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Fang W, Chen S, Xia X, Huang W, Du Y, Liu Z, Chen L, Wang X, Xu H. Interictal interleukin-6 and tumor necrosis factor α levels are associated with seizure recurrence in adults with epilepsy. Epilepsy Behav 2024; 155:109786. [PMID: 38653175 DOI: 10.1016/j.yebeh.2024.109786] [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: 10/17/2023] [Revised: 04/07/2024] [Accepted: 04/10/2024] [Indexed: 04/25/2024]
Abstract
BACKGROUND Although there are models predicting epilepsy recurrence under different clinical conditions, few studies have examined blood biomarkers. Inflammation plays a crucial role in the occurrence and development of epilepsy. We analyzed inflammatory mediators in a regional hospital-based epilepsy cohort and investigated their relationship with subsequent epilepsy recurrence. METHODS Interictal inflammatory mediators were measured in 128 patients diagnosed with epilepsy participating in a prospective study. Inflammatory mediators were compared during the follow-up period between patients who experienced epilepsy recurrence and those who did not. We also assessed the correlation between inflammatory mediators and the time interval until the next recurrence. RESULTS Over a median 4-month follow-up period, 41 patients experienced seizure recurrence. Differences in interleukin-6 (IL-6) and tumor necrosis factor α (TNF-α) levels were observed between seizure recurrence and non-recurrence groups. After adjusting for covariates through multivariate Cox regression analysis, the patients in the third IL-6 tertile (>2.31 pg/mL; HR: 2.49; 95 % CI: 1.00-6.16; P = 0.049) and in the third TNF-α tertile (>0.74 pg/mL; HR: 2.80; 95 % CI: 1.13-6.92; P = 0.026) had higher risk of seizure recurrence. The time until the next recurrence was negatively correlated with IL-6 level (ρ = - 0.392, P = 0.011). CONCLUSION High levels of IL-6 and TNF-α are associated with a higher possibility of seizure recurrence. Future predictive models should also include inflammatory mediators in addition to clinical variables.
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Affiliation(s)
- Wenqiang Fang
- Department of Neurology, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang Province, PR China
| | - Shihao Chen
- Department of Neurology, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang Province, PR China
| | - Xuefen Xia
- Department of Neurology, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang Province, PR China
| | - Wenting Huang
- Department of Neurology, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang Province, PR China
| | - Yanru Du
- Department of Neurology, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang Province, PR China
| | - Zhipeng Liu
- Department of Neurology, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang Province, PR China
| | - Lekai Chen
- Department of Neurology, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang Province, PR China
| | - Xinshi Wang
- Department of Neurology, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang Province, PR China
| | - Huiqin Xu
- Department of Neurology, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang Province, PR China.
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Ferretti A, Riva A, Fabrizio A, Bruni O, Capovilla G, Foiadelli T, Orsini A, Raucci U, Romeo A, Striano P, Parisi P. Best practices for the management of febrile seizures in children. Ital J Pediatr 2024; 50:95. [PMID: 38735928 PMCID: PMC11089695 DOI: 10.1186/s13052-024-01666-1] [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: 01/19/2024] [Accepted: 04/28/2024] [Indexed: 05/14/2024] Open
Abstract
Febrile seizures (FS) are commonly perceived by healthcare professionals as a self-limited condition with a generally 'benign' nature. Nonetheless, they frequently lead to pediatric consultations, and their management can vary depending on the clinical context. For parents and caregivers, witnessing a seizure can be a distressing experience, significantly impacting their quality of life. In this review, we offer an in-depth exploration of FS management, therapeutic interventions, and prognostic factors, with the aim of providing support for physicians and enhancing communication with families. We conducted a comprehensive literature search using the PubMed and Web of Science databases, spanning the past 50 years. The search terms utilized included "febrile seizure," "complex febrile seizure," "simple febrile seizure," in conjunction with "children" or "infant." Only studies published in English or those presenting evidence-based data were included in our assessment. Additionally, we conducted a cross-reference search to identify any additional relevant data sources. Our thorough literature search resulted in a compilation of references, with carefully selected papers thoughtfully integrated into this review.
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Affiliation(s)
- Alessandro Ferretti
- Pediatrics Unit, Neurosciences, Mental Health and Sensory Organ (NESMOS) Department, Faculty of Medicine and Psychology, S. Andrea Hospital, Sapienza University, via di Grottarossa 1035/1039, Rome, 00189, Italy.
