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Bai L, Di W, Xu Z, Liu B, Lin N, Fan S, Ren H, Lu Q, Wang J, Guan H. Febrile infection-related epilepsy syndrome with claustrum lesion: an underdiagnosed inflammatory encephalopathy. Neurol Sci 2024:10.1007/s10072-024-07363-5. [PMID: 38342839 DOI: 10.1007/s10072-024-07363-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Accepted: 12/29/2023] [Indexed: 02/13/2024]
Abstract
OBJECTIVE To summarize the clinical characteristics and prognosis of febrile infection-related epilepsy syndrome with claustrum lesions (FIRES-C). METHOD Clinical data of FIRES-C patients were collected retrospectively. The study reviewed and analyzed their clinical manifestations, treatment strategies, and prognosis. RESULT Twenty patients were enrolled, including 13 females and 7 males, with a median onset age of 20.5 years. All patients developed seizures after fever, with a median interval of 5 days. Brain MRI showed symmetric lesions in the claustrum in all patients. The median interval from seizure onset to abnormal MRI signals detection was 12.5 days. All patients had negative results for comprehensive tests of neurotropic viruses and antineuronal autoantibodies. Seventy percent of cases had been previously empirically diagnosed with autoimmune encephalitis or viral encephalitis before. All patients received anti-seizure medicine. Eleven patients (55%) received antiviral therapy. All patients received immunotherapy, including glucocorticoids (100%), intravenous immunoglobulin (IVIg) (65%), plasma exchange (PLEX) (10%), tocilizumab (10%), rituximab (5%), and cyclophosphamide (5%). Sixty percent of patients received long-term immunotherapy (≥ 3 months). The median follow-up was 11.5 months;60% of patients were diagnosed with refractory epilepsy. CONCLUSION Bilateral claustrum lesion on MRI is a distinctive neuroimage feature for FIRES, which may serve as an indication for the initial clinical assessments. FIRES-C should be classified as a type of inflammatory encephalopathy characterized by a monophasic nature. Some FIRES-C patients respond to immunotherapy and antiseizure treatments but most experience refractory epilepsy as a long-term outcome.
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Affiliation(s)
- Lin Bai
- Department of Neurology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Weiying Di
- Department of Neurology, Affiliated Hospital of Hebei University, Baoding, Hebei, China
| | - Zucai Xu
- Department of Neurology, Affiliated Hospital of Zunyi Medical University, Zunyi, Guizhou, China
| | - Bin Liu
- Department of Neurology, Inner Mongolia Autonomous Region People's Hospital, Hohhot, Inner Mongolia, China
| | - Nan Lin
- Department of Neurology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Siyuan Fan
- Department of Neurology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Haitao Ren
- Department of Neurology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Qiang Lu
- Department of Neurology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Jiawei Wang
- Department of Neurology, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Hongzhi Guan
- Department of Neurology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China.
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Bellingham EE, Hammond CG, Sahhar HS, Rishmawi SE. Multimodal Management of Febrile Infection-Related Epilepsy Syndrome in a 17-Year-Old Male. Cureus 2023; 15:e44412. [PMID: 37791156 PMCID: PMC10544845 DOI: 10.7759/cureus.44412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/30/2023] [Indexed: 10/05/2023] Open
Abstract
New-onset refractory status epilepticus (NORSE) is a clinical presentation, not a specific diagnosis, in which healthy people are suddenly struck by prolonged seizures that do not respond to at least two anti-seizure drugs and do not have a clear structural, toxic, or metabolic cause.Febrile infection-related epilepsy syndrome (FIRES) is considered a sub-category of NORSE. Our patient is a 17-year-old male admitted to the pediatric ward after a self-limited convulsive episode at home, noted to occur following five days of upper respiratory infection symptoms accompanied by fever. After multiple generalized tonic-clonic seizures necessitating treatment, he went into status epilepticus despite multiple antiepileptic drugs. The possibility of FIRES had been considered from the onset of refractory status epilepticus; as a result, an intensive multimodal treatment regimen was proactively implemented with some clinical improvement.
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Affiliation(s)
- Erin E Bellingham
- Pediatrics Department, Edward Via College of Osteopathic Medicine - Louisiana Campus, Monroe, USA
| | - Caroline G Hammond
- Pediatrics Department, Edward Via College of Osteopathic Medicine - Carolinas Campus, Spartanburg, USA
| | - Hanna S Sahhar
- Pediatric Intensive Care Unit, Spartanburg Regional Healthcare System, Spartanburg, USA
| | - Sami E Rishmawi
- Pediatric Intensive Care Unit, Spartanburg Regional Healthcare System, Spartanburg, USA
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3
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Stavropoulos I, Khaw JH, Valentin A. Neuromodulation in new-onset refractory status epilepticus. Front Neurol 2023; 14:1195844. [PMID: 37388544 PMCID: PMC10301751 DOI: 10.3389/fneur.2023.1195844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 05/17/2023] [Indexed: 07/01/2023] Open
Abstract
Background New-onset refractory status epilepticus (NORSE) and its subset of febrile infection-related epilepsy syndrome (FIRES) are devastating clinical presentations with high rates of mortality and morbidity. The recently published consensus on the treatment of these conditions includes anesthetics, antiseizure drugs, antivirals, antibiotics, and immune therapies. Despite the internationally accepted treatment, the outcome remains poor for a significant percentage of patients. Methods We conducted a systematic review of the use of neuromodulation techniques in the treatment of the acute phase of NORSE/FIRES using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Results Our search strategy brought up 74 articles of which 15 met our inclusion criteria. A total of 20 patients were treated with neuromodulation. Thirteen cases represented FIRES and in 17 cases the NORSE remained cryptogenic. Ten had electroconvulsive therapy (ECT), seven had vagal nerve stimulation (VNS), and four had deep brain stimulation (DBS); one patient had initially VNS and later DBS. Eight patients were female and nine were children. In 17 out of 20 patients, the status epilepticus was resolved after neuromodulation, while three patients died. Conclusion NORSE can have a catastrophic course and the first treatment goal should be the fastest possible termination of status epilepticus. The data presented are limited by the small number of published cases and the variability of neuromodulation protocols used. However, they show some potential clinical benefits of early neuromodulation therapy, suggesting that these techniques could be considered within the course of FIRES/NORSE.
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Affiliation(s)
- Ioannis Stavropoulos
- Department of Basic and Clinical Neuroscience, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom
- Department of Clinical Neurophysiology, King's College Hospital, London, United Kingdom
| | - Jin Han Khaw
- Faculty of Life Sciences and Medicine, King's College London, London, United Kingdom
| | - Antonio Valentin
- Department of Basic and Clinical Neuroscience, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom
- Department of Clinical Neurophysiology, King's College Hospital, London, United Kingdom
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4
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Taraschenko O, Pavuluri S, Schmidt CM, Pulluru YR, Gupta N. Seizure burden and neuropsychological outcomes of new-onset refractory status epilepticus: Systematic review. Front Neurol 2023; 14:1095061. [PMID: 36761344 PMCID: PMC9902772 DOI: 10.3389/fneur.2023.1095061] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Accepted: 01/02/2023] [Indexed: 01/26/2023] Open
Abstract
Background Long-term sequelae of the new onset refractory status epilepticus (NORSE) include the development of epilepsy, cognitive deficits, and behavioral disturbances. The prevalence of these complications has been previously highlighted in case reports and case series: however, their full scope has not been comprehensively assessed. Methods We conducted a systematic review of the literature (PROSPERO ID CRD42022361142) regarding neurological and functional outcomes of NORSE at 30 days or longer following discharge from the hospital. A systematic review protocol was developed using guidance from the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Results Of the 1,602 records for unique publications, 33 reports on adults and 52 reports on children met our inclusion criteria. They contained the description of 280 adults and 587 children of whom only 75.7 and 85% of patients, respectively had data on long-term follow-up. The mean age of adult and pediatric patients was 34.3 and 7.9 years, respectively; and the longest duration of follow up were 11 and 20 years, respectively. Seizure outcomes received major attention and were highlighted for 93.4 and 96.6% of the adult and pediatric NORSE patients, respectively. Seizures remained medically refractory in 41.1% of adults and 57.7% of children, while seizure freedom was achieved in only 26 and 23.3% of these patients, respectively. The long-term cognitive outcome data was provided for just 10.4% of the adult patients. In contrast, cognitive health data were supplied for 68.9% of the described children of whom 31.9% were moderately or severely disabled. Long-term functional outcomes assessed with various standardized scales were reported in 62.2 and 25.5% of the adults and children, respectively with majority of patients not being able to return to a pre-morbid level of functioning. New onset psychiatric disorders were reported in 3.3% of adults and 11.2% of children recovering from NORSE. Conclusion These findings concur with previous observations that the majority of adult and pediatric patients continue to experience recurrent seizures and suffer from refractory epilepsy. Moderate to severe cognitive disability, loss of functional independence, and psychiatric disorders represent a hallmark of chronic NORSE signifying the major public health importance of this disorder.
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Affiliation(s)
- Olga Taraschenko
- Division of Epilepsy, Department of Neurological Sciences, University of Nebraska Medical Center, Omaha, NE, United States
| | - Spriha Pavuluri
- Division of Epilepsy, Department of Neurological Sciences, University of Nebraska Medical Center, Omaha, NE, United States
| | - Cynthia M. Schmidt
- Leon S. McGoogan Health Sciences Library, University of Nebraska Medical Center, Omaha, NE, United States
| | - Yashwanth Reddy Pulluru
- Division of Epilepsy, Department of Neurological Sciences, University of Nebraska Medical Center, Omaha, NE, United States
| | - Navnika Gupta
- Division of Epilepsy, Department of Neurological Sciences, University of Nebraska Medical Center, Omaha, NE, United States
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Shrestha A, Wood EL, Berrios-Siervo G, Stredny CM, Boyer K, Vega C, Nangia S, Muscal E, Eschbach K. Long-term neuropsychological outcomes in children with febrile infection-related epilepsy syndrome (FIRES) treated with anakinra. Front Neurol 2023; 14:1100551. [PMID: 36970506 PMCID: PMC10030614 DOI: 10.3389/fneur.2023.1100551] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 02/13/2023] [Indexed: 03/29/2023] Open
Abstract
Background Febrile-infection related epilepsy syndrome (FIRES) is a rare epilepsy syndrome in which a previously healthy individual develops refractory status epilepticus in the setting of a preceding febrile illness. There are limited data regarding detailed long-term outcomes. This study aims to describe the long-term neuropsychological outcomes in a series of pediatric patients with FIRES. Methods This is a retrospective multi-center case series of pediatric patients with a diagnosis of FIRES treated acutely with anakinra who had neuropsychological testing at least 12 months after status epilepticus onset. Each patient underwent comprehensive neuropsychological evaluation as part of routine clinical care. Additional data collection included the acute seizure presentation, medication exposures, and outcomes. Results There were six patients identified with a median age of 11.08 years (IQR: 8.19-11.23) at status epilepticus onset. Anakinra initiation was a median of 11 days (IQR: 9.25-13.50) after hospital admission. All patients had ongoing seizures and none of the patients returned to baseline cognitive function with a median follow-up of 40 months (IQR 35-51). Of the five patients with serial full-scale IQ testing, three demonstrated a decline in scores over time. Testing results revealed a diffuse pattern of deficits across domains and all patients required special education and/or accommodations for academic learning. Conclusions Despite treatment with anakinra, neuropsychological outcomes in this series of pediatric patients with FIRES demonstrated ongoing diffuse neurocognitive impairment. Future research will need to explore the predictors of long-term neurocognitive outcomes in patients with FIRES and to evaluate if acute treatment interventions improve these outcomes.
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Affiliation(s)
- Anima Shrestha
- University of Colorado School of Medicine, Aurora, CO, United States
| | - E. Lynne Wood
- Department of Pediatrics, Section of Neurology, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, CO, United States
| | - Gretchen Berrios-Siervo
- Department of Pediatrics, Section of Neurology, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, CO, United States
- Department of Pediatrics, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, CO, United States
| | - Coral M. Stredny
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Boston, MA, United States
- Program in Neuroimmunology, Department of Neurology, Boston Children's Hospital, Boston, MA, United States
| | - Katrina Boyer
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Boston, MA, United States
| | - Clemente Vega
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Boston, MA, United States
| | - Srishti Nangia
- Department of Child Neurology, Weill Cornell Medicine, New York-Presbyterian Hospital, New York, NY, United States
| | - Eyal Muscal
- Department of Pediatrics and Child Neurology (Co-appointment), Baylor College of Medicine, Houston, TX, United States
| | - Krista Eschbach
- Department of Pediatrics, Section of Neurology, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, CO, United States
- *Correspondence: Krista Eschbach
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Rodent Models of Audiogenic Epilepsy: Genetic Aspects, Advantages, Current Problems and Perspectives. Biomedicines 2022; 10:biomedicines10112934. [PMID: 36428502 PMCID: PMC9687921 DOI: 10.3390/biomedicines10112934] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Revised: 11/10/2022] [Accepted: 11/11/2022] [Indexed: 11/18/2022] Open
Abstract
Animal models of epilepsy are of great importance in epileptology. They are used to study the mechanisms of epileptogenesis, and search for new genes and regulatory pathways involved in the development of epilepsy as well as screening new antiepileptic drugs. Today, many methods of modeling epilepsy in animals are used, including electroconvulsive, pharmacological in intact animals, and genetic, with the predisposition for spontaneous or refractory epileptic seizures. Due to the simplicity of manipulation and universality, genetic models of audiogenic epilepsy in rodents stand out among this diversity. We tried to combine data on the genetics of audiogenic epilepsy in rodents, the relevance of various models of audiogenic epilepsy to certain epileptic syndromes in humans, and the advantages of using of rodent strains predisposed to audiogenic epilepsy in current epileptology.
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Wickstrom R, Taraschenko O, Dilena R, Payne ET, Specchio N, Nabbout R, Koh S, Gaspard N, Hirsch LJ. International consensus recommendations for management of New Onset Refractory Status Epilepticus (NORSE) incl. Febrile Infection-Related Epilepsy Syndrome (FIRES): Statements and Supporting Evidence. Epilepsia 2022; 63:2840-2864. [PMID: 35997591 PMCID: PMC9828002 DOI: 10.1111/epi.17397] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Revised: 07/14/2022] [Accepted: 08/18/2022] [Indexed: 01/12/2023]
Abstract
OBJECTIVE To develop consensus-based recommendations for the management of adult and paediatric patients with NORSE/FIRES based on best evidence and experience. METHODS The Delphi methodology was followed. A facilitator group of 9 experts was established, who defined the scope, users and suggestions for recommendations. Following a review of the current literature, recommendation statements concerning diagnosis, treatment and research directions were generated which were then voted on a scale of 1 (strongly disagree) to 9 (strongly agree) by a panel of 48 experts in the field. Consensus that a statement was appropriate was reached if the median score was greater or equal to 7, and inappropriate if the median score was less than or equal to 3. The analysis of evidence was mapped to the results of each statement included in the Delphi survey. RESULTS Overall, 85 recommendation statements achieved consensus. The recommendations are divided into five sections: 1) disease characteristics, 2) diagnostic testing and sampling, 3) acute treatment, 4) treatment in the post-acute phase, and 5) research, registries and future directions in NORSE/FIRES. The detailed results and discussion of all 85 statements are outlined herein. A corresponding summary of findings and practical flowsheets are presented in a companion article. SIGNIFICANCE This detailed analysis offers insight into the supporting evidence and the current gaps in the literature that are associated with expert consensus statements related to NORSE/FIRES. The recommendations generated by this consensus can be used as a guide for the diagnosis, evaluation, and management of patients with NORSE/FIRES, and for planning of future research.
