1
|
Deckard E, Sathe R, Tabibzadeh D, Terango A, Groves A, Rajaraman RR, Nariai H, Hussain SA. Epileptic spasms relapse is associated with response latency but not conventional attributes of post-treatment EEG. Epilepsia Open 2024; 9:1034-1041. [PMID: 38588009 PMCID: PMC11145600 DOI: 10.1002/epi4.12931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Revised: 02/06/2024] [Accepted: 03/09/2024] [Indexed: 04/10/2024] Open
Abstract
OBJECTIVE Relapse of epileptic spasms after initial treatment of infantile epileptic spasms syndrome (IESS) is common. However, past studies of small cohorts have inconsistently linked relapse risk to etiology, treatment modality, and EEG features upon response. Using a large single-center IESS cohort, we set out to quantify the risk of epileptic spasms relapse and identify specific risk factors. METHODS We identified all children with epileptic spasms at our center using a clinical EEG database. Using the electronic medical record, we confirmed IESS syndrome classification and ascertained treatment, response, time to relapse, etiology, EEG features, and other demographic factors. Relapse-free survival analysis was carried out using Cox proportional hazards regression. RESULTS Among 599 children with IESS, 197 specifically responded to hormonal therapy and/or vigabatrin (as opposed to surgery or other second-line treatments). In this study, 41 (21%) subjects exhibited relapse of epileptic spasms within 12 months of response. Longer duration of IESS prior to response (>3 months) was strongly associated with shorter latency to relapse (hazard ratio = 3.11; 95% CI 1.59-6.10; p = 0.001). Relapse was not associated with etiology, developmental status, or any post-treatment EEG feature. SIGNIFICANCE This study suggests that long duration of IESS before response is the single largest clinical predictor of relapse risk, and therefore underscores the importance of prompt and successful initial treatment. Further study is needed to evaluate candidate biomarkers of epileptic spasms relapse and identify treatments to mitigate this risk. PLAIN LANGUAGE SUMMARY Relapse of infantile spasms is common after initially successful treatment. With study of a large group of children with infantile spasms, we determined that relapse is linked to long duration of infantile spasms. In contrast, relapse was not associated with the cause of infantile spasms, developmental measures, or EEG features at the time of initial response. Further study is needed to identify tools to predict impending relapse of infantile spasms.
Collapse
Affiliation(s)
- Emmi Deckard
- Department of PediatricsDivision of NeurologyUniversity of California Los Angeles and UCLA Mattel Children's HospitalCaliforniaLos AngelesUSA
| | - Rujuta Sathe
- Department of PediatricsDivision of NeurologyUniversity of California Los Angeles and UCLA Mattel Children's HospitalCaliforniaLos AngelesUSA
| | - David Tabibzadeh
- Department of PediatricsDivision of NeurologyUniversity of California Los Angeles and UCLA Mattel Children's HospitalCaliforniaLos AngelesUSA
| | - Aria Terango
- Department of PediatricsDivision of NeurologyUniversity of California Los Angeles and UCLA Mattel Children's HospitalCaliforniaLos AngelesUSA
| | - Aran Groves
- Department of PediatricsDivision of NeurologyUniversity of California Los Angeles and UCLA Mattel Children's HospitalCaliforniaLos AngelesUSA
| | - Rajsekar R. Rajaraman
- Department of PediatricsDivision of NeurologyUniversity of California Los Angeles and UCLA Mattel Children's HospitalCaliforniaLos AngelesUSA
| | - Hiroki Nariai
- Department of PediatricsDivision of NeurologyUniversity of California Los Angeles and UCLA Mattel Children's HospitalCaliforniaLos AngelesUSA
| | - Shaun A. Hussain
- Department of PediatricsDivision of NeurologyUniversity of California Los Angeles and UCLA Mattel Children's HospitalCaliforniaLos AngelesUSA
| |
Collapse
|
2
|
Corrêa DG, Telles B, Freddi TDAL. The vigabatrin-associated brain abnormalities on MRI and their differential diagnosis. Clin Radiol 2024; 79:94-101. [PMID: 38092645 DOI: 10.1016/j.crad.2023.11.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Revised: 10/12/2023] [Accepted: 11/14/2023] [Indexed: 01/02/2024]
Abstract
Vigabatrin is an anti-epileptic drug that inhibits the enzyme γ-aminobutyric acid (GABA)-transaminase. The anticonvulsant effect of vigabatrin involves increasing GABA levels and attenuating glutamate-glutamine cycling. Vigabatrin indications include infantile spasms and refractory focal seizures. Despite having a significant role in paediatric epileptology, vigabatrin has adverse effects, such as retinal toxicity, in up to 30% of patients after 1 year of use and brain abnormalities on magnetic resonance imaging (MRI). The percentage of patients with brain abnormalities on MRI varies between 22-32% of children using vigabatrin to treat infantile spasms. Risk factors for presenting these imaging abnormalities are cryptogenic infantile spasms, age <12 months old, high dosage, and possible concomitant hormonal therapy. Clinically, these abnormalities are usually asymptomatic. Histopathological analysis reveals white matter vacuolation and intramyelinic oedema. The typical findings of vigabatrin-associated brain abnormalities on MRI are bilateral and have a symmetrical hyperintense signal on T2-weighted imaging, with diffusion restriction, that often compromise the globi pallidi, thalami, subthalamic nuclei, cerebral peduncles, midbrain, dorsal brainstem, including the medial longitudinal fasciculi, and dentate nuclei of the cerebellum. In this article, the authors intend to review the clinical manifestations, histopathological features, imaging aspects, and differential diagnosis of vigabatrin-associated brain abnormalities on MRI.
Collapse
Affiliation(s)
- D G Corrêa
- Department of Radiology, Clínica de Diagnóstico por Imagem (CDPI)/DASA, Avenida das Américas, 4666, 302A, 303, 307, 325, 326, Barra da Tijuca, Rio de Janeiro, RJ 2640-102, Brazil; Department of Radiology, Rio de Janeiro State University, Boulevard 28 de Setembro, 77, Vila Isabel, Rio de Janeiro, RJ 20551-030, Brazil.
| | - B Telles
- Department of Radiology, Curitiba Institute of Neurology, Rua Jeremias Maciel Perretto, 300, Campo Comprido, Curitiba, PR 81210-310, Brazil; Department of Radiology, Hospital Pequeno Príncipe, Rua Desembargador Motta, 1070, Água Verde, Curitiba, PR 80250-060, Brazil
| | - T de A L Freddi
- Department of Radiology, Hcor, Rua Desembargador Eliseu Guilherme, 147, Paraíso, São Paulo, SP 04004-030, Brazil
| |
Collapse
|
3
|
Dinçer C, Özütemiz C. Vigabatrin Neurotoxicity in Pediatric Brain. Radiology 2024; 310:e231603. [PMID: 38226885 DOI: 10.1148/radiol.231603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2024]
Affiliation(s)
- Ceren Dinçer
- From the Department of Radiology, Dr Abdurrahman Yurtaslan Ankara Oncology Training and Research Hospital, Yenimahalle, Ankara, Turkey (C.D.); and Department of Radiology, University of Minnesota, Minneapolis, Minn (C.Ö.)
| | - Can Özütemiz
- From the Department of Radiology, Dr Abdurrahman Yurtaslan Ankara Oncology Training and Research Hospital, Yenimahalle, Ankara, Turkey (C.D.); and Department of Radiology, University of Minnesota, Minneapolis, Minn (C.Ö.)
| |
Collapse
|
4
|
Tierradentro-García LO, Zandifar A, Stern J, Nel JH, Ub Kim JD, Andronikou S. Magnetic Resonance Imaging-Based Distribution and Reversibility of Lesions in Pediatric Vigabatrin-Related Brain Toxicity. Pediatr Neurol 2023; 148:86-93. [PMID: 37690269 DOI: 10.1016/j.pediatrneurol.2023.08.012] [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: 10/26/2022] [Revised: 08/09/2023] [Accepted: 08/10/2023] [Indexed: 09/12/2023]
Abstract
BACKGROUND We aimed to systematically characterize the magnetic resonance imaging (MRI) findings in vigabatrin-related neurotoxicity in children and determine the reversibility of lesions based on follow-up images. METHODS We evaluated children with a history of refractory seizures who had a brain MRI while on vigabatrin therapy. We included available brain MRI studies before vigabatrin therapy initiation, during vigabatrin treatment, and after vigabatrin was discontinued. A pediatric neuroradiologist systematically assessed images on T2/fluid-attenuated inversion recovery (FLAIR) and diffusion-weighted imaging /apparent diffusion coefficient sequences to identify hyperintense lesions and/or restricted diffusion. The frequency of abnormal signal at each location was determined, as well as the reversibility of these after vigabatrin discontinuation. RESULTS MRIs of 43 patients were reviewed: 13 before vigabatrin initiation, 18 during treatment, and 12 after vigabatrin discontinuation. In the MRIs acquired during vigabatrin treatment, most lesions on T2/FLAIR occurred in the globus pallidi, thalami, and midbrain. Correspondingly, the most common locations for restricted diffusion were the globus pallidi, thalami, and subthalamic nuclei. On MRI after vigabatrin discontinuation, complete resolution of lesions on T2/FLAIR in all patients was seen in the midbrain, dentate nuclei, subthalamic nuclei, and hypothalami. Complete resolution of restricted diffusion was observed in the globus pallidi, midbrain, dentate nuclei, hippocampi, anterior commissure, and hypothalami. CONCLUSION Globus pallidi and thalami are the most commonly affected structures in vigabatrin-related toxicity, and most vigabatrin-related neuroimaging findings are reversible.
Collapse
Affiliation(s)
- Luis Octavio Tierradentro-García
- Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Alireza Zandifar
- Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Joseph Stern
- Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Jean Henri Nel
- School of Clinical Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Jorge Du Ub Kim
- Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Savvas Andronikou
- Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| |
Collapse
|
5
|
Lockard TJ, Rathore G. A Case of Vigabatrin Toxicity Mimicking Bilateral Thalamic Infarcts on MRI. Cureus 2023; 15:e45049. [PMID: 37829947 PMCID: PMC10566640 DOI: 10.7759/cureus.45049] [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: 09/11/2023] [Indexed: 10/14/2023] Open
Abstract
A 20-month-old female with a past medical history of tuberous sclerosis, epilepsy, and infantile spasms treated with vigabatrin presented for surveillance MRI for multiple brain hamartomatous lesions and subependymal nodules. MRI showed new restricted diffusion to bilateral thalami and globi pallidi. This finding was concerning for bilateral thalamic strokes, with differential to include infection, metabolic etiologies, or toxic injuries. Without focal or diffuse neurologic symptoms or additional MRI lesions to suggest an acute or chronic pathology, it was determined the MRI signal changes were likely induced by vigabatrin. Vigabatrin therapy was continued, and a repeat MRI 17 months later showed a resolution of the diffusion restriction with no residual sequelae. Vigabatrin-induced MRI abnormalities are an uncommon adverse effect of therapy for infantile spasms, with adverse events being most common in young infants. It is crucial to consider this adverse drug effect in an asymptomatic patient presenting with these MRI lesions as the findings are otherwise suggestive of a serious disease process, such as an inborn error of metabolism, requiring expensive and invasive workup.
Collapse
Affiliation(s)
- Trevor J Lockard
- Pediatric Neurology, University of Nebraska Medical Center, Omaha, USA
| | - Geetanjali Rathore
- Pediatric Neurology, Children's Hospital & Medical Center, Omaha, USA
- Pediatric Neurology, University of Nebraska Medical Center, Omaha, USA
| |
Collapse
|
6
|
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.
Collapse
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
| |
Collapse
|
7
|
Distelmaier F, Klopstock T. Neuroimaging in mitochondrial disease. HANDBOOK OF CLINICAL NEUROLOGY 2023; 194:173-185. [PMID: 36813312 DOI: 10.1016/b978-0-12-821751-1.00016-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/22/2023]
Abstract
The anatomic complexity of the brain in combination with its high energy demands makes this organ specifically vulnerable to defects of mitochondrial oxidative phosphorylation. Therefore, neurodegeneration is a hallmark of mitochondrial diseases. The nervous system of affected individuals typically shows selective regional vulnerability leading to distinct patterns of tissue damage. A classic example is Leigh syndrome, which causes symmetric alterations of basal ganglia and brain stem. Leigh syndrome can be caused by different genetic defects (>75 known disease genes) with variable disease onset ranging from infancy to adulthood. Other mitochondrial diseases are characterized by focal brain lesions, which is a core feature of MELAS syndrome (mitochondrial encephalopathy, lactic acidosis, and stroke-like episodes). Apart from gray matter, also white matter can be affected by mitochondrial dysfunction. White matter lesions vary depending on the underlying genetic defect and may progress into cystic cavities. In view of the recognizable patterns of brain damage in mitochondrial diseases, neuroimaging techniques play a key role in diagnostic work-up. In the clinical setting, magnetic resonance imaging (MRI) and MR spectroscopy (MRS) are the mainstay of diagnostic work-up. Apart from visualization of brain anatomy, MRS allows the detection of metabolites such as lactate, which is of specific interest in the context of mitochondrial dysfunction. However, it is important to note that findings like symmetric basal ganglia lesions on MRI or a lactate peak on MRS are not specific, and that there is a broad range of disorders that can mimic mitochondrial diseases on neuroimaging. In this chapter, we will review the spectrum of neuroimaging findings in mitochondrial diseases and discuss important differential diagnoses. Moreover, we will give an outlook on novel biomedical imaging tools that may provide interesting insights into mitochondrial disease pathophysiology.