| | - Antonella Riva
- IRCCS Giannina Gaslini, Genoa, Italy
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa, Genoa, Italy
| | - Alice Fabrizio
- Pediatrics Unit, Neurosciences, Mental Health and Sensory Organ (NESMOS) Department, Faculty of Medicine and Psychology, S. Andrea Hospital, Sapienza University, via di Grottarossa 1035/1039, Rome, 00189, Italy
| | - Oliviero Bruni
- Department of Social and Developmental Psychology, S. Andrea Hospital, Sapienza University, Rome, Italy
| | - Giuseppe Capovilla
- Child Neuropsychiatry Department, Epilepsy Center, Mantova, Italy
- C. Poma HospitalFondazione Poliambulanza, Brescia, Italy
| | - Thomas Foiadelli
- Pediatric Clinic, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Alessandro Orsini
- Pediatric Neurology, Pediatric University Department, Azienda Ospedaliera Universitaria Pisana, University of Pisa, Pisa, Italy
| | - Umberto Raucci
- General and Emergency Department, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Antonino Romeo
- Fatebenefratelli Hospital, ASST Fatebenefratelli-Sacco, Milan, Italy
| | - Pasquale Striano
- IRCCS Giannina Gaslini, Genoa, Italy
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa, Genoa, Italy
| | - Pasquale Parisi
- Pediatrics Unit, Neurosciences, Mental Health and Sensory Organ (NESMOS) Department, Faculty of Medicine and Psychology, S. Andrea Hospital, Sapienza University, via di Grottarossa 1035/1039, Rome, 00189, Italy
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3
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Liu X, Zhang Y, Zhao Y, Zhang Q, Han F. The Neurovascular Unit Dysfunction in the Molecular Mechanisms of Epileptogenesis and Targeted Therapy. Neurosci Bull 2024; 40:621-634. [PMID: 38564049 PMCID: PMC11127907 DOI: 10.1007/s12264-024-01193-3] [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: 08/04/2023] [Accepted: 12/09/2023] [Indexed: 04/04/2024] Open
Abstract
Epilepsy is a multifaceted neurological syndrome characterized by recurrent, spontaneous, and synchronous seizures. The pathogenesis of epilepsy, known as epileptogenesis, involves intricate changes in neurons, neuroglia, and endothelium, leading to structural and functional disorders within neurovascular units and culminating in the development of spontaneous epilepsy. Although current research on epilepsy treatments primarily centers around anti-seizure drugs, it is imperative to seek effective interventions capable of disrupting epileptogenesis. To this end, a comprehensive exploration of the changes and the molecular mechanisms underlying epileptogenesis holds the promise of identifying vital biomarkers for accurate diagnosis and potential therapeutic targets. Emphasizing early diagnosis and timely intervention is paramount, as it stands to significantly improve patient prognosis and alleviate the socioeconomic burden. In this review, we highlight the changes and molecular mechanisms of the neurovascular unit in epileptogenesis and provide a theoretical basis for identifying biomarkers and drug targets.
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Affiliation(s)
- Xiuxiu Liu
- Medical Basic Research Innovation Center for Cardiovascular and Cerebrovascular Diseases, Ministry of Education, Nanjing, 211166, China.
- International Joint Laboratory for Drug Target of Critical Illnesses, School of Pharmacy, Nanjing Medical University, Nanjing, 211166, China.
| | - Ying Zhang
- Medical Basic Research Innovation Center for Cardiovascular and Cerebrovascular Diseases, Ministry of Education, Nanjing, 211166, China
- International Joint Laboratory for Drug Target of Critical Illnesses, School of Pharmacy, Nanjing Medical University, Nanjing, 211166, China
| | - Yanming Zhao
- Medical Basic Research Innovation Center for Cardiovascular and Cerebrovascular Diseases, Ministry of Education, Nanjing, 211166, China
- International Joint Laboratory for Drug Target of Critical Illnesses, School of Pharmacy, Nanjing Medical University, Nanjing, 211166, China
| | - Qian Zhang
- Medical Basic Research Innovation Center for Cardiovascular and Cerebrovascular Diseases, Ministry of Education, Nanjing, 211166, China
- International Joint Laboratory for Drug Target of Critical Illnesses, School of Pharmacy, Nanjing Medical University, Nanjing, 211166, China
| | - Feng Han
- Medical Basic Research Innovation Center for Cardiovascular and Cerebrovascular Diseases, Ministry of Education, Nanjing, 211166, China.
- International Joint Laboratory for Drug Target of Critical Illnesses, School of Pharmacy, Nanjing Medical University, Nanjing, 211166, China.
- Institute of Brain Science, The Affiliated Brain Hospital of Nanjing Medical University, Nanjing, 211166, China.
- Gusu School, Nanjing Medical University, Suzhou Municipal Hospital, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou, 210019, China.
