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Macdonald-Laurs E, Dzau W, Warren AEL, Coleman M, Mignone C, Stephenson SEM, Howell KB. Identification and treatment of surgically-remediable causes of infantile epileptic spasms syndrome. Expert Rev Neurother 2024:1-20. [PMID: 38814860 DOI: 10.1080/14737175.2024.2360117] [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: 04/01/2024] [Accepted: 05/22/2024] [Indexed: 06/01/2024]
Abstract
INTRODUCTION Infantile epileptic spasms syndrome (IESS) is a common developmental and epileptic encephalopathy with poor long-term outcomes. A substantial proportion of patients with IESS have a potentially surgically remediable etiology. Despite this, epilepsy surgery is underutilized in this patient group. Some surgically remediable etiologies, such as focal cortical dysplasia and malformation of cortical development with oligodendroglial hyperplasia in epilepsy (MOGHE), are under-diagnosed in infants and young children. Even when a surgically remediable etiology is recognised, for example, tuberous sclerosis or focal encephalomalacia, epilepsy surgery may be delayed or not considered due to diffuse EEG changes, unclear surgical boundaries, or concerns about operating in this age group. AREAS COVERED In this review, the authors discuss the common surgically remediable etiologies of IESS, their clinical and EEG features, and the imaging techniques that can aid in their diagnosis. They then describe the surgical approaches used in this patient group, and the beneficial impact that early epilepsy surgery can have on developing brain networks. EXPERT OPINION Epilepsy surgery remains underutilized even when a potentially surgically remediable cause is recognized. Overcoming the barriers that result in under-recognition of surgical candidates and underutilization of epilepsy surgery in IESS will improve long-term seizure and developmental outcomes.
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Affiliation(s)
- Emma Macdonald-Laurs
- Department of Neurology, The Royal Children's Hospital, Parkville, VIC, Australia
- Neurosciences Group, Murdoch Children's Research Institute, Parkville, VIC, Australia
- Department of Paediatrics, The University of Melbourne, Melbourne, VIC, Australia
| | - Winston Dzau
- Neurosciences Group, Murdoch Children's Research Institute, Parkville, VIC, Australia
- Department of Paediatrics, The University of Melbourne, Melbourne, VIC, Australia
| | - Aaron E L Warren
- Department of Medicine (Austin Health), The University of Melbourne, Melbourne, VIC, Australia
- Brigham and Women's Hospital, Harvard Medical School, Massachusetts, USA
| | - Matthew Coleman
- Neurosciences Group, Murdoch Children's Research Institute, Parkville, VIC, Australia
- Department of Paediatrics, The University of Melbourne, Melbourne, VIC, Australia
| | - Cristina Mignone
- Department of Medical Imaging, The Royal Children's Hospital, Parkville, VIC, Australia
| | - Sarah E M Stephenson
- Neurosciences Group, Murdoch Children's Research Institute, Parkville, VIC, Australia
- Department of Paediatrics, The University of Melbourne, Melbourne, VIC, Australia
| | - Katherine B Howell
- Department of Neurology, The Royal Children's Hospital, Parkville, VIC, Australia
- Neurosciences Group, Murdoch Children's Research Institute, Parkville, VIC, Australia
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Cohen NT, Xie H, Gholipour T, Gaillard WD. A scoping review of the functional magnetic resonance imaging-based functional connectivity of focal cortical dysplasia-related epilepsy. Epilepsia 2023; 64:3130-3142. [PMID: 37731142 DOI: 10.1111/epi.17775] [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: 06/13/2023] [Revised: 09/17/2023] [Accepted: 09/18/2023] [Indexed: 09/22/2023]
Abstract
Focal cortical dysplasia (FCD) is the most frequent etiology of operable pharmacoresistant epilepsy in children. There is burgeoning evidence that FCD-related epilepsy is a disorder that involves distributed brain networks. Functional magnetic resonance imaging (fMRI) is a tool that allows one to infer neuronal activity and to noninvasively map whole-brain functional networks. Despite its relatively widespread availability at most epilepsy centers, the clinical application of fMRI remains mostly task-based in epilepsy. Another approach is to map and characterize cortical functional networks of individuals using resting state fMRI (rsfMRI). The focus of this scoping review is to summarize the evidence to date of investigations of the network basis of FCD-related epilepsy, and to highlight numerous potential future applications of rsfMRI in the exploration of diagnostic and therapeutic strategies for FCD-related epilepsy. There are numerous studies demonstrating a global disruption of cortical functional networks in FCD-related epilepsy. The underlying pathological subtypes of FCD influence overall functional network patterns. There is evidence that cortical functional network mapping may help to predict postsurgical seizure outcomes, highlighting the translational potential of these findings. Additionally, several studies emphasize the important effect of FCD interaction with cortical networks and the expression of epilepsy and its comorbidities.
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Affiliation(s)
- Nathan T Cohen
- Center for Neuroscience Research, Children's National Hospital, George Washington University School of Medicine, Washington, District of Columbia, USA
- Department of Neurology, Children's National Hospital, George Washington University School of Medicine, Washington, District of Columbia, USA
| | - Hua Xie
- Center for Neuroscience Research, Children's National Hospital, George Washington University School of Medicine, Washington, District of Columbia, USA
- Department of Neurology, Children's National Hospital, George Washington University School of Medicine, Washington, District of Columbia, USA
| | - Taha Gholipour
- Center for Neuroscience Research, Children's National Hospital, George Washington University School of Medicine, Washington, District of Columbia, USA
- Department of Neurology, George Washington University Epilepsy Center, Washington, District of Columbia, USA
| | - William D Gaillard
- Center for Neuroscience Research, Children's National Hospital, George Washington University School of Medicine, Washington, District of Columbia, USA
- Department of Neurology, Children's National Hospital, George Washington University School of Medicine, Washington, District of Columbia, USA
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Nurse ES, Dalic LJ, Clarke S, Cook M, Archer J. Deep learning for automated detection of generalized paroxysmal fast activity in Lennox-Gastaut syndrome. Epilepsy Behav 2023; 147:109418. [PMID: 37677902 DOI: 10.1016/j.yebeh.2023.109418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 08/22/2023] [Accepted: 08/25/2023] [Indexed: 09/09/2023]
Abstract
OBJECTIVES Generalized paroxysmal fast activity (GPFA) is a key electroencephalographic (EEG) feature of Lennox-Gastaut Syndrome (LGS). Automated analysis of scalp EEG has been successful in detecting more typical abnormalities. Automatic detection of GPFA has been more challenging, due to its variability from patient to patient and similarity to normal brain rhythms. In this work, a deep learning model is investigated for detection of GPFA events and estimating their overall burden from scalp EEG. METHODS Data from 10 patients recorded during four ambulatory EEG monitoring sessions are used to generate and validate the model. All patients had confirmed LGS and were recruited into a trial for thalamic deep-brain stimulation therapy (ESTEL Trial). RESULTS The correlation coefficient between manual and model estimates of event counts was r2 = 0.87, and for total burden was r2 = 0.91. The average GPFA detection sensitivity was 0.876, with an average false-positive rate of 3.35 per minute. There was no significant difference found between patients with early or delayed deep brain stimulation (DBS) treatment, or those with active vagal nerve stimulation (VNS). CONCLUSIONS Overall, the deep learning model was able to accurately detect GPFA and provide accurate estimates of the overall GPFA burden and electrographic event counts, albeit with a high false-positive rate. SIGNIFICANCE Automated GPFA detection may enable automated calculation of EEG biomarkers of burden of disease in LGS.
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Affiliation(s)
- Ewan S Nurse
- Seer Medical, Melbourne, VIC 3000, Australia; Department of Medicine (St. Vincent's Hospital Melbourne), University of Melbourne, Fitzroy, VIC 3065, Australia.
| | - Linda J Dalic
- Department of Medicine (Austin Hospital), University of Melbourne, Heidelberg, VIC 3084, Australia; Department of Neurology, Austin Health, Heidelberg, VIC 3084, Australia
| | | | - Mark Cook
- Department of Medicine (St. Vincent's Hospital Melbourne), University of Melbourne, Fitzroy, VIC 3065, Australia
| | - John Archer
- Department of Medicine (Austin Hospital), University of Melbourne, Heidelberg, VIC 3084, Australia; Department of Neurology, Austin Health, Heidelberg, VIC 3084, Australia; The Florey Institute of Neuroscience and Mental Health, Heidelberg, VIC 3084, Australia; Murdoch Children's Research Institute, Parkville, VIC 3052, Australia
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Brookes A, Jewell A, Feng W, Bradshaw TD, Butler J, Gershkovich P. Oral lipid-based formulations alter delivery of cannabidiol to different anatomical regions in the brain. Int J Pharm 2023; 635:122651. [PMID: 36720447 DOI: 10.1016/j.ijpharm.2023.122651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2022] [Revised: 01/19/2023] [Accepted: 01/22/2023] [Indexed: 01/30/2023]
Abstract
Delivery to the brain is a challenging task due to its protection by the blood-brain barrier (BBB). Lipids and fatty acids are reported to affect the permeability of the BBB, although this has not been reported following oral administration. Cannabidiol (CBD) has high therapeutic potential in the brain, therefore, this work investigated CBD delivery to anatomical brain regions following oral administration in lipid-based and lipid-free vehicles. All formulations resulted in a short brain Tmax (1 h) and brain-plasma ratios ≥ 3.5, with retention up to 18 h post administration. The highest CBD delivery was observed in the olfactory bulb and striatum, and the medulla pons and cerebellum the lowest. The lipid-free vehicle led to the highest levels of CBD in the whole brain. However, when each anatomical region was assessed individually, the long chain triglyceride-rich rapeseed oil formulation commonly showed optimal performance. The medium chain triglyceride-rich coconut oil formulation did not result in the highest CBD concentration in any brain region. Overall, differences in CBD delivery to the whole brain and various brain regions were observed following administration in different formulations, indicating that the oral formulation selection may be important for optimal delivery to specific regions of the brain.
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Affiliation(s)
- Alice Brookes
- School of Pharmacy, University of Nottingham, Nottingham NG7 2RD, UK
| | - Adelaide Jewell
- School of Pharmacy, University of Nottingham, Nottingham NG7 2RD, UK
| | - Wanshan Feng
- School of Pharmacy, University of Nottingham, Nottingham NG7 2RD, UK
| | - Tracey D Bradshaw
- School of Pharmacy, University of Nottingham, Nottingham NG7 2RD, UK
| | - James Butler
- GlaxoSmithKline Research and Development, Park Road, Ware, Hertfordshire SG12 0DP, UK
| | - Pavel Gershkovich
- School of Pharmacy, University of Nottingham, Nottingham NG7 2RD, UK.
