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Russo A, Mazzone S, Landolina L, Colucci R, Baccari F, Fetta A, Boni A, Cordelli DM. Efficacy and Safety of Pulse Intravenous Methylprednisolone in Pediatric Epileptic Encephalopathies: Timing and Networks Consideration. J Clin Med 2024; 13:2497. [PMID: 38731025 PMCID: PMC11084200 DOI: 10.3390/jcm13092497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Revised: 04/10/2024] [Accepted: 04/19/2024] [Indexed: 05/13/2024] Open
Abstract
Background: Epileptic encephalopathies (EE) are characterized by severe drug-resistant seizures, early onset, and unfavorable developmental outcomes. This article discusses the use of intravenous methylprednisolone (IVMP) pulse therapy in pediatric patients with EE to evaluate its efficacy and tolerability. Methods: This is a retrospective study from 2020 to 2023. Inclusion criteria were ≤18 years at the time of IVMP pulse therapy and at least 6 months of follow-up. Efficacy and outcome, defined as seizure reduction > 50% (responder rate), were evaluated at 6 and 9 months of therapy, and 6 months after therapy suspension; quality of life (QoL) was also assessed. Variables predicting positive post-IVMP outcomes were identified using statistical analysis. Results: The study included 21 patients, with a responder rate of 85.7% at 6 and 9 months of therapy, and 80.9% at 6 months after therapy suspension. Variables significantly predicting favorable outcome were etiology (p = 0.0475) and epilepsy type (p = 0.0475), with the best outcome achieved in patients with genetic epilepsy and those with encephalopathy related to electrical status epilepticus during slow-wave sleep (ESES). All patients evidenced improvements in QoL at the last follow-up, with no relevant adverse events reported. Conclusions: Our study confirmed the efficacy and high tolerability of IVMP pulse therapy in pediatric patients with EE. Genetic epilepsy and ESES were positive predictors of a favorable clinical outcome. QOL, EEG tracing, and postural-motor development showed an improving trend as well. IVMP pulse therapy should be considered earlier in patients with EE.
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Affiliation(s)
- Angelo Russo
- IRCCS, Istituto delle Scienze Neurologiche di Bologna, UOC Neuropsichiatria Dell’età Pediatrica, 40139 Bologna, Italy; (S.M.); (L.L.); (R.C.); (A.F.); (A.B.); (D.M.C.)
| | - Serena Mazzone
- IRCCS, Istituto delle Scienze Neurologiche di Bologna, UOC Neuropsichiatria Dell’età Pediatrica, 40139 Bologna, Italy; (S.M.); (L.L.); (R.C.); (A.F.); (A.B.); (D.M.C.)
| | - Laura Landolina
- IRCCS, Istituto delle Scienze Neurologiche di Bologna, UOC Neuropsichiatria Dell’età Pediatrica, 40139 Bologna, Italy; (S.M.); (L.L.); (R.C.); (A.F.); (A.B.); (D.M.C.)
- Dipartimento di Scienze Mediche e Chirurgiche (DIMEC), Università di Bologna, 40126 Bologna, Italy
| | - Roberta Colucci
- IRCCS, Istituto delle Scienze Neurologiche di Bologna, UOC Neuropsichiatria Dell’età Pediatrica, 40139 Bologna, Italy; (S.M.); (L.L.); (R.C.); (A.F.); (A.B.); (D.M.C.)
- Dipartimento di Scienze Mediche e Chirurgiche (DIMEC), Università di Bologna, 40126 Bologna, Italy
| | - Flavia Baccari
- IRCCS, Istituto delle Scienze Neurologiche di Bologna, UOS Epidemiologia e Biostatistica, 40139 Bologna, Italy;
| | - Anna Fetta
- IRCCS, Istituto delle Scienze Neurologiche di Bologna, UOC Neuropsichiatria Dell’età Pediatrica, 40139 Bologna, Italy; (S.M.); (L.L.); (R.C.); (A.F.); (A.B.); (D.M.C.)
- Dipartimento di Scienze Mediche e Chirurgiche (DIMEC), Università di Bologna, 40126 Bologna, Italy
| | - Antonella Boni
- IRCCS, Istituto delle Scienze Neurologiche di Bologna, UOC Neuropsichiatria Dell’età Pediatrica, 40139 Bologna, Italy; (S.M.); (L.L.); (R.C.); (A.F.); (A.B.); (D.M.C.)
| | - Duccio Maria Cordelli
- IRCCS, Istituto delle Scienze Neurologiche di Bologna, UOC Neuropsichiatria Dell’età Pediatrica, 40139 Bologna, Italy; (S.M.); (L.L.); (R.C.); (A.F.); (A.B.); (D.M.C.)
- Dipartimento di Scienze Mediche e Chirurgiche (DIMEC), Università di Bologna, 40126 Bologna, Italy
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Bashiri FA, Hundallah K, Al-Baradie R, Al-Otaibi A, Ismayl O, AlMalik ME, Muthaffar OY, Futaisi AA, Kurdi D, Tawari AA, AlSowat D, Shafi SA, Ali A, AlHajjar LM, Aldakhil A. Diagnosis and management of infantile epileptic spasms syndrome (IESS) in Gulf Cooperation Council (GCC) countries: Expert consensus statement. Seizure 2024; 117:174-182. [PMID: 38432081 DOI: 10.1016/j.seizure.2024.02.015] [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] [Received: 12/06/2023] [Revised: 02/20/2024] [Accepted: 02/22/2024] [Indexed: 03/05/2024] Open
Abstract
Despite the availability of international recommendations for the management of Infantile Epileptic Spasms Syndrome (IESS), there is a lack of recommendations adapted to the local context of clinical practice of pediatric neurology in the Gulf Cooperation Council (GCC) countries. By an initiative from the Saudi Pediatric Neurology Society (SPNS), a literature review was performed and an expert panel comprised of 13 pediatric neurologists from all GCC countries (Saudi Arabia, Kuwait, Bahrain, Oman, Qatar, and the United Arab Emirates) was subsequently convened to discuss all issues related to the management and diagnosis practices of IESS in the GCC. The overall aim of this consensus document was to develop practical recommendations to support the care of patients with IESS in the GCC and to reflect on how clinical management approaches compare with those adopted internationally.
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Affiliation(s)
- Fahad A Bashiri
- Pediatric Neurology Division, Department of Pediatrics, College of Medicine, King Saud University Medical City, King Saud University, Riyadh, Saudi Arabia.
| | - Khalid Hundallah
- Pediatric Neurology Division, Department of Pediatrics, Prince Sultan Military Medical City, Riyadh 13317, Saudi Arabia.
| | - Raidah Al-Baradie
- Neuroscience Center, King Fahd Specialist Hospital, PO Box 15215, Dammam 314444, Kingdom of Saudi Arabia.
| | - Ali Al-Otaibi
- Pediatric Neurology Division, Department of Neurophysiology, National Neuroscience Institute, King Fahad Medical City, As Sulimaniyah, Riyadh 12231, Saudi Arabia.
| | - Omar Ismayl
- Department of Child Neurology, Sheikh Khalifah Medical City, Al Karamah Street, Abu Dhabi, United Arab Emirates.
| | - Mohamed Elhadi AlMalik
- Department of Pediatric Neurology, Mediclinic Al Jowhara Hospital, Al Ain City, United Arab Emirates.
| | - Osama Y Muthaffar
- Pediatric Neurology Division, Department of Pediatrics, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia.
| | - Amna Al Futaisi
- Pediatric Neurology Division, Child Health Department, College of Medicine and Health Sciences, Sultan Qaboos University, P.O.Box 35, P.C 123 Al Khoud, Sultanate of Oman.
| | - Daniah Kurdi
- Pediatric Neurology Division, Department of Pediatrics, College of Medicine, King Saud University, Riyadh 12372, Saudi Arabia.
| | - Asmaa Al Tawari
- Pediatric Neurology Division, Department of Pediatrics, Al Sabah Hospital, Ministry of Health, Sabah Health Region, Shuwaikh Industrial, State of Kuwait.
| | - Daad AlSowat
- Pediatric Neurology Division, Department of Pediatrics, King Faisal Specialist Hospital & Research Centre, Riyadh 11211, Saudi Arabia.
| | - Shatha Al Shafi
- Neurology Division, Epilepsy and EEG Fellowship Program, Department of Pediatrics, Prince Sultan Military Medical City, Riyadh 13317, Saudi Arabia.
| | - Ayman Ali
- Pediatric Neurology Division, Department of Pediatrics, AlSalam Specialist Hospital, Riffa 80278, Bahrain.
| | - Lynn M AlHajjar
- Itkan Health Consulting Group, Al Olaya, Riyadh 12221, Saudi Arabia.
| | - Abdullah Aldakhil
- Itkan Health Consulting Group, Al Olaya, Riyadh 12221, Saudi Arabia.
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Pavone P, Falsaperla R. Real-life data comparing the efficacy of vigabatrin and oral steroids given sequentially or combined for infantile epileptic spasms syndrome. Eur J Paediatr Neurol 2024; 48:A1. [PMID: 38429149 DOI: 10.1016/j.ejpn.2024.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/03/2024]
Affiliation(s)
- Piero Pavone
- Section of Pediatrics and Child Neuropsychiatry, Department of Clinical and Experimental Medicine, University of Catania, 95124, Catania, Italy.
| | - Raffaele Falsaperla
- Section of Pediatrics and Child Neuropsychiatry, Department of Clinical and Experimental Medicine, University of Catania, 95124, Catania, Italy
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Dozieres-Puyravel B, Nasser H, Mauvais FX, De Saint Martin A, Perriard C, Di Meglio C, Cances C, Hachon-LE Camus C, Milh M, Auvin S. Real-life data comparing the efficacy of vigabatrin and oral steroids given sequentially or combined for infantile epileptic spasms syndrome. Eur J Paediatr Neurol 2024; 48:61-66. [PMID: 38041897 DOI: 10.1016/j.ejpn.2023.11.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Revised: 11/19/2023] [Accepted: 11/20/2023] [Indexed: 12/04/2023]
Abstract
AIMS The prognosis of Infantile epileptic spasm syndrome (IESS), relates to the underlying etiology and delay in controlling epileptic spasms. Based on the spasm-free rate, a randomized controlled trial has demonstrated the superiority of combining oral steroids and vigabatrin over oral steroids alone but confirmation in real-life conditions is mandatory. METHODS We compared two real-life IESS cohorts: a multicenter, retrospective cohort of 40 infants treated with vigabatrin followed by a sequential (ST) addition of steroids, and a prospective, single-center cohort of 58 infants treated with an immediate combination of vigabatrin and steroids (CT). RESULTS The two cohorts were similar. When the rate of spasm-free infants in the two cohorts was compared on day 14, a significant difference was observed between the ST (27,5 %) and CT cohorts (64 %) (p < 0.0004). This difference remained significant on day 30, with 55 % spasm-free patients in the ST cohort compared to 76 % in the CT cohort (p = 0.03). After the infants had received both vigabatrin and steroids, without taking into account the time point after treatment initiation, no significant difference was observed in the spasm-free rate between the two cohorts (p = 0.38). INTERPRETATION Real-life data confirm the interest of combination therapy as a first-line treatment for IESS.
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Affiliation(s)
| | - Hala Nasser
- Service de Physiologie - Explorations Fonctionnelles Pédiatriques - Centre Pédiatrique des Pathologies du Sommeil, AP-HP, Hôpital Universitaire Robert Debré, F-75019, Paris, France.
| | - François-Xavier Mauvais
- Service de Physiologie - Explorations Fonctionnelles Pédiatriques - Centre Pédiatrique des Pathologies du Sommeil, AP-HP, Hôpital Universitaire Robert Debré, F-75019, Paris, France; Université Paris Cité, CNRS, Inserm, Institut Necker-Enfants Malades, F- 75015, Paris, France.
| | | | | | - Chloé Di Meglio
- Aix-Marseille Univ, APHM, Service de Neurologie Pédiatrique, Hopital de la Timone-Enfants. Marseille, France.
| | - Claude Cances
- Service de neurologie pédiatrique, CHU de Toulouse, France.
| | | | - Mathieu Milh
- Aix-Marseille Univ, APHM, Service de Neurologie Pédiatrique, Hopital de la Timone-Enfants. Marseille, France.
| | - Stéphane Auvin
- APHP. Service de Neurologie Pédiatrique, EpiCARE ERN Membre, Hôpital Robert Debré, Paris, France; Université Paris-Cité, INSERM NeuroDiderot, Paris, France; Institut Universitaire de France (IUF), Paris, France.
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Aungaroon G. The ACTH Quandary: Balancing Efficacy and Affordability for Infantile Spasms Treatment. Epilepsy Curr 2023; 23:294-295. [PMID: 37901781 PMCID: PMC10601033 DOI: 10.1177/15357597231182484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2023] Open
Abstract
Temporal Trends in the Cost and Use of First-Line Treatments for Infantile Epileptic Spasms Syndrome Sanchez Fernandez I, Amengual-Gual M, Aguilar CB, Romeu A, Sheikh T, Torres A, Chao J, Jonas R, Gaínza-Lein M, Harini C, Douglass L. Epilepsia. 2023;64(3):630-640. doi:10.1111/epi.17498 Objective: To describe the temporal trends in the cost and use of adrenocorticotropic hormone (ACTH), oral prednisolone, and vigabatrin, the first-line treatments for infantile epileptic spasms syndrome (IESS). Methods: Retrospective observational study using the MarketScan Commercial database from 2006 to 2020. We identified patients with IESS diagnosed between birth and 18 months of age who received at least one of the first-line treatments within 60 days of diagnosis. Costs were adjusted for inflation using the Gross Domestic Product Implicit Price Deflator. Results: A total of 1131 patients received at least one first-line treatment (median [p25-p75] age: 6.3 [4.5-8.3] months, 55% male), of whom 592 patients received ACTH, 363 patients received oral prednisolone, and 355 patients received vigabatrin. After adjusting for inflation, the median average wholesale price of a 14-day course of treatment increased for ACTH from $3718 in 2006 to $100 457 in 2020, ∼2700% (by a factor of 27), whereas it decreased for oral prednisolone from $169 in 2006 to $89 in 2020, ∼50% (by a factor of 0.5), and increased for vigabatrin from $1206 in 2009 (first year with data on vigabatrin used for IESS) to $4102 in 2020, ∼340% (by a factor of 3.4). During the first 60 days after diagnosis, inpatient admission days and costs were higher for ACTH than for oral prednisolone and vigabatrin-5.0 (3.0-8.3) days vs 2.0 (0.0-5.0) days vs 2.0 (0.0-6.0) days, p < .0001; and $32 828 ($14 711-$67 216) vs $16 227 ($0-$35 829) vs $17 844 ($0-$47 642), p < .0001. ACTH use decreased from representing 78% of first-line treatments in 2006 to 18% in 2020 (p < .0001). Sensitivity analyses confirmed the robustness of the results. Significance: The gap between the cost of ACTH and the cost of oral prednisolone or vigabatrin has widened markedly from 2006 to 2020, whereas the relative proportion of ACTH use has decreased.
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Affiliation(s)
- Gewalin Aungaroon
- Department of Neurology, Cincinnati Children's Hospital Medical Center, University of Cincinnati
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Prezioso G, Chiarelli F, Matricardi S. Efficacy and safety of vigabatrin in patients with tuberous sclerosis complex and infantile epileptic spasm syndrome: a systematic review. Expert Rev Neurother 2023; 23:661-671. [PMID: 37243682 DOI: 10.1080/14737175.2023.2216385] [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] [Received: 02/14/2023] [Accepted: 05/17/2023] [Indexed: 05/29/2023]
Abstract
INTRODUCTION Tuberous sclerosis complex (TSC) is a common genetic cause of epilepsy. Infantile epileptic spasm syndrome (IESS) is often the presenting neurologic feature, progressively evolving into refractory epilepsy. Vigabatrin (VGB) is often used in clinical practice as a first-line therapy in TSC with IESS. This systematic review aims to collect and analyze the efficacy data about VGB in TSC cases with IESS, in order to evaluate the strength of evidence in the literature. METHODS A systematic search of trials, observational studies, and case series involving patients with TSC and IESS treated with VGB was performed using MEDLINE, CENTRAL, and the US NIH Clinical Trials Registry. Single case studies, animal and non-English language studies were excluded. Seventeen studies were selected, of which 3 were RCTs and 14 were observational studies. RESULTS An overall response rate of 67% (231/343 responders) resulted from the analysis, with a spasm-free rate restricted to RCTs of 88% (29/33 subjects). CONCLUSIONS Although all the studies analyzed reported beneficial effects of VGB in TSC patients with IESS, with higher response rates in comparison to non-TSC subjects with IESS, a low level of evidence and high heterogeneity do not guarantee sufficient strength for therapeutic recommendations.
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Affiliation(s)
- Giovanni Prezioso
- Pediatric Neurologist, Department of Pediatrics, G. D'Annunzio University, Chieti, Italy
| | - Francesco Chiarelli
- Department of Pediatrics, Department of Pediatrics, G. D'Annunzio University, Chieti, Italy
| | - Sara Matricardi
- Pediatric Neurologist, Department of Pediatrics, G. D'Annunzio University, Chieti, Italy
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Li J, Gao Y, Cao J, Cai F, Zhai X. Efficacy analysis of oral dexamethasone in the treatment of infantile spasms and infantile spasms related Lennox-Gastaut syndrome. BMC Pediatr 2023; 23:255. [PMID: 37217894 DOI: 10.1186/s12887-023-04062-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Accepted: 05/05/2023] [Indexed: 05/24/2023] Open
Abstract
OBJECTIVE Treatment with adrenocorticotropic hormone (ACTH) or a corticosteroid is the first choice for infantile spasms (IS), and vigabatrin is the first choice for children with tuberous sclerosis. Although corticosteroids may be also effective against IS and IS-related Lennox-Gastaut syndrome (LGS), the use of dexamethasone (DEX), a kind of corticosteroid, for these diseases has been rarely reported. This retrospective study aimed to evaluate the efficacy and tolerability of DEX for the treatment of IS and IS-related LGS. METHODS Patients diagnosed as having IS (including patients whose condition evolved to LGS after the failure of early treatment) in our hospital between May 2009 and June 2019 were treated with dexamethasone after failure of prednisone treatment. The oral dose of DEX was 0.15-0.3 mg/kg/d. Thereafter, the clinical efficacy, electroencephalogram (EEG) findings, and adverse effects were observed every 4-12 weeks depending on the individual patient's response. Then, the efficacy and safety of DEX in the treatment of IS and IS-related LGS were retrospectively evaluated. RESULTS Among 51 patients (35 cases of IS; 16 cases of IS-related LGS), 35 cases (68.63%) were identified as responders to DEX treatment, comprising 20 cases (39.22%) and 15 cases (29.41%) with complete control and obvious control, respectively. To discuss the syndromes individually, complete control and obvious control were achieved in 14/35 and 9/35 IS cases and in 6/16 and 6/16 IS-related LGS cases, respectively. During DEX withdrawal, 11 of the 20 patients with complete control relapsed (9/14 IS; 2/6 LGS). The duration of dexamethasone treatment (including weaning) in most of the 35 responders was less than 1 year. However, 5 patients were treated with prolonged, low-dose maintenance therapy, which continued for more than 1.5 years. These 5 patients showed complete control, and 3 patients had no recurrence. Except for one child who died of recurrent asthma and epileptic status 3 months after stopping DEX, there were no serious or life-threatening adverse effects during DEX treatment. CONCLUSION Oral DEX is effective and tolerable for IS and IS-related LGS. all LGS patients were evolved from IS in this study. The conclusion may not apply to patients with other etiology and courses of LGS. Even when prednisone or ACTH is failed, DEX may still be considered as a treatment option. For children who respond to DEX but do not show complete control after 6 months of treatment, prolonged treatment with low-dose DEX administered in the morning might be considered.
