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Lewis SA, Shetty S, Gamble S, Heim J, Zhao N, Stitt G, Pankratz M, Mangum T, Marku I, Rosenberg RB, Wilfong AA, Fahey MC, Kim S, Myers SJ, Appavu B, Kruer MC. Intrathecal magnesium delivery for Mg++-insensitive NMDA receptor activity due to GRIN1 mutation. Orphanet J Rare Dis 2023; 18:225. [PMID: 37537625 PMCID: PMC10398931 DOI: 10.1186/s13023-023-02756-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Accepted: 06/04/2023] [Indexed: 08/05/2023] Open
Abstract
BACKGROUND Mutations in the NMDA receptor are known to disrupt glutamatergic signaling crucial for early neurodevelopment, often leading to severe global developmental delay/intellectual disability, epileptic encephalopathy, and cerebral palsy phenotypes. Both seizures and movement disorders can be highly treatment-refractory. RESULTS We describe a targeted ABA n-of-1 treatment trial with intrathecal MgSO4, rationally designed based on the electrophysiologic properties of this gain of function mutation in the GRIN1 NMDA subunit. CONCLUSION Although the invasive nature of the trial necessitated a short-term, non-randomized, unblinded intervention, quantitative longitudinal neurophysiologic monitoring indicated benefit, providing class II evidence in support of intrathecal MgSO4 for select forms of GRIN disorders.
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Affiliation(s)
- Sara A Lewis
- Pediatric Movement Disorders Program, Barrow Neurological Institute, Phoenix Children's Hospital, Phoenix, AZ, 85016, USA
- Departments of Child Health, Neurology, Cellular & Molecular Medicine, and Program in Genetics, University of Arizona College of Medicine - Phoenix, Phoenix, AZ, USA
| | - Sheetal Shetty
- Pediatric Movement Disorders Program, Barrow Neurological Institute, Phoenix Children's Hospital, Phoenix, AZ, 85016, USA
- Departments of Child Health, Neurology, Cellular & Molecular Medicine, and Program in Genetics, University of Arizona College of Medicine - Phoenix, Phoenix, AZ, USA
| | - Sean Gamble
- Valley Anesthesia, Phoenix Children's Hospital, Phoenix, AZ, USA
| | - Jennifer Heim
- Pediatric Movement Disorders Program, Barrow Neurological Institute, Phoenix Children's Hospital, Phoenix, AZ, 85016, USA
| | - Ningning Zhao
- Department of Nutritional Sciences, University of Arizona, Tucson, AZ, USA
| | - Gideon Stitt
- Department of Pharmacy & Therapeutics, Phoenix Children's Hospital, Phoenix, AZ, USA
| | - Matthew Pankratz
- Phoenix Children's Hospital Biorepository, Phoenix Children's Hospital, Phoenix, AZ, USA
| | - Tara Mangum
- Pediatric Movement Disorders Program, Barrow Neurological Institute, Phoenix Children's Hospital, Phoenix, AZ, 85016, USA
| | - Iris Marku
- Pediatric Movement Disorders Program, Barrow Neurological Institute, Phoenix Children's Hospital, Phoenix, AZ, 85016, USA
| | - Robert B Rosenberg
- Division of Pediatric Critical Care Medicine, Phoenix Children's Hospital, Phoenix, AZ, USA
| | - Angus A Wilfong
- Pediatric Movement Disorders Program, Barrow Neurological Institute, Phoenix Children's Hospital, Phoenix, AZ, 85016, USA
| | - Michael C Fahey
- Departments of Paediatrics and Neurology, Monash University, Melbourne, VIC, Australia
| | - Sukhan Kim
- Center for Functional Evaluation of Rare Variants, Emory University, Atlanta, GA, USA
| | - Scott J Myers
- Center for Functional Evaluation of Rare Variants, Emory University, Atlanta, GA, USA
| | - Brian Appavu
- Pediatric Movement Disorders Program, Barrow Neurological Institute, Phoenix Children's Hospital, Phoenix, AZ, 85016, USA
| | - Michael C Kruer
- Pediatric Movement Disorders Program, Barrow Neurological Institute, Phoenix Children's Hospital, Phoenix, AZ, 85016, USA.
- Departments of Child Health, Neurology, Cellular & Molecular Medicine, and Program in Genetics, University of Arizona College of Medicine - Phoenix, Phoenix, AZ, USA.
- Programs in Neuroscience, Molecular & Cellular Biology, and Biomedical Informatics, Arizona State University, Tempe, AZ, USA.
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Sussman BL, Wyckoff SN, Heim J, Wilfong AA, Adelson PD, Kruer MC, Gonzalez MJ, Boerwinkle VL. Is Resting State Functional MRI Effective Connectivity in Movement Disorders Helpful? A Focused Review Across Lifespan and Disease. Front Neurol 2022; 13:847834. [PMID: 35493815 PMCID: PMC9046695 DOI: 10.3389/fneur.2022.847834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Accepted: 03/23/2022] [Indexed: 11/20/2022] Open
Abstract
In the evolving modern era of neuromodulation for movement disorders in adults and children, much progress has been made recently characterizing the human motor network (MN) with potentially important treatment implications. Herein is a focused review of relevant resting state fMRI functional and effective connectivity of the human motor network across the lifespan in health and disease. The goal is to examine how the transition from functional connectivity to dynamic effective connectivity may be especially informative of network-targeted movement disorder therapies, with hopeful implications for children.
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Affiliation(s)
- Bethany L. Sussman
- Division of Neuroscience, Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, AZ, United States
- *Correspondence: Bethany L. Sussman
| | - Sarah N. Wyckoff
- Division of Neuroscience, Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, AZ, United States
- Department of Research, Phoenix Children's Hospital, Phoenix, AZ, United States
| | - Jennifer Heim
- Division of Pediatric Neurology, Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, AZ, United States
| | - Angus A. Wilfong
- Division of Pediatric Neurology, Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, AZ, United States
| | - P. David Adelson
- Division of Pediatric Neurosurgery, Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, AZ, United States
| | - Michael C. Kruer
- Division of Pediatric Neurology, Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, AZ, United States
- Departments of Child Health, Neurology, Genetics and Cellular & Molecular Medicine, University of Arizona College of Medicine – Phoenix, Phoenix, AZ, United States
| | | | - Varina L. Boerwinkle
- Division of Pediatric Neurology, Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, AZ, United States
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Barcia Aguilar C, Amengual-Gual M, Sánchez Fernández I, Abend NS, Anderson A, Appavu B, Arya R, Brenton JN, Carpenter JL, Chapman KE, Clark J, Farias-Moeller R, Gaillard WD, Gaínza-Lein M, Glauser T, Goldstein JL, Goodkin HP, Guerriero RM, Huh L, Lai YC, McDonough TL, Mikati MA, Morgan LA, Novotny EJ, Ostendorf A, Payne ET, Peariso K, Piantino J, Riviello J, Sannagowdara K, Sheehan T, Sands TT, Tasker RC, Tchapyjnikov D, Topjian AA, Vasquez A, Wainwright MS, Wilfong AA, Williams K, Loddenkemper T. Time to Treatment in Pediatric Convulsive Refractory Status Epilepticus: The Weekend Effect. Pediatr Neurol 2021; 120:71-79. [PMID: 34022752 DOI: 10.1016/j.pediatrneurol.2021.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Revised: 03/13/2021] [Accepted: 03/19/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Time to treatment in pediatric refractory status epilepticus is delayed. We aimed to evaluate the influence of weekends and holidays on time to treatment of this pediatric emergency. METHODS We performed a retrospective analysis of prospectively collected observational data of pediatric patients with refractory status epilepticus. RESULTS We included 329 patients (56% males) with a median (p25 to p75) age of 3.8 (1.3 to 9) years. The median (p25 to p75) time to first BZD on weekdays and weekends/holidays was 20 (6.8 to 48.3) minutes versus 11 (5 to 35) minutes, P = 0.01; adjusted hazard ratio (HR) = 1.20 (95% confidence interval [CI]: 0.95 to 1.55), P = 0.12. The time to first non-BZD ASM was longer on weekdays than on weekends/holidays (68 [42.8 to 153.5] minutes versus 59 [27 to 120] minutes, P = 0.006; adjusted HR = 1.38 [95% CI: 1.08 to 1.76], P = 0.009). However, this difference was mainly driven by status epilepticus with in-hospital onset: among 108 patients, the time to first non-BZD ASM was longer during weekdays than during weekends/holidays (55.5 [28.8 to 103.5] minutes versus 28 [15.8 to 66.3] minutes, P = 0.003; adjusted HR = 1.65 [95% CI: 1.08 to 2.51], P = 0.01). CONCLUSIONS The time to first non-BZD ASM in pediatric refractory status epilepticus is shorter on weekends/holidays than on weekdays, mainly driven by in-hospital onset status epilepticus. Data on what might be causing this difference may help tailor policies to improve medication application timing.
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Affiliation(s)
- Cristina Barcia Aguilar
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts; Department of Child Neurology, Hospital Universitario La Paz, Universidad Autónoma de Madrid, Madrid, Spain.
| | - Marta Amengual-Gual
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts; Pediatric Neurology Unit, Department of Pediatrics, Hospital Universitari Son Espases, Universitat de les Illes Balears, Palma, Spain
| | - Iván Sánchez Fernández
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts; Department of Child Neurology, Hospital Sant Joan de Déu, Universidad de Barcelona, Barcelona, Spain
| | - Nicholas S Abend
- Division of Neurology, The Children's Hospital of Philadelphia, the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Anne Anderson
- Section of Neurology and Developmental Neuroscience, Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Brian Appavu
- Department of Neurosciences, Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, Arizona
| | - Ravindra Arya
- Division of Pediatric Neurology, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - J Nicholas Brenton
- Department of Neurology and Pediatrics, University of Virginia Health System, Charlottesville, Virginia
| | - Jessica L Carpenter
- Center for Neuroscience, Children's National Hospital, George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
| | - Kevin E Chapman
- Departments of Pediatrics and Neurology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado
| | - Justice Clark
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Raquel Farias-Moeller
- Department of Pediatric Neurology, Children's Hospital of Wisconsin, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - William D Gaillard
- Center for Neuroscience, Children's National Hospital, George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
| | - Marina Gaínza-Lein
- Instituto de Pediatría, Facultad de Medicina, Universidad Austral de Chile, Valdivia, Chile; Servicio de Neuropsiquiatría Infantil, Hospital Clínico San Borja Arriarán, Universidad de Chile, Santiago, Chile
| | - Tracy Glauser
- Division of Pediatric Neurology, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Joshua L Goldstein
- Davee Pediatric Neurocritical Care Program, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Howard P Goodkin
- Department of Neurology and Pediatrics, University of Virginia Health System, Charlottesville, Virginia
| | - Rejean M Guerriero
- Division of Pediatric and Developmental Neurology, Department of Neurology, Washington University School of Medicine, St. Louis, Missouri
| | - Linda Huh
- Department of Pediatrics, British Columbia Children's Hospital, the University of British Columbia, BC, Canada
| | - Yi-Chen Lai
- Section of Pediatric Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Tiffani L McDonough
- Division of Neurology and Epilepsy, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Mohamad A Mikati
- Division of Pediatric Neurology, Duke University Medical Center, Duke University, Durham, North Carolina
| | - Lyndsey A Morgan
- Division of Pediatric Neurology, Department of Neurology, University of Washington, Seattle, Washington
| | - Edward J Novotny
- Division of Pediatric Neurology, Department of Neurology, University of Washington, Seattle, Washington
| | - Adam Ostendorf
- Division of Pediatric Neurology, Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, Ohio
| | - Eric T Payne
- Division of Neurology, Department of Pediatrics, Alberta Children's Hospital, Calgary, AB, Canada
| | - Katrina Peariso
- Division of Pediatric Neurology, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Juan Piantino
- Department of Neurology, Doernbecher Children's Hospital, Oregon Health & Science University, Portland, Oregon
| | - James Riviello
- Section of Neurology and Developmental Neuroscience, Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Kumar Sannagowdara
- Department of Pediatric Neurology, Children's Hospital of Wisconsin, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Theodore Sheehan
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Tristan T Sands
- Department of Neurology, Columbia University Medical Center, New York, New York
| | - Robert C Tasker
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts; Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Dmitry Tchapyjnikov
- Division of Pediatric Neurology, Duke University Medical Center, Duke University, Durham, North Carolina
| | - Alexis A Topjian
- Division of Critical Care Medicine, The Children's Hospital of Philadelphia, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Alejandra Vasquez
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts; Division of Child and Adolescent Neurology, Mayo Clinic, Mayo Clinic School of Medicine, Rochester, Minnesota
| | - Mark S Wainwright
- Division of Pediatric Neurology, Department of Neurology, University of Washington, Seattle, Washington
| | - Angus A Wilfong
- Department of Neurosciences, Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, Arizona
| | - Korwyn Williams
- Department of Neurosciences, Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, Arizona
| | - Tobias Loddenkemper
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
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4
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Sculier C, Barcia Aguilar C, Gaspard N, Gaínza-Lein M, Sánchez Fernández I, Amengual-Gual M, Anderson A, Arya R, Burrows BT, Brenton JN, Carpenter JL, Chapman KE, Clark J, Gaillard WD, Glauser TA, Goldstein JL, Goodkin HP, Gorman M, Lai YC, McDonough TL, Mikati MA, Nayak A, Peariso K, Riviello J, Rusie A, Sperberg K, Stredny CM, Tasker RC, Tchapyjnikov D, Vasquez A, Wainwright MS, Wilfong AA, Williams K, Loddenkemper T. Clinical presentation of new onset refractory status epilepticus in children (the pSERG cohort). Epilepsia 2021; 62:1629-1642. [PMID: 34091885 PMCID: PMC8362203 DOI: 10.1111/epi.16950] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 05/09/2021] [Accepted: 05/11/2021] [Indexed: 01/14/2023]
Abstract
Objective We aimed to characterize the clinical profile and outcomes of new onset refractory status epilepticus (NORSE) in children, and investigated the relationship between fever onset and status epilepticus (SE). Methods Patients with refractory SE (RSE) between June 1, 2011 and October 1, 2016 were prospectively enrolled in the pSERG (Pediatric Status Epilepticus Research Group) cohort. Cases meeting the definition of NORSE were classified as "NORSE of known etiology" or "NORSE of unknown etiology." Subgroup analysis of NORSE of unknown etiology was completed based on the presence and time of fever occurrence relative to RSE onset: fever at onset (≤24 h), previous fever (2 weeks–24 h), and without fever. Results Of 279 patients with RSE, 46 patients met the criteria for NORSE. The median age was 2.4 years, and 25 (54%) were female. Forty (87%) patients had NORSE of unknown etiology. Nineteen (48%) presented with fever at SE onset, 16 (40%) had a previous fever, and five (12%) had no fever. The patients with preceding fever had more prolonged SE and worse outcomes, and 25% recovered baseline neurological function. The patients with fever at onset were younger and had shorter SE episodes, and 89% recovered baseline function. Significance Among pediatric patients with RSE, 16% met diagnostic criteria for NORSE, including the subcategory of febrile infection‐related epilepsy syndrome (FIRES). Pediatric NORSE cases may also overlap with refractory febrile SE (FSE). FIRES occurs more frequently in older children, the course is usually prolonged, and outcomes are worse, as compared to refractory FSE. Fever occurring more than 24 h before the onset of seizures differentiates a subgroup of NORSE patients with distinctive clinical characteristics and worse outcomes.