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Balfroid T, Warren AE, Dalic LJ, Aeby A, Berlangieri SU, Archer JS. Frontoparietal 18F-FDG-PET hypo-metabolism in Lennox-Gastaut syndrome: further evidence highlighting the key network. Epilepsy Res 2023; 192:107131. [PMID: 37054522 DOI: 10.1016/j.eplepsyres.2023.107131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Revised: 03/20/2023] [Accepted: 03/27/2023] [Indexed: 03/31/2023]
Abstract
INTRODUCTION Lennox Gastaut syndrome (LGS) can be conceptualised as a "secondary network epilepsy", in which the shared electroclinical manifestations reflect epileptic recruitment of a common brain network, despite a range of underlying aetiologies. We aimed to identify the key networks recruited by the epileptic process of LGS using interictal 2-deoxy-2-(18F)fluoro-D-glucose positron emission tomography (18F-FDG-PET). METHODS Group analysis of cerebral 18F-FDG-PET, comparing 21 patients with LGS (mean age = 15 years) and 18 pseudo-controls (mean age = 19 years), studied at Austin Health Melbourne, between 2004 and 2015. To minimise the influence of individual patient lesions in the LGS group, we only studied brain hemispheres without structural MRI abnormalities. The pseudo-control group consisted of age- and sex-matched patients with unilateral temporal lobe epilepsy, using only the hemispheres contralateral to the side of epilepsy. Voxel-wise permutation testing compared 18F-FDG-PET uptake between groups. Associations were explored between areas of altered metabolism and clinical variables (age of seizure onset, proportion of life with epilepsy, and verbal/nonverbal ability). Penetrance maps were calculated to explore spatial consistency of altered metabolic patterns across individual patients with LGS. RESULTS Although not always readily apparent on visual inspection of individual patient scans, group analysis revealed hypometabolism in a network of regions including prefrontal and premotor cortex, anterior and posterior cingulate, inferior parietal lobule, and precuneus (p < 0.05, corrected for family-wise error). These brain regions tended to show a greater reduction in metabolism in non-verbal compared to verbal LGS patients, although this difference was not statistically significant. No areas of hypermetabolism were detected on group analysis, although ∼25 % of individual patients showed increased metabolism (relative to pseudo-controls) in the brainstem, putamen, thalamus, cerebellum, and pericentral cortex. DISCUSSION Interictal hypometabolism in frontoparietal cortex in LGS is compatible with our previous EEG-fMRI and SPECT studies showing that interictal bursts of generalised paroxysmal fast activity and tonic seizures recruit similar cortical regions. This study provides further evidence that these regions are central to the electroclinical expression of LGS.
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Dalic LJ, Warren AEL, Spiegel C, Thevathasan W, Roten A, Bulluss KJ, Archer JS. Paroxysmal fast activity is a biomarker of treatment response in deep brain stimulation for Lennox-Gastaut syndrome. Epilepsia 2022; 63:3134-3147. [PMID: 36114808 PMCID: PMC10946931 DOI: 10.1111/epi.17414] [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: 06/18/2022] [Revised: 09/15/2022] [Accepted: 09/16/2022] [Indexed: 01/11/2023]
Abstract
OBJECTIVE Epilepsy treatment trials typically rely on seizure diaries to determine seizure frequency, but these are time-consuming and difficult to maintain accurately. Fast, reliable, and objective biomarkers of treatment response are needed, particularly in Lennox-Gastaut syndrome (LGS), where high seizure frequency and comorbid cognitive and behavioral issues are additional obstacles to accurate diary-keeping. Here, we measured generalized paroxysmal fast activity (GPFA), a key interictal electrographic feature of LGS, and correlated GPFA burden with seizure diaries during a thalamic deep brain stimulation (DBS) treatment trial (Electrical Stimulation of the Thalamus in Epilepsy of Lennox-Gastaut Phenotype [ESTEL]). METHODS GPFA and electrographic seizure counts from intermittent, 24-h electroencephalograms (EEGs) were compared to 3-month diary-recorded seizure counts in 17 young adults with LGS (mean age ± SD = 24.9 ± 6.6) in the ESTEL study, a randomized clinical trial of DBS lasting 12 months (comprising a 3-month baseline and 9 months of postimplantation follow-up). RESULTS Baseline median seizures measured by diaries numbered 2.6 (interquartile range [IQR] = 1.4-5) per day, compared to 284 (IQR = 120.5-360) electrographic seizures per day, confirming that diaries capture only a small fraction of seizure burden. Across all patient EEGs, the average number of GPFA discharges per hour of sleep was 138 (IQR =72-258). GPFA duration and frequency, quantified over 2-h windows of sleep EEG, were significantly associated with diary-recorded seizure counts over 3-month intervals (p < .001, η2 p = .30-.48). For every GPFA discharge, there were 20-25 diary seizures witnessed over 3 months. There was high between-patient variability in the ratio between diary seizure burden and GPFA burden; however, within individual patients, the ratio was similar over time, such that the percentage change from pre-DBS baseline in seizure diaries strongly correlated with the percentage change in GPFA. SIGNIFICANCE When seeking to optimize treatment in patients with LGS, monitoring changes in GPFA may allow rapid titration of treatment parameters, rather than waiting for feedback from seizure diaries.
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Affiliation(s)
- Linda J. Dalic
- Department of Medicine, Austin HealthUniversity of MelbourneHeidelbergVictoriaAustralia
- Department of Neurology, Austin HealthHeidelbergVictoriaAustralia
| | - Aaron E. L. Warren
- Department of Medicine, Austin HealthUniversity of MelbourneHeidelbergVictoriaAustralia
- The Florey Institute of Neuroscience and Mental HealthHeidelbergVictoriaAustralia
- Murdoch Children's Research InstituteParkvilleVictoriaAustralia
| | - Chloe Spiegel
- Department of Neurology, Austin HealthHeidelbergVictoriaAustralia
| | - Wesley Thevathasan
- Department of Medicine, Austin HealthUniversity of MelbourneHeidelbergVictoriaAustralia
- Bionics InstituteEast MelbourneVictoriaAustralia
- Department of MedicineUniversity of Melbourne, and Department of Neurology, Royal Melbourne HospitalParkvilleVictoriaAustralia
| | - Annie Roten
- Department of Neurology, Austin HealthHeidelbergVictoriaAustralia
| | - Kristian J. Bulluss
- Bionics InstituteEast MelbourneVictoriaAustralia
- Department of Neurosurgery, Austin HealthHeidelbergVictoriaAustralia
- Department of SurgeryUniversity of MelbourneParkvilleVictoriaAustralia
| | - John S. Archer
- Department of Medicine, Austin HealthUniversity of MelbourneHeidelbergVictoriaAustralia
- Department of Neurology, Austin HealthHeidelbergVictoriaAustralia
- The Florey Institute of Neuroscience and Mental HealthHeidelbergVictoriaAustralia
- Murdoch Children's Research InstituteParkvilleVictoriaAustralia
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Eisermann M, Fillon L, Saitovitch A, Boisgontier J, Vinçon-Leite A, Dangouloff-Ros V, Blauwblomme T, Bourgeois M, Dangles MT, Coste-Zeitoun D, Vignolo-Diard P, Aubart M, Kossorotoff M, Hully M, Losito E, Chemaly N, Zilbovicius M, Desguerre I, Nabbout R, Boddaert N, Kaminska A. Periodic electroencephalographic discharges and epileptic spasms involve cortico-striatal-thalamic loops on Arterial Spin Labeling Magnetic Resonance Imaging. Brain Commun 2022; 4:fcac250. [PMID: 36324869 PMCID: PMC9598541 DOI: 10.1093/braincomms/fcac250] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2021] [Revised: 06/15/2022] [Accepted: 10/05/2022] [Indexed: 11/07/2022] Open
Abstract
Periodic discharges are a rare peculiar electroencephalogram pattern, occasionally associated with motor or other clinical manifestations, usually observed in critically ill patients. Their underlying pathophysiology remains poorly understood. Epileptic spasms in clusters and periodic discharges with motor manifestations share similar electroencephalogram pattern and some aetiologies of unfavourable prognosis such as subacute sclerosing panencephalitis or herpes encephalitis. Arterial spin labelling magnetic resonance imaging identifies localizing ictal and inter-ictal changes in neurovascular coupling, therefore assumed able to reveal concerned cerebral structures. Here, we retrospectively analysed ictal and inter-ictal arterial spin labelling magnetic resonance imaging in patients aged 6 months to 15 years (median 3 years 4 months) with periodic discharges including epileptic spasms, and compared these findings with those of patients with drug-resistant focal epilepsy who never presented periodic discharges nor epileptic spasms as well as to those of age-matched healthy controls. Ictal electroencephalogram was recorded either simultaneously with arterial spin labelling magnetic resonance imaging or during the close time lapse of patients' periodic discharges, whereas inter-ictal examinations were performed during the patients' active epilepsy but without seizures during the arterial spin labelling magnetic resonance imaging. Ictal arterial spin labelling magnetic resonance imaging was acquired in five patients with periodic discharges [subacute sclerosing panencephalitis (1), stroke-like events (3), West syndrome with cortical malformation (1), two of them also had inter-ictal arterial spin labelling magnetic resonance imaging]. Inter-ictal group included patients with drug-resistant epileptic spasms of various aetiologies (14) and structural drug-resistant focal epilepsy (8). Cortex, striatum and thalamus were segmented and divided in six functional subregions: prefrontal, motor (rostral, caudal), parietal, occipital and temporal. Rest cerebral blood flow values, absolute and relative to whole brain, were compared with those of age-matched controls for each subregion. Main findings were diffuse striatal as well as cortical motor cerebral blood flow increase during ictal examinations in generalized periodic discharges with motor manifestations (subacute sclerosing panencephalitis) and focal cerebral blood flow increase in corresponding cortical-striatal-thalamic subdivisions in lateralized periodic discharges with or without motor manifestations (stroke-like events and asymmetrical epileptic spasms) with straight topographical correlation with the electroencephalogram focus. For inter-ictal examinations, patients with epileptic spasms disclosed cerebral blood flow changes in corresponding cortical-striatal-thalamic subdivisions (absolute-cerebral blood flow decrease and relative-cerebral blood flow increase), more frequently when compared with the group of drug-resistant focal epilepsies, and not related to Vigabatrin treatment. Our results suggest that corresponding cortical-striatal-thalamic circuits are involved in periodic discharges with and without motor manifestations, including epileptic spasms, opening new insights in their pathophysiology and new therapeutical perspectives. Based on these findings, we propose a model for the generation of periodic discharges and of epileptic spasms combining existing pathophysiological models of cortical-striatal-thalamic network dynamics.