Collapse
Affiliation(s)
- Felix Distelmaier
- Department of General Pediatrics, Neonatology and Pediatric Cardiology, University Children's Hospital Düsseldorf, Medical Faculty, Heinrich Heine University, Düsseldorf, Germany.
| | - Thomas Klopstock
- Department of Neurology, Friedrich-Baur-Institute, University Hospital, Ludwig-Maximilians-Universität (LMU) München, Munich, Germany; German Center for Neurodegenerative Diseases (DZNE), Munich, Germany; Munich Cluster for Systems Neurology (SyNergy), Munich, Germany; German Network for mitochondrial disorders (mitoNET), Munich, Germany
| |
Collapse
|
8
|
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.
Collapse
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
| | | |
Collapse
|
9
|
Sakpichaisakul K, Boonkrongsak R, Lertbutsayanukul P, Iemwimangsa N, Klumsathian S, Panthan B, Trachoo O. Epileptic spasms related to neuronal differentiation factor 2 (NEUROD2) mutation respond to combined vigabatrin and high dose prednisolone therapy. BMC Neurol 2022; 22:461. [PMID: 36494631 PMCID: PMC9733267 DOI: 10.1186/s12883-022-02992-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Accepted: 11/25/2022] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Epileptic spasms are a devastating form of early infantile epileptic encephalopathy (EIEE) with various etiologies. Early diagnosis and a shorter lead time to treatment are crucial to stop the seizures and optimize the neurodevelopmental outcome. Genetic testing has become an integral part of epilepsy care that directly guides management and family planning and discovers new targeted treatments. Neuronal differentiation Factor 2 (NEUROD2) variants have recently been a cause of neurodevelopmental disorders (NDDs) and EIEEs with distinctive features. However, there is limited information about the clinical and electroencephalographic response of epileptic spasm treatment in NEUROD2-related NDD syndrome. CASE PRESENTATION We report a female patient of Southeast Asian ethnicity with global developmental delay and epileptic spasms commencing in the first few months of life. A novel de novo heterozygous pathogenic NEUROD2 variant, p. E130Q, was subsequently identified by whole-exome sequencing. Electroencephalogram before treatment showed multifocal independent spikes predominantly in both posterior head regions and demonstrated marked improvement following combined vigabatrin and high-dose prednisolone treatment. However, multiple courses of relapse occurred after weaning off the antiseizure medication. CONCLUSIONS We propose that epileptic spasms related to de novo NEUROD2 pathogenic variant respond well to combined vigabatrin and high-dose prednisolone therapy. These findings may imply the benefit of using combination therapy to treat epileptic spasms in NEUROD2-related NDD syndrome.
Collapse
Affiliation(s)
- Kullasate Sakpichaisakul
- Department of Pediatrics, Queen Sirikit National Institute of Child Health, College of Medicine, Rangsit University, Bangkok, 10400, Thailand
| | - Rachata Boonkrongsak
- Department of Pediatrics, Queen Sirikit National Institute of Child Health, College of Medicine, Rangsit University, Bangkok, 10400, Thailand
| | | | - Nareenart Iemwimangsa
- Centre for Medical Genomics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, 10400, Thailand
| | - Sommon Klumsathian
- Centre for Medical Genomics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, 10400, Thailand
| | | | - Objoon Trachoo
- Centre for Medical Genomics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, 10400, Thailand.
- Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, 270 Rama 6 Road, Ratchathewi, Bangkok, 10400, Thailand.
| |
Collapse
|
10
|
Sahly AN, Buhas D, Myers KA. MT-TA pathogenic variants may cause developmental and epileptic encephalopathy without myopathy. Am J Med Genet A 2022; 188:3135-3138. [PMID: 35920329 DOI: 10.1002/ajmg.a.62925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Revised: 07/13/2022] [Accepted: 07/14/2022] [Indexed: 01/31/2023]
Affiliation(s)
- Ahmed N Sahly
- Division of Neurology, Department of Pediatrics, Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada.,Department of Neurosciences, King Faisal Specialist Hospital & Research Centre, Jeddah, Saudi Arabia
| | - Daniela Buhas
- Division of Medical Genetics, Department of Specialized Medicine, McGill University Health Centre, Montreal, Quebec, Canada.,Department of Human Genetics, McGill University, Montreal, Quebec, Canada
| | - Kenneth A Myers
- Division of Neurology, Department of Pediatrics, Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada.,Child Health and Human Development Program, Research Institute of the McGill University Medical Centre, Montreal, Quebec, Canada.,Department of Neurology and Neurosurgery, Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| |
Collapse
|
11
|
Liu LY, Wang Y, Zou LP. Letter to the editor. Epilepsy Behav 2022; 134:108759. [PMID: 35637100 DOI: 10.1016/j.yebeh.2022.108759] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Accepted: 05/17/2022] [Indexed: 11/25/2022]
Affiliation(s)
- Li-Ying Liu
- Department of Pediatrics, Chinese PLA General Hospital, Beijing 100853, China
| | - Yi Wang
- Department of Pediatrics, Chinese PLA General Hospital, Beijing 100853, China
| | - Li-Ping Zou
- Department of Pediatrics, Chinese PLA General Hospital, Beijing 100853, China.
| |
Collapse
|
12
|
Serrallach BL, Orman G, Boltshauser E, Hackenberg A, Desai NK, Kralik SF, Huisman TAGM. Neuroimaging in cerebellar ataxia in childhood: A review. J Neuroimaging 2022; 32:825-851. [PMID: 35749078 DOI: 10.1111/jon.13017] [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: 04/14/2022] [Revised: 05/27/2022] [Accepted: 06/05/2022] [Indexed: 11/28/2022] Open
Abstract
Ataxia is one of the most common pediatric movement disorders and can be caused by a large number of congenital and acquired diseases affecting the cerebellum or the vestibular or sensory system. It is mainly characterized by gait abnormalities, dysmetria, intention tremor, dysdiadochokinesia, dysarthria, and nystagmus. In young children, ataxia may manifest as the inability or refusal to walk. The diagnostic approach begins with a careful clinical history including the temporal evolution of ataxia and the inquiry of additional symptoms, is followed by a meticulous physical examination, and, depending on the results, is complemented by laboratory assays, electroencephalography, nerve conduction velocity, lumbar puncture, toxicology screening, genetic testing, and neuroimaging. Neuroimaging plays a pivotal role in either providing the final diagnosis, narrowing the differential diagnosis, or planning targeted further workup. In this review, we will focus on the most common form of ataxia in childhood, cerebellar ataxia (CA). We will discuss and summarize the neuroimaging findings of either the most common or the most important causes of CA in childhood or present causes of pediatric CA with pathognomonic findings on MRI. The various pediatric CAs will be categorized and presented according to (a) the cause of ataxia (acquired/disruptive vs. inherited/genetic) and (b) the temporal evolution of symptoms (acute/subacute, chronic, progressive, nonprogressive, and recurrent). In addition, several illustrative cases with their key imaging findings will be presented.
Collapse
Affiliation(s)
- Bettina L Serrallach
- Edward B. Singleton Department of Radiology, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas, USA
| | - Gunes Orman
- Edward B. Singleton Department of Radiology, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas, USA
| | - Eugen Boltshauser
- Department of Pediatric Neurology, University Children's Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Annette Hackenberg
- Department of Pediatric Neurology, University Children's Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Nilesh K Desai
- Edward B. Singleton Department of Radiology, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas, USA
| | - Stephen F Kralik
- Edward B. Singleton Department of Radiology, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas, USA
| | - Thierry A G M Huisman
- Edward B. Singleton Department of Radiology, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas, USA
| |
Collapse
|
13
|
Vigabatrin-associated brain abnormalities on MRI and other neurological symptoms in patients with West syndrome. Epilepsy Behav 2022; 129:108606. [PMID: 35180571 DOI: 10.1016/j.yebeh.2022.108606] [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] [Received: 11/22/2021] [Revised: 01/24/2022] [Accepted: 01/27/2022] [Indexed: 11/24/2022]
Abstract
OBJECTIVES Report a series of children with West syndrome (WS) treated with vigabatrin (VGB) who developed characteristic MRI alterations. In the majority, these adverse events were asymptomatic; however, some of the patients developed movement disorders and acute encephalopathy. METHODS This is a retrospective analysis of our epilepsy clinical and EEG database of 288 patients with WS seen between 2014 and 2020. All patients who received VGB alone or with concomitant therapies, such as adrenocorticotropic hormone (ACTH), high-dose oral corticosteroids, ketogenic diet, valproate, levetiracetam, or topiramate, were evaluated. RESULTS In 44 of 288 patients with WS receiving VGB, MRI findings compatible with VGB-associated brain abnormalities were identified; median age at diagnosis was 6.29 months (range, 2 weeks to 11 months). The etiology of WS with vigabatrin-associated brain abnormalities on MRI (VABAM) was unknown in 22 (52.27%), genetic in seven (15.9%), genetic-structural in three (6.8%), structural malformative in three others (6.8%), and structural acquired in eight patients (18.2%). Vigabatrin-associated brain abnormalities on MRI was asymptomatic in 25 of 44 patients. Ten of 44 (22.7%) infants were reported to have had a movement disorder (choreoathetosis, dystonic posturing). Nine of 42 infants exhibited progressive psychomotor deterioration associated with signs and symptoms of encephalopathy. CONCLUSION MRI abnormalities were observed in infants treated with VGB and they appeared to be dose dependent. In our study common locations for MRI abnormalities included globi pallidi and brainstem, followed by thalami and dentate nuclei. Risk factors for the development of VABAM may include age younger than 11 months and higher VGB dose of VGB (>165 mg/kg/day). Vigabatrin-associated brain abnormalities on MRI usually resolved following VGB discontinuation, probably after a period of 3 months.
Collapse
|
14
|
Lin S, Liao J, Zhao X, Hu Y, Chen L, Chen Y, Liu G, Yao Y, Su Q, Scheffer IE, Wen F. Focal Epilepsy in Children With Tuberous Sclerosis Complex: Does Vigabatrin Control Focal Seizures? J Child Neurol 2022; 37:329-333. [PMID: 35321578 DOI: 10.1177/08830738211048326] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
We evaluated the efficacy and safety of vigabatrin in focal epilepsy associated with tuberous sclerosis complex by retrospectively reviewing patients with focal epilepsy and tuberous sclerosis complex treated with vigabatrin at a pediatric epilepsy center over an 8-year period. Of 85 patients, 20 (23.5%) were seizure-free for >12 months, 45 (52.9%) were responders (≥50% seizure reduction), and 20 (23.5%) were nonresponders. The median age (in months) at seizure onset in the seizure-free group (median, 15; interquartile range [IQR], 6-23.3) was higher than that of responders (median, 5; IQR, 3-14) and nonresponders (median, 6; IQR, 2-12). Fewer patients in the seizure-free group had calcification in their largest tubers, but the presence of tuber calcification did not differ among groups. Vigabatrin is more likely to result in seizure freedom in children with tuberous sclerosis complex who have later infantile onset of focal seizures and no calcification in their largest tuber.