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4
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Hanin A, Muscal E, Hirsch LJ. Second-line immunotherapy in new onset refractory status epilepticus. Epilepsia 2024; 65:1203-1223. [PMID: 38430119 DOI: 10.1111/epi.17933] [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: 11/22/2023] [Revised: 02/06/2024] [Accepted: 02/12/2024] [Indexed: 03/03/2024]
Abstract
Several pieces of evidence suggest immune dysregulation could trigger the onset and modulate sequelae of new onset refractory status epilepticus (NORSE), including its subtype with prior fever known as febrile infection-related epilepsy syndrome (FIRES). Consensus-driven recommendations have been established to guide the initiation of first- and second-line immunotherapies in these patients. Here, we review the literature to date on second-line immunotherapy for NORSE/FIRES, presenting results from 28 case reports and series describing the use of anakinra, tocilizumab, or intrathecal dexamethasone in 75 patients with NORSE. Among them, 52 patients were managed with anakinra, 21 with tocilizumab, and eight with intrathecal dexamethasone. Most had elevated serum or cerebrospinal fluid cytokine levels at treatment initiation. Treatments were predominantly initiated during the acute phase of the disease (92%) and resulted, within the first 2 weeks, in seizure control for up to 73% of patients with anakinra, 70% with tocilizumab, and 50% with intrathecal dexamethasone. Cytokine levels decreased after treatment for most patients. Anakinra and intrathecal dexamethasone were mainly initiated in children with FIRES, whereas tocilizumab was more frequently prescribed for adults, with or without a prior febrile infection. There was no clear correlation between the response to treatment and the time to initiate the treatment. Most patients experienced long-term disability and drug-resistant post-NORSE epilepsy. Initiation of second-line immunotherapies during status epilepticus (SE) had no clear effect on the emergence of post-NORSE epilepsy or long-term functional outcomes. In a small number of cases, the initiation of anakinra or tocilizumab several years after SE onset resulted in a reduction of seizure frequency for 67% of patients. These data highlight the potential utility of anakinra, tocilizumab, and intrathecal dexamethasone in patients with NORSE. There continues to be interest in the utilization of early cytokine measurements to guide treatment selection and response. Prospective studies are necessary to understand the role of early immunomodulation and its associations with epilepsy and functional outcomes.
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Affiliation(s)
- Aurélie Hanin
- Comprehensive Epilepsy Center, Department of Neurology, Yale University School of Medicine, New Haven, Connecticut, USA
- Sorbonne Université, Institut du Cerveau-Paris Brain Institute-ICM, Inserm, CNRS, Assistance Publique - Hôpitaux de Paris, Hôpital de la Pitié-Salpêtrière, Paris, France
- Epilepsy Unit and Clinical Neurophysiology Department, DMU Neurosciences 6, Assistance Publique - Hôpitaux de Paris, Hôpital de la Pitié-Salpêtrière, Paris, France
| | - Eyal Muscal
- Department of Pediatrics, Section of Rheumatology, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas, USA
| | - Lawrence J Hirsch
- Comprehensive Epilepsy Center, Department of Neurology, Yale University School of Medicine, New Haven, Connecticut, USA
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5
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Zuo RR, Jin M, Sun SZ. Etiological analysis of 167 cases of drug-resistant epilepsy in children. Ital J Pediatr 2024; 50:50. [PMID: 38481309 PMCID: PMC10938754 DOI: 10.1186/s13052-024-01619-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 02/24/2024] [Indexed: 03/17/2024] Open
Abstract
BACKGROUND To analyze the etiological distribution characteristics of drug-resistant epilepsy (DRE) in children, with the aim of providing valuable perspectives to enhance clinical practice. METHODS In this retrospective study, clinical data were collected on 167 children with DRE who were hospitalized between January 2020 and December 2022, including gender, age of onset, seizure types, video electroencephalogram(VEEG) recordings, neuroimaging, and genetic testing results. Based on the etiology of epilepsy, the enrolled children were categorized into different groups. The rank-sum test was conducted to compare the age of onset for different etiologies. RESULTS Of the 167 cases, 89 (53.3%) had a clear etiology. Among them, structural factors account for 23.4%, genetic factors for 19.2%, multiple factors for 7.2%, and immunological factors for 3.6%. The age of onset was significantly earlier in children with genetic causes than those with structural (P < 0.001) or immunological (P = 0.001) causes. CONCLUSIONS More than half of children with DRE have a distinct underlying cause, predominantly attributed to structural factors, followed by genetic factors. Genetic etiology primarily manifests at an early age, especially among children aged less than one year. This underscores the need for proactive enhancements in genetic testing to unveil the underlying causes and subsequently guide treatment protocols.
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Affiliation(s)
- Ran-Ran Zuo
- Department of Neurology, Hebei Childrens Hospital, 133, Jianhua South Street, 050000, Shijiazhuang, Hebei Province, China
| | - Mei Jin
- Department of Neurology, Hebei Childrens Hospital, 133, Jianhua South Street, 050000, Shijiazhuang, Hebei Province, China
- The Key Laboratory of Pediatric Epilepsy and Neurological Disorders of Hebei Province, 050000, Shijiazhuang, Hebei, China
| | - Su-Zhen Sun
- Department of Neurology, Hebei Childrens Hospital, 133, Jianhua South Street, 050000, Shijiazhuang, Hebei Province, China.