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Affiliation(s)
- Claudine Sculier
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA.,Department of Neurology, Erasmus Hospital, Free University of Brussels, Brussels, Belgium
| | - Cristina Barcia Aguilar
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA.,Department of Child Neurology, La Paz University Hospital, Autonomous University of Madrid, Madrid, Spain
| | - Nicolas Gaspard
- Department of Neurology, Erasmus Hospital, Free University of Brussels, Brussels, Belgium.,Neurology Department, Comprehensive Epilepsy Center, Yale University School of Medicine, New Haven, CT, USA
| | - Marina Gaínza-Lein
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA.,Faculty of Medicine, Institute of Pediatrics, Austral University of Chile, Valdivia, Chile.,Children's Neuropsychiatry Service, San Borja Arriarán Clinical Hospital, University of Chile, Santiago, Chile
| | - Iván Sánchez Fernández
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA.,Department of Child Neurology, SJD Barcelona Children's Hospital, University of Barcelona, Barcelona, Spain
| | - Marta Amengual-Gual
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA.,Pediatric Neurology Unit, Department of Pediatrics, Son Espases University Hospital, University of the Balearic Islands, Palma, Spain
| | - Anne Anderson
- Section of Neurology and Developmental Neuroscience, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Ravindra Arya
- Division of Pediatric Neurology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Brian T Burrows
- Department of Pediatrics, Barrows Neurological Institute, Phoenix Children's Hospital, University of Arizona School of Medicine, Phoenix, AZ, USA.,Department of Neurology, Mayo Clinic, Scottsdale, AZ, USA
| | - James N Brenton
- Department of Neurology and Pediatrics, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Jessica L Carpenter
- Center for Neuroscience, Children's National Hospital, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Kevin E Chapman
- Departments of Pediatrics and Neurology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO, USA
| | - Justice Clark
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - William D Gaillard
- Center for Neuroscience, Children's National Hospital, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Tracy A Glauser
- Division of Pediatric Neurology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Joshua L Goldstein
- Ruth D. & Ken M. Davee Pediatric Neurocritical Care Program, Northwestern University Feinberg, School of Medicine, Chicago, IL, USA
| | - Howard P Goodkin
- Department of Neurology and Pediatrics, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Mark Gorman
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Yi-Chen Lai
- Section of Neurology and Developmental Neuroscience, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Tiffani L McDonough
- Division of Neurology and Epilepsy, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Mohamad A Mikati
- Division of Pediatric Neurology, Duke University Medical Center, Duke University, Durham, NC, USA
| | - Anuranjita Nayak
- Section of Neurology and Developmental Neuroscience, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Katrina Peariso
- Division of Pediatric Neurology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - James Riviello
- Section of Neurology and Developmental Neuroscience, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Allison Rusie
- Ruth D. & Ken M. Davee Pediatric Neurocritical Care Program, Northwestern University Feinberg, School of Medicine, Chicago, IL, USA
| | - Katherine Sperberg
- Center for Neuroscience, Children's National Hospital, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Coral M Stredny
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Robert C Tasker
- Department of Neurology, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Dmitry Tchapyjnikov
- Division of Neurology and Epilepsy, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Alejandra Vasquez
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA.,Division of Child and Adolescent Neurology, Mayo Clinic, Mayo Clinic School of Medicine, Rochester, MN, USA
| | - Mark S Wainwright
- Division of Pediatric Neurology, Department of Neurology, University of Washington, Seattle, WA, USA
| | - Angus A Wilfong
- Division of Pediatric Neurology, Department of Child Health, Phoenix Children's Hospital, University of Arizona College of Medicine, Phoenix, AZ, USA
| | - Korwyn Williams
- Division of Pediatric Neurology, Department of Child Health, Phoenix Children's Hospital, University of Arizona College of Medicine, Phoenix, AZ, USA
| | - Tobias Loddenkemper
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
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5
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Wheeler CE, Temkit M, Wilfong AA, Vanatta L, Jarrar R. Efficacy and tolerability of a whey-based, medium-chain triglyceride-enhanced ketogenic formula in children with refractory epilepsy: A retrospective study. Seizure 2021; 91:29-33. [PMID: 34058606 DOI: 10.1016/j.seizure.2021.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Revised: 02/24/2021] [Accepted: 05/01/2021] [Indexed: 11/17/2022] Open
Abstract
PURPOSE Ketogenic metabolic therapy (KMT) has demonstrated effectiveness in seizure reduction. However, patient compliance and adverse effects limit its use. Ready-to-feed (RTF) ketogenic formulas improve compliance and include components that mitigate adverse effects. This study is the first to evaluate the efficacy and tolerability of an RTF, whey-based, medium-chain triglyceride-enhanced (WBME) ketogenic formula. METHODS Retrospective data from patients who received KMT between January 1, 2015, and February 28, 2018, were analyzed. Patients who received ≥75% of their total calories from the WBME formula and who were monitored for 3 months were included. Outcome measures were gastrointestinal issues, acidosis, serum blood glucose and beta-hydroxybutyrate levels, unintentional weight changes, diet response (≥50% reduction in seizures), seizure freedom, and change in formula or discontinuation of therapy. Patients with incomplete outcome data or who received <75% of total calories from the formula were excluded. RESULTS Twenty-six patients (13 males; mean [SD] age, 6.1 [5.8] years) met the inclusion criteria. Thirteen patients were established patients who received a standard ketogenic formula before changing to the WBME formula; 13 were patients new to KMT whose therapy was initiated using the WBME formula. This formula was well tolerated; no patient in either group discontinued therapy or required a change in formula. The combined diet response rate (95% CI) for established and new patients was 96% (80-100%). Seizure-freedom (95% CI) for both groups at 3 months posttreatment was 20% (7-41%). The most prevalent adverse effect was constipation (69% [95% CI, 48-86%]). CONCLUSION The WBME ketogenic formula appears to be effective and well tolerated by pediatric patients with refractory epilepsy.
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Affiliation(s)
- Christine E Wheeler
- Department of Neurology, Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, AZ, USA
| | - M'hamed Temkit
- Department of Neurology, Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, AZ, USA
| | - Angus A Wilfong
- Department of Neurology, Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, AZ, USA
| | - Lisa Vanatta
- Department of Neurology, Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, AZ, USA
| | - Randa Jarrar
- Department of Neurology, Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, AZ, USA.
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6
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Smegal LF, Sebold AJ, Hammill AM, Juhász C, Lo WD, Miles DK, Wilfong AA, Levin AV, Fisher B, Ball KL, Pinto AL, Comi AM. Multicenter Research Data of Epilepsy Management in Patients With Sturge-Weber Syndrome. Pediatr Neurol 2021; 119:3-10. [PMID: 33813331 PMCID: PMC8162684 DOI: 10.1016/j.pediatrneurol.2021.02.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Revised: 02/10/2021] [Accepted: 02/14/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND Epilepsy in typical Sturge-Weber syndrome (SWS) is common, and many questions remain regarding the treatment outcomes. We analyzed a large multicenter database with focus on neurological drug treatment in different demographic and SWS characteristic groups. METHODS A total of 268 patients with brain involvement and a history of seizures were selected from a research data registry generated from a multicenter cross-sectional questionnaire. We examined associations between medication use and binary variables such as sex, ethnicity, and brain, skin, and eye involvement laterality. We analyzed group differences in mean number of antiseizure medications and age at diagnosis, enrollment, and seizure onset and examined differences in median SWS neurological scores in groups of interest. RESULTS The most frequently used medications were levetiracetam (48.1%), low-dose aspirin (44.8%), oxcarbazepine (39.9%), and phenobarbital (14.9%). Lamotrigine was more frequently used in adults than in children (P = 0.001). History of neurosurgery was associated with no current antiseizure medication use (P = 0.001), whereas bilateral brain involvement and family history of seizures were associated with using a higher number of antiseizure medications (P = 0.002, P = 0.027, respectively). Subjects with bilateral brain involvement and early seizure onset were associated with using a higher number of antiseizure medications (P = 0.002) and phenobarbital use (0.003). CONCLUSIONS Levetiracetam, low-dose aspirin, and oxcarbazepine were the most frequently used medications. More severely affected patients were frequently on a greater number of antiseizure medications. Surgery for epilepsy was associated with the ability to discontinue antiseizure medication. Longitudinal studies are needed to further investigate medication use in patients with SWS.
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Affiliation(s)
- Lindsay F. Smegal
- Department of Neurology, Hugo Moser Kennedy Krieger Research Institute, Baltimore, Maryland
| | - Alison J. Sebold
- Department of Neurology, Hugo Moser Kennedy Krieger Research Institute, Baltimore, Maryland
| | - Adrienne M. Hammill
- Division of Hematology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Csaba Juhász
- Departments of Pediatrics, Neurology, and Neurosurgery, Wayne State University School of Medicine, Children’s Hospital of Michigan, Detroit, Michigan
| | - Warren D. Lo
- Neurology, Nationwide Children’s Hospital, Columbus, Ohio
| | - Daniel K. Miles
- Department of Neurology, Pediatric Epilepsy, New York University Langone Health, New York, New York
| | - Angus A. Wilfong
- Neurology, Barrow Neurological Institute, Phoenix Children’s Hospital, Phoenix, Arizona
| | - Alex V. Levin
- Pediatric Ophthalmology and Ocular Genetics, Flaum Eye Institute, Golisano Children’s Hospital, University of Rochester, Rochester, New York
| | | | | | - Anna L. Pinto
- Department of Neurology, Boston Children’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Anne M. Comi
- Department of Neurology, Hugo Moser Kennedy Krieger Research Institute, Baltimore, Maryland,Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland,Department of Pediatrics, Johns Hopkins Hospital, Johns Hopkins University School of Medicine, Baltimore, Maryland,Communications should be addressed to: Dr. Comi; Department of Neurology; Hugo Moser Kennedy Krieger Research Institute; Rm 553, Kennedy Krieger Outpatient Bldg, 801 North Broadway; Baltimore, MD 21205. (A.M. Comi)
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7
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Abstract
INTRODUCTION Hypothalamic hamartoma is rarely associated with epileptic spasms. We describe epileptic spasms in a large cohort of hypothalamic hamartoma patients. METHODS We performed a retrospective chart review between March 2011 and March 2020 to identify patients with hypothalamic hamartoma and epilepsy. RESULTS We identified 114 patients with hypothalamic hamartoma and epilepsy, only 3 male patients (2.6%) also had epileptic spasms. The epileptic spasms developed between 6 and 18 months of age. Epileptic spasms resolved with oral prednisolone in 1 and with vigabatrin in the second patient. The third patient continued epileptic spasms despite multiple antiepileptic drugs and partial resection of hypothalamic hamartoma. All 3 patients underwent laser-ablation of hypothalamic hamartoma at the age of 14, 29, and 63 months. The seizure burden decreased by 100%, 84%, and 93% at follow-up (3-47 months). CONCLUSIONS Epileptic spasms are rare in hypothalamic hamartoma patients and early laser-ablation could potentially treat epileptic spasms and all other seizure types associated with hypothalamic hamartoma.