Collapse
Affiliation(s)
- Sufang Lin
- Department of Pediatrics, The First Affiliated Hospital 162698Jinan University, Guangzhou, Guangdong, China
- Department of Neurology, 85113Shenzhen Children's Hospital, Shenzhen, Guangdong, China
- Department of Epilepsy Surgery, Shenzhen Children's Hospital, Shenzhen, Guangdong, China
| | - Jianxiang Liao
- Department of Neurology, 85113Shenzhen Children's Hospital, Shenzhen, Guangdong, China
| | - Xia Zhao
- Department of Neurology, 85113Shenzhen Children's Hospital, Shenzhen, Guangdong, China
| | - Yan Hu
- Department of Neurology, 85113Shenzhen Children's Hospital, Shenzhen, Guangdong, China
| | - Li Chen
- Department of Neurology, 85113Shenzhen Children's Hospital, Shenzhen, Guangdong, China
| | - Yan Chen
- Department of Epilepsy Surgery, Shenzhen Children's Hospital, Shenzhen, Guangdong, China
| | - Guosheng Liu
- Department of Pediatrics, The First Affiliated Hospital 162698Jinan University, Guangzhou, Guangdong, China
| | - Yi Yao
- Department of Epilepsy Surgery, Shenzhen Children's Hospital, Shenzhen, Guangdong, China
| | - Qiru Su
- Institute of Pediatrics, Shenzhen Children's Hospital, Shenzhen, Guangdong, China
| | - Ingrid E Scheffer
- University of Melbourne, Austin Health and Royal Children's Hospital, Florey and Murdoch Institutes, Melbourne, Australia
| | - Feiqiu Wen
- Department of Pediatrics, The First Affiliated Hospital 162698Jinan University, Guangzhou, Guangdong, China
- Department of Hematology and Oncology, Shenzhen Children's Hospital, Shenzhen, Guangdong, China
| |
Collapse
|
15
|
Rootman M, Kornreich L, Osherov A, Konen O. DWI Hyperintensity in the Fornix Fimbria on MRI in Children. AJNR Am J Neuroradiol 2022; 43:480-485. [PMID: 35210274 PMCID: PMC8910804 DOI: 10.3174/ajnr.a7437] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Accepted: 01/01/2022] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE The fornix-fimbria complex is mainly involved in emotions and memory. In brain MR imaging studies of young children, we have occasionally noted DWI hyperintensity in this region. The significance of this finding remains unclear. This study evaluated the DWI signal in the fornix-fimbria complex of children 0-2 years of age, including the frequency of signal hyperintensity and clinical context. MATERIALS AND METHODS Brain MR imaging of 714 children 0-2 years of age (mean, 11 months), performed between September 2018 and May 2021, was reviewed and evaluated for DWI signal changes in the fornix-fimbria. All children with available MR imaging studies including DWI were included. Children with poor image quality, poor visualization of the fornix-fimbria region, and missing medical data were excluded. Additional imaging findings were also evaluated. Demographic data were retrieved from the medical files. We compared the ADC values of the fimbria and fornix between children with and without signal changes. The unpaired 2-tailed Student t test and χ2 test were used for statistical analysis. RESULTS DWI signal hyperintensity of the Fornix-fimbria complex was noted in 53 (7.4%) children (mean age, 10 months). Their mean ADC values were significantly lower than those of the children with normal DWI findings (P < .05). About half of the children had otherwise normal MR imaging findings. When detected, the most common abnormality was parenchymal volume loss (15%). The most common indication for imaging was seizures (26.5%). CONCLUSIONS DWI hyperintensity in the fornix-fimbria complex was detected in 7.4% of children 0-2 years of age. The etiology is not entirely clear, possibly reflecting a transient phenomenon.
Collapse
Affiliation(s)
- M.S. Rootman
- From the Department of Radiology (M.S.R., L.K., A.N.O., O.K.), Schneider Children’s Medical Center of Israel, Petach Tikvah, Israel,The Sackler Faculty of Medicine (M.S.R., L.K., A.N.O., O.K.), Tel Aviv University, Tel Aviv, Israel
| | - L. Kornreich
- From the Department of Radiology (M.S.R., L.K., A.N.O., O.K.), Schneider Children’s Medical Center of Israel, Petach Tikvah, Israel,The Sackler Faculty of Medicine (M.S.R., L.K., A.N.O., O.K.), Tel Aviv University, Tel Aviv, Israel
| | - A.N. Osherov
- From the Department of Radiology (M.S.R., L.K., A.N.O., O.K.), Schneider Children’s Medical Center of Israel, Petach Tikvah, Israel,The Sackler Faculty of Medicine (M.S.R., L.K., A.N.O., O.K.), Tel Aviv University, Tel Aviv, Israel
| | - O. Konen
- From the Department of Radiology (M.S.R., L.K., A.N.O., O.K.), Schneider Children’s Medical Center of Israel, Petach Tikvah, Israel,The Sackler Faculty of Medicine (M.S.R., L.K., A.N.O., O.K.), Tel Aviv University, Tel Aviv, Israel
| |
Collapse
|
16
|
Shah NR, Tavana S, Opoku A, Martin D. Toxic and metabolic leukoencephalopathies in emergency department patients: a primer for the radiologist. Emerg Radiol 2022; 29:545-555. [PMID: 35201508 DOI: 10.1007/s10140-022-02032-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Accepted: 02/14/2022] [Indexed: 10/19/2022]
Abstract
One of the most common chief complaints in the emergency department (ED) is altered mental status (AMS). Imaging plays a critical role in triaging patients and identifying the etiology of AMS. Toxic and metabolic etiologies are one of the primary differential categories for AMS, leading to toxic leukoencephalopathies. Toxic leukoencephalopathies are white matter disorders that result from either exogenous or endogenous sources. Common exogeneous causes of toxic leukoencephalopathy include drugs of abuse (heroin and cocaine), alcohol, inhaled gases (carbon monoxide), industrial agents (pesticides, toluene, ethylene glycol), and neurotoxic medications (methotrexate, metronidazole, vigabatrine, etc.); endogenous causes include hyper- and hypoglycemia, hyperammonemia, hyponatremia, and uremia. The imaging findings of toxic leukoencephalopathies manifest through a combination of vasogenic and cytotoxic edema, resulting in white matter patterns. These white matter patterns have been found to be pathognomonic. In the ED setting, it is imperative to develop a diagnosis based off of the imaging due to the lack of history and context that is typically provided with a chief complaint of altered mental status (AMS). To offer expeditious and accurate diagnosis, we present the classic imaging features of toxic leukoencephalopathies and correlate these imaging findings with pathophysiology.
Collapse
Affiliation(s)
- Neal R Shah
- Department of Radiology, University Hospitals Cleveland Medical Center, Case Western Reserve University, 11100 Euclid Ave, Cleveland, OH, 44106, USA.
| | - Shahrzad Tavana
- Department of Radiology, University Hospitals Cleveland Medical Center, Case Western Reserve University, 11100 Euclid Ave, Cleveland, OH, 44106, USA
| | - Akwasi Opoku
- Department of Radiology, Vanderbilt University Medical Center, 1211 Medical Center Dr, Nashville, TN, 37232, USA
| | - Douglas Martin
- Department of Radiology, University Hospitals Cleveland Medical Center, Case Western Reserve University, 11100 Euclid Ave, Cleveland, OH, 44106, USA
| |
Collapse
|
17
|
Ikeda A, Tomiyasu M, Yamamoto A, Tsuyusaki Y, Kawai Y, Tanabe M, Tsuji M, Iai M, Aida N, Goto T. Elevation of brain gamma‐aminobutyric acid levels is associated with vigabatrin‐associated brain abnormalities on magnetic resonance imaging. Epilepsy Res 2022; 181:106881. [DOI: 10.1016/j.eplepsyres.2022.106881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2021] [Revised: 01/14/2022] [Accepted: 02/04/2022] [Indexed: 11/29/2022]
|
18
|
Xu Y, Wan L, He W, Wang YY, Wang QH, Luo XM, Liu K, Yang XY, Wang J, Shi XY, Yang G, Han F, Gao J, Zou LP. Risk of vigabatrin-associated brain abnormalities on MRI: A retrospective and controlled study. Epilepsia 2021; 63:120-129. [PMID: 34786694 DOI: 10.1111/epi.17121] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Revised: 10/20/2021] [Accepted: 10/25/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Vigabatrin (VGB) is the first-line treatment for infantile spasms (IS). Previous studies have shown that VGB exposure may cause vigabatrin-associated brain abnormalities on magnetic resonance imaging (MRI) (VABAM). Based on previous studies, this study aimed to go further to explore the possible risk factors and the incidence of VABAM. In addition, diffusion-weighted imaging (DWI) and T2-weighted imaging (T2WI) were compared to explore whether DWI should be used as a routine examination sequence when MRI is performed in children receiving VGB. METHODS Children with IS receiving VGB were selected as the study subjects. Whether VABAM occurred or not was categorized as the VABAM group and the non-VABAM group, respectively. Their general clinical data and medication exposure were collected. The possible risk factors of VABAM and different MRI sequences were compared and statistically analyzed. RESULTS A total of 77 children with IS were enrolled in the study, of which 25 (32.5%) developed VABAM. Twenty-three of the 25 VABAM cases have a peak dosage of VGB between 50 and 150 mg/kg/day. The earliest observation time of VABAM was 30 days. Regression analysis of relevant risk factors showed that the peak dosage of VGB was the risk factor for VABAM. Comparison between different MRI sequences showed that DWI is more sensitive than T2WI to the evaluation of VABAM. SIGNIFICANCE In our study, the occurrence of VABAM was 32.5%, indicating a higher incidence than in most previous reports. In addition, we once again verified that the peak dosage of VGB was the risk factor of VABAM. Caution should be exercised that our data also suggest that VABAM may occur even using the conventional dosage of VGB (ie, 50-150 mg/kg/day). Therefore, even when using the conventional dosage of VGB, regular MRI examination should be required. Furthermore, DWI sequence should be used as a routine examination sequence when MRI is performed in children with IS who are receiving VGB.
Collapse
Affiliation(s)
- Yong Xu
- Department of Pediatrics, the First Medical Centre, Chinese PLA General Hospital, Beijing, China
| | - Lin Wan
- Department of Pediatrics, the First Medical Centre, Chinese PLA General Hospital, Beijing, China
| | - Wen He
- Department of Pediatrics, the First Medical Centre, Chinese PLA General Hospital, Beijing, China
| | - Yang-Yang Wang
- Department of Pediatrics, the First Medical Centre, Chinese PLA General Hospital, Beijing, China
| | - Qiu-Hong Wang
- Department of Pediatrics, the First Medical Centre, Chinese PLA General Hospital, Beijing, China
| | - Xiao-Mei Luo
- Center for Brain Disorders Research, Beijing Institute for Brain Disorders, Capital Medical University, Beijing, China
| | - Kun Liu
- Department of Pediatrics, the First Medical Centre, Chinese PLA General Hospital, Beijing, China
| | - Xiao-Yan Yang
- Department of Pediatrics, the First Medical Centre, Chinese PLA General Hospital, Beijing, China
| | - Jing Wang
- Department of Pediatrics, the First Medical Centre, Chinese PLA General Hospital, Beijing, China
| | - Xiu-Yu Shi
- Department of Pediatrics, the First Medical Centre, Chinese PLA General Hospital, Beijing, China
| | - Guang Yang
- Department of Pediatrics, the First Medical Centre, Chinese PLA General Hospital, Beijing, China
| | - Fang Han
- Department of Pediatrics, the First Medical Centre, Chinese PLA General Hospital, Beijing, China
| | - Jing Gao
- Department of Pediatrics, the First Medical Centre, Chinese PLA General Hospital, Beijing, China
| | - Li-Ping Zou
- Department of Pediatrics, the First Medical Centre, Chinese PLA General Hospital, Beijing, China
| |
Collapse
|
19
|
Walker MA, Miranda M, Allred A, Mootha VK. On the dynamic and even reversible nature of Leigh syndrome: Lessons from human imaging and mouse models. Curr Opin Neurobiol 2021; 72:80-90. [PMID: 34656053 PMCID: PMC8901530 DOI: 10.1016/j.conb.2021.09.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Revised: 08/01/2021] [Accepted: 09/07/2021] [Indexed: 12/13/2022]
Abstract
Leigh syndrome (LS) is a neurodegenerative disease characterized by bilaterally symmetric brainstem or basal ganglia lesions. More than 80 genes, largely impacting mitochondrial energy metabolism, can underlie LS, and no approved medicines exist. Described 70 years ago, LS was initially diagnosed by the characteristic, necrotic lesions on autopsy. It has been broadly assumed that antemortem neuroimaging abnormalities in these regions correspond to end-stage histopathology. However, clinical observations and animal studies suggest that neuroimaging findings may represent an intermediate state, that is more dynamic than previously appreciated, and even reversible. We review this literature, discuss related conditions that are treatable, and present two new LS cases with radiographic improvement. We review studies in which hypoxia reverses advanced LS in a mouse model. The fluctuating and potentially reversible nature of radiographic LS lesions will be important in clinical trial design. Better understanding of this plasticity could lead to new therapies.
