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Kruse SM, Fine AL, Gregory SW. Abnormal Eye Movements and Hypernatremia in a 4-month-old Girl. Pediatr Rev 2023; 44:S44-S47. [PMID: 37777236 DOI: 10.1542/pir.2021-005012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/02/2023]
Affiliation(s)
- Sarah M Kruse
- Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN
| | | | - Seth W Gregory
- Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN
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2
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Abstract
Surgery can cure or significantly improve both the frequency and the intensity of seizures in patients with medication-refractory epilepsy. The set of diagnostic and therapeutic interventions involved in the path from initial consultation to definitive surgery is complex and includes a multidisciplinary team of neurologists, neurosurgeons, neuroradiologists, and neuropsychologists, supported by a very large epilepsy-dedicated clinical architecture. In recent years, new practices and technologies have emerged that dramatically expand the scope of interventions performed. Stereoelectroencephalography has become widely adopted for seizure localization; stereotactic laser ablation has enabled more focal, less invasive, and less destructive interventions; and new brain stimulation devices have unlocked treatment of eloquent foci and multifocal onset etiologies. This article articulates and illustrates the full framework for how epilepsy patients are considered for surgical intervention, with particular attention given to stereotactic approaches.
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Affiliation(s)
- Kai J. Miller
- Neurosurgery, Mayo Clinic, 200 First St., Rochester, MN, 55902
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3
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Rozenova KA, Lehman JS, Grande JP, Fine AL, Wieland CN. Utilization of Skin Biopsy for Diagnosis in a case of Lafora Disease. J Cutan Pathol 2022; 49:885-888. [PMID: 35708461 DOI: 10.1111/cup.14275] [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: 02/11/2022] [Revised: 06/08/2022] [Accepted: 06/14/2022] [Indexed: 11/28/2022]
Abstract
Lafora disease is a rare inherited neurodegenerative disease with onset in adolescence. Patients present with progressive myoclonic seizures and cognitive decline. The disease is linked to mutations in either of the two genes encoding malin and laforin, and it is associated with the accumulation of polyglucosan inclusions (Lafora bodies) in various tissues, such as brain, liver, muscle, and skin, with the skin being particularly accessible for biopsy. Histopathologic examination of affected tissue with demonstration of Lafora bodies, together with presence of pathologic mutation in EPM2A or NHLRC1 genes, is sufficient for diagnosis of this neurologic disorder when clinically suspected. Here, we report the case of a 16-year-old female with progressive neurologic symptoms and homozygous mutation in the NHLRC1 gene encoding malin. Skin biopsy was instrumental in reaching the final diagnosis by demonstrating Lafora bodies in sweat glands by histopathologic and electron microscopic examination. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Krasimira A Rozenova
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| | - Julia S Lehman
- Department of Dermatology, Mayo Clinic, Rochester, Minnesota.,Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| | - Joseph P Grande
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| | - Anthony L Fine
- Department of Neurology and Pediatrics, Mayo Clinic, Rochester, Minnesota
| | - Carilyn N Wieland
- Department of Dermatology, Mayo Clinic, Rochester, Minnesota.,Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
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4
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Fine AL, Wong-Kisiel LC, Nickels KC, Wirrell EC. Masking for School-Age Children With Epilepsy: We Do Have Consensus! J Child Neurol 2022; 37:127-132. [PMID: 34986033 DOI: 10.1177/08830738211063684] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
INTRODUCTION This study was designed to assess current recommendations from child neurologists and epileptologists on masking for school-age children with epilepsy. METHODS A 7-item survey was created and sent out to members of the Child Neurology Society and Pediatric Epilepsy Research Consortium in August of 2021 to assess current practice and provider recommendations on masking. RESULTS One hundred four individuals participated with representation from all regions of the United States. Masking was recommended by 95.1%, with 63.4% (n = 66) noting exception of those with severe intellectual disability, autism, and behavioral problems. Of those who write exemption letters, 54% write these <5% of the time. Only 3% reported potential adverse events associated with masking. CONCLUSION Nearly all respondents recommended masking for school-age children with epilepsy. Potential risks of masking and adverse events were low. Improved guidance on masking is needed to ensure academic success of our patients with epilepsy.