- The Key Laboratory of Pediatric Epilepsy and Neurological Disorders of Hebei Province, 050000, Shijiazhuang, Hebei, China.
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6
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Ruttkowski L, Wallot I, Korell M, Daur E, Seipelt P, Leonhardt A, Weber S, Mand N. Case report: Febrile infection-related epilepsy syndrome in a 14-year-old girl with multiple organ failure and lethal outcome. Front Neurosci 2024; 18:1255841. [PMID: 38505775 PMCID: PMC10948546 DOI: 10.3389/fnins.2024.1255841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Accepted: 02/07/2024] [Indexed: 03/21/2024] Open
Abstract
We report a case of an otherwise healthy 14-year-old girl with febrile infection-related epilepsy syndrome (FIRES), multiple organ failure (MOF), and ultimately a lethal outcome. This is a rare case of FIRES with MOF and consecutive death. Only a few cases have been described in the literature. The adolescent girl was initially admitted to our pediatric emergency department with a first episode of generalized tonic-clonic seizures after a short history of fever a week before admission. Seizures progressed rapidly into refractory status epilepticus without any evidence of the underlying cause, and treatment subsequently had to be escalated to thiopental anesthesia. Since the initial diagnostics showed no promising leads, the rare syndrome of FIRES was suspected, representing a catastrophic epileptic encephalopathy linked to a prior benign febrile infection. Methylprednisolone, intravenous immunoglobulins, and a ketogenic diet were initiated. Respiratory, circulatory, kidney, and liver failure developed during treatment, requiring increasing intensive care. Multiple attempts to deescalate antiepileptic treatment resulted in recurrent status epilepticus. A cranial MRI on the 10th day of treatment revealed diffuse brain edema and no cerebral perfusion. The patient was declared dead on the 11th day of treatment. FIRES should be taken into account in previously healthy children with a new onset of difficult-to-treat seizures after a short febrile infection when no other cause is apparent. First-line treatment, besides seizure control, is the early initiation of immunomodulatory therapy and the start of a ketogenic diet. As treatment is difficult and MOF may develop, patients should be transferred to a specialized children's hospital providing full intensive care.
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Affiliation(s)
- Lars Ruttkowski
- Pediatric Intensive Care, Department of Pediatrics, Philipps-University Marburg, Marburg, Germany
| | - Ines Wallot
- Pediatric Neurology, Department of Pediatrics, Philipps-University Marburg, Marburg, Germany
| | - Marie Korell
- Pediatric Intensive Care, Department of Pediatrics, Philipps-University Marburg, Marburg, Germany
| | - Elke Daur
- Pediatric Intensive Care, Department of Pediatrics, Philipps-University Marburg, Marburg, Germany
| | - Peter Seipelt
- Pediatric Neurology, Department of Pediatrics, Philipps-University Marburg, Marburg, Germany
| | - Andreas Leonhardt
- Pediatric Intensive Care, Department of Pediatrics, Philipps-University Marburg, Marburg, Germany
| | - Stefanie Weber
- Pediatric Nephrology, Department of Pediatrics, Philipps-University Marburg, Marburg, Germany
| | - Nadine Mand
- Pediatric Intensive Care, Department of Pediatrics, Philipps-University Marburg, Marburg, Germany
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7
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Arcan A, Kızılkılıç EK, Gündüz A, Unkun R, Vezzani A, Özkara Ç. Rasmussen's syndrome treated with anakinra. J Neurol 2024; 271:723-726. [PMID: 37922068 DOI: 10.1007/s00415-023-12072-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Revised: 10/16/2023] [Accepted: 10/17/2023] [Indexed: 11/05/2023]
Abstract
BACKGROUND AND OBJECTIVE Rasmussen's encephalitis (RE) is a rare chronic neurological disorder, characterized by unilateral inflammation of the cerebral cortex, refractory focal epilepsy or epilepsia partialis continua, hemiparesis, and progressive cognitive decline. Interleukin-1 (IL-1) plays an important role in neuroinflammation as a key element in the activation of the inflammatory IL-1β-IL-1 receptor type 1 (IL-1R1) axis. Anakinra, an IL-1 inhibitor, is successfully used in patients with new onset refractory status epilepticus and febrile infection-related epilepsy syndrome. METHODS AND RESULTS We present 38-year-old male with RE having right-sided hemiparesis and continuous spasms being unresponsive to immune modulatory therapies like pulse steroid, intravenous immunoglobulin and anti-seizure drugs. After treatment with anakinra for three weeks, the continuous spasms almost completely subsided, and his muscle strength returned to normal. DISCUSSION Anakinra may be considered as a treatment option in patients with RE and refractory seizures.