Collapse
Affiliation(s)
- Melissa A Walker
- Howard Hughes Medical Institute, Department of Molecular Biology, Massachusetts General Hospital, United States; Broad Institute of Harvard, MIT, United States; Department of Neurology, Massachusetts General Hospital, United States.
| | - Maria Miranda
- Howard Hughes Medical Institute, Department of Molecular Biology, Massachusetts General Hospital, United States; Broad Institute of Harvard, MIT, United States
| | - Amanda Allred
- Howard Hughes Medical Institute, Department of Molecular Biology, Massachusetts General Hospital, United States
| | - Vamsi K Mootha
- Howard Hughes Medical Institute, Department of Molecular Biology, Massachusetts General Hospital, United States; Broad Institute of Harvard, MIT, United States.
| |
Collapse
|
20
|
Singhi S, Gupta A. A Review of the Selected and Newer Antiseizure Medications Used in Childhood Epilepsies. Indian J Pediatr 2021; 88:993-999. [PMID: 34374934 DOI: 10.1007/s12098-021-03857-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Accepted: 06/11/2021] [Indexed: 11/30/2022]
Abstract
There have been additions of newer antiseizure medications in the armamentarium of clinicians for the management of epilepsy. The newer antiseizure medications have advantages of better tolerability, lesser adverse effects, and minimal drug interactions in comparison with conventional antiseizure medications. However, high cost and availability are concerns. There are also peculiar pharmacokinetic and pharmacodynamic considerations for the pediatric age, particularly in the context of age-dependent electroclinical syndromes and precision-based medicine. This review attempts to provide a comprehensive and pragmatic update on newer antiseizure medications.
Collapse
Affiliation(s)
- Samata Singhi
- Department of Neurology, Kennedy Krieger Institute and Johns Hopkins School of Medicine, Baltimore, MD, 21205, USA.
| | - Ajay Gupta
- Pediatric Epilepsy, Epilepsy Center, Department of Neurology/Neurological Institute, Cleveland Clinic Lerner College of Medicine, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| |
Collapse
|
21
|
Harini C, Yuskaitis CJ, Libenson MH, Yang E, DeLeo M, Zhang B, Mysak K, Marti C, Peters JM, Bergin AM, Pearl PL, Prabhu SP. Hippocampal Involvement With Vigabatrin-Related MRI Signal Abnormalities in Patients With Infantile Spasms: A Novel Finding. J Child Neurol 2021; 36:575-582. [PMID: 33432856 DOI: 10.1177/0883073820985395] [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] [Indexed: 11/17/2022]
Abstract
BACKGROUND In a subset of infants exhibiting typical vigabatrin-related magnetic resonance imaging (MRI) changes, the authors observed additional hippocampal signal abnormalities. The authors investigated occurrence and significance of additional signal abnormalities. METHODS A retrospective review of infantile spasms patients with typical vigabatrin-related MRI abnormalities was performed. Atypical features included signal changes unilaterally or at previously unreported sites. Comparisons were made between patients with and without atypical features. RESULTS In all, 26/55 (47%) exhibited typical vigabatrin-related MRI changes, with additional signal abnormalities in the hippocampi in 6 of 26. On follow-up, evolution of hippocampal signal changes paralleled changes at typical locations in 4 patients. Two patients, clinically well, without follow-up MRI. Patients with and without additional hippocampal signal changes did not differ with respect to clinical factors, including seizure status. One patient had unilateral thalamic/cerebral peduncle signal abnormality along with typical vigabatrin changes. CONCLUSIONS Hippocampal changes seen in subset of patients with typical vigabatrin-related changes may be attributable to vigabatrin exposure in the appropriate circumstance.
Collapse
Affiliation(s)
- Chellamani Harini
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, 1862Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Christopher J Yuskaitis
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, 1862Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Mark H Libenson
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, 1862Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Edward Yang
- Neuroradiology Division, Department of Radiology, 1862Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Michelle DeLeo
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, 1862Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Bo Zhang
- Department of Neurology and ICCTR Biostatistics and Research Design Center, 1862Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | - Kate Mysak
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, 1862Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Candice Marti
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, 1862Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Jurriaan M Peters
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, 1862Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Ann Marie Bergin
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, 1862Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Phillip L Pearl
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, 1862Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Sanjay P Prabhu
- Neuroradiology Division, Department of Radiology, 1862Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| |
Collapse
|
22
|
Cohen AL, Mulder BPF, Prohl AK, Soussand L, Davis P, Kroeck MR, McManus P, Gholipour A, Scherrer B, Bebin EM, Wu JY, Northrup H, Krueger DA, Sahin M, Warfield SK, Fox MD, Peters JM. Tuber Locations Associated with Infantile Spasms Map to a Common Brain Network. Ann Neurol 2021; 89:726-739. [PMID: 33410532 PMCID: PMC7969435 DOI: 10.1002/ana.26015] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 01/04/2021] [Accepted: 01/04/2021] [Indexed: 12/18/2022]
Abstract
OBJECTIVE Approximately 50% of patients with tuberous sclerosis complex develop infantile spasms, a sudden onset epilepsy syndrome associated with poor neurological outcomes. An increased burden of tubers confers an elevated risk of infantile spasms, but it remains unknown whether some tuber locations confer higher risk than others. Here, we test whether tuber location and connectivity are associated with infantile spasms. METHODS We segmented tubers from 123 children with (n = 74) and without (n = 49) infantile spasms from a prospective observational cohort. We used voxelwise lesion symptom mapping to test for an association between spasms and tuber location. We then used lesion network mapping to test for an association between spasms and connectivity with tuber locations. Finally, we tested the discriminability of identified associations with logistic regression and cross-validation as well as statistical mediation. RESULTS Tuber locations associated with infantile spasms were heterogenous, and no single location was significantly associated with spasms. However, >95% of tuber locations associated with spasms were functionally connected to the globi pallidi and cerebellar vermis. These connections were specific compared to tubers in patients without spasms. Logistic regression found that globus pallidus connectivity was a stronger predictor of spasms (odds ratio [OR] = 1.96, 95% confidence interval [CI] = 1.10-3.50, p = 0.02) than tuber burden (OR = 1.65, 95% CI = 0.90-3.04, p = 0.11), with a mean receiver operating characteristic area under the curve of 0.73 (±0.1) during repeated cross-validation. INTERPRETATION Connectivity between tuber locations and the bilateral globi pallidi is associated with infantile spasms. Our findings lend insight into spasm pathophysiology and may identify patients at risk. ANN NEUROL 2021;89:726-739.
Collapse
Affiliation(s)
- Alexander L Cohen
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA
- Computational Radiology Laboratory, Department of Radiology, Boston Children's Hospital, Harvard Medical School, Boston, MA
- Laboratory for Brain Network Imaging and Modulation, Berenson-Allen Center for Noninvasive Brain Stimulation and Division of Cognitive Neurology, Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Brechtje P F Mulder
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA
- VUmc School of Medical Sciences, VU University Medical Center Amsterdam, Amsterdam, the Netherlands
| | - Anna K Prohl
- Computational Radiology Laboratory, Department of Radiology, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Louis Soussand
- Laboratory for Brain Network Imaging and Modulation, Berenson-Allen Center for Noninvasive Brain Stimulation and Division of Cognitive Neurology, Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Peter Davis
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Mallory R Kroeck
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA
- Computational Radiology Laboratory, Department of Radiology, Boston Children's Hospital, Harvard Medical School, Boston, MA
- Laboratory for Brain Network Imaging and Modulation, Berenson-Allen Center for Noninvasive Brain Stimulation and Division of Cognitive Neurology, Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Peter McManus
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA
- Computational Radiology Laboratory, Department of Radiology, Boston Children's Hospital, Harvard Medical School, Boston, MA
- Laboratory for Brain Network Imaging and Modulation, Berenson-Allen Center for Noninvasive Brain Stimulation and Division of Cognitive Neurology, Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Ali Gholipour
- Computational Radiology Laboratory, Department of Radiology, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Benoit Scherrer
- Computational Radiology Laboratory, Department of Radiology, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - E Martina Bebin
- Department of Neurology, University of Alabama at Birmingham, Birmingham, AL
| | - Joyce Y Wu
- Division of Pediatric Neurology, UCLA Mattel Children's Hospital, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA
| | - Hope Northrup
- Division of Medical Genetics, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX
| | - Darcy A Krueger
- Department of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Mustafa Sahin
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA
- F. M. Kirby Neurobiology Center, Boston Children's Hospital, Harvard Medical School, Harvard University, Boston, MA
| | - Simon K Warfield
- Computational Radiology Laboratory, Department of Radiology, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Michael D Fox
- Laboratory for Brain Network Imaging and Modulation, Berenson-Allen Center for Noninvasive Brain Stimulation and Division of Cognitive Neurology, Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Charlestown, MA
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Jurriaan M Peters
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA
- Computational Radiology Laboratory, Department of Radiology, Boston Children's Hospital, Harvard Medical School, Boston, MA
| |
Collapse
|
23
|
Abstract
Context Refractory status epilepticus (RSE) and super-refractory status epilepticus (SRSE) are neurological emergencies with considerable mortality and morbidity. In this paper, we provide an overview of causes, evaluation, treatment, and consequences of RSE and SRSE, reflecting the lack of high-quality evidence to inform therapeutic approach. Sources This is a narrative review based on personal practice and experience. Nevertheless, we searched MEDLINE (using PubMed and OvidSP vendors) and Cochrane central register of controlled trials, using appropriate keywords to incorporate recent evidence. Results Refractory status epilepticus is commonly defined as an acute convulsive seizure that fails to respond to two or more anti-seizure medications including at least one nonbenzodiazepine drug. Super-refractory status epilepticus is a status epilepticus that continues for ≥24 hours despite anesthetic treatment, or recurs on an attempted wean of the anesthetic regimen. Both can occur in patients known to have epilepsy or de novo, with increasing recognition of autoimmune and genetic causes. Electroencephalography monitoring is essential to monitor treatment response in refractory/super-refractory status epilepticus, and to diagnose non-convulsive status epilepticus. The mainstay of treatment for these disorders includes anesthetic infusions, primarily midazolam, ketamine, and pentobarbital. Dietary, immunological, and surgical treatments are viable in selected patients. Management is challenging due to multiple acute complications and long-term adverse consequences. Conclusions We have provided a synopsis of best practices for diagnosis and management of refractory/superrefractory status epilepticus and highlighted the lack of sufficient high-quality evidence to drive decision making, ending with a brief foray into avenues for future research.
Collapse
Affiliation(s)
- Debopam Samanta
- Child Neurology Division, Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Lisa Garrity
- Comprehensive Epilepsy Center, Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Ravindra Arya
- Comprehensive Epilepsy Center, Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio and Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio; USA. Correspondence to: Dr Ravindra Arya, Division of Neurology, Cincinnati Children's Hospital Medical Center, MLC 2015, 3333 Burnet Avenue, Cincinnati, Ohio, 45229 USA.
| |
Collapse
|
24
|
Craft JF, Cardenas AM. Vigabatrin-associated Reversible MRI Abnormalities in an Infant with Tuberous Sclerosis. J Radiol Case Rep 2021; 15:1-6. [PMID: 33717406 DOI: 10.3941/jrcr.v15i2.3918] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Vigabatrin therapy is commonly used in infants diagnosed with tuberous sclerosis complex, particularly in the setting of epilepsy. Utilization of vigabatrin can result in bilateral and symmetric abnormal sequence changes within the deep brain matter and brainstem on magnetic resonance imaging. These abnormalities occur predominantly in infancy, are reversible, and can be asymptomatic or result in symptomatic clinical manifestations. We present a case with classic neuroimaging findings. Familiarity with these findings can prevent unnecessary follow up tests or studies and the cost of continuing or discontinuing vigabatrin therapy should be weighed heavily against the potential manifestation of extrapyramidal symptoms.
Collapse
Affiliation(s)
- Joseph Franklin Craft
- Department of Radiology, Brookwood Baptist Health Network, Princeton Baptist Medical Center, Birmingham, Alabama, USA
| | - Agustin M Cardenas
- Department of Radiology, Children's of Alabama, Birmingham, Alabama, USA
| |
Collapse
|
25
|
Pediatric inflammatory demyelinating disorders and mimickers: How to differentiate with MRI? Autoimmun Rev 2021; 20:102801. [PMID: 33727154 DOI: 10.1016/j.autrev.2021.102801] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Accepted: 01/25/2021] [Indexed: 11/21/2022]
Abstract
Multiple sclerosis (MS) is a chronic, immune-mediated, neurodegenerative disorder of the central nervous system (CNS).While the clinical symptoms of MS most commonly manifest between 20 and 40 years of age, approximately 3 to 10% of all MS patients report that their first inaugural events can occur earlier in life, even in childhood, and thus include the pediatric population. The prevalence of MS onset in childhood/adolescence varies between 2.0% and 4.0% of all MS cases according to several extensive studies. The main imaging patterns of pediatric inflammatory demyelinating disorders and mimicking entities, including multiple sclerosis, neuromyelitis optica spectrum disorders, acute disseminated encephalomyelitis, MOG (myelin oligodendrocyte glycoprotein) antibody-related disorders and differential diagnoses will be addressed in this article, highlighting key points to the differential diagnosis.