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Affiliation(s)
- Jieling Li
- Department of Medical general Ward, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, National Clinical Research Center for Child Health and Disorders, China International Science and Technology Cooperation base of Child development and Critical Disorders, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Yujing Gao
- Department of Medical general Ward, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, National Clinical Research Center for Child Health and Disorders, China International Science and Technology Cooperation base of Child development and Critical Disorders, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Jie Cao
- Department of Medical general Ward, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, National Clinical Research Center for Child Health and Disorders, China International Science and Technology Cooperation base of Child development and Critical Disorders, Children's Hospital of Chongqing Medical University, Chongqing, China.
| | - Fangcheng Cai
- Department of Medical general Ward, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, National Clinical Research Center for Child Health and Disorders, China International Science and Technology Cooperation base of Child development and Critical Disorders, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Xiuquan Zhai
- Chongqing Kindcare Children's Hospital, Chongqing, China
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Takacs DS, Katyayan A, Vanderslice K, Riviello JJ. Inaccuracies in Parental Reporting of Treated Epileptic Spasms: Both Under- and Over-Reporting. Pediatr Neurol 2023; 145:119-123. [PMID: 37331271 DOI: 10.1016/j.pediatrneurol.2023.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2022] [Revised: 04/11/2023] [Accepted: 05/13/2023] [Indexed: 06/20/2023]
Abstract
BACKGROUND The purpose of this study was to evaluate the accuracy of parental reporting of epileptic spasms (ES) after 14 days of appropriate medical therapy for new-onset ES by comparison with extended video electroencephalography (vEEG) monitoring results. METHODS Fifty-eight patients were identified from August 2019 to February 2021 with new-onset ES, confirmed on vEEG. Patients were initiated on appropriate treatment (high-dose steroids or vigabatrin). After two weeks of therapy, patients underwent overnight (18 to 24 hours) vEEG monitoring in the epilepsy monitoring unit. Parental reporting of presence or absence of ES on admission was compared with results of vEEG monitoring. RESULTS The 58 patients ranged in age from three to 20 months (average 7.8 months). An underlying etiology was identified in 78%, whereas 22% patients had unknown etiology. The overall accuracy of parental reporting was 74% (43 of 58) when compared with results of vEEG within 14 to 18 days of starting therapy. Of these, 65% (28 of 43) reported ES resolution and 35% (15 of 43) reported continued ES. Of the 26% (15 of 58) families who were incorrect at two-week follow-up, 67% (10 of 15) reported resolution of ES. However, a minority of families, 33% (five of 15), who continued to report spasms clinically, were inaccurate. CONCLUSIONS Although a majority of inaccurate parental reports at two weeks of treatment were due to unrecognized ES (a widely known phenomenon), a minority were conversely inaccurate due to persistent over-reporting of ES. This fact highlights the importance of correlating parental history with objective vEEG monitoring, to prevent inappropriate escalation of medication therapy.
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Affiliation(s)
- Danielle Schwartzenburg Takacs
- Department of Pediatric Neurology and Developmental Neuroscience, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas.
| | - Akshat Katyayan
- Department of Pediatric Neurology and Developmental Neuroscience, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Kari Vanderslice
- Department of Pediatric Neurology and Developmental Neuroscience, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - James John Riviello
- Department of Pediatric Neurology and Developmental Neuroscience, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
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Becker LL, Kaindl AM. Corticosteroids in childhood epilepsies: A systematic review. Front Neurol 2023; 14:1142253. [PMID: 36970534 PMCID: PMC10036579 DOI: 10.3389/fneur.2023.1142253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Accepted: 02/15/2023] [Indexed: 03/12/2023] Open
Abstract
Corticosteroids have been used for the treatment of patients with epilepsy for more than 6 decades, based on the hypothesis of inflammation in the genesis and/or promotion of epilepsy. We, therefore, aimed to provide a systematic overview of the use of corticosteroid regimes in childhood epilepsies in line with the PRISMA guidelines. We performed a structured literature search via PubMed and identified 160 papers with only three randomized controlled trials excluding the substantial trials on epileptic spasms. Corticosteroid regimes, duration of treatment (days to several months), and dosage protocols were highly variable in these studies. Evidence supports the use of steroids in epileptic spasms; however, there is only limited evidence for a positive effect for other epilepsy syndromes, e.g., epileptic encephalopathy with spike-and-wave activity in sleep [(D)EE-SWAS] or drug-resistant epilepsies (DREs). In (D)EE-SWAS (nine studies, 126 patients), 64% of patients showed an improvement either in the EEG or in their language/cognition following various steroid treatment regimes. In DRE (15 studies, 436 patients), a positive effect with a seizure reduction in 50% of pediatric and adult patients and seizure freedom in 15% was identified; however, no recommendation can be drawn due to the heterozygous cohort. This review highlights the immense need for controlled studies using steroids, especially in DRE, to offer patients new treatment options.
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Affiliation(s)
- Lena-Luise Becker
- Department of Pediatric Neurology, Charité – Universitätsmedizin Berlin, Berlin, Germany
- Center for Chronically Sick Children, Charité – Universitätsmedizin Berlin, Berlin, Germany
- German Epilepsy Center for Children and Adolescents, Charité – Universitätsmedizin Berlin, Berlin, Germany
- Institute of Cell- and Neurobiology, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Angela M. Kaindl
- Department of Pediatric Neurology, Charité – Universitätsmedizin Berlin, Berlin, Germany
- Center for Chronically Sick Children, Charité – Universitätsmedizin Berlin, Berlin, Germany
- German Epilepsy Center for Children and Adolescents, Charité – Universitätsmedizin Berlin, Berlin, Germany
- Institute of Cell- and Neurobiology, Charité – Universitätsmedizin Berlin, Berlin, Germany
- *Correspondence: Angela M. Kaindl
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Sánchez Fernández I, Amengual-Gual M, Barcia Aguilar C, Romeu A, Sheikh T, Torres A, Chao J, Jonas R, Gaínza-Lein M, Harini C, Douglass L. Temporal trends in the cost and use of first-line treatments for infantile epileptic spasms syndrome. Epilepsia 2023; 64:630-640. [PMID: 36600453 DOI: 10.1111/epi.17498] [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] [Received: 10/08/2022] [Revised: 12/19/2022] [Accepted: 01/03/2023] [Indexed: 01/06/2023]
Abstract
OBJECTIVE To describe the temporal trends in the cost and use of adrenocorticotropic hormone (ACTH), oral prednisolone, and vigabatrin, the first-line treatments for infantile epileptic spasms syndrome (IESS). METHODS Retrospective observational study using the MarketScan Commercial database from 2006 to 2020. We identified patients with IESS diagnosed between birth and 18 months of age who received at least one of the first-line treatments within 60 days of diagnosis. Costs were adjusted for inflation using the Gross Domestic Product Implicit Price Deflator. RESULTS A total of 1131 patients received at least one first-line treatment (median [p25 -p75 ] age: 6.3 [4.5-8.3] months, 55% male), of whom 592 patients received ACTH, 363 patients received oral prednisolone, and 355 patients received vigabatrin. After adjusting for inflation, the median average wholesale price of a 14-day course of treatment increased for ACTH from $3718 in 2006 to $100 457 in 2020, ~2700% (by a factor of 27), whereas it decreased for oral prednisolone from $169 in 2006 to $89 in 2020, ~50% (by a factor of 0.5), and increased for vigabatrin from $1206 in 2009 (first year with data on vigabatrin used for IESS) to $4102 in 2020, ~340% (by a factor of 3.4). During the first 60 days after diagnosis, inpatient admission days and costs where higher for ACTH than for oral prednisolone and vigabatrin-5.0 (3.0-8.3) days vs 2.0 (0.0-5.0) days vs 2.0 (0.0-6.0) days, p < .0001; and $32 828 ($14 711-$67 216) vs $16 227 ($0-$35 829) vs $17 844 ($0-$47 642), p < .0001. ACTH use decreased from representing 78% of first-line treatments in 2006 to 18% in 2020 (p < .0001). Sensitivity analyses confirmed the robustness of the results. SIGNIFICANCE The gap between the cost of ACTH and the cost of oral prednisolone or vigabatrin has widened markedly from 2006 to 2020, whereas the relative proportion of ACTH use has decreased.
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Affiliation(s)
- Iván Sánchez Fernández
- Division of Pediatric Neurology, Department of Pediatrics, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Marta Amengual-Gual
- Pediatric Neurology Unit, Department of Pediatrics, Hospital Universitari Son Llàtzer, Universitat de les Illes Balears, Palma, Spain
| | - Cristina Barcia Aguilar
- Pediatric Neurology Unit, Department of Pediatrics, Complejo Hospitalario Universitario de La Coruña, La Coruña, Spain
| | - Amanda Romeu
- Division of Pediatric Neurology, Department of Pediatrics, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Tahir Sheikh
- Division of Pediatric Neurology, Department of Pediatrics, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Alcy Torres
- Division of Pediatric Neurology, Department of Pediatrics, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Jessica Chao
- Division of Pediatric Neurology, Department of Pediatrics, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Rinat Jonas
- Division of Pediatric Neurology, Department of Pediatrics, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Marina Gaínza-Lein
- Instituto de Pediatría, Facultad de Medicina, Universidad Austral de Chile, Valdivia, Chile
- Servicio de Neuropsiquiatría Infantil, Hospital Clínico San Borja Arriarán, Universidad de Chile, Santiago, Chile
| | - Chellamani Harini
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Laurie Douglass
- Division of Pediatric Neurology, Department of Pediatrics, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts, USA
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11
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Osborne JP, Edwards SW, Alber FD, Hancock E, Johnson AL, Kennedy CR, Likeman M, Lux AL, Mackay M, Mallick A, Newton RW, Nolan M, Pressler R, Rating D, Schmitt B, Verity CM, O'Callaghan FK. Prednisolone or tetracosactide depot for infantile epileptic spasms syndrome? A prospective analysis of data embedded within two randomised controlled trials. Eur J Paediatr Neurol 2023; 42:110-116. [PMID: 36621063 DOI: 10.1016/j.ejpn.2022.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 12/20/2022] [Accepted: 12/21/2022] [Indexed: 12/27/2022]
Abstract
OBJECTIVE To report a prospectively planned analysis of two randomised controlled trials with embedded comparisons of prednisolone versus tetracosactide depot for the treatment of infantile epileptic spasms syndrome (IESS). METHODS Individual patient data from patients randomly allocated to prednisolone or tetracosactide depot were analysed from two trials (UKISS, ICISS). The comparison was embedded within trials in which some patients also received vigabatrin but only patients receiving monotherapy with randomly allocated hormonal treatments are included in this analysis. The main outcome was cessation of spasms (Days 13-14 after randomisation). Lead time to treatment and underlying aetiology were taken into account. Cessation of spasms on Days 14-42 inclusive, electroclinical response (EEG Day 14), plus developmental and epilepsy outcomes (at 14 months in UKISS and 18 months in ICISS) are also reported. Minimum treatment was prednisolone 40 mg per day for two weeks or tetracosactide depot 0·5 mg IM on alternate days for two weeks, all followed by a reducing dose of prednisolone over two weeks. RESULTS 126 infants were included in this study. On tetracosactide depot, 47 of 62 (76%) were free of spasms on Days 13-14 compared to 43 of 64 (67%) on prednisolone (difference 9%, 95% CI -7·2% to +25·2%, chi square 1·15, p = 0·28). For Day 14-42 cessation of spasms, on tetracosactide depot, 41 of 61 (67%) were free of spasms compared to 35 of 62 (56%) on prednisolone (difference 11%, 95% CI -6·4% to +28·4%, chi square 1·51, p = 0·22). There was no significant difference in mean VABS score between infants who received prednisolone compared with those who received tetracosactide depot (74·8 (SD 18·3) versus 78·0 (SD 20·2) t = -0·91 p = 0·36). The proportion with ongoing epilepsy at the time of developmental assessment was 20 of 61 (33%) in the tetracosactide group compared with 26 out of 63 (41%) in the prednisolone group (difference 8%, 95% CI -9·2% to +25·2%, Chi [2] 0·95, p = 0·33). SIGNIFICANCE With hormone monotherapy, either prednisolone or tetracosactide depot may be recommended for infantile epileptic spasms syndrome.
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Affiliation(s)
- John P Osborne
- Department for Health, University of Bath, Claverton Down, Bath, BA2 7AY, UK; Children's Department, Royal United Hospitals Bath NHS Foundation Trust, Combe Park, Bath, BA1 3NG, UK
| | - Stuart W Edwards
- Department for Health, University of Bath, Claverton Down, Bath, BA2 7AY, UK; Children's Department, Royal United Hospitals Bath NHS Foundation Trust, Combe Park, Bath, BA1 3NG, UK
| | - Fabienne Dietrich Alber
- Division of Neurology/Neuropsychology, University Children's Hospital, Steinwiesstrasse 75, CH-8032, Zurich, Switzerland
| | - Eleanor Hancock
- Children's Department, Royal United Hospitals Bath NHS Foundation Trust, Combe Park, Bath, BA1 3NG, UK
| | - Anthony L Johnson
- Medical Research Council Clinical Trials Unit at UCL, Institute of Clinical Trials Methodology, 90, High Holborn, London, WC1V 6LJ, UK
| | - Colin R Kennedy
- Clinical Neurosciences, Faculty of Medicine, University of Southampton. Mailpoint 803 G, Southampton General Hospital, Southampton, SO16 6YB, UK
| | - Marcus Likeman
- Department of Paediatric Radiology, Bristol Royal Hospital for Children, Upper Maudlin Street, Bristol, BS3 8AE, UK
| | - Andrew L Lux
- Department of Paediatric Neurology, Bristol Royal Hospital for Children, Upper Maudlin Street, Bristol, BS3 8AE, UK
| | - Mark Mackay
- Neurology Department, The Royal Children's Hospital Melbourne, 50 Flemington Road, Parkville, Victoria, 3058, Australia
| | - Andrew Mallick
- Department of Paediatric Neurology, Bristol Royal Hospital for Children, Upper Maudlin Street, Bristol, BS3 8AE, UK
| | - Richard W Newton
- Department of Neurology, Royal Manchester Children's Hospital, Hathersage Road, Manchester, M13 9WL, UK
| | - Melinda Nolan
- Starship Children's Health, Private bag 92024, Auckland, 1142, New Zealand
| | - Ronit Pressler
- UCL Institute of Child Health, Clinical Neurosciences, London, WC1N 1EH, UK
| | | | - Bernhard Schmitt
- Division of Paediatric Neurology, University Children's Hospital, Steinwiesstrasse 75, CH-8032, Zurich, Switzerland
| | | | - FinbarJ K O'Callaghan
- Head of Clinical Neurosciences Section, Room 41, 4th Floor PUW South, Institute of Child Health, University College London, London, WC1N 1EH, UK.
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12
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Wan L, He W, Wang YY, Xu Y, Lu Q, Zhang MN, Wang QH, Dun S, Liu LY, Shi XY, Wang J, Hu LY, Zhang B, Yang G, Zou LP. Vigabatrin-associated brain abnormalities on MRI in tuberous sclerosis complex patients with infantile spasms: are they preventable? Ther Adv Neurol Disord 2022; 15:17562864221138148. [PMID: 36601084 PMCID: PMC9806385 DOI: 10.1177/17562864221138148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 10/22/2022] [Indexed: 12/28/2022] Open
Abstract
Background Vigabatrin (VGB) is currently the most widely prescribed first-line medication for individuals with infantile spasms (IS) and especially for those with tuberous sclerosis complex (TSC), with demonstrated efficacy. Meanwhile, its adverse events, such as vigabatrin-associated brain abnormalities on magnetic resonance imaging (MRI; VABAM), have also been widely reported. Objectives The objectives of this study were to observe the occurrences of VABAM in patients with IS caused by TSC (IST) and further explore the associated risk factors. Methods Children with IS receiving VGB were recruited from our institution; clinical, imaging, and medication data were collected. Cerebral MRI was reviewed to determine the occurrence of VABAM. Group comparisons (IS caused by TSC and other etiologies) were performed; subgroup analyses on IST were also performed. Next, a retrospective cohort study of children taking VGB was conducted to explore risk/protective factors associated with VABAM. Results The study enrolled 172 children with IS who received VGB. VABAM was observed in 38 patients (22.1%) with a peak dosage of 103.5 ± 26.7 mg/kg/day. Subsequent analysis found the incidence of VABAM was significantly lower in the 80 patients with IST than in the 92 patients with IS caused by other etiologies (10% versus 32.6%, p-value < 0.001). In subgroup analyses within the IST cohort, VABAM was significantly lower in children who received concomitant rapamycin therapy. Univariate and multivariate logistic regression analysis of the 172 IS children showed that treatment with rapamycin was the independent factor associated with a lower risk of VABAM; similar results were observed in the survival analysis. Conclusion The incidence of VABAM was significantly lower in IST patients. Further research is needed to examine the mechanisms that underlie this phenomenon and to determine if treatment with rapamycin may reduce the risk of VABAM.