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Affiliation(s)
- Cemal Karakas
- Department of Pediatrics, Section of Pediatric Neurology and Developmental Neuroscience, 12298Baylor College of Medicine, Houston, TX, USA.,Department of Neurology and Neurophysiology, 12298Baylor College of Medicine, Houston, TX, USA
| | - Angus A Wilfong
- Division of Pediatric Neurology, Phoenix Children's Hospital, Barrow Neurological Institute, Phoenix, AZ, USA
| | - James J Riviello
- Department of Pediatrics, Section of Pediatric Neurology and Developmental Neuroscience, 12298Baylor College of Medicine, Houston, TX, USA.,Department of Neurology and Neurophysiology, 12298Baylor College of Medicine, Houston, TX, USA
| | - Daniel J Curry
- Section of Pediatric Neurosurgery, Texas Children's Hospital, Houston, TX, USA
| | - Irfan Ali
- Department of Pediatrics, Section of Pediatric Neurology and Developmental Neuroscience, 12298Baylor College of Medicine, Houston, TX, USA.,Department of Neurology and Neurophysiology, 12298Baylor College of Medicine, Houston, TX, USA
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8
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Boerwinkle VL, Mirea L, Gaillard WD, Sussman BL, Larocque D, Bonnell A, Ronecker JS, Troester MM, Kerrigan JF, Foldes ST, Appavu B, Jarrar R, Williams K, Wilfong AA, Adelson PD. Resting-state functional MRI connectivity impact on epilepsy surgery plan and surgical candidacy: prospective clinical work. J Neurosurg Pediatr 2020; 25:1-8. [PMID: 32197251 DOI: 10.3171/2020.1.peds19695] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Accepted: 01/10/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The authors' goal was to prospectively quantify the impact of resting-state functional MRI (rs-fMRI) on pediatric epilepsy surgery planning. METHODS Fifty-one consecutive patients (3 months to 20 years old) with intractable epilepsy underwent rs-fMRI for presurgical evaluation. The team reviewed the following available diagnostic data: video-electroencephalography (n = 51), structural MRI (n = 51), FDG-PET (n = 42), magnetoencephalography (n = 5), and neuropsychological testing (n = 51) results to formulate an initial surgery plan blinded to the rs-fMRI findings. Subsequent to this discussion, the connectivity results were revealed and final recommendations were established. Changes between pre- and post-rs-fMRI treatment plans were determined, and changes in surgery recommendation were compared using McNemar's test. RESULTS Resting-state fMRI was successfully performed in 50 (98%) of 51 cases and changed the seizure onset zone localization in 44 (88%) of 50 patients. The connectivity results prompted 6 additional studies, eliminated the ordering of 11 further diagnostic studies, and changed the intracranial monitoring plan in 10 cases. The connectivity results significantly altered surgery planning with the addition of 13 surgeries, but it did not eliminate planned surgeries (p = 0.003). Among the 38 epilepsy surgeries performed, the final surgical approach changed due to rs-fMRI findings in 22 cases (58%), including 8 (28%) of 29 in which extraoperative direct electrical stimulation mapping was averted. CONCLUSIONS This study demonstrates the impact of rs-fMRI connectivity results on the decision-making for pediatric epilepsy surgery by providing new information about the location of eloquent cortex and the seizure onset zone. Additionally, connectivity results may increase the proportion of patients considered eligible for surgery while optimizing the need for further testing.
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Affiliation(s)
| | | | - William D Gaillard
- 3Department of Neurology, Children's National Medical Center, Washington, DC
| | | | | | | | - Jennifer S Ronecker
- 5Division of Pediatric Neurosurgery, Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, Arizona; and
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9
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Boerwinkle VL, Torrisi SJ, Foldes ST, Marku I, Ranjan M, Wilfong AA, Adelson PD. Resting-state fMRI in disorders of consciousness to facilitate early therapeutic intervention. Neurol Clin Pract 2019; 9:e33-e35. [PMID: 31583195 DOI: 10.1212/cpj.0000000000000596] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Accepted: 11/30/2018] [Indexed: 11/15/2022]
Affiliation(s)
- Varina L Boerwinkle
- Division of Pediatric Neurology (VLB, IM, AAW), Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, AZ; Neuroscience Research (SJT, STF, PDA), Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, AZ; and Division of Pediatric Neurosurgery (MR, PDA), Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, AZ
| | - Salvatore J Torrisi
- Division of Pediatric Neurology (VLB, IM, AAW), Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, AZ; Neuroscience Research (SJT, STF, PDA), Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, AZ; and Division of Pediatric Neurosurgery (MR, PDA), Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, AZ
| | - Stephen T Foldes
- Division of Pediatric Neurology (VLB, IM, AAW), Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, AZ; Neuroscience Research (SJT, STF, PDA), Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, AZ; and Division of Pediatric Neurosurgery (MR, PDA), Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, AZ
| | - Iris Marku
- Division of Pediatric Neurology (VLB, IM, AAW), Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, AZ; Neuroscience Research (SJT, STF, PDA), Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, AZ; and Division of Pediatric Neurosurgery (MR, PDA), Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, AZ
| | - Manish Ranjan
- Division of Pediatric Neurology (VLB, IM, AAW), Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, AZ; Neuroscience Research (SJT, STF, PDA), Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, AZ; and Division of Pediatric Neurosurgery (MR, PDA), Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, AZ
| | - Angus A Wilfong
- Division of Pediatric Neurology (VLB, IM, AAW), Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, AZ; Neuroscience Research (SJT, STF, PDA), Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, AZ; and Division of Pediatric Neurosurgery (MR, PDA), Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, AZ
| | - P David Adelson
- Division of Pediatric Neurology (VLB, IM, AAW), Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, AZ; Neuroscience Research (SJT, STF, PDA), Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, AZ; and Division of Pediatric Neurosurgery (MR, PDA), Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, AZ
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10
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Boerwinkle VL, Cediel EG, Mirea L, Williams K, Kerrigan JF, Lam S, Raskin JS, Desai VR, Wilfong AA, Adelson PD, Curry DJ. Network-targeted approach and postoperative resting-state functional magnetic resonance imaging are associated with seizure outcome. Ann Neurol 2019; 86:344-356. [PMID: 31294865 DOI: 10.1002/ana.25547] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Revised: 07/08/2019] [Accepted: 07/09/2019] [Indexed: 12/25/2022]
Abstract
OBJECTIVE Postoperative resting-state functional magnetic resonance imaging (MRI) in children with intractable epilepsy has not been quantified in relation to seizure outcome. Therefore, its value as a biomarker for epileptogenic pathology is not well understood. METHODS In a sample of children with intractable epilepsy who underwent prospective resting-state seizure onset zone (SOZ)-targeted epilepsy surgery, postoperative resting-state functional MRI (rs-fMRI) was performed 6 to 12 months later. Graded normalization of the postoperative resting-state SOZ was compared to seizure outcomes, patient, surgery, and anatomical MRI characteristics. RESULTS A total of 64 cases were evaluated. Network-targeted surgery, followed by postoperative rs-fMRI normalization was significantly (p < 0.001) correlated with seizure reduction, with a Spearman rank correlation coefficient of 0.83. Of 39 cases with postoperative rs-fMRI SOZ normalization, 38 (97%) became completely seizure free. In contrast, of the 25 cases without complete rs-fMRI SOZ normalization, only 3 (5%) became seizure free. The accuracy of rs-fMRI as a biomarker predicting seizure freedom is 94%, with 96% sensitivity and 93% specificity. INTERPRETATION Among seizure localization techniques in pediatric epilepsy, network-targeted surgery, followed by postoperative rs-fMRI normalization, has high correlation with seizure freedom. This study shows that rs-fMRI SOZ can be used as a biomarker of the epileptogenic zone, and postoperative rs-fMRI normalization is a biomarker for SOZ quiescence. ANN NEUROL 2019;86:344-356.
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Affiliation(s)
- Varina L Boerwinkle
- Division of Pediatric Neurology, Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, AZ
| | - Emilio G Cediel
- Division of Pediatric Neurosurgery, Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, AZ
| | - Lucia Mirea
- Department of Research, Phoenix Children's Hospital, Phoenix, AZ
| | - Korwyn Williams
- Division of Pediatric Neurology, Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, AZ
| | - John F Kerrigan
- Division of Pediatric Neurology, Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, AZ
| | - Sandi Lam
- Section of Pediatric Neurosurgery, Riley Hospital for Children, Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Jeffrey S Raskin
- Section of Pediatric Neurosurgery, Riley Hospital for Children, Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Virendra R Desai
- Department of Neurosurgery, Houston Methodist Hospital, Houston, TX
| | - Angus A Wilfong
- Division of Pediatric Neurology, Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, AZ
| | - P David Adelson
- Division of Pediatric Neurology, Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, AZ.,Division of Pediatric Neurosurgery, Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, AZ
| | - Daniel J Curry
- Department of Pediatric Neurosurgery, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
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11
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Boerwinkle VL, Foldes ST, Torrisi SJ, Temkit H, Gaillard WD, Kerrigan JF, Desai VR, Raskin JS, Vedantam A, Jarrar R, Williams K, Lam S, Ranjan M, Broderson JS, Adelson D, Wilfong AA, Curry DJ. Subcentimeter epilepsy surgery targets by resting state functional magnetic resonance imaging can improve outcomes in hypothalamic hamartoma. Epilepsia 2018; 59:2284-2295. [DOI: 10.1111/epi.14583] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Revised: 09/10/2018] [Accepted: 09/24/2018] [Indexed: 12/13/2022]
Affiliation(s)
- Varina L. Boerwinkle
- Division of Pediatric Neurology; Barrow Neurological Institute at Phoenix Children’s Hospital; Phoenix Arizona
| | - Stephen T. Foldes
- Neuroscience Research; Barrow Neurological Institute at Phoenix Children’s Hospital; Phoenix Arizona
| | - Salvatore J. Torrisi
- Section on the Neurobiology of Fear and Anxiety; National Institute of Mental Health; National Institutes of Health; Bethesda Maryland
| | - Hamy Temkit
- Department of Research; Phoenix Children’s Hospital; Phoenix Arizona
| | - William D. Gaillard
- Department of Neurology; Children’s National Medical Center; Washington District of Columbia
| | - John F. Kerrigan
- Division of Pediatric Neurology; Barrow Neurological Institute at Phoenix Children’s Hospital; Phoenix Arizona
| | - Virendra R. Desai
- Department of Neurosurgery; Houston Methodist Hospital; Houston Methodist Neurological Institute; Houston Texas
| | - Jeffrey S. Raskin
- Department of Pediatric Neurosurgery; Texas Children’s Hospital; Baylor College of Medicine; Houston Texas
| | - Aditya Vedantam
- Department of Pediatric Neurosurgery; Texas Children’s Hospital; Baylor College of Medicine; Houston Texas
| | - Randa Jarrar
- Division of Pediatric Neurology; Barrow Neurological Institute at Phoenix Children’s Hospital; Phoenix Arizona
| | - Korwyn Williams
- Division of Pediatric Neurology; Barrow Neurological Institute at Phoenix Children’s Hospital; Phoenix Arizona
| | - Sandi Lam
- Department of Pediatric Neurosurgery; Texas Children’s Hospital; Baylor College of Medicine; Houston Texas
| | - Manish Ranjan
- Division of Pediatric Neurosurgery; Barrow Neurological Institute at Phoenix Children’s Hospital; Phoenix Arizona
| | - Janna S. Broderson
- Division of Pediatric Neurology; Texas Children’s Hospital; Baylor College of Medicine; Houston Texas
| | - David Adelson
- Division of Pediatric Neurology; Barrow Neurological Institute at Phoenix Children’s Hospital; Phoenix Arizona
- Division of Pediatric Neurosurgery; Barrow Neurological Institute at Phoenix Children’s Hospital; Phoenix Arizona
| | - Angus A. Wilfong
- Division of Pediatric Neurology; Barrow Neurological Institute at Phoenix Children’s Hospital; Phoenix Arizona
| | - Daniel J. Curry
- Department of Pediatric Neurosurgery; Texas Children’s Hospital; Baylor College of Medicine; Houston Texas
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12
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Desai VR, Vedantam A, Lam SK, Mirea L, Foldes ST, Curry DJ, Adelson PD, Wilfong AA, Boerwinkle VL. Language lateralization with resting-state and task-based functional MRI in pediatric epilepsy. J Neurosurg Pediatr 2018; 23:171-177. [PMID: 30485177 DOI: 10.3171/2018.7.peds18162] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Accepted: 07/24/2018] [Indexed: 11/06/2022]
Abstract
In Brief: The study compared two types of functional MRI (fMRI) to see which side of the brain is most responsible for language: traditional task-based fMRI, which requires a high level of patient interaction, and resting-state fMRI, which is typically performed with the patient under light sedation and has no interaction requirement. The authors found that the test correlation was 93%, indicating resting state fMRI has potential to locate language in those unable to participate in task-based fMRI.
