosis and adequate treatment, most children with ADEM have a favorable outcome with full recovery, but in the case of diagnostic delays or inappropriate treatment some patients might display neurological sequelae and persistent deficits or even show an evolution to multiple sclerosis. The suspicion of ADEM rises on a clinical basis and derives from systemic and neurologic signs combined with magnetic resonance imaging of the central nervous system. Other advanced imaging techniques may help an appropriate differential diagnosis and definition of exact disease extension. Although there is no standardized protocol or management for ADEM, corticosteroids, intravenous immunoglobulin, and plasmapheresis have been successfully used. There is no marker that permits to identify the subset of children with worse prognosis and future studies should try to detect any biological clue for prevision of neurologic damage as well as should optimize treatment strategies using an approach based on the effective risk of negative evolution.
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Affiliation(s)
- Susanna Esposito
- Pediatric Highly Intensive Care Unit, Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.
| | - Giada Maria Di Pietro
- Pediatric Highly Intensive Care Unit, Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Barbara Madini
- Pediatric Highly Intensive Care Unit, Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Maria Vincenza Mastrolia
- Pediatric Highly Intensive Care Unit, Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Donato Rigante
- Institute of Pediatrics, Università Cattolica Sacro Cuore, Fondazione Policlinico Universitario Agostino Gemelli, Rome, Italy
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Nishiyama M, Tanaka T, Fujita K, Maruyama A, Nagase H. Targeted temperature management of acute encephalopathy without AST elevation. Brain Dev 2015; 37:328-33. [PMID: 24962726 DOI: 10.1016/j.braindev.2014.06.005] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2014] [Revised: 05/16/2014] [Accepted: 06/06/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND Acute encephalopathy is a leading cause of mortality and neurological sequelae in children. Although many strategies have been proposed, effective therapies have not yet been established. The objective of this retrospective study was to assess the effectiveness of targeted temperature management in children with acute encephalopathy. METHODS We retrospectively evaluated the clinical courses and outcomes of 57 children who were consecutively admitted at Kobe Children's Hospital between October 2002 and August 2011. These children had acute encephalopathy with serum aspartate aminotransferase (AST) levels below 90 IU/l within 6h of onset. We compared the clinical characteristics and neurological outcomes of children treated with targeted temperature management and those who received conventional care. Targeted temperature management was defined as temperature control (34.5-36°C) with intubation, and the continuous use of anticonvulsants and muscle relaxants induced within 24 h of onset. Outcome was measured using the Pediatric Cerebral Performance Category Scale with grade 1 representing a good clinical outcome and grades 2-6 reflecting poor outcomes. RESULTS Outcomes were good in all children treated with targeted temperature management (n=23) as well as in 24 out of the 34 children who received conventional care (p=0.004). The age, gender, refractory status epilepticus rate, prolonged neurological abnormality rate, preceding infection rate, and laboratory results were not significantly different between the two groups. CONCLUSIONS We determined that targeted temperature management could improve outcome in acute encephalopathy without AST elevation.
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Affiliation(s)
- Masahiro Nishiyama
- Department of Neurology, Hyogo Prefectural Kobe Children's Hospital, Kobe, Hyogo 654-0081, Japan
| | - Tsukasa Tanaka
- Department of Neurology, Hyogo Prefectural Kobe Children's Hospital, Kobe, Hyogo 654-0081, Japan
| | - Kyoko Fujita
- Department of Neurology, Hyogo Prefectural Kobe Children's Hospital, Kobe, Hyogo 654-0081, Japan
| | - Azusa Maruyama
- Department of Neurology, Hyogo Prefectural Kobe Children's Hospital, Kobe, Hyogo 654-0081, Japan
| | - Hiroaki Nagase
- Department of Neurology, Hyogo Prefectural Kobe Children's Hospital, Kobe, Hyogo 654-0081, Japan.