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Affiliation(s)
- Monika Eisermann
- Correspondence to: Monika Eisermann Clinical Neurophysiology, Hôpital Necker Enfants Malades AP-HP, Paris Université, 149 rue de Sèvres75015 Paris, France E-mail:
| | | | - Ana Saitovitch
- Pediatric Radiology Department, AP-HP, Hôpital Necker Enfants Malades, Université de Paris, F-75015, Paris, France
- Université de Paris, Institut Imagine INSERM U1163, F-75015, France
- INSERM U1299 Trajectoires développementales & psychiatrie, Paris, France
| | - Jennifer Boisgontier
- Pediatric Radiology Department, AP-HP, Hôpital Necker Enfants Malades, Université de Paris, F-75015, Paris, France
- Université de Paris, Institut Imagine INSERM U1163, F-75015, France
- INSERM U1299 Trajectoires développementales & psychiatrie, Paris, France
| | - Alice Vinçon-Leite
- Pediatric Radiology Department, AP-HP, Hôpital Necker Enfants Malades, Université de Paris, F-75015, Paris, France
- Université de Paris, Institut Imagine INSERM U1163, F-75015, France
- INSERM U1299 Trajectoires développementales & psychiatrie, Paris, France
| | - Volodia Dangouloff-Ros
- Pediatric Radiology Department, AP-HP, Hôpital Necker Enfants Malades, Université de Paris, F-75015, Paris, France
- Université de Paris, Institut Imagine INSERM U1163, F-75015, France
- INSERM U1299 Trajectoires développementales & psychiatrie, Paris, France
| | - Thomas Blauwblomme
- Pediatric Neurosurgery, Hôpital Necker, APHP, Paris France, Université de Paris, Paris, France, INSERM U1163, IHU Imagine, Paris, France
| | - Marie Bourgeois
- Pediatric Neurosurgery, Hôpital Necker, APHP, Paris France, Université de Paris, Paris, France, INSERM U1163, IHU Imagine, Paris, France
| | - Marie-Thérèse Dangles
- Clinical Neurophysiology, Hôpital Necker Enfants Malades, AP-HP, Paris Université, Paris, France
| | - Delphine Coste-Zeitoun
- Clinical Neurophysiology, Hôpital Necker Enfants Malades, AP-HP, Paris Université, Paris, France
| | - Patricia Vignolo-Diard
- Clinical Neurophysiology, Hôpital Necker Enfants Malades, AP-HP, Paris Université, Paris, France
| | - Mélodie Aubart
- Pediatric Neurology Department, Hôpital Necker Enfants Malades, AP-HP, INSERM U1163, Paris Université, Institut Imagine, Paris, France
| | - Manoelle Kossorotoff
- Pediatric Neurology Department, Necker Enfants Malades Hospital, AP-HP, Paris Université, Paris, France
| | - Marie Hully
- Pediatric Neurology Department, Necker Enfants Malades Hospital, AP-HP, Paris Université, Paris, France
| | - Emma Losito
- Clinical Neurophysiology, Hôpital Necker Enfants Malades, AP-HP, Paris Université, Paris, France
| | - Nicole Chemaly
- Reference Center for Rare Epilepsies, Department of Pediatric Neurology, Member of EPICARE Network, Institute Imagine INSERM 1163, Université de Paris, Paris, France
| | - Monica Zilbovicius
- Pediatric Radiology Department, AP-HP, Hôpital Necker Enfants Malades, Université de Paris, F-75015, Paris, France
- Université de Paris, Institut Imagine INSERM U1163, F-75015, France
- INSERM U1299 Trajectoires développementales & psychiatrie, Paris, France
| | - Isabelle Desguerre
- Pediatric Neurology Department, Hôpital Necker Enfants Malades, AP-HP, INSERM U1163, Paris Université, Institut Imagine, Paris, France
| | - Rima Nabbout
- Reference Center for Rare Epilepsies, Department of Pediatric Neurology, Member of EPICARE Network, Institute Imagine INSERM 1163, Université de Paris, Paris, France
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Aungaroon G. Does Deep Brain Stimulation Work in Lennox-Gastaut Syndrome? Well…it Depends. Epilepsy Curr 2022; 22:222-224. [PMID: 36187143 PMCID: PMC9483756 DOI: 10.1177/15357597221098819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
DBS of Thalamic Centromedian Nucleus for Lennox–Gastaut Syndrome (ESTEL
Trial) Dalic LJ, Warren AEL, Bulluss KJ, Thevathasan W, et al. Ann Nuerol.
2022;91(2):253-267. doi:10.1002/ana.26280. PMID:
34877694. Objective: Prior uncontrolled studies have reported seizure reductions following deep brain
stimulation (DBS) in patients with Lennox-Gastaut syndrome (LGS), but evidence from
randomized controlled studies is lacking. We aimed to formally assess the efficacy
and safety of DBS to the centromedian thalamic nucleus (CM) for the treatment of
LGS. Methods: We conducted a prospective, double-blind, randomized study of continuous, cycling
stimulation of CM-DBS, in patients with LGS. Following pre- and post-implantation
periods, half received 3 months of stimulation (blinded phase), then all received 3
months of stimulation (unblinded phase). The primary outcome was the proportion of
participants with ≥50% reduction in diary-recorded seizures in stimulated vs control
participants, measured at the end of the blinded phase. A secondary outcome was the
proportion of participants with a ≥50% reduction in electrographic seizures on
24-hour ambulatory electroencephalography (EEG) at the end of the blinded phase. Results: Between November 2017 and December 2019, 20 young adults with LGS (17-37 years;13
women) underwent bilateral CM-DBS at a single center in Australia, with 19
randomized (treatment, n = 10 and control, n = 9). Fifty percent of the stimulation
group achieved ≥50% seizure reduction, compared with 22% of controls (odds ratio
[OR] = 3.1, 95% confidence interval [CI] = .44-21.45, P = .25). For electrographic
seizures, 59% of the stimulation group had ≥50% reduction at the end of the blinded
phase, compared with none of the controls (OR= 23.25, 95% CI = 1.0-538.4, P = .05).
Across all patients, median seizure reduction (baseline vs study exit) was 46.7%
(interquartile range [IQR] = 28-67%) for diary recorded seizures and 53.8% (IQR =
27-73%) for electrographic seizures. Interpretation: CM-DBS in patients with LGS reduced electrographic rather than diary-recorded
seizures, after 3 months of stimulation. Fifty percent of all participants had
diary-recorded seizures reduced by half at the study exit, providing supporting
evidence of the treatment effect.
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Affiliation(s)
- Gewalin Aungaroon
- Department of Neurology, College of Medicine, Cincinnati Children’s Hospital, University of Cincinnati, OH, USA
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Devi N, Madaan P, Ameen R, Sahu JK, Bansal D. Short-term and long-term efficacy and safety of antiseizure medications in Lennox Gastaut syndrome: a network meta-analysis. Seizure 2022; 99:164-175. [DOI: 10.1016/j.seizure.2022.04.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 04/05/2022] [Accepted: 04/07/2022] [Indexed: 11/17/2022] Open
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Dalic LJ, Warren AEL, Bulluss KJ, Thevathasan W, Roten A, Churilov L, Archer JS. DBS of Thalamic Centromedian Nucleus for Lennox-Gastaut Syndrome (ESTEL Trial). Ann Neurol 2021; 91:253-267. [PMID: 34877694 DOI: 10.1002/ana.26280] [Citation(s) in RCA: 49] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Revised: 11/22/2021] [Accepted: 12/05/2021] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Prior uncontrolled studies have reported seizure reductions following deep brain stimulation (DBS) in patients with Lennox-Gastaut syndrome (LGS), but evidence from randomized controlled studies is lacking. We aimed to formally assess the efficacy and safety of DBS to the centromedian thalamic nucleus (CM) for the treatment of LGS. METHODS We conducted a prospective, double-blind, randomized study of continuous, cycling stimulation of CM-DBS, in patients with LGS. Following pre- and post-implantation periods, half received 3 months of stimulation (blinded phase), then all received 3 months of stimulation (unblinded phase). The primary outcome was the proportion of participants with ≥50% reduction in diary-recorded seizures in stimulated versus control participants, measured at the end of the blinded phase. A secondary outcome was the proportion of participants with a ≥50% reduction in electrographic seizures on 24-hour ambulatory electroencephalography (EEG) at the end of the blinded phase. RESULTS Between November 2017 and December 2019, 20 young adults with LGS (17-37 years;13 women) underwent bilateral CM-DBS at a single center in Australia, with 19 randomized (treatment, n = 10 and control, n = 9). Fifty percent of the stimulation group achieved ≥50% seizure reduction, compared with 22% of controls (odds ratio [OR] = 3.1, 95% confidence interval [CI] = 0.44-21.45, p = 0.25). For electrographic seizures, 59% of the stimulation group had ≥50% reduction at the end of the blinded phase, compared with none of the controls (OR= 23.25, 95% CI = 1.0-538.4, p = 0.05). Across all patients, median seizure reduction (baseline vs study exit) was 46.7% (interquartile range [IQR] = 28-67%) for diary-recorded seizures and 53.8% (IQR = 27-73%) for electrographic seizures. INTERPRETATION CM-DBS in patients with LGS reduced electrographic rather than diary-recorded seizures, after 3 months of stimulation. Fifty percent of all participants had diary-recorded seizures reduced by half at the study exit, providing supporting evidence of the treatment effect. ANN NEUROL 2021.
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Affiliation(s)
- Linda J Dalic
- Department of Medicine (Austin Health), University of Melbourne, Heidelberg, VIC, Australia.,Department of Neurology, Austin Health, Heidelberg, VIC, Australia
| | - Aaron E L Warren
- Department of Medicine (Austin Health), University of Melbourne, Heidelberg, VIC, Australia.,The Florey Institute of Neuroscience and Mental Health, Heidelberg, VIC, Australia.,Murdoch Children's Research Institute, Parkville, VIC, Australia
| | - Kristian J Bulluss
- Bionics Institute, East Melbourne, VIC, Australia.,Department of Neurosurgery, Austin Health, Heidelberg, VIC, Australia.,Department of Surgery, University of Melbourne, Parkville, VIC, Australia
| | - Wesley Thevathasan
- Department of Medicine (Austin Health), University of Melbourne, Heidelberg, VIC, Australia.,Bionics Institute, East Melbourne, VIC, Australia.,Department of Medicine, University of Melbourne, and Department of Neurology, The Royal Melbourne Hospital, Parkville, VIC, Australia
| | - Annie Roten
- Department of Neurology, Austin Health, Heidelberg, VIC, Australia
| | - Leonid Churilov
- Department of Medicine (Austin Health), University of Melbourne, Heidelberg, VIC, Australia
| | - John S Archer
- Department of Medicine (Austin Health), University of Melbourne, Heidelberg, VIC, Australia.,Department of Neurology, Austin Health, Heidelberg, VIC, Australia.,The Florey Institute of Neuroscience and Mental Health, Heidelberg, VIC, Australia.,Murdoch Children's Research Institute, Parkville, VIC, Australia
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11
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Asadi-Pooya AA, Bazrafshan M, Farazdaghi M. Long-term medical and social outcomes of patients with Lennox-Gastaut syndrome. Epilepsy Res 2021; 178:106813. [PMID: 34798494 DOI: 10.1016/j.eplepsyres.2021.106813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 09/10/2021] [Accepted: 11/10/2021] [Indexed: 10/19/2022]
Abstract
OBJECTIVE The aim of the current study was to investigate the long-term outcome in a large cohort of patients with Lennox-Gastaut syndrome (LGS). METHODS This was a longitudinal study (a retrospective database review with a telephone follow-up interview). All patients 18 years of age and older, with a diagnosis of LGS were studied at the outpatient epilepsy clinic at Shiraz University of Medical Sciences, Shiraz, Iran, from 2008 until 2020. The inclusion criteria were: multiple seizure types, characteristic electroencephalographic patterns [either bursts of slow spike-waves or generalized paroxysmal fast activity], with or without intellectual disability. Being lost on follow-up was the only exclusion criterion. RESULTS 78 patients fulfilled the inclusion criteria. All the patients were followed for one to 12 years (9.3 ± 2.8 years). In the last follow-up (call), 14 patients (17.9%) were seizure-free for at least 12 months. Tonic seizure at diagnosis was associated with a poor seizure outcome (not seizure-free) (p = 0.045). Four patients (5.1%) reported having high school degree (diploma), four patients (5.1%) were married, and one person (1.3%) reported driving a motor vehicle; none of the patients were employed. CONCLUSION A minority of patients with LGS (almost one in six patients) may enjoy a seizure-free state in their adulthood. However, very few of them could enjoy a healthy social life. While intellectual dysfunction may not be evident at the onset of the disease, cognitive impairment usually becomes apparent over time, and almost all patients would suffer from poor social outcomes in their adulthood.