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Affiliation(s)
| | | | | | - Yong Xu
- Department of Pediatrics, PLA General Hospital,
Beijing, China,Division of Pediatrics, The First Medical
Center of PLA General Hospital, Beijing, China
| | - Qian Lu
- Department of Pediatrics, PLA General
Hospital, Beijing, China,Division of Pediatrics, The First Medical
Center of PLA General Hospital, Beijing, China
| | - Meng-Na Zhang
- Department of Pediatrics, PLA General
Hospital, Beijing, China,Division of Pediatrics, The First Medical
Center of PLA General Hospital, Beijing, China
| | - Qiu-Hong Wang
- Department of Pediatrics, PLA General
Hospital, Beijing, China,Division of Pediatrics, The First Medical
Center of PLA General Hospital, Beijing, China
| | - Shuo Dun
- Department of Pediatrics, PLA General
Hospital, Beijing, China,Division of Pediatrics, The First Medical
Center of PLA General Hospital, Beijing, China
| | - Li-Ying Liu
- Department of Pediatrics, PLA General
Hospital, Beijing, China,Division of Pediatrics, The First Medical
Center of PLA General Hospital, Beijing, China
| | - Xiu-Yu Shi
- Department of Pediatrics, PLA General
Hospital, Beijing, China,Division of Pediatrics, The First Medical
Center of PLA General Hospital, Beijing, China,The Second School of Clinical Medicine,
Southern Medical University, Guangzhou, China
| | - Jing Wang
- Department of Pediatrics, PLA General
Hospital, Beijing, China,Division of Pediatrics, The First Medical
Center of PLA General Hospital, Beijing, China
| | - Lin-Yan Hu
- Department of Pediatrics, PLA General
Hospital, Beijing, China,Division of Pediatrics, The First Medical
Center of PLA General Hospital, Beijing, China
| | - Bo Zhang
- Department of Neurology and ICCTR
Biostatistics and Research Design Center, Boston Children’s Hospital,
Harvard Medical School, Boston, MA, USA
| | - Guang Yang
- Department of Pediatrics, PLA General
Hospital, Beijing, China,Division of Pediatrics, The First Medical
Center of PLA General Hospital, Beijing, China,Medical School of Chinese People’s Liberation
Army, Beijing, China,The Second School of Clinical Medicine,
Southern Medical University, Guangzhou, China
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13
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Dzau W, Cheng S, Snell P, Fahey M, Scheffer IE, Harvey AS, Howell KB. Response to sequential treatment with prednisolone and vigabatrin in infantile spasms. J Paediatr Child Health 2022; 58:2197-2202. [PMID: 36054157 PMCID: PMC10087127 DOI: 10.1111/jpc.16181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Revised: 05/30/2022] [Accepted: 07/17/2022] [Indexed: 10/15/2022]
Abstract
AIM To report response to first treatment in infants with infantile spasms (IS), including incremental benefit of prednisolone 60 mg/day and vigabatrin following prednisolone 40 mg/day failure in infants commenced on the United Kingdom Infantile Spasms Study (UKISS) treatment sequence. METHODS In this retrospective analysis, we compared effectiveness of prednisolone, vigabatrin and nonstandard treatments as first treatment for IS. In infants who commenced the UKISS treatment sequence, we evaluated response to each step. Primary outcome was spasm cessation after 42 days. Secondary outcomes were severe side effects and spasm relapse after 42 days. RESULTS Treatment response data were available for 151 infants. First treatment was prednisolone in 99 infants, vigabatrin in 18 and nonstandard treatment in 34. The rate of spasm cessation with first treatment was significantly higher with prednisolone (62/99, 63%) than vigabatrin (5/18, 28%, P = 0.01) or nonstandard treatment (2/34, 5.9%, P < 0.01). Of 112 infants who commenced the UKISS treatment sequence, 71/112 (63%) responded to prednisolone 40 mg/day. Among non-responders, 12/29 (41%) subsequently responded to prednisolone 60 mg/day, and 10/22 (45%) to vigabatrin. Severe side effects and spasm relapse were not significantly different between each treatment. CONCLUSION We confirm higher rates of spasm cessation with initial treatment with prednisolone than vigabatrin and nonstandard therapy. Non-use of prednisolone as first treatment in over one third of infants highlights a concerning treatment gap. The UKISS treatment sequence has high overall treatment response (total 93/112; 83%), with similar benefit of subsequent prednisolone 60 mg/day and vigabatrin in prednisolone 40 mg/day non-responders.
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Affiliation(s)
- Winston Dzau
- Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
| | - Sally Cheng
- Department of Neurology, The Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Penny Snell
- Neuroscience Research Group, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Michael Fahey
- Department of Paediatrics, Monash University, Melbourne, Victoria, Australia
| | - Ingrid E Scheffer
- Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia.,Department of Neurology, The Royal Children's Hospital, Melbourne, Victoria, Australia.,Neuroscience Research Group, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Medicine, University of Melbourne, Austin Health, Melbourne, Victoria, Australia.,Florey Institute of Neurosciences and Mental Health, Melbourne, Victoria, Australia
| | - A Simon Harvey
- Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia.,Department of Neurology, The Royal Children's Hospital, Melbourne, Victoria, Australia.,Neuroscience Research Group, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Katherine B Howell
- Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia.,Department of Neurology, The Royal Children's Hospital, Melbourne, Victoria, Australia.,Neuroscience Research Group, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Florey Institute of Neurosciences and Mental Health, Melbourne, Victoria, Australia
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14
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Muacevic A, Adler JR, Luis Nogueira A. West Syndrome and the Importance of Routine Physical Examinations and Parental Education: A Case Report. Cureus 2022; 14:e31848. [PMID: 36579257 PMCID: PMC9792333 DOI: 10.7759/cureus.31848] [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: 11/23/2022] [Indexed: 11/25/2022] Open
Abstract
West syndrome (WS), also known as infantile spasms, is a severe form of epileptic disorder of infancy and early childhood. It was first described by William West in 1841. Children with WS exhibit a triad of myoclonic-tonic seizures (spasms), a distinct electroencephalogram (EEG) pattern known as hypsarrhythmia and psychomotor development arrest. WS is classified into three main categories as symptomatic, idiopathic and cryptogenic based on etiological factors. The long-term prognosis depends on the etiological cause, but generally has a poor prognosis, and is associated with impaired development, neurologic structural anomalies, autism spectrum disorder and death. Treatment guidelines from the American Academy of Neurology and Child Neurology Society recommend that adrenocorticotropic hormone (ACTH) and vigabatrin are possibly effective in the cessation of spasms and hypsarrhythmia. We report an incidental diagnosis of WS in a six-month-old male baby that went to the Pediatric Emergency Department due to upper respiratory tract symptoms. The diagnosis was made after the development of spasms during a medical examination. This case highlights the importance of early diagnosis, parental education and prompt effective treatment as it may improve prognosis.
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15
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Jain P, Sahu JK, Horn PS, Chau V, Go C, Mahood Q, Arya R. Treatment of children with infantile spasms: A network meta-analysis. Dev Med Child Neurol 2022; 64:1330-1343. [PMID: 35765990 DOI: 10.1111/dmcn.15330] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 05/28/2022] [Accepted: 05/30/2022] [Indexed: 12/12/2022]
Abstract
AIM We performed a systematic review and network meta-analysis (NMA) to obtain comparative effectiveness estimates and rankings of non-surgical interventions used to treat infantile spasms. METHOD All randomized controlled trials (RCTs) including children 2 months to 3 years of age with infantile spasms (with hypsarrhythmia or hypsarrhythmia variants on electroencephalography) receiving appropriate first-line medical treatment were included. Electroclinical and clinical remissions within 1 month of starting treatment were analyzed. RESULTS Twenty-two RCTs comparing first-line treatments for infantile spasms were reviewed; of these, 17 were included in the NMA. Both frequentist and Bayesian network rankings for electroclinical remission showed that high dose adrenocorticotropic hormone (ACTH), methylprednisolone, low dose ACTH and magnesium sulfate (MgSO4 ) combination, low dose ACTH, and high dose prednisolone were most likely to be the 'best' interventions, although these were not significantly different from each other. For clinical remission, low dose ACTH/MgSO4 combination, high dose ACTH (with/without vitamin B6 ), high dose prednisolone, and low dose ACTH were 'best'. INTERPRETATION Treatments including ACTH and high dose prednisolone are more effective in achieving electroclinical and clinical remissions for infantile spasms. WHAT THIS PAPER ADDS Adrenocorticotropic hormone and high dose prednisolone are more effective than other medications for infantile spasms. Symptomatic etiology decreases the likelihood of remission even after adjusting for treatment lag.
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Affiliation(s)
- Puneet Jain
- Epilepsy Program, Division of Neurology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Jitendra K Sahu
- Pediatric Neurology Unit, Department of Pediatrics, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | - Paul S Horn
- Comprehensive Epilepsy Center, Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Vann Chau
- Neonatal Neurology Program, Division of Neurology, Department of Pediatrics, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Cristina Go
- Epilepsy Program, Division of Neurology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Quenby Mahood
- Hospital Library and Archives, Learning Institute, Toronto, ON, Canada
| | - Ravindra Arya
- Comprehensive Epilepsy Center, Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
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16
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Yan J, Kothur K, Innes EA, Han VX, Jones HF, Patel S, Tsang E, Webster R, Gupta S, Troedson C, Menezes MP, Antony J, Ardern-Holmes S, Tantsis E, Mohammad S, Wienholt L, Pires AS, Heng B, Guillemin GJ, Guller A, Gill D, Bandodkar S, Dale RC. Decreased cerebrospinal fluid kynurenic acid in epileptic spasms: A biomarker of response to corticosteroids. EBioMedicine 2022; 84:104280. [PMID: 36174397 PMCID: PMC9515432 DOI: 10.1016/j.ebiom.2022.104280] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Revised: 09/06/2022] [Accepted: 09/07/2022] [Indexed: 11/15/2022] Open
Abstract
Background Epileptic (previously infantile) spasms is the most common epileptic encephalopathy occurring during infancy and is frequently associated with abnormal neurodevelopmental outcomes. Epileptic spasms have a diverse range of known (genetic, structural) and unknown aetiologies. High dose corticosteroid treatment for 4 weeks often induces remission of spasms, although the mechanism of action of corticosteroid is unclear. Animal models of epileptic spasms have shown decreased brain kynurenic acid, which is increased after treatment with the ketogenic diet. We quantified kynurenine pathway metabolites in the cerebrospinal fluid (CSF) of infants with epileptic spasms and explored clinical correlations. Methods A panel of nine metabolites in the kynurenine pathway (tryptophan, kynurenine, kynurenic acid, 3-hydroxykynurenine, xanthurenic acid, anthranilic acid, 3-hydroxyanthranilic acid, quinolinic acid, and picolinic acid) were measured using liquid chromatography coupled to tandem mass spectrometry (LC-MS/MS). CSF collected from paediatric patients less than 3 years of age with epileptic spasms (n=34, 19 males, mean age 0.85, median 0.6, range 0.3–3 yrs) were compared with other epilepsy syndromes (n=26, 9 males, mean age 1.44, median 1.45, range 0.3–3 yrs), other non-inflammatory neurological diseases (OND) (n=29, 18 males, mean age 1.47, median 1.6, range 0.1–2.9 yrs) and inflammatory neurological controls (n=12, 4 males, mean age 1.80, median 1.80, range 0.8–2.5 yrs). Findings There was a statistically significant decrease of CSF kynurenic acid in patients with epileptic spasms compared to OND (p<0.0001). In addition, the kynurenic acid/kynurenine (KYNA/KYN) ratio was lower in the epileptic spasms subgroup compared to OND (p<0.0001). Epileptic spasms patients who were steroid responders or partial steroid responders had lower KYNA/KYN ratio compared to patients who were refractory to steroids (p<0.005, p<0.05 respectively). Interpretation This study demonstrates decreased CSF kynurenic acid and KYNA/KYN in epileptic spasms, which may also represent a biomarker for steroid responsiveness. Given the anti-inflammatory and neuroprotective properties of kynurenic acid, further therapeutics able to increase kynurenic acid should be explored. Funding Financial support for the study was granted by Dale NHMRC Investigator grant APP1193648, Petre Foundation, Cerebral Palsy Alliance and Department of Biochemistry at the Children's Hospital at Westmead. Prof Guillemin is funded by NHMRC Investigator grant APP1176660 and Macquarie University.
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Affiliation(s)
- Jingya Yan
- Kids Neuroscience Centre, The Children's Hospital at Westmead, Faculty of Medicine and Health, University of Sydney, NSW, Australia; Department of Biochemistry, The Children's Hospital at Westmead, NSW, Australia; Clinical School, The Children's Hospital at Westmead, Faculty of Medicine and Health, University of Sydney, NSW, Australia
| | - Kavitha Kothur
- Kids Neuroscience Centre, The Children's Hospital at Westmead, Faculty of Medicine and Health, University of Sydney, NSW, Australia; TY Nelson Department of Neurology and Neurosurgery, The Children's Hospital at Westmead, The University of Sydney, Westmead, New South Wales, Australia
| | - Emily A Innes
- TY Nelson Department of Neurology and Neurosurgery, The Children's Hospital at Westmead, The University of Sydney, Westmead, New South Wales, Australia
| | - Velda X Han
- Khoo Teck Puat-National University Children's Medical Institute, National University Health System, Singapore, Singapore
| | - Hannah F Jones
- Starship Hospital, Centre for Brain Research, Faculty of Medical and Health Sciences, University of Auckland, New Zealand
| | - Shrujna Patel
- Kids Neuroscience Centre, The Children's Hospital at Westmead, Faculty of Medicine and Health, University of Sydney, NSW, Australia; Clinical School, The Children's Hospital at Westmead, Faculty of Medicine and Health, University of Sydney, NSW, Australia
| | - Erica Tsang
- Clinical School, The Children's Hospital at Westmead, Faculty of Medicine and Health, University of Sydney, NSW, Australia
| | - Richard Webster
- TY Nelson Department of Neurology and Neurosurgery, The Children's Hospital at Westmead, The University of Sydney, Westmead, New South Wales, Australia
| | - Sachin Gupta
- TY Nelson Department of Neurology and Neurosurgery, The Children's Hospital at Westmead, The University of Sydney, Westmead, New South Wales, Australia
| | - Christopher Troedson
- TY Nelson Department of Neurology and Neurosurgery, The Children's Hospital at Westmead, The University of Sydney, Westmead, New South Wales, Australia; Clinical School, The Children's Hospital at Westmead, Faculty of Medicine and Health, University of Sydney, NSW, Australia
| | - Manoj P Menezes
- TY Nelson Department of Neurology and Neurosurgery, The Children's Hospital at Westmead, The University of Sydney, Westmead, New South Wales, Australia; Clinical School, The Children's Hospital at Westmead, Faculty of Medicine and Health, University of Sydney, NSW, Australia
| | - Jayne Antony
- TY Nelson Department of Neurology and Neurosurgery, The Children's Hospital at Westmead, The University of Sydney, Westmead, New South Wales, Australia
| | - Simone Ardern-Holmes
- TY Nelson Department of Neurology and Neurosurgery, The Children's Hospital at Westmead, The University of Sydney, Westmead, New South Wales, Australia
| | - Esther Tantsis
- Kids Neuroscience Centre, The Children's Hospital at Westmead, Faculty of Medicine and Health, University of Sydney, NSW, Australia; Clinical School, The Children's Hospital at Westmead, Faculty of Medicine and Health, University of Sydney, NSW, Australia
| | - Shekeeb Mohammad
- Kids Neuroscience Centre, The Children's Hospital at Westmead, Faculty of Medicine and Health, University of Sydney, NSW, Australia; TY Nelson Department of Neurology and Neurosurgery, The Children's Hospital at Westmead, The University of Sydney, Westmead, New South Wales, Australia; Clinical School, The Children's Hospital at Westmead, Faculty of Medicine and Health, University of Sydney, NSW, Australia
| | - Louise Wienholt
- Department of Clinical Immunology and Allergy, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
| | - Ananda S Pires
- Neuroinflammation Group, Macquarie Medical School, Faculty of Medicine, Health and Human Sciences, Macquarie University, NSW, Australia
| | - Benjamin Heng
- Neuroinflammation Group, Macquarie Medical School, Faculty of Medicine, Health and Human Sciences, Macquarie University, NSW, Australia
| | - Gilles J Guillemin
- Neuroinflammation Group, Macquarie Medical School, Faculty of Medicine, Health and Human Sciences, Macquarie University, NSW, Australia
| | - Anna Guller
- Computational NeuroSurgery Lab, Macquarie University, Sydney, NSW, Australia
| | - Deepak Gill
- TY Nelson Department of Neurology and Neurosurgery, The Children's Hospital at Westmead, The University of Sydney, Westmead, New South Wales, Australia
| | - Sushil Bandodkar
- Department of Biochemistry, The Children's Hospital at Westmead, NSW, Australia; Clinical School, The Children's Hospital at Westmead, Faculty of Medicine and Health, University of Sydney, NSW, Australia
| | - Russell C Dale
- Kids Neuroscience Centre, The Children's Hospital at Westmead, Faculty of Medicine and Health, University of Sydney, NSW, Australia; Clinical School, The Children's Hospital at Westmead, Faculty of Medicine and Health, University of Sydney, NSW, Australia.
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Ramantani G, Bölsterli BK, Alber M, Klepper J, Korinthenberg R, Kurlemann G, Tibussek D, Wolff M, Schmitt B. Treatment of Infantile Spasm Syndrome: Update from the Interdisciplinary Guideline Committee Coordinated by the German-Speaking Society of Neuropediatrics. Neuropediatrics 2022; 53:389-401. [PMID: 35882373 PMCID: PMC9643068 DOI: 10.1055/a-1909-2977] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
OBJECTIVES The manuscript serves as an update on the current management practices for infantile spasm syndrome (ISS). It includes a detailed summary of the level of current evidence of different treatment options for ISS and gives recommendations for the treatment and care of patients with ISS. METHODS A literature search was performed using the Cochrane and Medline Databases (2014 to July 2020). All studies were objectively rated using the Scottish Intercollegiate Guidelines Network. For recommendations, the evidence from these studies was combined with the evidence from studies used in the 2014 guideline. RECOMMENDATIONS If ISS is suspected, electroencephalography (EEG) should be performed within a few days and, if confirmed, treatment should be initiated immediately. Response to first-line treatment should be evaluated clinically and electroencephalographically after 14 days. The preferred first-line treatment for ISS consists of either hormone-based monotherapy (AdrenoCorticoTropic Hormone [ACTH] or prednisolone) or a combination of hormone and vigabatrin. Children with tuberous sclerosis complex and those with contraindications against hormone treatment should be treated with vigabatrin. If first-line drugs are ineffective, second-line treatment options such as ketogenic dietary therapies, sulthiame, topiramate, valproate, zonisamide, or benzodiazepines should be considered. Children refractory to drug therapy should be evaluated early for epilepsy surgery, especially if focal brain lesions are present. Parents should be informed about the disease, the efficacy and adverse effects of the medication, and support options for the family. Regular follow-up controls are recommended.
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Affiliation(s)
- Georgia Ramantani
- Division of Clinical Neurophysiology and Epilepsy, University Children's Hospital, Zurich, Switzerland,Address for correspondence Georgia Ramantani, MD, PhD Department of Neuropediatrics, Steinwiesstrasse 758032 ZurichSwitzerland
| | - Bigna K. Bölsterli
- Division of Clinical Neurophysiology and Epilepsy, University Children's Hospital, Zurich, Switzerland
| | - Michael Alber
- Department of Pediatric Neurology and Developmental Medicine, University Children's Hospital, Tubingen, Germany
| | - Joerg Klepper
- Department of Pediatrics, Klinikum Aschaffenburg-Alzenau, Aschaffenburg, Germany
| | - Rudolf Korinthenberg
- Department of Neuropediatrics and Muscular Diseases, Centre of Pediatrics and Adolescent Medicine, University Medical Centre, Freiburg, Germany
| | - Gerhard Kurlemann
- St. Bonifatius Hospital Lingen, Children's Hospital, Lingen, Germany
| | - Daniel Tibussek
- Center for Pediatric and Teenage Health Care, Child Neurology, Sankt Augustin, Germany
| | - Markus Wolff
- Department of Pediatric Neurology, Vivantes Hospital Neukölln, Berlin, Germany
| | - Bernhard Schmitt
- Division of Clinical Neurophysiology and Epilepsy, University Children's Hospital, Zurich, Switzerland
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18
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Brabec JL, Ouardouz M, Mahoney JM, Scott RC, Hernan AE. Differential regulation of gene expression pathways with dexamethasone and ACTH after early life seizures. Neurobiol Dis 2022; 174:105873. [PMID: 36152945 PMCID: PMC10048589 DOI: 10.1016/j.nbd.2022.105873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 09/19/2022] [Accepted: 09/20/2022] [Indexed: 10/31/2022] Open
Abstract
Early-life seizures (ELS) are associated with persistent cognitive deficits such as ADHD and memory impairment. These co-morbidities have a dramatic negative impact on the quality of life of patients. Therapies that improve cognitive outcomes have enormous potential to improve patients' quality of life. Our previous work in a rat flurothyl-induction model showed that administration of adrenocorticotropic hormone (ACTH) at time of seizure induction led to improved learning and memory in the animals despite no effect on seizure latency or duration. Administration of dexamethasone (Dex), a corticosteroid, did not have the same positive effect on learning and memory and has even been shown to exacerbate injury in a rat model of temporal lobe epilepsy. We hypothesized that ACTH exerted positive effects on cognitive outcomes through beneficial changes to gene expression and proposed that administration of ACTH at seizure induction would return gene-expression in the brain towards the normal pattern of expression in the Control animals whereas Dex would not. Twenty-six Sprague-Dawley rats were randomized into vehicle- Control, and ACTH-, Dex-, and vehicle- ELS. Rat pups were subjected to 60 flurothyl seizures from P5 to P14. After seizure induction, brains were removed and the hippocampus and PFC were dissected, RNA was extracted and sequenced, and differential expression analysis was performed using generalized estimating equations. Differential expression analysis showed that ACTH pushes gene expression in the brain back to a more normal state of expression through enrichment of pathways involved in supporting homeostatic balance and down-regulating pathways that might contribute to excitotoxic cell-damage post-ELS.