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Affiliation(s)
- Abdullah Arcan
- Cerrahpaşa Faculty of Medicine, Department of Neurology, Istanbul University-Cerrahpaşa, Istanbul, Turkey
| | | | - Ayşegül Gündüz
- Cerrahpaşa Faculty of Medicine, Department of Neurology, Istanbul University-Cerrahpaşa, Istanbul, Turkey
| | - Rümeysa Unkun
- Cerrahpaşa Faculty of Medicine, Department of Neurology, Istanbul University-Cerrahpaşa, Istanbul, Turkey
| | - Annamaria Vezzani
- Department of Neuroscience, Istituto Di Ricerche Farmacologiche Mario Negri, Milano, Italy
| | - Çiğdem Özkara
- Cerrahpaşa Faculty of Medicine, Department of Neurology, Istanbul University-Cerrahpaşa, Istanbul, Turkey
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Jean G, Carton J, Haq K, Musto AE. The role of dendritic spines in epileptogenesis. Front Cell Neurosci 2023; 17:1173694. [PMID: 37601280 PMCID: PMC10433379 DOI: 10.3389/fncel.2023.1173694] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Accepted: 07/06/2023] [Indexed: 08/22/2023] Open
Abstract
Epilepsy is a chronic central nervous system (CNS) disease associated with high morbidity. To date, there is no known disease-modifying therapy for epilepsy. A leading hypothesis for a mechanism of epileptogenesis is the generation of aberrant neuronal networks. Although the underlying biological mechanism is not clear, scientific evidence indicates that it is associated with a hyperexcitable synchronous neuronal network and active dendritic spine plasticity. Changes in dendritic spine morphology are related to altered expression of synaptic cytoskeletal proteins, inflammatory molecules, neurotrophic factors, and extracellular matrix signaling. However, it remains to be determined if these aberrant dendritic spine formations lead to neuronal hyperexcitability and abnormal synaptic connections or whether they constitute an underlying mechanism of seizure susceptibility. Focusing on dendritic spine machinery as a potential target for medications could limit or reverse the development of epilepsy.
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Affiliation(s)
- Gary Jean
- Medical Program, School of Medicine, Eastern Virginia Medical School, Norfolk, VA, United States
| | - Joseph Carton
- Medical Program, School of Medicine, Eastern Virginia Medical School, Norfolk, VA, United States
| | - Kaleem Haq
- Department of Pathology and Anatomy, Eastern Virginia Medical School, Norfolk, VA, United States
| | - Alberto E. Musto
- Department of Pathology and Anatomy, Eastern Virginia Medical School, Norfolk, VA, United States
- Department of Neurology, Eastern Virginia Medical School, Norfolk, VA, United States
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9
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Perucca E, Perucca P, White HS, Wirrell EC. Drug resistance in epilepsy. Lancet Neurol 2023:S1474-4422(23)00151-5. [PMID: 37352888 DOI: 10.1016/s1474-4422(23)00151-5] [Citation(s) in RCA: 24] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 03/23/2023] [Accepted: 04/06/2023] [Indexed: 06/25/2023]
Abstract
Drug resistance is estimated to affect about a third of individuals with epilepsy, but its prevalence differs in relation to the epilepsy syndrome, the cause of epilepsy, and other factors such as age of seizure onset and presence of associated neurological deficits. Although drug-resistant epilepsy is not synonymous with unresponsiveness to any drug treatment, the probability of achieving seizure freedom on a newly tried medication decreases with increasing number of previously failed treatments. After two appropriately used antiseizure medications have failed to control seizures, individuals should be referred whenever possible to a comprehensive epilepsy centre for diagnostic re-evaluation and targeted management. The feasibility of epilepsy surgery and other treatments, including those targeting the cause of epilepsy, should be considered early after diagnosis. Substantial evidence indicates that a delay in identifying an effective treatment can adversely affect ultimate outcome and carry an increased risk of cognitive disability, other comorbidities, and premature mortality. Research on mechanisms of drug resistance and novel therapeutics is progressing rapidly, and potentially improved treatments, including those targeting disease modification, are on the horizon.
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Affiliation(s)
- Emilio Perucca
- Department of Medicine, Austin Health, University of Melbourne, Melbourne, VIC, Australia; Department of Neuroscience, Central Clinical School, Monash University, Melbourne, VIC, Australia.