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Affiliation(s)
- Ali A Asadi-Pooya
- Epilepsy Research Center, Shiraz University of Medical Sciences, Shiraz, Iran; Jefferson Comprehensive Epilepsy Center, Department of Neurology, Thomas Jefferson University, Philadelphia, PA, USA.
| | - Mehdi Bazrafshan
- Epilepsy Research Center, Shiraz University of Medical Sciences, Shiraz, Iran.
| | - Mohsen Farazdaghi
- Epilepsy Research Center, Shiraz University of Medical Sciences, Shiraz, Iran.
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12
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Automatic detection of generalized paroxysmal fast activity in interictal EEG using time-frequency analysis. Comput Biol Med 2021; 133:104287. [PMID: 34022764 DOI: 10.1016/j.compbiomed.2021.104287] [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: 10/22/2020] [Revised: 02/12/2021] [Accepted: 02/13/2021] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Markup of generalized interictal epileptiform discharges (IEDs) on EEG is an important step in the diagnosis and characterization of epilepsy. However, manual EEG markup is a time-consuming, subjective, and the specialized task where the human reviewer needs to visually inspect a large amount of data to facilitate accurate clinical decisions. In this study, we aimed to develop a framework for automated detection of generalized paroxysmal fast activity (GPFA), a generalized IED seen in scalp EEG recordings of patients with the severe epilepsy of Lennox-Gastaut syndrome (LGS). METHODS We studied 13 children with LGS who had GPFA events in their interictal EEG recordings. Time-frequency information derived from manually marked IEDs across multiple EEG channels was used to automatically detect similar events in each patient's interictal EEG. We validated true positives and false positives of the proposed spike detection approach using both standalone scalp EEG and simultaneous EEG-functional MRI (EEG-fMRI) recordings. RESULTS GPFA events displayed a consistent low-high frequency arrangement in the time-frequency domain. This 'bimodal' spectral feature was most prominent over frontal EEG channels. Our automatic detection approach using this feature identified EEG events with similar time-frequency properties to the manually marked GPFAs. Brain maps of EEG-fMRI signal change during these automatically detected IEDs were comparable to the EEG-fMRI brain maps derived from manual IED markup. CONCLUSION GPFA events have a characteristic bimodal time-frequency feature that can be automatically detected from scalp EEG recordings in patients with LGS. The validity of this time-frequency feature is demonstrated by EEG-fMRI analysis of automatically detected events, which recapitulates the brain maps we have previously shown to underlie generalized IEDs in LGS. SIGNIFICANCE This study provides a novel methodology that enables a fast, automated, and objective inspection of generalized IEDs in LGS. The proposed framework may be extendable to a wider range of epilepsy syndromes in which monitoring the burden of epileptic activity can aid clinical decision-making and faster assessment of treatment response and estimation of future seizure risk.
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Abstract
PURPOSE OF REVIEW To review the evolution of the concept of epileptic encephalopathy during the course of past years and analyze how the current definition might impact on both clinical practice and research. RECENT FINDINGS Developmental delay in children with epilepsy could be the expression of the cause, consequence of intense epileptiform activity (seizures and EEG abnormalities), or because of the combination of both factors. Therefore, the current International League Against Epilepsy classification identified three electroclinical entities that are those of developmental encephalopathy, epileptic encephalopathy, and developmental and epileptic encephalopathy (DEE). Many biological pathways could be involved in the pathogenesis of DEEs. DNA repair, transcriptional regulation, axon myelination, metabolite and ion transport, and peroxisomal function could all be involved in DEE. Also, epilepsy and epileptiform discharges might impact on cognition via several mechanisms, although they are not fully understood. SUMMARY The correct and early identification of cause in DEE might increase the chances of a targeted treatment regimen. Interfering with neurobiological processes of the disease will be the most successful way in order to improve both the cognitive disturbances and epilepsy that are the key features of DEE.
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14
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Kwon HE, Kim SH, Kang HC, Lee JS, Kim HD. Epilepsy surgery for pediatric patients with mild malformation of cortical development. Seizure 2020; 82:50-55. [PMID: 33002834 DOI: 10.1016/j.seizure.2020.09.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 09/14/2020] [Accepted: 09/15/2020] [Indexed: 11/27/2022] Open
Abstract
PURPOSE The observation of mild malformation of cortical development (mMCD) has yet to have a major clinical impact due to the lack of clinical and research data. We characterized the clinical features, surgical outcomes, and postoperative seizure control patterns in pediatric patients with mMCD. METHODS We examined 40 patients with isolated mMCD who underwent resective surgery during a 10-year period. RESULTS The median age at seizure onset was 1.2 years, and the median age at surgery was 7.9 years. Twenty-seven patients (67.5%) presented with childhood-onset epileptic encephalopathy (21 Lennox-Gastaut syndrome, 6 West syndrome), and 13 patients (32.5%) presented with intractable focal epilepsy (10 extratemporal lesions, 3 temporal lesions). Twenty-one patients (52.5%) showed "suspected focal cortical malformation" on MRI, whereas 16 patients (40.0%) and 3 patients (7.5%) showed normal MRI findings or mild brain atrophy, respectively. The most common surgical procedures were two lobar resections (18 patients, 45.0%), followed by unilobar resections (12 patients, 30.0%) and resections exceeding two lobar boundaries (10 patients, 25.0%). As a final surgical outcome, 24 patients (60.0%) were ILAE Class 1-3. Discontinuation of all AEDs was possible for 36.8% of ILAE Class 1 patients. Regarding the seizure control pattern, fluctuating seizure control was observed most frequently (21 patients, 52.5%). CONCLUSION Our results suggest that mMCD is an important pathological finding in children related to a significant degree of epileptogenicity, and resective surgery can have positive outcomes. However, these patients showed unstable postoperative seizure control patterns with a high rate of late recurrence, suggesting difficulties in the surgical treatment of intractable epilepsy.
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Affiliation(s)
- Hye Eun Kwon
- Department of Pediatrics, International St. Mary's Hospital, Catholic Kwandong University, College of Medicine, Incheon, Republic of Korea.
| | - Se Hoon Kim
- Department of Pathology, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea.
| | - Hoon-Chul Kang
- Division of Pediatric Neurology, Severance Children's Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea.
| | - Joon Soo Lee
- Division of Pediatric Neurology, Severance Children's Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea.
| | - Heung Dong Kim
- Division of Pediatric Neurology, Severance Children's Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea.
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15
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Dalic LJ, Warren AEL, Young JC, Thevathasan W, Roten A, Bulluss KJ, Archer JS. Cortex leads the thalamic centromedian nucleus in generalized epileptic discharges in Lennox‐Gastaut syndrome. Epilepsia 2020; 61:2214-2223. [DOI: 10.1111/epi.16657] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 07/23/2020] [Accepted: 07/24/2020] [Indexed: 01/01/2023]
Affiliation(s)
- Linda J. Dalic
- Department of Medicine (Austin Health) University of Melbourne Heidelberg Victoria Australia
- Department of Neurology Austin Health Heidelberg Victoria Australia
| | - Aaron E. L. Warren
- Department of Medicine (Austin Health) University of Melbourne Heidelberg Victoria Australia
- Florey Institute of Neuroscience and Mental Health Heidelberg Victoria Australia
- Murdoch Children’s Research Institute Parkville Victoria Australia
| | - James C. Young
- Florey Institute of Neuroscience and Mental Health Heidelberg Victoria Australia
| | - Wesley Thevathasan
- Department of Medicine (Austin Health) University of Melbourne Heidelberg Victoria Australia
- Bionics Institute East Melbourne Victoria Australia
- Department of Medicine Royal Melbourne Hospital and Department of Neurology University of Melbourne Parkville Victoria Australia
| | - Annie Roten
- Department of Neurology Austin Health Heidelberg Victoria Australia
| | - Kristian J. Bulluss
- Bionics Institute East Melbourne Victoria Australia
- Department of Neurosurgery Austin Health Heidelberg Victoria Australia
- Department of Surgery University of Melbourne Parkville Victoria Australia
| | - John S. Archer
- Department of Medicine (Austin Health) University of Melbourne Heidelberg Victoria Australia
- Department of Neurology Austin Health Heidelberg Victoria Australia
- Florey Institute of Neuroscience and Mental Health Heidelberg Victoria Australia
- Murdoch Children’s Research Institute Parkville Victoria Australia
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16
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Sharma S, Anand A, Garg D, Batra S, Mukherjee SB, Patra B, Aneja S. Use of the International League Against Epilepsy (ILAE) 1989, 2010, and 2017 Classification of Epilepsy in children in a low-resource setting: A hospital-based cross-sectional study. Epilepsia Open 2020; 5:397-405. [PMID: 32913948 PMCID: PMC7469804 DOI: 10.1002/epi4.12401] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 04/18/2020] [Accepted: 05/10/2020] [Indexed: 01/26/2023] Open
Abstract
OBJECTIVES This cross-sectional study was designed to test the applicability of the 1989, 2010, and 2017 International League Against Epilepsy (ILAE) classification of epilepsy in children from a resource-limited setting in India. METHODS Classification of seizure types and syndromes was done through parental interviews and review of medical records in children with epilepsy aged one month to 18 years. Available investigations including EEG, MRI, and metabolic/genetic tests were used in classifying patients as per the 1989, 2010, and 2017 ILAE (level II-epilepsy type) classification. We compared the proportion of children remaining unclassified by each scheme. RESULTS Seven hundred and twenty-six children (436 males, mean age 6.4 ± 4.6 years) were enrolled. Using the 1989 ILAE classification, we were able to classify 95.7%, and 82.6% children by the 2010 scheme. The 2017 ILAE classification could classify all 726 children at level I (seizure type), 664 (91.0%) children at level II (epilepsy type), and an electroclinical syndrome could be identified in 409 (56.1%) of the children. An etiology could be identified in 75%, perinatal brain injury being the most frequent. West syndrome was the most common electroclinical syndrome, identified in 22.7% patients. The 1989 ILAE classification system was superior to the 2010 system (P = .01) in epilepsy classification. There was no difference between the 1989 and 2017 schemes (P = .31) or the 2010 and 2017 schemes (P = .10). SIGNIFICANCE The 2017 ILAE classification, being multidimensional, allowed classification of children who could not undergo extensive evaluation due to economic constraints and also provided room for overlapping etiologies.