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Fine AL, Liebo G, Gavrilova RH, Britton JW. Seizure Semiology, EEG, and Imaging Findings in Epilepsy Secondary to Mitochondrial Disease. Front Neurol 2021; 12:779052. [PMID: 34912288 PMCID: PMC8666417 DOI: 10.3389/fneur.2021.779052] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [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] [Received: 09/17/2021] [Accepted: 10/28/2021] [Indexed: 11/27/2022] Open
Abstract
Background: Identification of an underlying mitochondrial disorder can be challenging due to the significant phenotypic variability between and within specific disorders. Epilepsy can be a presenting symptom with several mitochondrial disorders. In this study, we evaluated clinical, electrophysiologic, and imaging features in patients with epilepsy and mitochondrial disorders to identify common features, which could aid in earlier identification of a mitochondrial etiology. Methods: This is a retrospective case series from January 2011 to December 2019 at a tertiary referral center of patients with epilepsy and a genetically confirmed diagnosis of a mitochondrial disorder. A total of 164 patients were reviewed with 20 patients fulfilling inclusion criteria. Results: A total of 20 patients (14 females, 6 males) aged 0.5-61 years with epilepsy and genetically confirmed mitochondrial disorders were identified. Status epilepticus occurred in 15 patients, with focal status epilepticus in 13 patients, including 9 patients with visual features. Abnormalities over the posterior cerebral regions were seen in 66% of ictal recordings and 44% of imaging studies. All the patients were on nutraceutical supplementation with no significant change in disease progression seen. At last follow-up, eight patients were deceased and the remainder had moderate-to-severe disability. Discussion: In this series of patients with epilepsy and mitochondrial disorders, we found increased propensity for seizures arising from the posterior cerebral regions. Over time, electroencephalogram (EEG) and imaging abnormalities increasingly occurred over the posterior cerebral regions. Focal seizures and focal status epilepticus with visual symptoms were common. Additional study is needed on nutraceutical supplementation in mitochondrial disorders.
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Affiliation(s)
- Anthony L. Fine
- Department of Neurology, Mayo Clinic, Rochester, MN, United States
| | - Greta Liebo
- Department of Radiology, Mayo Clinic, Rochester, MN, United States
| | - Ralitza H. Gavrilova
- Department of Neurology, Mayo Clinic, Rochester, MN, United States
- Department of Clinical Genomics, Mayo Clinic, Rochester, MN, United States
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Baumer FM, McNamara NA, Fine AL, Pestana-Knight E, Shellhaas RA, He Z, Arndt DH, Gaillard WD, Kelley SA, Nagan M, Ostendorf AP, Singhal NS, Speltz L, Chapman KE. Treatment Practices and Outcomes in Continuous Spike and Wave during Slow Wave Sleep: A Multicenter Collaboration. J Pediatr 2021; 232:220-228.e3. [PMID: 33484700 PMCID: PMC8934740 DOI: 10.1016/j.jpeds.2021.01.032] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Revised: 10/20/2020] [Accepted: 01/14/2021] [Indexed: 11/18/2022]
Abstract
OBJECTIVES To determine how continuous spike and wave during slow wave sleep (CSWS) is currently managed and to compare the effectiveness of current treatment strategies using a database from 11 pediatric epilepsy centers in the US. STUDY DESIGN This retrospective study gathered information on baseline clinical characteristics, CSWS etiology, and treatment(s) in consecutive patients seen between 2014 and 2016 at 11 epilepsy referral centers. Treatments were categorized as benzodiazepines, steroids, other antiseizure medications (ASMs), or other therapies. Two measures of treatment response (clinical improvement as noted by the treating physician; and electroencephalography improvement) were compared across therapies, controlling for baseline variables. RESULTS Eighty-one children underwent 153 treatment trials during the study period (68 trials of benzodiazepines, 25 of steroids, 45 of ASMs, 14 of other therapies). Children most frequently received benzodiazepines (62%) or ASMs (27%) as first line therapy. Treatment choice did not differ based on baseline clinical variables, nor did these variables correlate with outcome. After adjusting for baseline variables, children had a greater odds of clinical improvement with benzodiazepines (OR 3.32, 95%CI 1.57-7.04, P = .002) or steroids (OR 4.04, 95%CI 1.41-11.59, P = .01) than with ASMs and a greater odds of electroencephalography improvement after steroids (OR 3.36, 95% CI 1.09-10.33, P = .03) than after ASMs. CONCLUSIONS Benzodiazepines and ASMs are the most frequent initial therapy prescribed for CSWS in the US. Our data suggests that ASMs are inferior to benzodiazepines and steroids and support earlier use of these therapies. Multicenter prospective studies that rigorously assess treatment protocols and outcomes are needed.