| | - Piero Perucca
- Department of Medicine, Austin Health, University of Melbourne, Melbourne, VIC, Australia; Department of Neuroscience, Central Clinical School, Monash University, Melbourne, VIC, Australia; Bladin-Berkovic Comprehensive Epilepsy Program, Department of Neurology, Austin Health, Melbourne, VIC, Australia; Department of Neurology, Royal Melbourne Hospital, Melbourne, VIC, Australia; Department of Neurology, Alfred Health, Melbourne, VIC, Australia
| | - H Steve White
- Department of Pharmacy, School of Pharmacy, University of Washington, Seattle, WA, USA
| | - Elaine C Wirrell
- Divisions of Child and Adolescent Neurology and Epilepsy, Department of Neurology, Mayo Clinic, Rochester, MN, USA
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10
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Stredny C, Rotenberg A, Leviton A, Loddenkemper T. Systemic inflammation as a biomarker of seizure propensity and a target for treatment to reduce seizure propensity. Epilepsia Open 2023; 8:221-234. [PMID: 36524286 PMCID: PMC9978091 DOI: 10.1002/epi4.12684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Accepted: 12/12/2022] [Indexed: 12/23/2022] Open
Abstract
People with diabetes can wear a device that measures blood glucose and delivers just the amount of insulin needed to return the glucose level to within bounds. Currently, people with epilepsy do not have access to an equivalent wearable device that measures a systemic indicator of an impending seizure and delivers a rapidly acting medication or other intervention (e.g., an electrical stimulus) to terminate or prevent a seizure. Given that seizure susceptibility is reliably increased in systemic inflammatory states, we propose a novel closed-loop device where release of a fast-acting therapy is governed by sensors that quantify the magnitude of systemic inflammation. Here, we review the evidence that patients with epilepsy have raised levels of systemic indicators of inflammation than controls, and that some anti-inflammatory drugs have reduced seizure occurrence in animals and humans. We then consider the options of what might be incorporated into a responsive anti-seizure system.
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Affiliation(s)
- Coral Stredny
- Division of Epilepsy and Clinical Neurophysiology, Department of NeurologyBoston Children's HospitalBostonMassachusettsUSA
- Department of NeurologyHarvard Medical SchoolBostonMassachusettsUSA
| | - Alexander Rotenberg
- Division of Epilepsy and Clinical Neurophysiology, Department of NeurologyBoston Children's HospitalBostonMassachusettsUSA
- Department of NeurologyHarvard Medical SchoolBostonMassachusettsUSA
| | - Alan Leviton
- Division of Epilepsy and Clinical Neurophysiology, Department of NeurologyBoston Children's HospitalBostonMassachusettsUSA
- Department of NeurologyHarvard Medical SchoolBostonMassachusettsUSA
| | - Tobias Loddenkemper
- Division of Epilepsy and Clinical Neurophysiology, Department of NeurologyBoston Children's HospitalBostonMassachusettsUSA
- Department of NeurologyHarvard Medical SchoolBostonMassachusettsUSA
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11
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Guo HL, Wang WJ, Dong N, Zhao YT, Dai HR, Hu YH, Zhang YY, Wang J, Qiu JC, Lu XP, Chen F. Integrating metabolomics and lipidomics revealed a decrease in plasma fatty acids but an increase in triglycerides in children with drug-refractory epilepsy. Epilepsia Open 2023. [PMID: 36808532 DOI: 10.1002/epi4.12712] [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: 10/27/2022] [Accepted: 02/13/2023] [Indexed: 02/22/2023] Open
Abstract
OBJECTIVE The drug-refractory epilepsy (DRE) in children is commonly observed but the underlying mechanisms remain elusive. We examined whether fatty acids (FAs) and lipids are potentially associated with the pharmacoresistance to valproic acid (VPA) therapy. METHODS This single-center, retrospective cohort study was conducted using data from pediatric patients collected between May 2019 and December 2019 at the Children's Hospital of Nanjing Medical University. Ninety plasma samples from 53 responders with VPA monotherapy (RE group) and 37 non-responders with VPA polytherapy (NR group) were collected. Non-targeted metabolomics and lipidomics analysis for those plasma samples were performed to compare the potential differences of small metabolites and lipids between the two groups. Plasma metabolites and lipids passing the threshold of variable importance in projection value >1, fold change >1.2 or <0.8, and p-value <0.05 were regarded as statistically different substances. RESULTS A total of 204 small metabolites and 433 lipids comprising 16 different lipid subclasses were identified. The well-established partial least squares-discriminant analysis (PLS-DA) revealed a good separation of the RE from the NR group. The FAs and glycerophospholipids status were significantly decreased in the NR group, but their triglycerides (TG) levels were significantly increased. The trend of TG levels in routine laboratory tests was in line with the lipidomics analysis. Meanwhile, cases from the NR group were characterized by a decreased level of citric acid and L-thyroxine, but with an increased level of glucose and 2-oxoglutarate. The top two enriched metabolic pathways involved in the DRE condition were biosynthesis of unsaturated FAs and linoleic acid metabolism. SIGNIFICANCE The results of this study suggested an association between metabolism of FAs and the medically intractable epilepsy. Such novel findings might propose a potential mechanism linked to the energy metabolism. Ketogenic acid and FAs supplementation might therefore be high-priority strategies for DRE management.