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Affiliation(s)
- Suvasini Sharma
- Department of PediatricsLady Hardinge Medical College and associated Kalawati Saran Children’s HospitalNew DelhiIndia
| | - Aakanksha Anand
- Department of PediatricsLady Hardinge Medical College and associated Kalawati Saran Children’s HospitalNew DelhiIndia
| | - Divyani Garg
- Department of NeurologyLady Hardinge Medical College and associated Smt. Sucheta Kriplani HospitalNew DelhiIndia
| | - Sakshi Batra
- Department of PediatricsLady Hardinge Medical College and associated Kalawati Saran Children’s HospitalNew DelhiIndia
| | - Sharmila B. Mukherjee
- Department of PediatricsLady Hardinge Medical College and associated Kalawati Saran Children’s HospitalNew DelhiIndia
| | - Bijoy Patra
- Department of PediatricsLady Hardinge Medical College and associated Kalawati Saran Children’s HospitalNew DelhiIndia
| | - Satinder Aneja
- Department of PediatricsLady Hardinge Medical College and associated Kalawati Saran Children’s HospitalNew DelhiIndia
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17
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Combined Isoflurane-Remifentanil Anaesthesia Permits Resting-State fMRI in Children with Severe Epilepsy and Intellectual Disability. Brain Topogr 2020; 33:618-635. [PMID: 32623611 DOI: 10.1007/s10548-020-00782-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2020] [Accepted: 06/25/2020] [Indexed: 12/23/2022]
Abstract
Head motion is a significant barrier to functional MRI (fMRI) in patients who are unable to tolerate awake scanning, including young children or those with cognitive and behavioural impairments. General anaesthesia minimises motion and ensures patient comfort, however the optimal anaesthesia regimen for fMRI in the paediatric setting is unknown. In this study, we tested the feasibility of anaesthetised fMRI in 11 patients (mean age = 9.8 years) with Lennox-Gastaut syndrome, a severe form of childhood-onset epilepsy associated with intellectual disability. fMRI was acquired during clinically-indicated MRI sessions using a synergistic anaesthesia regimen we typically administer for epilepsy neurosurgery: combined low-dose isoflurane (≤ 0.8% end-tidal concentration) with remifentanil (≤ 0.1 mcg/kg/min). Using group-level independent component analysis, we assessed the presence of resting-state networks by spatially comparing results in the anaesthetised patients to resting-state network templates from the 'Generation R' study of 536 similarly-aged non-anaesthetised healthy children (Muetzel et al. in Hum Brain Mapp 37(12):4286-4300, 2016). Numerous resting-state networks commonly studied in non-anaesthetised healthy children were readily identifiable in the anaesthetised patients, including the default-mode, sensorimotor, and frontoparietal networks. Independent component time-courses associated with these networks showed spectral characteristics suggestive of a neuronal origin of fMRI signal fluctuations, including high dynamic range and temporal frequency power predominantly below 0.1 Hz. These results demonstrate the technical feasibility of anaesthetised fMRI in children, suggesting that combined isoflurane-remifentanil anaesthesia may be an effective strategy to extend the emerging clinical applications of resting-state fMRI (for example, neurosurgical planning) to the variety of patient groups who may otherwise be impractical to scan.
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18
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Qu S, Catron M, Zhou C, Janve V, Shen W, Howe RK, Macdonald RL. GABA A receptor β3 subunit mutation D120N causes Lennox-Gastaut syndrome in knock-in mice. Brain Commun 2020; 2:fcaa028. [PMID: 32467926 PMCID: PMC7238755 DOI: 10.1093/braincomms/fcaa028] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Revised: 12/27/2019] [Accepted: 02/02/2020] [Indexed: 01/27/2023] Open
Abstract
The Lennox-Gastaut syndrome is a devastating early-onset epileptic encephalopathy, associated with severe behavioural abnormalities. Its pathophysiology, however, is largely unknown. A de novo mutation (c.G358A, p.D120N) in the human GABA type-A receptor β3 subunit gene (GABRB3) has been identified in a patient with Lennox-Gastaut syndrome. To determine whether the mutation causes Lennox-Gastaut syndrome in vivo in mice and to elucidate its mechanistic effects, we generated the heterozygous Gabrb3+/D120N knock-in mouse and found that it had frequent spontaneous atypical absence seizures, as well as less frequent tonic, myoclonic, atonic and generalized tonic-clonic seizures. Each of these seizure types had a unique and characteristic ictal EEG. In addition, knock-in mice displayed abnormal behaviours seen in patients with Lennox-Gastaut syndrome including impaired learning and memory, hyperactivity, impaired social interactions and increased anxiety. This Gabrb3 mutation did not alter GABA type-A receptor trafficking or expression in knock-in mice. However, cortical neurons in thalamocortical slices from knock-in mice had reduced miniature inhibitory post-synaptic current amplitude and prolonged spontaneous thalamocortical oscillations. Thus, the Gabrb3+/D120N knock-in mouse recapitulated human Lennox-Gastaut syndrome seizure types and behavioural abnormalities and was caused by impaired inhibitory GABAergic signalling in the thalamocortical loop. In addition, treatment with antiepileptic drugs and cannabinoids ameliorated atypical absence seizures in knock-in mice. This congenic knock-in mouse demonstrates that a single-point mutation in a single gene can cause development of multiple types of seizures and multiple behavioural abnormalities. The knock-in mouse will be useful for further investigation of the mechanisms of Lennox-Gastaut syndrome development and for the development of new antiepileptic drugs and treatments.
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Affiliation(s)
- Shimian Qu
- Department of Neurology, Vanderbilt University Medical Center, Nashville, TN 37232, USA
| | - Mackenzie Catron
- Department of Neurology, Vanderbilt University Medical Center, Nashville, TN 37232, USA.,Neuroscience Graduate Program, Vanderbilt University, Nashville, TN 37232, USA
| | - Chengwen Zhou
- Department of Neurology, Vanderbilt University Medical Center, Nashville, TN 37232, USA
| | - Vaishali Janve
- Department of Neurology, Vanderbilt University Medical Center, Nashville, TN 37232, USA.,Neuroscience Graduate Program, Vanderbilt University, Nashville, TN 37232, USA
| | - Wangzhen Shen
- Department of Neurology, Vanderbilt University Medical Center, Nashville, TN 37232, USA
| | - Rachel K Howe
- Department of Neurology, Vanderbilt University Medical Center, Nashville, TN 37232, USA
| | - Robert L Macdonald
- Department of Neurology, Vanderbilt University Medical Center, Nashville, TN 37232, USA.,Department of Molecular Physiology and Biophysics, Vanderbilt University Medical Center, Nashville, TN 37232, USA.,Department of Pharmacology, Vanderbilt University Medical Center, Nashville, TN 37232, USA
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Shamshiri EA, Sheybani L, Vulliemoz S. The Role of EEG-fMRI in Studying Cognitive Network Alterations in Epilepsy. Front Neurol 2019; 10:1033. [PMID: 31608007 PMCID: PMC6771300 DOI: 10.3389/fneur.2019.01033] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Accepted: 09/11/2019] [Indexed: 02/01/2023] Open
Abstract
Brain functions do not arise from isolated brain regions, but from interactions in widespread networks necessary for both normal and pathological conditions. These Intrinsic Connectivity Networks (ICNs) support cognitive processes such as language, memory, or executive functions, but can be disrupted by epileptic activity. Simultaneous EEG-fMRI can help explore the hemodynamic changes associated with focal or generalized epileptic discharges, thus providing information about both transient and non-transient impairment of cognitive networks related to spatio-temporal overlap with epileptic activity. In the following review, we discuss the importance of interictal discharges and their impact on cognition in different epilepsy syndromes. We explore the cognitive impact of interictal activity in both animal models and human connectivity networks in order to confirm that this effect could have a possible clinical impact for prescribing medication and characterizing post-surgical outcome. Future work is needed to further investigate electrophysiological changes, such as amplitude/latency of single evoked responses or spontaneous epileptic activity in either scalp or intracranial EEG and determine its relative change in hemodynamic response with subsequent network modifications.
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Affiliation(s)
- Elhum A Shamshiri
- EEG and Epilepsy Unit, Neurology Department, University Hospitals and Faculty of Medicine of Geneva, Geneva, Switzerland
| | - Laurent Sheybani
- Neurology Clinic, University Hospitals and Faculty of Medicine of Geneva, Geneva, Switzerland
| | - Serge Vulliemoz
- EEG and Epilepsy Unit, Neurology Department, University Hospitals and Faculty of Medicine of Geneva, Geneva, Switzerland.,Neurology Clinic, University Hospitals and Faculty of Medicine of Geneva, Geneva, Switzerland
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Juhász C. Prefrontal cortex in the driving seat of epileptic networks in Lennox-Gastaut syndrome. Neurology 2019; 93:91-92. [DOI: 10.1212/wnl.0000000000007770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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21
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Auvin S, Williams B, McMurray R, Kumar D, Perdomo C, Malhotra M. Novel seizure outcomes in patients with Lennox-Gastaut syndrome: Post hoc analysis of seizure-free days in rufinamide Study 303. Epilepsia Open 2019; 4:275-280. [PMID: 31168494 PMCID: PMC6546073 DOI: 10.1002/epi4.12314] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Revised: 01/25/2019] [Accepted: 02/15/2019] [Indexed: 11/07/2022] Open
Abstract
OBJECTIVE Drug development for patients with Lennox-Gastaut syndrome (LGS) is based on clinical trials that use drop seizure counts. However, such counts do not assess total seizure burden and affect a patient's quality of life (QoL). In this post hoc analysis, we evaluated two novel seizure efficacy parameters related to QoL in pediatric patients with LGS, using seizure diary data from rufinamide Study 303 (NCT01405053). METHODS Study 303 was a phase III, multicenter, randomized, controlled, open-label study involving patients aged ≥1 to <4 years with inadequately controlled LGS. Patients were randomized 2:1 to receive add-on therapy with rufinamide or any other approved antiseizure drug (ASD), in addition to their existing treatment of 1-3 ASDs, across a 106-week treatment phase. Seizure diaries, completed by parents or caregivers, recorded seizure occurrence, and were used in this post hoc analysis to evaluate two novel efficacy parameters comparing baseline vs postbaseline mean number of seizure-free days and assessing time to reach the number of prerandomization seizures for patients receiving rufinamide or any other ASD. RESULTS Patients received rufinamide (n = 25) or any other ASD (n = 12). For rufinamide, mean number of seizure-free days was 42.2% greater postbaseline compared with baseline (P < 0.0001); only one rufinamide patient experienced a decrease in number of seizure-free days postbaseline. Median time to reach the baseline number of seizures increased by 10.5 days for rufinamide and 0.5 days for the any-other-ASD group during the treatment phase, to 46.0 and 54.0 days, respectively. SIGNIFICANCE Both of these novel and contrasting endpoints demonstrated potential improvements in seizure outcomes in patients receiving rufinamide postbaseline vs baseline. Although these parameters should be investigated in larger patient populations, our initial findings suggest that they could be applied as predefined primary endpoints for seizure assessment in future clinical trials for LGS drug development.