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Affiliation(s)
- Ronny Wickstrom
- Neuropaediatric UnitDepartment of Women's and Children's HealthKarolinska Institutet and Karolinska University HospitalStockholmSweden
| | - Olga Taraschenko
- Department of Neurological SciencesUniversity of Nebraska Medical CenterOmahaNebraskaUSA
| | - Robertino Dilena
- Neuropathophysiology UnitFoundation IRCCS Ca' Granda Ospedale Maggiore PoliclinicoMilanItaly
| | - Eric T. Payne
- Department of Pediatrics, Section of NeurologyAlberta Children's HospitalCalgaryAlbertaCanada
| | - Nicola Specchio
- Rare and Complex Epilepsy Unit, Department of NeurosciencesBambino Gesù Children's Hospital, IRCCS, Full Member of European Reference Network EpiCARERomeItaly
| | - Rima Nabbout
- Department of Pediatric Neurology, APHP, Member of EPICARE ERN, Centre de Reference Epilepsies RaresUniversite de Paris, Institut Imagine, INSERM 1163ParisFrance
| | - Sookyong Koh
- Department of Pediatrics, Children's Hospital and Medical CenterUniversity of NebraskaOmahaNebraskaUSA
| | | | - Lawrence J. Hirsch
- Department of Neurology, Comprehensive Epilepsy CenterYale UniversityNew HavenConnecticutUSA
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Harrar D, Mondok L, Adams S, Farias-Moeller R. Zebras Seize the Day. Crit Care Clin 2022; 38:349-373. [DOI: 10.1016/j.ccc.2021.11.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Périn B, Szurhaj W. New onset refractory status epilepticus: State of the art. Rev Neurol (Paris) 2022; 178:74-83. [PMID: 35031143 DOI: 10.1016/j.neurol.2021.12.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 12/14/2021] [Indexed: 12/11/2022]
Abstract
NORSE (new onset refractory status epilepticus) has recently been defined as a clinical presentation, not a specific diagnosis, in a patient without active epilepsy or other preexisting relevant neurological disorder, with new onset of refractory status epilepticus without a clear acute or active structural, toxic or metabolic cause. It includes the concept of FIRES described in children with a similar condition but preceded by a 2-14-day febrile illness. NORSE constitutes the acute phase of an entity preceded by a prodromal phase which may be accompanied by numerous manifestations (febrile episode, behavioural changes, headache, …), and followed by a chronic phase marked by long-term neurological sequelae, cognitive impairment, epilepsy and functional disability. There are many causes of NORSE: autoimmune, infectious, genetic, toxic, … but in half of the cases, despite an exhaustive assessment, the cause remains undetermined. Paraneoplastic and non-paraneoplastic autoimmune encephalitis remains by far the leading cause of NORSE. For these reasons, immunotherapy should be considered rapidly in parallel with the treatment of the status epilepticus, including in cryptogenic NORSE. Good communication with the family is important because the management of the acute phase is long and difficult. Although mortality remains high (11-22%), and sequelae can be severe, the majority of survivors can have a good or fair outcome.
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Affiliation(s)
- B Périn
- Department of clinical neurophysiology, Amiens University Medical Center, France
| | - W Szurhaj
- Department of clinical neurophysiology, Amiens University Medical Center, France; Équipe CHIMERE EA7516, université Picardie Jules-Verne, France.
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10
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Sivathanu D, Kewalramani D, Kumar Manokaran R. Favorable response to classic ketogenic diet in a child with anti-GAD 65 antibody mediated super refractory status epilepticus. Epilepsy Behav Rep 2022; 19:100557. [PMID: 35789965 PMCID: PMC9250004 DOI: 10.1016/j.ebr.2022.100557] [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] [Received: 03/06/2022] [Revised: 05/30/2022] [Accepted: 06/05/2022] [Indexed: 11/10/2022] Open
Abstract
Autoimmune encephalitis is a disease condition which presents with refractory seizures in children requiring immunotherapy. KD is a non-pharmacological treatment modality used worldwide in people with drug-resistant epilepsy. It acts through many anti-inflammatory mechanisms leading to seizure control. This article highlights the use of adjuvant effect of ketogenic diet in anti GAD-65 antibody positive autoimmune encephalitis. It is the need of the hour to formulate treatment protocols incorporating newer treatment strategies including KD.
Autoimmune encephalitis refers to a spectrum of inflammatory brain diseases which can present as drug-resistant seizures in children. Hereby, we report a case of anti-GAD-65 antibody encephalitis in a 7-year-old child who presented with superrefractory status epilepticus (SRSE). The traditional management with multiple anti-seizure medications at appropriate dosage and immunotherapy was tried despite which the child continued to have seizures. Hence the child was initiated on a classic ketogenic diet. He achieved ketosis within 48 h of diet initiation and there was a drastic reduction in the seizure frequency followed by a completed remission. Hence, this non-pharmacological intervention was an effective adjunct in achieving seizure control in our patient. A ketogenic diet has been sparingly used for the management of post-encephalitic epilepsy and autoimmune epilepsy. However, the data onthe effectiveness of the ketogenic diet in the management of autoimmune encephalitis is scarce. Starting KD early in the disease course helped not only in seizure control but also preserved the cognitive and neurological well-being of the child.
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Lattanzi S, Leitinger M, Rocchi C, Salvemini S, Matricardi S, Brigo F, Meletti S, Trinka E. Unraveling the enigma of new-onset refractory status epilepticus: a systematic review of aetiologies. Eur J Neurol 2021; 29:626-647. [PMID: 34661330 PMCID: PMC9298123 DOI: 10.1111/ene.15149] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2021] [Revised: 09/10/2021] [Accepted: 10/11/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND PURPOSE New-onset refractory status epilepticus (NORSE) is a clinical presentation, neither a specific diagnosis nor a clinical entity. It refers to a patient without active epilepsy or other pre-existing relevant neurological disorder, with a NORSE without a clear acute or active structural, toxic or metabolic cause. This study reviews the currently available evidence about the aetiology of patients presenting with NORSE and NORSE-related conditions. METHODS A systematic search was carried out for clinical trials, observational studies, case series and case reports including patients who presented with NORSE, febrile-infection-related epilepsy syndrome or the infantile hemiconvulsion-hemiplegia and epilepsy syndrome. RESULTS Four hundred and fifty records were initially identified, of which 197 were included in the review. The selected studies were retrospective case-control (n = 11), case series (n = 83) and case reports (n = 103) and overall described 1334 patients both of paediatric and adult age. Aetiology remains unexplained in about half of the cases, representing the so-called 'cryptogenic NORSE'. Amongst adult patients without cryptogenic NORSE, the most often identified cause is autoimmune encephalitis, either non-paraneoplastic or paraneoplastic. Infections are the prevalent aetiology of paediatric non-cryptogenic NORSE. Genetic and congenital disorders can have a causative role in NORSE, and toxic, vascular and degenerative conditions have also been described. CONCLUSIONS Far from being a unitary condition, NORSE is a heterogeneous and clinically challenging presentation. The development and dissemination of protocols and guidelines to standardize diagnostic work-up and guide therapeutic approaches should be implemented. Global cooperation and multicentre research represent priorities to improve the understanding of NORSE.
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Affiliation(s)
- Simona Lattanzi
- Neurological Clinic, Department of Experimental and Clinical Medicine, Marche Polytechnic University, Ancona, Italy
| | - Markus Leitinger
- Department of Neurology, Christian Doppler University Hospital, Center for Cognitive Neuroscience, Paracelsus Medical University, Salzburg, Austria.,Neuroscience Institute, Christian Doppler University Hospital, Center for Cognitive Neuroscience, Paracelsus Medical University, Salzburg, Austria
| | - Chiara Rocchi
- Neurological Clinic, Department of Experimental and Clinical Medicine, Marche Polytechnic University, Ancona, Italy
| | - Sergio Salvemini
- Neurological Clinic, Department of Experimental and Clinical Medicine, Marche Polytechnic University, Ancona, Italy
| | - Sara Matricardi
- Department of Child Neuropsychiatry, Children's Hospital 'G. Salesi', Ancona, Italy
| | - Francesco Brigo
- Department of Neuroscience, Biomedicine and Movement Science, University of Verona, Verona, Italy.,Division of Neurology, 'Franz Tappeiner' Hospital, Merano, BZ, Italy
| | - Stefano Meletti
- Neurology Unit, OCB Hospital, AOU Modena, Modena, Italy.,Department of Biomedical, Metabolic and Neural Science, Center for Neuroscience and Neurotechnology, University of Modena and Reggio Emilia, Modena, Italy
| | - Eugen Trinka
- Department of Neurology, Christian Doppler University Hospital, Center for Cognitive Neuroscience, Paracelsus Medical University, Salzburg, Austria.,Neuroscience Institute, Christian Doppler University Hospital, Center for Cognitive Neuroscience, Paracelsus Medical University, Salzburg, Austria.,Public Health, Health Services Research and HTA, Medical Informatics and Technology, University for Health Sciences, Hall i.T, Austria
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12
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Histopathology of new-onset refractory status epilepticus (NORSE) in adults. Seizure 2021; 93:95-101. [PMID: 34740145 DOI: 10.1016/j.seizure.2021.09.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Revised: 09/22/2021] [Accepted: 09/24/2021] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVE new-onset refractory status epilepticus (NORSE) is defined as de novo refractory seizures occurring in previously healthy adults, without a clear underlying etiology. Due to refractory seizures and insufficient understanding of pathophysiology, management of these patients remains challenging and often leads to poor clinical outcomes. Various infectious and autoimmune mechanisms have been proposed but have not been validated and a large number of patients are thus labeled 'cryptogenic'. Moreover, histopathological findings have rarely been described in NORSE and are usually autopsy evaluations. In this paper, we describe the clinical correlates and histopathological findings in patients presenting with NORSE. METHODS A case series of five patients with NORSE who underwent neurosurgical intervention and had histopathological examination during their acute clinical course. RESULTS In all patients,status epileptics was refractory to treatment with antiseizure drugs (ASDs) and anesthetic agents. Autoimmune work-up revealed elevated titer of anti-GAD antibody in one patient but was unremarkable in others. Empiric use of immunomodulation therapy in three patients did not lead to cessation of status epilepticus (SE). Due to failure of prolonged medical management, three patients underwent palliative surgery for resection of epileptogenic tissue whereas the other two had diagnostic brain biopsy. Histopathology obtained during biopsy revealed evidence of vasculitis in one and necrotizing vasculopathy in another. The patient with anti-GAD antibodies had evidence of lymphocytic infiltration in limbic structures. The remaining two had nonspecific histopathological findings. SIGNIFICANCE Although our findings are limited by a small number of patients, it adds to the growing premise of NORSE being related to an underlying autoimmune process. Additional studies, especially with histopathological data are needed to better understand this devastating disorder.
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13
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Yang F, Sun L, Li J, Lin W. Repetitive seizures after febrile period exclusively involving bilateral claustrum. Medicine (Baltimore) 2021; 100:e27129. [PMID: 34664837 PMCID: PMC8448018 DOI: 10.1097/md.0000000000027129] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 08/18/2021] [Indexed: 11/26/2022] Open
Abstract
The purpose of this study is to demonstrate the relationship between acute repetitive seizures and claustrum damage, and to provide basis for the treatment of repetitive seizures exclusively involved the bilateral claustrum.Between August 2014 and October 2015, 5 patients with repetitive seizures after a febrile period were admitted to our hospital, showing exclusive involvement of bilateral claustrum on magnetic resonance images (MRI). All patients underwent serum virology testing, autoimmune antibody test, MRI, and electroencephalograph examination.All patients were young women (16-29 years) with an unremarkable previous medical history, and 2 of them were pregnant. Similar clinical symptoms like antecedent febrile illness in the 3 to 7 days preceding seizures, psychiatric disorder, or dysautonomia occurred in 5 patients. Abnormal MRI signals exclusively confined to the bilateral claustrum appeared in 4 patients during the acute phase and in 1 patient during the chronic phase. All patients accepted empirical treatment with anti-viral and anti-seizure drugs and had good outcomes (seizure-free, though with some residual short-term memory loss) at the 3rd year follow-up.Although the clinical and associated brain imaging findings were characteristic, the etiology was still unclear. Contrary to previous studies, the patients presented here have all received a good prognosis.
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Affiliation(s)
- Fan Yang
- Department of Neurology, The First Hospital of Jilin University, Changchun, Jilin, China
| | - Lichao Sun
- Department of Emergency, The First Hospital of Jilin University, Changchun, Jilin, China
| | - Jing Li
- Department of Neurology, The First Hospital of Jilin University, Changchun, Jilin, China
| | - Weihong Lin
- Department of Neurology, The First Hospital of Jilin University, Changchun, Jilin, China
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14
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Dramatic Course of Paediatric Cryptogenic Febrile Infection-Related Epilepsy Syndrome with Unusual Chronic Phase Presentation-A Case Report with Literature Study. Brain Sci 2021; 11:brainsci11081030. [PMID: 34439649 PMCID: PMC8392460 DOI: 10.3390/brainsci11081030] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 07/28/2021] [Accepted: 07/29/2021] [Indexed: 12/03/2022] Open
Abstract
Febrile Infection-Related Epilepsy Syndrome (FIRES) is a catastrophic, extremely rare epileptic encephalopathy. It strikes previously healthy school-aged children and is usually cryptogenic. Its dramatic onset with refractory status epilepticus is always preceded by a nonspecific febrile illness. The seizure activity in FIRES may last for several weeks with little to no response to antiepileptic treatment, usually resulting in the usage of anaesthetics. This acute phase is followed by a chronic, refractory epilepsy and cognitive deficit, that persist for the rest of the patient’s life. Still to this day no definite cause has been described. In this study we review the current finding in FIRES and describe a case of a 4-year-old patient with a dramatic course of the acute phase in FIRES and unusual presentation of the chronic phase, which is dominated by extrapyramidal symptoms such as dystonia. This case highlights that the clinical presentation of FIRES may differ from those frequently described in literature.