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Affiliation(s)
- Hong-Li Guo
- Department of Pharmacy, Pharmaceutical Sciences Research Center, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Wei-Jun Wang
- School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, China
| | - Na Dong
- Institute of Pharmaceutical Sciences, China Pharmaceutical University, Nanjing, China
| | - Yue-Tao Zhao
- School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, China
| | - Hao-Ran Dai
- School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, China
| | - Ya-Hui Hu
- Department of Pharmacy, Pharmaceutical Sciences Research Center, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Yuan-Yuan Zhang
- Department of Pharmacy, Pharmaceutical Sciences Research Center, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Jie Wang
- Department of Pharmacy, Pharmaceutical Sciences Research Center, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Jin-Chun Qiu
- Department of Pharmacy, Pharmaceutical Sciences Research Center, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Xiao-Peng Lu
- Department of Neurology, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Feng Chen
- Department of Pharmacy, Pharmaceutical Sciences Research Center, Children's Hospital of Nanjing Medical University, Nanjing, China
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12
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Flammer J, Neziraj T, Rüegg S, Pröbstel AK. Immune Mechanisms in Epileptogenesis: Update on Diagnosis and Treatment of Autoimmune Epilepsy Syndromes. Drugs 2023; 83:135-158. [PMID: 36696027 PMCID: PMC9875200 DOI: 10.1007/s40265-022-01826-9] [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] [Accepted: 12/07/2022] [Indexed: 01/26/2023]
Abstract
Seizures and epilepsy can result from various aetiologies, yet the underlying cause of several epileptic syndromes remains unclear. In that regard, autoimmune-mediated pathophysiological mechanisms have been gaining attention in the past years and were included as one of the six aetiologies of seizures in the most recent classification of the International League Against Epilepsy. The increasing number of anti-neuronal antibodies identified in patients with encephalitic disorders has contributed to the establishment of an immune-mediated pathophysiology in many cases of unclear aetiology of epileptic syndromes. Yet only a small number of patients with autoimmune encephalitis develop epilepsy in the proper sense where the brain transforms into a state where it will acquire the enduring propensity to produce seizures if it is not hindered by interventions. Hence, the term autoimmune epilepsy is often wrongfully used in the context of autoimmune encephalitis since most of the seizures are acute encephalitis-associated and will abate as soon as the encephalitis is in remission. Given the overlapping clinical presentation of immune-mediated seizures originating from different aetiologies, a clear distinction among the aetiological entities is crucial when it comes to discussing pathophysiological mechanisms, therapeutic options, and long-term prognosis of patients. Moreover, a rapid and accurate identification of patients with immune-mediated epilepsy syndromes is required to ensure an early targeted treatment and, thereby, improve clinical outcome. In this article, we review our current understanding of pathogenesis and critically discuss current and potential novel treatment options for seizures and epilepsy syndromes of underlying or suspected immune-mediated origin. We further outline the challenges in proper terminology.
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Affiliation(s)
- Julia Flammer
- Department of Neurology, University Hospital Basel and University of Basel, Petersgraben 4, 4031, Basel, Switzerland.,Departments of Biomedicine and Clinical Research, University Hospital Basel and University of Basel, Basel, Switzerland.,Research Center for Clinical Neuroimmunology and Neuroscience Basel (RC2NB), University Hospital Basel and University of Basel, Basel, Switzerland
| | - Tradite Neziraj
- Department of Neurology, University Hospital Basel and University of Basel, Petersgraben 4, 4031, Basel, Switzerland.,Departments of Biomedicine and Clinical Research, University Hospital Basel and University of Basel, Basel, Switzerland.,Research Center for Clinical Neuroimmunology and Neuroscience Basel (RC2NB), University Hospital Basel and University of Basel, Basel, Switzerland
| | - Stephan Rüegg
- Department of Neurology, University Hospital Basel and University of Basel, Petersgraben 4, 4031, Basel, Switzerland.
| | - Anne-Katrin Pröbstel
- Department of Neurology, University Hospital Basel and University of Basel, Petersgraben 4, 4031, Basel, Switzerland. .,Departments of Biomedicine and Clinical Research, University Hospital Basel and University of Basel, Basel, Switzerland. .,Research Center for Clinical Neuroimmunology and Neuroscience Basel (RC2NB), University Hospital Basel and University of Basel, Basel, Switzerland.
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13
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Liu S, Fan M, Ma MD, Ge JF, Chen FH. Long non-coding RNAs: Potential therapeutic targets for epilepsy. Front Neurosci 2022; 16:986874. [PMID: 36278003 PMCID: PMC9582525 DOI: 10.3389/fnins.2022.986874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Accepted: 09/16/2022] [Indexed: 11/13/2022] Open
Abstract
Epilepsy is a common and disastrous neurological disorder characterized by abnormal firing of neurons in the brain, affecting about 70 million people worldwide. Long non-coding RNAs (LncRNAs) are a class of RNAs longer than 200 nucleotides without the capacity of protein coding, but they participate in a wide variety of pathophysiological processes. Alternated abundance and diversity of LncRNAs have been found in epilepsy patients and animal or cell models, suggesting a potential role of LncRNAs in epileptogenesis. This review will introduce the structure and function of LncRNAs, summarize the role of LncRNAs in the pathogenesis of epilepsy, especially its linkage with neuroinflammation, apoptosis, and transmitter balance, which will throw light on the molecular mechanism of epileptogenesis, and accelerate the clinical implementation of LncRNAs as a potential therapeutic target for treatment of epilepsy.