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Affiliation(s)
- Stéphane Auvin
- Pediatric Neurology Department & INSERM U1141Robert‐Debré University HospitalAPHPParisFrance
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22
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Jia JL, Chen S, Sivarajah V, Stephens D, Cortez MA. Latitudinal differences on the global epidemiology of infantile spasms: systematic review and meta-analysis. Orphanet J Rare Dis 2018; 13:216. [PMID: 30486850 PMCID: PMC6262963 DOI: 10.1186/s13023-018-0952-x] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Accepted: 11/14/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Infantile spasms represent the catastrophic, age-specific seizure type associated with acute and long-term neurological morbidity. However, due to rarity and heterogenous determination, there is persistent uncertainty of its pathophysiological and epidemiological characteristics. The purpose of the current study was to address a historically suspected latitudinal basis of infantile spasms incidence, and to interrogate a geographical basis of epidemiology, including the roles of latitude and other environmental factors, using meta-analytic and -regression methods. METHODS A systematic search was performed in Ovid MEDLINE and Embase for primary reports on infantile spasms incidence and prevalence epidemiology. RESULTS One thousand fifteen studies were screened to yield 54 eligible publications, from which 39 incidence figures and 18 prevalence figures were extracted. The pooled incidence was 0.249 cases/1000 live births. The pooled prevalence was 0.015 cases/1000 population. Univariate meta-regression determined a continental effect, with Europe demonstrating the highest onset compared from Asia (OR = 0.51, p = 0.004) and from North America (OR = 0.50, p = 0.004). Latitude was also positively correlated with incidence globally (OR = 1.02, p < 0.001). Sub-analyses determined a particularly elevated Scandinavian incidence compared to the rest of world (OR = 1.88, p < 0.001), and lack of latitudinal effect with Scandinavian exclusion (p = 0.10). Metrics of healthcare quality did not predict incidence. Multiple meta-regression determined that latitude was the key predictor of incidence (OR = 1.02, p = 0.001). CONCLUSIONS This is the first systematic epidemiological study of infantile spasms. Limitations included lack of Southern hemispheric representation, insufficient study selection and size to support some sub-continental analyses, and lack of accessible ethnic and healthcare quality data. Meta-analyses determined a novel, true geographical difference in incidence which is consistent with a latitudinal and/or ethnic contribution to epileptogenesis. These findings justify the establishment of a global registry of infantile spasms epidemiology to promote future systematic studies, clarify risk factors, and expand understanding of the pathophysiology.
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Affiliation(s)
- Jason L. Jia
- Department of Medicine, University of Toronto, 190 Elizabeth Street R. Fraser Elliott Wing, Toronto, M5G 2C4 Canada
| | - Shiyi Chen
- Child Health Evaluative Sciences Research Program, SickKids Research Institute, The Hospital for Sick Children, Toronto, Canada
| | - Vishalini Sivarajah
- Department of Medicine, University of Toronto, 190 Elizabeth Street R. Fraser Elliott Wing, Toronto, M5G 2C4 Canada
| | - Derek Stephens
- Child Health Evaluative Sciences Research Program, SickKids Research Institute, The Hospital for Sick Children, Toronto, Canada
| | - Miguel A. Cortez
- Department of Pediatrics, Division of Neurology, University of Toronto, Toronto, Canada
- Neurosciences & Mental Health Program, Peter Gilgan Centre for Research and Learning, SickKids Research Institute, The Hospital for Sick Children, 555 University Avenue, Toronto, ON M5G 1X8 Canada
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23
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Multifocal epilepsy in children is associated with increased long-distance functional connectivity: An explorative EEG-fMRI study. Eur J Paediatr Neurol 2018; 22:1054-1065. [PMID: 30017619 DOI: 10.1016/j.ejpn.2018.07.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2017] [Revised: 06/12/2018] [Accepted: 07/01/2018] [Indexed: 01/22/2023]
Abstract
OBJECTIVE Multifocal epileptic activity is an unfavourable feature of a number of epileptic syndromes (Lennox-Gastaut syndrome, West syndrome, severe focal epilepsies) which suggests an overall vulnerability of the brain to pathological synchronization. However, the mechanisms of multifocal activity are insufficiently understood. This explorative study investigates whether pathological connectivity within brain areas of the default mode network as well as thalamus, brainstem and retrosplenial cortex may predispose individuals to multifocal epileptic activity. METHODS 33 children suffering from multifocal and monofocal (control group) epilepsies were investigated using EEG-fMRI recordings during sleep. The blood oxygenated level dependent (BOLD) signal of 15 regions of interest was extracted and temporally correlated (resting-state functional connectivity). RESULTS Patients with monofocal epilepsies were characterized by strong correlations between the corresponding interhemispheric homotopic regions. This pattern of correlations with pronounced short-distance and weak long-distance functional connectivity resembles the connectivity pattern described for healthy children. Patients with multifocal epileptic activity, however, demonstrated significantly stronger correlations between a large number of regions of the default mode network as well as thalamus and brainstem, with a significant increase in long-distance connectivity compared to children with monofocal epileptic activity. In the group of patients with multifocal epilepsies there were no differences in functional connectivity between patients with or without Lennox-Gastaut syndrome. CONCLUSION This explorative study shows that multifocal activity is associated with generally increased long-distance functional connectivity in the brain. It can be suggested that this pronounced connectivity may represent either a risk to pathological over-synchronization or a consequence of the multifocal epileptic activity.
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24
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Kang JW, Eom S, Hong W, Kwon HE, Park S, Ko A, Kang HC, Lee JS, Lee YM, Kim DS, Kim HD. Long-term Outcome of Resective Epilepsy Surgery in Patients With Lennox-Gastaut Syndrome. Pediatrics 2018; 142:peds.2018-0449. [PMID: 30194277 DOI: 10.1542/peds.2018-0449] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/06/2018] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE We aimed to evaluate the long-term outcome of resective epilepsy surgery in patients with Lennox-Gastaut syndrome (LGS). METHODS We reviewed the case reports of 90 patients with LGS who had undergone resective surgery between 2003 and 2014 at the Severance Children's Hospital and managed them for a minimum period of 2 years. RESULTS At the time of surgery, the patients were between 3.0 and 23.5 years old (mean ± SD: 9.3 ± 4.4). The time from seizure onset to surgery ranged from 0.7 to 20.1 years (7.2 ± 4.3). On postoperative follow-up for an average period of 6.1 ± 2.2 years (range: 2.1-11.4 years), 45 patients (50.0%) had no seizures, and 15 (16.7%) reported infrequent seizures. Seizure-free outcomes were achieved in 15 of the 21 (71.4%) hemispherectomies, 23 of the 51 (45.1%) multilobar resections, and 7 of the 18 (38.9%) single lobar resections. On high-resolution MRIs, 20 patients (22.2%) had negative findings, 8 of whom (40.0%) became seizure-free after resective surgery. Malformation of cortical development was the most common pathologic finding and was noted in 57 patients (63.3%). Seizure-free patients achieved better adaptive behavior and social competence than did patients with persistent seizures at the second (2-3 years after surgery) and third (4-6 years after surgery) follow-ups, as indicated by social quotients (P < .05). CONCLUSIONS Resective surgery is a viable option in some patients to treat seizures that are associated with LGS, with a high probability of seizure control and better adaptive function.
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Affiliation(s)
- Joon Won Kang
- Departments of Pediatrics and Medical Science, Chungnam National University Hospital and College of Medicine, Chungnam National University, Daejeon, Republic of Korea
| | - Soyong Eom
- Epilepsy Research Institute, College of Medicine
| | - William Hong
- Section of Neurology and Developmental Neuroscience, Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Hye Eun Kwon
- Department of Pediatrics, International St Mary's Hospital and College of Medicine, Catholic Kwandong University, Incheon, Republic of Korea; and
| | - Soyoung Park
- Department of Pediatrics, Soon Chun Hyang University Hospital and College of Medicine, Soonchunhyang University, Bucheon, Republic of Korea
| | - Ara Ko
- Epilepsy Research Institute, College of Medicine.,Pediatric Epilepsy Clinics, Division of Pediatric Neurology, Department of Pediatrics, Severance Children's Hospital
| | - Hoon-Chul Kang
- Epilepsy Research Institute, College of Medicine.,Pediatric Epilepsy Clinics, Division of Pediatric Neurology, Department of Pediatrics, Severance Children's Hospital
| | - Joon Soo Lee
- Epilepsy Research Institute, College of Medicine.,Pediatric Epilepsy Clinics, Division of Pediatric Neurology, Department of Pediatrics, Severance Children's Hospital
| | - Young-Mock Lee
- Department of Pediatrics, Gangnam Severance Hospital, and
| | - Dong Seok Kim
- Division of Pediatric Neurosurgery, Severance Hospital, Yonsei University, Seoul, Republic of Korea
| | - Heung Dong Kim
- Epilepsy Research Institute, College of Medicine, .,Pediatric Epilepsy Clinics, Division of Pediatric Neurology, Department of Pediatrics, Severance Children's Hospital
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25
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Abstract
Lennox-Gastaut syndrome is one of the rare childhood-onset epileptic encephalopathies, characterized by multiple type seizure disorder, the typical pattern on electroencephalogram and intellectual disability. Tonic-type seizures are most commonly seen in these patients. Behavioral disturbances and cognitive decline are gradual-onset and last long after the first episode of epileptiform activity. In most cases, there is some identifiable cause that has led to the clinical presentation of the patient. Various pharmacological and surgical procedures have been proposed for the treatment of Lennox-Gastaut syndrome and many more to come in the very near future to overcome the drug resistance and to avoid the patient forming a life-long dependency.