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Lin KL, Wang HS. Role of antineuronal antibodies in children with encephalopathy and febrile status epilepticus. Pediatr Neonatol 2014; 55:161-7. [PMID: 24050844 DOI: 10.1016/j.pedneo.2013.07.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2013] [Revised: 07/03/2013] [Accepted: 07/16/2013] [Indexed: 01/24/2023] Open
Abstract
Status epilepticus in childhood is more common, with a different range of causes and a lower risk of death, than convulsive status epilepticus in adults. Acute central nervous system infections appear to be markers for morbidity and mortality. Nevertheless, central nervous infection is usually presumed in these conditions. Many aspects of the pathogenesis of acute encephalitis and acute febrile encephalopathy with status epilepticus have been clarified in the past decade. The pathogenesis is divided into direct pathogens invasion or immune-mediated mechanisms. Over the past few decades, the number of antineuronal antibodies to ion channels, receptors, and other synaptic proteins described in association with central nervous system disorders has increased dramatically, especially their role in pediatric encephalitis and status epilepticus. These antineuronal antibodies are divided according to the location of their respective antigens: (1) intracellular antigens, including glutamic acid decarboxylase and classical onconeural antigens such as Hu (antineuronal nuclear antibody 1, ANNA1), Ma2, Yo (Purkinje cell autoantibody, PCA1), Ri (antineuronal nuclear antibody 2, ANNA2), CV2/CRMP5, and amphiphysin; and (2) cell membrane ion channels or surface antigens including voltage-gated potassium channel receptor, N-methyl-d-aspartate receptor, α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid receptor, γ-aminobutyric acid(B) receptor, leucine-rich glioma-inactivated protein 1, and contactin-associated protein-like 2. Identifying the mechanism of the disease may have important therapeutic implications.
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Affiliation(s)
- Kuang-Lin Lin
- Division of Pediatric Neurology, Chang Gung Children's Hospital and Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Huei-Shyong Wang
- Division of Pediatric Neurology, Chang Gung Children's Hospital and Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan.
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Barros P, Brito H, Ferreira PC, Ramalheira J, Lopes J, Rangel R, Temudo T, Figueiroa S. Resective surgery in the treatment of super-refractory partial status epilepticus secondary to NMDAR antibody encephalitis. Eur J Paediatr Neurol 2014; 18:449-52. [PMID: 24594428 DOI: 10.1016/j.ejpn.2014.01.013] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2013] [Revised: 12/15/2013] [Accepted: 01/26/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND Anti-NMDAR encephalitis is an increasingly described clinical entity in children, comprising 40% of all cases. We present a case of super-refractory status epilepticus secondary to anti-NMDAR encephalitis treated with emergent resective surgery. CASE STUDY A 7 years-old boy presented with progressive abnormal irritability. On the day after admission he had multiple seizures, characterized by head and eye version to the right. EEG revealed left parietal-occipital continuous paroxysmal activity. Anti-NMDAR antibodies were positive in CSF and serum. After almost 3 months in the Intensive Care Unit, in barbituric coma, and given the failure of all treatment regimens, a preoperative evaluation was conducted. Ictal SPECT showed significant hiperperfusion and brain FDG-PET a cortical hypometabolism in the left occipital lobe; a left occipital lobectomy was performed. In the next days it was possible to progressively suspend Thiopental. Currently, patient presents right homonymous hemianopsia, eats by his own hand but needs help in almost all other activities. DISCUSSION Status epilepticus (SE) in the setting of anti-NMDAR encephalitis is unusual but described. Whilst the role of surgery in the management of refractory focal epilepsy is established, it is seldom used in the treatment of SE. In the patient with refractory SE (RSE), awareness of surgery as a potentially life saving treatment is an important issue. To our knowledge, this is the first report of a partial RSE secondary to anti-NMDAR encephalitis treated with resective surgery and illustrates the need to consider anti-NMDAR encephalitis as a cause of super-refractory SE.
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Affiliation(s)
- Pedro Barros
- Neurology Department, Centro Hospitalar de Vila Nova de Gaia/Espinho, Portugal; Faculty of Health Sciences, University Fernando Pessoa, Portugal.
| | - Hernâni Brito
- Pediatrics Department, Centro Hospitalar do Porto, Portugal
| | | | - João Ramalheira
- Neurophysiology Department, Centro Hospitalar do Porto, Portugal
| | - João Lopes
- Neurophysiology Department, Centro Hospitalar do Porto, Portugal
| | - Rui Rangel
- Neurosurgery Department, Centro Hospitalar do Porto, Portugal
| | - Teresa Temudo
- Neuropediatrics Department, Centro Hospitalar do Porto, Portugal
| | - Sónia Figueiroa
- Neuropediatrics Department, Centro Hospitalar do Porto, Portugal
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17
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Matsuzono K, Kurata T, Deguchi S, Yamashita T, Deguchi K, Abe K. Ketogenic diet therapy is effective in encephalitis with refractory seizures. Neurol Res 2014; 36:906-10. [PMID: 24735348 DOI: 10.1179/1743132814y.0000000371] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
OBJECTIVE AND IMPORTANCE Although ketogenic diet therapy is effective in refractory seizures in childhood, its effect on adult encephalitis with similar refractory seizures and prolonged encephalopathy has not been well reported. CLINICAL PRESENTATION We report here a case of a 22-year-old man with acute encephalitis with refractory repetitive partial seizures (AERRPS). INTERVENTION Partial seizures of the face developed to repeated generalized convulsions, which were refractory against anti-epileptic drugs and a high dose of propofol. After struggling for 9 months, he dramatically recovered after ketogenic diet therapy. CONCLUSION Ketogenic diet therapy may be an important tool to help cure AERRPS.