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Affiliation(s)
- Fiona M Baumer
- Department of Neurology, Stanford University School of Medicine, Palo Alto, CA.
| | - Nancy A McNamara
- Department of Pediatrics, Michigan Medicine, University of Michigan, Ann Arbor, MI
| | - Anthony L Fine
- Department of Neurology, Divisions of Epilepsy & Child Neurology, Mayo Clinic, Rochester, MN
| | - Elia Pestana-Knight
- Epilepsy Center, Cleveland Clinic Neurological Institute, Cleveland Clinic Lerner College of Medicine, Cleveland, OH
| | - Renée A Shellhaas
- Department of Pediatrics, Michigan Medicine, University of Michigan, Ann Arbor, MI
| | - Zihuai He
- Department of Neurology, Stanford University School of Medicine, Palo Alto, CA
| | - Daniel H Arndt
- Beaumont Children's, Oakland University William Beaumont School of Medicine, Royal Oak, MI
| | - William D Gaillard
- Center for Neuroscience, Children's National Hospital, George Washington University, Washington, DC
| | - Sarah A Kelley
- Department of Neurology, Johns Hopkins School of Medicine, Baltimore, MD
| | - Margot Nagan
- Department of Pediatrics & Neurology, University of Colorado, Aurora, CO
| | - Adam P Ostendorf
- Department of Pediatrics, Nationwide Children's Hospital, Ohio State University, Columbus, OH
| | - Nilika S Singhal
- UCSF Weill Institute for Neurosciences, UCSF School of Medicine, San Francisco, CA
| | - Laura Speltz
- Department of Neurology, University of Minnesota School of Medicine, Minneapolis, MN
| | - Kevin E Chapman
- Department of Pediatrics & Neurology, University of Colorado, Aurora, CO
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Ryan CS, Fine AL, Cohen AL, Schiltz BM, Renaud DL, Wirrell EC, Patterson MC, Boczek NJ, Liu R, Babovic-Vuksanovic D, Chan DC, Payne ET. De Novo DNM1L Variant in a Teenager With Progressive Paroxysmal Dystonia and Lethal Super-refractory Myoclonic Status Epilepticus. J Child Neurol 2018; 33:651-658. [PMID: 29877124 PMCID: PMC8176639 DOI: 10.1177/0883073818778203] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [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] [Indexed: 01/25/2023]
Abstract
BACKGROUND The dynamin 1-like gene ( DNM1L) encodes a GTPase that mediates mitochondrial and peroxisomal fission and fusion. We report a new clinical presentation associated with a DNM1L pathogenic variant and review the literature. RESULTS A 13-year-old boy with mild developmental delays and paroxysmal dystonia presented acutely with multifocal myoclonic super-refractory status epilepticus. Despite sustained and aggressive treatment, seizures persisted and care was ultimately withdrawn in the context of extensive global cortical atrophy. Rapid trio-whole exome sequencing revealed a de novo heterozygous c.1207C>T (p.R403C) pathogenic variant in DNM1L. Immunofluorescence staining of fibroblast mitochondria revealed abnormally elongated and tubular morphology. CONCLUSIONS This case highlights the diagnostic importance of rapid whole exome sequencing within a critical care setting and reveals the expanding phenotypic spectrum associated with DNM1L variants. This now includes progressive paroxysmal dystonia and adolescent-onset super-refractory myoclonic status epilepticus contributing to strikingly rapid and progressive cortical atrophy and death.