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Affiliation(s)
- Jeffrey L Brabec
- University of Vermont, Department of Neurological Sciences, 149 Beaumont Avenue, Burlington, VT 05401, USA.
| | - Mohamed Ouardouz
- Nemours Children's Health, Division of Neuroscience, 1600 Rockland Road, Wilmington, DE 19803, USA
| | - J Matthew Mahoney
- University of Vermont, Department of Neurological Sciences, 149 Beaumont Avenue, Burlington, VT 05401, USA; The Jackson Laboratory, 600 Main Street, Bar Harbor, ME 04609, USA
| | - Rod C Scott
- Nemours Children's Health, Division of Neuroscience, 1600 Rockland Road, Wilmington, DE 19803, USA; Neurosciences Unit University College London, Institute of Child Health, London WC1N 1EH, UK; University of Delaware, Psychological and Brain Sciences, South College Avenue, Newark, DE 19716, USA
| | - Amanda E Hernan
- Nemours Children's Health, Division of Neuroscience, 1600 Rockland Road, Wilmington, DE 19803, USA; University of Delaware, Psychological and Brain Sciences, South College Avenue, Newark, DE 19716, USA
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Abstract
There are numerous potential factors that may affect growth in children with epilepsy, and these must be evaluated in any child with appetite and weight concerns. Antiseizure medications (ASMs) have potential adverse effects, and many may affect appetite, thus impacting normal growth and weight gain. The aim of this review is to focus on the impact of both epilepsy and ASMs on appetite and weight in children. We systematically reviewed studies using Medline assessing the impact of ASMs on appetite and weight in children. Eligible studies included randomized controlled trials and open-label studies (open-label extension and interventional) that targeted or included the pediatric population (0-18 years of age). Each study was classified using the American Academy of Neurology (AAN) Classification of Evidence for Therapeutic Studies, and the level of evidence for impact on appetite and weight in children was graded. ASMs associated with decreased appetite and/or weight loss include fenfluramine, topiramate, zonisamide, felbamate, rufinamide, stiripentol, cannabidiol, brivaracetam and ethosuximide; ASMs with minimal impact on weight and appetite in children include oxcarbazepine, eslicarbazepine, lamotrigine, levetiracetam, lacosamide, carbamazepine, vigabatrin and clobazam. The ASM most robustly associated with increased appetite and/or weight gain is valproic acid; however, both pregabalin and perampanel may also lead to modest weight gain or increased appetite in children. Certain ASMs may impact both appetite and weight, which may lead to increased morbidity of the underlying disease and impaired adherence to the treatment regimen.
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20
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Basit A, Noreen N, Saleem SF, Yousuf M, Zafar F. Comparison of Efficacy and Safety of Low- Versus High-Dose Oral Prednisolone in Infantile Spasm (IS): An Open Label Randomized Controlled Trial at the Children’s Hospital & Institute of Child Health, Multan, Pakistan. Cureus 2022; 14:e23164. [PMID: 35444917 PMCID: PMC9009990 DOI: 10.7759/cureus.23164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/14/2022] [Indexed: 11/21/2022] Open
Abstract
Background: Infantile spasm (IS) is an epileptic syndrome characterized by epileptic spasms, hypsarrhythmia on electroencephalography (EEG), and high risk of neurodevelopmental regression. This study was done to compare the efficacy and safety of the high versus the usual dose in children with IS. Methodology: This open label randomized controlled trial was conducted at Department of Pediatric Neurology, The Children’s Hospital & Institute of Child Health, Multan, Pakistan, from January 1, 2020 to December 31, 2020. A total of 62 children (31 in each group) aged three months to two years presenting with epileptic spasms (at least one cluster per day) with EEG evidence of hypsarrhythmia were included. All 62 children were randomized to receive either high-dose prednisolone (10mg per dose four times a day) or the usual-dose prednisolone (2mg/kg/day thrice a day) for 14 days. Primary outcome measure was noted in terms of proportion of children who achieved complete, partial, or no response. Secondary outcome measure was proportion of children with adverse effects. Results: In a total of 62 children, there were 34 (54.8%) male. Overall, mean age was noted to be 9.1±3.4 months. The most common etiology of IS was noted to be hypoxic-ischemic encephalopathy (HIE) in 28 children (45.2%). Significantly better clinical efficacy was reported in high-dose prednisolone group when compared to low-dose prednisolone cases as complete response, partial response and no response were noted in nine (29.0%), eight (25.8%), and 14 (45.2%) patients of low-dose group versus 18 (58.1%), eight (25.8%), and five (16.1%) patients in high-dose group, respectively (p=0.0265). Weight gain was the most frequently reported adverse effects noted in 11 (17.7%) cases. Overall, no statistically significant difference in the frequency of adverse effects (p=0.9573). Conclusion: In comparison to low-dose prednisolone, high-dose prednisolone was found to be significantly more efficacious among cases of IS. Adverse effect in both treatment groups were relatively low and similar.
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21
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Knupp KG, Coryell J, Singh RK, Gaillard WD, Shellhaas RA, Koh S, Mitchell WG, Harini C, Millichap JJ, May A, Dlugos D, Nickels K, Mytinger JR, Keator C, Yozawitz E, Singhal N, Lockrow J, Thomas JF, Juarez-Colunga E. Comparison of Cosyntropin, Vigabatrin, and Combination Therapy in New-Onset Infantile Spasms in a Prospective Randomized Trial. J Child Neurol 2022; 37:186-193. [PMID: 35044272 DOI: 10.1177/08830738211073400] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objective: In a randomized trial, we aimed to evaluate the efficacy of cosyntropin injectable suspension, 1 mg/mL, compared to vigabatrin for infantile spasms syndrome. An additional arm was included to assess the efficacy of combination therapy (cosyntropin and vigabatrin) compared with cosyntropin monotherapy. Methods: Children (2 months to 2 years) with new-onset infantile spasms syndrome and hypsarhythmia were randomized into 3 arms: cosyntropin, vigabatrin, and cosyntropin and vigabatrin combined. Daily seizures and adverse events were recorded, and EEG was repeated at day 14 to assess for resolution of hypsarhythmia. The primary outcome measure was the composite of resolution of hypsarhythmia and absence of clinical spasms at day 14. Fisher exact test was used to compare outcomes. Results: 37 children were enrolled and 34 were included in the final efficacy analysis (1 withdrew prior to treatment and 2 did not return seizure diaries). Resolution of both hypsarhythmia and clinical spasms was achieved in in 9 of 12 participants (75%) treated with cosyntropin, 1/9 (11%) vigabatrin, and 5/13 (38%) cosyntropin and vigabatrin combined. The primary comparison of cosyntropin versus vigabatrin was significant (64% [95% confidence interval 21, 82], P < .01). Adverse events were reported in all 3 treatment arms: 31 (86%) had an adverse event, 7 (19%) had a serious adverse event, and 15 (42%) had an adverse event of special interest with no difference between treatment arms. Significance: This randomized trial was underpowered because of incomplete enrollment, yet it demonstrated that cosyntropin was more effective for short-term outcomes than vigabatrin as initial treatment for infantile spasms.
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Affiliation(s)
- Kelly G Knupp
- Pediatrics and Neurology, 12225University of Colorado, Anschutz Campus, Aurora, CO, USA
| | - Jason Coryell
- Department of Pediatrics and Neurology, 89020Oregon Health and Sciences University, Portland, Oregon, USA
| | - Rani K Singh
- Department of Pediatrics, Division of Pediatric Neurology, Atrium Health/Levine Children's Hospital, Charlotte, NC, USA
| | - William D Gaillard
- Department of Pediatrics and Neurology, George Washington University, Washington, DC, USA
| | - Renée A Shellhaas
- Department of Pediatrics, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Sookyong Koh
- Department of Pediatrics, Children's Hospital, 12284University of Nebraska Medical Center, Omaha, NE, USA
| | - Wendy G Mitchell
- Neurology Division, Keck School of Medicine, 8785University of Southern California and Children's Hospital Los Angeles, Los Angeles, CA, USA
| | | | - John J Millichap
- Department of Pediatrics and Neurology, Lurie Children's Hospital, Chicago, Illinois, USA
| | - Alison May
- Department of Neurology, Morgan Stanley Children's Hospital, 21611Columbia University Irving Medical Center, New York, NY, USA
| | - Dennis Dlugos
- Departments of Neurology and Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | | | - John R Mytinger
- Department of Pediatrics, Division of Pediatric Neurology, Nationwide Children's Hospital, The Ohio State University, Columbus, OH, USA
| | - Cynthia Keator
- Jane and John Justin Neurosciences, Cook Children's Medical Center, Fort Worth, TX, USA
| | - Elissa Yozawitz
- Isabelle Rapin Division of Child Neurology, Saul R. Korey Department of Neurology, Department of Pediatrics, 550033Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY, USA
| | - Nilika Singhal
- Department of Neurology, Division of Epilepsy, UCSF Benioff Children's Hospital, San Francisco, CA, USA
| | - Jason Lockrow
- Division of Pediatric Neurology, Department of Pediatrics, University of Washington, Seattle, WA, USA
| | - Jacob F Thomas
- School of Medicine, Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado, Aurora, Colorado, USA
| | - Elizabeth Juarez-Colunga
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
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22
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Effectiveness of ACTH in Patients with Infantile Spasms. Brain Sci 2022; 12:brainsci12020254. [PMID: 35204017 PMCID: PMC8870252 DOI: 10.3390/brainsci12020254] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 02/04/2022] [Accepted: 02/07/2022] [Indexed: 02/01/2023] Open
Abstract
(1) Background: West syndrome is a severe, refractory, epileptic syndrome that usually appears in infancy or early childhood. ACTH is one of the more effective drugs for treating this condition. (2)Aim of the study and methods: The objective of our study was to examine short-term efficacy (during treatment schedule) and long-term outcome of intramuscular 0.02 mg/kg/day ACTH (tetracosactide) depot, used concomitantly with other antiepileptic drugs (AEDs) in patients with infantile spasms who did not achieve seizure cessation or relapse when taking only the AEDs. The drug efficacy was evaluated in retrospective and prospective analyses of 50 patients diagnosed with infantile spasms. (3) Results: Complete cessation of spasms was achieved in 42 cases (84%). EEG improvement was seen in 41 (82%) patients who responded to ACTH therapy. Information on the clinical course of 28 patients was obtained duringlong-term follow-up. In 17 (60.7%) cases, seizures were still present. Normal or near-normal development was observed in 11 out of 28 children (39%). ACTH used concomitantly with other AEDis a highly effective treatment with acceptable side effects. (4) Conclusion: Randomized controlled clinical trialswith long-term follow-up are needed to compare the effectiveness of ACTH in polytherapy and monotherapy.Dyskinesias as a potential side effect observed in our study group should be investigated in the following studies.
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Guang S, Mao L, Zhong L, Liu F, Pan Z, Yin F, Peng J. Hormonal Therapy for Infantile Spasms: A Systematic Review and Meta-Analysis. Front Neurol 2022; 13:772333. [PMID: 35222241 PMCID: PMC8867209 DOI: 10.3389/fneur.2022.772333] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Accepted: 01/06/2022] [Indexed: 11/13/2022] Open
Abstract
ObjectiveThe limitations of adrenocorticotrophic hormone (ACTH) treatment for infantile spasms (ISs), such as high costs, limited availability, and adverse effects (AEs), make it necessary to explore whether corticosteroids are optimal alternatives. Many other compelling treatments have gone through trials due to the suboptimal effectiveness of hormonal therapy. A systematic review and meta-analysis were performed to evaluate the effectiveness and safety of hormonal therapy for patients with ISs.MethodsEMBASE, Ovid MEDLINE, Cochrane Central Register of Controlled Trials (CENTRAL), and online registers were searched through April 2021 for randomized controlled trials (RCTs).ResultsA total of 19 RCTs (N = 1,279) were included. There was no significant difference in the effectiveness of oral corticosteroids and ACTH in electro-clinical response (risk ratio [RR] = 0.85, 95% CI 0.41–1.76). Low-dose ACTH had similar effectiveness in electro-clinical response compared to usual-dose group (RR = 0.94, 95% CI 0.60–1.47) but conferred a lower risk of AEs (RR = 1.71, 95% CI 1.08–2.71). ACTH was more beneficial in controlling spasms than vigabatrin (VGB) (RR = 1.31, 95% CI 1.05–1.64) for patients without tuberous sclerosis complex (TSC). All RCTs were connected through network meta-analysis, and we found that ketogenic diet (KD), zonisamide, methylprednisolone, or combined treatment of hormonal therapy with topiramate (TPM) or pyridoxine was not different in electro-clinical response compared to usual-dose ACTH.ConclusionOur analysis showed that oral corticosteroids could be optional alternatives when ACTH is not applicable, and ACTH is more beneficial for patients without TSC. Moreover, low-dose ACTH is recommended due to comparative effectiveness but lower risk of AEs. However, due to the high heterogeneity of included patients and treatment protocols, these results must be interpreted with caution. RCTs with multicentric involvement and larger sample size are needed for solid evaluation of other alternative treatments.
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Saleh DA, Hassan A. Clinical profile, treatment modalities, and outcomes in patients with infantile spasms: A retrospective study from the United Arab of Emirates (UAE). Epilepsy Behav 2022; 127:108519. [PMID: 34999500 DOI: 10.1016/j.yebeh.2021.108519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 12/18/2021] [Accepted: 12/18/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Infantile spasms (IS) are an epileptic encephalopathy where the prognosis is generally poor, with most patients exhibiting psychomotor retardation or intractable epilepsy. However, it is claimed that early and aggressive treatment is related to better response rate and outcome, especially in patients with idiopathic IS. OBJECTIVE To investigate different treatment modalities and outcomes in patients with IS attending a pediatric neurology clinic at a specialized neurology center in Abu Dhabi, United Arab Emirates. METHODS Retrospective chart review was done for detailed history, demographic data, etiology, neuro-diagnostic workup, treatment modalities, and the outcomes for all patients diagnosed with IS from September 2014 to September 2019. RESULTS Three treatment modalities were identified as 1st line- Prednisolone United Kingdom Infantile Spasms Study (UKISS) (N = 15, 46.8%), Anti-Seizure Medications (ASMs) (N = 12, 37.5%), and Vigabatrin (N = 5, 15.6%). The complete response rate to Vigabatrin as a 1st line treatment showed the highest statistical significance (X2 = 7.34, p = 0.007). Patients with idiopathic IS showed a comparable response to treatment to those with symptomatic IS. Additional response to 2nd line treatment with Prednisolone UKISS protocol (25%) and Vigabatrin (15%) was noted in patients who showed partial or no response to the 1st line treatment. None of our patients received Adrenocorticotropic Hormone as treatment. All patients with desirable final outcomes were with idiopathic IS and none were symptomatic. CONCLUSION More than a third of our patients showed poor treatment response whenever they were not offered treatment according to the current available protocols. This indicates an urgent need for having a unified treatment protocol that takes into consideration the availability of medications, professional expertise as well as diagnostic workup outside major tertiary care centers in our region.
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Affiliation(s)
- Dina Amin Saleh
- Division of Neurology, American Center for Psychiatry and Neurology, Abu Dhabi, UAE; Department of Pediatrics, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Abeera Hassan
- Division of Neurology, American Center for Psychiatry and Neurology, Abu Dhabi, UAE.
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Menon R, Chandrasekharan S, Nanda S, Nair J, Radhakrishnan A, Cherian A, Thomas S. Does Etiology and Hypsarrhythmia Subtype Influence Outcome in West Syndrome? Challenges Encountered from a Referral Center Perspective. Neurol India 2022; 70:188-196. [DOI: 10.4103/0028-3886.336325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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26
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Kaushik J, Kumari N, Nanda S, Bala K. Pulse methylprednisolone plus low-dose prednisolone versus low-dose prednisolone alone for treatment of children with West syndrome: A single-center, open-label randomized controlled trial. J Pediatr Neurosci 2022. [DOI: 10.4103/jpn.jpn_42_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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27
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Fatema K, Rahman M, Hossain MM, Akhter S, Shomee DA, Akhter S, Mannan M. Pulse Methylprednisolone with Oral Prednisolone versus Adrenocorticotropic Hormone in Children with West Syndrome: a Randomized Controlled Trial. J Epilepsy Res 2021; 11:136-141. [PMID: 35087722 PMCID: PMC8767225 DOI: 10.14581/jer.21020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2021] [Revised: 07/11/2021] [Accepted: 12/08/2021] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND AND PURPOSE West syndrome is an epileptic encephalopathy of infancy. According to guidelines, adrenocorticotrophic hormone (ACTH) is probably effective for the short-term management of infantile spasm, but there is little uniformity in treatment due to variable response. This study has been done to evaluate the efficacy of pulse methylprednisolone as compared to ACTH in children with West syndrome. METHODS Children between 3 months to 24 months with the diagnosis of West syndrome were included and ACTH and pulse methyl prednisolone followed by oral prednisolone were given after randomization. Total duration of treatment was 6 weeks in both groups. RESULTS Total 87 children were enrolled; 12 patients lost in follow up. Finally, 43 received ACTH and 32 received pulse methylprednisolone. In pulse methylprednisolone group, 28.13% showed 50-80% response, 28.13% showed 80-99% response and 21.87% patients showed 100% response. In ACTH group, 41.86% showed 50-80% response, 25.58% showed 80-99% response and only 3 (6.97%) patients showed 100% response. Methylprednisolone treatment regimen did not cause significant or persistent adverse effects. CONCLUSIONS Pulse methylprednisolone followed by oral prednisolone for 6 weeks is as effective as ACTH. Thus, methylprednisolone therapy can be an important alternative to ACTH.