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18
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Ramanathan S, Bleasel A, Parratt J, Orr C, Dale RC, Vincent A, Fung VSC. Characterisation of a syndrome of autoimmune adult onset focal epilepsy and encephalitis. J Clin Neurosci 2013; 21:1169-75. [PMID: 24518268 DOI: 10.1016/j.jocn.2013.09.024] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2013] [Revised: 09/19/2013] [Accepted: 09/24/2013] [Indexed: 01/12/2023]
Abstract
We report a series of patients with a clinical syndrome characterised by the explosive onset in adulthood of recurrent focal seizures of frontotemporal onset and features suggestive of autoimmune encephalitis. We propose that this presentation of "autoimmune adult onset focal epilepsy and encephalitis" is a recognisable clinical syndrome, and provide evidence it may be associated with heterogeneous immunological targets. Between 2008 and 2011 we encountered six patients with new-onset epilepsy in whom we suspected an autoimmune aetiology. We first characterised the clinical, electroencephalographic, cerebrospinal fluid (CSF), imaging, and pathological findings of this syndrome. We subsequently tested them for antibodies against both intracellular and neuronal cell surface antigens. All patients presented with recurrent seizures with focal frontotemporal onset, refractory to multiple anticonvulsants. Four had focal T2-weighted hyperintensities on MRI. CSF mononuclear cells were variably elevated with positive oligoclonal bands in four. Brain biopsy in one patient demonstrated perivascular lymphocytic infiltration. Two were treated with immunosuppression and went on to achieve complete seizure control and return to baseline cognition. Three of four patients who received only pulsed steroids or no treatment had ongoing frequent seizures, with two dying of sudden unexpected death in epilepsy. Subsequently, three had antibodies identified against neuronal cell surface antigens including N-methyl-D-aspartate receptor and leucine-rich glioma inactivated 1. We suggest that patients with such a presentation should be carefully evaluated for a suspected autoimmune aetiology targeting cell surface antigens and have a therapeutic trial of immunosuppression as this may improve their long-term outcome.
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Affiliation(s)
- Sudarshini Ramanathan
- Department of Neurology, Westmead Hospital, Westmead, NSW 2145, Australia; Westmead Clinical School, University of Sydney, Sydney, NSW, Australia
| | - Andrew Bleasel
- Department of Neurology, Westmead Hospital, Westmead, NSW 2145, Australia; Westmead Clinical School, University of Sydney, Sydney, NSW, Australia
| | - John Parratt
- Department of Neurology, Royal North Shore Hospital, St Leonards, NSW, Australia; Northern Clinical School, University of Sydney, Sydney, NSW, Australia
| | - Carolyn Orr
- Macquarie Neurology, Macquarie University Hospital, Macquarie University, NSW, Australia
| | - Russell C Dale
- Neuroimmunology Group, Institute for Neuroscience and Muscle Research, The Kids Research Institute at the Children's Hospital at Westmead, University of Sydney, Westmead, NSW, Australia
| | - Angela Vincent
- Nuffield Department of Clinical Neurosciences, University of Oxford, John Radcliffe Hospital, Oxford, UK
| | - Victor S C Fung
- Department of Neurology, Westmead Hospital, Westmead, NSW 2145, Australia; Westmead Clinical School, University of Sydney, Sydney, NSW, Australia.