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Affiliation(s)
- Virendra R Desai
- Division of Pediatric Neurosurgery, Texas Children's Hospital/Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Aditya Vedantam
- Division of Pediatric Neurosurgery, Texas Children's Hospital/Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Sandi K Lam
- Division of Pediatric Neurosurgery, Texas Children's Hospital/Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Lucia Mirea
- Department of Research, Phoenix Children's Hospital, Phoenix, Arizona
| | | | - Daniel J Curry
- Division of Pediatric Neurosurgery, Texas Children's Hospital/Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - P David Adelson
- Division of Pediatric Neurosurgery, and.,Division of Pediatric Neurology, Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, Arizona
| | - Angus A Wilfong
- Division of Pediatric Neurology, Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, Arizona
| | - Varina L Boerwinkle
- Division of Pediatric Neurology, Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, Arizona
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13
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Boerwinkle VL, Mohanty D, Foldes ST, Guffey D, Minard CG, Vedantam A, Raskin JS, Lam S, Bond M, Mirea L, Adelson PD, Wilfong AA, Curry DJ. Correlating Resting-State Functional Magnetic Resonance Imaging Connectivity by Independent Component Analysis-Based Epileptogenic Zones with Intracranial Electroencephalogram Localized Seizure Onset Zones and Surgical Outcomes in Prospective Pediatric Intractable Epilepsy Study. Brain Connect 2018; 7:424-442. [PMID: 28782373 PMCID: PMC5647510 DOI: 10.1089/brain.2016.0479] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
The purpose of this study was to prospectively investigate the agreement between the epileptogenic zone(s) (EZ) localization by resting-state functional magnetic resonance imaging (rs-fMRI) and the seizure onset zone(s) (SOZ) identified by intracranial electroencephalogram (ic-EEG) using novel differentiating and ranking criteria of rs-fMRI abnormal independent components (ICs) in a large consecutive heterogeneous pediatric intractable epilepsy population without an a priori alternate modality informing EZ localization or prior declaration of total SOZ number. The EZ determination criteria were developed by using independent component analysis (ICA) on rs-fMRI in an initial cohort of 350 pediatric patients evaluated for epilepsy surgery over a 3-year period. Subsequently, these rs-fMRI EZ criteria were applied prospectively to an evaluation cohort of 40 patients who underwent ic-EEG for SOZ identification. Thirty-seven of these patients had surgical resection/disconnection of the area believed to be the primary source of seizures. One-year seizure frequency rate was collected postoperatively. Among the total 40 patients evaluated, agreement between rs-fMRI EZ and ic-EEG SOZ was 90% (36/40; 95% confidence interval [CI], 0.76-0.97). Of the 37 patients who had surgical destruction of the area believed to be the primary source of seizures, 27 (73%) rs-fMRI EZ could be classified as true positives, 7 (18%) false positives, and 2 (5%) false negatives. Sensitivity of rs-fMRI EZ was 93% (95% CI 78-98%) with a positive predictive value of 79% (95% CI, 63-89%). In those with cryptogenic localization-related epilepsy, agreement between rs-fMRI EZ and ic-EEG SOZ was 89% (8/9; 95% CI, 0.52-99), with no statistically significant difference between the agreement in the cryptogenic and symptomatic localization-related epilepsy subgroups. Two children with negative ic-EEG had removal of the rs-fMRI EZ and were seizure free 1 year postoperatively. Of the 33 patients where at least 1 rs-fMRI EZ agreed with the ic-EEG SOZ, 24% had at least 1 additional rs-fMRI EZ outside the resection area. Of these patients with un-resected rs-fMRI EZ, 75% continued to have seizures 1 year later. Conversely, among 75% of patients in whom rs-fMRI agreed with ic-EEG SOZ and had no anatomically separate rs-fMRI EZ, only 24% continued to have seizures 1 year later. This relationship between extraneous rs-fMRI EZ and seizure outcome was statistically significant (p = 0.01). rs-fMRI EZ surgical destruction showed significant association with postoperative seizure outcome. The pediatric population with intractable epilepsy studied prospectively provides evidence for use of resting-state ICA ranking criteria, to identify rs-fMRI EZ, as developed by the lead author (V.L.B.). This is a high yield test in this population, because no seizure nor particular interictal epilepiform activity needs to occur during the study. Thus, rs-fMRI EZ detected by this technique are potentially informative for epilepsy surgery evaluation and planning in this population. Independent of other brain function testing modalities, such as simultaneous EEG-fMRI or electrical source imaging, contextual ranking of abnormal ICs of rs-fMRI localized EZs correlated with the gold standard of SOZ localization, ic-EEG, across the broad range of pediatric epilepsy surgery candidates, including those with cryptogenic epilepsy.
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Affiliation(s)
- Varina L Boerwinkle
- 1 Division of Pediatric Neurology, Barrow Neurological Institute at Phoenix Children's Hospital , Phoenix, Arizona.,2 Department of Pediatric Neurology, Texas Children's Hospital , Baylor College of Medicine, Houston, Texas
| | - Deepankar Mohanty
- 2 Department of Pediatric Neurology, Texas Children's Hospital , Baylor College of Medicine, Houston, Texas
| | - Stephen T Foldes
- 3 Neuroscience Research, Barrow Neurological Institute at Phoenix Children's Hospital , Phoenix, Arizona
| | - Danielle Guffey
- 4 Dan L. Duncan Institute for Clinical and Translational Research , Baylor College of Medicine, Houston, Texas
| | - Charles G Minard
- 4 Dan L. Duncan Institute for Clinical and Translational Research , Baylor College of Medicine, Houston, Texas
| | - Aditya Vedantam
- 5 Department of Pediatric Neurosurgery, Texas Children's Hospital , Baylor College of Medicine, Houston, Texas
| | - Jeffrey S Raskin
- 5 Department of Pediatric Neurosurgery, Texas Children's Hospital , Baylor College of Medicine, Houston, Texas
| | - Sandi Lam
- 5 Department of Pediatric Neurosurgery, Texas Children's Hospital , Baylor College of Medicine, Houston, Texas
| | - Margaret Bond
- 2 Department of Pediatric Neurology, Texas Children's Hospital , Baylor College of Medicine, Houston, Texas
| | - Lucia Mirea
- 6 Department of Research, Phoenix Children's Hospital , Phoenix, Arizona
| | - P David Adelson
- 1 Division of Pediatric Neurology, Barrow Neurological Institute at Phoenix Children's Hospital , Phoenix, Arizona.,7 Division of Pediatric Neurosurgery, Barrow Neurological Institute at Phoenix Children's Hospital , Phoenix, Arizona
| | - Angus A Wilfong
- 1 Division of Pediatric Neurology, Barrow Neurological Institute at Phoenix Children's Hospital , Phoenix, Arizona.,2 Department of Pediatric Neurology, Texas Children's Hospital , Baylor College of Medicine, Houston, Texas
| | - Daniel J Curry
- 5 Department of Pediatric Neurosurgery, Texas Children's Hospital , Baylor College of Medicine, Houston, Texas
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14
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Arya R, Peariso K, Gaínza-Lein M, Harvey J, Bergin A, Brenton JN, Burrows BT, Glauser T, Goodkin HP, Lai YC, Mikati MA, Fernández IS, Tchapyjnikov D, Wilfong AA, Williams K, Loddenkemper T. Efficacy and safety of ketogenic diet for treatment of pediatric convulsive refractory status epilepticus. Epilepsy Res 2018; 144:1-6. [PMID: 29727818 DOI: 10.1016/j.eplepsyres.2018.04.012] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Revised: 04/17/2018] [Accepted: 04/25/2018] [Indexed: 12/29/2022]
Abstract
PURPOSE To describe the efficacy and safety of ketogenic diet (KD) for convulsive refractory status epilepticus (RSE). METHODS RSE patients treated with KD at the 6/11 participating institutions of the pediatric Status Epilepticus Research Group from January-2011 to December-2016 were included. Patients receiving KD prior to the index RSE episode were excluded. RSE was defined as failure of ≥2 anti-seizure medications, including at least one non-benzodiazepine drug. Ketosis was defined as serum beta-hydroxybutyrate levels >20 mg/dl (1.9 mmol/l). Outcomes included proportion of patients with electrographic (EEG) seizure resolution within 7 days of starting KD, defined as absence of seizures and ≥50% suppression below 10 μV on longitudinal bipolar montage (suppression-burst ratio ≥50%); time to start KD after onset of RSE; time to achieve ketosis after starting KD; and the proportion of patients weaned off continuous infusions 2 weeks after KD initiation. Treatment-emergent adverse effects (TEAEs) were also recorded. RESULTS Fourteen patients received KD for treatment of RSE (median age 4.7 years, interquartile range [IQR] 5.6). KD was started via enteral route in 11/14 (78.6%) patients. KD was initiated a median of 13 days (IQR 12.5) after the onset of RSE, at 4:1 ratio in 8/14 (57.1%) patients. Ketosis was achieved within a median of 2 days (IQR 2.0) after starting KD. EEG seizure resolution was achieved within 7 days of starting KD in 10/14 (71.4%) patients. Also, 11/14 (78.6%) patients were weaned off their continuous infusions within 2 weeks of starting KD. TEAEs, potentially attributable to KD, occurred in 3/14 (21.4%) patients, including gastro-intestinal paresis and hypertriglyceridemia. Three month outcomes were available for 12/14 (85.7%) patients, with 4 patients being seizure-free, and 3 others with decreased seizure frequency compared to pre-RSE baseline. CONCLUSIONS This series suggests efficacy and safety of KD for treatment of pediatric RSE.
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Affiliation(s)
- Ravindra Arya
- Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA.