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Affiliation(s)
| | | | - Memoona Jahangir
- Internal Medicine, Punjab Medical College Allied Hospital Faisalabad, Faisalabad, PAK
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26
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Padmaja RD, Chanda K. A Short Review on Synthetic Advances toward the Synthesis of Rufinamide, an Antiepileptic Drug. Org Process Res Dev 2018. [DOI: 10.1021/acs.oprd.7b00373] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Affiliation(s)
- R. D. Padmaja
- Department of Chemistry, School of Advanced Sciences, VIT University, Vellore-632014, India
| | - Kaushik Chanda
- Department of Chemistry, School of Advanced Sciences, VIT University, Vellore-632014, India
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27
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Warren AEL, Abbott DF, Jackson GD, Archer JS. Thalamocortical functional connectivity in Lennox-Gastaut syndrome is abnormally enhanced in executive-control and default-mode networks. Epilepsia 2017; 58:2085-2097. [PMID: 29098688 DOI: 10.1111/epi.13932] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/01/2017] [Indexed: 12/26/2022]
Abstract
OBJECTIVE To identify abnormal thalamocortical circuits in the severe epilepsy of Lennox-Gastaut syndrome (LGS) that may explain the shared electroclinical phenotype and provide potential treatment targets. METHODS Twenty patients with a diagnosis of LGS (mean age = 28.5 years) and 26 healthy controls (mean age = 27.6 years) were compared using task-free functional magnetic resonance imaging (MRI). The thalamus was parcellated according to functional connectivity with 10 cortical networks derived using group-level independent component analysis. For each cortical network, we assessed between-group differences in thalamic functional connectivity strength using nonparametric permutation-based tests. Anatomical locations were identified by quantifying spatial overlap with a histologically informed thalamic MRI atlas. RESULTS In both groups, posterior thalamic regions showed functional connectivity with visual, auditory, and sensorimotor networks, whereas anterior, medial, and dorsal thalamic regions were connected with networks of distributed association cortex (including the default-mode, anterior-salience, and executive-control networks). Four cortical networks (left and right executive-control network; ventral and dorsal default-mode network) showed significantly enhanced thalamic functional connectivity strength in patients relative to controls. Abnormal connectivity was maximal in mediodorsal and ventrolateral thalamic nuclei. SIGNIFICANCE Specific thalamocortical circuits are affected in LGS. Functional connectivity is abnormally enhanced between the mediodorsal and ventrolateral thalamus and the default-mode and executive-control networks, thalamocortical circuits that normally support diverse cognitive processes. In contrast, thalamic regions connecting with primary and sensory cortical networks appear to be less affected. Our previous neuroimaging studies show that epileptic activity in LGS is expressed via the default-mode and executive-control networks. Results of the present study suggest that the mediodorsal and ventrolateral thalamus may be candidate targets for modulating abnormal network behavior underlying LGS, potentially via emerging thalamic neurostimulation therapies.
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Affiliation(s)
- Aaron E L Warren
- Department of Medicine, University of Melbourne, Heidelberg, Victoria, Australia.,Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - David F Abbott
- Department of Medicine, University of Melbourne, Heidelberg, Victoria, Australia.,Florey Institute of Neuroscience and Mental Health, Heidelberg, Victoria, Australia
| | - Graeme D Jackson
- Department of Medicine, University of Melbourne, Heidelberg, Victoria, Australia.,Florey Institute of Neuroscience and Mental Health, Heidelberg, Victoria, Australia.,Department of Neurology, Austin Health, Heidelberg, Victoria, Australia
| | - John S Archer
- Department of Medicine, University of Melbourne, Heidelberg, Victoria, Australia.,Murdoch Children's Research Institute, Parkville, Victoria, Australia.,Florey Institute of Neuroscience and Mental Health, Heidelberg, Victoria, Australia.,Department of Neurology, Austin Health, Heidelberg, Victoria, Australia
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28
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Liang JG, Lee D, Youn SE, Kim HD, Kim NY. Electroencephalography Network Effects of Corpus Callosotomy in Patients with Lennox-Gastaut Syndrome. Front Neurol 2017; 8:456. [PMID: 28928710 PMCID: PMC5591410 DOI: 10.3389/fneur.2017.00456] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2017] [Accepted: 08/16/2017] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES This study aimed to investigate the functional network effects of corpus callosotomy (CC), a well-recognized palliative surgical therapy for patients with Lennox-Gastaut syndrome (LGS). Specifically, we sought to gain insight into the effects of CC on LGS remission, based on brain networks in LGS by calculating network metrics and evaluating by network measures before and after surgery. METHODS Electroencephalographic recordings made during preoperative and 3-month postoperative states in 14 patients with LGS who had undergone successful CC were retrospectively analyzed. First, undirected correlation matrices were constituted for the mathematical expression of functional networks. Then, we plotted these networks to analyze the effects of CC on connectivity. In addition, conventional local and global network measures were applied to evaluate differences in network topology between preoperative and postoperative states. RESULTS In the preoperative state, hubs were mainly distributed around the paramedian regions. After CC, the hubs moved from the paramedian regions to the dual-hemisphere and even the lateral regions. Thus, the general connectivity state became more homogeneous, which was verified by network plots and statistical analysis of local measures. The results of global network measures indicated a decreased clustering coefficient in the delta band, decreased characteristic path length in both the delta and gamma bands, and increased global efficiency in the gamma band. CONCLUSION Our results showed a consistent variation in the global brain network that converted to a small-world topology with an optimal balance of functional integration and segregation of the network. Such changes were positively correlated with satisfactory surgery results, which could be interpreted as being indicative of LGS recovery process after CC. For patients with refractory LGS along with no focal epileptogenic zone findings, which were not suitable for the resective surgical therapy, our results verified that CC could work as an effective surgical treatment option.
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Affiliation(s)
- Jun-Ge Liang
- RFIC Center, Kwangwoon University, Seoul, South Korea
| | - Dongpyo Lee
- Epilepsy Research Institute, Yonsei University College of Medicine, Seoul, South Korea
| | - Song Ee Youn
- Department of Pediatrics, Padiatric Epilepsy Clinic, Severance Children's Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Heung Dong Kim
- Epilepsy Research Institute, Yonsei University College of Medicine, Seoul, South Korea.,Department of Pediatrics, Padiatric Epilepsy Clinic, Severance Children's Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Nam-Young Kim
- RFIC Center, Kwangwoon University, Seoul, South Korea
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29
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Outcome of childhood-onset epilepsy from adolescence to adulthood: Transition issues. Epilepsy Behav 2017; 69:161-169. [PMID: 28256379 DOI: 10.1016/j.yebeh.2016.11.010] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Accepted: 11/06/2016] [Indexed: 11/21/2022]
Abstract
This is the second of three papers that summarize the second symposium on Transition in Epilepsies held in Paris in June 2016. This paper addresses the outcome for some particularly challenging childhood-onset epileptic disorders with the goal of recommending the best approach to transition. We have grouped these disorders in five categories with a few examples for each. The first group includes disorders presenting in childhood that may have late- or adult-onset epilepsy (metabolic and mitochondrial disorders). The second group includes disorders with changing problems in adulthood (tuberous sclerosis complex, Rett syndrome, Dravet syndrome, and autism). A third group includes epilepsies that change with age (Childhood Absence Epilepsy, Juvenile Myoclonic Epilepsy, West Syndrome, and Lennox-Gastaut syndrome). A fourth group consists of epilepsies that vary in symptoms and severity depending on the age of onset (autoimmune encephalitis, Rasmussen's syndrome). A fifth group has epilepsy from structural causes that are less likely to evolve in adulthood. Finally we have included a discussion about the risk of later adulthood cerebrovascular disease and dementia following childhood-onset epilepsy. A detailed knowledge of each of these disorders should assist the process of transition to be certain that attention is paid to the most important age-related symptoms and concerns.
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30
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Warren AEL, Harvey AS, Abbott DF, Vogrin SJ, Bailey C, Davidson A, Jackson GD, Archer JS. Cognitive network reorganization following surgical control of seizures in Lennox-Gastaut syndrome. Epilepsia 2017; 58:e75-e81. [PMID: 28295228 DOI: 10.1111/epi.13720] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/12/2017] [Indexed: 01/03/2023]
Abstract
We previously observed that adults with Lennox-Gastaut syndrome (LGS) show abnormal functional connectivity among cognitive networks, suggesting that this may contribute to impaired cognition. Herein we report network reorganization following seizure remission in a child with LGS who underwent functional magnetic resonance imaging (fMRI) before and after resection of a cortical dysplasia. Concurrent electroencephalography (EEG) was acquired during presurgical fMRI. Presurgical and postsurgical functional connectivity were compared using (1) graph theoretical analyses of small-world network organization and node-wise strength; and (2) seed-based analyses of connectivity within and between five functional networks. To explore the specificity of these postsurgical network changes, connectivity was further compared to nine children with LGS who did not undergo surgery. The presurgical EEG-fMRI revealed diffuse activation of association cortex during interictal discharges. Following surgery and seizure control, functional connectivity showed increased small-world organization, stronger connectivity in subcortical structures, and greater within-network integration/between-network segregation. These changes suggest network improvement, and diverged sharply from the comparison group of nonoperated children. Following surgery, this child with LGS achieved seizure control and showed extensive reorganization of networks that underpin cognition. This case illustrates that the epileptic process of LGS can directly contribute to abnormal network organization, and that this network disruption may be reversible.