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19
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Riviello JJ, Claassen J, LaRoche SM, Sperling MR, Alldredge B, Bleck TP, Glauser T, Shutter L, Treiman DM, Vespa PM, Bell R, Brophy GM. Treatment of status epilepticus: an international survey of experts. Neurocrit Care 2013; 18:193-200. [PMID: 23097138 DOI: 10.1007/s12028-012-9790-1] [Citation(s) in RCA: 75] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND As part of the development of the Neurocritical Care Society (NCS) Status Epilepticus (SE) Guidelines, the NCS SE Writing Committee conducted an international survey of SE experts. METHODS The survey consisted of three patient vignettes (case 1, an adult; case 2, an adolescent; case 3, a child) and questions regarding treatment. The questions for each case focused on initial and sequential therapy as well as when to use continuous intravenous (cIV) therapy and for what duration. Responses were obtained from 60/120 (50%) of those surveyed. RESULTS This survey reveals that there is expert consensus for using intravenous lorazepam for the emergent (first-line) therapy of SE in children and adults. For urgent (second-line) therapy, the most common agents chosen were phenytoin/fosphenytoin, valproate sodium, and levetiracetam; these choices varied by the patient age in the case scenarios. Physicians who care for adult patients chose cIV therapy for RSE, especially midazolam and propofol, rather than a standard AED sooner than those who care for children; and in children, there is a reluctance to choose propofol. Pentobarbital was chosen later in the therapy for all ages. CONCLUSION There is close agreement between the recently published NCS guideline for SE and this survey of experts in the treatment of SE.
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Affiliation(s)
- James J Riviello
- NYU Comprehensive Epilepsy Center, NYU Langone Medical Center, Division of Pediatric Neurology, Department of Neurology, New York University School of Medicine, 223 East 34th Street, New York, NY 10016, USA.
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20
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Suleiman J, Brilot F, Lang B, Vincent A, Dale RC. Autoimmune epilepsy in children: Case series and proposed guidelines for identification. Epilepsia 2013; 54:1036-45. [DOI: 10.1111/epi.12142] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/04/2013] [Indexed: 01/16/2023]
Affiliation(s)
- Jehan Suleiman
- Neuroimmunology Group; Institute for Neuroscience and Muscle Research, the Children's Hospital at Westmead; University of Sydney; Sydney New South Wales Australia
| | - Fabienne Brilot
- Neuroimmunology Group; Institute for Neuroscience and Muscle Research, the Children's Hospital at Westmead; University of Sydney; Sydney New South Wales Australia
| | - Bethan Lang
- Nuffield Department of Clinical Neurosciences; John Radcliffe Hospital; University of Oxford; Oxford United Kingdom
| | - Angela Vincent
- Nuffield Department of Clinical Neurosciences; John Radcliffe Hospital; University of Oxford; Oxford United Kingdom
| | - Russell C. Dale
- Neuroimmunology Group; Institute for Neuroscience and Muscle Research, the Children's Hospital at Westmead; University of Sydney; Sydney New South Wales Australia
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21
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Kobayashi K, Ohzono H, Shinohara M, Saitoh M, Ohmori I, Ohtsuka Y, Mizuguchi M. Acute encephalopathy with a novel point mutation in the SCN2A gene. Epilepsy Res 2012; 102:109-12. [DOI: 10.1016/j.eplepsyres.2012.04.016] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2012] [Revised: 04/19/2012] [Accepted: 04/21/2012] [Indexed: 12/23/2022]
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22
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Wakamoto H, Takahashi Y, Ebihara T, Okamoto K, Hayashi M, Ichiyama T, Ishii E. An immunologic case study of acute encephalitis with refractory, repetitive partial seizures. Brain Dev 2012; 34:763-7. [PMID: 22265641 DOI: 10.1016/j.braindev.2011.12.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2011] [Revised: 12/10/2011] [Accepted: 12/16/2011] [Indexed: 01/11/2023]
Abstract
Acute encephalitis with refractory, repetitive partial seizures (AERRPS) is a neurologic syndrome characterized by extraordinarily frequent and refractory partial seizures, which immediately evolve into refractory epilepsy. To elucidate the pathophysiology of AERRPS, we performed an immunologic study of an affected boy, revealing decreased natural killer (NK) cell activity in the peripheral blood mononuclear cells. IgG antibodies against the glutamate receptor (GluR)ε2, ζ1, and δ2 subunits were all positive in both the serum and cerebrospinal fluid (CSF). There were raised plasma concentrations of interleukin (IL)-2, IL-6, IL-10, tumor necrosis factor-α, and interferon-γ as well as an extremely elevated CSF level of IL-6. These findings suggest that AERRPS is immune-mediated encephalitis, in which both autoimmunity and exaggerated cytokine production are involved. NK cell dysfunction may be the underlying abnormality in this AERRPS case, which might have contributed to the production of GluR autoantibodies.