| | - Katrina Peariso
- Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Marina Gaínza-Lein
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA; Facultad de Medicina, Universidad Austral de Chile, Valdivia, Chile
| | - Jessica Harvey
- Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Ann Bergin
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Brian T Burrows
- Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, AZ, USA
| | - Tracy Glauser
- Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | | | - Yi-Chen Lai
- Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | | | - Iván Sánchez Fernández
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Angus A Wilfong
- Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, AZ, USA
| | - Korwyn Williams
- Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, AZ, USA
| | - Tobias Loddenkemper
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
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15
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Kruse CA, Pardo CA, Hartman AL, Jallo G, Vining EPG, Voros J, Gaillard WD, Liu J, Oluigbo C, Malone S, Bleasel AF, Dexter M, Micati A, Velasco TR, Machado HR, Martino AM, Huang A, Wheatley BM, Grant GA, Granata T, Freri E, Garbelli R, Koh S, Nordli DR, Campos AR, O'Neill B, Handler MH, Chapman KE, Wilfong AA, Curry DJ, Yaun A, Madsen JR, Smyth MD, Mercer D, Bingaman W, Harvey AS, Leventer RJ, Lockhart PJ, Gillies G, Pope K, Giller CA, Park YD, Rojiani AM, Sharma SJ, Jenkins P, Tung S, Huynh MN, Chirwa TW, Cepeda C, Levine MS, Chang JW, Owens GC, Vinters HV, Mathern GW. Rasmussen encephalitis tissue transfer program. Epilepsia 2018; 57:1005-7. [PMID: 27286752 DOI: 10.1111/epi.13383] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Carol A Kruse
- David Geffen School of Medicine at UCLA, Los Angeles, California, U.S.A.,Brain Research Institute, UCLA, Los Angeles, California, U.S.A
| | - Carlos A Pardo
- Johns Hopkins University School of Medicine, Baltimore, Maryland, U.S.A
| | - Adam L Hartman
- Johns Hopkins University School of Medicine, Baltimore, Maryland, U.S.A
| | - George Jallo
- Johns Hopkins University School of Medicine, Baltimore, Maryland, U.S.A
| | - Eileen P G Vining
- Johns Hopkins University School of Medicine, Baltimore, Maryland, U.S.A
| | - Joe Voros
- Public Health Management, Los Angeles, California, U.S.A
| | - William D Gaillard
- Children's National Health System, Washington, DC, U.S.A.,George Washington University, Washington, DC, U.S.A
| | - Judy Liu
- Children's National Health System, Washington, DC, U.S.A.,George Washington University, Washington, DC, U.S.A
| | - Chima Oluigbo
- Children's National Health System, Washington, DC, U.S.A.,George Washington University, Washington, DC, U.S.A
| | - Stephen Malone
- Lady Cilento Children's Hospital, Brisbane, Queensland, Australia
| | - Andrew F Bleasel
- Westmead Hospital, Westmead, New South Wales, Australia.,The Children's Hospital at Westmead, Westmead, New South Wales, Australia
| | - Mark Dexter
- The Children's Hospital at Westmead, Westmead, New South Wales, Australia
| | - Alex Micati
- The Sydney Children's Hospitals Network, Sydney, New South Wales, Australia
| | - Tonicarlo R Velasco
- Hospital Clinic of Ribeirão Preto, Ribeirão Preto, São Paulo, Brazil.,University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Helio R Machado
- Hospital Clinic of Ribeirão Preto, Ribeirão Preto, São Paulo, Brazil.,University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | | | - Adam Huang
- University of South Alabama, Mobile, Alabama, U.S.A
| | - B M Wheatley
- University of Alberta, Edmonton, Alberta, Canada
| | - Gerald A Grant
- Stanford University School of Medicine, Stanford, California, U.S.A.,Lucile Packard Children's Hospital, Stanford, California, U.S.A
| | - Tiziana Granata
- Carlo Besta, Neurological Institute Foundation, Milano, Lombardia, Italy
| | - Elena Freri
- Carlo Besta, Neurological Institute Foundation, Milano, Lombardia, Italy
| | - Rita Garbelli
- Carlo Besta, Neurological Institute Foundation, Milano, Lombardia, Italy
| | - Sookyong Koh
- Emory+Children's Pediatric Research Center, Atlanta, Georgia, U.S.A
| | - Douglas R Nordli
- Children's Memorial Hospital, Chicago, Illinois, U.S.A.,Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, U.S.A
| | | | - Brent O'Neill
- University of Colorado Anschutz Medical Campus, Aurora, Colorado, U.S.A
| | - Michael H Handler
- University of Colorado Anschutz Medical Campus, Aurora, Colorado, U.S.A.,The Children's Hospital, Aurora, Colorado, U.S.A
| | - Kevin E Chapman
- University of Colorado Anschutz Medical Campus, Aurora, Colorado, U.S.A
| | - Angus A Wilfong
- Texas Children's Hospital, Houston, Texas, U.S.A.,Baylor College of Medicine, Houston, Texas, U.S.A
| | - Daniel J Curry
- Texas Children's Hospital, Houston, Texas, U.S.A.,Baylor College of Medicine, Houston, Texas, U.S.A
| | - Amanda Yaun
- University of Oklahoma College of Medicine, Oklahoma City, Oklahoma, U.S.A
| | - Joseph R Madsen
- Boston Children's Hospital, Boston, Massachusetts, U.S.A.,Harvard Medical School, Boston, Massachusetts, U.S.A
| | - Matthew D Smyth
- Washington University School of Medicine, St. Louis, Missouri, U.S.A
| | - Deanna Mercer
- Washington University School of Medicine, St. Louis, Missouri, U.S.A
| | | | - A S Harvey
- The Royal Children's Hospital Melbourne, Parkville, Victoria, Australia
| | - Richard J Leventer
- The Royal Children's Hospital Melbourne, Parkville, Victoria, Australia.,Bruce Lefroy Centre for Genetic Health Research, Murdoch Children's Research Institute, Parkville, Victoria, Australia.,University of Melbourne, Melbourne, Victoria, Australia
| | - Paul J Lockhart
- Bruce Lefroy Centre for Genetic Health Research, Murdoch Children's Research Institute, Parkville, Victoria, Australia.,University of Melbourne, Melbourne, Victoria, Australia
| | - Greta Gillies
- Bruce Lefroy Centre for Genetic Health Research, Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - Kate Pope
- Bruce Lefroy Centre for Genetic Health Research, Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - Cole A Giller
- Medical College of Georgia at Augusta University, Augusta, Georgia, U.S.A
| | - Yong D Park
- Medical College of Georgia at Augusta University, Augusta, Georgia, U.S.A
| | - Amyn M Rojiani
- Medical College of Georgia at Augusta University, Augusta, Georgia, U.S.A
| | - Suash J Sharma
- Medical College of Georgia at Augusta University, Augusta, Georgia, U.S.A
| | - Patrick Jenkins
- Medical College of Georgia at Augusta University, Augusta, Georgia, U.S.A
| | - Spencer Tung
- David Geffen School of Medicine at UCLA, Los Angeles, California, U.S.A
| | - My N Huynh
- David Geffen School of Medicine at UCLA, Los Angeles, California, U.S.A
| | - Thabiso W Chirwa
- David Geffen School of Medicine at UCLA, Los Angeles, California, U.S.A
| | - Carlos Cepeda
- David Geffen School of Medicine at UCLA, Los Angeles, California, U.S.A
| | - Michael S Levine
- David Geffen School of Medicine at UCLA, Los Angeles, California, U.S.A.,Brain Research Institute, UCLA, Los Angeles, California, U.S.A
| | - Julia W Chang
- David Geffen School of Medicine at UCLA, Los Angeles, California, U.S.A
| | - Geoffrey C Owens
- David Geffen School of Medicine at UCLA, Los Angeles, California, U.S.A
| | - Harry V Vinters
- David Geffen School of Medicine at UCLA, Los Angeles, California, U.S.A
| | - Gary W Mathern
- David Geffen School of Medicine at UCLA, Los Angeles, California, U.S.A.. .,Brain Research Institute, UCLA, Los Angeles, California, U.S.A..
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16
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Dillman NO, Messinger MM, Dinh KN, Placencia JL, Moffett BS, Guaman MC, Erklauer JC, Kaiser JR, Wilfong AA. Evaluation of the Effects of Extracorporeal Membrane Oxygenation on Antiepileptic Drug Serum Concentrations in Pediatric Patients. J Pediatr Pharmacol Ther 2017; 22:352-357. [PMID: 29042836 DOI: 10.5863/1551-6776-22.5.352] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVES Patients supported on extracorporeal membrane oxygenation (ECMO) have an increased incidence of seizures. Phenobarbital (PB) and fosphenytoin (fos-PHT) are common antiepileptic drugs (AEDs) used to manage seizures in the pediatric population; however, it is unknown what effect ECMO has on the serum concentrations of AEDs. The purpose of this study is to evaluate the effect of ECMO on AED serum concentrations. METHODS A retrospective, matched-cohort study was performed in patients younger than 18 years who received ECMO and were treated with intravenous (IV) PB or fos-PHT at Texas Children's Hospital between 2004 and 2014. Patients receiving IV AED therapy and ECMO were matched, based on age, sex, and weight, with patients receiving IV AED therapy without ECMO. The 24-hour cumulative AED dose, serum concentrations, number of doses per serum concentration drawn ratio, volume of distribution, therapeutic serum concentrations, and time to therapeutic serum concentration were compared between both groups. The fos-PHT and PB groups were analyzed in all patients and in neonates only. RESULTS Fourteen patients met inclusion criteria. The fos-PHT neonatal (20.1 vs 11.3 mg/kg/day, p = 0.044), PB composite (33.9 vs 21.6 mg/kg/day, p = 0.012), and PB neonatal (40.3 vs 20 mg/kg/day, p = 0.04) had larger 24-hour cumulative doses compared with non-ECMO patients. Lower serum concentrations were observed in the PB composite ECMO group (19.1 vs 35.4 mg/L, p < 0.001) and the PB neonatal ECMO group (20.5 vs 27.8 mg/L, p = 0.01) compared with non-ECMO patients. CONCLUSION Pediatric patients receiving PB on ECMO and neonatal patients receiving fos-PHT on ECMO required larger doses, and in pediatric patients achieved lower serum concentrations, suggesting the necessity for alternative dosing strategies in these populations.
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Affiliation(s)
- Nicholas O Dillman
- Department of Pharmacy (NOD, MMM, KND, JLP, BSM), Texas Children's Hospital, Houston, Texas, and Department of Pediatrics (MMM, KND, JLP, BSM, MCG, JCE, JRK, AAW), Baylor College of Medicine, Houston, Texas
| | - Mindl M Messinger
- Department of Pharmacy (NOD, MMM, KND, JLP, BSM), Texas Children's Hospital, Houston, Texas, and Department of Pediatrics (MMM, KND, JLP, BSM, MCG, JCE, JRK, AAW), Baylor College of Medicine, Houston, Texas
| | - Kimberly N Dinh
- Department of Pharmacy (NOD, MMM, KND, JLP, BSM), Texas Children's Hospital, Houston, Texas, and Department of Pediatrics (MMM, KND, JLP, BSM, MCG, JCE, JRK, AAW), Baylor College of Medicine, Houston, Texas
| | - Jennifer L Placencia
- Department of Pharmacy (NOD, MMM, KND, JLP, BSM), Texas Children's Hospital, Houston, Texas, and Department of Pediatrics (MMM, KND, JLP, BSM, MCG, JCE, JRK, AAW), Baylor College of Medicine, Houston, Texas
| | - Brady S Moffett
- Department of Pharmacy (NOD, MMM, KND, JLP, BSM), Texas Children's Hospital, Houston, Texas, and Department of Pediatrics (MMM, KND, JLP, BSM, MCG, JCE, JRK, AAW), Baylor College of Medicine, Houston, Texas
| | - Milenka Cuevas Guaman
- Department of Pharmacy (NOD, MMM, KND, JLP, BSM), Texas Children's Hospital, Houston, Texas, and Department of Pediatrics (MMM, KND, JLP, BSM, MCG, JCE, JRK, AAW), Baylor College of Medicine, Houston, Texas
| | - Jennifer C Erklauer
- Department of Pharmacy (NOD, MMM, KND, JLP, BSM), Texas Children's Hospital, Houston, Texas, and Department of Pediatrics (MMM, KND, JLP, BSM, MCG, JCE, JRK, AAW), Baylor College of Medicine, Houston, Texas
| | - Jeffrey R Kaiser
- Department of Pharmacy (NOD, MMM, KND, JLP, BSM), Texas Children's Hospital, Houston, Texas, and Department of Pediatrics (MMM, KND, JLP, BSM, MCG, JCE, JRK, AAW), Baylor College of Medicine, Houston, Texas
| | - Angus A Wilfong
- Department of Pharmacy (NOD, MMM, KND, JLP, BSM), Texas Children's Hospital, Houston, Texas, and Department of Pediatrics (MMM, KND, JLP, BSM, MCG, JCE, JRK, AAW), Baylor College of Medicine, Houston, Texas
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17
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Krueger DA, Wilfong AA, Mays M, Talley CM, Agricola K, Tudor C, Capal J, Holland-Bouley K, Franz DN. Long-term treatment of epilepsy with everolimus in tuberous sclerosis. Neurology 2016; 87:2408-2415. [PMID: 27815402 DOI: 10.1212/wnl.0000000000003400] [Citation(s) in RCA: 116] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2016] [Accepted: 09/06/2016] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVE To evaluate the long-term benefit and safety of everolimus for the treatment of medically refractory epilepsy in patients with tuberous sclerosis complex (TSC). METHODS Everolimus was titrated over 4 weeks and continued an additional 8 weeks in a prospective, open-label, phase I/II clinical trial design. Participants demonstrating initial benefit continued treatment until study completion (48 months). The primary endpoint was percentage of patients with a ≥50% reduction in seizure frequency compared to baseline. Secondary endpoints assessed absolute seizure frequency, adverse events (AEs), behavior, and quality of life. RESULTS Of the 20 participants who completed the initial study phase, 18 continued extended treatment. Fourteen of 18 (78%) participants completed the study, all but 1 of whom reported ≥50% reduction in seizure frequency at 48 months. All participants reported at least 1 AE, the vast majority (94%) of which were graded mild or moderate severity. Improvements in behavior and quality of life were also observed, but failed to achieve statistical significance at 48 months. CONCLUSIONS Improved seizure control was maintained for 4 years in the majority of patients with TSC with medically refractory epilepsy treated with everolimus. Long-term treatment with everolimus is safe and well-tolerated in this population. Everolimus may be a therapeutic option for refractory epilepsy in TSC. CLASSIFICATION OF EVIDENCE This study provides Class IV evidence that for patients with TSC with medically refractory epilepsy everolimus improves seizure control.