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15
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Le Roux M, Barth M, Gueden S, Desbordes de Cepoy P, Aeby A, Vilain C, Hirsch E, de Saint Martin A, Portes VD, Lesca G, Riquet A, Chaton L, Villeneuve N, Villard L, Cances C, Valton L, Renaldo F, Vermersch AI, Altuzarra C, Nguyen-Morel MA, Van Gils J, Angelini C, Biraben A, Arnaud L, Riant F, Van Bogaert P. CACNA1A-associated epilepsy: Electroclinical findings and treatment response on seizures in 18 patients. Eur J Paediatr Neurol 2021; 33:75-85. [PMID: 34102571 DOI: 10.1016/j.ejpn.2021.05.010] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 04/25/2021] [Accepted: 05/19/2021] [Indexed: 02/02/2023]
Abstract
CACNA1A pathogenic mutations are involved in various neurological phenotypes including episodic ataxia (EA2), spinocerebellar ataxia (SCA6), and familial hemiplegic migraine (FHM1). Epilepsy is poorly documented. We studied 18 patients (10 males) carrying de novo or inherited CACNA1A mutations, with median age of 2,5 years at epilepsy onset. Eight mutations were novel. Two variants known leading to gain of function (GOF) were found in 5 patients. Five other patients had non-sense variants leading to loss of function (LOF). Seizures were most often revealed by either status epilepticus (SE) (n = 8), eventually triggered by fever (n = 5), or absences/behavioural arrests (n = 7). Non-epileptic paroxysmal events were frequent and consisted in recurrent hemiplegic accesses (n = 9), jitteriness in the neonatal period (n = 6), and ocular paroxysmal events (n = 9). Most of the patients had early permanent cerebellar dysfunction (n = 16) and early moderate to severe global developmental delay (GDD)/intellectual deficiency (ID) (n = 17). MRI was often abnormal, with cerebellar (n = 8) and/or cerebral (n = 6) atrophy. Stroke-like occurred in 2 cases. Some antiepileptic drugs including topiramate, levetiracetam, lamotrigine and valproate were effective on seizures. Acetazolamide and calcium channel blockers were often effective when used. More than half of the patients had refractory epilepsy. CACNA1A mutation should be evoked in front of 2 main electro-clinical phenotypes that are associated with permanent cerebellar dysfunction and moderate to severe GDD/ID. The first one, found in all 5 patients with GOF variants, is characterized by intractable seizures, early and recurrent SE and hemiplegic accesses. The second, less severe, found in 5 patients with LOF variants, is characterized by refractory early onset absence seizures.
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Affiliation(s)
- Marie Le Roux
- Department of Pediatric Neurology and Neurosurgery, CHU Angers, France.
| | | | - Sophie Gueden
- Department of Pediatric Neurology and Neurosurgery, CHU Angers, France
| | | | - Alec Aeby
- Department of Pediatric Neurology, HUDERF, Bruxelles, Belgium
| | - Catheline Vilain
- Department of Medical Genetics, Erasme Hospital, Bruxelles, Belgium
| | | | | | - Vincent des Portes
- Department of Pediatric Neurology, Hospices civils de Lyon, Bron, France
| | - Gaëtan Lesca
- Department of Genetics, Hospices civils de Lyon, Bron, France
| | - Audrey Riquet
- Department of Pediatric Neurology, CHRU Lille, France
| | | | - Nathalie Villeneuve
- Department of Pediatric Neurology, Hôpital de La Timone, AP-HM, Marseille, France
| | - Laurent Villard
- Department of Medical Genetics, Hôpital de La Timone, AP-HM, Marseille, France; Aix Marseille Univ, Inserm, Marseille Medical Genetics, U1251, Marseille, France
| | - Claude Cances
- Department of Pediatric Neurology, CHU Purpan, Toulouse, France
| | - Luc Valton
- Explorations Neurophysiologiques, CHU Purpan, Toulouse, France; Centre de Recherche Cerveau et Cognition (CerCo), University of Toulouse, Toulouse F, 31300, France
| | - Florence Renaldo
- Department of Pediatric Neurology, Hôpital Trousseau, Assistance publique-Hôpitaux de Paris, France
| | - Anne-Isabelle Vermersch
- Department of Neurophysiology, Hôpital Trousseau, Assistance publique-Hôpitaux de Paris, France
| | | | | | - Julien Van Gils
- Department of Medical Genetics, CHU Bordeaux Pellegrin, Bordeaux, France
| | - Chloé Angelini
- Department of Medical Genetics, CHU Bordeaux Pellegrin, Bordeaux, France
| | - Arnaud Biraben
- Department of Neurology, CHU Rennes Pontchaillou, Rennes, France
| | - Lionel Arnaud
- Department of Genetics, Hôpital de la Pitie Salpetrière, Assistance publique-Hôpitaux de Paris, France
| | - Florence Riant
- Department of Genetics, Groupe hospitalier Saint Louis-Lariboisière, Assistance publique-Hôpitaux de Paris, France
| | - Patrick Van Bogaert
- Department of Pediatric Neurology and Neurosurgery, CHU Angers, France; Laboratoire Angevin de Recherche en Ingénierie des Systèmes (LARIS), Université d'Angers, France
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16
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Sculier C, Barcia Aguilar C, Gaspard N, Gaínza-Lein M, Sánchez Fernández I, Amengual-Gual M, Anderson A, Arya R, Burrows BT, Brenton JN, Carpenter JL, Chapman KE, Clark J, Gaillard WD, Glauser TA, Goldstein JL, Goodkin HP, Gorman M, Lai YC, McDonough TL, Mikati MA, Nayak A, Peariso K, Riviello J, Rusie A, Sperberg K, Stredny CM, Tasker RC, Tchapyjnikov D, Vasquez A, Wainwright MS, Wilfong AA, Williams K, Loddenkemper T. Clinical presentation of new onset refractory status epilepticus in children (the pSERG cohort). Epilepsia 2021; 62:1629-1642. [PMID: 34091885 PMCID: PMC8362203 DOI: 10.1111/epi.16950] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 05/09/2021] [Accepted: 05/11/2021] [Indexed: 01/14/2023]
Abstract
Objective We aimed to characterize the clinical profile and outcomes of new onset refractory status epilepticus (NORSE) in children, and investigated the relationship between fever onset and status epilepticus (SE). Methods Patients with refractory SE (RSE) between June 1, 2011 and October 1, 2016 were prospectively enrolled in the pSERG (Pediatric Status Epilepticus Research Group) cohort. Cases meeting the definition of NORSE were classified as "NORSE of known etiology" or "NORSE of unknown etiology." Subgroup analysis of NORSE of unknown etiology was completed based on the presence and time of fever occurrence relative to RSE onset: fever at onset (≤24 h), previous fever (2 weeks–24 h), and without fever. Results Of 279 patients with RSE, 46 patients met the criteria for NORSE. The median age was 2.4 years, and 25 (54%) were female. Forty (87%) patients had NORSE of unknown etiology. Nineteen (48%) presented with fever at SE onset, 16 (40%) had a previous fever, and five (12%) had no fever. The patients with preceding fever had more prolonged SE and worse outcomes, and 25% recovered baseline neurological function. The patients with fever at onset were younger and had shorter SE episodes, and 89% recovered baseline function. Significance Among pediatric patients with RSE, 16% met diagnostic criteria for NORSE, including the subcategory of febrile infection‐related epilepsy syndrome (FIRES). Pediatric NORSE cases may also overlap with refractory febrile SE (FSE). FIRES occurs more frequently in older children, the course is usually prolonged, and outcomes are worse, as compared to refractory FSE. Fever occurring more than 24 h before the onset of seizures differentiates a subgroup of NORSE patients with distinctive clinical characteristics and worse outcomes.
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Affiliation(s)
- Claudine Sculier
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA.,Department of Neurology, Erasmus Hospital, Free University of Brussels, Brussels, Belgium
| | - Cristina Barcia Aguilar
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA.,Department of Child Neurology, La Paz University Hospital, Autonomous University of Madrid, Madrid, Spain
| | - Nicolas Gaspard
- Department of Neurology, Erasmus Hospital, Free University of Brussels, Brussels, Belgium.,Neurology Department, Comprehensive Epilepsy Center, Yale University School of Medicine, New Haven, CT, USA
| | - Marina Gaínza-Lein
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA.,Faculty of Medicine, Institute of Pediatrics, Austral University of Chile, Valdivia, Chile.,Children's Neuropsychiatry Service, San Borja Arriarán Clinical Hospital, University of Chile, Santiago, Chile
| | - Iván Sánchez Fernández
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA.,Department of Child Neurology, SJD Barcelona Children's Hospital, University of Barcelona, Barcelona, Spain
| | - Marta Amengual-Gual
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA.,Pediatric Neurology Unit, Department of Pediatrics, Son Espases University Hospital, University of the Balearic Islands, Palma, Spain
| | - Anne Anderson
- Section of Neurology and Developmental Neuroscience, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Ravindra Arya
- Division of Pediatric Neurology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Brian T Burrows
- Department of Pediatrics, Barrows Neurological Institute, Phoenix Children's Hospital, University of Arizona School of Medicine, Phoenix, AZ, USA.,Department of Neurology, Mayo Clinic, Scottsdale, AZ, USA
| | - James N Brenton
- Department of Neurology and Pediatrics, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Jessica L Carpenter
- Center for Neuroscience, Children's National Hospital, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Kevin E Chapman
- Departments of Pediatrics and Neurology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO, USA
| | - Justice Clark
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - William D Gaillard
- Center for Neuroscience, Children's National Hospital, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Tracy A Glauser
- Division of Pediatric Neurology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Joshua L Goldstein
- Ruth D. & Ken M. Davee Pediatric Neurocritical Care Program, Northwestern University Feinberg, School of Medicine, Chicago, IL, USA
| | - Howard P Goodkin
- Department of Neurology and Pediatrics, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Mark Gorman
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Yi-Chen Lai
- Section of Neurology and Developmental Neuroscience, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Tiffani L McDonough
- Division of Neurology and Epilepsy, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Mohamad A Mikati
- Division of Pediatric Neurology, Duke University Medical Center, Duke University, Durham, NC, USA
| | - Anuranjita Nayak
- Section of Neurology and Developmental Neuroscience, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Katrina Peariso
- Division of Pediatric Neurology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - James Riviello
- Section of Neurology and Developmental Neuroscience, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Allison Rusie
- Ruth D. & Ken M. Davee Pediatric Neurocritical Care Program, Northwestern University Feinberg, School of Medicine, Chicago, IL, USA
| | - Katherine Sperberg
- Center for Neuroscience, Children's National Hospital, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Coral M Stredny
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Robert C Tasker
- Department of Neurology, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Dmitry Tchapyjnikov
- Division of Neurology and Epilepsy, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Alejandra Vasquez
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA.,Division of Child and Adolescent Neurology, Mayo Clinic, Mayo Clinic School of Medicine, Rochester, MN, USA
| | - Mark S Wainwright
- Division of Pediatric Neurology, Department of Neurology, University of Washington, Seattle, WA, USA
| | - Angus A Wilfong
- Division of Pediatric Neurology, Department of Child Health, Phoenix Children's Hospital, University of Arizona College of Medicine, Phoenix, AZ, USA
| | - Korwyn Williams
- Division of Pediatric Neurology, Department of Child Health, Phoenix Children's Hospital, University of Arizona College of Medicine, Phoenix, AZ, USA
| | - Tobias Loddenkemper
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
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17
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Schoeler NE, Simpson Z, Zhou R, Pujar S, Eltze C, Cross JH. Dietary Management of Children With Super-Refractory Status Epilepticus: A Systematic Review and Experience in a Single UK Tertiary Centre. Front Neurol 2021; 12:643105. [PMID: 33776895 PMCID: PMC7994594 DOI: 10.3389/fneur.2021.643105] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Accepted: 02/17/2021] [Indexed: 12/16/2022] Open
Abstract
Ketogenic diet therapies (KDT) are high-fat, low carbohydrate diets used as an effective treatment option for drug-resistant epilepsy. There is limited research on the efficacy of KDT for super-refractory status epilepticus (SRSE). We systematically review evidence for use of KDT in children with SRSE and present a single UK tertiary centre's experience. Thirty one articles were included, of which 24 were “medium” or “low” quality. One hundred and forty seven children with SRSE started KDT, of which 141 (96%) achieved ketosis. KDT was started mean 5.3 days (range 1–420) after status epilepticus (SE) started. SRSE resolved in 85/141 (60%) children after mean 6.3 days (range 0–19) post SE onset, but it is unclear whether further treatments were initiated post-KDT. 13/141 (9%) children died. Response to KDT was more likely when initiated earlier (p = 0.03) and in females (p = 0.01). Adverse side effects were reported in 48/141 (34%), mostly gastrointestinal; potentially serious adverse effects occurred in ≤4%. Eight children with SRSE, all diagnosed with febrile infection-related epilepsy syndrome, were treated with KDT at Great Ormond Street Hospital for Children. KDT was initiated enterally at mean day 13.6+/− 5.1 of admission. Seven of 8 (88%) children reported adverse side effects, which were potentially serious in 4/8 (50%), including metabolic acidosis, hypoglycaemia and raised amylase. SE ceased in 6/8 (75%) children after mean 25+/− 9.4 days post onset, but other treatments were often started concomitantly and all children started other treatments post-KDT. Two of 8 (25%) children died during admission and another died post-admission. Four of the remaining 5 children continue to have drug-resistant seizures, one of whom remains on KDT; seizure burden was unknown for one child. Our findings indicate that KDT is possible and safe in children with SRSE. Cessation of SRSE may occur in almost two-thirds of children initiated with KDT, but a causal effect is difficult to determine due to concomitant treatments, treatments started post-KDT and the variable length of time post-KDT onset when SRSE cessation occurs. Given that serious adverse side effects seem rare and response rates are (cautiously) favorable, KDT should be considered as an early treatment option in this group.
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Affiliation(s)
- Natasha E Schoeler
- Developmental Neurosciences Research and Teaching Department, University College London Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Zoe Simpson
- Department of Dietetics, Great Ormond Street Hospital for Children, London, United Kingdom
| | - Runming Zhou
- Developmental Neurosciences Research and Teaching Department, University College London Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Suresh Pujar
- Department of Paediatric and Neurology, Great Ormond Street Hospital for Children, London, United Kingdom
| | - Christin Eltze
- Department of Paediatric and Neurology, Great Ormond Street Hospital for Children, London, United Kingdom
| | - J H Cross
- Developmental Neurosciences Research and Teaching Department, University College London Great Ormond Street Institute of Child Health, London, United Kingdom.,Department of Paediatric and Neurology, Great Ormond Street Hospital for Children, London, United Kingdom.,Young Epilepsy, Lingfield, United Kingdom
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18
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Mantoan Ritter L, Nashef L. New-onset refractory status epilepticus (NORSE). Pract Neurol 2021; 21:practneurol-2020-002534. [PMID: 33674412 DOI: 10.1136/practneurol-2020-002534] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/24/2021] [Indexed: 11/04/2022]
Abstract
New-onset refractory status epilepticus and its subcategory febrile infection-related epilepsy syndrome are rare devastating clinical presentations in those without pre-existing relevant history, often in schoolchildren or young adults, without a clear cause on initial investigations. A cause is later identified in up to half of adults, but in many fewer children. Patients often require protracted intensive care and are at significant risk of dying. Functional disability is common and subsequent chronic epilepsy is the norm, but some people do have good outcomes, even after prolonged status epilepticus. Patients need prompt investigations and treatment. Anaesthetic and antiseizure medications are supplemented by other treatment modalities, including the ketogenic diet. Despite limited evidence, it is appropriate to try to modify the presumed underlying pathogenesis with immune modulation early, with a more recent focus on using interleukin inhibitors. Optimising management will require concerted multicentre international efforts.