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Affiliation(s)
- Conor S Ryan
- 1 Department of Neurology, Division of Child and Adolescent Neurology, Mayo Clinic, Rochester, MN, USA
| | - Anthony L Fine
- 1 Department of Neurology, Division of Child and Adolescent Neurology, Mayo Clinic, Rochester, MN, USA
| | - Alexander L Cohen
- 1 Department of Neurology, Division of Child and Adolescent Neurology, Mayo Clinic, Rochester, MN, USA
| | - Brenda M Schiltz
- 2 Department of Pediatrics, Division of Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
| | - Deborah L Renaud
- 1 Department of Neurology, Division of Child and Adolescent Neurology, Mayo Clinic, Rochester, MN, USA
| | - Elaine C Wirrell
- 1 Department of Neurology, Division of Child and Adolescent Neurology, Mayo Clinic, Rochester, MN, USA
| | - Marc C Patterson
- 1 Department of Neurology, Division of Child and Adolescent Neurology, Mayo Clinic, Rochester, MN, USA.,3 Department of Clinical Genomics, Mayo Clinic, Rochester, MN, USA
| | - Nicole J Boczek
- 4 Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA.,5 Center for Individualized Medicine, Mayo Clinic, Rochester, MN, USA
| | - Raymond Liu
- 6 Division of Biology and Biological Engineering, California Institute of Technology, Pasadena, CA, USA
| | | | - David C Chan
- 6 Division of Biology and Biological Engineering, California Institute of Technology, Pasadena, CA, USA
| | - Eric T Payne
- 1 Department of Neurology, Division of Child and Adolescent Neurology, Mayo Clinic, Rochester, MN, USA
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Carvalho KS, Fine AL, Haines CJ, Valencia I, Khurana DS, Legido A. Cost-Effectiveness of Evaluation of Children With Epilepsy in the Emergency Department: Need for Investment in Patient Education. J Child Neurol 2018; 33:193-197. [PMID: 29318927 DOI: 10.1177/0883073817749378] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [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] [Indexed: 11/17/2022]
Abstract
We aimed to study cost-effectiveness of seizure evaluation of children with epilepsy in the emergency department (ED). We reviewed epilepsy patients seen at our ED for 1 year. Age, laboratory and neuroimaging results, treatment, disposition, and usefulness of the visit (need for hospitalization, clinical improvement) were analyzed. We identified 330 patients, aged 23 days-21 years, 190 (57.5%) had blood tests, 45 (13.6%) urinalysis, 2 (0.6%) cerebrospinal fluid testing, and 44 neuroimaging studies (13.3%). Tests' positive yield were 41%, 11%, 0%, and 4.5%, respectively. One-third of patients (n = 122) were treated with antiepileptic drugs. Other treatments were administered to 44 (13.3%). One hundred eighteen patients (35.7%) were admitted to our hospital, 208 (63%) discharged to home. Two hundred eight visits were useful (63%). One-third of visits did not provide useful patient care. Their visits were expensive and not very cost-effective. Investment in patient education could decrease unnecessary ED visits.