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Affiliation(s)
- Darcy A Krueger
- From the Departments of Pediatrics and Neurology (D.A.K., M.M., K.A., C.T., J.C., K.H.-B., D.N.F.), University of Cincinnati College of Medicine; Division of Child Neurology (D.A.K., M.M., K.A., C.T., J.C., K.H.-B., D.N.F.) and Pediatric Neurology (A.A.W., C.M.T.), Texas Children's Hospital, Baylor College of Medicine, Houston.
| | - Angus A Wilfong
- From the Departments of Pediatrics and Neurology (D.A.K., M.M., K.A., C.T., J.C., K.H.-B., D.N.F.), University of Cincinnati College of Medicine; Division of Child Neurology (D.A.K., M.M., K.A., C.T., J.C., K.H.-B., D.N.F.) and Pediatric Neurology (A.A.W., C.M.T.), Texas Children's Hospital, Baylor College of Medicine, Houston
| | - Maxwell Mays
- From the Departments of Pediatrics and Neurology (D.A.K., M.M., K.A., C.T., J.C., K.H.-B., D.N.F.), University of Cincinnati College of Medicine; Division of Child Neurology (D.A.K., M.M., K.A., C.T., J.C., K.H.-B., D.N.F.) and Pediatric Neurology (A.A.W., C.M.T.), Texas Children's Hospital, Baylor College of Medicine, Houston
| | - Christina M Talley
- From the Departments of Pediatrics and Neurology (D.A.K., M.M., K.A., C.T., J.C., K.H.-B., D.N.F.), University of Cincinnati College of Medicine; Division of Child Neurology (D.A.K., M.M., K.A., C.T., J.C., K.H.-B., D.N.F.) and Pediatric Neurology (A.A.W., C.M.T.), Texas Children's Hospital, Baylor College of Medicine, Houston
| | - Karen Agricola
- From the Departments of Pediatrics and Neurology (D.A.K., M.M., K.A., C.T., J.C., K.H.-B., D.N.F.), University of Cincinnati College of Medicine; Division of Child Neurology (D.A.K., M.M., K.A., C.T., J.C., K.H.-B., D.N.F.) and Pediatric Neurology (A.A.W., C.M.T.), Texas Children's Hospital, Baylor College of Medicine, Houston
| | - Cindy Tudor
- From the Departments of Pediatrics and Neurology (D.A.K., M.M., K.A., C.T., J.C., K.H.-B., D.N.F.), University of Cincinnati College of Medicine; Division of Child Neurology (D.A.K., M.M., K.A., C.T., J.C., K.H.-B., D.N.F.) and Pediatric Neurology (A.A.W., C.M.T.), Texas Children's Hospital, Baylor College of Medicine, Houston
| | - Jamie Capal
- From the Departments of Pediatrics and Neurology (D.A.K., M.M., K.A., C.T., J.C., K.H.-B., D.N.F.), University of Cincinnati College of Medicine; Division of Child Neurology (D.A.K., M.M., K.A., C.T., J.C., K.H.-B., D.N.F.) and Pediatric Neurology (A.A.W., C.M.T.), Texas Children's Hospital, Baylor College of Medicine, Houston
| | - Katherine Holland-Bouley
- From the Departments of Pediatrics and Neurology (D.A.K., M.M., K.A., C.T., J.C., K.H.-B., D.N.F.), University of Cincinnati College of Medicine; Division of Child Neurology (D.A.K., M.M., K.A., C.T., J.C., K.H.-B., D.N.F.) and Pediatric Neurology (A.A.W., C.M.T.), Texas Children's Hospital, Baylor College of Medicine, Houston
| | - David Neal Franz
- From the Departments of Pediatrics and Neurology (D.A.K., M.M., K.A., C.T., J.C., K.H.-B., D.N.F.), University of Cincinnati College of Medicine; Division of Child Neurology (D.A.K., M.M., K.A., C.T., J.C., K.H.-B., D.N.F.) and Pediatric Neurology (A.A.W., C.M.T.), Texas Children's Hospital, Baylor College of Medicine, Houston
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18
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Messinger MM, Dinh KL, McDade EJ, Moffett BS, Wilfong AA, Cabrera AG. Outcomes in Postoperative Pediatric Cardiac Surgical Patients Who Received an Antiepileptic Drug. J Pediatr Pharmacol Ther 2016; 21:327-331. [PMID: 27713672 DOI: 10.5863/1551-6776-21.4.327] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND: Advances in cardiac operations over the last few decades, including corrective operations in early life, have dramatically increased the survival of children with congenital heart disease. However, postoperative care has been associated with neurologic complications, with seizures being the most common manifestation. The primary objective of this study is to describe the outcomes in pediatric patients who received an antiepileptic drug (AED) post-cardiac surgery. METHOD: A retrospective cohort study was performed in all patients less than 18 years of age who received an AED in the cardiovascular intensive care unit at Texas Children's Hospital from June 2002 until June 2012. Cardiac surgical patients initiated on phenobarbital, phenytoin, and levetiracetam were queried. Patients were excluded if the AED was not initiated on the admission for surgery. Patients who received 1 AED were compared to patients who received 2 AED, and differences in outcomes examined between the 3 AEDs used were evaluated. RESULTS: A total of 37 patients met the study criteria. Patients were initiated on an AED a median of 4 days following surgery and became seizure free a median of 1 day after initiation, with 65% remaining seizure free after the first dose. Half of all patients required 2 AEDs for seizure control, with a higher proportion of adolescents requiring 2 AEDs (p = 0.04). No differences were found when comparing the collected outcomes between phenobarbital, fosphenytoin, or levetiracetam. CONCLUSION: No adverse events were reported with the AEDs reviewed. Further work is necessary to evaluate long-term neurodevelopmental outcomes in this population and whether outcomes are a result of the AED or of other clinical sequelae.
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Affiliation(s)
- Mindl M Messinger
- Texas Children's Hospital, Department of Pharmacy, Houston, Texas, Houston, Texas ; Baylor College of Medicine, Department of Pediatrics, Division of Pediatric Neurology, Houston, Texas
| | - Kimberly L Dinh
- Texas Children's Hospital, Department of Pharmacy, Houston, Texas, Houston, Texas
| | - Erin J McDade
- Texas Children's Hospital, Department of Pharmacy, Houston, Texas, Houston, Texas
| | - Brady S Moffett
- Texas Children's Hospital, Department of Pharmacy, Houston, Texas, Houston, Texas ; Baylor College of Medicine, Department of Pediatrics, Section of Pediatric Cardiology, Houston, Texas
| | - Angus A Wilfong
- Baylor College of Medicine, Department of Pediatrics, Division of Pediatric Neurology, Houston, Texas
| | - Antonio G Cabrera
- Baylor College of Medicine, Department of Pediatrics, Section of Pediatric Cardiology, Houston, Texas
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19
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Boerwinkle VL, Wilfong AA, Curry DJ. Resting-state functional connectivity by independent component analysis-based markers corresponds to areas of initial seizure propagation established by prior modalities from the hypothalamus. Brain Connect 2016; 6:642-651. [PMID: 27503346 PMCID: PMC5069733 DOI: 10.1089/brain.2015.0404] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
OBJECTIVE The aims of this study were to evaluate a clinically practical functional connectivity protocol designed to blindly identify the corresponding areas of initial seizure propagation and also to differentiate these areas from remote secondary areas affected by seizure. The patients in this cohort had intractable epilepsy caused by intrahypothalamic hamartoma, which is the location of the ictal focus. The ictal propagation pathway is homogeneous and established, thus creating the optimum situation for the proposed method validation study. METHODS Twelve patients with seizures from hypothalamic hamartoma and 6 normal control patients underwent resting state functional MRI, using independent component analysis to identify network differences in patients. This was followed by seed-based connectivity measures to determine the extent of functional connectivity derangement between hypothalamus and these areas. The areas with significant change in connectivity were compared with the results of prior studies' modalities used to evaluate seizure propagation. RESULTS The left amygdala-parahippocampal gyrus area, cingulate gyrus, and occipito-temporal gyrus demonstrated the highest derangement in connectivity with the hypothalamus, p < 0.01, corresponding to the initial seizure propagation areas established by prior modalities. Areas of secondary ictal propagation were differentiated from these initial locations by first being identified as an abnormal neuronal signal source via independent component analysis, but did not show significant connectivity directly with the known ictal focus. CONCLUSION Non-invasive connectivity measures correspond to areas of initial ictal propagation and differentiate such areas from secondary ictal propagation, which may aid in ictal focus surgical disconnection planning and support the use of this newer modality for adjunctive information in epilepsy surgery evaluation.
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Affiliation(s)
| | - Angus A Wilfong
- Baylor College of Medicine, Pediatrics, Houston, Texas, United States ;
| | - Daniel J Curry
- Baylor College of Medicine, Neurosurgery, Houston, Texas, United States ;
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20
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Akman CI, Micic V, Quach M, Wilfong AA, Schultz R, Riviello JJ, Chapieski ML. Application of envelope trend to analyze early EEG changes in the frontal regions during intracarotid amobarbital procedure in children. Epilepsy Behav 2015; 43:66-73. [PMID: 25561380 DOI: 10.1016/j.yebeh.2014.08.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2014] [Revised: 08/03/2014] [Accepted: 08/06/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND Intracarotid amobarbital procedure (IAP) is acknowledged as the gold standard test for language lateralization. EEG is performed routinely during IAP to monitor the anesthetization of a brain hemisphere. Here, we studied the correlation between the early EEG changes using envelope trend and the clinical outcome of IAP. METHOD Fifty consecutive patients underwent IAP at Texas Children's Hospital (2004-2009). Intracarotid amobarbital procedure was considered "complete" or "incomplete" based on the outcome if the procedure was completed or aborted due to behavior changes. Envelope trend was used to calculate the median EEG amplitude changes within the first 60s of IAP. Statistical analysis was performed to determine the role of EEG changes and clinical features on the procedure outcome. RESULTS Only 30 IAP-EEG files were available for review. Amobarbital was administered at the dose of 60-150mg (mean: 110±20). The intracarotid amobarbital procedure was recorded as complete in 23 patients and incomplete in 7 patients. EEG changes occurred within the first few seconds following amobarbital injection. Following amobarbital injection, focal slowing was present in the ipsilateral frontal region or both ipsilateral and contralateral frontal regions. Elapsed time to the first EEG change or duration and change in median EEG amplitude in the ipsilateral frontal regions were indifferent between the complete and incomplete groups (p>0.05). However, the median amplitude changes between the ipsilateral and contralateral frontal regions within each group were found significant only in the complete group (p<0.05), suggesting ipsilateral without contralateral frontal slowing. Other than age at the time of IAP (p=0.03), none of the other clinical features correlated with the clinical outcome of IAP (p>0.05). CONCLUSION Early EEG changes during IAP using envelope trend may predict successful completion of the IAP test. Younger children are at risk of behavioral changes during IAP.
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Affiliation(s)
- Cigdem I Akman
- Division of Pediatric Neurology, Texas Children's Hospital, Houston, TX, USA; Division of Pediatric Neurology, Clinical Neurophysiology, Texas Children's Hospital, Houston, TX, USA.
| | - Vesna Micic
- Division of Pediatric Neurology, Texas Children's Hospital, Houston, TX, USA
| | - Michael Quach
- Division of Pediatric Neurology, Texas Children's Hospital, Houston, TX, USA; Division of Pediatric Neurology, Clinical Neurophysiology, Texas Children's Hospital, Houston, TX, USA
| | - Angus A Wilfong
- Division of Pediatric Neurology, Texas Children's Hospital, Houston, TX, USA
| | - Rebecca Schultz
- Division of Pediatric Neurology, Texas Children's Hospital, Houston, TX, USA
| | - James J Riviello
- Division of Pediatric Neurology, Texas Children's Hospital, Houston, TX, USA; Division of Pediatric Neurology, Clinical Neurophysiology, Texas Children's Hospital, Houston, TX, USA
| | - Mary L Chapieski
- Division of Pediatric Neurology, Texas Children's Hospital, Houston, TX, USA
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21
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Gross RE, Willie JT, Sharan AD, Sperling M, Shih JJ, Wharen RE, Tatum W, Popli G, Couture DE, Laxton AW, Labiner DM, Weinand ME, Marsh WR, Cascino G, Worrell GA, Wilfong AA, Curry D. 103 Stereotactic Laser Amygdalohippocampotomy for Mesial Temporal Lobe Epilepsy. Neurosurgery 2014. [DOI: 10.1227/01.neu.0000452377.10458.80] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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22
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Abuelem T, Friedman DE, Agadi S, Wilfong AA, Yoshor D. Interhemispheric subdural electrodes: technique, utility, and safety. Neurosurgery 2014; 73:ons253-60; discussion ons260. [PMID: 23615084 DOI: 10.1227/01.neu.0000430287.08552.83] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Invasive monitoring using subdural electrodes is often valuable for characterizing the anatomic source of seizures in intractable epilepsy. Covering the interhemispheric surface with subdural electrodes represents a particular challenge, with a potentially higher risk of complications than covering the dorsolateral cortex. OBJECTIVE To better understand the safety and utility of interhemispheric subdural electrodes (IHSE). METHODS We retrospectively reviewed the charts of 24 patients who underwent implantation of IHSE by a single neurosurgeon from 2003 to 2010. Generous midline exposure, meticulous preservation of veins, and sharp microdissection were used to facilitate safe interhemispheric grid placement under direct visualization. RESULTS The number of IHSE contacts implanted ranged from 10 to 106 (mean = 39.8) per patient. Monitoring lasted for 5.5 days on average (range, 2-24 days), with an adequate sample of seizures captured in all patients before explantation, and with a low complication rate similar to that reported for grid implantation of the dorsolateral cortex. One patient (of 24) experienced symptomatic mass effect. No other complications clearly related to grid implantation and monitoring, such as clinically evident neurological deficits, infection, hematoma, or infarction, were noted. Among patients implanted with IHSE, monitoring led to a paramedian cortical resection in 67%, a resection in a region not covered by IHSE in 17%, and explantation without resection in 17%. CONCLUSION When clinical factors suggest the possibility of an epileptic focus at or near the midline, invasive monitoring of the paramedian cortex with interhemispheric grids can be safely used to define the epileptogenic zone and map local cortical function.