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Affiliation(s)
- Laura Mantoan Ritter
- Department of Neurology, King's College Hospital, London, UK
- Maurice Wohl Clinical Neuroscience Institute, King's College London, London, UK
| | - Lina Nashef
- Department of Neurology, King's College Hospital, London, UK
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19
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Horino A, Kuki I, Inoue T, Nukui M, Okazaki S, Kawawaki H, Togawa M, Amo K, Ishikawa J, Ujiro A, Shiomi M, Sakuma H. Intrathecal dexamethasone therapy for febrile infection-related epilepsy syndrome. Ann Clin Transl Neurol 2021; 8:645-655. [PMID: 33547757 PMCID: PMC7951105 DOI: 10.1002/acn3.51308] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 01/12/2021] [Indexed: 01/21/2023] Open
Abstract
OBJECTIVE Increasing reports suggest a role for immunological mechanisms in febrile infection-related epilepsy syndrome (FIRES). The objective of this study was to elucidate the efficacy and safety of intrathecal dexamethasone therapy (IT-DEX). METHODS We assessed six pediatric patients with FIRES who were administered add-on IT-DEX in the acute (n = 5) and chronic (n = 1) phases. We evaluated clinical courses and prognosis. We measured cytokines/chemokines in cerebrospinal fluid (CSF) from FIRES patients at several points, including pre- and post-IT-DEX, and compared them with control patients with chronic epilepsy (n = 12, for cytokines/chemokines) or with noninflammatory neurological disease (NIND, n = 13, for neopterin). RESULTS Anesthesia was weaned after a median of 5.5 days from IT-DEX initiation (n = 6). There was a positive correlation between the duration from the disease onset to the introduction of IT-DEX and the length of ICU stay and the duration of mechanical ventilation. No patient experienced severe adverse events. Seizure spreading and background activities on electroencephalography were improved after IT-DEX in all patients. The levels of CXCL10, CXCL9, IFN-γ, and neopterin at pre-IT-DEX were significantly elevated compared to levels in epilepsy controls, and CXCL10 and neopterin were significantly decreased post-IT-DEX, but were still higher compared to patients with chronic epilepsy. IL-6, IL-8, and IL-1β were significantly elevated before IT-DEX compared to epilepsy controls, though there was no significant decrease post-treatment. INTERPRETATION IT-DEX represents a therapeutic option for patients with FIRES that could shorten the duration of the critical stage of the disease. The effect of IT-DEX on FIRES might include cytokine-independent mechanisms.
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Affiliation(s)
- Asako Horino
- Department of Pediatric NeurologyChildren's Medical CenterOsaka City General HospitalOsakaJapan
- Department of Brain and NeuroscienceTokyo Metropolitan Institute of Medical ScienceTokyoJapan
| | - Ichiro Kuki
- Department of Pediatric NeurologyChildren's Medical CenterOsaka City General HospitalOsakaJapan
| | - Takeshi Inoue
- Department of Pediatric NeurologyChildren's Medical CenterOsaka City General HospitalOsakaJapan
| | - Megumi Nukui
- Department of Pediatric NeurologyChildren's Medical CenterOsaka City General HospitalOsakaJapan
| | - Shin Okazaki
- Department of Pediatric NeurologyChildren's Medical CenterOsaka City General HospitalOsakaJapan
| | - Hisashi Kawawaki
- Department of Pediatric NeurologyChildren's Medical CenterOsaka City General HospitalOsakaJapan
| | - Masao Togawa
- Department of Pediatric Emergency MedicineChildren's Medical CenterOsaka City General HospitalOsakaJapan
| | - Kiyoko Amo
- Department of Pediatric Emergency MedicineChildren's Medical CenterOsaka City General HospitalOsakaJapan
| | - Junichi Ishikawa
- Department of Pediatric Emergency MedicineChildren's Medical CenterOsaka City General HospitalOsakaJapan
| | - Atsushi Ujiro
- Department of Intensive Care MedicineOsaka City General HospitalOsakaJapan
| | | | - Hiroshi Sakuma
- Department of Brain and NeuroscienceTokyo Metropolitan Institute of Medical ScienceTokyoJapan
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20
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Tan THL, Perucca P, O'Brien TJ, Kwan P, Monif M. Inflammation, ictogenesis, and epileptogenesis: An exploration through human disease. Epilepsia 2020; 62:303-324. [PMID: 33316111 DOI: 10.1111/epi.16788] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Revised: 11/21/2020] [Accepted: 11/22/2020] [Indexed: 12/14/2022]
Abstract
Epilepsy is seen historically as a disease of aberrant neuronal signaling manifesting as seizures. With the discovery of numerous auto-antibodies and the subsequent growth in understanding of autoimmune encephalitis, there has been an increasing emphasis on the contribution of the innate and adaptive immune system to ictogenesis and epileptogenesis. Pathogenic antibodies, complement activation, CD8+ cytotoxic T cells, and microglial activation are seen, to various degrees, in different seizure-associated neuroinflammatory and autoimmune conditions. These aberrant immune responses are thought to cause disruptions in neuronal signaling, generation of acute symptomatic seizures, and, in some cases, the development of long-term autoimmune epilepsy. Although early treatment with immunomodulatory therapies improves outcomes in autoimmune encephalitides and autoimmune epilepsies, patient identification and treatment selection are not always clear-cut. This review examines the role of the different components of the immune system in various forms of seizure disorders including autoimmune encephalitis, autoimmune epilepsy, Rasmussen encephalitis, febrile infection-related epilepsy syndrome (FIRES), and new-onset refractory status epilepticus (NORSE). In particular, the pathophysiology and unique cytokine profiles seen in these disorders and their links with diagnosis, prognosis, and treatment decision-making are discussed.
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Affiliation(s)
- Tracie Huey-Lin Tan
- Department of Neuroscience, Central Clinical School, Faculty of Medicine, Nursing and Health Science, Monash University, Melbourne, Victoria, Australia.,Department of Neurology, Alfred Hospital, Melbourne, Victoria, Australia.,Department of Neurology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Piero Perucca
- Department of Neuroscience, Central Clinical School, Faculty of Medicine, Nursing and Health Science, Monash University, Melbourne, Victoria, Australia.,Department of Neurology, Alfred Hospital, Melbourne, Victoria, Australia.,Department of Neurology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Terence J O'Brien
- Department of Neuroscience, Central Clinical School, Faculty of Medicine, Nursing and Health Science, Monash University, Melbourne, Victoria, Australia.,Department of Neurology, Alfred Hospital, Melbourne, Victoria, Australia.,Department of Neurology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Patrick Kwan
- Department of Neuroscience, Central Clinical School, Faculty of Medicine, Nursing and Health Science, Monash University, Melbourne, Victoria, Australia.,Department of Neurology, Alfred Hospital, Melbourne, Victoria, Australia
| | - Mastura Monif
- Department of Neuroscience, Central Clinical School, Faculty of Medicine, Nursing and Health Science, Monash University, Melbourne, Victoria, Australia.,Department of Neurology, Alfred Hospital, Melbourne, Victoria, Australia.,Department of Neurology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
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21
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Culler GW, VanHaerents S. Immunologic Treatments of Seizures and Status Epilepticus. Semin Neurol 2020; 40:708-718. [DOI: 10.1055/s-0040-1719111] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
AbstractAn autoimmune etiology for seizures, epilepsy, and status epilepticus is becoming increasingly recognized. The role of autoimmunity in epilepsy has been highlighted in the literature and the International League Against Epilepsy now recognizes autoimmune epilepsy as a distinct entity. An appropriate and thorough work-up of all new-onset seizures and status epilepticus is paramount in determining the likely efficacy of immunotherapeutic agents in treating seizures and status epilepticus. Criteria for the clinical diagnosis of autoimmune mediated epilepsy and encephalitis have been published by expert consensus and validated models to predict response to immunotherapy exist. These guidelines should guide clinicians about when to promptly start immunotherapy. Immunotherapy has been shown to improve outcomes and may reduce relapse rates in autoimmune encephalitis. Treatment algorithms with immunotherapeutic agents have been established by expert opinion and multiple observational retrospective trials in the past 10 years. However, future prospective randomized controlled trials are still needed to better understand the optimal regimen, dosing schedule, and duration of treatment with immunotherapeutic agents.
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Affiliation(s)
- George W. Culler
- Department of Neurology, Northwestern Memorial Hospital, Chicago, Illinois
- Department of Neurology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Stephen VanHaerents
- Department of Neurology, Northwestern Memorial Hospital, Chicago, Illinois
- Department of Neurology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
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McDonald TJW, Cervenka MC. Ketogenic Diet Therapies for Seizures and Status Epilepticus. Semin Neurol 2020; 40:719-729. [PMID: 33155184 DOI: 10.1055/s-0040-1719077] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Ketogenic diet therapies are high-fat, low-carbohydrate diets designed to mimic a fasting state. Although initially developed nearly one century ago for seizure management, most clinical trials for the management of drug-resistant epilepsy in children as well as adults have been conducted over the last 3 decades. Moreover, ketogenic diets offer promising new adjunctive strategies in the critical care setting for the resolution of acute status epilepticus when traditional antiseizure drugs and anesthetic agents fail. Here, we review the history of ketogenic diet development, the clinical evidence supporting its use for the treatment of drug-resistant epilepsy in children and adults, and the early evidence supporting ketogenic diet feasibility, safety, and potential efficacy in the management of status epilepticus.
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Yu Y, Yang Z, Jin B, Qin X, Zhu X, Sun J, Huo L, Wang R, Shi Y, Jia Z, Shi YS, Chu S, Kong D, Zhang W. Cannabidiol inhibits febrile seizure by modulating AMPA receptor kinetics through its interaction with the N-terminal domain of GluA1/GluA2. Pharmacol Res 2020; 161:105128. [DOI: 10.1016/j.phrs.2020.105128] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Revised: 07/30/2020] [Accepted: 08/05/2020] [Indexed: 12/15/2022]
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Specchio N, Pietrafusa N. New-onset refractory status epilepticus and febrile infection-related epilepsy syndrome. Dev Med Child Neurol 2020; 62:897-905. [PMID: 32372459 DOI: 10.1111/dmcn.14553] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/19/2020] [Indexed: 12/11/2022]
Abstract
New-onset refractory status epilepticus (NORSE) and febrile infection-related epilepsy syndrome (FIRES) are relatively rare clinical presentations. They are characterized by de novo onset of refractory status epilepticus (RSE) without clearly identifiable acute or active cause (structural, toxic, or metabolic). We reviewed the literature using PubMed reports published between 2003 and 2019 and summarized the clinical, neurophysiological, imaging, and treatment findings. Focal motor seizures, which tend to evolve into status epilepticus, characterize the typical presentation. Disease course is biphasic: acute phase followed by chronic phase with refractory epilepsy and neurological impairment. Aetiology is unknown, but immune-inflammatory-mediated epileptic encephalopathy is suspected. Electroencephalograms show variety in discharges (sporadic or periodic, focal, generalized, or more frequently bilateral), sometimes with a multifocal pattern. About 70% of adult NORSE have abnormal magnetic resonance imaging (MRI); in paediatric series of FIRES, 61.2% of patients have a normal brain MRI at the beginning and only 18.5% during the chronic phase. No specific therapy for FIRES and NORSE currently exists; high doses of barbiturates and ketogenic diet can be used with some effectiveness. Recently, anakinra and tocilizumab, targeting interleukin pathways, have emerged as potential specific therapies. Mortality rate is around 12% in children and even higher in adults (16-27%).
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Affiliation(s)
- Nicola Specchio
- Rare and Complex Epilepsy Unit, Department of Neuroscience and Neurorehabilitation, Bambino Gesù Children Hospital, Rome, Italy.,European Reference Network EpiCARE, Rome, Italy
| | - Nicola Pietrafusa
- Rare and Complex Epilepsy Unit, Department of Neuroscience and Neurorehabilitation, Bambino Gesù Children Hospital, Rome, Italy
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Lin KL, Lin JJ, Wang HS. Application of ketogenic diets for pediatric neurocritical care. Biomed J 2020; 43:218-225. [PMID: 32641260 PMCID: PMC7424092 DOI: 10.1016/j.bj.2020.02.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Revised: 01/13/2020] [Accepted: 02/18/2020] [Indexed: 02/07/2023] Open
Abstract
In this review, we summarize the general mechanisms of the ketogenic diet, and the application of a ketogenic diet in pediatric intensive care units for the neurological disorders of children and young infants. A ketogenic diet is a high-fat, low-carbohydrate, adequate-protein diet. It can alter the primary cerebral energy metabolism from glucose to ketone bodies, which involves multiple mechanisms of antiepileptic action, antiepileptogenic properties, neuro-protection, antioxidant and anti-inflammatory effects, and it is potentially a disease-modifying intervention. Although a ketogenic diet is typically used for the chronic stage of pharmacoresistant of epilepsy, recent studies have shown its efficacy in patients with the acute stage of refractory/super-refractory status epilepticus. The application of a ketogenic diet in pediatric intensive care units is a challenge because of the critical status of the patients, who are often in a coma or have a nothing by mouth order. Moreover, a ketogenic diet needs to be started early and sometimes through parenteral administration in patients with critical conditions such as refractory status epilepticus or febrile infection-related epilepsy syndrome. Animal models and some case reports have shown that the neuro-protective effects of a ketogenic diet can be extended to other emergent neurological diseases, such as traumatic brain injury and ischemic stroke.
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Affiliation(s)
- Kuang-Lin Lin
- Division of Pediatric Neurology, Chang Gung Children's Hospital at Linkou, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Jann-Jim Lin
- Division of Pediatric Critical Care and Pediatric Neurocritical Care Center, Chang Gung Children's Hospital at Linkou, Taoyuan, Taiwan; Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Huei-Shyong Wang
- Division of Pediatric Neurology, Chang Gung Children's Hospital at Linkou, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan.
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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: 1.0] [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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Valton L, Benaiteau M, Denuelle M, Rulquin F, Hachon Le Camus C, Hein C, Viguier A, Curot J. Etiological assessment of status epilepticus. Rev Neurol (Paris) 2020; 176:408-426. [PMID: 32331701 DOI: 10.1016/j.neurol.2019.12.010] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Accepted: 12/23/2019] [Indexed: 12/30/2022]
Abstract
Status epilepticus (SE) is a potentially serious condition that can affect vital and functional prognosis and requires urgent treatment. Etiology is a determining factor in the patient's functional outcome and in almost half of all cases justifies specific treatment to stop progression. Therefore, identifying and addressing the cause of SE is a key priority in SE management. However, the etiology can be difficult to identify among acute and remote causes, which can also be multiple and interrelated. The most common etiologies are the discontinuation of antiepileptic medication in patients with a prior history of epilepsy, and acute brain aggression in cases of new onset SE (cerebrovascular pathologies are the most common). The list of remaining possible etiologies includes heterogeneous pathological contexts. Refractory SE and especially New-Onset Refractory Status Epilepticus (NORSE) lead to an extension of the etiological assessment in the search for encephalitis of autoimmune or infectious origin in adults and in children, as well as a genetic pathology in children in particular. This is an overview of current knowledge of SE etiologies and a pragmatic approach for carrying out an etiological assessment based on the following steps: - Which etiological orientation is identified according to the field and clinical presentation?; - Which etiologies to look for in an inaugural SE?; - Which first-line assessment should be carried out? The place of the biological, EEG and imaging assessment is discussed; - Which etiologies to look for in case of refractory SE?