Collapse
|
26
|
Sarma A, Heck JM, Bhatia A, Krishnasarma RS, Pruthi S. Magnetic resonance imaging of the brainstem in children, part 2: acquired pathology of the pediatric brainstem. Pediatr Radiol 2021; 51:189-204. [PMID: 33464360 DOI: 10.1007/s00247-020-04954-0] [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: 04/24/2020] [Revised: 09/10/2020] [Accepted: 12/20/2020] [Indexed: 10/22/2022]
Abstract
Part 1 of this series of two articles describes conventional and advanced MRI techniques that are useful for evaluating brainstem pathologies. In addition, it provides a review of the embryology, normal progression of myelination, and clinically and radiologically salient imaging anatomy of the normal brainstem. Finally, it discusses congenital diseases of the brainstem with a focus on distinctive imaging features that allow for differentiating pathologies. Part 2 of this series of two articles includes discussion of neoplasms; infections; and vascular, demyelinating, toxic, metabolic and miscellaneous disease processes affecting the brainstem. The ultimate goal of this pair of articles is to empower the radiologist to add clinical value in the care of pediatric patients with brainstem pathologies.
Collapse
Affiliation(s)
- Asha Sarma
- Department of Radiology and Radiological Sciences, Monroe Carell Jr. Children's Hospital, Vanderbilt University Medical Center, 2200 Children's Way, Nashville, TN, 37232, USA
| | - Josh M Heck
- Department of Radiology and Radiological Sciences, Monroe Carell Jr. Children's Hospital, Vanderbilt University Medical Center, 2200 Children's Way, Nashville, TN, 37232, USA
| | - Aashim Bhatia
- Department of Radiology, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA, USA
| | - Rekha S Krishnasarma
- Department of Radiology and Radiological Sciences, Monroe Carell Jr. Children's Hospital, Vanderbilt University Medical Center, 2200 Children's Way, Nashville, TN, 37232, USA
| | - Sumit Pruthi
- Department of Radiology and Radiological Sciences, Monroe Carell Jr. Children's Hospital, Vanderbilt University Medical Center, 2200 Children's Way, Nashville, TN, 37232, USA.
| |
Collapse
|
27
|
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.
Collapse
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.
| |
Collapse
|
28
|
Isovaline efficacy in a rat pup model of infantile spasms. Neuroreport 2020; 32:61-65. [PMID: 33196548 DOI: 10.1097/wnr.0000000000001556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Infantile spasms, also known as epileptic spasms during infancy, is an epileptic disorder of infancy and early childhood that is associated with developmental delay or regression, high mortality rate and is difficult to treat with conventional antiseizure medication. Previously, we reported that a unique amino acid called isovaline had potent anticonvulsive efficacy in the 4-aminopyridine and pilocarpine rat models of seizures. In this study, we examined whether isovaline possess therapeutic utility in a well-established rat model of infantile spasms which involves the pretreatment of a pregnant dam with betamethasone and subsequent induction of spasms with N-methyl-D-asparate (NMDA), a glutamate receptor agonist, in 15-day old pups. We treated seven of these pups with saline prior to administering NMDA and eight of these pups with isovaline (300 mg/kg) intraperitoneal (i.p.) prior to NMDA. Isovaline significantly reduced the number of full-body jumps from 18.1 ± 5.0 to 6.3 ± 1.8 and leg/arm/tail strains from 4.4 ± 1.6 to 1.1 ± 0.5. A trend in a reduction of body twitch was noted in rat pups administered isovaline (P = 0.05), but no significant difference was seen in NMDA-induced head nods (P = 0.221). In conclusion, our data demonstrate a potential for isovaline to attenuate an aggressive form of epilepsy that typically requires highly toxic medications to treat in children.
Collapse
|
29
|
Mohammad SS, Angiti RR, Biggin A, Morales-Briceño H, Goetti R, Perez-Dueñas B, Gregory A, Hogarth P, Ng J, Papandreou A, Bhattacharya K, Rahman S, Prelog K, Webster RI, Wassmer E, Hayflick S, Livingston J, Kurian M, Chong WK, Dale RC. Magnetic resonance imaging pattern recognition in childhood bilateral basal ganglia disorders. Brain Commun 2020; 2:fcaa178. [PMID: 33629063 PMCID: PMC7891249 DOI: 10.1093/braincomms/fcaa178] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 08/24/2020] [Accepted: 09/18/2020] [Indexed: 12/18/2022] Open
Abstract
Bilateral basal ganglia abnormalities on MRI are observed in a wide variety of childhood disorders. MRI pattern recognition can enable rationalization of investigations and also complement clinical and molecular findings, particularly confirming genomic findings and also enabling new gene discovery. A pattern recognition approach in children with bilateral basal ganglia abnormalities on brain MRI was undertaken in this international multicentre cohort study. Three hundred and five MRI scans belonging to 201 children with 34 different disorders were rated using a standard radiological scoring proforma. In addition, literature review on MRI patterns was undertaken in these 34 disorders and 59 additional disorders reported with bilateral basal ganglia MRI abnormalities. Cluster analysis on first MRI findings from the study cohort grouped them into four clusters: Cluster 1-T2-weighted hyperintensities in the putamen; Cluster 2-T2-weighted hyperintensities or increased MRI susceptibility in the globus pallidus; Cluster 3-T2-weighted hyperintensities in the globus pallidus, brainstem and cerebellum with diffusion restriction; Cluster 4-T1-weighted hyperintensities in the basal ganglia. The 34 diagnostic categories included in this study showed dominant clustering in one of the above four clusters. Inflammatory disorders grouped together in Cluster 1. Mitochondrial and other neurometabolic disorders were distributed across clusters 1, 2 and 3, according to lesions dominantly affecting the striatum (Cluster 1: glutaric aciduria type 1, propionic acidaemia, 3-methylglutaconic aciduria with deafness, encephalopathy and Leigh-like syndrome and thiamine responsive basal ganglia disease associated with SLC19A3), pallidum (Cluster 2: methylmalonic acidaemia, Kearns Sayre syndrome, pyruvate dehydrogenase complex deficiency and succinic semialdehyde dehydrogenase deficiency) or pallidum, brainstem and cerebellum (Cluster 3: vigabatrin toxicity, Krabbe disease). The Cluster 4 pattern was exemplified by distinct T1-weighted hyperintensities in the basal ganglia and other brain regions in genetically determined hypermanganesemia due to SLC39A14 and SLC30A10. Within the clusters, distinctive basal ganglia MRI patterns were noted in acquired disorders such as cerebral palsy due to hypoxic ischaemic encephalopathy in full-term babies, kernicterus and vigabatrin toxicity and in rare genetic disorders such as 3-methylglutaconic aciduria with deafness, encephalopathy and Leigh-like syndrome, thiamine responsive basal ganglia disease, pantothenate kinase-associated neurodegeneration, TUBB4A and hypermanganesemia. Integrated findings from the study cohort and literature review were used to propose a diagnostic algorithm to approach bilateral basal ganglia abnormalities on MRI. After integrating clinical summaries and MRI findings from the literature review, we developed a prototypic decision-making electronic tool to be tested using further cohorts and clinical practice.
Collapse
Affiliation(s)
- Shekeeb S Mohammad
- Kids Neuroscience Centre, The Children’s Hospital at Westmead, Westmead, NSW 2145, Australia
- TY Nelson Department of Neurology and Neurosurgery, The Children’s Hospital at Westmead, Sydney, Australia
- The Children’s hospital at Westmead Clinical School, Faculty of Medicine, University of Sydney, Sydney, NSW 2145, Australia
| | - Rajeshwar Reddy Angiti
- Newborn and Peadiatric Emergency Transport Service (NETS), Bankstown, NSW, Australia
- Department of Neonatology, Liverpool Hospital, Liverpool, NSW, Australia
| | - Andrew Biggin
- The Children’s hospital at Westmead Clinical School, Faculty of Medicine, University of Sydney, Sydney, NSW 2145, Australia
| | - Hugo Morales-Briceño
- Movement Disorders Unit, Neurology Department, Westmead Hospital, Westmead, NSW 2145, Australia
| | - Robert Goetti
- Medical Imaging, The Children’s Hospital at Westmead and Sydney Medical School, University of Sydney, Sydney, Australia
| | - Belen Perez-Dueñas
- Paediatric Neurology Department, Hospital Vall d'Hebrón Universitat Autónoma de Barcelona, Vall d'Hebron Research Institute Barcelona, Barcelona, Spain
| | - Allison Gregory
- Department of Molecular and Medical Genetics, Oregon Health & Science University, Portland, OR, USA
| | - Penelope Hogarth
- Department of Molecular and Medical Genetics, Oregon Health & Science University, Portland, OR, USA
| | - Joanne Ng
- Molecular Neurosciences, Developmental Neurosciences, UCL-Institute of Child Health, London, UK
| | - Apostolos Papandreou
- Molecular Neurosciences, Developmental Neurosciences, UCL-Institute of Child Health, London, UK
| | - Kaustuv Bhattacharya
- Western Sydney Genomics Program, The Children’s Hospital at Westmead and Sydney Medical School, University of Sydney, Sydney, Australia
| | - Shamima Rahman
- Mitochondrial Research Group, Genetics and Genomic Medicine, Institute of Child Health, University College London and Metabolic Unit, Great Ormond Street Hospital, London, UK
| | - Kristina Prelog
- Medical Imaging, The Children’s Hospital at Westmead and Sydney Medical School, University of Sydney, Sydney, Australia
| | - Richard I Webster
- TY Nelson Department of Neurology and Neurosurgery, The Children’s Hospital at Westmead, Sydney, Australia
| | - Evangeline Wassmer
- Department of Paediatric Neurology, Birmingham Children's Hospital, Birmingham, UK
| | - Susan Hayflick
- Department of Molecular and Medical Genetics, Oregon Health & Science University, Portland, OR, USA
| | - John Livingston
- Department of Paediatric Neurology, Leeds Teaching Hospitals Trust, University of Leeds, UK
| | - Manju Kurian
- Molecular Neurosciences, Developmental Neurosciences, UCL-Institute of Child Health, London, UK
| | - W Kling Chong
- Department of Radiology, Great Ormond Street Hospital, London, UK
| | - Russell C Dale
- Kids Neuroscience Centre, The Children’s Hospital at Westmead, Westmead, NSW 2145, Australia
- TY Nelson Department of Neurology and Neurosurgery, The Children’s Hospital at Westmead, Sydney, Australia
- The Children’s hospital at Westmead Clinical School, Faculty of Medicine, University of Sydney, Sydney, NSW 2145, Australia
| |
Collapse
|
30
|
Biswas A, Yossofzai O, Vincent A, Go C, Widjaja E. Vigabatrin-related adverse events for the treatment of epileptic spasms: systematic review and meta-analysis. Expert Rev Neurother 2020; 20:1315-1324. [PMID: 33078964 DOI: 10.1080/14737175.2020.1840356] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Objective: Although vigabatrin (VGB) is effective and well tolerated for the treatment of epileptic spasms, there are safety concerns. The aim of this systematic review and metaanalysis was to assess adverse events of VGB for the treatment of epileptic spasms. Methods: MEDLINE, EMBASE, and Cochrane databases were searched. The population was infants treated with VGB for epileptic spasms. The outcomes were VGB-related adverse events. Meta-analyses of VGB-related MRI abnormalities, retinal toxicity as measured by electroretinogram (ERG), visual field defect as measured by perimetry, and other adverse events were conducted. Results: Fifty-seven articles were included in the systematic review. The rate of VGB-related MRI abnormalities was 21% (95% CI: 15-29%). Risk factors for MRI abnormalities were age younger than 12 months and higher VGB dose. VGB-related retinal toxicity and visual field defect occurred in 29% (95% CI: 7-69%) and 28% (95% CI: 4-78%) respectively. Other adverse events occurred in 23% (95% CI: 16-34%), consisting predominantly of central nervous system symptoms, and the majority of these did not require therapeutic modification. Conclusion: This study will inform physicians and families on the risk profile of VGB for the treatment of epileptic spasms and will help decisions on treatment options.
Collapse
Affiliation(s)
- Asthik Biswas
- Department of Diagnostic Imaging, The Hospital for Sick Children , Toronto, Ontario, Canada.,Department of Medical Imaging, University of Toronto , Toronto, ON, Canada
| | - Omar Yossofzai
- Neuroscience and Mental Health, The Hospital for Sick Children , Toronto, Ontario, Canada
| | - Ajoy Vincent
- Department of Ophthalmology and Vision Sciences, The Hospital for Sick Children , Toronto, Ontario, Canada
| | - Cristina Go
- Division of Neurology, The Hospital for Sick Children , Toronto, Ontario, Canada
| | - Elysa Widjaja
- Department of Diagnostic Imaging, The Hospital for Sick Children , Toronto, Ontario, Canada.,Department of Medical Imaging, University of Toronto , Toronto, ON, Canada.,Neuroscience and Mental Health, The Hospital for Sick Children , Toronto, Ontario, Canada.,Division of Neurology, The Hospital for Sick Children , Toronto, Ontario, Canada
| |
Collapse
|
31
|
Bhalla S, Skjei K. Fulminant vigabatrin toxicity during combination therapy with adrenocorticotropic hormone for infantile spasms: Three cases and review of the literature. Epilepsia 2020; 61:e159-e164. [PMID: 32944947 DOI: 10.1111/epi.16663] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 07/31/2020] [Accepted: 08/01/2020] [Indexed: 11/28/2022]
Abstract
Vigabatrin (VGB), adrenocorticotropic hormone (ACTH), and prednisone are first-line treatments for infantile spasms (IS). A recent study reported benefits from the use of combination VGB and hormonal therapy over hormonal treatment alone in IS. We describe three patients with IS who developed acute encephalopathy with extrapyramidal symptoms, vigabatrin-associated brain abnormalities on magnetic resonance imaging (VABAM), and death in one patient shortly after initiation of therapy with VGB and ACTH. A literature review supports increased risk of fulminant, symptomatic VABAM in patients receiving VGB in association with hormonal therapy, raising concerns regarding its safety in IS.