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Affiliation(s)
- Kanij Fatema
- Department of Pediatric Neurology, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh
| | - Mizanur Rahman
- Department of Pediatric Neurology, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh
| | - Mohammad Monir Hossain
- Department of Pediatric Neurology, National Institute of Neuroscience and Hospital, Dhaka, Bangladesh
| | - Shaheen Akhter
- Institute of Pediatric Neurodisorder and Autism, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh
| | - Dewan Afsana Shomee
- Department of Radiology & Imaging, National Institute of Cardiovascular Diseases, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh
| | - Sohela Akhter
- Department of Pediatrics, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh
| | - Mazharul Mannan
- Institute of Pediatric Neurodisorder and Autism, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh
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The Discordance between Network Excitability and Cognitive Performance Following Vigabatrin Treatment during Epileptogenesis. Life (Basel) 2021; 11:life11111213. [PMID: 34833089 PMCID: PMC8618433 DOI: 10.3390/life11111213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 10/29/2021] [Accepted: 11/08/2021] [Indexed: 11/17/2022] Open
Abstract
Vigabatrin (VGB), a potent selective γ-aminobutyric acid transaminase (GABA-T) inhibitor, is an approved non-traditional anti-seizure drug for patients with intractable epilepsy. Nevertheless, its effect on epileptogenesis, and whether this effect is correlated with post-epileptogenic cognitive function remain unclear. Based on lithium-pilocarpine-induced seizure modeling, we evaluated the effect of VGB on epileptogenesis and neuronal damage following status epilepticus in Sprague-Dawley rats. Cognitive evaluations were performed with the aid of inhibitory avoidance testing. We found that VGB could interrupt epileptogenesis by reducing spontaneous recurrent seizures, hippocampal neuronal damage, and chronic mossy fiber sprouting. Nevertheless, VGB did not help with the retention of cognitive performance. Our findings suggest that further research into the role of VGB in epileptogenesis and the treatment of epilepsy in clinical practice is warranted.
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Grinspan ZM, Knupp KG, Patel AD, Yozawitz EG, Wusthoff CJ, Wirrell EC, Valencia I, Singhal NS, Nordli DR, Mytinger JR, Mitchell WG, Keator CG, Loddenkemper T, Hussain SA, Harini C, Gaillard WD, Fernandez IS, Coryell J, Chu CJ, Berg AT, Shellhaas RA. Comparative Effectiveness of Initial Treatment for Infantile Spasms in a Contemporary US Cohort. Neurology 2021; 97:e1217-e1228. [PMID: 34266919 PMCID: PMC8480478 DOI: 10.1212/wnl.0000000000012511] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 06/24/2021] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To compare the effectiveness of initial treatment for infantile spasms. METHODS The National Infantile Spasms Consortium prospectively followed up children with new-onset infantile spasms that began at age 2 to 24 months at 23 US centers (2012-2018). Freedom from treatment failure at 60 days required no second treatment for infantile spasms and no clinical spasms after 30 days of treatment initiation. We managed treatment selection bias with propensity score weighting and within-center correlation with generalized estimating equations. RESULTS Freedom from treatment failure rates were as follows: adrenocorticotropic hormone (ACTH) 88 of 190 (46%), oral steroids 42 of 95 (44%), vigabatrin 32 of 87 (37%), and nonstandard therapy 4 of 51 (8%). Changing from oral steroids to ACTH was not estimated to affect response (observed 44% estimated to change to 44% [95% confidence interval 34%-54%]). Changing from nonstandard therapy to ACTH would improve response from 8% to 39% (17%-67%), and changing to oral steroids would improve response from 8% to 38% (15%-68%). There were large but not statistically significant estimated effects of changing from vigabatrin to ACTH (29% to 42% [15%-75%]), from vigabatrin to oral steroids (29% to 42% [28%-57%]), and from nonstandard therapy to vigabatrin (8% to 20% [6%-50%]). Among children treated with vigabatrin, those with tuberous sclerosis complex (TSC) responded more often than others (62% vs 29%; p < 0.05). DISCUSSION Compared to nonstandard therapy, ACTH and oral steroids are superior for initial treatment of infantile spasms. The estimated effectiveness of vigabatrin is between that of ACTH/oral steroids and nonstandard therapy, although the sample was underpowered for statistical confidence. When used, vigabatrin worked best for TSC. CLASSIFICATION OF EVIDENCE This study provides Class III evidence that for children with new-onset infantile spasms, ACTH or oral steroids were superior to nonstandard therapies.
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Affiliation(s)
- Zachary M Grinspan
- From Weill Cornell Medicine (Z.M.G.), New York, NY; University of Colorado Anschutz Medical Campus (K.G.K.), Aurora; Nationwide Children's Hospital (A.D.P., J.R.M.), Ohio State University, Columbus; Montefiore Medicine (E.G.Y.), Bronx, NY; Stanford University (C.J.W.), Palo Alto, CA; Mayo Clinic (E.W.), Rochester, MN; Drexel University College of Medicine (I.V.), Philadelphia, PA; University of California San Francisco (N.S.S.); University of Chicago Medicine (D.R.N.), IL; Children's Hospital of Los Angeles (W.M.), CA; Cook Children's Hospital (C.G.K.), Fort Worth, TX; Boston Children's Hospital (T.L., C.H., I.S.F.), MA; University of California Los Angeles (S.A.H.); Children's National Hospital (W.D.G.), Washington, DC; Oregon Health Services University (J.C.), Portland; Massachusetts General Hospital (C.J.C.), Boston; Lurie Children's Hospital (A.T.B.), Chicago, IL; and University of Michigan (R.A.S.), Ann Arbor.
| | - Kelly G Knupp
- From Weill Cornell Medicine (Z.M.G.), New York, NY; University of Colorado Anschutz Medical Campus (K.G.K.), Aurora; Nationwide Children's Hospital (A.D.P., J.R.M.), Ohio State University, Columbus; Montefiore Medicine (E.G.Y.), Bronx, NY; Stanford University (C.J.W.), Palo Alto, CA; Mayo Clinic (E.W.), Rochester, MN; Drexel University College of Medicine (I.V.), Philadelphia, PA; University of California San Francisco (N.S.S.); University of Chicago Medicine (D.R.N.), IL; Children's Hospital of Los Angeles (W.M.), CA; Cook Children's Hospital (C.G.K.), Fort Worth, TX; Boston Children's Hospital (T.L., C.H., I.S.F.), MA; University of California Los Angeles (S.A.H.); Children's National Hospital (W.D.G.), Washington, DC; Oregon Health Services University (J.C.), Portland; Massachusetts General Hospital (C.J.C.), Boston; Lurie Children's Hospital (A.T.B.), Chicago, IL; and University of Michigan (R.A.S.), Ann Arbor
| | - Anup D Patel
- From Weill Cornell Medicine (Z.M.G.), New York, NY; University of Colorado Anschutz Medical Campus (K.G.K.), Aurora; Nationwide Children's Hospital (A.D.P., J.R.M.), Ohio State University, Columbus; Montefiore Medicine (E.G.Y.), Bronx, NY; Stanford University (C.J.W.), Palo Alto, CA; Mayo Clinic (E.W.), Rochester, MN; Drexel University College of Medicine (I.V.), Philadelphia, PA; University of California San Francisco (N.S.S.); University of Chicago Medicine (D.R.N.), IL; Children's Hospital of Los Angeles (W.M.), CA; Cook Children's Hospital (C.G.K.), Fort Worth, TX; Boston Children's Hospital (T.L., C.H., I.S.F.), MA; University of California Los Angeles (S.A.H.); Children's National Hospital (W.D.G.), Washington, DC; Oregon Health Services University (J.C.), Portland; Massachusetts General Hospital (C.J.C.), Boston; Lurie Children's Hospital (A.T.B.), Chicago, IL; and University of Michigan (R.A.S.), Ann Arbor
| | - Elissa G Yozawitz
- From Weill Cornell Medicine (Z.M.G.), New York, NY; University of Colorado Anschutz Medical Campus (K.G.K.), Aurora; Nationwide Children's Hospital (A.D.P., J.R.M.), Ohio State University, Columbus; Montefiore Medicine (E.G.Y.), Bronx, NY; Stanford University (C.J.W.), Palo Alto, CA; Mayo Clinic (E.W.), Rochester, MN; Drexel University College of Medicine (I.V.), Philadelphia, PA; University of California San Francisco (N.S.S.); University of Chicago Medicine (D.R.N.), IL; Children's Hospital of Los Angeles (W.M.), CA; Cook Children's Hospital (C.G.K.), Fort Worth, TX; Boston Children's Hospital (T.L., C.H., I.S.F.), MA; University of California Los Angeles (S.A.H.); Children's National Hospital (W.D.G.), Washington, DC; Oregon Health Services University (J.C.), Portland; Massachusetts General Hospital (C.J.C.), Boston; Lurie Children's Hospital (A.T.B.), Chicago, IL; and University of Michigan (R.A.S.), Ann Arbor
| | - Courtney J Wusthoff
- From Weill Cornell Medicine (Z.M.G.), New York, NY; University of Colorado Anschutz Medical Campus (K.G.K.), Aurora; Nationwide Children's Hospital (A.D.P., J.R.M.), Ohio State University, Columbus; Montefiore Medicine (E.G.Y.), Bronx, NY; Stanford University (C.J.W.), Palo Alto, CA; Mayo Clinic (E.W.), Rochester, MN; Drexel University College of Medicine (I.V.), Philadelphia, PA; University of California San Francisco (N.S.S.); University of Chicago Medicine (D.R.N.), IL; Children's Hospital of Los Angeles (W.M.), CA; Cook Children's Hospital (C.G.K.), Fort Worth, TX; Boston Children's Hospital (T.L., C.H., I.S.F.), MA; University of California Los Angeles (S.A.H.); Children's National Hospital (W.D.G.), Washington, DC; Oregon Health Services University (J.C.), Portland; Massachusetts General Hospital (C.J.C.), Boston; Lurie Children's Hospital (A.T.B.), Chicago, IL; and University of Michigan (R.A.S.), Ann Arbor
| | - Elaine C Wirrell
- From Weill Cornell Medicine (Z.M.G.), New York, NY; University of Colorado Anschutz Medical Campus (K.G.K.), Aurora; Nationwide Children's Hospital (A.D.P., J.R.M.), Ohio State University, Columbus; Montefiore Medicine (E.G.Y.), Bronx, NY; Stanford University (C.J.W.), Palo Alto, CA; Mayo Clinic (E.W.), Rochester, MN; Drexel University College of Medicine (I.V.), Philadelphia, PA; University of California San Francisco (N.S.S.); University of Chicago Medicine (D.R.N.), IL; Children's Hospital of Los Angeles (W.M.), CA; Cook Children's Hospital (C.G.K.), Fort Worth, TX; Boston Children's Hospital (T.L., C.H., I.S.F.), MA; University of California Los Angeles (S.A.H.); Children's National Hospital (W.D.G.), Washington, DC; Oregon Health Services University (J.C.), Portland; Massachusetts General Hospital (C.J.C.), Boston; Lurie Children's Hospital (A.T.B.), Chicago, IL; and University of Michigan (R.A.S.), Ann Arbor
| | - Ignacio Valencia
- From Weill Cornell Medicine (Z.M.G.), New York, NY; University of Colorado Anschutz Medical Campus (K.G.K.), Aurora; Nationwide Children's Hospital (A.D.P., J.R.M.), Ohio State University, Columbus; Montefiore Medicine (E.G.Y.), Bronx, NY; Stanford University (C.J.W.), Palo Alto, CA; Mayo Clinic (E.W.), Rochester, MN; Drexel University College of Medicine (I.V.), Philadelphia, PA; University of California San Francisco (N.S.S.); University of Chicago Medicine (D.R.N.), IL; Children's Hospital of Los Angeles (W.M.), CA; Cook Children's Hospital (C.G.K.), Fort Worth, TX; Boston Children's Hospital (T.L., C.H., I.S.F.), MA; University of California Los Angeles (S.A.H.); Children's National Hospital (W.D.G.), Washington, DC; Oregon Health Services University (J.C.), Portland; Massachusetts General Hospital (C.J.C.), Boston; Lurie Children's Hospital (A.T.B.), Chicago, IL; and University of Michigan (R.A.S.), Ann Arbor
| | - Nilika S Singhal
- From Weill Cornell Medicine (Z.M.G.), New York, NY; University of Colorado Anschutz Medical Campus (K.G.K.), Aurora; Nationwide Children's Hospital (A.D.P., J.R.M.), Ohio State University, Columbus; Montefiore Medicine (E.G.Y.), Bronx, NY; Stanford University (C.J.W.), Palo Alto, CA; Mayo Clinic (E.W.), Rochester, MN; Drexel University College of Medicine (I.V.), Philadelphia, PA; University of California San Francisco (N.S.S.); University of Chicago Medicine (D.R.N.), IL; Children's Hospital of Los Angeles (W.M.), CA; Cook Children's Hospital (C.G.K.), Fort Worth, TX; Boston Children's Hospital (T.L., C.H., I.S.F.), MA; University of California Los Angeles (S.A.H.); Children's National Hospital (W.D.G.), Washington, DC; Oregon Health Services University (J.C.), Portland; Massachusetts General Hospital (C.J.C.), Boston; Lurie Children's Hospital (A.T.B.), Chicago, IL; and University of Michigan (R.A.S.), Ann Arbor
| | - Douglas R Nordli
- From Weill Cornell Medicine (Z.M.G.), New York, NY; University of Colorado Anschutz Medical Campus (K.G.K.), Aurora; Nationwide Children's Hospital (A.D.P., J.R.M.), Ohio State University, Columbus; Montefiore Medicine (E.G.Y.), Bronx, NY; Stanford University (C.J.W.), Palo Alto, CA; Mayo Clinic (E.W.), Rochester, MN; Drexel University College of Medicine (I.V.), Philadelphia, PA; University of California San Francisco (N.S.S.); University of Chicago Medicine (D.R.N.), IL; Children's Hospital of Los Angeles (W.M.), CA; Cook Children's Hospital (C.G.K.), Fort Worth, TX; Boston Children's Hospital (T.L., C.H., I.S.F.), MA; University of California Los Angeles (S.A.H.); Children's National Hospital (W.D.G.), Washington, DC; Oregon Health Services University (J.C.), Portland; Massachusetts General Hospital (C.J.C.), Boston; Lurie Children's Hospital (A.T.B.), Chicago, IL; and University of Michigan (R.A.S.), Ann Arbor
| | - John R Mytinger
- From Weill Cornell Medicine (Z.M.G.), New York, NY; University of Colorado Anschutz Medical Campus (K.G.K.), Aurora; Nationwide Children's Hospital (A.D.P., J.R.M.), Ohio State University, Columbus; Montefiore Medicine (E.G.Y.), Bronx, NY; Stanford University (C.J.W.), Palo Alto, CA; Mayo Clinic (E.W.), Rochester, MN; Drexel University College of Medicine (I.V.), Philadelphia, PA; University of California San Francisco (N.S.S.); University of Chicago Medicine (D.R.N.), IL; Children's Hospital of Los Angeles (W.M.), CA; Cook Children's Hospital (C.G.K.), Fort Worth, TX; Boston Children's Hospital (T.L., C.H., I.S.F.), MA; University of California Los Angeles (S.A.H.); Children's National Hospital (W.D.G.), Washington, DC; Oregon Health Services University (J.C.), Portland; Massachusetts General Hospital (C.J.C.), Boston; Lurie Children's Hospital (A.T.B.), Chicago, IL; and University of Michigan (R.A.S.), Ann Arbor
| | - Wendy G Mitchell
- From Weill Cornell Medicine (Z.M.G.), New York, NY; University of Colorado Anschutz Medical Campus (K.G.K.), Aurora; Nationwide Children's Hospital (A.D.P., J.R.M.), Ohio State University, Columbus; Montefiore Medicine (E.G.Y.), Bronx, NY; Stanford University (C.J.W.), Palo Alto, CA; Mayo Clinic (E.W.), Rochester, MN; Drexel University College of Medicine (I.V.), Philadelphia, PA; University of California San Francisco (N.S.S.); University of Chicago Medicine (D.R.N.), IL; Children's Hospital of Los Angeles (W.M.), CA; Cook Children's Hospital (C.G.K.), Fort Worth, TX; Boston Children's Hospital (T.L., C.H., I.S.F.), MA; University of California Los Angeles (S.A.H.); Children's National Hospital (W.D.G.), Washington, DC; Oregon Health Services University (J.C.), Portland; Massachusetts General Hospital (C.J.C.), Boston; Lurie Children's Hospital (A.T.B.), Chicago, IL; and University of Michigan (R.A.S.), Ann Arbor
| | - Cynthia G Keator
- From Weill Cornell Medicine (Z.M.G.), New York, NY; University of Colorado Anschutz Medical Campus (K.G.K.), Aurora; Nationwide Children's Hospital (A.D.P., J.R.M.), Ohio State University, Columbus; Montefiore Medicine (E.G.Y.), Bronx, NY; Stanford University (C.J.W.), Palo Alto, CA; Mayo Clinic (E.W.), Rochester, MN; Drexel University College of Medicine (I.V.), Philadelphia, PA; University of California San Francisco (N.S.S.); University of Chicago Medicine (D.R.N.), IL; Children's Hospital of Los Angeles (W.M.), CA; Cook Children's Hospital (C.G.K.), Fort Worth, TX; Boston Children's Hospital (T.L., C.H., I.S.F.), MA; University of California Los Angeles (S.A.H.); Children's National Hospital (W.D.G.), Washington, DC; Oregon Health Services University (J.C.), Portland; Massachusetts General Hospital (C.J.C.), Boston; Lurie Children's Hospital (A.T.B.), Chicago, IL; and University of Michigan (R.A.S.), Ann Arbor
| | - Tobias Loddenkemper
- From Weill Cornell Medicine (Z.M.G.), New York, NY; University of Colorado Anschutz Medical Campus (K.G.K.), Aurora; Nationwide Children's Hospital (A.D.P., J.R.M.), Ohio State University, Columbus; Montefiore Medicine (E.G.Y.), Bronx, NY; Stanford University (C.J.W.), Palo Alto, CA; Mayo Clinic (E.W.), Rochester, MN; Drexel University College of Medicine (I.V.), Philadelphia, PA; University of California San Francisco (N.S.S.); University of Chicago Medicine (D.R.N.), IL; Children's Hospital of Los Angeles (W.M.), CA; Cook Children's Hospital (C.G.K.), Fort Worth, TX; Boston Children's Hospital (T.L., C.H., I.S.F.), MA; University of California Los Angeles (S.A.H.); Children's National Hospital (W.D.G.), Washington, DC; Oregon Health Services University (J.C.), Portland; Massachusetts General Hospital (C.J.C.), Boston; Lurie Children's Hospital (A.T.B.), Chicago, IL; and University of Michigan (R.A.S.), Ann Arbor
| | - Shaun A Hussain
- From Weill Cornell Medicine (Z.M.G.), New York, NY; University of Colorado Anschutz Medical Campus (K.G.K.), Aurora; Nationwide Children's Hospital (A.D.P., J.R.M.), Ohio State University, Columbus; Montefiore Medicine (E.G.Y.), Bronx, NY; Stanford University (C.J.W.), Palo Alto, CA; Mayo Clinic (E.W.), Rochester, MN; Drexel University College of Medicine (I.V.), Philadelphia, PA; University of California San Francisco (N.S.S.); University of Chicago Medicine (D.R.N.), IL; Children's Hospital of Los Angeles (W.M.), CA; Cook Children's Hospital (C.G.K.), Fort Worth, TX; Boston Children's Hospital (T.L., C.H., I.S.F.), MA; University of California Los Angeles (S.A.H.); Children's National Hospital (W.D.G.), Washington, DC; Oregon Health Services University (J.C.), Portland; Massachusetts General Hospital (C.J.C.), Boston; Lurie Children's Hospital (A.T.B.), Chicago, IL; and University of Michigan (R.A.S.), Ann Arbor
| | - Chellamani Harini