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Affiliation(s)
- L Valton
- Explorations Neurophysiologiques, Département de Neurologie, Hôpital Pierre-Paul-Riquet, Purpan, CHU de Toulouse, Toulouse, France; Centre de Recherche Cerveau et Cognition, Université de Toulouse, Université Paul-Sabatier Toulouse, Toulouse, France; CerCo, UMR 5549, Centre National de la Recherche Scientifique, Toulouse Mind and Brain Institute, Toulouse, France.
| | - M Benaiteau
- Unité Cognition, Épilepsie, Mouvements Anormaux, Département de Neurologie, Hôpital Pierre-Paul-Riquet, Purpan, CHU de Toulouse, Toulouse, France
| | - M Denuelle
- Explorations Neurophysiologiques, Département de Neurologie, Hôpital Pierre-Paul-Riquet, Purpan, CHU de Toulouse, Toulouse, France; Centre de Recherche Cerveau et Cognition, Université de Toulouse, Université Paul-Sabatier Toulouse, Toulouse, France; CerCo, UMR 5549, Centre National de la Recherche Scientifique, Toulouse Mind and Brain Institute, Toulouse, France
| | - F Rulquin
- Post-Urgence Neurologique, Département de Neurologie, Hôpital Pierre-Paul-Riquet, Purpan, CHU de Toulouse, Toulouse, France
| | - C Hachon Le Camus
- Neuropédiatrie, Hôpital des Enfants, Purpan, CHU de Toulouse, Toulouse, France
| | - C Hein
- Neurogériatrie, Hôpital Purpan, CHU de Toulouse, Toulouse, France
| | - A Viguier
- Soins Intensifs Neurovasculaires, Département de Neurologie, Hôpital Pierre-Paul-Riquet, Purpan, CHU de Toulouse, Toulouse, France
| | - J Curot
- Explorations Neurophysiologiques, Département de Neurologie, Hôpital Pierre-Paul-Riquet, Purpan, CHU de Toulouse, Toulouse, France; Centre de Recherche Cerveau et Cognition, Université de Toulouse, Université Paul-Sabatier Toulouse, Toulouse, France; CerCo, UMR 5549, Centre National de la Recherche Scientifique, Toulouse Mind and Brain Institute, Toulouse, France
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Lee YJ. Febrile Infection-Related Epilepsy Syndrome: Refractory Status Epilepticus and Management Strategies. ANNALS OF CHILD NEUROLOGY 2020. [DOI: 10.26815/acn.2019.00283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
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GRIN2D/GluN2D NMDA receptor: Unique features and its contribution to pediatric developmental and epileptic encephalopathy. Eur J Paediatr Neurol 2020; 24:89-99. [PMID: 31918992 PMCID: PMC7035963 DOI: 10.1016/j.ejpn.2019.12.007] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Accepted: 12/06/2019] [Indexed: 12/14/2022]
Abstract
N-methyl-d-aspartate receptors (NMDARs), a subset of ligand-gated ionotropic glutamate receptors, are critical for learning, memory, and neuronal development. However, when NMDAR subunits are mutated, a host of neuropathological conditions can occur, including epilepsy. Recently, genetic variation within the GRIN2D gene, which encodes the GluN2D subunit of the NMDAR, has been associated with a set of early-onset neurological diseases, notably developmental and epileptic encephalopathy (DEE). Importantly, patients with GRIN2D variants are largely refractory to conventional anti-epileptic drug (AED) treatment, highlighting the need to further understand the distinctive characteristics of GluN2D in neurological and pathological functions. In this review, we first summarize GluN2D's unique spatial and temporal expression patterns, electrophysiological profiles, and contributions to both pre- and postsynaptic signaling. Next, we review thirteen unique case studies from DEE patients harboring ten different causal GRIN2D variants. These patients are highly heterogenous, manifesting multiple seizure types, electroencephalographic recordings, and neurological and developmental outcomes. Lastly, this review concludes by highlighting the difficulty in treating patients with DEE-associated GRIN2D variants, and stresses the need for selective therapeutic agents delivered within a precise time window.
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Iizuka T. [Recent progress in autoimmune encephalitis and its related disorders]. Rinsho Shinkeigaku 2019; 59:491-501. [PMID: 31341132 DOI: 10.5692/clinicalneurol.cn-001314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
After the discovery of a series of autoantibodies against neuronal cell surface antigens (NSAs) of the CNS in the past 10 years, the concept of encephalitis has changed dramatically. Accordingly, a practical, syndrome-based diagnostic approach to autoimmune encephalitis was proposed in 2016. These autoantibodies have also been identified in a subset of overlapping encephalitis and demyelinating syndrome, epilepsy, first episode psychosis, movement disorders, post-herpes simplex encephalitis, progressive dementia, postpartum psychosis, stiff-person spectrum disorders, or non-REM/REM sleep behavior disorder. Although not all neuronal antibody tests are available in Japan, we have entered a new era that we have to make a correct diagnosis and start appropriate immunotherapy based on initial neurological assessment and conventional tests, without being constrained by conventional fixed ideas or normal-appearing brain MRIs while waiting for neuronal antibody test results. Although many issues need to be resolved in Japan in terms of diagnosis and treatment in autoimmune encephalitis, this review focusses on recent progress in autoimmune encephalitis and its related disorders closely related to clinical practice, including Hashimoto encephalopathy and new-onset refractory status epilepticus (NORSE).
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Affiliation(s)
- Takahiro Iizuka
- Department of Neurology, Kitasato University School of Medicine
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31
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Fox K, Wells ME, Tennison M, Vaughn B. Febrile Infection-Related Epilepsy Syndrome (FIRES): A Literature Review and Case Study. Neurodiagn J 2019; 57:224-233. [PMID: 28898171 DOI: 10.1080/21646821.2017.1355181] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Febrile infection-related epilepsy syndrome (FIRES) is a catastrophic epileptic syndrome that strikes previously healthy children aged 3-15 years and has an unknown pathogenesis and few treatments. These children experience a nonspecific febrile illness that is followed by prolonged refractory status epilepticus. Although the etiology is unknown, FIRES has a biphasic presentation, with the acute phase beginning as seizure activity lasting 1-12 weeks, then followed by the chronic phase, which is characterized by refractory seizures that cluster every 2-4 weeks, and may continue to be multifocal and independent. Treatment of FIRES is difficult, typically unresponsive to antiepileptic drugs. Some children resolve temporarily with drug-induced burst suppression comas. Other therapies such as a ketogenic diet have limited benefit. The outcome varies with the length of the acute phase and is usually poor, with up to 30% of cases ending in death and 66-100% of survivors having intellectual disability. The authors present a case of a 6-year-old child presenting with FIRES and refractory status epilepticus, which continued despite multidrug therapy. The patient underwent immunomodulatory therapy with the eventual resolution of status, but she developed a chronic, moderately severe encephalopathy, including intractable epilepsy. This case highlights the challenges of FIRES and the potential of immunomodulatory therapies for children with this disorder.
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Affiliation(s)
- Kristy Fox
- a Neurodiagnostics and Sleep Science Program , University of North Carolina, Chapel Hill , Chapel Hill , North Carolina
| | - Mary Ellen Wells
- a Neurodiagnostics and Sleep Science Program , University of North Carolina, Chapel Hill , Chapel Hill , North Carolina
| | - Michael Tennison
- b Department of Neurology, School of Medicine , University of North Carolina , Chapel Hill, Chapel Hill , North Carolina
| | - Bradley Vaughn
- b Department of Neurology, School of Medicine , University of North Carolina , Chapel Hill, Chapel Hill , North Carolina
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The short-term and long-term outcome of febrile infection-related epilepsy syndrome in children. Epilepsy Behav 2019; 95:117-123. [PMID: 31035103 DOI: 10.1016/j.yebeh.2019.02.033] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Revised: 02/23/2019] [Accepted: 02/28/2019] [Indexed: 11/22/2022]
Abstract
BACKGROUND The febrile infection-related epilepsy syndrome (FIRES) is a catastrophic epileptic encephalopathy which developed the refractory status epilepticus following or during a nonspecific febrile illness. To analyze the short-term and long-term outcome of FIRES in the children, we retrospectively analyzed the related data. METHODS The motor outcome was evaluated by modified Rankin scale (mRS). Poor motor outcome was defined as a mRS score of 4 or higher at discharge. Significant motor decline was defined as the mRS difference more than 2 before hospital admission and at discharge. RESULTS We totally enrolled 25 patients for analysis. Four patients were expired during hospitalization, and one patient was lost to follow-up after discharge. Therefore, a total 20 patients were finally analyzed. The age of disease onset ranged from 1.6 to 17.2 years (mean: 9.6 ± 4.4 years). Newly acquired epilepsy and cognitive deficit occurred in 100% and 61%, respectively. The duration of the anesthetic agents ranged from 7 to 149 days (mean: 34.2 ± 36.1 days). The duration of anesthetic agent usage (p = 0.011), refractory epilepsy (p = 0.003), and the use of ketogenic diet (p = 0.004) were significantly associated with the poor long-term motor outcome, and the number of anesthetic agents tended to be associated with the poor long-term motor outcome (p = 0.050). In-hospital mortality was 16%. Significant functional decline at discharge occurred in 100%. However, there was improvement in long-term follow-up. CONCLUSION The outcome of FIRES is poor with significant mortality and morbidities. Refractory epilepsy with cognitive deficit in survived cases is common, but improvement is possible.
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Park EG, Lee J, Lee J. The ketogenic diet for super-refractory status epilepticus patients in intensive care units. Brain Dev 2019; 41:420-427. [PMID: 30638692 DOI: 10.1016/j.braindev.2018.12.007] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Revised: 11/21/2018] [Accepted: 12/25/2018] [Indexed: 12/29/2022]
Abstract
OBJECTIVES Super-refractory status epilepticus (SRSE) is one of the most challenging issues in intensive care units (ICUs) in that it is associated with high morbidity and mortality. Although the ketogenic diet (KD) has been reported to be effective in treating of SRSE, the use of the diet as therapy can be complicated by concomitant medical problems specific to critically ill patients. In this study, we aimed to describe our experience of the KD for SRSE patients in ICUs. METHODS We retrospectively reviewed the medical records of 16 patients (10 males, 6 females) with SRSE who were treated with the KD in the ICUs at Samsung Medical Center from July 2005 to July 2017. RESULTS The median age of seizure onset was 8 years (interquartile range 5-13.5). Prior to diet initiation, the patients were in convulsive or non-convulsive SRSE for a median of 23 days (range, 3-420). The median time to achieve ketosis was 3 days (range, 2-6). The KD was continued for a median of 2.1 months (range, 0.1-15.8). Of the 16 patients, nine (56.3%) achieved seizure freedom, six (37.5%) reported >50% seizure reduction, and one (6.2%) had <50% seizure improvement after the KD. There was no significant change in the number of antiepileptic drugs. The most commonly encountered complication during the KD was gastrointestinal disturbance. CONCLUSIONS Our experience indicates that the KD is an effective alternative therapeutic strategy for SRSE patients in ICUs with adequate efficacy and safety in reducing seizure frequency and weaning from prolonged mechanical ventilation, although functional outcome was not favorable for most patients. Close monitoring and preventive management of potential adverse effects are critical elements for success with the KD in patients with SRSE.
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Affiliation(s)
- Eu Gene Park
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University, School of Medicine, Seoul, Republic of Korea
| | - Jiwon Lee
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University, School of Medicine, Seoul, Republic of Korea
| | - Jeehun Lee
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University, School of Medicine, Seoul, Republic of Korea.
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Serino D, Santarone ME, Caputo D, Fusco L. Febrile infection-related epilepsy syndrome (FIRES): prevalence, impact and management strategies. Neuropsychiatr Dis Treat 2019; 15:1897-1903. [PMID: 31371963 PMCID: PMC6635824 DOI: 10.2147/ndt.s177803] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Accepted: 06/13/2019] [Indexed: 12/27/2022] Open
Abstract
Febrile infection-related epilepsy syndrome (FIRES) is a rare catastrophic epileptic encephalopathy with a yet undefined etiology, affecting healthy children. It is characterized by acute manifestation of recurrent seizures or refractory status epilepticus preceded by febrile illness, but without evidence of infectious encephalitis. To date, the absence of specific biomarkers poses a significant diagnostic challenge; nonetheless, early diagnosis is very important for optimal management. FIRES is mostly irreversible and its sequelae include drug-resistant epilepsy and neuropsychological impairments. The treatment of FIRES represents a significant challenge for clinicians and is associated with low success rates. Early introduction of ketogenic diet seems to represent the most effective and promising treatment. This review aims to highlight the most recent insights on clinical features, terminology, epidemiology, pathogenesis, diagnostic challenges and therapeutic options.
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Affiliation(s)
- Domenico Serino
- Department of Child Neurology, Royal Aberdeen Children's Hospital, Aberdeen, UK
| | | | - Davide Caputo
- Neurology Unit, Neuroscience Department, San Paolo Hospital, Milan, Italy
| | - Lucia Fusco
- Department of Neuroscience, Bambino Gesù Children's Hospital, Rome, Italy
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Bumanglag AV, Sloviter RS. No latency to dentate granule cell epileptogenesis in experimental temporal lobe epilepsy with hippocampal sclerosis. Epilepsia 2018; 59:2019-2034. [PMID: 30338519 DOI: 10.1111/epi.14580] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Revised: 09/19/2018] [Accepted: 09/19/2018] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To determine when spontaneous granule cell epileptiform discharges first occur after hippocampal injury, and to identify the postinjury "latent" period as either a "silent" gestational state of epileptogenesis or a subtle epileptic state in gradual transition to a more obvious epileptic state. METHODS Nonconvulsive status epilepticus evoked by perforant path stimulation in urethane-sedated rats produced selective and extensive hippocampal injury and a "latent" period that preceded the onset of the first clinically obvious epileptic seizures. Continuous granule cell layer depth recording and video monitoring assessed the time course of granule cell hyperexcitability and the onset/offset times of spontaneous epileptiform discharges and behavioral seizures. RESULTS One day postinjury, granule cells in awake rats were hyperexcitable to afferent input, and continuously generated spontaneous population spikes. During the ~2-4 week "latent" period, granule cell epileptiform discharges lasting ~30 seconds caused subtle focal seizures characterized by immobilization and facial automatisms that were undetected by behavioral assessment alone but identified post hoc. Granule cell layer epileptiform discharge duration eventually tripled, which caused the first clinically obvious seizure, ending the "latent" period. Behavioral seizure duration was linked tightly to spontaneous granule cell layer events. Granule cell epileptiform discharges preceded all behavioral seizure onsets, and clonic behaviors ended abruptly within seconds of the termination of each granule cell epileptiform discharge. Noninjurious hippocampal excitation produced no evidence of granule cell hyperexcitability or epileptogenesis. SIGNIFICANCE The latent period in this model is a subtle epileptic state in transition to a more clinically obvious epileptic state, not a seizure-free "gestational" state when an unidentified epileptogenic mechanism gradually develops. Based on the onset/offset times of electrographic and behavioral events, granule cell behavior may be the prime determinant of seizure onset, phenotype, duration, and offset in this model of hippocampal-onset epilepsy. Extensive hippocampal neuron loss could be the primary epileptogenic mechanism.