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Affiliation(s)
- Aaron E L Warren
- Department of Medicine, The University of Melbourne, Heidelberg, Victoria, Australia.,Murdoch Childrens Research Institute, Melbourne, Victoria, Australia
| | - A Simon Harvey
- Murdoch Childrens Research Institute, Melbourne, Victoria, Australia.,The Florey Institute of Neuroscience and Mental Health, The University of Melbourne, Heidelberg, Victoria, Australia.,Department of Neurology, The Royal Children's Hospital, Parkville, Victoria, Australia.,Department of Paediatrics, The University of Melbourne, Heidelberg, Victoria, Australia
| | - David F Abbott
- Department of Medicine, The University of Melbourne, Heidelberg, Victoria, Australia.,The Florey Institute of Neuroscience and Mental Health, The University of Melbourne, Heidelberg, Victoria, Australia
| | - Simon J Vogrin
- Murdoch Childrens Research Institute, Melbourne, Victoria, Australia
| | - Catherine Bailey
- Department of Neurology, The Royal Children's Hospital, Parkville, Victoria, Australia
| | - Andrew Davidson
- Murdoch Childrens Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics, The University of Melbourne, Heidelberg, Victoria, Australia.,Department of Anaesthesia and Pain Management, The Royal Children's Hospital, Parkville, Victoria, Australia
| | - Graeme D Jackson
- Department of Medicine, The University of Melbourne, Heidelberg, Victoria, Australia.,The Florey Institute of Neuroscience and Mental Health, The University of Melbourne, Heidelberg, Victoria, Australia.,Department of Neurology, Austin Health, Melbourne, Victoria, Australia
| | - John S Archer
- Department of Medicine, The University of Melbourne, Heidelberg, Victoria, Australia.,Murdoch Childrens Research Institute, Melbourne, Victoria, Australia.,The Florey Institute of Neuroscience and Mental Health, The University of Melbourne, Heidelberg, Victoria, Australia.,Department of Neurology, Austin Health, Melbourne, Victoria, Australia
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31
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Park KM, Hur YJ, Kim SE. Brainstem dysfunction in patients with late-onset Lennox-Gastaut syndrome: Voxel-based morphometry and tract-based spatial statistics study. Ann Indian Acad Neurol 2016; 19:518-522. [PMID: 27994367 PMCID: PMC5144479 DOI: 10.4103/0972-2327.194462] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Background: There have been a few reports of patients who developed Lennox–Gastaut syndrome (LGS) in the second decades of their life. Objectives: The aim of this study was to investigate electroclinical presentation in patients with late-onset LGS. In addition, we evaluated structural abnormalities of the brain, which may give some clue about the common pathogenic pathway in LGS. Materials and Methods: We enrolled the patients with late-onset LGS. We collected electroclinical characteristics of the patients and evaluated structural abnormalities using voxel-based morphometry (VBM) and tract-based spatial statistics (TBSS) analysis. Results: The three subjects were diagnosed with late-onset LGS. The patients have no mental retardation and normal background activities on electroencephalography (EEG), and they had generalized paroxysmal fast activities on EEG, especially during sleep. The TBSS analysis revealed that fractional anisotropy values in the patients were significantly reduced in the white matter of brainstem compared with normal controls. However, VBM analysis did not show any significant difference between the patients and normal controls. Conclusions: Patients with late-onset LGS have different clinical and EEG characteristics from those with early-onset LGS. In addition, we demonstrated that brainstem dysfunction might contribute to the pathogenesis of late-onset LGS.
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Affiliation(s)
- Kang Min Park
- Department of Neurology, Haeundae Paik Hospital, Inje University College of Medicine, Haeundae-gu, Busan 612-896, India
| | - Yun Jung Hur
- Department of Pediatrics, Haeundae Paik Hospital, Inje University College of Medicine, Haeundae-gu, Busan 612-896, India
| | - Sung Eun Kim
- Department of Neurology, Haeundae Paik Hospital, Inje University College of Medicine, Haeundae-gu, Busan 612-896, India
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32
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Affiliation(s)
- Carl E. Stafstrom
- Division of Pediatric Neurology, John M. Freeman Pediatric Epilepsy Center, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Eric H. Kossoff
- Division of Pediatric Neurology, John M. Freeman Pediatric Epilepsy Center, Johns Hopkins University School of Medicine, Baltimore, MD
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33
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Shao LR, Stafstrom CE. Pediatric Epileptic Encephalopathies: Pathophysiology and Animal Models. Semin Pediatr Neurol 2016; 23:98-107. [PMID: 27544466 DOI: 10.1016/j.spen.2016.05.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Epileptic encephalopathies are syndromes in which seizures or interictal epileptiform activity contribute to or exacerbate brain function, beyond that caused by the underlying pathology. These severe epilepsies begin early in life, are associated with poor lifelong outcome, and are resistant to most treatments. Therefore, they represent an immense challenge for families and the medical care system. Furthermore, the pathogenic mechanisms underlying the epileptic encephalopathies are poorly understood, hampering attempts to devise novel treatments. This article reviews animal models of the three classic epileptic encephalopathies-West syndrome (infantile spasms), Lennox-Gastaut syndrome, and continuous spike waves during sleep or Landau-Kleffner syndrome-with discussion of how animal models are revealing underlying pathophysiological mechanisms that might be amenable to targeted therapy.
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Affiliation(s)
- Li-Rong Shao
- Division of Pediatric Neurology, Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Carl E Stafstrom
- Division of Pediatric Neurology, Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD.
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34
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Warren AEL, Abbott DF, Vaughan DN, Jackson GD, Archer JS. Abnormal cognitive network interactions in Lennox-Gastaut syndrome: A potential mechanism of epileptic encephalopathy. Epilepsia 2016; 57:812-22. [DOI: 10.1111/epi.13342] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/28/2016] [Indexed: 12/12/2022]
Affiliation(s)
- Aaron E. L. Warren
- Department of Medicine; The University of Melbourne; Heidelberg Victoria Australia
| | - David F. Abbott
- Department of Medicine; The University of Melbourne; Heidelberg Victoria Australia
- The Florey Institute of Neuroscience and Mental Health; Heidelberg Victoria Australia
| | - David N. Vaughan
- The Florey Institute of Neuroscience and Mental Health; Heidelberg Victoria Australia
- Department of Neurology; Austin Health; Heidelberg Victoria Australia
| | - Graeme D. Jackson
- Department of Medicine; The University of Melbourne; Heidelberg Victoria Australia
- The Florey Institute of Neuroscience and Mental Health; Heidelberg Victoria Australia
- Department of Neurology; Austin Health; Heidelberg Victoria Australia
| | - John S. Archer
- Department of Medicine; The University of Melbourne; Heidelberg Victoria Australia
- The Florey Institute of Neuroscience and Mental Health; Heidelberg Victoria Australia
- Department of Neurology; Austin Health; Heidelberg Victoria Australia
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35
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Howell KB, Harvey AS, Archer JS. Epileptic encephalopathy: Use and misuse of a clinically and conceptually important concept. Epilepsia 2016; 57:343-7. [DOI: 10.1111/epi.13306] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/08/2015] [Indexed: 12/18/2022]
Affiliation(s)
- Katherine B. Howell
- Department of Neurology; The Royal Children's Hospital; Parkville Victoria Australia
- Department of Paediatrics; The University of Melbourne; Melbourne Victoria Australia
- Murdoch Children Research Institute; Parkville Victoria Australia
| | - A. Simon Harvey
- Department of Neurology; The Royal Children's Hospital; Parkville Victoria Australia
- Department of Paediatrics; The University of Melbourne; Melbourne Victoria Australia
- Murdoch Children Research Institute; Parkville Victoria Australia
| | - John S. Archer
- Department of Medicine; The University of Melbourne; Melbourne Victoria Australia
- The Florey Institute of Neuroscience and Mental Health; Parkville Victoria Australia
- Austin Health; Melbourne Victoria Australia
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36
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Kapoor I, Rath GP. Anesthetic management of a child with Lennox-Gastaut syndrome with intractable epilepsy posted for intracranial surgery! J Pediatr Neurosci 2016; 11:290-291. [PMID: 27857813 PMCID: PMC5108147 DOI: 10.4103/1817-1745.193384] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Indu Kapoor
- Department of Neuroanaesthesiology and Critical Care, Neuroscience Centre, All Institute of Medical Sciences, New Delhi, India
| | - Girija Prasad Rath
- Department of Neuroanaesthesiology and Critical Care, Neuroscience Centre, All Institute of Medical Sciences, New Delhi, India
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37
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Abbott DF. Interictal Epileptiform Discharges Might Be More Likely During Particular Phases of Brain Activity. Front Neurol 2015; 6:253. [PMID: 26696954 PMCID: PMC4669409 DOI: 10.3389/fneur.2015.00253] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2015] [Accepted: 11/16/2015] [Indexed: 11/17/2022] Open
Affiliation(s)
- David F Abbott
- The Florey Institute of Neuroscience and Mental Health, Austin Hospital , Melbourne, VIC , Australia ; The University of Melbourne , Melbourne, VIC , Australia
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38
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Pontine and cerebral atrophy in Lennox-Gastaut syndrome. Epilepsy Res 2015; 120:98-103. [PMID: 26808205 DOI: 10.1016/j.eplepsyres.2015.12.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2015] [Revised: 11/20/2015] [Accepted: 12/07/2015] [Indexed: 11/23/2022]
Abstract
OBJECTIVES Lennox-Gastaut syndrome (LGS) is a severe epilepsy of childhood onset associated with intellectual disability and multiple seizure types. Characteristic interictal electrographic discharges include generalized paroxysmal fast activity and slow spike and wave, which we have previously shown recruit widespread areas of association cortex. We wished to determine whether patients with Lennox-Gastaut syndrome (LGS) have changes in cerebral volumes that match this pattern of cortical recruitment. METHODS High resolution T1 weighted structural MRI was collected from 10 patients with LGS and 10 age and sex matched controls. Voxel-based morphometry (VBM) was used to compare tissue volumes across the whole brain (grey matter, white matter and CSF) and pontine volume between patients and controls, as well as to identify other regions of maximal tissue loss. RESULTS LGS patients showed a significant decrease in whole brain volume compared to controls. Cortical atrophy was prominent in the mesial frontal region and bilateral anterior temporal poles. White matter atrophy was widespread and included peri-central and premotor regions. Atrophy was prominent in the pons, particularly in the region of the reticular formation. Grey matter atrophy trended to progress with age. SIGNIFICANCE Grey and white matter atrophy are a feature of Lennox-Gastaut syndrome. Grey matter atrophy is apparent in the mesial frontal lobe suggesting this region may be an important node in the epilepsy network of LGS. Atrophy maximal in the pons and cerebellum mimics the patterns of seizure spread that has been previously observed during tonic seizures. This supports the idea that the pons is a key part of the epilepsy network in LGS.
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Pedersen M, Curwood EK, Archer JS, Abbott DF, Jackson GD. Brain regions with abnormal network properties in severe epilepsy of Lennox-Gastaut phenotype: Multivariate analysis of task-free fMRI. Epilepsia 2015; 56:1767-73. [DOI: 10.1111/epi.13135] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/05/2015] [Indexed: 01/17/2023]
Affiliation(s)
- Mangor Pedersen
- The Florey Institute of Neuroscience and Mental Health; Melbourne Victoria Australia
- The University of Melbourne; Florey Department of Neuroscience and Mental Health; Melbourne Victoria Australia
| | - Evan K. Curwood
- The University of Melbourne; Florey Department of Neuroscience and Mental Health; Melbourne Victoria Australia
| | - John S. Archer
- Department of Medicine; The University of Melbourne; Melbourne Victoria Australia
- Department of Neurology; Austin Health; Melbourne Victoria Australia
| | - David F. Abbott
- The Florey Institute of Neuroscience and Mental Health; Melbourne Victoria Australia
- The University of Melbourne; Florey Department of Neuroscience and Mental Health; Melbourne Victoria Australia
| | - Graeme D. Jackson
- The Florey Institute of Neuroscience and Mental Health; Melbourne Victoria Australia
- The University of Melbourne; Florey Department of Neuroscience and Mental Health; Melbourne Victoria Australia
- Department of Medicine; The University of Melbourne; Melbourne Victoria Australia
- Department of Neurology; Austin Health; Melbourne Victoria Australia
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