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Affiliation(s)
- Karen S Carvalho
- 1 Section of Neurology, Department of Pediatrics, St. Christopher's Hospital for Children, Drexel University College of Medicine, Philadelphia, PA, USA
| | - Anthony L Fine
- 2 Division of Child Neurology, Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | | | - Ignacio Valencia
- 1 Section of Neurology, Department of Pediatrics, St. Christopher's Hospital for Children, Drexel University College of Medicine, Philadelphia, PA, USA
| | - Divya S Khurana
- 1 Section of Neurology, Department of Pediatrics, St. Christopher's Hospital for Children, Drexel University College of Medicine, Philadelphia, PA, USA
| | - Agustin Legido
- 1 Section of Neurology, Department of Pediatrics, St. Christopher's Hospital for Children, Drexel University College of Medicine, Philadelphia, PA, USA
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Fine AL, Wirrell EC, Wong-Kisiel LC, Nickels KC. Acetazolamide for electrical status epilepticus in slow-wave sleep. Epilepsia 2015; 56:e134-8. [DOI: 10.1111/epi.13101] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/02/2015] [Indexed: 11/28/2022]
Affiliation(s)
- Anthony L. Fine
- Child and Adolescent Neurology; Department of Neurology; Mayo Clinic; Rochester Minnesota U.S.A
| | - Elaine C. Wirrell
- Child and Adolescent Neurology; Department of Neurology; Mayo Clinic; Rochester Minnesota U.S.A
| | - Lily C. Wong-Kisiel
- Child and Adolescent Neurology; Department of Neurology; Mayo Clinic; Rochester Minnesota U.S.A
| | - Katherine C. Nickels
- Child and Adolescent Neurology; Department of Neurology; Mayo Clinic; Rochester Minnesota U.S.A
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10
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Samdani AF, Fine AL, Sagoo SS, Shah SC, Cahill PJ, Clements DH, Betz RR. A patient with myelomeningocele: is untethering necessary prior to scoliosis correction? Neurosurg Focus 2010; 29:E8. [PMID: 20594006 DOI: 10.3171/2010.3.focus1072] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Tethering of the spinal cord is thought to increase the chance of neurological injury when scoliosis correction is undertaken. All patients with myelomeningocele (MM) are radiographically tethered, and untethering procedures carry significant morbidity risks including worsening neurological function and wound complications. No guidelines exist as regards untethering in patients with MM prior to scoliosis correction surgery. The authors' aim in this study was to evaluate their experience in patients with MM who were not untethered before scoliosis correction. METHODS Seventeen patients with MM were retrospectively identified and 1) had no evidence of a clinically symptomatic tethered cord, 2) had undergone spinal fusion for scoliosis correction, and 3) had not been untethered for at least 1 year prior to surgery. The minimum follow-up after fusion was 2 years. Charts and radiographs were reviewed for neurological or shunt complications in the perioperative period. RESULTS The average age of the patients was 12.4 years, and the following neurological levels were affected: T-12 and above, 7 patients; L-1/L-2, 6 patients; L-3, 2 patients; and L-4, 2 patients. All were radiographically tethered as confirmed on MR imaging. Fourteen of the patients (82%) had a ventriculoperitoneal shunt. The mean Cobb angle was corrected from 82 degrees to 35 degrees , for a 57% correction. All patients underwent neuromonitoring of their upper extremities, and some underwent lower extremity monitoring as well. Postoperatively, no patient experienced a new cranial nerve palsy, shunt malfunction, change in urological function, or upper extremity weakness/sensory loss. One patient had transient lower extremity weakness, which returned to baseline within 1 month of surgery. CONCLUSIONS The study results suggested that spinal cord untethering may be unnecessary in patients with MM who are undergoing scoliosis corrective surgery and do not present with clinical symptoms of a tethered cord, even though tethering is radiographically demonstrated.
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Affiliation(s)
- Amer F Samdani
- Shriners Hospital for Children, Philadelphia, Pennsylvania 19140, USA.
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11
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Fine AL. Problems in primary care. N Engl J Med 1993; 329:729; author reply 731-2. [PMID: 8345863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
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