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Affiliation(s)
| | - Robert S Sloviter
- Neuroscience Institute, Morehouse School of Medicine, Atlanta, Georgia.,Department of Neurobiology, Morehouse School of Medicine, Atlanta, Georgia.,Department of Pharmacology & Toxicology, Morehouse School of Medicine, Atlanta, Georgia
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Fessas P, Duret A. Question 1: Is there a role for the ketogenic diet in refractory status epilepticus? Arch Dis Child 2018; 103:994-997. [PMID: 30104393 DOI: 10.1136/archdischild-2018-315755] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Revised: 07/20/2018] [Accepted: 07/20/2018] [Indexed: 12/25/2022]
Affiliation(s)
- Petros Fessas
- School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Amedine Duret
- School of Clinical Medicine, University of Cambridge, Cambridge, UK
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New onset refractory status epilepticus (NORSE). Seizure 2018; 68:72-78. [PMID: 30482654 DOI: 10.1016/j.seizure.2018.09.018] [Citation(s) in RCA: 71] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2018] [Revised: 08/03/2018] [Accepted: 09/22/2018] [Indexed: 12/28/2022] Open
Abstract
PURPOSE To summarize the clinical features, suggested work-up, treatment and prognosis of new-onset refractory status epilepticus (NORSE), a condition recently defined as the occurrence of refractory status epilepticus (RSE) in a patient without active epilepsy, and without a clear acute or active structural, toxic or metabolic cause; and of the related syndrome of febrile infection-related epilepsy syndrome (FIRES), also recently defined as a subgroup of NORSE preceded by a febrile illness between 2 weeks and 24 h prior to the onset of RSE. METHOD Narrative review of the medical literature about NORSE and FIRES. RESULTS NORSE and FIRES mainly affect school-age children and young adults. A prodromal phase with flu-like symptoms precedes the SE onset in two third of NORSE cases, and by definition in all FIRES. Status epilepticus usually starts with repeated focal seizures with secondary bilateralization. Most cases evolve to super RSE (SRSE) and have unfavorable outcome, with short-term mortality of 12-27%, long-term disability and epilepsy. No specific imaging or laboratory abnormalities have been identified so far that allows an early diagnosis and half of adult cases remain of unknown etiology. A standardized diagnostic algorithm is provided and. Autoimmune encephalitis is the most frequent identified cause. In the absence of specific diagnosis, immunotherapy could be tried in addition to antiepileptic treatment. CONCLUSIONS This review presents the rare but devastating syndrome of NORSE, including the subcategory of FIRES. Early recognition with complete work-up is primordial to identify the underlying cause and promptly start appropriate treatment.
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Febrile infection-related epilepsy syndrome (FIRES): therapeutic complications, long-term neurological and neuroimaging follow-up. Seizure 2018; 56:53-59. [DOI: 10.1016/j.seizure.2018.02.003] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2016] [Revised: 02/02/2018] [Accepted: 02/06/2018] [Indexed: 11/22/2022] Open
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Jafarpour S, Hodgeman RM, De Marchi Capeletto C, de Lima MTA, Kapur K, Tasker RC, Loddenkemper T. New-Onset Status Epilepticus in Pediatric Patients: Causes, Characteristics, and Outcomes. Pediatr Neurol 2018; 80:61-69. [PMID: 29373157 DOI: 10.1016/j.pediatrneurol.2017.11.016] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2017] [Revised: 11/20/2017] [Accepted: 11/26/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Many pediatric patients presenting with status epilepticus have no history of seizures. METHODS We retrospectively analyzed the clinical characteristics of patients aged one month to 21 years who presented during six consecutive years with convulsive status epilepticus and without a history of seizures. New-onset refractory status epilepticus was defined as status epilepticus refractory to two lines of treatment, without an identified cause in the first 48 hours. RESULTS Of 460 patients with status epilepticus, 79 (17.2%) presented with new-onset status epilepticus, including four (0.9%) with new-onset refractory status epilepticus. Of those patients, 54.4% were female, and the median age was 3.5 years (IQR: 1.08 to 6.75). The median seizure duration was 20 minutes (IQR: 10 to 40 minutes). Etiology was unknown in 36.7%, symptomatic in 30.3%, provoked in 16.5%, and provoked with an existing symptomatic etiology in 16.5%. Patients were followed for a median duration of 63 months (IQR: 21 to 97). The mortality rate was 3.8%. Of 55 patients who were developmentally normal at baseline, 29.1% had a significant cognitive impairment at the last follow-up, and 20% had academic difficulties or behavioral problems. Patients with symptomatic etiology had greater odds of having cognitive and behavioral problems compared with patients with unknown etiology (odds ratio = 3.83, P = 0.012). CONCLUSIONS Patients with new-onset status epilepticus are at risk for recurrent seizures, recurrent status epilepticus, death, and subsequent cognitive-behavioral impairment. Specific monitoring and care interventions might be required in this high-risk population.
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Affiliation(s)
- Saba Jafarpour
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Ryan M Hodgeman
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts; Michigan State University College of Osteopathic Medicine East Lansing, MI
| | - Carolina De Marchi Capeletto
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts; Medical School, Faculdade Evangélica do Paraná, Curitiba, Brazil
| | - Mateus Torres Avelar de Lima
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts; Faculty of Medicine, Universidade de Brasilia, Brasilia, Brazil
| | - Kush Kapur
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Robert C Tasker
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts; Division of Critical Care Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Tobias Loddenkemper
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts.
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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: 21.5] [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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Aponte-Puerto A, Rozo-Osorio JD, Guzman-Porras JJ, Patiño-Moncayo AD, Amortegui-Beltrán JA, Uscategui AM. Febrile Infection-Related Epilepsy Syndrome (FIRES), a possible cause of super-refractory status epilepticus. Case report. CASE REPORTS 2018. [DOI: 10.15446/cr.v4n1.61288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Introducción: El estado epiléptico superrefractario (EES) es una patología con importante morbimortalidad que afecta el ambiente neuronal según el tipo y duración de las crisis.Presentación del caso: Se presenta el caso de un escolar con estado epiléptico superrefractario y crisis multifocales. Se descartaron causas metabólicas, estructurales, infecciosas, toxicológicas y autoinmunes y se utilizaron diferentes manejos anticonvulsivantes sin respuesta, lográndose control de las crisis 6 semanas después del ingreso a UCI. Se realizó un seguimiento de 12 años, periodo en el que el paciente presentó múltiples recaídas del estado epiléptico asociadas a la presencia de epilepsia refractaria con múltiples tipos de crisis, en su mayoría vegetativas; además se dio involución cognitiva.Discusión: Esta forma de estado epiléptico corresponde al síndrome de estado epiléptico facilitado por fiebre (FIRES), entidad de posible origen inmunológico conocida por ser refractaria al tratamiento agudo y al manejo cró- nico de la epilepsia y que se presenta como secuela. Su evolución no se ha descrito a largo plazo y por tanto no hay consenso sobre el manejo en la fase crónica.Conclusión: Es importante considerar esta etiología en estado epiléptico superrefractario para utilizar de forma temprana diferentes estrategias terapéuticas, como la dieta cetogénica, que permitan, por un lado, controlar su condición crítica y las crisis epilépticas a largo plazo y, por el otro, mejorar el pronóstico cognitivo, logrando así un impacto en la calidad de vida.
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Iizuka T, Kanazawa N, Kaneko J, Tominaga N, Nonoda Y, Hara A, Onozawa Y, Asari H, Hata T, Kaneko J, Yoshida K, Sugiura Y, Ugawa Y, Watanabe M, Tomita H, Kosakai A, Kaneko A, Ishima D, Kitamura E, Nishiyama K. Cryptogenic NORSE: Its distinctive clinical features and response to immunotherapy. NEUROLOGY-NEUROIMMUNOLOGY & NEUROINFLAMMATION 2017; 4:e396. [PMID: 28959704 PMCID: PMC5614728 DOI: 10.1212/nxi.0000000000000396] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Accepted: 08/02/2017] [Indexed: 01/01/2023]
Abstract
Objective: To report the distinctive clinical features of cryptogenic new-onset refractory status epilepticus (C-NORSE) and the C-NORSE score based on initial clinical assessments. Methods: A retrospective study was conducted for 136 patients with clinically suspected autoimmune encephalitis who underwent testing for autoantibodies to neuronal surface antigens between January 1, 2007, and August 31, 2016. Eleven patients with C-NORSE were identified. Their clinical features were compared with those of 32 patients with anti-NMDA receptor encephalitis (NMDARE). Results: The clinical outcome of 11 patients (median age, 27 years; 7 [64%] women) with C-NORSE was evaluated after a median follow-up of 11 months (range, 6–111 months). Status epilepticus was frequently preceded by fever (10/11 [91%]). Brain MRIs showed symmetric T2/fluid-attenuated inversion recovery hyperintensities (8/11 [73%]) and brain atrophy (9/11 [82%]). Only 2 of the 10 treated patients responded to the first-line immunotherapy, and 4 of the 5 patients treated with IV cyclophosphamide responded to the therapy. The long-term outcome was poor in 8 patients (73%). Compared with 32 patients with NMDARE (median age, 27 years; 24 [75%] women), those with C-NORSE had more frequent prodromal fever, status epilepticus, ventilatory support, and symmetric brain MRI abnormalities, had less frequent involuntary movements, absent psychobehavioral symptoms, CSF oligoclonal bands, or tumor association, and had a worse outcome. The C-NORSE score was higher in patients with C-NORSE than those with NMDARE. Conclusions: Patients with C-NORSE have a spectrum of clinical-immunological features different from those with NMDARE. The C-NORSE score may be useful for discrimination between them. Some patients could respond to immunotherapy.
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Affiliation(s)
- Takahiro Iizuka
- Department of Neurology (T.I., N.K., J.K., N.T., A.Kaneko, D.I., E.K., K.N.), Department of Pediatrics (Y.N.), and Department of Pathology (A.H.), Kitasato University School of Medicine; Department of Clinical Laboratory (Y.O.), Kitasato University Hospital, Sagamihara, Japan; Department of Neurology (H.A., T.H.), Shizuoka City Shimizu Hospital, Shizuoka, Japan; Department of Emergency and Critical Care Medicine (J.K.), Nippon Medical School Tama Nagayama Hospital, Tama, Japan; Department of Neurology (K.Y., Y.S., Y.U.), School of Medicine, Fukushima Medical Hospital and Fukushima Global Medical Science Center (Y.U.), Advanced Clinical Research Center, Fukushima Medical University, Fukushima, Japan; Department of Neurology (M.W., H.T.), Ehime Prefectural Central Hospital, Matsuyama, Japan; and Department of Neurology (A.Kosakai), Keiyu Hospital, Yokohama, Japan
| | - Naomi Kanazawa
- Department of Neurology (T.I., N.K., J.K., N.T., A.Kaneko, D.I., E.K., K.N.), Department of Pediatrics (Y.N.), and Department of Pathology (A.H.), Kitasato University School of Medicine; Department of Clinical Laboratory (Y.O.), Kitasato University Hospital, Sagamihara, Japan; Department of Neurology (H.A., T.H.), Shizuoka City Shimizu Hospital, Shizuoka, Japan; Department of Emergency and Critical Care Medicine (J.K.), Nippon Medical School Tama Nagayama Hospital, Tama, Japan; Department of Neurology (K.Y., Y.S., Y.U.), School of Medicine, Fukushima Medical Hospital and Fukushima Global Medical Science Center (Y.U.), Advanced Clinical Research Center, Fukushima Medical University, Fukushima, Japan; Department of Neurology (M.W., H.T.), Ehime Prefectural Central Hospital, Matsuyama, Japan; and Department of Neurology (A.Kosakai), Keiyu Hospital, Yokohama, Japan
| | - Juntaro Kaneko
- Department of Neurology (T.I., N.K., J.K., N.T., A.Kaneko, D.I., E.K., K.N.), Department of Pediatrics (Y.N.), and Department of Pathology (A.H.), Kitasato University School of Medicine; Department of Clinical Laboratory (Y.O.), Kitasato University Hospital, Sagamihara, Japan; Department of Neurology (H.A., T.H.), Shizuoka City Shimizu Hospital, Shizuoka, Japan; Department of Emergency and Critical Care Medicine (J.K.), Nippon Medical School Tama Nagayama Hospital, Tama, Japan; Department of Neurology (K.Y., Y.S., Y.U.), School of Medicine, Fukushima Medical Hospital and Fukushima Global Medical Science Center (Y.U.), Advanced Clinical Research Center, Fukushima Medical University, Fukushima, Japan; Department of Neurology (M.W., H.T.), Ehime Prefectural Central Hospital, Matsuyama, Japan; and Department of Neurology (A.Kosakai), Keiyu Hospital, Yokohama, Japan
| | - Naomi Tominaga
- Department of Neurology (T.I., N.K., J.K., N.T., A.Kaneko, D.I., E.K., K.N.), Department of Pediatrics (Y.N.), and Department of Pathology (A.H.), Kitasato University School of Medicine; Department of Clinical Laboratory (Y.O.), Kitasato University Hospital, Sagamihara, Japan; Department of Neurology (H.A., T.H.), Shizuoka City Shimizu Hospital, Shizuoka, Japan; Department of Emergency and Critical Care Medicine (J.K.), Nippon Medical School Tama Nagayama Hospital, Tama, Japan; Department of Neurology (K.Y., Y.S., Y.U.), School of Medicine, Fukushima Medical Hospital and Fukushima Global Medical Science Center (Y.U.), Advanced Clinical Research Center, Fukushima Medical University, Fukushima, Japan; Department of Neurology (M.W., H.T.), Ehime Prefectural Central Hospital, Matsuyama, Japan; and Department of Neurology (A.Kosakai), Keiyu Hospital, Yokohama, Japan
| | - Yutaka Nonoda
- Department of Neurology (T.I., N.K., J.K., N.T., A.Kaneko, D.I., E.K., K.N.), Department of Pediatrics (Y.N.), and Department of Pathology (A.H.), Kitasato University School of Medicine; Department of Clinical Laboratory (Y.O.), Kitasato University Hospital, Sagamihara, Japan; Department of Neurology (H.A., T.H.), Shizuoka City Shimizu Hospital, Shizuoka, Japan; Department of Emergency and Critical Care Medicine (J.K.), Nippon Medical School Tama Nagayama Hospital, Tama, Japan; Department of Neurology (K.Y., Y.S., Y.U.), School of Medicine, Fukushima Medical Hospital and Fukushima Global Medical Science Center (Y.U.), Advanced Clinical Research Center, Fukushima Medical University, Fukushima, Japan; Department of Neurology (M.W., H.T.), Ehime Prefectural Central Hospital, Matsuyama, Japan; and Department of Neurology (A.Kosakai), Keiyu Hospital, Yokohama, Japan