- From Weill Cornell Medicine (Z.M.G.), New York, NY; University of Colorado Anschutz Medical Campus (K.G.K.), Aurora; Nationwide Children's Hospital (A.D.P., J.R.M.), Ohio State University, Columbus; Montefiore Medicine (E.G.Y.), Bronx, NY; Stanford University (C.J.W.), Palo Alto, CA; Mayo Clinic (E.W.), Rochester, MN; Drexel University College of Medicine (I.V.), Philadelphia, PA; University of California San Francisco (N.S.S.); University of Chicago Medicine (D.R.N.), IL; Children's Hospital of Los Angeles (W.M.), CA; Cook Children's Hospital (C.G.K.), Fort Worth, TX; Boston Children's Hospital (T.L., C.H., I.S.F.), MA; University of California Los Angeles (S.A.H.); Children's National Hospital (W.D.G.), Washington, DC; Oregon Health Services University (J.C.), Portland; Massachusetts General Hospital (C.J.C.), Boston; Lurie Children's Hospital (A.T.B.), Chicago, IL; and University of Michigan (R.A.S.), Ann Arbor
| | - William D Gaillard
- From Weill Cornell Medicine (Z.M.G.), New York, NY; University of Colorado Anschutz Medical Campus (K.G.K.), Aurora; Nationwide Children's Hospital (A.D.P., J.R.M.), Ohio State University, Columbus; Montefiore Medicine (E.G.Y.), Bronx, NY; Stanford University (C.J.W.), Palo Alto, CA; Mayo Clinic (E.W.), Rochester, MN; Drexel University College of Medicine (I.V.), Philadelphia, PA; University of California San Francisco (N.S.S.); University of Chicago Medicine (D.R.N.), IL; Children's Hospital of Los Angeles (W.M.), CA; Cook Children's Hospital (C.G.K.), Fort Worth, TX; Boston Children's Hospital (T.L., C.H., I.S.F.), MA; University of California Los Angeles (S.A.H.); Children's National Hospital (W.D.G.), Washington, DC; Oregon Health Services University (J.C.), Portland; Massachusetts General Hospital (C.J.C.), Boston; Lurie Children's Hospital (A.T.B.), Chicago, IL; and University of Michigan (R.A.S.), Ann Arbor
| | - Ivan S Fernandez
- From Weill Cornell Medicine (Z.M.G.), New York, NY; University of Colorado Anschutz Medical Campus (K.G.K.), Aurora; Nationwide Children's Hospital (A.D.P., J.R.M.), Ohio State University, Columbus; Montefiore Medicine (E.G.Y.), Bronx, NY; Stanford University (C.J.W.), Palo Alto, CA; Mayo Clinic (E.W.), Rochester, MN; Drexel University College of Medicine (I.V.), Philadelphia, PA; University of California San Francisco (N.S.S.); University of Chicago Medicine (D.R.N.), IL; Children's Hospital of Los Angeles (W.M.), CA; Cook Children's Hospital (C.G.K.), Fort Worth, TX; Boston Children's Hospital (T.L., C.H., I.S.F.), MA; University of California Los Angeles (S.A.H.); Children's National Hospital (W.D.G.), Washington, DC; Oregon Health Services University (J.C.), Portland; Massachusetts General Hospital (C.J.C.), Boston; Lurie Children's Hospital (A.T.B.), Chicago, IL; and University of Michigan (R.A.S.), Ann Arbor
| | - Jason Coryell
- From Weill Cornell Medicine (Z.M.G.), New York, NY; University of Colorado Anschutz Medical Campus (K.G.K.), Aurora; Nationwide Children's Hospital (A.D.P., J.R.M.), Ohio State University, Columbus; Montefiore Medicine (E.G.Y.), Bronx, NY; Stanford University (C.J.W.), Palo Alto, CA; Mayo Clinic (E.W.), Rochester, MN; Drexel University College of Medicine (I.V.), Philadelphia, PA; University of California San Francisco (N.S.S.); University of Chicago Medicine (D.R.N.), IL; Children's Hospital of Los Angeles (W.M.), CA; Cook Children's Hospital (C.G.K.), Fort Worth, TX; Boston Children's Hospital (T.L., C.H., I.S.F.), MA; University of California Los Angeles (S.A.H.); Children's National Hospital (W.D.G.), Washington, DC; Oregon Health Services University (J.C.), Portland; Massachusetts General Hospital (C.J.C.), Boston; Lurie Children's Hospital (A.T.B.), Chicago, IL; and University of Michigan (R.A.S.), Ann Arbor
| | - Catherine J Chu
- From Weill Cornell Medicine (Z.M.G.), New York, NY; University of Colorado Anschutz Medical Campus (K.G.K.), Aurora; Nationwide Children's Hospital (A.D.P., J.R.M.), Ohio State University, Columbus; Montefiore Medicine (E.G.Y.), Bronx, NY; Stanford University (C.J.W.), Palo Alto, CA; Mayo Clinic (E.W.), Rochester, MN; Drexel University College of Medicine (I.V.), Philadelphia, PA; University of California San Francisco (N.S.S.); University of Chicago Medicine (D.R.N.), IL; Children's Hospital of Los Angeles (W.M.), CA; Cook Children's Hospital (C.G.K.), Fort Worth, TX; Boston Children's Hospital (T.L., C.H., I.S.F.), MA; University of California Los Angeles (S.A.H.); Children's National Hospital (W.D.G.), Washington, DC; Oregon Health Services University (J.C.), Portland; Massachusetts General Hospital (C.J.C.), Boston; Lurie Children's Hospital (A.T.B.), Chicago, IL; and University of Michigan (R.A.S.), Ann Arbor
| | - Anne T Berg
- From Weill Cornell Medicine (Z.M.G.), New York, NY; University of Colorado Anschutz Medical Campus (K.G.K.), Aurora; Nationwide Children's Hospital (A.D.P., J.R.M.), Ohio State University, Columbus; Montefiore Medicine (E.G.Y.), Bronx, NY; Stanford University (C.J.W.), Palo Alto, CA; Mayo Clinic (E.W.), Rochester, MN; Drexel University College of Medicine (I.V.), Philadelphia, PA; University of California San Francisco (N.S.S.); University of Chicago Medicine (D.R.N.), IL; Children's Hospital of Los Angeles (W.M.), CA; Cook Children's Hospital (C.G.K.), Fort Worth, TX; Boston Children's Hospital (T.L., C.H., I.S.F.), MA; University of California Los Angeles (S.A.H.); Children's National Hospital (W.D.G.), Washington, DC; Oregon Health Services University (J.C.), Portland; Massachusetts General Hospital (C.J.C.), Boston; Lurie Children's Hospital (A.T.B.), Chicago, IL; and University of Michigan (R.A.S.), Ann Arbor
| | - Renee A Shellhaas
- From Weill Cornell Medicine (Z.M.G.), New York, NY; University of Colorado Anschutz Medical Campus (K.G.K.), Aurora; Nationwide Children's Hospital (A.D.P., J.R.M.), Ohio State University, Columbus; Montefiore Medicine (E.G.Y.), Bronx, NY; Stanford University (C.J.W.), Palo Alto, CA; Mayo Clinic (E.W.), Rochester, MN; Drexel University College of Medicine (I.V.), Philadelphia, PA; University of California San Francisco (N.S.S.); University of Chicago Medicine (D.R.N.), IL; Children's Hospital of Los Angeles (W.M.), CA; Cook Children's Hospital (C.G.K.), Fort Worth, TX; Boston Children's Hospital (T.L., C.H., I.S.F.), MA; University of California Los Angeles (S.A.H.); Children's National Hospital (W.D.G.), Washington, DC; Oregon Health Services University (J.C.), Portland; Massachusetts General Hospital (C.J.C.), Boston; Lurie Children's Hospital (A.T.B.), Chicago, IL; and University of Michigan (R.A.S.), Ann Arbor
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Kapoor D, Sharma S, Garg D, Samaddar S, Panda I, Patra B, Mukherjee SB, Pemde HK. Intravenous Methylprednisolone Versus Oral Prednisolone for West Syndrome: A Randomized Open-Label Trial. Indian J Pediatr 2021; 88:778-784. [PMID: 33575989 PMCID: PMC7877308 DOI: 10.1007/s12098-020-03630-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Accepted: 12/16/2020] [Indexed: 12/22/2022]
Abstract
OBJECTIVE To compare intravenous methylprednisolone (IVMP) with oral prednisolone (OP) for the treatment of West syndrome. METHODS In this randomized, open-label trial, children aged 2 to 30 mo presenting with epileptic spasms with hypsarrhythmia or its variants on EEG were randomized to receive either IVMP (30 mg/kg/d for 3 d followed by oral prednisolone taper) or OP (4 mg/kg/d for two weeks followed by taper). The primary outcome measure was spasms cessation on day 14. Secondary outcomes included time to response, electroclinical remission at 2 and 6 wk, and frequency of adverse effects. ( ClinicalTrials.gov Identifier: NCT03876444). RESULTS Sixty children were enrolled; 31 in the IVMP and 29 in the OP arm. Proportion of children achieving spasms cessation at day 14 was similar in both groups (54.8% versus 68.9%, p = 0.26). Time to achieve remission was lower in the IVMP group (mean 5.4 ± 0.9 versus 9.5 ± 2.6 d, p < 0.0001). Electroclinical remission at 2 wk was similar in both groups (51.6% versus 44.8%, p = 0.59) but lower at 6 wk in the IVMP group (45.2% versus 75.9%, p < 0.015). Adverse effects like sleep disturbance, irritability and hypertension were more common in IVMP group whereas weight gain was more common in the OP group. CONCLUSIONS There was no significant difference in spasms cessation between the groups on day 14 although remission was higher at 6 wk in OP group. Our study suggests that OP was better than IVMP in efficacy and sustained remission with fewer adverse effects.
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Affiliation(s)
- Dipti Kapoor
- Division of Neurology, Department of Pediatrics, Kalawati Saran Children's Hospital and Lady Hardinge Medical College, New Delhi, 110001, India
| | - Suvasini Sharma
- Division of Neurology, Department of Pediatrics, Kalawati Saran Children's Hospital and Lady Hardinge Medical College, New Delhi, 110001, India.
| | - Divyani Garg
- Department of Neurology, Smt. Sucheta Kriplani Hospital and Lady Hardinge Medical College, New Delhi, India
| | - Sukla Samaddar
- Division of Neurology, Department of Pediatrics, Kalawati Saran Children's Hospital and Lady Hardinge Medical College, New Delhi, 110001, India
| | - Isha Panda
- Division of Neurology, Department of Pediatrics, Kalawati Saran Children's Hospital and Lady Hardinge Medical College, New Delhi, 110001, India
| | - Bijoy Patra
- Division of Neurology, Department of Pediatrics, Kalawati Saran Children's Hospital and Lady Hardinge Medical College, New Delhi, 110001, India
| | - Sharmila B Mukherjee
- Division of Neurology, Department of Pediatrics, Kalawati Saran Children's Hospital and Lady Hardinge Medical College, New Delhi, 110001, India
| | - Harish K Pemde
- Division of Neurology, Department of Pediatrics, Kalawati Saran Children's Hospital and Lady Hardinge Medical College, New Delhi, 110001, India
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Abstract
Epilepsy can now be diagnosed even in the presence of one unprovoked seizure or if the diagnosis of an epilepsy syndrome can be made. Epilepsy syndromes represent a specific set of seizure types and electroencephalographic and imaging features that tend to have age-dependent features, triggers, and prognosis. Epilepsy syndromes are the third and final level of epilepsy diagnosis, after classification of seizure and epilepsy types. Some epilepsy syndromes are self-limiting and pharmacoresponsive and others are pharmacoresistant and associated with poor developmental outcomes (epileptic and developmental encephalopathy). Features and management of 7 common age-dependent pediatric epilepsy syndromes are described.
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Affiliation(s)
- Akshat Katyayan
- Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, 6701, Fannin Street, Suite 1250, Houston, TX 77030, USA; Department of Neurology, Baylor College of Medicine, Texas Children's Hospital, 6701, Fannin Street, Suite 1250, Houston, TX 77030, USA.
| | - Gloria Diaz-Medina
- Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, 6701, Fannin Street, Suite 1250, Houston, TX 77030, USA; Department of Neurology, Baylor College of Medicine, Texas Children's Hospital, 6701, Fannin Street, Suite 1250, Houston, TX 77030, USA
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Nelson JA, Demarest S, Thomas J, Juarez-Colunga E, Knupp KG. Evolution of Infantile Spasms to Lennox-Gastaut Syndrome: What Is There to Know? J Child Neurol 2021; 36:752-759. [PMID: 33764203 DOI: 10.1177/08830738211000514] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Children with infantile spasms may develop Lennox-Gastaut syndrome. The diagnostic criteria for Lennox-Gastaut syndrome are vague, and many experts use varying combinations of the following criteria for diagnosis: paroxysmal fast activity on electroencephalography (EEG), slow spike and wave on EEG, developmental delay, multiple seizure types, and nocturnal tonic seizures. Our objective was to determine the prevalence of Lennox-Gastaut syndrome in a high-risk cohort of children with a history of infantile spasms and the characteristics of infantile spasms that were associated with the diagnosis of Lennox-Gastaut syndrome. METHODS Children with infantile spasms who were diagnosed and treated at Children's Hospital Colorado between 2012 and 2018 were included. Lennox-Gastaut syndrome was defined as having 3 of 5 of the following characteristics: paroxysmal fast activity, slow spike and wave, current developmental delay, multiple seizure types, or tonic seizures. Descriptive statistics were performed using median and interquartile range. Univariable analysis was performed with Pearson chi-square, Fisher exact, or the Kruskal-Wallis test. RESULTS Ninety-seven children met inclusion criteria, and 36% (35/97) met criteria for Lennox-Gastaut syndrome. Developmental delay and history of seizures prior to the onset of infantile spasms were identified as risk factors for the development of Lennox-Gastaut syndrome (P = .003) as was poor response to first treatment for spasms (P = .004). Children with an unknown etiology of infantile spasms were less likely to develop Lennox-Gastaut syndrome (P = .019). Eighty percent (28/35) of the children who met Lennox-Gastaut syndrome criteria lacked a documented diagnosis. CONCLUSIONS Thirty-six percent of children with infantile spasms met criteria for Lennox-Gastaut syndrome. Risk factors for development of Lennox-Gastaut syndrome were developmental delay and seizures prior to the onset of infantile spasms and poor response to first treatment for infantile spasms. Children with an unknown etiology of infantile spasms were less likely to develop Lennox-Gastaut syndrome. Eighty percent of the children who met our criteria were not given a documented diagnosis of Lennox-Gastaut syndrome, which highlights the fact that many children may not be receiving a diagnosis of Lennox-Gastaut syndrome. We recommend establishing clear guidelines for the diagnosis of Lennox-Gastaut syndrome to ensure that the diagnosis is being made accurately.
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Affiliation(s)
- Julie A Nelson
- Department of Pediatrics and Neurology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Scott Demarest
- Department of Pediatrics and Neurology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Jake Thomas
- Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Elizabeth Juarez-Colunga
- Department of Biostatistics and Informatics, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Kelly G Knupp
- Department of Pediatrics and Neurology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
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Abstract
OBJECTIVES This research aimed to study the short-term seizure outcomes following treatment with 8 mg/kg/day prednisolone in children with infantile spasms (IS) refractory to vigabatrin. We hypothesized that high-dose prednisolone may result in similar rates of electroclinical remission when compared to published ACTH rates. METHODS All consecutive children with hypsarrhythmia or hypsarrhythmia variant on EEG with/without IS, who had been treated with vigabatrin as first-line anti-seizure medication (ASM) followed by high-dose oral prednisolone (8 mg/kg/day; maximum 60 mg/day) in cases who did not respond to vigabatrin, were included. Clinical and electroclinical response (ECR) at 2 weeks following initiation of treatment and adverse effects were assessed. RESULTS Sixty-five children were included. A genetic etiology was seen in 38.5% cases. Complete ECR was seen in 30.8% (20/65) of the patients 2 weeks after vigabatrin. Complete ECR was noted in 77.8% (35/45) of the patients, 2 weeks after prednisolone initiation in children who failed vigabatrin, and this was sustained at 6 weeks in 66.7% (30/45) patients. Prednisolone was generally well tolerated. CONCLUSIONS High-dose (8 mg/kg/day) oral prednisolone resulted in sustained complete ECR (at 6 weeks) in two-thirds of the children with hypsarrhythmia or hypsarrhythmia variant on EEG with/without parentally reported IS. It was generally well tolerated and found to be safe.
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Schönberger J, Eckenweiler M, Klotz KA, Sag Y, Shah M, Fuchs H, Kirschner J, Jacobs J. Facilitation of drug-resistant epilepsy and catastrophic status epilepticus in children with combined pituitary hormone deficiency. Eur J Paediatr Neurol 2021; 33:99-105. [PMID: 34126363 DOI: 10.1016/j.ejpn.2021.05.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 05/18/2021] [Accepted: 05/30/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE Clinicians and researchers often focus on the primary cause of seizures and epilepsy, but outcomes in individual patients also depend on multiple other variables, which might be easy to adjust. Previous studies suggest mutual interactions between endocrine disorders and epilepsy. We therefore hypothesized that combined pituitary hormone deficiency (CPHD) facilitates seizures and epilepsy. METHODS This is a retrospective study from a pediatric center. We determined the proportion of CPHD patients with epilepsy and examined basic clinical features in this group. Patients with super-refractory status epilepticus (SRSE) were reviewed to identify subjects with co-morbid CPHD. Those cases were analyzed in detail. RESULTS 12 of 73 CPHD patients (16%) also had epilepsy. Various etiologies of CPHD were represented, though five subjects had a cranial tumor or cortical malformation. Epilepsy was drug resistant in all but one patient. Among 12 identified patients with SRSE, 4 were unexpected new-onset cases. Three of these subjects also had CPHD with ACTH deficiency and a febrile infection prior to SRSE. Another common feature was the devastating clinical course: In all three patients, initial MRI already suggested severe neuronal damage, SRSE persisted for at least one week with ongoing need for anesthetic coma, and outcome was poor (two patients survived with major sequelae, one child deceased during the episode). CONCLUSION Our findings indicate that CPHD may predispose for drug-resistant epilepsy and refractory seizures with catastrophic outcome. We suggest that in children with new-onset SRSE, screening for CPHD should be considered.