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Affiliation(s)
- Hiroyuki Wakamoto
- Department of Pediatrics, Ehime Prefectural Central Hospital, Ehime, Japan.
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23
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Hoshino A, Saitoh M, Oka A, Okumura A, Kubota M, Saito Y, Takanashi JI, Hirose S, Yamagata T, Yamanouchi H, Mizuguchi M. Epidemiology of acute encephalopathy in Japan, with emphasis on the association of viruses and syndromes. Brain Dev 2012; 34:337-43. [PMID: 21924570 DOI: 10.1016/j.braindev.2011.07.012] [Citation(s) in RCA: 285] [Impact Index Per Article: 21.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2011] [Revised: 07/27/2011] [Accepted: 07/30/2011] [Indexed: 10/17/2022]
Abstract
A research committee supported by the Japanese government conducted a nationwide survey on the epidemiology of acute encephalopathy in Japan using a questionnaire. A total of 983 cases reportedly had acute encephalopathy during the past 3 years, 2007-2010. Among the pathogens of the preceding infection, influenza virus was the most common, followed by human herpesvirus-6 (HHV-6) and rotavirus. Among syndromes of acute encephalopathy, acute encephalopathy with biphasic seizures and late reduced diffusion (AESD) was the most frequent, followed by clinically mild encephalitis/encephalopathy with a reversible splenial lesion (MERS), acute necrotizing encephalopathy (ANE) and hemorrhagic shock and encephalopathy syndrome (HSES). Influenza virus was strongly associated with ANE and MERS, HHV-6 with AESD, and rotavirus with MERS. Mortality was high in ANE and HSES, but was low in AESD, MERS and HHV-6-associated encephalopathy. Neurologic sequelae were common in AESD and ANE, but were absent in MERS.
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Affiliation(s)
- Ai Hoshino
- Department of Developmental Medical Sciences, Graduate School of Medicine, The University of Tokyo, Japan
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24
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Anti-N-methyl-d-aspartate receptor encephalitis. Pediatr Neonatol 2011; 52:361-4. [PMID: 22192267 DOI: 10.1016/j.pedneo.2011.08.012] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2010] [Revised: 01/04/2011] [Accepted: 01/14/2011] [Indexed: 01/28/2023] Open
Abstract
Anti-N-methyl-d-aspartate (NMDA) receptor encephalitis is a treatment-responsive encephalitis associated with anti-NMDA receptor antibodies, which bind to the NR1/NR2 heteromers of the NMDA receptors. It is a highly characteristic syndrome evolving in five stages: the prodromal phase (viral infection-like symptoms), psychotic phase, unresponsive phase, hyperkinetic phase, and gradual recovery phase. It has been considered as a paraneoplastic syndrome usually affecting childbearing-age female with ovarian tumors; however, recent reports suggest a much higher incidence of nonparaneoplastic cases in children. We report a 14-year-old girl with anti-NMDA receptor encephalitis without a detectable tumor who showed a nearly complete recovery after intensive immunotherapy.
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25
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Shiloh-Malawsky Y, Fan Z, Greenwood R, Tennison M. Successful treatment of childhood prolonged refractory status epilepticus with lacosamide. Seizure 2011; 20:586-8. [DOI: 10.1016/j.seizure.2011.03.005] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2010] [Revised: 02/20/2011] [Accepted: 03/18/2011] [Indexed: 10/18/2022] Open
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26
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Kawashima H, Ishii C, Yamanaka G, Ioi H, Takekuma K, Ogihara M, Hoshika A, Takahashi Y. A Boy with Non-Herpes Simplex Acute Limbic Encephalitis and Antiglutamate Receptor Antibodies. CLINICAL MEDICINE INSIGHTS: CASE REPORTS 2011; 4:43-7. [PMID: 22084613 PMCID: PMC3201105 DOI: 10.4137/ccrep.s6337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
This report concerns a 12-year-old male with intractable seizures over a long period. The case fulfilled the diagnostic criteria for nonherpetic acute limbic encephalitis. He had frequent convulsions starting with a partial seizure at the left angle of the mouth and progressing to secondary generalized seizures. He was treated with several anticonvulsants, combined with methylprednisolone and γ-globulin under mechanical ventilation. However, his convulsions reappeared after tapering of the barbiturate. His magnetic resonance imaging showed a high intensity area in the hippocampus by FLAIR and diffusion. After five months he recovered without serious sequelae. Virological studies, including for herpes simplex virus, were all negative. He was transiently positive for antiglutamate receptor antibodies in cerebrospinal fluid and serum.