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Affiliation(s)
- Tarek Abuelem
- *Department of Neurosurgery, Baylor College of Medicine, Houston, Texas; ‡Department of Neurology, Baylor College of Medicine, Houston, Texas
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23
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Abstract
Hypothalamic hamartomas (HHs) present a difficult medical problem, manifested by gelastic seizures, which are often medically intractable. Although existing techniques offer modest surgical outcomes with the potential for significant morbidity, the relatively novel technique of magnetic resonance imaging (MRI)-guided stereotactic laser ablation (SLA) offers a potentially safer, minimally invasive method with high efficacy for the HH treatment. We report here on 14 patients with medically refractory gelastic epilepsy who underwent stereotactic frame-based placement of an MR-compatible laser catheter (1.6 mm diameter) through a 3.2-mm twist drill hole. A U.S. Food and Drug Administration (FDA)-cleared laser surgery system (Visualase, Inc.) was utilized to ablate the HH, using real-time MRI thermometry. Seizure freedom was obtained in 12 (86%) of 14 cases, with mean follow-up of 9 months. There were no permanent surgical complications, neurologic deficits, or neuroendocrine disturbances. One patient had a minor subarachnoid hemorrhage that was asymptomatic. Most patients were discharged home within 1 day. SLA was demonstrated to be a safe and effective minimally invasive tool in the ablation of epileptogenic HH. Because use of SLA for HH is being adopted by other medical centers, further data will be acquired to help treat this difficult disorder.
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Affiliation(s)
- Angus A Wilfong
- Division of Pediatric Neurology, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, U.S.A
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Krueger DA, Wilfong AA, Holland-Bouley K, Anderson AE, Agricola K, Tudor C, Mays M, Lopez CM, Kim MO, Franz DN. Everolimus treatment of refractory epilepsy in tuberous sclerosis complex. Ann Neurol 2013; 74:679-87. [PMID: 23798472 DOI: 10.1002/ana.23960] [Citation(s) in RCA: 303] [Impact Index Per Article: 27.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2013] [Revised: 05/28/2013] [Accepted: 06/07/2013] [Indexed: 01/14/2023]
Abstract
OBJECTIVE Epilepsy is a major manifestation of tuberous sclerosis complex (TSC). Everolimus is an mammalian target of rapamycin complex 1 inhibitor with demonstrated benefit in several aspects of TSC. We report the first prospective human clinical trial to directly assess whether everolimus will also benefit epilepsy in TSC patients. METHODS The effect of everolimus on seizure control was assessed using a prospective, multicenter, open-label, phase I/II clinical trial. Patients≥2 years of age with confirmed diagnosis of TSC and medically refractory epilepsy were treated for a total of 12 weeks. The primary endpoint was percentage of patients with a ≥50% reduction in seizure frequency over a 4-week period before and after treatment. Secondary endpoints assessed impact on electroencephalography (EEG), behavior, and quality of life. RESULTS Twenty-three patients were enrolled, and 20 patients were treated with everolimus. Seizure frequency was reduced by ≥50% in 12 of 20 subjects. Overall, seizures were reduced in 17 of the 20 by a median reduction of 73% (p<0.001). Seizure frequency was also reduced during 23-hour EEG monitoring (p=0.007). Significant reductions in seizure duration and improvement in parent-reported behavior and quality of life were also observed. There were 83 reported adverse events that were thought to be treatment-related, all of which were mild or moderate in severity. INTERPRETATION Seizure control improved in the majority of TSC patients with medically refractory epilepsy following treatment with everolimus. Everolimus demonstrated additional benefits on behavior and quality of life. Treatment was safe and well tolerated. Everolimus may be a therapeutic option for refractory epilepsy in this population.
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Affiliation(s)
- Darcy A Krueger
- Departments of Pediatrics and Neurology, University of Cincinnati College of Medicine and Division of Child Neurology Cincinnati Children's Hospital Medical Center, Cincinnati, OH
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Curry DJ, Gowda A, McNichols RJ, Wilfong AA. MR-guided stereotactic laser ablation of epileptogenic foci in children. Epilepsy Behav 2012; 24:408-14. [PMID: 22687387 DOI: 10.1016/j.yebeh.2012.04.135] [Citation(s) in RCA: 355] [Impact Index Per Article: 29.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/29/2012] [Revised: 04/29/2012] [Accepted: 04/30/2012] [Indexed: 10/28/2022]
Abstract
OBJECTIVE For about 30% of epilepsy patients, pharmaceutical therapy fails to control their seizures. MR-guided laser interstitial thermal therapy (MRgLITT) allows for real-time thermal monitoring of the ablation process and feedback control over the laser energy delivery. We report on minimally invasive surgical techniques of MRgLITT and short-term follow-up results from the first five pediatric cases in which this system was used to ablate focal epileptic lesions. METHODS We studied the patients with MRI of the brain, localized the seizure with video-EEG and used the Visualase Thermal Therapy 25 System for laser ablation of their seizure foci. RESULTS All 5 patients are seizure free and there were no complications as of 2-13-month follow-up. CONCLUSION MR-guided laser interstitial thermal therapy has a significant potential to be a minimally invasive alternative to more conventional techniques to surgically treat medically refractory epilepsy in children.
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Affiliation(s)
- Daniel J Curry
- Division of Pediatric Neurosurgery, Texas Children's Hospital, Department of Neurosurgery, Baylor College of Medicine, Houston, TX, USA.
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Dharmadhikari AV, Kang SHL, Szafranski P, Person RE, Sampath S, Prakash SK, Bader PI, Phillips JA, Hannig V, Williams M, Vinson SS, Wilfong AA, Reimschisel TE, Craigen WJ, Patel A, Bi W, Lupski JR, Belmont J, Cheung SW, Stankiewicz P. Small rare recurrent deletions and reciprocal duplications in 2q21.1, including brain-specific ARHGEF4 and GPR148. Hum Mol Genet 2012; 21:3345-55. [PMID: 22543972 DOI: 10.1093/hmg/dds166] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
We have identified a rare small (~450 kb unique sequence) recurrent deletion in a previously linked attention-deficit hyperactivity disorder (ADHD) locus at 2q21.1 in five unrelated families with developmental delay (DD)/intellectual disability (ID), ADHD, epilepsy and other neurobehavioral abnormalities from 17 035 samples referred for clinical chromosomal microarray analysis. Additionally, a DECIPHER (http://decipher.sanger.ac.uk) patient 2311 was found to have the same deletion and presented with aggressive behavior. The deletion was not found in either six control groups consisting of 13 999 healthy individuals or in the DGV database. We have also identified reciprocal duplications in five unrelated families with autism, developmental delay (DD), seizures and ADHD. This genomic region is flanked by large, complex low-copy repeats (LCRs) with directly oriented subunits of ~109 kb in size that have 97.7% DNA sequence identity. We sequenced the deletion breakpoints within the directly oriented paralogous subunits of the flanking LCR clusters, demonstrating non-allelic homologous recombination as a mechanism of formation. The rearranged segment harbors five genes: GPR148, FAM123C, ARHGEF4, FAM168B and PLEKHB2. Expression of ARHGEF4 (Rho guanine nucleotide exchange factor 4) is restricted to the brain and may regulate the actin cytoskeletal network, cell morphology and migration, and neuronal function. GPR148 encodes a G-protein-coupled receptor protein expressed in the brain and testes. We suggest that small rare recurrent deletion of 2q21.1 is pathogenic for DD/ID, ADHD, epilepsy and other neurobehavioral abnormalities and, because of its small size, low frequency and more severe phenotype might have been missed in other previous genome-wide screening studies using single-nucleotide polymorphism analyses.
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Affiliation(s)
- Avinash V Dharmadhikari
- Department of Molecular and Human Genetics, Baylor College of Medicine, One Baylor Plaza, Room R809, Houston, TX 77030, USA
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Abstract
Dravet syndrome is a rare epileptic encephalopathy linked to mutations in SCN1A (neuronal sodium channel α1 subunit) and characterized by an onset in infancy with polymorphous seizure types and developmental decline. It was reported recently that a proportion of patients previously diagnosed with alleged vaccine encephalopathy might possess SCN1A mutations and clinical histories that enabled a diagnosis of Dravet syndrome, but these results have not been replicated. We present here the cases of 5 children who presented for epilepsy care with presumed parental diagnoses of alleged vaccine encephalopathy caused by pertussis vaccinations in infancy. Their conditions were all rediagnosed years later, with the support of genetic testing, as Dravet syndrome. We hope that these cases will raise awareness of Dravet syndrome among health care providers who care for children and adolescents and aid in earlier recognition and diagnosis.
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Affiliation(s)
- Ila S Reyes
- Department of Pediatrics, San Antonio Military Medical Center, Fort Sam Houston, Texas 78234, USA.
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Abstract
Children with epilepsy, particularly infants, differ from adults not only in the clinical manifestations of their seizures but also in the presence of unique electroencephalographic patterns, etiologies, and response to antiepileptic drugs (AEDs). There is a growing list of newer AEDs and nonpharmacologic therapies available to manage childhood epilepsy. These newer AEDs may not be overall more efficacious than the older drugs, but they do appear to be safer, better tolerated, and to have fewer drug-drug interactions. Selection of the AED for initial therapy must be based upon clinical judgment and patient-specific circumstances, such as the specific epilepsy syndrome being treated, anticipated duration of treatment, presence of comorbidities, ability to use certain formulations, and overall cost effectiveness. In some cases, seizures may be aggravated by the use of certain AEDs. Overall, oxcarbazepine is the first-line treatment for localization-related epilepsy with partial-onset seizures. For generalized epilepsies, the AED choice is highly dependent upon which specific syndrome is being treated. For generalized epilepsies with primarily absence seizures, lamotrigine is the AED of first choice. For mixed generalized epilepsies such as Lennox-Gastaut syndrome or juvenile myoclonic epilepsy, zonisamide or topiramate are the first-line agents. For infants with West syndrome, treatment is based upon the underlying etiology: vigabatrin for tuberous sclerosis; adrenocorticotropic hormone for children with no specific etiology uncovered (cryptogenic); and zonisamide for those with a severe symptomatic etiology other than tuberous sclerosis. Single drug therapy (monotherapy) is the goal of epilepsy treatment because this is associated with better compliance, fewer adverse effects, and lower cost. If the seizures prove intractable or adverse effects are encountered with the first AED, then a second monotherapy trial is undertaken. Once three appropriate medications at therapeutic doses have failed, other modalities should be considered, including epilepsy surgery, vagus nerve stimulation, and the ketogenic diet.
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Affiliation(s)
- Amy D Malphrus
- Angus A. Wilfong, MD Baylor College of Medicine, 6621 Fannin Street, CC1250, Houston, TX 77030, USA.
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Joseph JR, Schultz RJ, Wilfong AA. Rufinamide for refractory epilepsy in a pediatric and young adult population. Epilepsy Res 2011; 93:87-9. [DOI: 10.1016/j.eplepsyres.2010.10.017] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2010] [Revised: 10/27/2010] [Accepted: 10/31/2010] [Indexed: 11/28/2022]
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Abstract
Use of vagus nerve stimulation (VNS) has increased in the past decade, resulting in frequent revision cases for device failure. The authors report their series of children who underwent reimplantation of the VNS device after removal of old electrodes and leads. Patients with medically refractory seizures who underwent revision of VNS electrodes were included (n = 23). Twenty patients had high lead impedance and underwent removal of the device and replacement of the VNS electrodes during the same procedure. In 3 patients, electrodes and the device had been removed previously at an outside institution because of infection. None of the patients experienced any major complications. Mean operative time was 2.3 ± 0.9 hours. The reimplanted device worked well in all patients, and seizure control was similar to or better than that reported with the previous device. Thus, implantation of the VNS electrodes is reversible, and it appears that the electrodes can be removed or replaced safely if the device is not functioning properly.