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Affiliation(s)
- Jan Schönberger
- Department of Neuropediatrics and Muscle Disorders, Medical Center - University of Freiburg, Germany; Epilepsy Center, Medical Center - University of Freiburg, Germany; Faculty of Medicine, University of Freiburg, Germany; Berta-Ottenstein-Programme, Faculty of Medicine, University of Freiburg, Germany.
| | - Matthias Eckenweiler
- Department of Neuropediatrics and Muscle Disorders, Medical Center - University of Freiburg, Germany; Faculty of Medicine, University of Freiburg, Germany
| | - Kerstin Alexandra Klotz
- Department of Neuropediatrics and Muscle Disorders, Medical Center - University of Freiburg, Germany; Epilepsy Center, Medical Center - University of Freiburg, Germany; Faculty of Medicine, University of Freiburg, Germany; Berta-Ottenstein-Programme, Faculty of Medicine, University of Freiburg, Germany
| | - Yusuf Sag
- Department of Neuropediatrics and Muscle Disorders, Medical Center - University of Freiburg, Germany; Faculty of Medicine, University of Freiburg, Germany
| | - Mukesch Shah
- Faculty of Medicine, University of Freiburg, Germany; Department of Neurosurgery, Medical Center - University of Freiburg, Germany
| | - Hans Fuchs
- Faculty of Medicine, University of Freiburg, Germany; Department of General Pediatrics, Adolescent Medicine and Neonatology, Medical Center - University of Freiburg, Germany
| | - Janbernd Kirschner
- Department of Neuropediatrics and Muscle Disorders, Medical Center - University of Freiburg, Germany; Faculty of Medicine, University of Freiburg, Germany; Department of Neuropediatrics, University Hospital Bonn, Germany
| | - Julia Jacobs
- Department of Neuropediatrics and Muscle Disorders, Medical Center - University of Freiburg, Germany; Faculty of Medicine, University of Freiburg, Germany; Department of Paediatrics and Department of Neuroscience, Cumming School of Medicine, University of Calgary, Canada; Hotchkiss Brain Institute and Alberta Children's Hospital Research Institute, University of Calgary, Canada
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Banerjee A, Sahu JK, Sankhyan N, Pattanaik S, Suthar R, Saini AG, Saini L, Negi S, Malhi P, Singhi P. Randomized trial of high-dose pyridoxine in combination with standard hormonal therapy in West syndrome. Seizure 2021; 91:75-80. [PMID: 34118609 DOI: 10.1016/j.seizure.2021.05.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 05/07/2021] [Accepted: 05/14/2021] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To determine whether high-dose, oral pyridoxine in combination with standard adrenocorticotropic hormone (ACTH) therapy has superior effectiveness than ACTH therapy alone in increasing cessation of epileptic spasms for children with West syndrome. METHODS This study was an open-label, randomized controlled trial with masked endpoint assessments. Eligible children with West syndrome, age ranged 3-18 months, were randomized into the intervention (n = 43) and the standard arm (n = 37) of therapy. The intervention group received oral pyridoxine at 100-300 mg/kg/day in addition to standard therapy of intramuscular ACTH at 150 IU/m2/day. Primary effectiveness outcome was a complete cessation of spasms at two weeks and sustained till six weeks. RESULTS Comparison of effectiveness measures between intervention and standard groups were : complete cessation of epileptic spasms (48.8% vs 58.3%; group difference -9.6%; 95% confidence interval [CI] -30% to 12.3%; p = 0.4), median EEG scores (Q1-Q3) by Jeavons Score at six weeks [3 (1-5) vs 3 (1-5); p = 0.6], median motor scores (Q1-Q3) by DASII (Development Assessment Scales for Indian Infants) at 12 weeks [35 (29-49) vs 42 (34.3-63.8), p = 0.04], and median mental scores (Q1-Q3) by DASII at 12 weeks [35 (29.5-46) vs 41.5 (31.3-60), p = 0.02]. Adverse events were comparable in both arms. CONCLUSIONS There was no evidence to suggest the superiority of high-dose pyridoxine in combination with ACTH versus ACTH alone for the treatment of West syndrome, considering the limitations of the study design.
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Affiliation(s)
- Arundhati Banerjee
- Pediatric Neurology Unit, Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Jitendra Kumar Sahu
- Pediatric Neurology Unit, Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, India.
| | - Naveen Sankhyan
- Pediatric Neurology Unit, Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Smita Pattanaik
- Department of Pharmacology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Renu Suthar
- Pediatric Neurology Unit, Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Arushi Gahlot Saini
- Pediatric Neurology Unit, Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Lokesh Saini
- Pediatric Neurology Unit, Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Sandeep Negi
- Pediatric Neurology Unit, Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Prahbhjot Malhi
- Child Psychology Unit, Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Pratibha Singhi
- Pediatric Neurology Unit, Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Wanigasinghe J, Arambepola C, Ranganathan SS, Jayasundara K, Weerasinghe A, Wickramarachchi P. Epilepsy Outcome at Four Years in a Randomized Clinical Trial Comparing Oral Prednisolone and Intramuscular ACTH in West Syndrome. Pediatr Neurol 2021; 119:22-26. [PMID: 33836476 DOI: 10.1016/j.pediatrneurol.2021.01.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 01/01/2021] [Accepted: 01/24/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND This article explores the role of initial treatment on control of spasms and other epilepsies at four years in children previously treated for West syndrome. METHODS The Sri Lanka Infantile Spasm Study is a prospective clinical trial evaluating response to intra-muscular adrenocorticotropic hormone (ACTH) versus oral prednisolone. A previous report documented response through age 12 months. This article provides four-year follow-up data. RESULTS At age four years, 65 of the original 97 were available for follow-up; another 13 had died, and 19 moved and could not be contacted. Of the 65 children, 37 (57%) continued to have seizures and 28 were seizure free. In the 37 children with ongoing epilepsy, 32.4% continued to have spasms, either alone or in combination with other seizure types. The epilepsy types seen in these children were focal epilepsy (59.4%), mixed focal and generalized epilepsy (24%), generalized epilepsy only (10.8%), and uncertain (5%). The majority of those still having epilepsy (66.7%) were controlled on medication. There was no significant difference in the rate of epilepsy or spasms or their control by medication between those treated with ACTH or oral prednisolone. Spasm control at day 14 did not influence the four-year spasm or epilepsy outcome. CONCLUSIONS A majority of children diagnosed with West syndrome continued to have seizures at age four years, although most were controlled on antiseizure medication. The long-term risk of developing epilepsy or its control was the same, regardless of whether ACTH or prednisolone was initially used as treatment.
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Affiliation(s)
- Jithangi Wanigasinghe
- Faculty of Medicine, Department of Paediatrics, University of Colombo, Colombo, Sri Lanka.
| | - Carukshi Arambepola
- Faculty of Medicine, Department of Community Medicine, University of Colombo, Colombo, Sri Lanka
| | | | - Kasun Jayasundara
- University Paediatric Unit, Lady Ridgeway Hospital, Colombo, Sri Lanka
| | - Ashangi Weerasinghe
- Faculty of Medicine, Department of Paediatrics, University of Colombo, Colombo, Sri Lanka
| | - Piyumi Wickramarachchi
- Faculty of Medicine, Department of Paediatrics, University of Colombo, Colombo, Sri Lanka
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Wan L, Yang G, Sun Y, Li Z, Zhang S, Shi X, Wang J. Combined melatonin and adrenocorticotropic hormone treatment attenuates N-methyl-d-aspartate-induced infantile spasms in a rat model by regulating activation of the HPA axis. Neurosci Lett 2021; 748:135713. [PMID: 33571576 DOI: 10.1016/j.neulet.2021.135713] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Revised: 01/21/2021] [Accepted: 02/01/2021] [Indexed: 10/22/2022]
Abstract
Infantile spasms (IS) is a serious epileptic syndrome that frequently occurs in infancy. Adrenocorticotropic hormone (ACTH) is generally the first-line treatment for IS; however, side effects limit its application. Melatonin (MT) has been used in clinical treatment for sleep disorders with only minor side effects. Further, MT was shown to be a powerful anticonvulsant in an animal model of epilepsy. In this research, we aimed to compare the anticonvulsant efficacy of ACTH and/or MT for treatment of IS and explore the mechanisms underlying the anticonvulsant activity of MT, using an N-methyl-d-aspartate (NMDA)-induced IS model in neonatal rats following exposure to prenatal stress. Latency to the onset of spasms and the total number of spasms were recorded to assess spasm severity. Treatment with ACTH and/or MT significantly reduced the number of spasms and prolonged the latency period. Additionally, expression of GR-α, HDAC2, BNDF, TrkB, and C-Cbl were significantly increased by induction with NMDA, and this effect was reversed by ACTH and/or MT treatment. Hence, our data suggest that combined ACTH and MT treatment is effective for reducing the number of spasms and increasing the latency period in NMDA rats, by restoring dysregulation of the HPA axis. These findings have the potential to provide a new strategy for the treatment of IS.
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Affiliation(s)
- Lin Wan
- Department of Pediatrics, The First Medical Center of Chinese PLA General Hospital, No. 28 Fuxing Road, Haidian District, Beijing, 100853, China
| | - Guang Yang
- Department of Pediatrics, The First Medical Center of Chinese PLA General Hospital, No. 28 Fuxing Road, Haidian District, Beijing, 100853, China.
| | - Yulin Sun
- Department of Pediatrics, The First Medical Center of Chinese PLA General Hospital, No. 28 Fuxing Road, Haidian District, Beijing, 100853, China
| | - Zhichao Li
- Department of Pediatrics, The First Medical Center of Chinese PLA General Hospital, No. 28 Fuxing Road, Haidian District, Beijing, 100853, China
| | - Shan Zhang
- Department of Pediatrics, The First Medical Center of Chinese PLA General Hospital, No. 28 Fuxing Road, Haidian District, Beijing, 100853, China
| | - Xiuyu Shi
- Department of Pediatrics, The First Medical Center of Chinese PLA General Hospital, No. 28 Fuxing Road, Haidian District, Beijing, 100853, China
| | - Jing Wang
- Department of Pediatrics, The First Medical Center of Chinese PLA General Hospital, No. 28 Fuxing Road, Haidian District, Beijing, 100853, China
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Le JT, Frost JD, Swann JW. Acthar® Gel (repository corticotropin injection) dose-response relationships in an animal model of epileptic spasms. Epilepsy Behav 2021; 116:107786. [PMID: 33548914 PMCID: PMC7940582 DOI: 10.1016/j.yebeh.2021.107786] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Revised: 12/30/2020] [Accepted: 01/01/2021] [Indexed: 11/27/2022]
Abstract
Studies were undertaken to evaluate the effectiveness of Acthar® Gel (repository corticotropin injection [RCI]) in the tetrodotoxin (TTX) model of early-life-induced epileptic spasms. Repository corticotropin injection (RCI) is widely used in the United States to treat infantile spasms. A major component of RCI is N25 deamidated ACTH. Additionally, we hoped to provide some insight into the possible role circulating corticosteroids play in spasm cessation by comparing the RCI dose-response relationships for spasm suppression to RCI-induced corticosterone release from the adrenal gland. Spasms were induced by chronic TTX infusion into the neocortex beginning on postnatal day 11. Repository corticotropin injection (RCI) dosages were between 8 and 32 IU/kg/day. Drug titration protocols were used, and comparisons were made to injections of a vehicle gel. Video/EEG recordings (24/7) monitored the drug's effects continuously for up to 2 months. Tetrodotoxin (TTX)-infused control rats were monitored for the same period of time. In separate experiments, the same dosages of RCI were given to rats and 1 h later plasma was collected and assayed for corticosterone. A parallel study compared the effects of 1-day and 10-day RCI treatments on circulating corticosterone. Results showed that RCI was ineffective at dosages of 8, 12, and 16 IU/kg/day but eliminated spasms in 66% of animals treated with 24 or 32 IU/kg/day. Treating animals with 32 IU/kg/day alone produced the same degree of spasms suppression as observed during the titration protocols. In rats that had hypsarrhythmia-like activity, RCI eliminated this abnormal interictal EEG pattern in all rats that became seizure-free. In terms of plasma corticosterone, 1- and 10-day treatments with RCI produced similar increases in this hormone and the levels increased linearly with increasing dosages of RCI. This stood in sharp contrast to the sigmoid-like dose-response curve for decreases in spasm counts. Our results further validate the TTX model as relevant for the study of infantile spasms. The model should be useful for investigating how RCI acts to eliminate seizures and hypsarrhythmia. Dose-response results suggest that either very high concentrations of circulating corticosteroids are required to abolish spasms or RCI acts through a different mechanism.
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Affiliation(s)
- John T. Le
- The Cain Foundation Laboratories, The Jan and Dan Duncan Neurological Research Institute, Texas Children’s Hospital, Houston TX 77030,Department of Pediatrics, Baylor College of Medicine, Houston, TX 77030
| | - James D. Frost
- Department of Neurology, Baylor College of Medicine, Houston, TX 77030
| | - John W. Swann
- The Cain Foundation Laboratories, The Jan and Dan Duncan Neurological Research Institute, Texas Children’s Hospital, Houston TX 77030,Department of Pediatrics, Baylor College of Medicine, Houston, TX 77030,Department of Neuroscience, Baylor College of Medicine, Houston, TX 77030
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Karakas C, Wilfong AA, Riviello JJ, Curry DJ, Ali I. Epileptic Spasms in a Large Hypothalamic Hamartoma Cohort. J Child Neurol 2021; 36:304-309. [PMID: 33170063 DOI: 10.1177/0883073820968652] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Hypothalamic hamartoma is rarely associated with epileptic spasms. We describe epileptic spasms in a large cohort of hypothalamic hamartoma patients. METHODS We performed a retrospective chart review between March 2011 and March 2020 to identify patients with hypothalamic hamartoma and epilepsy. RESULTS We identified 114 patients with hypothalamic hamartoma and epilepsy, only 3 male patients (2.6%) also had epileptic spasms. The epileptic spasms developed between 6 and 18 months of age. Epileptic spasms resolved with oral prednisolone in 1 and with vigabatrin in the second patient. The third patient continued epileptic spasms despite multiple antiepileptic drugs and partial resection of hypothalamic hamartoma. All 3 patients underwent laser-ablation of hypothalamic hamartoma at the age of 14, 29, and 63 months. The seizure burden decreased by 100%, 84%, and 93% at follow-up (3-47 months). CONCLUSIONS Epileptic spasms are rare in hypothalamic hamartoma patients and early laser-ablation could potentially treat epileptic spasms and all other seizure types associated with hypothalamic hamartoma.
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Affiliation(s)
- Cemal Karakas
- Department of Pediatrics, Section of Pediatric Neurology and Developmental Neuroscience, 12298Baylor College of Medicine, Houston, TX, USA.,Department of Neurology and Neurophysiology, 12298Baylor College of Medicine, Houston, TX, USA
| | - Angus A Wilfong
- Division of Pediatric Neurology, Phoenix Children's Hospital, Barrow Neurological Institute, Phoenix, AZ, USA
| | - James J Riviello
- Department of Pediatrics, Section of Pediatric Neurology and Developmental Neuroscience, 12298Baylor College of Medicine, Houston, TX, USA.,Department of Neurology and Neurophysiology, 12298Baylor College of Medicine, Houston, TX, USA
| | - Daniel J Curry
- Section of Pediatric Neurosurgery, Texas Children's Hospital, Houston, TX, USA
| | - Irfan Ali
- Department of Pediatrics, Section of Pediatric Neurology and Developmental Neuroscience, 12298Baylor College of Medicine, Houston, TX, USA.,Department of Neurology and Neurophysiology, 12298Baylor College of Medicine, Houston, TX, USA
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TÜRAY S, HANCI F, DİLEK M, KABAKUŞ N. The prognostic Evaluation of West Syndrome Patients: A Retrospective Observational Study. KONURALP TIP DERGISI 2021. [DOI: 10.18521/ktd.751363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Sharma S, Kaushik JS, Srivastava K, Goswami JN, Sahu JK, Vinayan KP, Mittal R. Association of Child Neurology (AOCN) — Indian Epilepsy Society (IES) Consensus Guidelines for the Diagnosis and Management of West Syndrome. Indian Pediatr 2021. [DOI: 10.1007/s13312-021-2097-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Duchowny MS, Chopra I, Niewoehner J, Wan GJ, Devine B. A Systematic Literature Review and Indirect Treatment Comparison of Efficacy of Repository Corticotropin Injection versus Synthetic Adrenocorticotropic Hormone for Infantile Spasms. JOURNAL OF HEALTH ECONOMICS AND OUTCOMES RESEARCH 2021; 8:1-9. [PMID: 33521161 PMCID: PMC7839629 DOI: 10.36469/jheor.2021.18727] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 01/04/2021] [Indexed: 05/07/2023]
Abstract
Background: Infantile spasms is a rare disease characterized by distinct seizures and hypsarrhythmia. Adrenocorticotropic hormone (ACTH) is available as a natural product (repository corticotropin injection, [RCI]; Acthar® Gel) and as synthetic analogs. RCI is a naturally-sourced complex mixture of purified ACTH analogs and other pituitary peptides approved by the United States Food and Drug Administration as a monotherapy for the treatment of infantile spasms. RCI is commonly used in the United States. Outside the United States, synthetic analogs of ACTH-synthetic ACTH1-24 (tetracosactide) and synthetic ACTH1-39 (corticotropin carboxymethyl-cellulose [CCMC])-are used. The efficacy of RCI may differ from that of synthetic ACTH treatments based on the structure of peptide; however, no head-to-head clinical trials have compared the efficacy of RCI and synthetic ACTH treatments. Objective: A systematic review and indirect treatment comparison of clinical trials was conducted to assess the comparative efficacy of RCI and synthetic ACTH treatments in infantile spasms. Methods: A search was conducted in MEDLINE, EMBASE, and Cochrane databases through September 30, 2020. Relevant clinical trials on RCI or synthetic ACTH therapy and reporting either cessation of spasms or resolution of hypsarrhythmia, separately or as a combined outcome were included. A Bayesian indirect treatment comparison using a fixed-effects model was used for comparative efficacy. Results: Of 473 citations screened, 21 studies were reviewed qualitatively. In the indirect treatment comparison of six eligible clinical trial studies, the odds of achieving efficacy outcomes were five to eight times greater with RCI than with tetracosactide and 14 to 16 times greater than CCMC. This translated to a risk reduction of 10% to 14% and 40% to 50% with RCI versus tetracosactide and CCMC, respectively. For every two to five patients treated, RCI improved efficacy outcomes in one additional patient compared to synthetic ACTH (adjusted number needed-to-treat). Conclusions: Based on the available limited evidence, results suggest RCI may be more efficacious for infantile spasms than synthetic ACTH treatments. Our findings provide a blueprint to inform the design of future prospective studies for the treatment of infantile spasms.
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Affiliation(s)
| | - Ishveen Chopra
- Manticore Consultancy, Bethesda, Maryland, United States
| | - John Niewoehner
- Mallinckrodt Pharmaceuticals, Bedminster, New Jersey, United States
| | - George J Wan
- Mallinckrodt Pharmaceuticals, Bedminster, New Jersey, United States
| | - Beth Devine
- University of Washington, Seattle, Washington, United States
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Depressive effectiveness of vigabatrin (γ-vinyl-GABA), an antiepileptic drug, in intermediate-conductance calcium-activated potassium channels in human glioma cells. BMC Pharmacol Toxicol 2021; 22:6. [PMID: 33441172 PMCID: PMC7807716 DOI: 10.1186/s40360-021-00472-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 01/04/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Vigabatrin (VGB) is an approved non-traditional antiepileptic drug that has been revealed to have potential for treating brain tumors; however, its effect on ionic channels in glioma cells remains largely unclear. METHODS With the aid of patch-clamp technology, we investigated the effects of VGB on various ionic currents in the glioblastoma multiforme cell line 13-06-MG. RESULTS In cell-attached configuration, VGB concentration-dependently reduced the activity of intermediate-conductance Ca2+-activated K+ (IKCa) channels, while DCEBIO (5,6-dichloro-1-ethyl-1,3-dihydro-2H-benzimidazol-2-one) counteracted the VGB-induced inhibition of IKCa channels. However, the activity of neither large-conductance Ca2+-activated (BKCa) nor inwardly rectifying K+ (KIR) channels were affected by the presence of VGB in human 13-06-MG cells. However, in the continued presence of VGB, the addition of GAL-021 or BaCl2 effectively suppressed BKCa and KIR channels. CONCLUSIONS The inhibitory effect of VGB on IKCa channels demonstrated in the current study could be an important underlying mechanism of VGB-induced antineoplastic (e.g., anti-glioma) actions.