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Affiliation(s)
| | - Chiako Ishii
- Department of Pediatrics, Tokyo Medical University, Tokyo, Japan
| | - Gaku Yamanaka
- Department of Pediatrics, Tokyo Medical University, Tokyo, Japan
| | - Hiroaki Ioi
- Department of Pediatrics, Tokyo Medical University, Tokyo, Japan
| | - Kouji Takekuma
- Department of Pediatrics, Tokyo Medical University, Tokyo, Japan
| | - Masaaki Ogihara
- Department of Pediatrics, Tokyo Medical University, Tokyo, Japan
| | - Akinori Hoshika
- Department of Pediatrics, Tokyo Medical University, Tokyo, Japan
| | - Yukitoshi Takahashi
- National Epilepsy Center, Shizuoka Institute of Epilepsy and Neurological Disorders, Tokyo, Japan
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Okumura A, Komatsu M, Abe S, Kitamura T, Matsui K, Ikeno M, Shimizu T. Amplitude-integrated electroencephalography in patients with acute encephalopathy with refractory, repetitive partial seizures. Brain Dev 2011; 33:77-82. [PMID: 20092972 DOI: 10.1016/j.braindev.2009.12.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2009] [Revised: 12/26/2009] [Accepted: 12/27/2009] [Indexed: 10/19/2022]
Abstract
We report amplitude-integrated EEG findings in two children with acute encephalopathy with refractory, repetitive partial seizures. Both patients had a febrile illness one week before the onset of seizure. They had reduction of consciousness and repetitive seizures refractory to first-line antiepileptic drugs. Seizure frequency rapidly increased and evolved into status epilepticus. Continuous seizure monitoring with amplitude-integrated EEG revealed frequent subclinical seizures which were missed by direct observation. In addition, the site of origin of seizures was multifocal, and seizure foci shifted from one hemisphere to the other. Their seizures were controlled after an administration of high-dose phenobarbital. Continuous seizure monitoring with amplitude-integrated EEG will contribute to correct estimation of seizure burden and efficacy of antiepileptic drugs in children with acute encephalopathy with refractory, repetitive partial seizures.
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Affiliation(s)
- Akihisa Okumura
- Department of Pediatrics, Juntendo University School of Medicine, Bunkyo-ku, Tokyo, Japan.
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28
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Kumar A, Chugani HT. Delineating Cortical Networks Underlying Epileptic Encephalopathy and Cognitive Impairment with PET: A Perspective. J Nucl Med 2010; 52:8-9. [DOI: 10.2967/jnumed.110.079012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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29
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Genetic seizure susceptibility underlying acute encephalopathies in childhood. Epilepsy Res 2010; 91:143-52. [DOI: 10.1016/j.eplepsyres.2010.07.005] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2010] [Revised: 06/10/2010] [Accepted: 07/04/2010] [Indexed: 11/22/2022]
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30
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The growing recognition of immunotherapy-responsive seizure disorders with autoantibodies to specific neuronal proteins. Curr Opin Neurol 2010; 23:144-50. [PMID: 20164770 DOI: 10.1097/wco.0b013e32833735fe] [Citation(s) in RCA: 78] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
PURPOSE OF REVIEW The concept of epilepsy and seizure disorders caused by autoantibodies to specific neuronal membrane proteins has developed significantly during the past few years. RECENT FINDINGS Antibodies to cell-surface membrane proteins such as voltage-gated potassium channels or N-methyl-D-aspartate receptors, or to glutamic acid decarboxylase, are found in patients with different forms of limbic encephalitis, and in a few patients with epilepsy as their main or only condition. Many of these patients do not show a good response to conventional antiepileptic drugs, but respond to immunotherapies. By contrast, studies of other antibodies in idiopathic forms of epilepsy, or epilepsy associated with systemic lupus erythematosus or coeliac disease, have not in general disclosed consistent, clinically helpful results. SUMMARY There are a growing number of specific antibodies associated with new onset epilepsy. These patients are likely to have an immune-mediated disorder that may benefit from immunotherapies. In autoimmune diseases such as systemic lupus erythematosus or coeliac disease, antibodies to specific membrane targets may also prove to be important in the future.
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