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Affiliation(s)
- Sen Liu
- School of Pharmacy, Anhui Medical University, Hefei, China
- The Key Laboratory of Anti-Inflammatory and Immune Medicine, Ministry of Education, Hefei, China
- Anhui Provincial Laboratory of Inflammatory and Immunity Disease, Hefei, China
| | - Min Fan
- School of Pharmacy, Anhui Medical University, Hefei, China
- The Key Laboratory of Anti-Inflammatory and Immune Medicine, Ministry of Education, Hefei, China
- Anhui Provincial Laboratory of Inflammatory and Immunity Disease, Hefei, China
| | - Meng-Die Ma
- School of Pharmacy, Anhui Medical University, Hefei, China
- The Key Laboratory of Anti-Inflammatory and Immune Medicine, Ministry of Education, Hefei, China
- Anhui Provincial Laboratory of Inflammatory and Immunity Disease, Hefei, China
| | - Jin-Fang Ge
- School of Pharmacy, Anhui Medical University, Hefei, China
- The Key Laboratory of Anti-Inflammatory and Immune Medicine, Ministry of Education, Hefei, China
- Anhui Provincial Laboratory of Inflammatory and Immunity Disease, Hefei, China
- *Correspondence: Jin-Fang Ge,
| | - Fei-Hu Chen
- School of Pharmacy, Anhui Medical University, Hefei, China
- The Key Laboratory of Anti-Inflammatory and Immune Medicine, Ministry of Education, Hefei, China
- Anhui Provincial Laboratory of Inflammatory and Immunity Disease, Hefei, China
- Fei-Hu Chen,
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14
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Zhao Y, Li J, Gao L, Yang X, Zhao H, Li Y, Su L, Zhao X, Ding H, Li B. The value of immunotherapy in children with initial short-term frequent seizures. Front Neurol 2022; 13:948727. [PMID: 36158962 PMCID: PMC9490574 DOI: 10.3389/fneur.2022.948727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Accepted: 08/01/2022] [Indexed: 12/02/2022] Open
Abstract
This study aimed to discuss clinical characteristics, therapy, and antibody prevalence in epilepsy (APE) score for short-term, frequent epileptic seizures in children who are autoimmune-antibody negative and respond well to immunotherapy. The clinical characteristics, imaging manifestations, electrophysiology, and effective treatment plan of 9 children who met the above criteria were retrospectively analyzed in the Pediatric Neurology Department of Qilu Hospital at Shandong University from June 2019 to December 2021. All 9 patients (6 boys, 3 girls; aged 13 months−11 years and 5 months, median 3.5 years) had acute-onset seizures within 3 months. All had previous normal growth/development with no family history of disease. Seizure types were focal motor seizures (6), generalized tonic-clonic seizures (2), and generalized secondary-to-focal (1); occurred >10 times/day; and lasted <1 min/episode. Formal treatment with ≥2 types of antiseizure medicine (ASM) achieved an unsatisfactory effect. Cranial magnetic resonance imaging showed an abnormal result in 1 case. The APE score was ≥4 in 3 cases and <4 in 6 cases. All patients experienced symptomatic relief with immunotherapy; subsequently, 8 patients were free of recurrence and 1 had significantly reduced seizure frequency. Autoimmune antibody screening is recommended for children who were previously well and have acute-onset epilepsy; high frequency, short-duration seizures; no good response to 2 types of ASM; and other etiologic factors excluded, even with APE score <4. Even with negative autoimmune antibody results, the possibility of autoimmune epilepsy should be considered for urgent initiation of immunotherapy, which can achieve good results.
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Affiliation(s)
- Yongheng Zhao
- Department of Pediatrics, Qilu Hospital of Shandong University, Jinan, China
- Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Jun Li
- Department of Pediatrics, Qilu Hospital of Shandong University, Jinan, China
| | - Liang Gao
- Department of Pediatrics, Qilu Hospital of Shandong University, Jinan, China
- Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Xiaofan Yang
- Department of Pediatrics, Qilu Hospital of Shandong University, Jinan, China
| | - Haiqing Zhao
- Department of Pediatrics, Qilu Hospital of Shandong University, Jinan, China
- Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Yumei Li
- Department of Pediatrics, Qilu Hospital of Shandong University, Jinan, China
- Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Li Su
- Department of Pediatrics, Qilu Hospital of Shandong University, Jinan, China
- Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Xiaoyu Zhao
- Department of Pediatrics, Qilu Hospital of Shandong University, Jinan, China
- Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Hao Ding
- Department of Pediatrics, Qilu Hospital of Shandong University, Jinan, China
- Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Baomin Li
- Department of Pediatrics, Qilu Hospital of Shandong University, Jinan, China
- *Correspondence: Baomin Li
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