Collapse
Affiliation(s)
- Sonam Bhalla
- Department of Pediatrics, Division of Pediatric Neurology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Karen Skjei
- Department of Neurology, Division of Pediatric Neurology, University of Texas, Austin, Texas, USA
| |
Collapse
|
32
|
Velíšek L, Velíšková J. Modeling epileptic spasms during infancy: Are we heading for the treatment yet? Pharmacol Ther 2020; 212:107578. [PMID: 32417271 PMCID: PMC7299814 DOI: 10.1016/j.pharmthera.2020.107578] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Accepted: 05/07/2020] [Indexed: 12/22/2022]
Abstract
Infantile spasms (IS or epileptic spasms during infancy) were first described by Dr. William James West (aka West syndrome) in his own son in 1841. While rare by definition (occurring in 1 per 3200-3400 live births), IS represent a major social and treatment burden. The etiology of IS varies - there are many (>200) different known pathologies resulting in IS and still in about one third of cases there is no obvious reason. With the advancement of genetic analysis, role of certain genes (such as ARX or CDKL5 and others) in IS appears to be important. Current treatment strategies with incomplete efficacy and serious potential adverse effects include adrenocorticotropin (ACTH), corticosteroids (prednisone, prednisolone) and vigabatrin, more recently also a combination of hormones and vigabatrin. Second line treatments include pyridoxine (vitamin B6) and ketogenic diet. Additional treatment approaches use rapamycin, cannabidiol, valproic acid and other anti-seizure medications. Efficacy of these second line medications is variable but usually inferior to hormonal treatments and vigabatrin. Thus, new and effective models of this devastating condition are required for the search of additional treatment options as well as for better understanding the mechanisms of IS. Currently, eight models of IS are reviewed along with the ideas and mechanisms behind these models, drugs tested using the models and their efficacy and usefulness. Etiological variety of IS is somewhat reflected in the variety of the models. However, it seems that for finding precise personalized approaches, this variety is necessary as there is no "one-size-fits-all" approach possible for both IS in particular and epilepsy in general.
Collapse
Affiliation(s)
- Libor Velíšek
- Departments of Cell Biology & Anatomy, New York Medical College, Valhalla, NY, USA; Departments of Pediatrics, New York Medical College, Valhalla, NY, USA; Departments of Neurology, New York Medical College, Valhalla, NY, USA.
| | - Jana Velíšková
- Departments of Cell Biology & Anatomy, New York Medical College, Valhalla, NY, USA; Departments of Neurology, New York Medical College, Valhalla, NY, USA; Departments of Obstetrics & Gynecology, New York Medical College, Valhalla, NY, USA
| |
Collapse
|
33
|
Tondelli M, Vaudano AE, Sisodiya SM, Meletti S. Valproate Use Is Associated With Posterior Cortical Thinning and Ventricular Enlargement in Epilepsy Patients. Front Neurol 2020; 11:622. [PMID: 32714274 PMCID: PMC7351506 DOI: 10.3389/fneur.2020.00622] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Accepted: 05/27/2020] [Indexed: 01/06/2023] Open
Abstract
Valproate is a drug widely used to treat epilepsy, bipolar disorder, and occasionally to prevent migraine headache. Despite its clinical efficacy, prenatal exposure to valproate is associated with neurodevelopmental impairments and its use in children and adults was associated with rare cases of reversible brain atrophy and ventricular enlargement. To determine whether valproate use is related with structural brain changes we examined through a cross-sectional study cortical and subcortical structures in a group of 152 people with epilepsy and a normal clinical brain MRI. Patients were grouped into those currently using valproate (n = 54), those taking drugs other than valproate (n = 47), and drug-naïve patients (n = 51) at the time of MRI, irrespectively of their epilepsy syndrome. Cortical thickness and subcortical volumes were analyzed using Freesurfer, version 5.0. Subjects exposed to valproate (either in mono- or polytherapy) showed reduced cortical thickness in the occipital lobe, more precisely in the cuneus bilaterally, in the left lingual gyrus, and in left and right pericalcarine gyri when compared to patients who used other antiepileptic drugs, to drug-naïve epilepsy patients, and to healthy controls. Considering the subgroup of patients using valproate monotherapy (n = 25), both comparisons with healthy controls and drug-naïve groups confirmed occipital lobe cortical thickness reduction. Moreover, patients using valproate showed increased left and right lateral ventricle volume compared to all other groups. Notably, subjects who were non-valproate users at the time of MRI, but who had valproate exposure in the past (n = 27) did not show these cortical or subcortical brain changes. Cortical changes in the posterior cortex, particularly in the visual cortex, and ventricular enlargement, are present in people with epilepsy using valproate, independently from clinical and demographical variables. These findings are relevant both for the efficacy and adverse events profile of valproate use in people with epilepsy.
Collapse
Affiliation(s)
| | | | - Sanjay M Sisodiya
- Department of Clinical and Experimental Epilepsy, UCL Queen Square Institute of Neurology, London, United Kingdom.,Chalfont Centre for Epilepsy, Chalfont, United Kingdom
| | - Stefano Meletti
- Neurology Unit, OCSAE Hospital, AOU Modena, Modena, Italy.,Department of Biomedical, Metabolic and Neural Science, University of Modena and Reggio Emilia, Modena, Italy
| |
Collapse
|
34
|
Abstract
Children with infantile spasms are likely to have a poor outcome. Outcome measures for infantile spasms include primary response to treatment, relapse of spasms, neurological development, death, and progression to another type of epilepsy (Consensus Statements of the WEST Delphi Group 2004). This review is based mainly on prospective studies and emphasizes data about the current first-line drugs, adrenocorticotropic hormone, vigabatrin, and prednisolone, taking into account the proportion of patients with known and unknown etiology, which has a very strong effect on seizure outcome. In most studies, hormonal treatment (adrenocorticotropic hormone or prednisolone) is the optimal monotherapy, except for patients with tuberous sclerosis complex, in whom vigabatrin appears superior. Combination therapy (hormones plus vigabatrin) may well be more effective than either agent alone. The underlying etiology is the most important prognostic factor. In studies with a long follow-up (up to 50 years), a favorable cognitive outcome has been observed in approximately one quarter of patients and complete seizure freedom in one-third. Autism is relatively frequent, and premature mortality is high throughout life. Modifiable prognostic factors include early recognition of the spasms with prompt treatment, short duration of hypsarrhythmia, prompt treatment of relapses of spasms and multifocal epileptic discharges, and early treatment of adverse effects. It is hoped that eventually advanced genetics and molecular data will allow an understanding of the pathogenetic mechanisms of many specific etiologies to allow disease-specific treatment such as is emerging for tuberous sclerosis.
Collapse
Affiliation(s)
- Raili Riikonen
- Children's Hospital, University of Eastern Finland and Kuopio University Hospital, Kuopio, Finland.
| |
Collapse
|
35
|
van der Poest Clement E, Jansen FE, Braun KPJ, Peters JM. Update on Drug Management of Refractory Epilepsy in Tuberous Sclerosis Complex. Paediatr Drugs 2020; 22:73-84. [PMID: 31912454 DOI: 10.1007/s40272-019-00376-0] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Tuberous sclerosis complex (TSC) is a genetic neurocutaneous disorder with epilepsy as a common and early presenting symptom. The neurological phenotype, however, is variable and unpredictable. Early and refractory seizures, infantile spasms in particular, are associated with a poor neurological outcome. Preliminary data suggests early and aggressive seizure control may mitigate the detrimental neurodevelopmental effects of epilepsy. For infantile spasms, vigabatrin is the first line of treatment, and steroids and classic antiepileptic drugs (AEDs) are suitable for second line. Based on retrospective data, vigabatrin should be considered for other indications, especially in infants with focal seizures, as this may prevent infantile spasms, but also in children and adults with epileptic spasms and tonic seizures. Otherwise, for most seizure types, treatment is similar to that for patients without TSC, including the use of novel AEDs, although limited data are available. Three major developments are changing the field of epilepsy management in TSC. First, final recommendations on preventive treatment with vigabatrin will result from two multicenter trials in the US (PREVeNT, clinicaltrials.gov #NCT02849457) and Europe (EPISTOP, clinicaltrials.gov #NCT02098759). Second, treatment with everolimus, an inhibitor of the mechanistic target of rapamycin (mTOR), reduced seizures when compared to placebo. Further, mTOR inhibitors may have an overall disease-modifying effect. Third, the role of cannabidiol in the treatment of refractory seizures in TSC is yet to be established. With treatment recommendations in TSC, we keep an eye on the prize for the broader field of pediatric epilepsy: the lessons learned from TSC are likely applicable to other epileptic encephalopathies.
Collapse
Affiliation(s)
| | - Floor E Jansen
- Department of Child Neurology, University Medical Center Utrecht Brain Center, Utrecht, The Netherlands
| | - Kees P J Braun
- Department of Child Neurology, University Medical Center Utrecht Brain Center, Utrecht, The Netherlands
| | - Jurriaan M Peters
- Division of Epilepsy and Clinical Neurophysiology, Boston Children's Hospital and Harvard Medical School, 300 Longwood Ave, FE9, Boston, 02115, USA.
| |
Collapse
|
36
|
Synthetic pharmaceutical grade cannabidiol for treatment of refractory infantile spasms: A multicenter phase-2 study. Epilepsy Behav 2020; 102:106826. [PMID: 31816477 DOI: 10.1016/j.yebeh.2019.106826] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Revised: 11/04/2019] [Accepted: 11/24/2019] [Indexed: 11/23/2022]
Abstract
PURPOSE Limited data suggest that cannabidiol (CBD) may be effective for treatment of refractory infantile spasms (IS). This study was designed to more rigorously evaluate the efficacy and safety of synthetic CBD in the treatment of IS. METHODS Children six to 36 months of age with IS that failed treatment with both adrenocorticotropic hormone (ACTH) and vigabatrin (VGB) were eligible for enrollment. Children receiving clobazam were excluded. After baseline overnight video-electroencephalography (vEEG) to confirm diagnosis and ascertain hypsarrhythmia, patients were treated with synthetic CBD oral solution (20 mg/kg/day). Overnight video-EEG was repeated after 14 days, and both baseline and repeat video-EEGs were completely de-identified and reviewed in a pairwise fashion by an independent, blinded pediatric electroencephalographer. The primary efficacy endpoint was freedom from spasms and hypsarrhythmia on day 14. RESULTS Nine patients were enrolled, comprising an older (median age = 23 months) cohort with long-standing IS (median duration = 13 months) and numerous prior treatment failures (median = 6). One patient responded to therapy and eight patients exhibited neither clinical nor electrographic response. CONCLUSIONS The immediate but temporary response in a single patient suggests that CBD oral solution is not particularly effective in highly refractory cases, but may, nevertheless, be effective in younger patients with shorter durations of IS. Further study, examining both short- and long-term outcomes, is warranted to further evaluate the efficacy and safety of CBD oral solution in the treatment of IS.
Collapse
|
37
|
Zelleke T, Pasupuleti A, Depositario-Cabacar D, Kao A. Antiepileptic Drugs in Pediatrics. Handb Exp Pharmacol 2020; 261:1-24. [PMID: 31342278 DOI: 10.1007/164_2019_248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Epilepsy affects approximately 1% of the population. First-line treatment for epilepsy is the administration of anti-seizure medication, also referred to as antiepileptic drugs (AEDs), although this nomenclature is erroneous as these medications typically do not impact underlying epileptogenic processes; the goal of these medications is to control symptoms. Over 30% of patients are classified as having "medically refractory" epilepsy, i.e., lack of adequate seizure control despite trials of two or three AEDs (Kwan and Brodie, N Engl J Med 342:314-9, 2000). Epilepsy is associated with worse quality of life in children, adolescents, and their families (Cianchetti et al., Seizure 24:93-101, 2015). Patients with epilepsy have a two to three times greater risk of death than the general population, by various causes including sudden unexplained death in epilepsy patients (SUDEP) (Abdel-Mannan et al., Epilepsy Behav 90:99-106, 2019). It is these factors, among others, that have motivated the continued development of AEDs. This chapter will review the history and evolution of AED development, features of specific AEDs with a focus on the newest generation, and examples of AEDs in development.