| | - Atsuko Hara
- Department of Neurology (T.I., N.K., J.K., N.T., A.Kaneko, D.I., E.K., K.N.), Department of Pediatrics (Y.N.), and Department of Pathology (A.H.), Kitasato University School of Medicine; Department of Clinical Laboratory (Y.O.), Kitasato University Hospital, Sagamihara, Japan; Department of Neurology (H.A., T.H.), Shizuoka City Shimizu Hospital, Shizuoka, Japan; Department of Emergency and Critical Care Medicine (J.K.), Nippon Medical School Tama Nagayama Hospital, Tama, Japan; Department of Neurology (K.Y., Y.S., Y.U.), School of Medicine, Fukushima Medical Hospital and Fukushima Global Medical Science Center (Y.U.), Advanced Clinical Research Center, Fukushima Medical University, Fukushima, Japan; Department of Neurology (M.W., H.T.), Ehime Prefectural Central Hospital, Matsuyama, Japan; and Department of Neurology (A.Kosakai), Keiyu Hospital, Yokohama, Japan
| | - Yuya Onozawa
- Department of Neurology (T.I., N.K., J.K., N.T., A.Kaneko, D.I., E.K., K.N.), Department of Pediatrics (Y.N.), and Department of Pathology (A.H.), Kitasato University School of Medicine; Department of Clinical Laboratory (Y.O.), Kitasato University Hospital, Sagamihara, Japan; Department of Neurology (H.A., T.H.), Shizuoka City Shimizu Hospital, Shizuoka, Japan; Department of Emergency and Critical Care Medicine (J.K.), Nippon Medical School Tama Nagayama Hospital, Tama, Japan; Department of Neurology (K.Y., Y.S., Y.U.), School of Medicine, Fukushima Medical Hospital and Fukushima Global Medical Science Center (Y.U.), Advanced Clinical Research Center, Fukushima Medical University, Fukushima, Japan; Department of Neurology (M.W., H.T.), Ehime Prefectural Central Hospital, Matsuyama, Japan; and Department of Neurology (A.Kosakai), Keiyu Hospital, Yokohama, Japan
| | - Hiroki Asari
- Department of Neurology (T.I., N.K., J.K., N.T., A.Kaneko, D.I., E.K., K.N.), Department of Pediatrics (Y.N.), and Department of Pathology (A.H.), Kitasato University School of Medicine; Department of Clinical Laboratory (Y.O.), Kitasato University Hospital, Sagamihara, Japan; Department of Neurology (H.A., T.H.), Shizuoka City Shimizu Hospital, Shizuoka, Japan; Department of Emergency and Critical Care Medicine (J.K.), Nippon Medical School Tama Nagayama Hospital, Tama, Japan; Department of Neurology (K.Y., Y.S., Y.U.), School of Medicine, Fukushima Medical Hospital and Fukushima Global Medical Science Center (Y.U.), Advanced Clinical Research Center, Fukushima Medical University, Fukushima, Japan; Department of Neurology (M.W., H.T.), Ehime Prefectural Central Hospital, Matsuyama, Japan; and Department of Neurology (A.Kosakai), Keiyu Hospital, Yokohama, Japan
| | - Takashi Hata
- Department of Neurology (T.I., N.K., J.K., N.T., A.Kaneko, D.I., E.K., K.N.), Department of Pediatrics (Y.N.), and Department of Pathology (A.H.), Kitasato University School of Medicine; Department of Clinical Laboratory (Y.O.), Kitasato University Hospital, Sagamihara, Japan; Department of Neurology (H.A., T.H.), Shizuoka City Shimizu Hospital, Shizuoka, Japan; Department of Emergency and Critical Care Medicine (J.K.), Nippon Medical School Tama Nagayama Hospital, Tama, Japan; Department of Neurology (K.Y., Y.S., Y.U.), School of Medicine, Fukushima Medical Hospital and Fukushima Global Medical Science Center (Y.U.), Advanced Clinical Research Center, Fukushima Medical University, Fukushima, Japan; Department of Neurology (M.W., H.T.), Ehime Prefectural Central Hospital, Matsuyama, Japan; and Department of Neurology (A.Kosakai), Keiyu Hospital, Yokohama, Japan
| | - Junya Kaneko
- Department of Neurology (T.I., N.K., J.K., N.T., A.Kaneko, D.I., E.K., K.N.), Department of Pediatrics (Y.N.), and Department of Pathology (A.H.), Kitasato University School of Medicine; Department of Clinical Laboratory (Y.O.), Kitasato University Hospital, Sagamihara, Japan; Department of Neurology (H.A., T.H.), Shizuoka City Shimizu Hospital, Shizuoka, Japan; Department of Emergency and Critical Care Medicine (J.K.), Nippon Medical School Tama Nagayama Hospital, Tama, Japan; Department of Neurology (K.Y., Y.S., Y.U.), School of Medicine, Fukushima Medical Hospital and Fukushima Global Medical Science Center (Y.U.), Advanced Clinical Research Center, Fukushima Medical University, Fukushima, Japan; Department of Neurology (M.W., H.T.), Ehime Prefectural Central Hospital, Matsuyama, Japan; and Department of Neurology (A.Kosakai), Keiyu Hospital, Yokohama, Japan
| | - Kenji Yoshida
- Department of Neurology (T.I., N.K., J.K., N.T., A.Kaneko, D.I., E.K., K.N.), Department of Pediatrics (Y.N.), and Department of Pathology (A.H.), Kitasato University School of Medicine; Department of Clinical Laboratory (Y.O.), Kitasato University Hospital, Sagamihara, Japan; Department of Neurology (H.A., T.H.), Shizuoka City Shimizu Hospital, Shizuoka, Japan; Department of Emergency and Critical Care Medicine (J.K.), Nippon Medical School Tama Nagayama Hospital, Tama, Japan; Department of Neurology (K.Y., Y.S., Y.U.), School of Medicine, Fukushima Medical Hospital and Fukushima Global Medical Science Center (Y.U.), Advanced Clinical Research Center, Fukushima Medical University, Fukushima, Japan; Department of Neurology (M.W., H.T.), Ehime Prefectural Central Hospital, Matsuyama, Japan; and Department of Neurology (A.Kosakai), Keiyu Hospital, Yokohama, Japan
| | - Yoshihiro Sugiura
- Department of Neurology (T.I., N.K., J.K., N.T., A.Kaneko, D.I., E.K., K.N.), Department of Pediatrics (Y.N.), and Department of Pathology (A.H.), Kitasato University School of Medicine; Department of Clinical Laboratory (Y.O.), Kitasato University Hospital, Sagamihara, Japan; Department of Neurology (H.A., T.H.), Shizuoka City Shimizu Hospital, Shizuoka, Japan; Department of Emergency and Critical Care Medicine (J.K.), Nippon Medical School Tama Nagayama Hospital, Tama, Japan; Department of Neurology (K.Y., Y.S., Y.U.), School of Medicine, Fukushima Medical Hospital and Fukushima Global Medical Science Center (Y.U.), Advanced Clinical Research Center, Fukushima Medical University, Fukushima, Japan; Department of Neurology (M.W., H.T.), Ehime Prefectural Central Hospital, Matsuyama, Japan; and Department of Neurology (A.Kosakai), Keiyu Hospital, Yokohama, Japan
| | - Yoshikazu Ugawa
- Department of Neurology (T.I., N.K., J.K., N.T., A.Kaneko, D.I., E.K., K.N.), Department of Pediatrics (Y.N.), and Department of Pathology (A.H.), Kitasato University School of Medicine; Department of Clinical Laboratory (Y.O.), Kitasato University Hospital, Sagamihara, Japan; Department of Neurology (H.A., T.H.), Shizuoka City Shimizu Hospital, Shizuoka, Japan; Department of Emergency and Critical Care Medicine (J.K.), Nippon Medical School Tama Nagayama Hospital, Tama, Japan; Department of Neurology (K.Y., Y.S., Y.U.), School of Medicine, Fukushima Medical Hospital and Fukushima Global Medical Science Center (Y.U.), Advanced Clinical Research Center, Fukushima Medical University, Fukushima, Japan; Department of Neurology (M.W., H.T.), Ehime Prefectural Central Hospital, Matsuyama, Japan; and Department of Neurology (A.Kosakai), Keiyu Hospital, Yokohama, Japan
| | - Masashi Watanabe
- Department of Neurology (T.I., N.K., J.K., N.T., A.Kaneko, D.I., E.K., K.N.), Department of Pediatrics (Y.N.), and Department of Pathology (A.H.), Kitasato University School of Medicine; Department of Clinical Laboratory (Y.O.), Kitasato University Hospital, Sagamihara, Japan; Department of Neurology (H.A., T.H.), Shizuoka City Shimizu Hospital, Shizuoka, Japan; Department of Emergency and Critical Care Medicine (J.K.), Nippon Medical School Tama Nagayama Hospital, Tama, Japan; Department of Neurology (K.Y., Y.S., Y.U.), School of Medicine, Fukushima Medical Hospital and Fukushima Global Medical Science Center (Y.U.), Advanced Clinical Research Center, Fukushima Medical University, Fukushima, Japan; Department of Neurology (M.W., H.T.), Ehime Prefectural Central Hospital, Matsuyama, Japan; and Department of Neurology (A.Kosakai), Keiyu Hospital, Yokohama, Japan
| | - Hitomi Tomita
- Department of Neurology (T.I., N.K., J.K., N.T., A.Kaneko, D.I., E.K., K.N.), Department of Pediatrics (Y.N.), and Department of Pathology (A.H.), Kitasato University School of Medicine; Department of Clinical Laboratory (Y.O.), Kitasato University Hospital, Sagamihara, Japan; Department of Neurology (H.A., T.H.), Shizuoka City Shimizu Hospital, Shizuoka, Japan; Department of Emergency and Critical Care Medicine (J.K.), Nippon Medical School Tama Nagayama Hospital, Tama, Japan; Department of Neurology (K.Y., Y.S., Y.U.), School of Medicine, Fukushima Medical Hospital and Fukushima Global Medical Science Center (Y.U.), Advanced Clinical Research Center, Fukushima Medical University, Fukushima, Japan; Department of Neurology (M.W., H.T.), Ehime Prefectural Central Hospital, Matsuyama, Japan; and Department of Neurology (A.Kosakai), Keiyu Hospital, Yokohama, Japan
| | - Arifumi Kosakai
- Department of Neurology (T.I., N.K., J.K., N.T., A.Kaneko, D.I., E.K., K.N.), Department of Pediatrics (Y.N.), and Department of Pathology (A.H.), Kitasato University School of Medicine; Department of Clinical Laboratory (Y.O.), Kitasato University Hospital, Sagamihara, Japan; Department of Neurology (H.A., T.H.), Shizuoka City Shimizu Hospital, Shizuoka, Japan; Department of Emergency and Critical Care Medicine (J.K.), Nippon Medical School Tama Nagayama Hospital, Tama, Japan; Department of Neurology (K.Y., Y.S., Y.U.), School of Medicine, Fukushima Medical Hospital and Fukushima Global Medical Science Center (Y.U.), Advanced Clinical Research Center, Fukushima Medical University, Fukushima, Japan; Department of Neurology (M.W., H.T.), Ehime Prefectural Central Hospital, Matsuyama, Japan; and Department of Neurology (A.Kosakai), Keiyu Hospital, Yokohama, Japan
| | - Atsushi Kaneko
- Department of Neurology (T.I., N.K., J.K., N.T., A.Kaneko, D.I., E.K., K.N.), Department of Pediatrics (Y.N.), and Department of Pathology (A.H.), Kitasato University School of Medicine; Department of Clinical Laboratory (Y.O.), Kitasato University Hospital, Sagamihara, Japan; Department of Neurology (H.A., T.H.), Shizuoka City Shimizu Hospital, Shizuoka, Japan; Department of Emergency and Critical Care Medicine (J.K.), Nippon Medical School Tama Nagayama Hospital, Tama, Japan; Department of Neurology (K.Y., Y.S., Y.U.), School of Medicine, Fukushima Medical Hospital and Fukushima Global Medical Science Center (Y.U.), Advanced Clinical Research Center, Fukushima Medical University, Fukushima, Japan; Department of Neurology (M.W., H.T.), Ehime Prefectural Central Hospital, Matsuyama, Japan; and Department of Neurology (A.Kosakai), Keiyu Hospital, Yokohama, Japan
| | - Daisuke Ishima
- Department of Neurology (T.I., N.K., J.K., N.T., A.Kaneko, D.I., E.K., K.N.), Department of Pediatrics (Y.N.), and Department of Pathology (A.H.), Kitasato University School of Medicine; Department of Clinical Laboratory (Y.O.), Kitasato University Hospital, Sagamihara, Japan; Department of Neurology (H.A., T.H.), Shizuoka City Shimizu Hospital, Shizuoka, Japan; Department of Emergency and Critical Care Medicine (J.K.), Nippon Medical School Tama Nagayama Hospital, Tama, Japan; Department of Neurology (K.Y., Y.S., Y.U.), School of Medicine, Fukushima Medical Hospital and Fukushima Global Medical Science Center (Y.U.), Advanced Clinical Research Center, Fukushima Medical University, Fukushima, Japan; Department of Neurology (M.W., H.T.), Ehime Prefectural Central Hospital, Matsuyama, Japan; and Department of Neurology (A.Kosakai), Keiyu Hospital, Yokohama, Japan
| | - Eiji Kitamura
- Department of Neurology (T.I., N.K., J.K., N.T., A.Kaneko, D.I., E.K., K.N.), Department of Pediatrics (Y.N.), and Department of Pathology (A.H.), Kitasato University School of Medicine; Department of Clinical Laboratory (Y.O.), Kitasato University Hospital, Sagamihara, Japan; Department of Neurology (H.A., T.H.), Shizuoka City Shimizu Hospital, Shizuoka, Japan; Department of Emergency and Critical Care Medicine (J.K.), Nippon Medical School Tama Nagayama Hospital, Tama, Japan; Department of Neurology (K.Y., Y.S., Y.U.), School of Medicine, Fukushima Medical Hospital and Fukushima Global Medical Science Center (Y.U.), Advanced Clinical Research Center, Fukushima Medical University, Fukushima, Japan; Department of Neurology (M.W., H.T.), Ehime Prefectural Central Hospital, Matsuyama, Japan; and Department of Neurology (A.Kosakai), Keiyu Hospital, Yokohama, Japan
| | - Kazutoshi Nishiyama
- Department of Neurology (T.I., N.K., J.K., N.T., A.Kaneko, D.I., E.K., K.N.), Department of Pediatrics (Y.N.), and Department of Pathology (A.H.), Kitasato University School of Medicine; Department of Clinical Laboratory (Y.O.), Kitasato University Hospital, Sagamihara, Japan; Department of Neurology (H.A., T.H.), Shizuoka City Shimizu Hospital, Shizuoka, Japan; Department of Emergency and Critical Care Medicine (J.K.), Nippon Medical School Tama Nagayama Hospital, Tama, Japan; Department of Neurology (K.Y., Y.S., Y.U.), School of Medicine, Fukushima Medical Hospital and Fukushima Global Medical Science Center (Y.U.), Advanced Clinical Research Center, Fukushima Medical University, Fukushima, Japan; Department of Neurology (M.W., H.T.), Ehime Prefectural Central Hospital, Matsuyama, Japan; and Department of Neurology (A.Kosakai), Keiyu Hospital, Yokohama, Japan
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Epileptogenesis meets Occam's Razor. Curr Opin Pharmacol 2017; 35:105-110. [PMID: 28781107 DOI: 10.1016/j.coph.2017.07.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2017] [Revised: 07/23/2017] [Accepted: 07/23/2017] [Indexed: 01/01/2023]
Abstract
Pharmacological treatment to prevent brain injury-induced temporal lobe epileptogenesis has been generally unsuccessful, raising the issues of exactly when the conversion process to an epileptic brain state occurs and reaches completion, and which cellular or network processes might be the most promising therapeutic targets. The time course of epileptogenesis is a central issue, with recent results suggesting that injury-induced epileptogenesis can be a much more rapid process than previously thought, and may be inconsistent with a delayed epileptogenic mechanism. Simplification of the seemingly complex issues involved in the use of epilepsy animal models might lead to a better understanding of the nature of injury-induced epileptogenesis, the significance of the 'latent' period, and whether current strategies should focus on preventing or modifying epilepsy.