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Sánchez Fernández I, Amengual-Gual M, Gaínza-Lein M, Barcia Aguilar C, Bergin AM, Yuskaitis CJ, Harini C. Cost-effectiveness of adrenocorticotropic hormone versus oral steroids for infantile spasms. Epilepsia 2021; 62:347-357. [PMID: 33417252 DOI: 10.1111/epi.16799] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Revised: 11/24/2020] [Accepted: 12/03/2020] [Indexed: 01/19/2023]
Abstract
OBJECTIVE To compare the effectiveness and cost-effectiveness of adrenocorticotropic hormone (ACTH) and oral steroids as first-line treatment for infantile spasm resolution, we performed a systematic review, meta-analysis, and cost-effectiveness study. METHODS A decision analysis model was populated with effectiveness data from a systematic review and meta-analysis of existing literature and cost data from publicly available prices. Effectiveness was defined as the probability of clinical spasm resolution 14 days after treatment initiation. RESULTS We included 21 studies with a total of 968 patients. The effectiveness of ACTH was not statistically significantly different from that of oral steroids (.70, 95% confidence interval [CI] = .60-.79 vs. .63, 95% CI = .56-.70; p = .28). Considering only the three available randomized trials with a total of 185 patients, the odds ratio of spasm resolution at 14 days with ACTH compared to high-dose prednisolone (4-8 mg/kg/day) was .92 (95% CI = .34-2.52, p = .87). Adjusting for potential publication bias, estimates became even more favorable to high-dose prednisolone. Using US prices, the more cost-effective treatment was high-dose prednisolone, with an incremental cost-effectiveness ratio (ICER) of $333 per case of spasms resolved, followed by ACTH, with an ICER of $1 432 200 per case of spasms resolved. These results were robust to multiple sensitivity analyses and different assumptions. Prednisolone at 4-8 mg/kg/day was more cost-effective than ACTH under a wide range of assumptions. SIGNIFICANCE For infantile spasm resolution 2 weeks after treatment initiation, current evidence does not support the preeminence of ACTH in terms of effectiveness and, especially, cost-effectiveness.
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Affiliation(s)
- Iván Sánchez Fernández
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA.,Department of Child Neurology, Sant Joan de Déu 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, Massachusetts, USA.,Pediatric Neurology Unit, Department of Pediatrics, Son Espases University Hospital, University of the Balearic Islands, Palma, Spain
| | - Marina Gaínza-Lein
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA.,Institute of Pediatrics, Faculty of Medicine, Austral University of Chile, Valdivia, Chile.,Child Neuropsychiatry Service, San Borja Arriarán Clinical Hospital, University of Chile, Santiago, Chile
| | - Cristina Barcia Aguilar
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA.,Department of Child Neurology, La Paz University Hospital, Autonomous University of Madrid, Madrid, Spain
| | - Ann Marie Bergin
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Christopher J Yuskaitis
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Chellamani Harini
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Fortini S, Valenzuela GR, Fasulo L, Caraballo R. West syndrome: A study of 26 patients receiving short-term therapy. Epilepsy Behav 2021; 114:107235. [PMID: 32694038 DOI: 10.1016/j.yebeh.2020.107235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Revised: 04/12/2020] [Accepted: 06/05/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVE We describe the electroclinical characteristics of a series of 26 patients with idiopathic West syndrome (WS), who had an excellent response to treatment with vigabatrin (VGB) and corticosteroids alone or in combination. METHODS Evaluating the records of 178 patients with WS studied at Garrahan Hospital, Niño Jesús Hospital, and Clínica San Lucas between January 2005 and June 2017, we selected 26 patients that met the inclusion criteria of idiopathic WS. The inclusion criteria for idiopathic WS were (1) no personal history of disease, (2) normal neurological examination and neurodevelopment, (3) symmetric spasms in clusters not preceded by any other type of seizure, (d) symmetric hypsarrhythmia, (e) normal electroencephalogram (EEG) background, e.g., normal sleep EEG pattern, (f) normal magnetic resonance imaging (MRI) recording, (g) normal neurometabolic and genetic studies, and (h) at least 2 years of follow-up. RESULTS Fifteen boys and 11 girls met the inclusion criteria of idiopathic WS. The current age of the children ranges between 2 years 10 months and 12 years 10 months. Age at first epileptic spasms (ES) ranged from 4 to 11 months, with a mean age of 7 and a median of 7.5 months, respectively; ES were in clusters, bilateral and symmetrical in all cases. Spasms were flexor in nine (34.7%), mixed flexor-extensor in 15 (57.7%), and extensor in three (7.6%). In all patients the EEG showed typical pattern of hypsarrhythmia. CONCLUSION These patients with idiopathic WS who have an excellent response to initial treatment should be treated for a short period of time with adrenocorticotropic hormone (ACTH) and VGB alone or in combination.
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Affiliation(s)
- Sebastián Fortini
- Department of Neurology, Hospital de Pediatría Niño Jesús, Tucumán, Argentina
| | | | - Lorena Fasulo
- Department of Neurology, Clínica San Lucas, Neuquén, Argentina
| | - Roberto Caraballo
- Department of Neurology, Hospital de Pediatría "Prof. Dr. Juan P Garrahan", Buenos Aires, Argentina.
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Daida A, Hamano SI, Hayashi K, Nonoyama H, Ikemoto S, Hirata Y, Matsuura R, Koichihara R, Yamanaka G, Kikuchi K. Comparison of adrenocorticotropic hormone efficacy between aetiologies of infantile spasms. Seizure 2020; 85:6-11. [PMID: 33360040 DOI: 10.1016/j.seizure.2020.12.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 12/13/2020] [Accepted: 12/15/2020] [Indexed: 11/27/2022] Open
Abstract
PURPOSE We aimed to study the efficacy of adrenocorticotropic hormone (ACTH) treatment on infantile spasms with different aetiologies. In particular, we were interested in patients with structural-acquired aetiology. METHODS Patients with infantile spasms, who were treated with ACTH, were divided into three groups based on the aetiologies: unknown aetiology with normal development (unknown-normal), structural-acquired, and combined-congenital aetiologies that included genetic, metabolic, structural-congenital, or unknown aetiology with developmental delay. RESULTS Of the 107 patients included (58 males, 49 females), 25 patients had unknown-normal aetiology [median age at onset 5 months, standard deviation (SD) 3.12, range 2-16 months]; 20 patients had structural-acquired aetiology (median age at onset 6.5 months, SD 3.85 months, range 4-17 months); and 62 patients had combined-congenital aetiologies (median age at onset 5 months, SD 2.73 months, range 2-16 months). The efficacy of ACTH was 64.0 %, 65 %, and 30.6 % in the unknown-normal aetiology, structural-acquired aetiology, and combined-congenital aetiologies, respectively (p < 0.01). Multivariate analysis showed a statistically significant higher efficacy in the unknown-normal aetiology [Odds ratio (OR) 4.63, 95 % confidence interval (CI) 1.60-13.30] and structural-acquired aetiology (OR 3.41, 95 % CI 1.01-11.50) compared to that in the combined-congenital aetiologies. CONCLUSION Infantile spasms with structural-acquired aetiology had greater response to ACTH treatment than those with combined-congenital aetiologies. The efficacy of standard therapy of infantile spasms should be considered based on aetiology.
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Affiliation(s)
- Atsuro Daida
- Division of Neurology, Saitama Children's Medical Center, 1-2 Shintoshin, Chuo-ku, Saitama-city, Saitama, Japan; Department of Pediatrics and Adolescent Medicine, Tokyo Medical University, 6-7-1, Nishi-shinjuku, Shinjuku-ku, Tokyo, Japan.
| | - Shin-Ichiro Hamano
- Division of Neurology, Saitama Children's Medical Center, 1-2 Shintoshin, Chuo-ku, Saitama-city, Saitama, Japan
| | - Kuniyoshi Hayashi
- Graduate School of Public Health, St. Luke's International University, 3-6-2 Tsukiji Chuo-ku, Tokyo, Japan
| | - Hazuki Nonoyama
- Division of Neurology, Saitama Children's Medical Center, 1-2 Shintoshin, Chuo-ku, Saitama-city, Saitama, Japan
| | - Satoru Ikemoto
- Division of Neurology, Saitama Children's Medical Center, 1-2 Shintoshin, Chuo-ku, Saitama-city, Saitama, Japan
| | - Yuko Hirata
- Division of Neurology, Saitama Children's Medical Center, 1-2 Shintoshin, Chuo-ku, Saitama-city, Saitama, Japan
| | - Ryuki Matsuura
- Division of Neurology, Saitama Children's Medical Center, 1-2 Shintoshin, Chuo-ku, Saitama-city, Saitama, Japan
| | - Reiko Koichihara
- Division of Neurology, Saitama Children's Medical Center, 1-2 Shintoshin, Chuo-ku, Saitama-city, Saitama, Japan
| | - Gaku Yamanaka
- Department of Pediatrics and Adolescent Medicine, Tokyo Medical University, 6-7-1, Nishi-shinjuku, Shinjuku-ku, Tokyo, Japan
| | - Kenjiro Kikuchi
- Division of Neurology, Saitama Children's Medical Center, 1-2 Shintoshin, Chuo-ku, Saitama-city, Saitama, Japan
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Abstract
Over the last several decades, significant progress has been made in the discovery of appropriate therapy in the management of infantile spasms (IS). Based on several well-controlled studies, the American Academy of Neurology and the Child Neurology Society have published the current best practice parameters for the treatment of IS. However, dissemination and implementation of evidence-based guidelines remain a significant challenge. Though the number of well-performed controlled trials and systematic reviews is increasing exponentially, the proportion of valuable new information subsequently embedding into the routine clinical care is significantly lower. Planned and systematic implementation of evidence-based interventions in a given health care structure may outstrip the benefits of discovering a new insight, procedure, or drug in another controlled setting. Implementation problems can be broad-ranging to hinder effective, efficient, safe, timely, and patient-centered care without significant variation. The first part of this review article provides a detailed summary of some crucial comparative treatment studies of IS available in the literature. In the second part, practical challenges to mitigate the gap between knowledge and practice to improve outcomes in the management of IS has been explored, and a consolidated framework approach for systematic implementation research methodology has been discussed to implement evidence-based guidelines for the management of IS. Although large multicenter controlled studies will help gather quality evidence in the treatment of IS, a more comprehensive range of scientific methodologies, including qualitative research and mixed research methodologies, will hold the more considerable promise for implementing evidence-based practices in the health care system.
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Affiliation(s)
- Debopam Samanta
- Child Neurology Section, Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, Arkansas, United States
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Wirrell EC, Grinspan ZM, Knupp KG, Jiang Y, Hammeed B, Mytinger JR, Patel AD, Nabbout R, Specchio N, Cross JH, Shellhaas RA. Care Delivery for Children With Epilepsy During the COVID-19 Pandemic: An International Survey of Clinicians. J Child Neurol 2020; 35:924-933. [PMID: 32666891 PMCID: PMC7364331 DOI: 10.1177/0883073820940189] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To evaluate the effect of the COVID-19 pandemic on global access to care and practice patterns for children with epilepsy. METHODS We conducted a cross-sectional, online survey of pediatric neurologists across the world affiliated with the International Child Neurology Association, the Chinese Child Neurology Society, the Child Neurology Society, and the Pediatric Epilepsy Research Consortium. Results were analyzed in relation to regional burden of COVID-19 disease. RESULTS From April 10 to 24, 2020, a sample of 212 respondents from 49 countries indicated that the COVID-19 pandemic has dramatically changed many aspects of pediatric epilepsy care, with 91.5% reporting changes to outpatient care, 90.6% with reduced access to electroencephalography (EEG), 37.4% with altered management of infantile spasms, 92.3% with restrictions in ketogenic diet initiation, 93.4% with closed or severely limited epilepsy monitoring units, and 91.3% with canceled or limited epilepsy surgery. Telehealth use had increased, with 24.7% seeing patients exclusively via telehealth. Changes in practice were related both to COVID-19 burden and location. CONCLUSIONS In response to COVID-19, pediatric epilepsy programs have implemented crisis standards of care that include increased telemedicine, decreased EEG use, changes in treatments of infantile spasms, and cessation of epilepsy surgery. The long-term impact of these abrupt changes merit careful study.
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Affiliation(s)
- Elaine C. Wirrell
- Divisions of Child and Adolescent Neurology and Epilepsy, Department
of Neurology, Mayo Clinic, Rochester, MN, USA,These are co-first authors of this article
| | - Zachary M. Grinspan
- Departments of Population Sciences and Pediatrics, Weill Cornell
Medicine, New York, NY, USA,These are co-first authors of this article
| | - Kelly G. Knupp
- Department of Pediatrics and Neurology, University of Colorado
Anschutz Medical Campus, Aurora, CO, USA
| | - Yuwu Jiang
- Department of Pediatrics, Peking University First
Hospital, Beijing, China
| | - Biju Hammeed
- Paediatric Neurosciences, Great Ormond Street Children’s Hospital, London, United Kingdom
| | - John R. Mytinger
- Department of Pediatrics, Division of Pediatric Neurology,
Nationwide Children’s Hospital, The Ohio State University, Columbus, OH, USA
| | - Anup D. Patel
- Department of Pediatrics, Division of Pediatric Neurology,
Nationwide Children’s Hospital, The Ohio State University, Columbus, OH, USA
| | - Rima Nabbout
- Centre de Reference Epilepsies Rares, Department of Pediatric
Neurology, Necker Enfants Malades Hospital, Imagine Institute, Paris Descartes University, Paris,
France
| | - Nicola Specchio
- Rare and Complex Epilepsy Unit, Department of Neuroscience, Bambino
Gesu’ Children’s Hospital, IRCCS, Rome, Italy and Member of European Reference
Network EpiCARE
| | - J. Helen Cross
- Developmental Neurosciences, UCL NIHR BRC Great Ormond Street
Institute of Child Health, London, WC1 N 1EH, & and Member of European Reference
Network EpiCARE
| | - Renée A. Shellhaas
- Department of Pediatrics (Pediatric Neurology), Michigan Medicine,
University of Michigan, Ann Arbor, MI, USA,Renée A. Shellhaas, MD, MS, CS Mott
Children’s Hospital, Room 12-733, 1540 E. Hospital Dr, Ann Arbor, MI 48109, USA.
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Infantile spasms: Etiology, lead time and treatment response in a resource limited setting. Epilepsy Behav Rep 2020; 14:100397. [PMID: 33196034 PMCID: PMC7656466 DOI: 10.1016/j.ebr.2020.100397] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Revised: 09/24/2020] [Accepted: 10/03/2020] [Indexed: 01/03/2023] Open
Abstract
Neonatal hypoglycemic brain injury was the commonest cause of Infantile Spasms (IS). Comprehensive genetic evaluation was performed in presumed genetic IS patients. Molecular diagnosis was achieved in 44% of presumed genetic patients. Longer lead time to treatment was significantly associated with resistant spasms.
This study explores the etiology and lead time to treatment for infantile spasm (IS) patients and their effect on treatment responsiveness, in a limited resource setting. Patients with IS onset age ≤12 months’, seen over 3 years were recruited retrospectively. Clinical information, neuroimaging and genetic results retrieved. Patients categorized into three primary etiological groups: Structural (including Structural Genetic), Genetic, and Unknown. The effect of etiology and lead time from IS onset to initiating appropriate treatment on spasm resolution, evaluated. Total 113 patients were eligible. Mean IS onset age was 6.86(±4.25) months (M: F 3.3:1). Patients were grouped into: Structural 85, Genetic 11 and Unknown 17. Etiology was ascertained in 94/113 (83.1%) with neonatal hypoglycemic brain injury (NHBI) being the most common (40/113, 36%). A genetic etiology identified in 17 (including 6 Structural Genetic, of which five had Tuberous Sclerosis). Structural group was less likely to be treatment resistant (p = 0.013, OR 0.30 [0.12–0.76]). Median treatment lead time – 60 days. Longer lead time to treatment was significantly associated with resistant spasms (χ2 for trend = 10.0, p = 0.0015). NHBI was the commonest underlying cause of IS. There was significant time lag to initiating appropriate treatment, affecting treatment responsiveness.
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Riikonen R, Lähdetie J, Kokki H. ACTH Treatment of Infantile Spasms: Low-Moderate- Versus High-Dose, Natural Versus Synthetic ACTH-A Retrospective Cohort Study. Pediatr Neurol 2020; 111:46-50. [PMID: 32951660 DOI: 10.1016/j.pediatrneurol.2020.06.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Revised: 06/06/2020] [Accepted: 06/10/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND High dosages of natural adrenocorticotropic hormone are used in many centers in the United States for the treatment of infantile spasms. However, lower dosages of synthetic adrenocorticotropic hormone (tetracosactide) might be equally efficient as high dosages. We analyzed the treatment options for infantile spasms, especially regarding the adrenocorticotropic hormone dosage and the formulation (natural versus synthetic) and evaluated which options were more effective in a retrospective cohort from 1960 to 1976. METHODS We compared the short-term response rates of patients treated with high dosages of natural adrenocorticotropic hormone (120 IU/day) (N = 31) (Group1) with those of patients treated with low-moderate dosages of natural adrenocorticotropic hormone (40 IU/day) (N = 52) (Group2). We also compared the short-term response rates of patients treated with natural adrenocorticotropic hormone (N = 83) with those of patients treated with synthetic adrenocorticotropic hormone, (N = 23) (Group3). The responses were evaluated clinically and by electroencephalography at two to three weeks after the onset of therapy. RESULTS A response was seen in 24 of 31 children treated with high dosages and in 43 of 52 children treated with low-moderate dosages of natural adrenocorticotropic hormone (P = 0.56). All children with an unknown etiology responded to both high and low-moderate dosages of natural adrenocorticotropic hormone. The proportion of children with a good early response to synthetic adrenocorticotropic hormone (16 of 23) did not differ from the proportion of children with a good early response treated with natural adrenocorticotropic hormone (67 of 83) (P = 0.25). CONCLUSIONS High dosages of adrenocorticotropic hormone are not more effective than low-moderate dosages in the short term for treating infantile spasms. Synthetic adrenocorticotropic hormone is equally effective as natural adrenocorticotropic hormone.
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Affiliation(s)
- Raili Riikonen
- Professor in Child Neurology, Children's Hospital, University of Eastern Finland and Kuopio University Hospital, Kuopio, Finland.
| | - Jaana Lähdetie
- Child Neurologist, University of Turku, University Hospital of Turku, Turku, Finland
| | - Hannu Kokki
- Associated Professor in Anesthesiology and Intensive Care Medicine, School of Medicine, University of Eastern, Kuopio, Finland
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