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Affiliation(s)
- Garima Agarwal
- University of Texas Medical School at Houston, Houston, Texas, USA
| | | | - Joseph L. Edmonds
- University of Texas Medical School at Houston, Houston, Texas, USA
- Baylor College of Medicine, Houston, Texas, USA
- Texas Children’s Hospital, Houston, Texas, USA
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Abd-El-Barr MM, Joseph JR, Schultz R, Edmonds JL, Wilfong AA, Yoshor D. Vagus nerve stimulation for drop attacks in a pediatric population. Epilepsy Behav 2010; 19:394-9. [PMID: 20800554 DOI: 10.1016/j.yebeh.2010.06.044] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2010] [Revised: 06/15/2010] [Accepted: 06/23/2010] [Indexed: 11/28/2022]
Abstract
A retrospective analysis of 43 patients with drop attack seizures who were treated with vagus nerve stimulation (VNS) was undertaken to determine the efficacy of VNS and to determine pre-implantation characteristics associated with VNS success. It was found that on last follow-up, 46% of patients had at least a 75% reduction in drops per day. Forty-six percent of patients had less than a 50% reduction in drops per day and were considered nonresponders. Univariate analysis failed to uncover significant associations between pre-implantation characteristics and VNS success. It was found that atonic head nods were more amenable to VNS treatment as compared with atonic or tonic drop attacks. In addition, patients with focal or lateralized epileptiform abnormalities responded better to VNS compared with those with more diffuse or poorly localized findings on ictal and/or interictal recordings. Our data suggest that VNS offers significant palliative benefit to many children with medically intractable drop attack seizures.
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Lega BC, Wilfong AA, Goldsmith IL, Verma A, Yoshor D. Cortical Resection Tailored to Awake, Intraoperative Ictal Recordings and Motor Mapping in the Treatment of Intractable Epilepsia Partialis Continua: Technical Case Report. Oper Neurosurg (Hagerstown) 2009; 64:ons195-6; discussion ons196. [DOI: 10.1227/01.neu.0000335656.12271.a9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
Objective:
Epilepsia partialis continua (EPC) is a form of status epilepticus that is characterized by continuous simple partial seizures and can occur as a manifestation of a variety of underlying pathological processes. Because these seizures typically take onset within or close to motor cortex, the treatment of refractory EPC with resective surgery risks significant postoperative deficits.
Clinical Presentation:
We describe our experience using ictal recordings obtained intraoperatively during awake craniotomy, in conjunction with direct cortical stimulation mapping, to tailor surgical resections in 2 patients with refractory EPC. Both patients had pan-hemispheric pathologies that made extraoperative recording difficult.
Intervention:
Awake craniotomy takes advantage of a unique feature of refractory EPC, namely the near-continuous presence of focal seizure activity. It allows the surgeon to record seizures in the operating room and precisely define the anatomic location of epileptic activity, to resect the seizure focus, and to both visually and electrographically confirm successful cessation of EPC after resection, all within a single operation. We used standard methods of awake craniotomy to finely tailor a cortical resection to the epileptogenic cortex while sparing nearby eloquent motor areas. The precision of awake mapping made this approach safe and effective.
Conclusion:
The cases we describe demonstrate the role of focal resection in the treatment of EPC. Standard techniques of awake craniotomy have application in the treatment of this challenging problem.
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Affiliation(s)
- Bradley C. Lega
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Angus A. Wilfong
- Department of Neurology, and Division of Pediatric Neurology, Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Ian L. Goldsmith
- Peter Kellaway Section of Neurophysiology, Department of Neurology, Baylor College of Medicine, Houston, Texas
| | - Amit Verma
- Department of Neurology, The Methodist Neurological Institute, Houston, Texas
| | - Daniel Yoshor
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
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Brunetti-Pierri N, Wilfong AA, Hunter JV, Craigen WJ. A severe case of dentatorubro-pallidoluysian atrophy (DRPLA) with microcephaly, very early onset of seizures, and cerebral white matter involvement. Neuropediatrics 2006; 37:308-11. [PMID: 17236112 DOI: 10.1055/s-2006-955967] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
We report a severe case of Dentatorubro-pallidoluysian atrophy (DRPLA) presenting with microcephaly, developmental delay, severe epilepsy, and progressive mental deterioration with a very early onset of disease. The case is notable for the early detection of white matter changes by brain MRI. Neuroradiological findings from the case were compared to those of previously reported patients with disease onset before 10 years of age.
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Affiliation(s)
- N Brunetti-Pierri
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX 77030, United States.
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Abstract
Zonisamide is a modern antiepileptic drug (AED) that is distinguished from other AEDs by its unique structure and broad mechanistic profile. Preclinical studies have reported a range of potential mechanisms of action for zonisamide, such as blocking voltage-gated sodium channels, reduction of T-type calcium channel currents, and enhancement of gamma-aminobutyric acid (GABA)-mediated inhibition, which are indicative of its broad antiseizure effects. Zonisamide has a favorable linear pharmacokinetic profile, a long half-life, and a low incidence of protein-binding interactions with other AEDs. Hepatically metabolized through the cytochrome P450 pathway, zonisamide does not induce its own metabolism or liver enzymes. For more than 2 decades, zonisamide has been extensively used as monotherapy and adjunctive therapy for the treatment of partial and generalized seizures in pediatric and adult patients in Japan. Zonisamide was approved in the USA in 2000 as adjunctive therapy for partial seizures in adults. With over 2 million patient-years of exposure internationally, zonisamide has demonstrated safety and efficacy against a multitude of epilepsy and seizure types, including both partial and generalized seizures. This review focuses on the experience and use of zonisamide in partial seizures, as well as possible new uses for zonisamide.
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Abstract
This case series presents the outcomes of seven females with Rett syndrome and medically refractory epilepsy who were treated with adjunctive vagus nerve stimulation (VNS) therapy for a minimum of 12 months. Patients ranged in age from 1 to 14 years (median age 9 y) at the time of implantation, had experienced seizures for a median period of approximately 6 years, and had failed at least two trials of antiepileptic drugs before receiving VNS. The median number of seizures per month was 150 (range 12-3600). At 12 months, six females had >or=50% reduction in seizure frequency. VNS was safe and well tolerated, with no surgical complications and no patients requiring explantation of the device. Quality of life outcomes of note among these patients included reports at 12 months of increased alertness among all seven patients. No change in mood or communication abilities was noted.
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Affiliation(s)
- Angus A Wilfong
- Baylor College of Medicine, Pediatric Neurology, Houston, Texas 77030-2399, USA
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Abstract
Several of the newer antiepilepsy drugs have not been tested as monotherapy in controlled trials. Zonisamide is a broad-spectrum antiepilepsy drug indicated for the adjunctive treatment of partial seizures in adults. However, several small, open-label studies have indicated that it may be safe and effective as monotherapy. The present chart review study was conducted to evaluate the safety and effectiveness of zonisamide monotherapy in a pediatric and young adult patient group. Patient records at the Blue Bird Circle Clinic for Pediatric Neurology were reviewed to identify patients receiving zonisamide monotherapy. Efficacy was assessed from seizure diaries and patients' subjective evaluations. Safety and tolerability were evaluated by analysis of adverse events and change in body weight. The study included 131 patients aged 1 to 21.8 years with a broad spectrum of seizure types and epilepsy syndromes. A total of 101 patients (77.1%) achieved a 50% or greater decrease in seizure frequency, including 39 patients who achieved seizure freedom. Zonisamide monotherapy was well tolerated, with three patients (2.3%) discontinuing for adverse events. These results support open-label studies from Japan reporting that zonisamide monotherapy is safe and effective in pediatric and young adult patients.
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Affiliation(s)
- Angus A Wilfong
- Division of Pediatric Neurology, Baylor College of Medicine, Texas Children's Hospital, 6621 Fannin, Houston, TX 77030, USA
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Abstract
The authors evaluated zonisamide for symptomatic infantile spasms in 23 patients. Spasm cessation, EEG evolution, and tolerability were assessed for a mean duration of 6.5 months. Six patients (26%) had complete control with cessation of spasms and clearing of hypsarrhythmia. Mean latency time from onset of zonisamide treatment to complete spasm control was 19 days. There were no discontinuations due to adverse effects.
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Affiliation(s)
- Timothy E Lotze
- Texas Children's Hospital, Baylor College of Medicine, Houston, TX 77030, USA
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Abstract
Epilepsy is considerably more common in individuals with mental retardation and developmental delays than in the general population. Compared with other groups with epilepsy, these individuals have higher seizure burdens, more often experience multiple seizure types, and more frequently have seizures that are medically refractory. The majority of these patients with refractory epilepsy will not have a surgically amenable epilepsy syndrome. For these individuals, the vagus nerve stimulator offers the potential for improved seizure control, abortive treatment of seizures, and medication reduction, which may lead to greater independence and other improvements in quality of life.
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Affiliation(s)
- Angus A. Wilfong
- Department of Pediatrics and Neurology, Baylor College of Medicine, 6621 Fannin Street, CC1710, 77030, Houston, TX, USA
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Abstract
Repetitive nerve stimulation (RNS) of the trapezius muscle at slow rates was performed on 192 patients with amyotrophic lateral sclerosis (ALS). Fifty-six patients (29%) showed classical neuromuscular decrement of 10-43% (mean 16.8%) while 44 patients (23%) had a borderline decrement of 5-9%. The trapezius was significantly more sensitive in revealing the defect than the distal hypothenar muscles. In 30 patients followed serially, the decremental response remained constant or increased with time. However, 25% of patients continued to show no decrement in spite of progression of disease. No statistical correlation was found between decrement and clinical severity, disease staging, or disease progression. The finding that at least 50% of ALS patients show some degree of decrement on RNS of the trapezius muscle suggests that functional alterations of the neuromuscular junction accompany this disease.
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Affiliation(s)
- J M Killian
- Department of Neurology, Baylor College of Medicine, Houston, Texas
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Wilfong AA, Fernandez F. Myasthenia gravis in a child with sequelae of opsoclonus-myoclonus syndrome. Neurol Sci 1992; 19:88-9. [PMID: 1562915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Immune-mediated myasthenia gravis occurred in a 13-month-old girl who had sequelae of an opsoclonus-myoclonus syndrome. She had an abnormal Raji cell assay along with elevated antiacetylcholine receptor and antithyroglobulin antibodies. No evidence of an associated malignancy was found with either condition. Clearly, the co-occurrence of two diseases within a single patient does not establish a common pathogenesis. Nevertheless, this is a provocative association and may point to an immunologically mediated process in the opsoclonus-myoclonus syndrome.
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Affiliation(s)
- A A Wilfong
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas
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Abstract
The association between Beckwith-Wiedemann syndrome and hepatoblastoma is well established and relatively commonplace. The occurrence of opsoclonus-myoclonus syndrome in individuals with occult neoplasia is also well documented. However, the development of opsoclonus-myoclonus syndrome in an infant with Beckwith-Wiedemann syndrome and hepatoblastoma has not been reported previously. The list of underlying causes of opsoclonus-myoclonus syndrome should be expanded to include hepatoblastoma, particularly in any child with features suggestive of Beckwith-Wiedemann syndrome.
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Affiliation(s)
- A A Wilfong
- Department of Pediatric Neurology, Baylor College of Medicine, Texas Children's Hospital, Houston 77030
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Thornhill JA, Ewen M, Wilfong AA, Gregor L, Saunders WS. Pressor effects of systemic administration of methionine and leucine enkephalin in the conscious rat. Can J Physiol Pharmacol 1986; 64:1353-60. [PMID: 3791038 DOI: 10.1139/y86-230] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Experiments were designed using conscious Sprague-Dawley rats to determine the blood pressure (BP) and heart rate (HR) responses to intravenous doses of (1) the adrenal catecholamines noradrenaline (NA) and adrenaline (A), (2) adrenal pentapeptides methionine enkephalin (ME) and leucine enkephalin (LE), (3) combination (i.v.) injections of both ME or LE with NA or A that modulate the hemodynamic responses when the adrenal catecholamines were given alone, and (4) the possible receptor mechanisms mediating the resultant BP and HR response to i.v. pentapeptide administration. NA (0.48 and 2.4 nmol) and A (0.3 and 1.5 nmol) given i.v. evoked potent, dose-related pressor responses associated with reflex bradycardia. ME and LE (1.6 - 48 nmol) elicited transient (10-20 s) increases in mean arterial pressure (MAP), which was associated either with no change in mean heart rate (MHR), such as ME, or with slight bradycardia (i.e., LE). Combining ME or LE (16 nmol) with NA (2.4 nmol) or A (0.3 or 1.5 nmol) did not change MAP and MHR from when these respective doses of NA or A were given alone. However, 16 nmol of ME or LE with a low dose of NA (0.48 nmol) increased the pressor response compared with NA (0.48 nmol) given alone. Other experiments whereby specific receptor blockers (naloxone, diprenorphine, atropine, propranolol, phentolamine or guanethidine) were given i.v. 5 min before subsequent i.v. administration of LE or ME (16 nmol) indicated that only phentolamine or guanethidine could completely suppress the pressor responses of LE and ME. Naloxone and diprenorphine pretreatment attenuated the pressor response of LE but did not affect the BP response to ME.(ABSTRACT TRUNCATED AT 250 WORDS)
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