Collapse
Affiliation(s)
- Tesfaye Zelleke
- Division of Epilepsy and Neurophysiology, Children's National Health System, Washington, DC, USA
| | - Archana Pasupuleti
- Division of Epilepsy and Neurophysiology, Children's National Health System, Washington, DC, USA
| | - Dewi Depositario-Cabacar
- Division of Epilepsy and Neurophysiology, Children's National Health System, Washington, DC, USA
| | - Amy Kao
- Division of Epilepsy and Neurophysiology, Children's National Health System, Washington, DC, USA.
- Center for Behavioral Neurosciences, Children's National Health System, Washington, DC, USA.
| |
Collapse
|
38
|
Abstract
PURPOSE OF REVIEW The treatment of epilepsy in children is highly individualized at each and every major step in the management. This review examines various factors that modify the treatment from the point of initiation of therapy to the decision to stop an antiepileptic drug (AED). RECENT FINDINGS AED therapy leads to seizure freedom in about 70% of all children with epilepsy. AED initiation could be delayed until a second seizure in most children and may be avoided altogether in many children with self-limited childhood focal epilepsies. Three key factors influence the choice of AED: seizure type(s), efficacy of the drug for the seizure type, and the side effect profile of the drug(s). For epileptic spasms, steroids and vigabatrin are the most effective treatment options. For absence seizures, ethosuximide and valproic acid are superior to lamotrigine. For focal seizures, many newer AEDs have favorable side effect profiles with efficacy comparable to older-generation drugs. For generalized epilepsies, valproic acid remains the most effective drug for a broad range of seizure types. Genetic and metabolic etiologies may guide unique treatment choices in some children. After 2 years or more of seizure freedom, if the recurrence risk after AED withdrawal is acceptable, slow weaning of AEDs should be done over the span of 6 weeks or longer. After discontinuation, about 70% of patients remain seizure free, and of those with recurrence, the majority achieve seizure control with restarting an AED. When treatment with two or more AEDs fails, other treatment opportunities for drug-resistant epilepsy, including epilepsy surgery, vagal nerve stimulation, and dietary therapies should be considered. SUMMARY Carefully selected medical therapy guided by seizure type and AED characteristics is effective in more than two-thirds of children with epilepsy.
Collapse
|
39
|
de Oliveira AM, Paulino MV, Vieira APF, McKinney AM, da Rocha AJ, dos Santos GT, Leite CDC, Godoy LFDS, Lucato LT. Imaging Patterns of Toxic and Metabolic Brain Disorders. Radiographics 2019; 39:1672-1695. [DOI: 10.1148/rg.2019190016] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
|
40
|
Vigabatrin-Induced Encephalopathy in a 5.5-Month-Old Girl with Infantile Spasms due to Tuberous Sclerosis. Case Rep Pediatr 2019; 2019:7249237. [PMID: 31534811 PMCID: PMC6732644 DOI: 10.1155/2019/7249237] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Revised: 07/25/2019] [Accepted: 08/01/2019] [Indexed: 12/29/2022] Open
Abstract
A 5.5-month-old female infant with tuberous sclerosis complex presented with infantile spasms and was treated with vigabatrin. As her condition did not improve, she was given adrenocorticotropic hormone (ACTH) intramuscularly which stopped the spasms and improved the electroencephalogram (EEG) abnormalities. However, she developed encephalopathy with apathy, drowsiness, and generalized slowing in the EEG. Discontinuation of vigabatrin quickly improved her symptoms and reversed the EEG slowing. A high index of suspicion is required in order to diagnose vigabatrin-induced encephalopathy, especially as the underlying disorders of these patients can be erroneously considered the cause of the observed encephalopathy.
Collapse
|
41
|
Moghaddam SM, Birbeck GL, Taylor TE, Seydel KB, Kampondeni SD, Potchen MJ. Diffusion-Weighted MR Imaging in a Prospective Cohort of Children with Cerebral Malaria Offers Insights into Pathophysiology and Prognosis. AJNR Am J Neuroradiol 2019; 40:1575-1580. [PMID: 31439630 PMCID: PMC7048462 DOI: 10.3174/ajnr.a6159] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Accepted: 06/28/2019] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Validation of diffusion-weighted images obtained on 0.35T MR imaging in Malawi has facilitated meaningful review of previously unreported findings in cerebral malaria. Malawian children with acute cerebral malaria demonstrated restricted diffusion on brain MR imaging, including an unusual pattern of restriction isolated to the subcortical white matter. We describe the patterns of diffusion restriction in cerebral malaria and further evaluate risk factors for and outcomes associated with an isolated subcortical white matter diffusion restriction. MATERIALS AND METHODS Between 2009 and 2014, comatose Malawian children admitted to the hospital with cerebral malaria underwent admission brain MR imaging. Imaging data were compiled via NeuroInterp, a RedCap data base. Clinical information obtained included coma score, serum studies, and coma duration. Electroencephalograms were obtained between 2009 and 2011. Outcomes captured included death, neurologic sequelae, or full recovery. RESULTS One hundred ninety-four/269 (72.1%) children with cerebral malaria demonstrated at least 1 area of diffusion restriction. The most common pattern was bilateral subcortical white matter involvement (41.6%), followed by corpus callosum (37.5%), deep gray matter (36.8%), cortical gray matter (17.8%), and posterior fossa (8.9%) involvement. Sixty-one (22.7%) demonstrated isolated subcortical white matter diffusion restriction. These children had lower whole-blood lactate levels (OR, 0.9; 95% CI, 0.85-0.98), were less likely to require anticonvulsants (OR, 0.6; 95% CI, 0.30-0.98), had higher average electroencephalogram voltage (OR, 1.01; 95% CI, 1.00-1.02), were less likely to die (OR, 0.09; 95% CI, 0.01-0.67), and were more likely to recover without neurologic sequelae (OR, 3.7; 95% CI, 1.5-9.1). CONCLUSIONS Restricted diffusion is common in pediatric cerebral malaria. Isolated subcortical white matter diffusion restriction is a unique imaging pattern associated with less severe disease and a good prognosis for full recovery. The underlying pathophysiology may be related to selective white matter vulnerability.
Collapse
Affiliation(s)
- S M Moghaddam
- From the Department of Imaging Sciences (S.M.M., M.J.P.)
| | - G L Birbeck
- Department of Neurology, Department of Public Health, Center for Experimental Therapeutics (G.L.B.), University of Rochester, Rochester, New York
| | - T E Taylor
- Department of Osteopathic Medical Specialties (T.E.T., K.B.S.), Michigan State University, East Lansing, Michigan
| | - K B Seydel
- Department of Osteopathic Medical Specialties (T.E.T., K.B.S.), Michigan State University, East Lansing, Michigan
| | - S D Kampondeni
- Queen Elizabeth Central Hospital (S.D.K.), University of Malawi College of Medicine, Blantyre, Malawi
| | - M J Potchen
- From the Department of Imaging Sciences (S.M.M., M.J.P.)
| |
Collapse
|
42
|
Yoon DH, Moon JU, Lee JY, Lee IG. Reconsideration of Vigabatrin Effect in Infantile Spasms Treatment. ANNALS OF CHILD NEUROLOGY 2019. [DOI: 10.26815/acn.2019.00094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
|
43
|
Kennedy AD, Pappan KL, Donti T, Delgado MR, Shinawi M, Pearson TS, Lalani SR, Craigen WE, Sutton VR, Evans AM, Sun Q, Emrick LT, Elsea SH. 2-Pyrrolidinone and Succinimide as Clinical Screening Biomarkers for GABA-Transaminase Deficiency: Anti-seizure Medications Impact Accurate Diagnosis. Front Neurosci 2019; 13:394. [PMID: 31133775 PMCID: PMC6517487 DOI: 10.3389/fnins.2019.00394] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Accepted: 04/05/2019] [Indexed: 11/13/2022] Open
Abstract
Broad-scale untargeted biochemical phenotyping is a technology that supplements widely accepted assays, such as organic acid, amino acid, and acylcarnitine analyses typically utilized for the diagnosis of inborn errors of metabolism. In this study, we investigate the analyte changes associated with 4-aminobutyrate aminotransferase (ABAT, GABA transaminase) deficiency and treatments that affect GABA metabolism. GABA-transaminase deficiency is a rare neurodevelopmental and neurometabolic disorder caused by mutations in ABAT and resulting in accumulation of GABA in the cerebrospinal fluid (CSF). For that reason, measurement of GABA in CSF is currently the primary approach to diagnosis. GABA-transaminase deficiency results in severe developmental delay with intellectual disability, seizures, and movement disorder, and is often associated with death in childhood. Using an untargeted metabolomics platform, we analyzed EDTA plasma, urine, and CSF specimens from four individuals with GABA-transaminase deficiency to identify biomarkers by comparing the biochemical profile of individual patient samples to a pediatric-centric population cohort. Metabolomic analyses of over 1,000 clinical plasma samples revealed a rich source of biochemical information. Three out of four patients showed significantly elevated levels of the molecule 2-pyrrolidinone (Z-score ≥2) in plasma, and whole exome sequencing revealed variants of uncertain significance in ABAT. Additionally, these same patients also had elevated levels of succinimide in plasma, urine, and CSF and/or homocarnosine in urine and CSF. In the analysis of clinical EDTA plasma samples, the levels of succinimide and 2-pyrrolidinone showed a high level of correlation (R = 0.73), indicating impairment in GABA metabolism and further supporting the association with GABA-transaminase deficiency and the pathogenicity of the ABAT variants. Further analysis of metabolomic data across our patient population revealed the association of elevated levels of 2-pyrrolidinone with administration of vigabatrin, a commonly used anti-seizure medication and a known inhibitor of GABA-transaminase. These data indicate that anti-seizure medications may alter the biochemical and metabolomic data, potentially impacting the interpretation and diagnosis for the patient. Further, these data demonstrate the power of combining broad scale genotyping and phenotyping technologies to diagnose inherited neurometabolic disorders and support the use of metabolic phenotyping of plasma to screen for GABA-transaminase deficiency.
Collapse
Affiliation(s)
| | | | - Taraka Donti
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX, United States
| | - Mauricio R Delgado
- Department of Neurology and Neurotherapeutics, Texas Scottish Rite Hospital for Children, The University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Marwan Shinawi
- Department of Pediatrics, Washington University School of Medicine St. Louis, St. Louis, MO, United States
| | - Toni S Pearson
- Department of Neurology, Washington University School of Medicine St. Louis, St. Louis, MO, United States
| | - Seema R Lalani
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX, United States
| | - William E Craigen
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX, United States
| | - V Reid Sutton
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX, United States
| | | | - Qin Sun
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX, United States
| | - Lisa T Emrick
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX, United States.,Department of Neurology, Baylor College of Medicine, Houston, TX, United States
| | - Sarah H Elsea
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX, United States
| |
Collapse
|
44
|
Abstract
The treatment of infantile spasms is challenging, especially in the context of the following: (1) a severe phenotype with high morbidity and mortality; (2) the urgency of diagnosis and successful early response to therapy; and (3) the paucity of effective, safe, and well-tolerated therapies. Even after initially successful treatment, relapse risk is substantial and the most effective therapies pose considerable risk with long-term administration. In evaluating any treatment for infantile spasms, the key short-term outcome measure is freedom from both epileptic spasms and hypsarrhythmia. In contrast, the most important long-term outcomes are enduring seizure-freedom and measures of intellectual performance in later childhood and adulthood. First-line treatment options-namely hormonal therapy and vigabatrin-display moderate to high efficacy but also exhibit substantial side-effect burdens. Data on efficacy and safety of each class of therapy, as well as the combination of these therapies, are reviewed in detail. Specific hormonal therapies (adrenocorticotropic hormone and various corticosteroids) are contrasted. Those etiologies that prompt specific therapies are reviewed briefly, as are an array of second-line therapies supported by less-compelling data. The ketogenic diet is discussed in greater detail, with a focus on the limitations of numerous available studies that generally suggest that it is efficacious. Special discussion is allocated to cannabidiol-the investigational therapy that has received the most attention, and which is already in use in the form of various artisanal cannabis extracts. Finally, a treatment algorithm reflecting the concepts and controversies discussed in this review is presented.