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Abstract
Autoimmune epilepsies describe clinical syndromes wherein the immune system is suspected to be involved in the pathogenesis of seizures or as a mechanism for neuronal injury following seizures. These diseases typically affect otherwise healthy children and are characterized by explosive onset of focal seizures, encephalopathy, cognitive deterioration, or other focal neurological deficits, or all of these. Traditional neurological diagnostics lack sensitivity and specificity in the diagnosis of autoimmune epilepsies, and results must be considered in the clinical context. Consideration of an autoimmune etiology early in the clinical course is important to ensure timely initiation of immunotherapy, as appropriate, as conventional antiepileptic drugs alone are typically unable to control seizures and other neurological symptoms. This article discusses the autoimmune epilepsies of autoimmune encephalitis (including anti-N-methyl-D-aspartate receptor encephalitis), Rasmussen's encephalitis, and febrile infection-related epilepsy syndrome. Further research is needed to better understand pathogenic mechanisms, optimal immunotherapy, and the effect of treatment on prognosis.
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Affiliation(s)
- Anusha K Yeshokumar
- Department of Neurology, The Johns Hopkins University School of Medicine, Baltimore, MD.
| | - Carlos A Pardo
- Department of Neurology, The Johns Hopkins University School of Medicine, Baltimore, MD
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O'Connell BK, Gloss D, Devinsky O. Cannabinoids in treatment-resistant epilepsy: A review. Epilepsy Behav 2017; 70:341-348. [PMID: 28188044 DOI: 10.1016/j.yebeh.2016.11.012] [Citation(s) in RCA: 130] [Impact Index Per Article: 18.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2016] [Revised: 11/07/2016] [Accepted: 11/07/2016] [Indexed: 02/03/2023]
Abstract
Treatment-resistant epilepsy (TRE) affects 30% of epilepsy patients and is associated with severe morbidity and increased mortality. Cannabis-based therapies have been used to treat epilepsy for millennia, but only in the last few years have we begun to collect data from adequately powered placebo-controlled, randomized trials (RCTs) with cannabidiol (CBD), a cannabis derivative. Previously, information was limited to case reports, small series, and surveys reporting on the use of CBD and diverse medical marijuana (MMJ) preparations containing: tetrahydrocannabinol (THC), CBD, and many other cannabinoids in differing combinations. These RCTs have studied the safety and explored the potential efficacy of CBD use in children with Dravet Syndrome (DS) and Lennox-Gastaut Syndrome (LGS). The role of the placebo response is of paramount importance in studying medical cannabis products given the intense social and traditional media attention, as well as the strong beliefs held by many parents and patients that a natural product is safer and more effective than FDA-approved pharmaceutical agents. We lack valid data on the safety, efficacy, and dosing of artisanal preparations available from dispensaries in the 25 states and District of Columbia with MMJ programs and online sources of CBD and other cannabinoids. On the other hand, open-label studies with 100mg/ml CBD (Epidiolex®, GW Pharmaceuticals) have provided additional evidence of its efficacy along with an adequate safety profile (including certain drug interactions) in children and young adults with a spectrum of TREs. Further, Phase 3 RCTs with Epidiolex support efficacy and adequate safety profiles for children with DS and LGS at doses of 10- and 20-mg/kg/day. This article is part of a Special Issue titled "Cannabinoids and Epilepsy".
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Abstract
Febrile infection-related epilepsy syndrome (FIRES) is a form of epileptic encephalopathy with severe refractory epilepsy that presents in previously healthy, school-aged children after significant febrile illness with concomitant rise in body temperature. Suspected causes include genetic or acquired channelopathies, as well as mitochondrial disturbances. In FIRES, the EEG shows diffuse slowing, generalized, and/or multifocal discharges. Seizures are present and resistant to treatment. Moyamoya angiopathy (MMA) is characterized by progressive stenosis of cerebral arteries and subsequent development of a network of collateral circulation that is prone to rupture. We present here a case of a 6-year-old patient with a postfebrile illness, acute and explosive bilateral independent seizure onset that was most consistent with FIRES, but also with imaging evidence of right-sided-only MMA. Our patient demonstrated two diseases not described together previously in the literature. It is unknown whether this patient's MMA is related to FIRES. In spite of successful corrective surgery (encephaloduroarteriosynangiosis), the patient continues to suffer from intractable seizures (mostly on the right) and apparent mild encephalopathy. The impact of our interventions (surgery, antiepileptic medication) is unclear. In this article, we describe a case of MMA and FIRES, and the history, physical, laboratory, imaging, and developmental elements of the 6-year-old patient with previously normal development.
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Affiliation(s)
- Taylor Kaufman
- a Denver Health and Hospital Authority , Denver , Colorado
- b Department of Neurology , University of Colorado Health Sciences Center , Aurora , Colorado
| | - Andrew White
- a Denver Health and Hospital Authority , Denver , Colorado
- c Children's Hospital of Colorado , Aurora , Colorado
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Gofshteyn JS, Wilfong A, Devinsky O, Bluvstein J, Charuta J, Ciliberto MA, Laux L, Marsh ED. Cannabidiol as a Potential Treatment for Febrile Infection-Related Epilepsy Syndrome (FIRES) in the Acute and Chronic Phases. J Child Neurol 2017; 32:35-40. [PMID: 27655472 DOI: 10.1177/0883073816669450] [Citation(s) in RCA: 100] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Febrile infection-related epilepsy syndrome (FIRES) is a devastating epilepsy affecting normal children after a febrile illness. FIRES presents with an acute phase with super-refractory status epilepticus and all patients progress to a chronic phase with persistent refractory epilepsy. The typical outcome is severe encephalopathy or death. The authors present 7 children from 5 centers with FIRES who had not responded to antiepileptic drugs or other therapies who were given cannabadiol (Epidiolex, GW Pharma) on emergency or expanded investigational protocols in either the acute or chronic phase of illness. After starting cannabidiol, 6 of 7 patients' seizures improved in frequency and duration. One patient died due to multiorgan failure secondary to isoflourane. An average of 4 antiepileptic drugs were weaned. Currently 5 subjects are ambulatory, 1 walks with assistance, and 4 are verbal. While this is an open-label case series, the authors add cannabidiol as a possible treatment for FIRES.
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Affiliation(s)
- Jacqueline S Gofshteyn
- 1 Division of Child Neurology, Pediatric Regional Epilepsy Program, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Angus Wilfong
- 2 Division of Child Neurology, Texas Children's Hospital, Houston, TX, USA
| | - Orrin Devinsky
- 3 NYU Comprehensive Epilepsy Center, Department of Neurology, NYU School of Medicine, New York, NY, USA
| | - Judith Bluvstein
- 3 NYU Comprehensive Epilepsy Center, Department of Neurology, NYU School of Medicine, New York, NY, USA
| | - Joshi Charuta
- 4 Division of Child Neurology, University of Iowa School of Medicine, Iowa City, IA, USA
| | - Michael A Ciliberto
- 4 Division of Child Neurology, University of Iowa School of Medicine, Iowa City, IA, USA
| | - Linda Laux
- 5 Division of Child Neurology, Northwestern University Medical School, Robert H. Lurie Children's Hospital, Chicago, IL, USA
| | - Eric D Marsh
- 1 Division of Child Neurology, Pediatric Regional Epilepsy Program, Children's Hospital of Philadelphia, Philadelphia, PA, USA.,6 Departments of Neurology and Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
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Chiusolo F, Diamanti A, Bianchi R, Fusco L, Elia M, Capriati T, Vigevano F, Picardo S. From intravenous to enteral ketogenic diet in PICU: A potential treatment strategy for refractory status epilepticus. Eur J Paediatr Neurol 2016; 20:843-847. [PMID: 27594068 DOI: 10.1016/j.ejpn.2016.08.004] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2016] [Revised: 07/06/2016] [Accepted: 08/05/2016] [Indexed: 12/17/2022]
Abstract
BACKGROUND Ketogenic diet (KD) has been used to treat refractory status epilepticus (RSE). KD is a high-fat, restricted-carbohydrate regimen that may be administered with different fat to protein and carbohydrate ratios (3:1 and 4:1 fat to protein and carbohydrate ratios). Other ketogenic regimens have a lower fat and higher protein and carbohydrate ratio to improve taste and thus compliance to treatment. We describe a case of RSE treated with intravenous KD in the Pediatric Intensive Care Unit (PICU). CASE REPORT An 8-year-old boy was referred to the PICU because of continuous tonic-clonic and myoclonic generalized seizures despite several antiepileptic treatments. After admission he was intubated and treated with intravenous thiopental followed by ketamine. Seizures continued with frequent myoclonic jerks localized on the face and upper arms. EEG showed seizure activity with spikes on rhythmic continuous waves. Thus we decided to begin KD. The concomitant ileus contraindicated KD by the enteral route and we therefore began IV KD. The ketogenic regimen consisted of conventional intravenous fat emulsion, plus dextrose and amino-acid hyperalimentation in a 2:1 then 3:1 fat to protein and carbohydrate ratio. Exclusive IV ketogenic treatment, well tolerated, was maintained for 3 days; peristalsis then reappeared so KD was continued by the enteral route at 3:1 ratio. Finally, after 8 days and no seizure improvement, KD was deemed unsuccessful and was discontinued. CONCLUSIONS Our experience indicates that IV KD may be considered as a temporary "bridge" towards enteral KD in patients with partial or total intestinal failure who need to start KD. It allows a prompt initiation of KD, when indicated for the treatment of severe diseases such as RSE.
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Affiliation(s)
- F Chiusolo
- Department of Anesthesia and Critical Care, ARCO Rome, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy.
| | - A Diamanti
- Artificial Nutrition Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - R Bianchi
- Department of Anesthesia and Critical Care, ARCO Rome, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - L Fusco
- Neurology Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - M Elia
- Department of Anesthesia and Critical Care, ARCO Rome, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - T Capriati
- Department of Anesthesia and Critical Care, ARCO Rome, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - F Vigevano
- Neurology Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - S Picardo
- Department of Anesthesia and Critical Care, ARCO Rome, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
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Patil SB, Roy AG, Vinayan KP. Clinical profile and treatment outcome of febrile infection-related epilepsy syndrome in South Indian children. Ann Indian Acad Neurol 2016; 19:188-94. [PMID: 27293328 PMCID: PMC4888680 DOI: 10.4103/0972-2327.173305] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Purpose: To describe the clinical features and outcome of febrile infection-related epilepsy syndrome (FIRES), a catastrophic epileptic encephalopathy, in a cohort of South Indian children. Materials and Methods: We performed a retrospective chart review of a cohort of children with previously normal development who presented with status epilepticus or encephalopathy with recurrent seizures following a nonspecific febrile illness during the period between January 2007 and January 2012. They were divided into two groups super refractory status epilepticus (SRSE) and refractory status epilepticus (RSE) depending on the duration and severity of the seizures. Key Findings: Fifteen children who met the inclusion criteria were included for the final analysis. The age of the children at presentation ranged 3-15 years (median 6.3 years). All the children presented with prolonged or recurrent seizures occurring 1-12 days (median 4 days) after the onset of fever. Eight children had SRSE while seven children had refractory seizures with encephalopathy. Cerebrospinal fluid (CSF) analysis was done in all the children in the acute phase, and the cell count ranged 0-12 cells/μL (median 2 cells/μL) with normal sugar and protein levels. Initial neuroimaging done in all children (MRI in 10 and CT in 5), and it was normal in 13 children. Treatment modalities included multiple antiepileptic drugs (AEDs) (4-9 drugs) (median 5 drugs). Midazolam (MDZ) infusion was administered in seven patients. Eight patients required barbiturate coma to suppress the seizure activity. The duration of the barbiturate coma ranged 2-90 days (median 3 days). Steroids were used in 14 children and intravenous immunoglobulin (2 g/kg) in 7 children. Three children died in the acute phase. All children were maintained on multiple AEDs till the last follow-up, the number of AEDs ranged 1-6 (median 5 AEDs). The patients with super refractory status in the acute phase were found to be more severely disabled at the follow-up; the median score of these patients on the Glasgow Outcome Scale (GOS) was 2 compared to 5 in the RSE group. Significance: This study reports one of the largest single center cohorts from India, with an adverse long-term developmental and seizure outcome. The duration and severity of seizures in the acute period correlated directly with the short-term and long-term clinical outcomes. There is an urgent need for developing new effective therapeutic strategies to treat this acute catastrophic epileptic syndrome.
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Affiliation(s)
- Sandeep B Patil
- Division of Pediatric Neurology, Department of Neurology, Amrita Institute of Medical Sciences, Kochi, Kerala, India
| | - Arun Grace Roy
- Division of Pediatric Neurology, Department of Neurology, Amrita Institute of Medical Sciences, Kochi, Kerala, India
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50
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Abstract
Investigators from the University of Alabama, Birmingham, AL, and University of Michigan, Ann Arbor, MI, report 2 children who presented with FIRES and prolonged AED-resistant status epilepticus.
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Affiliation(s)
- John J Millichap
- Division of Neurology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL; Departments of Pediatrics and Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - J Gordon Millichap
- Division of Neurology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL; Departments of Pediatrics and Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL
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