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Berg AT, Coryell J, Saneto RP, Grinspan ZM, Alexander JJ, Kekis M, Sullivan JE, Wirrell EC, Shellhaas RA, Mytinger JR, Gaillard WD, Kossoff EH, Valencia I, Knupp KG, Wusthoff C, Keator C, Dobyns WB, Ryan N, Loddenkemper T, Chu CJ, Novotny EJ, Koh S. Early-Life Epilepsies and the Emerging Role of Genetic Testing. JAMA Pediatr 2017; 171:863-871. [PMID: 28759667 PMCID: PMC5710404 DOI: 10.1001/jamapediatrics.2017.1743] [Citation(s) in RCA: 101] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
IMPORTANCE Early-life epilepsies are often a consequence of numerous neurodevelopmental disorders, most of which are proving to have genetic origins. The role of genetic testing in the initial evaluation of these epilepsies is not established. OBJECTIVE To provide a contemporary account of the patterns of use and diagnostic yield of genetic testing for early-life epilepsies. DESIGN, SETTING, AND PARTICIPANTS In this prospective cohort, children with newly diagnosed epilepsy with an onset at less than 3 years of age were recruited from March 1, 2012, to April 30, 2015, from 17 US pediatric hospitals and followed up for 1 year. Of 795 families approached, 775 agreed to participate. Clinical diagnosis of the etiology of epilepsy were characterized based on information available before genetic testing was performed. Added contributions of cytogenetic and gene sequencing investigations were determined. EXPOSURES Genetic diagnostic testing. MAIN OUTCOMES AND MEASURES Laboratory-confirmed pathogenic variant. RESULTS Of the 775 patients in the study (367 girls and 408 boys; median age of onset, 7.5 months [interquartile range, 4.2-16.5 months]), 95 (12.3%) had acquired brain injuries. Of the remaining 680 patients, 327 (48.1%) underwent various forms of genetic testing, which identified pathogenic variants in 132 of 327 children (40.4%; 95% CI, 37%-44%): 26 of 59 (44.1%) with karyotyping, 32 of 188 (17.0%) with microarrays, 31 of 114 (27.2%) with epilepsy panels, 11 of 33 (33.3%) with whole exomes, 4 of 20 (20.0%) with mitochondrial panels, and 28 of 94 (29.8%) with other tests. Forty-four variants were identified before initial epilepsy presentation. Apart from dysmorphic syndromes, pathogenic yields were highest for children with tuberous sclerosis complex (9 of 11 [81.8%]), metabolic diseases (11 of 14 [78.6%]), and brain malformations (20 of 61 [32.8%]). A total of 180 of 446 children (40.4%), whose etiology would have remained unknown without genetic testing, underwent some testing. Pathogenic variants were identified in 48 of 180 children (26.7%; 95% CI, 18%-34%). Diagnostic yields were greater than 15% regardless of delay, spasms, and young age. Yields were greater for epilepsy panels (28 of 96 [29.2%]; P < .001) and whole exomes (5 of 18 [27.8%]; P = .02) than for chromosomal microarray (8 of 101 [7.9%]). CONCLUSIONS AND RELEVANCE Genetic investigations, particularly broad sequencing methods, have high diagnostic yields in newly diagnosed early-life epilepsies regardless of key clinical features. Thorough genetic investigation emphasizing sequencing tests should be incorporated into the initial evaluation of newly presenting early-life epilepsies and not just reserved for those with severe presentations and poor outcomes.
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Affiliation(s)
- Anne T. Berg
- Epilepsy Center, Ann and Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois,Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Jason Coryell
- Department of Pediatrics, Oregon Health & Science University, Portland,Department of Neurology, Oregon Health & Science University, Portland
| | - Russell P. Saneto
- Division of Pediatric Neurology, Seattle Children’s Hospital, Seattle, Washington,Department of Neurology, University of Washington, Seattle
| | - Zachary M. Grinspan
- Department of Pediatrics, Weill Cornell Medicine, New York, New York,Department of Pediatrics, New York Presbyterian Hospital, New York, New York,Health Information Technology Evaluation Collaborative, New York, New York
| | | | - Mariana Kekis
- Department of Human Genetics, Emory University, Atlanta, Georgia
| | | | | | | | - John R. Mytinger
- Department of Pediatrics, The Ohio State University, Columbus,Department of Neurology, Nationwide Children’s Hospital, Columbus, Ohio
| | - William D. Gaillard
- Department of Neurology, Children’s National Health System, George Washington University School of Medicine, Washington, DC
| | - Eric H. Kossoff
- Department of Neurology, Johns Hopkins Hospital, Baltimore, Maryland,Department of Pediatrics, Johns Hopkins Hospital, Baltimore, Maryland
| | - Ignacio Valencia
- Section of Neurology, St. Christopher’s Hospital for Children, Drexel University College of Medicine, Philadelphia, Pennsylvania
| | - Kelly G. Knupp
- Department of Pediatrics, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora,Department of Neurology, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora
| | - Courtney Wusthoff
- Division of Child Neurology, Stanford University, Palo Alto, California
| | - Cynthia Keator
- Cook Children’s Health Care System, Jane and John Justin Neurosciences Center, Fort Worth, Texas
| | - William B. Dobyns
- Division of Pediatric Neurology, Seattle Children’s Hospital, Seattle, Washington,Division of Pediatric Neurology, Seattle Children’s Hospital, Seattle, Washington,Department of Pediatrics, University of Washington, Seattle
| | - Nicole Ryan
- Department of Neurology, The Children’s Hospital of Philadelphia and The Perelman School of Medicine at the University of Pennsylvania, Philadelphia,Department of Pediatrics, The Children’s Hospital of Philadelphia and The Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Tobias Loddenkemper
- Division of Epilepsy and Clinical Neurophysiology, Boston Children’s Hospital and Harvard Medical School, Boston, Massachusetts
| | | | - Edward J. Novotny
- Division of Pediatric Neurology, Seattle Children’s Hospital, Seattle, Washington,Department of Neurology, University of Washington, Seattle,Department of Pediatrics, University of Washington, Seattle,Center for Integrative Brain Research, University of Washington, Seattle,Seattle Children’s Research Institute, Seattle, Washington,Department of Pediatrics, University of Washington, Seattle
| | - Sookyong Koh
- Department of Pediatrics, Children’s Healthcare of Atlanta, Emory University, Atlanta, Georgia
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