Collapse
Affiliation(s)
- Shaun A. Hussain
- Division of Pediatric NeurologyDavid Geffen School of MedicineUCLA Mattel Children's HospitalLos AngelesCaliforniaU.S.A.
| |
Collapse
|
45
|
Hussain SA, Schmid E, Peters JM, Goyal M, Bebin EM, Northrup H, Sahin M, Krueger DA, Wu JY. High vigabatrin dosage is associated with lower risk of infantile spasms relapse among children with tuberous sclerosis complex. Epilepsy Res 2018; 148:1-7. [PMID: 30296632 DOI: 10.1016/j.eplepsyres.2018.09.016] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Revised: 09/07/2018] [Accepted: 09/28/2018] [Indexed: 11/16/2022]
Abstract
After initially successful treatment of infantile spasms, the long-term cumulative risk of relapse approaches 50%, and there is no established protocol to mitigate this risk. Although vigabatrin may be an effective means to prevent relapse, there is little guidance as to ideal duration and dosage. Using a cohort of children with infantile spasms and tuberous sclerosis complex (TSC), we evaluated the potential association of post-response VGB treatment and the rate of infantile spasms relapse. Patients with infantile spasms and clinical response to vigabatrin were identified among a multicenter prospective observational cohort of children with TSC. For each patient we recorded dates of infantile spasms onset, response to vigabatrin, relapse (if any), and quantified duration and dosage of vigabatrin after response. Time to relapse as a function of vigabatrin exposure was evaluated using survival analyses. We identified 50 children who responded to VGB. During a median follow-up of 16.6 months (IQR 10.3-22.9), 12 (24%) patients subsequently relapsed after a median of 7.8 months (IQR 3.1-9.6). Relapse occurred after VGB discontinuation in four patients, and during continued VGB treatment in the remaining eight cases. In survival analyses, risk of relapse was unaffected by the presence or absence of VGB treatment (HR 0.31, 95%CI 0.01-28.4, P = 0.61), but weighted-average dosage was associated with marked reduction in relapse risk: Each 50 mg/kg/d increment in dosage was associated with 61% reduction in risk (HR 0.39, 95%CI 0.17 - 0.90, P = 0.026). This study suggests that the risk of infantile spasms relapse in TSC may be reduced by high-dose vigabatrin treatment.
Collapse
Affiliation(s)
- Shaun A Hussain
- Division of Pediatric Neurology, UCLA Mattel Children's Hospital and David Geffen School of Medicine, Los Angeles, California, United States.
| | - Ernst Schmid
- Division of Pediatric Neurology, UCLA Mattel Children's Hospital and David Geffen School of Medicine, Los Angeles, California, United States
| | - Jurriaan M Peters
- Translational Neuroscience Center, Department of Neurology, Boston Children's Hospital, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts, United States
| | - Monisha Goyal
- Department of Neurology, University of Alabama at Birmingham, Birmingham, Alabama, United States
| | - E Martina Bebin
- Department of Neurology, University of Alabama at Birmingham, Birmingham, Alabama, United States
| | - Hope Northrup
- University of Texas Houston, Houston, Texas, United States
| | - Mustafa Sahin
- Translational Neuroscience Center, Department of Neurology, Boston Children's Hospital, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts, United States
| | - Darcy A Krueger
- Department of Neurology, Cincinnati Children's Hospital, Cincinnati, Ohio, United States
| | - Joyce Y Wu
- Division of Pediatric Neurology, UCLA Mattel Children's Hospital and David Geffen School of Medicine, Los Angeles, California, United States
| | | |
Collapse
|
46
|
Kontzialis M, Huisman TAGM. Toxic-Metabolic Neurologic Disorders in Children: A Neuroimaging Review. J Neuroimaging 2018; 28:587-595. [PMID: 30066477 DOI: 10.1111/jon.12551] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Revised: 07/12/2018] [Accepted: 07/13/2018] [Indexed: 12/19/2022] Open
Abstract
There are multiple causes of neurotoxicity in children including medications, extrinsic toxins and insults, illicit drugs, built up of toxic metabolites due to genetic or acquired disorders, and metabolic abnormalities. The review is centered on causes of neurotoxicity affecting the pediatric brain and producing typical and easily recognized imaging manifestations. Early identification of common and less common imaging findings may point toward the correct direction, and may facilitate early diagnosis and institution of appropriate treatment to reverse or at least limit the injury to the developing brain. Two common imaging patterns of neurotoxicity in children are the posterior reversible encephalopathy syndrome and acute toxic leukoencephalopathy that are usually related to chemotherapy and immunosuppression for common pediatric malignancies. Another well-described imaging pattern of injury in children involves reversible splenial lesions with or without associated white matter abnormalities. Multiple additional extrinsic causes of neurotoxicity are presented including radiation and chemoradiation, various medications and treatment regimens, poisoning, illicit drug use or accidental exposure, and the respective characteristic neuroimaging findings are highlighted. Intrinsic neurotoxicity may occur in the setting of inborn errors of metabolism or acquired progressive organ failure leading to build up of toxic metabolites. Additional intrinsic causes of neurotoxicity include metabolic derangements and characteristic imaging findings in all instances are reviewed. The goal of the article is to enhance familiarity of neurologists and neuroradiologists with the imaging appearance of common and less common toxic insults to the pediatric brain.
Collapse
Affiliation(s)
- Marinos Kontzialis
- Section of Neuroradiology, Department of Radiology, Rush University Medical Center, Chicago, IL
| | - Thierry A G M Huisman
- Pediatric Radiology, Russell H. Morgan Department of Radiology and Radiological Science, The Johns Hopkins University School of Medicine, Baltimore, MD
| |
Collapse
|
47
|
Abstract
West syndrome (WS), also known as infantile spasms, occurs in infancy with a peak between 4 and 7 months. Spasms, neurodevelopmental regression and hypsarrhythmia on electroencephalogram (EEG) basically define WS. The International League Against Epilepsy commission classifies the aetiologies of WS into genetic, structural, metabolic and unknown. Early diagnosis and a shorter lag time to treatment are essential for the overall outcome of WS patients. These goals are feasible with the addition of brain magnetic resonance imaging (MRI) and genetic and metabolic testing. The present work analysed the medical literature on WS and reports the principal therapeutic protocols of its management. Adrenocorticotropic hormone (ACTH), vigabatrin (VGB) and corticosteroids are the first-line treatments for WS. There is no unique therapeutic protocol for ACTH, but most of the evidence suggests that low doses are as effective as high doses for short-term treatment, which is generally 2 weeks followed by dose tapering. VGB is generally administered at doses from 50 to 150 mg/kg/day, but its related retinal toxicity, which occurs in 21-34% of infants, is most frequently observed when treatment periods last longer than 6 months. Among corticosteroids, a treatment of 14 days of oral prednisolone (40-60 mg/day) has been considered effective and well tolerated. Considering that an early diagnosis and a shorter lag time to treatment are essential for successful outcomes in these patients, further studies on efficacy of the different therapeutic approaches with evaluation of final outcome after cessation of therapy are needed.
Collapse
|
48
|
Pearl PL, Poduri A, Prabhu SP, Harini C, Goldstein R, Atkinson RM, Armstrong D, Kinney H. White matter spongiosis with vigabatrin therapy for infantile spasms. Epilepsia 2018; 59:e40-e44. [PMID: 29473152 DOI: 10.1111/epi.14032] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/25/2018] [Indexed: 11/26/2022]
Abstract
The histopathology, "white matter spongiosis," defined by electron microscopy (EM) as "intramyelinic edema," has been associated with vigabatrin therapy in various animal models, but its role or significance in clinical studies is unknown. We conducted a neuropathological examination on a 27-month-old boy with bilateral polymicrogyria and epilepsy after sudden unexpected death in epilepsy (SUDEP). The patient was initiated on vigabatrin at 4 months of age, which controlled infantile spasms, and was continued as maintenance therapy. Autopsy showed a combination of developmental and acquired lesions: (1) bilateral gyral malformations of the frontal, parietal, temporal, and insular cortex; (2) agenesis of the olfactory tracts and bulbs; (3) hippocampal abnormalities: dentate gyrus bilamination and granule cell dispersion; and (4) areas of microscopic bilateral, symmetric white matter spongiosis in the brainstem central tegmental tract, amiculum and hilum of the inferior olive, medial longitudinal fasciculus, paragigantocellularis lateralis, optic nerves and chiasm, and hypothalamus. The white matter spongiosis was identical to the histopathologic lesions (which by EM exhibited intramyelinic edema) that were demonstrated in animal models on vigabatrin therapy, indicating that vigabatrin toxicity is not restricted to animal models.
Collapse
Affiliation(s)
- Phillip L Pearl
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Annapurna Poduri
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
- Robert's Program, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Sanjay P Prabhu
- Robert's Program, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
- Department of Radiology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Chellamani Harini
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Richard Goldstein
- Robert's Program, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
- Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Dawna Armstrong
- Department of Pathology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Hannah Kinney
- Robert's Program, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
- Department of Pathology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| |
Collapse
|
49
|
Efficacy and safety of vigabatrin in Japanese patients with infantile spasms: Primary short-term study and extension study. Epilepsy Behav 2018; 78:134-141. [PMID: 29190579 DOI: 10.1016/j.yebeh.2017.09.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Revised: 09/15/2017] [Accepted: 09/15/2017] [Indexed: 11/20/2022]
Abstract
Vigabatrin was approved for the treatment of infantile spasms by the US Food and Drug Administration, but not in Japan at the time of initiating this clinical study because of concerns about irreversible peripheral visual field defects (VFDs). This study evaluated the efficacy and safety of vigabatrin for Japanese patients with infantile spasms. Of 15 patients (aged ≥4weeks and <2years) enrolled, with the exception of two patients who did not receive vigabatrin, 13 were treated with a titrated dosage of vigabatrin (50-150mg/kg/day; limited to 3000mg/day). Twelve out of 13 patients receiving vigabatrin had spasms that were treatment refractory; these patients were concurrently treated with at least one other antiepileptic drug. One patient received vigabatrin monotherapy. Eight of the 13 patients (61.5% [95% CI: 31.6-86.1%]) had a ≥50% reduction during the dose-adjustment phase compared with baseline in the frequency of spasms, with efficacy maintained through a 2-week maintenance phase. Spasms disappeared in six out of nine patients (66.7% [95% CI: 29.9-92.5%]) who transitioned to the maintenance phase and hypsarrhythmia on electroencephalography also resolved in four patients. Hypsarrhythmia was improved in another two patients. Six out of seven patients who continued treatment through Week 32 of an extension study reported ongoing efficacy for vigabatrin. The most common adverse events (AEs) were psychiatric disorders and nervous system disorders (n=8; 61.5%) that were generally mild in severity. No treatment-related peripheral VFDs were observed. No severe AEs or AEs resulting in discontinuation of vigabatrin therapy were reported. An abnormality in magnetic resonance images was observed in one patient during the extension period. Vigabatrin was deemed to be clinically effective and well tolerated in Japanese patients with infantile spasms.
Collapse
|
50
|
Costain G, Shugar A, Krishnan P, Mahmutoglu S, Laughlin S, Kannu P. Homozygous mutation in PRUNE1 in an Oji-Cree male with a complex neurological phenotype. Am J Med Genet A 2017; 173:740-743. [PMID: 28211990 DOI: 10.1002/ajmg.a.38066] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2016] [Accepted: 10/27/2016] [Indexed: 01/09/2023]
Abstract
The PRUNE1 gene encodes a member of the phosphoesterases (DHH) protein superfamily that is highly expressed in the human fetal brain and involved in the regulation of cell migration. Homozygous or compound heterozygous PRUNE1 mutations were recently identified in five individuals with brain malformations from four families. We present a case of a 2-year-old male with a complex neurological phenotype and abnormalities on brain MRI. Re-annotation of clinical whole-exome sequencing data revealed a homozygous likely pathogenic variant in PRUNE1 (c.521-2A>G). These results further delineate a new PRUNE1-related syndrome, and highlight the importance of periodic data re-annotation in individuals who remain without a diagnosis after undergoing genome-wide testing. © 2017 Wiley Periodicals, Inc.
Collapse
Affiliation(s)
- Gregory Costain
- Medical Genetics Residency Training Program, University of Toronto, Ontario, Canada.,Division of Clinical and Metabolic Genetics, The Hospital for Sick Children, Ontario, Canada
| | - Andrea Shugar
- Division of Clinical and Metabolic Genetics, The Hospital for Sick Children, Ontario, Canada.,Department of Molecular Genetics, University of Toronto, Ontario, Canada
| | - Pradeep Krishnan
- Department of Diagnostic Imaging, The Hospital for Sick Children, Ontario, Canada
| | - Saadet Mahmutoglu
- Division of Clinical and Metabolic Genetics, The Hospital for Sick Children, Ontario, Canada
| | - Suzanne Laughlin
- Department of Diagnostic Imaging, The Hospital for Sick Children, Ontario, Canada
| | - Peter Kannu
- Division of Clinical and Metabolic Genetics, The Hospital for Sick Children, Ontario, Canada.,Institute of Medical Sciences, University of Toronto, Ontario, Canada
| |
Collapse
|